A 55-year-old woman presents to the emergency department at 11:30 p.m. with hematemesis. She is otherwise healthy and has no risk factors for liver disease. Her only medication is aspirin (at a dose of 81 mg daily), which she started to take 6 months ago after reading that it reduces the risk of heart disease. The blood pressure is 94/60 mm Hg, and the heart rate is 108 beats per minute; the physical examination is otherwise normal. The hemoglobin level is 11.0 g per deciliter, platelet count 220,000 per cubic millimeter, international normalized ratio 1.0, and blood urea nitrogen level 20 mg per deciliter (7
.1 mmol per liter). How should this case be further evaluated and managed?This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist.The article ends with the author's clinical recommendations.The New England Journal of Medicine Downloaded from nejm.org on June 15, 2016. For personal use only. No other uses without permission.