DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ADMISSION DIAGNOSES:
1. Lower gastrointestinal bleeding.
2. Hypertension.
3. Congestive heart failure, rule out myocardial infarction.
4. Stable angina and diabetes mellitus.
5. Obstructive sleep apnea.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with a past medical history of hypertension, CHF, pacemaker placed in the past, diabetes, obstructive sleep apnea, hypercholesterolemia, and morbid obesity. He complains of 24 hours of rectal bleeding with bright red blood with some blood clots per rectum. The patient states that he has had two episodes of this; one the night prior to admission and one the morning of admission. The patient also complains of retrosternal chest pain, like someone sitting on him, associated with dizziness that presented with a second episode of bleeding per rectum. The patient has had palpitations over the past month, and he asked his wife to check the pulse, which was fast. The patient had chest pain, which was nonradiating and disappeared with nitroglycerin. The patient had been admitted to the hospital a year ago for chest pain. He also had a stress test done, which was negative. He is scheduled for a cath upcoming Monday.
MEDICATIONS AT HOME: Glucotrol XL 5 mg, Accupril 10 mg twice a day, Lasix 40 mg a day, aspirin 325 mg a day, and Lipitor 10 mg a day.
SOCIAL HISTORY: The patient denies smoking, alcohol or drug use. He lives with his wife.
FAMILY HISTORY: The patient states his mother passed away from a heart attack, unsure of the age, father has heart disease, and sister has heart disease and diabetes.
REVIEW OF SYSTEMS: No fever or chills. No skin rashes. Shortness of breath present with exertion. No cough, nausea, vomiting, diarrhea or constipation. No dysuria.
PHYSICAL EXAMINATION: VITAL SIGNS: Vitals on admission showed temperature 99.4 degrees, pulse 82,respirations 22, blood pressure 144/88, and saturation was 100%. GENERAL: The patient was in no apparent distress. Awake, alert and oriented x3. Pupils were equal, round, and reactive to light. LUNGS: Clear to auscultation. HEART: S1 and S2 present. No murmurs. ABDOMEN: Very obese and nontender. Bowel sounds were present. Asymmetric fat distribution, no hernia. RECTAL: Grossly heme positive.
LABORATORY DATA: White blood cells were 5.9, H&H 14.6 and 44, and platelets 178,000. Sodium 136, potassium 4.9, chloride 106, bicarb 24, BUN 12, creatinine 1.1, and glucose 96. Liver function tests were normal. Troponin was negative x2. Chest x-ray showed cardiomegaly and no infiltrates.
HOSPITAL COURSE: The patient was admitted for chest pain, rule out MI. Troponin was ordered x3. EKG was ordered x3. The patient was given nitroglycerin. The patient was scheduled for a stress test, and the patient was monitored for his rectal bleeding. Hemoglobin and hematocrits were ordered every 8 hours and Protonix was started.
A GI consult was ordered, and the patient was placed on Accupril, Toprol, and Lasix for his CHF and CPAP for the OSA. For diabetes, the patient was placed on insulin sliding scale. For hypertension, the patient was placed on Toprol. The patient had GI consult done and remained without any episodes of rectal bleeding.
While he was in the hospital, his hemoglobin remained stable at 14, and the patient was stressed. The patient’s stress echo showed mild LVH with ejection fraction of 55%, hypokinesis of the basal and inferoposterior wall and basal lateral wall, suspicious for ischemia, and overall ejection fraction with stress was 70%. The patient was okayed for discharge per GI who decided that they would address him as an outpatient, and the patient was scheduled for an outpatient GI appointment and medical appointment.
The patient has an appointment for a cardiac cath. The patient was discharged home on instructions to continue the home medications.
