Hospital Medicine Admission History & Physical Patient:  DOB:  MRN:  Date: 8/3/2022 Room: 03/03   Chief Complaint:  Melena   History Of Present Illness:  Patient is a 61 y.o. female with a history of melanosis been present since yesterday. Patient states it persisted today she has this on and off but states usually resolve but it persisted today has had increased weakness fatigue no nausea no vomiting denies abdominal cramping or pain patient with a history of AVMs as well as colonic polyps in the past patient also on chronic Coumadin therapy for valve replacement seen in return trip being admitted for further evaluation and care patient also tested positive for Covid she is asymptomatic from this no cough no nausea no vomiting denies sick contacts she is vaccinated but is not boosted   Medical/Surgical/Family/Social History:   Past Medical History:  Patient  has a past medical history of Allergic rhinitis, Anemia, Aortic stenosis, Arthritis, Asthma, Back problem, Blood transfusion, without reported diagnosis, Chronic kidney disease, Colon polyp, Community acquired pneumonia, COPD (chronic obstructive pulmonary disease), Depression, Esophageal reflux, Former smoker, History of recurrent UTIs, OTHER MEDICAL (g-2 p-2), Knee injuries, Migraine, Morbid obesity with BMI of 40.0-44.9, adult, Nausea alone, Neuropathy, Osteoarthrosis, unspecified whether generalized or localized, unspecified site, Other chronic pain, Sepsis, unspecified, Sleep apnea, and Sprain (2018).   She has no past medical history of Cancer, Diabetes mellitus, or Osteoporosis.   Past Surgical History:  Patient's  has a past surgical history that includes Hx Cervical Discectomy; Hx Cone Biopsy, Cervix; Hx Other Surgical History; Hx Tonsillectomy; Hx Cystectomy; Hx Polypectomy; Hx Broken/Fx Bones; Hx Eye Surgery; Hx Joint Replacement (Bilateral); Hx Capsule Endoscopy (N/A, 08/06/2015); Hx Colonoscopy (N/A, 08/06/2015); Hx Colonoscopy (08/06/2015); Hx EGJ (N/A, 06/04/2015); Hx Colonoscopy (N/A, 06/04/2015); Hx Colonoscopy (N/A, 06/04/2015); Hx Colonoscopy (N/A, 06/04/2015); PICC Line Insertion (N/A, 10/29/2013); Hx Colonoscopy (N/A, 12/13/2012); Hx Rectal Exam (N/A, 02/02/2012); Hx Proctosigmoidoscopy, Rigid, Intraoperative (N/A, 02/02/2012); Hx Capsule Endoscopy (N/A, 01/30/2012); Hx Colonoscopy (12/19/2011); Hx Colonoscopy (12/19/2011); Hx Colonoscopy (N/A, 12/02/2011); Hx Colonoscopy (N/A, 12/02/2011); Hx Colonoscopy (12/02/2011); Hx Cholecystectomy; Left heart cath (N/A, 9/30/2020); Hx Teeth Restorations And Extractions (N/A, 10/2/2020); Hx Aortic Valve Replacement (N/A, 10/5/2020); Hx Transesophageal Echocardiogram (N/A, 10/5/2020); Hx Swan-Ganz Insertion (Right, 10/5/2020); Hx Arterial Line Insertion (Left, 10/5/2020); Hx Swan-Ganz Insertion (Right, 10/5/2020); Hx Coronary Artery Bypass Graft; Joint Aspiration Knee (Right, 12/2/2020); Ultrasound Guidance (N/A, 12/2/2020); Arthrogram - knee (N/A, 12/2/2020); Hx EGJ (N/A, 2/22/2021); Hx Colonoscopy (N/A, 2/22/2021); Hx Colonoscopy (N/A, 2/23/2021); Hx Colonoscopy (N/A, 2/23/2021); Hx EGJ (N/A, 12/10/2021); Hx EGJ (12/10/2021); and Hx EGJ (N/A, 12/10/2021).   Family History:   Patient's family history includes Alzheimer's Disease in her mother; Cancer in her father, maternal grandfather, and paternal grandfather; Diabetes in her mother; Epilepsy in her mother; Heart Disease in her father and mother; Heart Failure in her father; Hypertension in her father; Liver Disease in her maternal uncle; Stroke in her mother.      Social History:  She  reports current alcohol use.  She  reports no history of drug use.  She  reports that she quit smoking about 11 years ago. She has a 25.00 pack-year smoking history. She has never used smokeless tobacco.  Social History   Social History Narrative ? Not on file     Allergies:  Augmentin [amoxicillin-pot clavulanate], Lortab [hydrocodone-acetaminophen], Methadone, and Nsaids (non-steroidal anti-inflammatory drug)   PTA Medications:   Prior to Admission Medications Prescriptions Last Dose Informant Patient Reported? Taking? Budesonide-Formoterol (SYMBICORT 160-4.5 MCG) 160-4.5 mcg/Actuation inhaler     No No Sig: Take 2 Puffs by inhalation Every 12 hours. DULoxetine (CYMBALTA) 60 mg DR capsule     No No Sig: Take 1 Capsule by mouth Twice a day. HYDROcodone-acetaminophen (NORCO) 7.5-325 mg per tablet     No No Sig: Take 1 Tablet by mouth Three times a day as needed for Pain for up to 30 days. Do not fill until  6/8/22 Nebulizer & Compressor For Neb Devi   Self Yes No Sig: Nebulizer, dx asthma Pregabalin (LYRICA) 150 mg Capsule     Yes No Sig: Take 200 mg by mouth Three times a day. QUEtiapine (SEROQUEL) 25 mg     No No Sig: Take 2 Tabs by mouth At bedtime. Take two tablets at bedtime SUMAtriptan (IMITREX) 50 mg     No No Sig: TAKE 1 TABLET BY MOUTH 1 TIME ONLY FOR 1 DOSE acetaminophen (TYLENOL) 500 mg tablet   Self Yes No Sig: Take 500 mg by mouth Every 4 hours as needed. albuterol (ALBUTEROL) 2.5 mg /3 mL (0.083 %) nebulization     No No Sig: Take 3 mL by nebulization Three times a day as needed for Wheezing. albuterol (VENTOLIN HFA) 90 mcg/Actuation inhaler     No No Sig: Take 2 Puffs by inhalation Every 4 hours as needed. atorvastatin (LIPITOR) 20 mg tablet     No No Sig: Take 1 Tablet by mouth At bedtime. colchicine (COLCRYS) 0.6 mg tablet     No No Sig: Take 1 Tablet by mouth Daily as needed. docusate sodium (COLACE) 100 mg capsule     No No Sig: Take 1 Capsule by mouth Twice a day. ferrous sulfate 325 mg (65 mg iron) DR tablet     No No Sig: Take 1 Tablet by mouth Twice a day with meals. fluticasone propionate (FLONASE) 50 mcg/Actuation nasal spray     No No Sig: Spray 2 Sprays in nose Daily. furosemide (LASIX) 20 mg tablet     No No Sig: Take 1 Tablet by mouth Once Daily. hydrOXYzine pamoate (VISTARIL) 25 mg capsule     No No Sig: Take 1 Capsule by mouth Twice a day as needed. ipratropium (ATROVENT) 0.06 % nasal spray     No No Sig: Spray 2 Sprays in nose Every 12 hours as needed. levocetirizine (XYZAL) 5 mg tablet     No No Sig: Take 5 mg by mouth Daily. levothyroxine (SYNTHROID) 25 mcg tablet     No No Sig: Take 1 Tablet by mouth Once Daily. linaCLOtide (LINZESS) 72 mcg capsule     No No Sig: Take 1 Capsule by mouth Daily. magnesium oxide (MAG-OX) 400 mg tablet     No No Sig: Take 1 Tablet by mouth Twice a day. metoprolol (TOPROL-XL) 25 mg XL tablet     No No Sig: Take 0.5 Tabs by mouth Once Daily. montelukast (SINGULAIR) 10 mg tablet     No No Sig: Take 1 Tablet by mouth Every evening. multivitamin w/iron-FA-calcium-mins (THERA-M) tablet     Yes No Sig: Take 1 Tab by mouth Daily. pantoprazole (PROTONIX) 40 mg DR tablet     No No Sig: Take 1 Tablet by mouth Once Daily. potassium chloride (KLOR-CON) 20 mEq tablet     No No Sig: Take 1 Tablet by mouth Once Daily. When taking lasix sertraline (ZOLOFT) 50 mg tablet     No No Sig: Take 1 Tablet by mouth Once Daily. tiZANidine (ZANAFLEX) 4 mg tablet     No No Sig: Take 1 Tablet by mouth Every 8 hours as needed for Muscle spasms. warfarin (COUMADIN) 7.5 mg tablet     No No Sig: Warfarin 7.5 mg daily except for 11.25 mg on Tuesday,Thursday, and Saturday or as direcred  Facility-Administered Medications: None     Review of Systems: A 10 Point Comprehensive review of systems performed all were negative except for above mentioned in HPI   Physical Exam: Blood pressure 109/63, pulse 52, temperature 98.2 °F (36.8 °C), temperature source Oral, resp. rate 13, height 5' 8" (172.7 cm), weight 106.6 kg (235 lb), last menstrual period 02/24/2016, SpO2 98 %. General - NAD, appears stated age, well-nourished  Eyes - PERLA, conjunctivae normal, no icterus  Nose - no rhinorrhea  Ears - TM clear bilaterally  Mouth - moist, no post erythema  Neck - no lymphadenopathy, JVD, or thyromegaly  Lungs - CTA bilaterally  Cardiovascular - RRR, no murmur, rub or gallop GI - Soft, non-tender, non-distended, normal bowel sounds, no guarding, no masses  Neuro - AAOx3, speech fluent, face symmetric, no focal or sensory deficit noted  Psych - appropriate judgement, insight, behavior, affect; no agitation  Skin - warm and dry, no rashes  Extremities - negative for edema    Data Review:   CBC: Lab Results Component Value Date   WBC 8.2 08/03/2022   HGB 11.7 (L) 08/03/2022   HCT 36.4 08/03/2022   MCV 72.2 (L) 08/03/2022   CMP: Lab Results Component Value Date   SODIUM 134 (L) 08/03/2022   POTASSIUM 4.4 08/03/2022   MAGNESIUM 1.6 (L) 07/13/2022   PHOSPHORUS 3.7 01/29/2016   CHLORIDE 98 (L) 08/03/2022   CO2 19 (L) 08/03/2022   GLUCOSE 114 (H) 08/03/2022   BUN 18 08/03/2022   CREATININE 1.5 (H) 08/03/2022   CALCIUM 8.6 08/03/2022   TBILIRUBIN 1.0 08/03/2022   ALP 77 08/03/2022   AST 32 08/03/2022   ALBUMIN 4.0 08/03/2022   INR: Lab Results Component Value Date   INR 6.6 (HH) 08/03/2022   INR 6.7 03/07/2022     ABG's:  No results for input(s): PHBLOOD, PCO2ARTERIAL, PO2, HCO3, O2SATURATION, O2, MODE in the last 72 hours.       Imaging: X-Ray:kub pending   Assessment/Plan:   Problems: Active Problems:   S/P AVR (aortic valve replacement) with On-X valve (10/5/20)   Melena   AKI (acute kidney injury)   COVID   Chronic kidney disease (CKD), stage III (moderate)         DVT ppx - coumadin held   Plan #1 melena patient with a history of AVMs and colonic polyps Protonix IV check H&H every 8 hours consult GI for evaluation patient is supratherapeutic INR will hold Coumadin for now   #2 essential hypertension blood pressure on the low side we'll hold blood pressure medications for now   #3 acute kidney injury on chronic kidney disease stage III a baseline 1.3 will hold Lasix plan IV fluid trial check urinalysis   #4 Covid positive patient is asymptomatic with this will monitor in isolation continue vitamin C vitamin D zinc melatonin patient vaccinated ×2 hold on remdesivir for now   #5 history of aortic valve replacement with on x valve patient is supratherapeutic will hold Coumadin for now   Greater than 35 minutes spent on historical and physical examination. --- Patient was discharged home in fair condition