Medical Text: Admission Date:  [**2150-4-17**]              Discharge Date:   [**2150-4-21**]

Date of Birth:  [**2090-5-19**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
coffee ground emesis

Major Surgical or Invasive Procedure:
EGD
Right IJ CVL


History of Present Illness:
Mr. [**Known lastname 52368**] is a 59M w HepC cirrhosis c/b grade I/II esophageal
varices and portal gastropathy (last EGD [**3-/2150**]), who p/w
coffee-ground emesis and melena x2 days.
.
Pt was in his USOH until about 2-3 days PTA, when he began
experiencing intermittent nausea. He had 2-3 episodes of
coffee-ground emesis and 1 episode of tarry black stool in the
morning of admission. He reports some lightheadedness which is
not new, but denies frank hematemesis, BRBPR, abdominal pain,
fever, chills, significant increases in his abdominal girth. He
denies drinking or medication non-compliance. He also reports
taking naproxen for back pain 2-3 times a day in the recent
past.
.
In the ED, his vitals were 97.4, 93/41, 69, 18, 100% on RA. He
was given 4L NS IV, protonix 40mg IV, started on an octreotide
drip. He had guaiac positive brown stool on rectal exam. He was
seen by the liver fellow in the ED who felt this was unlikely a
variceal bleed and recommended work up for infection. An NG tube
was attempted, however, patient was unable to tolerate it in the
ED. Abdominal ultrasound was done which showed a patent portal
vein, scant ascites but not enough to tap. BP dropped to 80/34,
pt transferred to MICU for hemodynamic monitoring.
.
In the MICU, pt was given 3 pRBC, Hct bumped from 21.3 to 28.
Started on norepinephrine gtt for a few hours, but BP
stabilized. On transfer to the floor, remains hemodynamically
stable. Feels good, denies tarry or bloody BMs, emesis.

Past Medical History:
HCV Cirrhosis (tx with interferon x2 with no response)
Portal Gastropathy
Grade II Esophageal varices
HTN

Social History:
He lives alone.  He is drinking alcohol, usually one session per
week. He has four to five drinks per session. He was told to
completely abstain from alcohol, effective as of today. He
smokes about 20 cigarettes per day.


Family History:
NC

Physical Exam:
ON ADMISSION:
VS: T95.9 HR 71 BP 83/36 RR 11  96% 2L NC
Gen: somnolent, oriented x 3, unable to assess for asterixis
given somnolence
HEENT: PERRLA, EOMI
Neck: supple, JVP at angle of jaw (fluid bolus running wide
open)
CV: RRR s1 s2 no appreciable murmur
Lungs: CTAB
Abd: distended, non tender, no rebound or guarding, bowel sounds
positive
Ext: 1+ pitting edema bilaterally
Skin: warm, diaphoretic, no rash or lesions noted

Pertinent Results:
LABS ON ADMISSION:
[**2150-4-17**] 01:30PM BLOOD WBC-17.9*# RBC-2.78* Hgb-8.5* Hct-26.0*
MCV-94 MCH-30.6 MCHC-32.7 RDW-20.6* Plt Ct-186
[**2150-4-17**] 01:30PM BLOOD Neuts-61.2 Lymphs-28.8 Monos-6.9 Eos-2.2
Baso-0.9
[**2150-4-17**] 02:13PM BLOOD PT-17.7* PTT-34.5 INR(PT)-1.6*
[**2150-4-17**] 01:30PM BLOOD Glucose-92 UreaN-51* Creat-1.3* Na-131*
K-5.7* Cl-104 HCO3-21* AnGap-12
[**2150-4-17**] 01:30PM BLOOD ALT-126* AST-260* LD(LDH)-426*
AlkPhos-157* TotBili-3.3*
[**2150-4-17**] 06:41PM BLOOD Calcium-7.5* Phos-3.8 Mg-1.9
.
LABS ON DISCHARGE:
[**2150-4-21**] 05:00AM BLOOD WBC-10.7 RBC-2.94* Hgb-9.6* Hct-27.0*
MCV-92 MCH-32.6* MCHC-35.6* RDW-21.2* Plt Ct-110*
[**2150-4-21**] 05:00AM BLOOD PT-17.4* PTT-35.6* INR(PT)-1.6*
[**2150-4-21**] 05:00AM BLOOD Glucose-84 UreaN-15 Creat-1.0 Na-132*
K-4.4 Cl-99 HCO3-25 AnGap-12
[**2150-4-21**] 05:00AM BLOOD ALT-113* AST-210* AlkPhos-111
TotBili-3.6*
[**2150-4-21**] 05:00AM BLOOD Calcium-8.1* Phos-3.8 Mg-1.7
.
OTHER LABS:
[**2150-4-18**] 06:25AM BLOOD CK-MB-9 cTropnT-<0.01
[**2150-4-17**] 06:41PM BLOOD CK-MB-11* MB Indx-4.9 cTropnT-<0.01
[**2150-4-17**] 01:30PM BLOOD Lipase-85*
.
URINE:
[**2150-4-17**] 11:01PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2150-4-17**] 11:01PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2150-4-17**] 11:01PM URINE RBC-63* WBC-7* Bacteri-NONE Yeast-NONE
Epi-<1
.
MICROBIOLOGY:
Blood, urine cultures - negative
H.pylori serum antibody - negative
.
CARDIOLOGY:
.
TTE ([**4-18**]):
Conclusions
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. Left ventricular systolic function
is hyperdynamic (EF>75%). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Hyperdynamic LV systolic function. Mild mitral
regurgitation. Moderate pulmonary artery systolic hypertension.

.
EKG ([**4-17**]):
Sinus rhythm
Prolonged QT interval is nonspecific but clinical correlation is
suggested
No previous tracing available for comparison
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 160 96 462/479 70 55 52
.
GI:
EGD ([**4-20**]):
1. Varices at the lower third of the esophagus and middle third
of the esophagus.
2. Erythema and erosion in the antrum and pylorus compatible
with non-steroidal induced gastritis.
3. Bleeding from a pyloric ulcer in the pylorus compatible with
non-steroidal induced ulcer (injection, thermal therapy).
4. Normal mucosa in the duodenum.
5. Otherwise normal EGD to third part of the duodenum
.
RADIOLOGY:
.
CXR ([**4-17**]):
The prominent bulge to the right heart border could be due to
pericardial
effusion, _____ cyst, and enlarged right atrium. There is no
mediastinal
vascular engorgement to suggest cardiac tamponade. Pulmonary
vasculature is normal. The lungs are clear and there is no
pleural effusion. Overall heart size is normal. Right jugular
line ends at the junction of the
brachiocephalic veins. No pneumothorax or pleural effusion.
.
ABD U/S ([**4-17**]):
IMPRESSION:
1. No son[**Name (NI) 493**] evidence for portal venous thrombosis. Portal
vein flow is hepatopetal and wall-to-wall.
2. No significant ascites. A sliver of perihepatic ascites.
3. Persistent coarsened echotexture of the liver consistent with
known
history of cirrhosis.
4. Splenomegaly

Brief Hospital Course:
Mr [**Known lastname 52368**] is a 59M w HCV cirrhosis w grade II esophageal varices
admitted w coffee-ground emesis and melena concerning for UGIB,
s/p MICU stay for hypotension.
.
# UGIB: Pt did not have any more bleeds while in hospital. EGD
revealed erythema and erosion in the antrum and pylorus
compatible with non-steroidal induced gastritis. Pt did remember
taking increased doses of naproxen for backache. Started on
pantoprazole 40mg PO BID for one week with repeat endoscopy
scheduled in one week ([**4-30**]). Recommended to take tylenol (max
daily dose of 2gm) for pain instead of NSAIDs. Blood pressure
meds were held at first, given MICU admission for hypotension,
but were restarted on discharge.
.
# HCV Cirrhosis: appears to be progressing to liver failure,
with elevated INR at 1.6, decreased albumin at 2.6, tbili
slightly elevated at 3.6, and chronic LE edema. Pt was continued
on prophylactic medications.
.
# FULL CODE

Medications on Admission:
FUROSEMIDE 20mg daily
LISINOPRIL 10 mg daily
SPIRONOLACTONE 100 mg daily

Discharge Medications:
1. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane PRN (as needed).
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**6-15**]
hours as needed: no more than 6 tablets of regular strength
tylenol per day.
8. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) for 1 weeks.
Disp:*qs * Refills:*0*
9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day for 1 weeks:
then take 1 tablet daily.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*qs * Refills:*0*
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Peptic ulcer
GI bleed

Discharge Condition:
asymptomatic

Discharge Instructions:
You were admitted for bleeding from an ulcer in your stomach.
This ulcer is at least partially caused by naproxen.  You should
stop taking naproxen and take only tylenol for pain.  You should
not take any NSAIDS for pain including ibuprofen, naproxen,
aleve, motrin, aspirin, toradol, or advil. It is okay to take
tylenol but do not take more than 4 extra strength tylenol a day
(2gram daily maximum).
.
The following medication changes were made:
Do not take naproxen
Take pantoprazole 40 mg twice daily for one week.  Then take 40
mg daily.
.
You are scheduled to get a repeat endoscopy next week.  Prior to
the procedure do not have anything to drink or eat after
midnight.
.
Please return to the ER if you have any chest pain,
lightheadeness, fever, chills, bloody or black stools or any
other concerning symptoms.

Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2150-4-30**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2150-4-30**]
1:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2150-5-7**] 11:00



Completed by:[**2150-4-24**]
ICD9 Codes: 2851, 5715, 4019