DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: GI bleeding.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old male with complaints of dizziness yesterday a.m. when trying to ambulate to the bathroom and noted to have diarrhea. His stools were black in color. Secondary to his dizziness and black stools, he proceeded to go to the emergency department. He denies any dyspepsia, heartburn, indigestion, any increase in acid, any dysphagia or odynophagia. He states that his appetite has been good. His weight has been stable. He denies any chest pain or shortness of breath with any of these or other symptoms. He has never had an EGD. He has never had a colonoscopy in the past. He has never had any problems with the GI bleed in the past. On admission, the patient was noted to be anemic with hemoglobin of 7.4 and 22.2.
PAST MEDICAL HISTORY: Coronary artery disease with history of an MI and CABG with PTCA stenting, benign prostatic hypertrophy, peripheral vascular disease with a history of elevated cholesterol and hypertension.
PAST SURGICAL HISTORY: CABG, catheterization with PTCA stenting, cholecystectomy, and prostate surgery x2.
ALLERGIES: None.
MEDICATIONS: Protonix.
SOCIAL HISTORY: The patient is married and has two children. He denies any tobacco use. Alcohol intake is may be one time a week socially.
FAMILY HISTORY: Father deceased at the age of 88 with a history of hypertension. Mother deceased at the age of 79, unknown reasons, but with a history of hypertension.
REVIEW OF SYSTEMS: A 12-point review of systems completed and incorporated in H&P, otherwise unremarkable.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 108/52, pulse 68, respirations 24. The patient is afebrile.
GENERAL: The patient is alert and oriented.
CHEST: Clear and bilaterally expanding. Respirations are even and unlabored.
CARDIOVASCULAR: S1 and S2. No rubs, murmurs or gallops. Rhythm is regular.
ABDOMEN: Soft, obese, nondistended, and nontender. Bowel sounds are noted throughout.
EXTREMITIES: The patient is moving all extremities well and equal.
SKIN: Warm, dry, and pink.
LABORATORY DATA: Laboratories reviewed. Troponin and CK-MBs were negative. PT/INR 14.4 and 1.1, PTT of 25.8. Total protein 5.8, albumin 3.6, total bilirubin 0.2, direct bilirubin 0.1, ALT of 11, AST of 13. White count of 13.4 with hemoglobin 7.4 and 22.2, platelet count of 264, neutrophils are 79, MCV of 98.2, MCHC of 33.8 with RDW 52. Sodium 141, potassium 4.6, chloride 108, CO2 of 22, BUN 100 and creatinine 1.8 with a blood glucose of 242.
IMPRESSION:
1. Melena
2. Severe anemia.
3. History of cardiovascular disease and coronary artery bypass graft with myocardial infarction.
PLAN AND RECOMMENDATIONS: At this time to continue with supportive care, monitor H&H, transfuse as needed. Upper endoscopy to be performed today. The patient is presently n.p.o. We will continue with PPI therapy.
