Age: 69.0
Sex: F
Vaccine: COVID19, FLU3
Symptoms: Faeces discoloured, Full blood count, Gastrointestinal haemorrhage, Glomerular filtration rate normal, Haematemesis
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on December 10, 2024 15:39    Verified By: MD on December 10, 2024 18:09    Encounter Info: Hospital, Observation, 12/10/24 - 12/11/24    * Final Report *          History of Present Illness/Subjective     69 year old female with Pmhx: HTN,  DM II, myeloproliferative disorder on hydroxyurea presents via private vehicle due to black stools that started 4 days ago.   Patient was seen and evaluated While still in the ER with husband present by the bedside. She states 4 days ago, she had vomiting x 1 and that it was coffee-ground in nature.  Since that time she has had no further vomiting but she endorses mild nausea and decreased appetite.  The next day after vomiting started, she endorsed that she has multiple episodes of tarry colored stool.  She denies any abdominal pain, diarrhea, shortness of breath, chest pain, hematuria or any other form of bleeding.  She denies having any prior episode of bleeding.  Last colonoscopy was July 2023 and last upper GI endoscopy was more than 30 years ago.  No history of gastric or duodenal ulcers.  She is not on any anticoagulation however she reports that she has been on meloxicam for many years, more than 30 years for bilateral knee pain.  She notes that she took meloxicam 15 mg every day until 3 years ago when it was changed to 15 mg every other day.  She denied any prior complaints from the medication.    She takes low-dose aspirin daily as well   She endorsed feeling much better than on presentation.  Denied any further vomiting, nausea or black stools   In the ER  Vital signs  Blood pressure 116/60, heart rate 91, SpO2 100% on room air  Was given pantoprazole 40 mg x 1 and IV fluid  GI was consulted and recommended admission and endoscopy the next day   Labs  WBC 6.6, hemoglobin 9.2 baseline hemoglobin is 12 to 13 g per DL, platelet 256, PT/INR 12.3/1.05, sodium 140, potassium 4.6, bicarb 26, BUN/creatinine 25/0.76, LFTs unremarkable, lactic venous 3.1  Occult blood stool positive  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 Vitals & Measurements most recent past 24 hours  T: 36.8 °C (Oral)  BP: 126/61  BP: 119/73(Supine)  BP: 112/60(Sitting)  BP: 106/59(Standing)  HR: 89 (Peripheral)  RR: 16  SpO2: 99%  Oxygen Therapy: Room air  WT: 75.50 kg (WFC)    Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    75.5 kg    12/10/24    Patient Height  Current Height:    149.9 cm    12/10/24         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      1. GI bleed   K92.2    2. Anemia   D64.9    1. GI bleed   K92.2  69-year-old woman presenting with multiple episodes of dark stool and 1 episode of coffee-ground emesis concerning for ongoing GI bleed, slow bleed resulting in anemia as baseline hemoglobin is 12 to 13 g per DL.  Hemoglobin on presentation is 9. ??NSAID induced  Vital signs are currently stable and GI was consulted in ER and recommended to admit with scope in the morning.  ???????No immediate need of NG tube since patient is not vomiting today.  Will reconsider if patient starts to vomit again  She feels well   Maintain 2 large-bore peripheral IVs or at least 1 large-bore with 18-gauge.  Every 4 hours CBC.  will obtain STAT Hb if pt has an event of acute bleeding  Transfuse if hemoglobin less than 7 g/dL or actively bleeding.  IV Protonix 40 mg twice daily   GI has been consulted and will scope tomorrow  NPO from MN  Telemetry monitoring repeat Hb pending  Will monitor patient closely  Hold meloxicam and other NSAIDs.   3. Myeloproliferative disorder   D47.1  on hydroxyurea  Outpatient follow-up   4. Hyperlipidemia, mixed   E78.2  Chronic.  Resume home meds.  Obtain lipid profile   5. Hypertension   I10  Blood pressure is currently soft.  In view of ongoing GI bleed, will hold blood pressure medications for now   6. Type II diabetes mellitus   E11.9  .CDA protocol  f/u Hba1c   Greater than 35 minutes total with greater than 50% of time face-to-face with patient reviewing course, plan of care, and in care coordination  Code Status   None Recorded   Chronic Problem List    B12 deficiency  Colonic polyp  Diffuse diabetic maculopathy with mild nonproliferative retinopathy without macular edema  H/O bone density study  Health care maintenance  History of ductal carcinoma in situ (DCIS) of breast  Hyperlipidemia, mixed  Hypertension  Long-term insulin use  Long-term use of high-risk medication  Lung nodule  Mild non proliferative diabetic retinopathy  Mild nonproliferative diabetic retinopathy of both eyes  Multiple thyroid nodules  Myeloproliferative disorder  Needs flu shot  Neuropathy due to medical condition  Nonproliferative diabetic retinopathy of both eyes  Obesity due to excess calories  Ovarian cyst  Polycythemia  Type 2 diabetes mellitus with hyperglycemia  Type 2 DM w/mild nonproliferative diabetic retinop w/macular edema  Type II diabetes mellitus  Vitamin D deficiency  Procedure/Surgical History  ?Diabetic retinal eye exam (10/07/2024) ?Diabetic retinal eye exam (08/21/2024) ?Diabetic retinal eye exam (07/10/2024) ?Diabetic retinal eye exam (05/08/2024) ?Diabetic retinal eye exam (02/21/2024) ?Colonoscopy (07/17/2023) ?Eye examination (03/30/2022) ?Mammogram - screening (12/04/2021) ?Diabetic retinal eye exam (09/26/2021) ?DNC (04/05/2017) ?Hysteroscopy (04/05/2017) ?Mammogram (10/23/2014) ?Breast Lumpectomy (06/13/2013) ?Colonoscopy (06/10/2013) ?DNC (05/22/2007) ?STRESS ECHO (05/18/2007) ?Cesarean Section (1981) ?Diabetic retinal eye exam   Surgical History Internal  07/17/2023    Colonoscopy Diagnostic/Screen    MD  04/05/2017    Hysteroscopy Diagnostic     MD  Medications   Home Medications (18) Active  Accu-Chek Fastclix Lancets Not Applicable, Other, Unscheduled, Use to check blood sugar BID. Dx: E11.65  Accu-Chek Guide Blood Glucose Meter (ONCE) Not Applicable, Other, Unscheduled, Use to check blood sugar. E11.65  Accu-Chek Guide Test Strips Not Applicable, Other, Unscheduled, Use to check blood sugar BID. Dx: E11.65 90 day supply  Aspirin Low Dose 81 mg, Orally, Daily  Culturelle , Orally, Daily  cyanocobalamin 2500 mCg sublingual tablet 2,500 mCg = 1 Tablet, Sublingually, QAM  Hydrea 500 mg oral capsule 1,000 mg = 2 Capsule, Orally, Daily  latanoprost 0.005% ophthalmic solution 1 Drop, Eyes, Both, Every PM  lisinopril 20 mg oral tablet See Instructions, TAKE ONE TABLET BY MOUTH DAILY  meloxicam 15 mg oral tablet See Instructions, TAKE ONE TABLET BY MOUTH every other day for joint pain  metFORMIN 500 mg oral tablet 1,000 mg = 2 Tablet, Orally, BID  metoPROLOL succinate 25 mg oral tablet, extended release 25 mg = 1 Tablet, Orally, Daily  Ozempic 4 mg/3 mL (1 mg dose) subcutaneous solution 1 mg, Subcutaneous, Weekly  Pen Needles - Insulin (5mm x 31G) See Instructions, use to inject insulin BID, Dx: E11.65. 90 day supply  PreserVision oral capsule 1 Capsule, Orally, QAM  Semglee (insulin glargine-yfgn) (Prefilled Pen) 100 units/mL subcutaneous solution 70 Units, Subcutaneous, BID, d/c lantus  Singulair 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Vitamin D3 1000 intl units oral capsule 4 capsules, Orally, QAM  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 12/09/24 00:00:00 TO 12/10/24 15:39:34  Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 12/10/24 15:15:00)  PRN Medications (0600 - 0559) from 12/09 - 12/10  None Reported  Allergies   NKA  Social History    Alcohol   Current, 1-2 times per year   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Married, 1 child - employed    Nutrition/Health   Caffeine intake amount: 5-6 servings per day.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Aneurysm: Father.  Diabetes mellitus: Brother.  Diabetes mellitus type 2: Mother.  Prediabetes: Brother and Brother.  Thyroid disorder: Brother.   Deceased Family Member(s)  Relationship: Father, Age: Unknown  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 6.4 k/cumm (12/10/24 14:28:00)  RBC: 2.2 million/cumm Low (12/10/24 14:28:00)  Hgb: 9 GM/dL Low (12/10/24 14:28:00)  Hct: 26.3 % Low (12/10/24 14:28:00)  MCV: 120 fL High (12/10/24 14:28:00)  MCH: 40.8 pg High (12/10/24 14:28:00)  MCHC: 34.1 GM/dL (12/10/24 14:28:00)  RDW: 14.1 % (12/10/24 14:28:00)  Platelet: 240 k/cumm (12/10/24 14:28:00)  MPV: 6.7 fL Low (12/10/24 14:28:00)  Neutrophils %: 78 % (12/10/24 14:28:00)  Lymphocytes %: 17 % (12/10/24 14:28:00)  Monocytes %: 3 % (12/10/24 14:28:00)  Eosinophils %: 2 % (12/10/24 14:28:00)  Basophils %: 1 % (12/10/24 14:28:00)  Absolute Neutrophil: 5 k/cumm (12/10/24 14:28:00)  Absolute Lymphocyte: 1.1 k/cumm (12/10/24 14:28:00)  Absolute Monocyte: 0.2 k/cumm (12/10/24 14:28:00)  Absolute Eosinophil: 0.1 k/cumm (12/10/24 14:28:00)  Absolute Basophil: 0 k/cumm (12/10/24 14:28:00)  Chemistry:  Sodium SerPl QN: 140 mmol/L (12/10/24 14:28:00)  Potassium SerPl QN: 4.6 mmol/L (12/10/24 14:28:00)  Chloride SerPl QN: 108 mmol/L (12/10/24 14:28:00)  Carbon Dioxide SerPl QN: 26 mmol/L (12/10/24 14:28:00)  Anion Gap: 6 mmol/L (12/10/24 14:28:00)  BUN SerPl QN: 25 mg/dL High (12/10/24 14:28:00)  Creatinine SerPl QN: 0.76 mg/dL (12/10/24 14:28:00)  Estimated GFR (CKD-EPI, no race): 85 mL/min/1.73m2 (12/10/24 14:28:00)  Estimated CRCL (CG): 62 mL/min (12/10/24 14:28:00)  Glucose SerPl QN: 78 mg/dL (12/10/24 14:28:00)  Calcium Total SerPl QN: 9.3 mg/dL (12/10/24 14:28:00)  Alkaline Phos SerPl QN: 43 Units/L (12/10/24 14:28:00)  ALT SerPl QN: 15 Units/L (12/10/24 14:28:00)  AST SerPl QN: 24 Units/L (12/10/24 14:28:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (12/10/24 14:28:00)  Total Protein SerPl QN: 6.7 GM/dL (12/10/24 14:28:00)  Albumin SerPl QN: 4.1 GM/dL (12/10/24 14:28:00)  Lactate Venous Pl QN: 3.1 mmol/L High (12/10/24 14:28:00)  Gluc-Strip, POC: 96 mg/dL (12/10/24 13:24:00)  Coagulation:  PT: 12.3 seconds (12/10/24 14:28:00)  INR: 1.05 (12/10/24 14:28:00)  All Other Labs:  Specimen Type Occult Blood: Stool (12/10/24 14:08:00)  Occult Blood Stool: Positive Abnormal (12/10/24 14:08:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.             Signature Line Electronically Signed on 12/10/24 18:09  ________________________________________________________ MD