Age: 64.0
Sex: M
Vaccine: COVID19
Symptoms: Haemoglobin decreased, Hepatic cirrhosis, Hepatic fibrosis, Intervertebral disc disorder, Peripheral swelling
Clinical narrative: Physician Discharge Summary   Patient ID: Age: 65 y.o. Admit Date: 8/1/2022  9:04 PM Discharge Date:  8/4/22 Unit:  Admitting Physician:  Discharge Physician:    Discharge Diagnosis: Principal Problem:   Acute blood loss anemia Active Problems:   Hematemesis   Rectal bleed   COVID-19 virus infection       HPI: Patient is a 65 y.o. male who signed out AMA earlier today for GI bleed admission. States he was wrong and will stay this time. Hgb has dropped to 7.7 now. He also Covid-19 infection. States he is till vomiting blood.   Hospital Course: Patient is a 65-year-old male who was admitted to hospital on 8/1/2022 for a GI bleed after signing out AMA earlier that day. He returned to admit this was mistaken his hemoglobin had dropped again. It was found to be 7.7 and he was also found to have Covid not taking infection. After admission, gel was consult at performed upper endoscopy where grade 3 esophageal varices were found and banded. Following the procedure, his hemoglobin had remained stable. He was started on Rocephin 1 g IV daily as well as IV Protonix twice a day. For the last few days, his hemoglobin has been stable and he denies any bleeding at this time. His Covid not pain is not causing any respiratory symptoms and the patient is now wishing to go home. GI recommends follow-up in 4 weeks with EGD to further assess. He will be started on iron replacement therapy as well as propranolol 10 mg 3 times a day to assist with his portal vein pressures. Patient is now aware that he has cirrhosis of the liver and will continue to follow-up with this. He will be mechanically soft diet for the next 7 days. His IV Protonix is being switched to by mouth 40 mg twice daily and his Rocephin IV has been switched to Cefdinir twice daily for the next 2 days to total 5 days of treatment. Otherwise, he is now stable for discharge to follow-up with PCP in one week in GI in 4 weeks     Important follow-up reminders: ========================= EGD 4 weeks with GI follow-up     Physical Exam on the Date of Discharge: Physical exam:  General Appearance: alert, NAD  Neck: no JVD, no LN enlargement  Lungs: clear, no wheezing  Heart: RRR, S1 S2 heard  Abdomen / GI: soft, non-tender, BS+ Extremities / musculoskeletal:  edema, no synovitis  Skin: no rash, dry skin  Neuro: follows commands, moves extremities      Consults:   IP CONSULT TO GASTROENTEROLOGY IP CONSULT TO SOCIAL WORK   Significant Diagnostic Studies:    endoscopy: gastroscopy: Varices Found and Banded      Disposition:  home   Discharge Condition:  good   Discharge Medications and Orders:   Current Discharge Medication List   START taking these medications   Details cholecalciferol, vitamin D3, 4,000 unit Tab Take 4,000 Units by mouth Once Daily. Indications: COVID-19 Positive Qty: 30 Tablet, Refills: 0   Associated Diagnoses: Liver fibrosis   ferrous sulfate 325 mg (65 mg iron) DR tablet Take 1 Tablet by mouth Once Daily. Qty: 30 Tablet, Refills: 0   Associated Diagnoses: Anemia   cefdinir (OMNICEF) 300 mg capsule Take 1 Capsule by mouth Twice a day for 2 days. Qty: 4 Capsule, Refills: 0   Associated Diagnoses: GI bleed   propranoloL (INDERAL) 10 mg tablet Take 1 Tablet by mouth Three times a day. Qty: 90 Tablet, Refills: 1   Associated Diagnoses: GI bleed     CONTINUE these medications which have CHANGED   Details pantoprazole (PROTONIX) 40 mg DR tablet Take 1 Tablet by mouth Twice a day. Qty: 90 Tablet, Refills: 1   Associated Diagnoses: Gastroesophageal reflux disease without esophagitis     CONTINUE these medications which have NOT CHANGED   Details multivitamin with folic acid (THERA) tablet Take 1 Tablet by mouth Once Daily.   glecaprevir-pibrentasvir (MAVYRET) 100-40 mg Tab Take 3 Tabs by mouth Once Daily for 60 days. Qty: 180 Tablet, Refills: 0   Associated Diagnoses: Chronic hepatitis C without hepatic coma; Liver fibrosis   methocarbamoL (ROBAXIN-750) 750 mg tablet Take 1 Tablet by mouth Twice a day as needed. Qty: 60 Tablet, Refills: 2   Associated Diagnoses: Lumbar disc disease   spironolactone (ALDACTONE) 25 mg tablet Take 1 Tablet by mouth Once Daily. Qty: 90 Tablet, Refills: 1   Associated Diagnoses: Swelling of lower extremity