Age: 71.0
Sex: M
Vaccine: UNK
Symptoms: Hypoglycaemia, Hyponatraemia, International normalised ratio increased, Liver function test normal, Lung opacity
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: on November 11, 2022 18:22  Verified By: on November 11, 2022 19:19   Encounter Info: Emergency, 11/11/22 - 11/11/22    * Final Report *          History of Present Illness/Subjective     71 year old male with hx of anemia, CAD, COPD, GERD, HLD, HTN, and psoriasis presents to the ED via private vehicle for evaluation of pancytopenia.  According to patient, he has been having weakness, shortness of breath with ambulation, lightheadedness which has persisted for a long time.     He was evaluated at primary care office this AM for the symptoms and was later called back due to hemoglobin of 6.  Pt had labs drawn this AM; Hgb was noted to be 6.0 and WBC was 1.7. He was instructed to present to the ED. of note, patient had an episode of bright red rectal bleeding last week after an episode of constipation followed by diarrhea after intake of prune juice.  No hematemesis, dark stool, chest pain, headache or blurry vision.  He has had an upper GI endoscopy several years ago which was normal, last colonoscopy was about 3 years ago which showed a benign polyp.  There was no evidence of source of chronic bleeding.  pt reports transient episodes of hypoglycemia as low as the 40s. He also reports significant weight loss; he states "I was attempting to lose weight, but I lost too much.  Patient is unaware of previous blood transfusion.   Pt reports recent abscess tooth for which he required abx. Pt received his COVID booster 11/1/22; . Past surgical hx includes CABG x3.  Does not smoke or drink alcohol  No history of allergies  CODE STATUS-DNI DNR comprehensive   In the ER  Blood pressure 113/56, heart rate 102 down trended to 98, respiratory rate 23 SPO2 97 on room air   On evaluation, patient was awake and alert, AAOx3, has the second unit of PRBC running, telemetry monitoring by the bedside with stable vitals.  Reports feeling much better than on presentation.   Labs  WBC 1.7 up trended 2.3, hemoglobin 6 which repeat 5.6, platelets 68 PT/INR 14.61.27  Sodium 133 potassium 4.1 bicarb 19 anion gap 14 BUN creatinine 22/0.91, glucose 190  LFTs within normal limits  BNP 21  Venous blood gas pH 7.37, bicarb 17, PCO2 30  TSH 3.070  Stool occult blood positive   Imaging CT chest abdomen and pelvis-- >1.  No CT evidence for malignancy in the chest, abdomen, or pelvis, as clinically queried.  2.  Linear and groundglass opacities in the upper lobes, middle lobe, and lung bases are nonspecific but may reflect an inflammatory or infectious process if the patient has respiratory symptoms. Otherwise, these could represent chronic changes.   Patient is admitted for symptomatic anemia and pancytopenia work-up.  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.3 (36.3-36.3)  Temp (FAHR) 97.3 (97.3-97.3), BP 116/58 (113-147)/(56-66), HR 102 (99-116), RR 23 (13-23), O2Sat 97 (97-97)     Patient Weight  Current Daily Weight:    92.7 kg    11/11/22    Patient Height  Current Height:    175 cm    11/11/22        General: Alert and oriented, No acute distress. Eye: Normal conjunctiva. Cardiovascular: Regular rate, Normal rhythm, No murmur. Respiratory: Lungs are clear to auscultation, Respirations are non-labored. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly. Neurologic: Alert, Oriented, non focal Psychiatric: Cooperative, Appropriate mood & affect. Musculoskeletal: No swelling,     Assessment/Plan     71 year old male with hx of anemia, CAD, COPD, GERD, HLD, HTN, and psoriasis presents to the ED via private vehicle for evaluation of pancytopenia.  Status post 2 units of PRBC   1. GIB (gastrointestinal bleeding)   K92.2  Likely because of anemia given positive occult blood stool   -NPO except medications, followed by 40mg IV BID, q4 Hgb, type and screen, gentle hydration, and notification to GI for evaluation and formal recommendations moving forward regarding ongoing management and need for endoscopy  -GI already on board and will follow  -Telemetry to monitor vitals closely and if patient decompensates, will call GI for emergent endoscopy  -We will be cautious with antihypertensives to prevent hypotension with GI bleeding   2. Pancytopenia   D61.818  Evidenced on labs.  Symptomatic  Unknown cause currently  CT abdomen pelvis is unrevealing for any possible malignancy  -Hematology consult  -May require peripheral smear to rule out bone marrow problems   3. Symptomatic anemia   D64.9  Likely due to GI blood loss.  CT abdomen pelvis negative for ongoing GI bleeding  -We will follow-up with GI for possible endoscopy   4. Chronic constipation   K59.09  Noted.  Also history of rectal bleeding  No current rectal bleeding  -We will give MiraLAX as needed while monitoring stool color for ongoing GI bleed   5. Hyperglycemia   R73.9  Noted  History of diabetes  -We will order insulin ISS for now  -Monitor BGM closely   6. Hyponatremia   E87.1  Sodium is 133, mild hyponatremia  We will trend daily   7. Psoriasis   L40.9  Continue home meds   8. CAD (coronary artery disease)   I25.10  Continue home meds   9. GERD (gastroesophageal reflux disease)   K21.9  On PPI, will continue   10. DVT prophylaxis   Z29.9  We will use mechanical DVT prophylaxis for now and avoid pharmacological prophylaxis due to concern for ongoing GI bleeding    Code Status   None Recorded   Chronic Problem List    Anemia  Arthritis  CAD (coronary artery disease)  Chronic constipation  Diastolic dysfunction  Dyspnea  Erectile dysfunction  ESR raised  Fatigue  GERD (gastroesophageal reflux disease)  Hyperglycemia due to type 2 diabetes mellitus (disorder)  Hyperlipidemia  Hypertension  Inflamed seborrheic keratosis  Major depression  Obesity  Pancytopenia  Psoriasis  Weight loss  Procedure/Surgical History  ?Diabetic retinal eye exam (01/18/2022) ?Diabetic retinal eye exam (01/14/2021) ?Colonoscopy (10/18/2018) ?Excision of lesion right shoulder (12/2017) ?left heart catherization (09/11/2017) ?EGSD/Colonoscopy (06/14/2005) ?CABG x 3 - Coronary artery bypass grafts x 3 ?History of placement of stent in LAD coronary artery ?Myringotomy   Surgical History Internal  10/18/2018    Colonscpy Snare Tmr Polyp Lsn    09/12/2017    Coronary Artery Bypass Graft      Medications   Home Medications (18) Active  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  Amaryl 4 mg oral tablet 4 mg = 1 Tablet, Orally, BID  aspirin 325 mg oral tablet 325 mg = 1 Tablet, Orally, Daily  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  bisacodyl 5 mg oral delayed release tablet 10 mg = 2 Tablet, PRN, Orally, Daily  Blood Glucose Meter E11.65 Use as directed, Other, Unscheduled  Blood Glucose Test Strips Check daily, Other, Daily, e11.65 90 day supply tests once daily  clotrimazole-betamethasone cream 1 App, Topical, BID, 1%/0.05%  Jardiance 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  Lancets Check daily, Other, Unscheduled, e11.65 Dispense QS 90 days  melatonin 6 mg = 2 Tablet, PRN, Orally, At Bedtime  metFORMIN 1000 mg oral tablet 1,000 mg = 1 Tablet, Orally, BID, E11.65  metoPROLOL succinate 25 mg oral tablet, extended release 25 mg = 1 Tablet, Orally, Daily  Ozempic (1 mg dose) 4 mg/3 mL subcutaneous solution 1 mg, Subcutaneous, Weekly, Dispense 1 month supply  Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  Shingrix intramuscular injection 0.5 mL, IM, ONCE  Viagra 100 mg oral tablet 100 mg = 1 Tablet, PRN, Orally, Daily  Zyrtec 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 11/10/22 00:00:00 TO 11/11/22 18:21:49  None Reported  PRN Medications (0600 - 0559) from 11/10 - 11/11  None Reported  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired, Work/School description: TOOL AND DYE MAKER.   Home/Environment   DIVORCED, 1 CHILD, Lives with Alone.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Breast cancer...: Mother.  CAD (coronary atherosclerotic disease)...: Father.  COPD (chronic obstructive pulmonary disease)...: Sister.  EtOH - Alcohol: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 2.3 k/cumm Low (11/11/22 13:53:00)  RBC: 1.56 million/cumm Low (11/11/22 13:53:00)  Hgb: 5.6 GM/dL Critical (11/11/22 13:53:00)  Hct: 16.3 % Critical (11/11/22 13:53:00)  MCV: 105 fL High (11/11/22 13:53:00)  MCH: 36.1 pg High (11/11/22 13:53:00)  MCHC: 34.5 GM/dL (11/11/22 13:53:00)  RDW: 19.5 % High (11/11/22 13:53:00)  Platelet: 68 k/cumm Low (11/11/22 13:53:00)  MPV: 9.7 fL (11/11/22 13:53:00)  Neutrophils %: 31 % (11/11/22 13:53:00)  Lymphocytes %: 52 % (11/11/22 13:53:00)  Monocytes %: 6 % (11/11/22 13:53:00)  Eosinophils %: 9 % (11/11/22 13:53:00)  Basophils %: 1 % (11/11/22 13:53:00)  Absolute Neutrophil: 0.7 k/cumm Low (11/11/22 13:53:00)  Absolute Lymphocyte: 1.2 k/cumm (11/11/22 13:53:00)  Absolute Monocyte: 0.1 k/cumm (11/11/22 13:53:00)  Absolute Eosinophil: 0.2 k/cumm (11/11/22 13:53:00)  Absolute Basophil: 0 k/cumm (11/11/22 13:53:00)  Reticulocyte Count: 1.2 % (11/11/22 09:23:00)  Absolute Retic Number: 20 k/cumm Low (11/11/22 09:23:00)  Sed Rate: >120 High (11/11/22 09:23:00)  Chemistry:  Sodium SerPl QN: 133 mmol/L Low (11/11/22 13:58:00)  Potassium SerPl QN: 4.1 mmol/L (11/11/22 13:58:00)  Chloride SerPl QN: 100 mmol/L (11/11/22 13:58:00)  Carbon Dioxide SerPl QN: 19 mmol/L Low (11/11/22 13:58:00)  Anion Gap: 14 mmol/L High (11/11/22 13:58:00)  BUN SerPl QN: 22 mg/dL High (11/11/22 13:58:00)  Creatinine SerPl QN: 0.91 mg/dL (11/11/22 13:58:00)  Estimated GFR (CKD-EPI, no race): 90 mL/min/1.73m2 (11/11/22 13:58:00)  Estimated CRCL (CG): 84 mL/min (11/11/22 13:58:00)  Glucose SerPl QN: 190 mg/dL High (11/11/22 13:58:00)  Calcium Total SerPl QN: 9.4 mg/dL (11/11/22 13:58:00)  Alkaline Phos SerPl QN: 73 Units/L (11/11/22 13:58:00)  ALT SerPl QN: 8 Units/L (11/11/22 13:58:00)  AST SerPl QN: 10 Units/L Low (11/11/22 13:58:00)  Bilirubin Total SerPl QN: 1 mg/dL (11/11/22 13:58:00)  Total Protein SerPl QN: 7.1 GM/dL (11/11/22 13:58:00)  Albumin SerPl QN: 4.9 GM/dL (11/11/22 13:58:00)  Troponin-I High Sensitivity: 4 ng/L (11/11/22 13:58:00)  BNP Pl QN: 21 pg/mL (11/11/22 13:58:00)  Gluc-Strip, POC: 200 mg/dL High (11/11/22 13:31:00)  pH Bld Venous QN: 7.37 (11/11/22 13:54:00)  PCO2 Bld Venous QN: 30 mmHg Low (11/11/22 13:54:00)  PO2 Bld Venous QN: 41 mmHg (11/11/22 13:54:00)  Base Excess Bld Venous: -7 mmol/L Low (11/11/22 13:54:00)  Bicarb Bld Venous Calc: 17 mmol/L Low (11/11/22 13:54:00)  O2 Sat Bld Venous Calc: 74 % (11/11/22 13:54:00)  Patient Temperature: 37 DegC (11/11/22 13:54:00)  TSH 3rd Gen SerPl QN: 3.07 mcU/mL (11/11/22 09:23:00)  Coagulation:  PT: 14.6 seconds High (11/11/22 13:58:00)  INR: 1.27 High (11/11/22 13:58:00)  All Other Labs:  Specimen Type Occult Blood: Stool (11/11/22 16:02:00)  Occult Blood Stool: Positive Abnormal (11/11/22 16:02:00)  ABO Rh: O Neg (11/11/22 13:54:00)  IAT Interp: Neg (11/11/22 13:54:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 11/11/2022 17:54 - CT Chest Abdomen and Pelvis W/ IV Contr  IMPRESSION:1.  No CT evidence for malignancy in the chest, abdomen, or pelvis,as clinically queried.2.  Linear and groundglass opacities in the upper lobes, middle lobe,and lung bases are nonspecific but may reflect an inflammatory orinfectious process if the patient has respiratory symptoms.Otherwise, these could represent chronic changes.Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discussthis case further can contact1. For after-hours or emergency department cases.                Signature Line Electronically Signed on 11/11/22 19:19 ________________________________________________________