DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DIAGNOSES:
1. Gastrointestinal hemorrhage.
2. Blood loss anemia.
3. Gastric ulcer and gastritis and duodenitis.
4. Hypertension.
5. Renal failure.
6. Diabetes mellitus.
7. Hydronephrosis.
8. Hyperlipidemia.
9. Multiple strokes.
PROCEDURES: Esophagogastroduodenoscopy with biopsies.
CHIEF COMPLAINT: Vomiting blood.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman, previously admitted for melena in the past on two occasions, had EGD done on both occasions with history of ulcers and has also some history of diabetes and hypertension and renal insufficiency, who has not been compliant with followup for at least one year and taking any medications.
The patient came to the emergency room because of a history of six episodes of watery bloody diarrhea of cranberry juice color, hematemesis, and then came to the emergency room. She had been taking apparently some Advil for various aches and pains, particularly in the shoulders, for the past two years, at a rate of at least 400 mg twice a day. She denies any lightheadedness, dizziness, syncope, anorexia, weight loss, nausea, abdominal pain, hematuria or dysuria. She does feel a little short of breath, and she had some chest pains two days prior to admission. When she was seen in the emergency room, the NG tube was placed, and she was found to have 1 liter of burgundy fluid and was immediately given infusions of O type blood, 3 units of packed red blood cells, at which time her hemoglobin was approximately 6. The patient was transferred to the intensive care unit for further evaluation and treatment.
PAST MEDICAL HISTORY: Includes a history of diabetes mellitus, hypertension, hyperlipidemia, melena, acute renal failure, and TIA. For the melena, she has had EGD done twice with bleeding ulcers.
ALLERGIES: No known allergies.
MEDICATIONS: Her only medication currently is Advil.
SOCIAL HISTORY: The patient lives with a significant other. The patient has quit smoking, and there is no known alcohol use.
PHYSICAL EXAMINATION:
GENERAL: The patient is a pleasant, alert, middle-aged woman in no acute distress.
VITAL SIGNS: Temperature 96.4, pulse 100, respiratory rate 28, blood pressure 138/40, and 99% O2 saturation on oxygen.
HEENT: Normal.
NECK: Supple. No JVD.
LUNGS: Clear.
HEART: Regular rhythm and rate.
ABDOMEN: Nontender.
RECTAL: No masses but has gross blood present.
EXTREMITIES: No edema or cyanosis.
NEUROLOGIC: Within normal limits.
DIAGNOSTIC DATA: Followup hemoglobin is 8.9 and 26.2 with the initial one being about 6. The white blood cell count is, however, 29,600. Chest x-ray shows no infiltrates. Initial potassium was 6.5 and decreased to 5.2 with a bicarbonate of 9 and a BUN of 58, creatinine of 2.5, glucose of 162. Liver function tests are slightly abnormal with AST of 96 and ALT of 40. Total bilirubin is 0.8.
HOSPITAL COURSE AND TREATMENT: The patient was admitted to the intensive care unit where she was given sodium bicarbonate to correct the acidosis. She was given insulin and D50 and calcium gluconate for the hyperkalemia. She was given IV Protonix, and GI consultation was obtained. She was monitored with respect to her glucoses and her blood pressure.
The patient was given additional packed red blood cells and FFP, and EGD was performed showing the presence of the gastritis and gastric ulcers and duodenitis, and she was observed in the intensive care unit for several days. She had only 10,000 colonies on the urine culture, so she had been started on ciprofloxacin, but this was discontinued. The patient had been given metoprolol and nitroglycerin paste for the hypertension that she had. At the time that she left the intensive care unit, her hemoglobin was 9.6 and electrolytes were normal and her BUN was 50 and creatinine was 1.6.
The patient was then transferred to the monitored floor. She was continued on IV Protonix and continued on the same antihypertensives and observed. She was switched over to Norvasc 10 mg, lisinopril 20 mg, and Toprol-XL 100 mg for blood pressure control. Her A1c was checked. The lipids were checked. The patient’s white blood cell count was 4800. Her BUN has decreased to 24 and creatinine was 1.2. Glucoses were approximately 140. She was negative for Helicobacter pylori on her biopsies.
The patient did complain of some possible neurologic deficits on the right side, mostly incoordination in the right upper and right lower extremities and some paresthesias. A CT discovered that she had some strokes of undetermined age, mostly the several low attenuation foci within the basal ganglia, left corona radiata, and left thalamus. These were probably lacunar infarcts; they were of undetermined age. The patient could, however, walk but she had poor coordination with her right hand.
The patient was seen to be stable on the Norvasc, lisinopril, Toprol for her blood pressure, and her glucoses were quite stable as well on insulin, and her activities were increased. She was stabilized and then she was discharged to home to continue on these various medications and will be followed up in a few days with Dr. John Doe. She is to be on a regular diet, no concentrated sweets, and activities are as tolerated.
