HPI
presenting with moderate GI bleeding characterized as hematemesis that began today.

There is associated abdominal pain.
The patient endorses feeling weak or lightheaded.
There is a history of similar bleeding.
Positive for melena.
The patient endorses a history of alcohol abuse and liver disease.
 
Associated symptoms include:
No recent illness or fever
+ nausea and vomiting

ROS: No headache.  No shortness of breath.  A 10 point ROS was done and was negative except as otherwise indicated above.

Physical Exam:
General: Alert with [moderate] distress
HEENT: PERRL, EOMI, pharynx normal, mucous membranes dry
Neck: Supple without LAD, thyromegaly, or JVD
Respiratory: No respiratory distress, lungs are clear to auscultation
Cardiovascular: ___ Tachycardic without murmur, gallop, or rub.  Pulses equal in all 4 extremities
Abdomen: Nontender and nondistended though with midline incision with wound vac dressing in place.

Rectal: ___ melena, guaiac test card internal control positive

Skin: pallor, cold without rash or embolic lesions.
Extremities: full ROM without edema or tenderness.
Neuro: oriented x 4, cranial nerves 2-10 intact, motor and sensory function grossly intact in all 4 extremities.
Psych: lucid without apparent psychosis or suicidality