tokens: Admission Date : 2015-12-03 Discharge Date : 2015-12-08 Date of Birth : 1960-04-22 Sex : M Service : MEDICINE Allergies : Patient recorded as having No Known Allergies to Drugs Attending : Geoffrey F Corney , M.D. Chief Complaint : bright red blood per rectum Major Surgical or Invasive Procedure : Colonoscopy Virtual colonoscopy History of Present Illness : 55 yo M w/ h/o recurrent bladder ca s/p cystectomy w/ ileal conduit p/w BRBPR to OSH . Hct dropped 34 -> 22 . EGD normal . Cscope unable to complete due to blood but tics seen . Tagged RBC + activity in RLQ . Transferred to Mediplex Rehab Hospital ICU where Hct has remained stable . Seen by GI and plan is to continue holding anticoagulation and repeat scope on Monday . Pt feeling well , denies abd pain , N/V , LH , SOB , CP . Past Medical History : Metastatic bladder CA now in remission s/p chemo/xrt s/p cystectomy and ileal loop urinary diversion and also radical prstatectomy with bilateral pelvic lymph node dissection . b/l DVT s, most recent seen in IVC to right femoral vein s/p IVC filter 2015-01-15 Nephrolithiasis . Anemia - baseline mid 30 s. Social History : From Sao Tome originally . denies smoking works at a deli in beaconhill . Family History : denies fh of bleeding or clotting disorders . Physical Exam : per admitting resident : T 97.4 BP 100/62 P 56 RR 16 Mid aged man in NAD sclera anicteric , MMM supple , no LAD CTAB RRR S1/S2 no M soft , +BS , NT , Midline surgical scar , nephrostomy bag draining yellowish urine in RLQ no edema , no clubbing Pertinent Results : 2015-12-03 10:27 PM GLUCOSE - 88 UREA N - 12 CREAT - 1.0 SODIUM - 138 POTASSIUM - 3.3 CHLORIDE - 107 TOTAL CO2 - 25 ANION GAP - 9 2015-12-03 10:27 PM estGFR - Using this 2015-12-03 10:27 PM CALCIUM - 8.7 PHOSPHATE - 2.4 * MAGNESIUM - 1.5 * 2015-12-03 10:27 PM WBC - 8.4 RBC - 2.98 * HGB - 9.3 * HCT - 26.3 * MCV - 88 MCH - 31.1 MCHC - 35.3 * RDW - 14.4 2015-12-03 10:27 PM PLT COUNT - 164 2015-12-03 10:27 PM PT - 11.4 PTT - 27.5 INR(PT) - 1.0 Brief Hospital Course : 55 year old man with history of metastatic bladder cancer and recurrent DVT s on Lovenox admitted with lower GI bleeding . Right lower quadrant source of bleed on red blood cell scan . Attempts to visualize colon by conventional and CT virtual colonoscopy failed because of sigmoid angulation and inadequate preparation , respectively . On Ct scan , a right psoas mass , most consistent with a hematoma , was seen . Since the hematocrit of the patient was stable and outside records from 2015-03-28 mentioned a mass in the right pelvis , the patient was discharged . Lovenox was held until follow-up with primary care doctor . Also , a repeat outpatient CT colonoscopy with better preparation should be considered . Medications on Admission : Lovenox 0.6 mg / kg SC BID Discharge Medications : 1. Pantoprazole 40 mg Tablet , Delayed Release ( E.C. ) Sig : One ( 1 ) Tablet , Delayed Release ( E.C. ) PO once a day . 2. Outpatient Lab Work cbc , creatinine Discharge Disposition : Home Discharge Diagnosis : Primary diagnosis : GIB Secondary diagnosis : Metastatic , recurrent bladder cancer h/o DVT s Discharge Condition : Good . Stable Hct of 31 . Discharge Instructions : We recommend that you do NOT resume your lovenox until talking to your PCP , Dr. Jessie . You likely have a bleeding source in your colon that we have been unable to visualize . The bleeding has stopped and you have remained hemodynamically stable and your hematocrit is stable , but you are at risk of bleeding from this source again with anticoagulation . A CT scan of your abdomen showed a right pelvic mass , most likely a hematoma , which had been described previously in 2015-03-28 . Please continue to take your other medications as prescribed . Please follow up with your PCP as scheduled . Please bring your outpatient lab results to your PCP ( Dr. Hemler ) Please see a doctor if you feel dizzy , or have blood in your stool again . Followup Instructions : Please follow up with your PCP S. Saracino on 2015-12-30 at 8:00 AM . Her number is ( 512 ) 677-6547 . Please go to Dr. Colombo office later this week to have your labs drawn and sent to Dr. Powell . James Jennifer MD , PHD 12-944 Completed by : Kimberly Sarah MD 97-625 2015-12-08 @ 1543 Signed electronically by : DR. Joanne Gilbert YANG on : MON 2016-02-08 9:27 AM ( End of Report )