DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Acute GI bleed.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who has significant history of dementia. The patient has been admitted to this hospital due to lethargy, change in mental status for the past three days. According to the son, he also has possible melena, which was only noted today.
The patient presently is mildly confused and not able to provide medical information. However, he denied abdominal pain, nausea, vomiting. During this hospital course, his hemoglobin was recorded at 6.6 and hematocrit at 20.8. The patient also has other complications, including acute renal failure, hyperkalemia with potassium at 6.5, metabolic acidosis, CO2 at 11.
The patient denied prior EGD/colonoscopy. Medical information was obtained via computer records and also through the patient’s son and his wife.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, hypothyroidism, dementia, osteoarthritis, atrial fibrillation, and possible history of ascites; however, the son is not aware of this.
PAST SURGICAL HISTORY: Right hip replacement x2, bilateral knee surgery, back surgery, hernia repair, and bilateral shoulder surgery.
MEDICATIONS: Pravastatin, amiodarone, Lortab, lisinopril, metoprolol, triamterene, HCTZ, Synthroid, sertraline, omeprazole, Pradaxa, and aspirin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Denied alcohol or tobacco use.
FAMILY HISTORY: Denies family history of colorectal cancer or colon polyps.
REVIEW OF SYSTEMS: Fourteen systems reviewed, as stated in HPI. Limited due to patient’s poor input and also patient’s son has limited information and medical information.
PHYSICAL EXAMINATION:
GENERAL: The patient is awake, alert, and oriented x2, in no acute distress, pleasant.
HEENT: EOMI, anicteric. Oral mucosa is moist.
NECK: No JVD. No bruits bilaterally. Supple.
HEART: Regular rhythm. No murmur, regurg, or gallops. No S3.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi, or crackles.
ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds.
EXTREMITIES: Positive for pitting edema, moderate to severe.
LABORATORY STUDIES: White blood cells 7, hemoglobin 6.6, hematocrit 20.8, platelets 180, MCV 92.2, PT 12.8, INR 1.1. Sodium 134, potassium 6.5, chloride 106, CO2 is 12, BUN 178, creatinine 8.66, glucose 120, alkaline phosphatase 62, AST 24, total bilirubin 0.3, ALT 24, and troponin level 0.02.
IMPRESSION:
1. Acute gastrointestinal bleed, melena.
2. Anemia.
3. Acute renal failure.
4. Altered mental status.
5. Hyperkalemia.
6. Metabolic acidosis.
7. Possible atrial fibrillation, on Pradaxa.
RECOMMENDATIONS:
1. H&H, monitor and transfuse.
2. Agree with PPI drip.
3. EGD tomorrow given that his potassium, metabolic acidosis, and functional status are better.
4. Discontinue Pradaxa for now.
