Chief Complaint Vomitting blood X 9 hours. Tackycardic; HX of GI bleed.

Coming from
Levindale.
History of Present Illness Mr. Richardson is a 59 Y.O. male with a past medical history of HTN,
GERD, Anemia, Schizoaffective disorder (admitted to Levindale psych facility two weeks ago)
and upper GI bleeds. Presented to the ED with coffee ground emesis on 5/8/10 from Levindale.

History was obtained from the patient, ED, EMS and Levindale facility. He was admitted to
Levindale over two weeks ago for Schizoaffective disorder. While there, patient had been
experiencing nausea/vomiting on and off since 5/1/18. According to facility notes, the vomiting
was likely self induced because he reported auditory hallucinations that told him to make himself
throw up. Yesterday, when he was sitting on the couch watching TV he felt lower abdominal
pain that became diffuse, 5/10, constant and non radiating. No aggravations/alleviating factors.
He then felt nauseated and started to vomit. According to facility it was coffee ground in nature.
He was then transferred to ED at UMH with active coffee-ground emesis.

Pt has a history of multiple upper GI bleeds. He denied any fever, chills, dysphagia or cough.
Denied any SOB, chest pain, orthopnea. Denied any dyspnea. Denied any blurry vision or
palpitations. Denied any diarrhea, constipation. No history of syncope, pre syncope. Pt was not
on any anticoagulant medication, and no bright red vomitus or per rectum. Pt has no history of
IV drug abuse, blood transfusion, alcohol abuse liver disease or weight loss.

In the ED pts vitals were T 36, HR 128, RR 22, BP 192/124, SpO2 100% RA. Patient arrived
tachycardic, with a heart rate 125 bpm, hypertensive, active vomiting with coffee-ground emesis,
350 CC coffee ground contents obtained via NGT. Pt did not vomit after insertion of NGT. Was
given Zofran IV, Pepcid IV and Labetalol IV given for hypertension. Labs showed elevated
fingerstick 180mg/dL, low Hgb 10gm/dL. CXR showed no significant abnormalities. EKG
showed no significant abnormalities. Troponin not elevated <0.015. GI was consulted in the ED
and no intervention was needed at that time since patient was hemodynamically stable. Rectal
exam performed-dark stool present.

Patient was transferred to IMCU for upper GI bleed and HTN for further management. Review
of Systems negative unless stated in the HPI Physical Exam
Vitals & Measurements T: 36 °C (Rectal) HR: 107(Monitored) RR: 14 BP: 174/94 SpO2:
100% WT: 80 kg Oxygen Delivery Device: Room air (05/08/18 20:38:25)
Pain Assessment Primary: Numeric Pain Score: 8 (05/08/18 19:02:53)
Pain Present: Yes actual or suspected pain (05/08/18 19:02:53) General: Well-developed
gentleman, in no acute distress
HEENT: normocephalic, moist mucous membranes.
lung: clear to auscultation, no wheeze , no crackles.
CVS: Tachycardic, normal rhythm, normal S1, S2, no murmur, palpable peripheral pulses, no
lower extremities edema bilaterally.
Abdominal: Soft, lower abdominal pain tenderness, audible bowel sounds.
Musculoskeletal: Normal range of motion, muscle bulks are symmetrical bilaterally.
Neuro: AAO ×1-2 which is his baseline.
Psych: No suicidal ideation.
Assessment/Plan .
1. Upper GI bleeding K92.2 This is most likely in the setting of secondary to self induced–
emesis that can cause his upper GI bleed today. Patient hemoglobin today is 10. No other signs
of bleeding.
This could be secondary to gastritis/esophagitis in the setting of history of GERD and history of
upper GI bleed. Patient being pantoprazole at home and no history of nonsteroidal anti-
inflammatory medications at home. We do not have data regarding if the patient had previous
upper endoscopy or colonoscopy.
Less likely secondary to liver disease and esophageal varices given no history of alcohol abuse,
AST/ALT and PT levels within normal range.
Was given 1 L of IV fluids in the ED along with 20 mg of famotidine.
Plan:
-Continue with IV fluids 150 cc/h
-Protonix 40 mg IV twice daily
-Monitor CBC
-Repeat FOBT
-If bleeding recurs consider upper GI endoscopy.
-Follow-up with GI recommendation
2. Hypertensive urgency I16.0 Pt has a long standing history of HTN. No evidence of end organ
damage.
Last BP in facility was 180/130, HR 130. In the ED, pt presented with a BP of 192/124.
He was given 10 mg of labetalol IV push. So on the floors he was given 5 mg of labetalol IV
push then another dose of 10 mg IV push and he was started on his carvedilol home dose 12.5
twice daily.
At home at home, patient is on carvedilol 12.5 twice daily, and hydralazine 50 twice daily.
Plan:
-Decrease the blood pressure gradually with the goal of decrease of blood pressure 25% in the
next 6 hours.
-Monitor blood pressure
3. Abdominal pain R10.9 Physical exam patient has suprapubic tenderness, otherwise benign
abdominal exam. No CVA tenderness.
We are unable to obtain from the history of the patient has dysuria urgency or any symptoms of
urinary tract infection that might cause this suprapubic tenderness.

Plan:
Urine analysis
Will monitor urine output if decreased will consider bladder scan
4. Anemia D64.9 Hb level in ED 10.0. Likely in the setting of upper GI bleed. It is unclear what
is his baseline hemoglobin. However hemoglobin about a week ago in the facility was around
7.5.
This could be in the setting of mixed iron/B12 deficiency since patient has been taking iron and
cyanocobalamin at home.
We do not have enough data about his last colonoscopy and if the patient had previous upper
endoscopy. No signs of bleeding.
Plan:
-Monitor CBC
-Transfuse if hemoglobin less than 7, if the patient is symptomatic or if actively bleeding.
5. Leukocytosis D72.829 White blood cells 12.9 could be reactive to his upper GI bleed and
hypertension
At this time it doesnot seem like secondary to infection, no fever. Patient has no signs of
infection. Chest x-ray did not show any active infection.
Plan:
Monitor CBC
Monitor signs of infection
6. Schizoaffective disorder F25.9 History of schizoaffective, patient has been in the facility for
over 2 weeks. Has been on fluphenazine 5 mg and Remeron 15 mg nightly, and benztropine 0.5
BID.
Plan:
Resume his home meds.
#Diet -NPO
#Code -Full based on MOST from the facility
#DVT ppx -Hold in the setting of bleeding
#Dispo -IMCU2
Problem List/Past Medical History Ongoing Ambulatory dysfunction Anemia At risk of venous
thromboembolus Chronic GERD Constipation GI bleeding HTN (hypertension) Psychosis
Schizoaffective disorder Vertigo Historical

Medications Inpatient benztropine, 0.5 mg= 1 tab, PO, 2x/day carvedilol, 12.5 mg= 1 tab, PO,
2x/day fluPHENAZine, 5 mg= 1 tab, PO, q12h labetalol, 20 mg= 4 mL, IV Push, q1h, PRN
normal saline 1,000 mL, 1000 mL, IV Protonix IV, 40 mg, IV Push, 2x/day Remeron, 15 mg= 1
tab, PO, Nightly Home benztropine 0.5 mg oral tablet, 0.5 mg= 1 tab, PO, 2x/day Carafate 1 g
oral tablet, PO, 3x/day + PM on empty stomach carvedilol 12.5 mg oral tablet, 12.5 mg= 1 tab,
PO, 2x/day Colace 100 mg oral capsule, 100 mg= 1 cap, PO, 2x/day, PRN cyanocobalamin,
1000 mcg= 1 tab, PO, Daily ferrous sulfate ( Iron), 325 mg= 1 tab, PO, 3x/day fluPHENAZine 5
mg oral tablet, 10 mg= 2 tab, PO, Nightly fluPHENAZine 5 mg oral tablet, 5 mg= 1 tab, PO,
Daily, In the morning Haldol injection, 2 mg, IM, q6h haloperidol 2 mg oral tablet, 2 mg= 1 tab,
PO, q6h hydrALAZINE 50 mg oral tablet, 100 mg= 2 tab, PO, 2x/day meclizine 25 mg oral
tablet, PO, 4x/day, PRN MiraLax, 17 gm, PO, Daily pantoprazole 40 mg oral delayed release
tablet, 40 mg= 1 tab, PO, Daily Remeron 15 mg oral tablet, 15 mg= 1 tab, PO, Nightly Senokot,
8.6 mg= 2 tab, PO, Nightly, PRN Vitamin D3 (cholecalciferol), PO, Daily Allergies NKA Social
History Smoking Status - 05/08/2018
Never smoker Lab Results CBC
WBC: 12.9 k/uL High (05/08/18 16:45:00 EDT)
Hgb: 10 gm/dL Low (05/08/18 16:45:00 EDT)
Hct: 31.3 % Low (05/08/18 16:45:00 EDT)
Platelet: 342 k/uL (05/08/18 16:45:00 EDT)

BMP
Sodium Lvl: 137 mmol/L (05/08/18 16:53:00 EDT)
Potassium Lvl: 3.5 mmol/L (05/08/18 16:53:00 EDT)
Chloride: 98 mmol/L (05/08/18 16:53:00 EDT)
CO2: 24 mmol/L (05/08/18 16:53:00 EDT)
BUN: 24 mg/dL High (05/08/18 16:53:00 EDT)
Creatinine: 1.28 mg/dL (05/08/18 16:53:00 EDT)
Glucose Lvl Random: 180 mg/dL High (05/08/18 16:53:00 EDT)

Electrolytes
Calcium Lvl: 9.7 mg/dL (05/08/18 16:53:00 EDT)

LFTs (latest in last 72H):

05/08/2018 16:53
Total Protein: 8.1 gm/dL
Albumin Lvl: 3.8 gm/dL
AST: 11 units/L
ALT: 15 units/L
Bili Total: 0.6 mg/dL
Bili Direct: 0.14 mg/dL
Alk Phos: 72 units/L

Coag Panel
Platelet: 342 k/uL (05/08/18 16:45:00 EDT)
PT: 14.7 sec High (05/08/18 16:53:00 EDT)
INR: 1.2 (05/08/18 16:53:00 EDT)

SECOND PATIENT

Chief Complaint Pt presents to ED via EMS in respiratory distress. C/O chest

tightness/lightheadeness at this time. !1 duoneb/1 albuterol given pta.
History of Present Illness Ms. Chandler is a 53-year-old woman with history of COPD,
hypertension, substance use (cocaine), obesity. Presents to the ED complaining of progressive
worsening of shortness of breath and orthopnea for the past month with acute worsening in the
past 2 days.

Patient states that for the past 1-2 months she has had worsening dyspnea on exertion, she was
able to walk about 1-2 blocks and now she is only able to walk a few steps, she needs 2-3 pillows
to sleep, last time she used 1 was about 1-2y ago, she also states that her legs, especially left,
swell at the end of the day and improve with elevation. She endorses a chronic productive cough,
that has worsened over the past 1-2 months. She brings up grayish thick mucous, that has
increased in quantity, but characteristics have not changed.

States she has not been taking her medications, with exception of the nebulizer, for the past 3
weeks. She has a PCP, Dr. Speede, however has not seen him for over a year and has not gotten
refills for her medications. She has had multiple hospitalizations for similar episodes and the last
time she got medications was when she was hospitalized here in March. Previous Echo in
November shows EF 65%, normal diastolic function.

She believes this is all driven by her cocaine use and asks for help getting into rehab. She states
when she uses cocaine (2-3 times per week) she has chest pain, however, no pressure, no
palpitations, no syncope, no loss of consciousness.
Review of Systems Constitutional: No fevers, no chills, no night sweats, ~30lbs weight gain for
3-4 months. Hot and cold sweats for 1-2 months.
Eye: No change of vision, no eye pain, no visual problems, no diplopia, no blurry vision. Blurry
vision for 2 weeks.
ENMT: No ear pain, no nasal congestion, no sore throat
Gastrointestinal: Diarrhea for 2 weeks, 2 times per day, at times has normal stools.
Genitourinary: Has been urinating more for the past month.
Hema/Lymph: No bruising tendency, no swollen lymph glands
Endocrine: Increased thirst and cravings for ice, increased appetite for 1 month.
Musculoskeletal: + chronic back pain
Integumentary: No rash, no pruritus, no abrasions
Neurologic: no headache, no paresthesia, no limb weakness, Alert & oriented X 3
Psychiatric: History of depression not active or currently on treatment, no suicidal ideation. Used
to see psychiatrist, Dr. Jenssen, last time was 3-4 y ago, took medicine but does not remember
the treatment she was on.
Physical Exam
Vitals & Measurements T: 36.9 °C (Oral) HR: 74(Monitored) RR: 24 BP: 215/114 SpO2: 98%
WT: 103 kg Oxygen Delivery Device: BiPAP (05/10/18 12:12:00 EDT)
BP during encounter 171/84
Pain Assessment Primary: Numeric Pain Score: 0 (05/10/18 11:30:00 EDT)
Pain Present: No actual or suspected pain (05/10/18 11:19:00 EDT) General: Good general
appearance. Alert and oriented, no acute distress.
Eye: Pupils round, equal and reactive to light bilaterally. Sclera are non-icteric and the
conjunctiva are pink bilaterally.
HENT: Normocephalic, normal hearing, moist oral mucosa, no sinus tenderness. Oropharynx
clear, no erythema or exudates.
Neck: Supple, non-tender, no limitations in motion, no carotid bruits, no JVD, no
lymphadenopathy.
Lungs: No respiratory distress. Vesicular sounds present bilaterally. Lungs are clear to
auscultation. No crackles, no wheezes, no rhonchi.
Cardiovascular: Normal rate, regular rhythm, no murmurs, gallops or rubs. Distal pulses strong
and equal in all limbs.
Abdomen: Soft, supple, non-distended. No tenderness to palpation. Bowel sounds are present
and normal. No masses or organomegaly noted.
Musculoskeletal: Extremities are symmetrical with no gross deformity, no tenderness or
swelling. There is no peripheral edema.
Skin: Skin is warm and dry. No rashes or lesions.
Neurologic: Awake, alert, and oriented to person, place and time. No focal motor deficits.
Strength and sensation are intact.
Psychiatric: appropriate mood, affect, and thought. Speaks very fast.
Assessment/Plan 53yo woman presents with progressively increasing dyspnea on exertion and
orthopnea for the past 1 month that acutely worsened in the past 1-2 days. Diagnosed with acute
heart failure in the setting of hypertensive emergency with component of COPD.

1. Hypertensive urgency I16.0 Likely in the setting of medication non-adherence for the past 3
weeks. Presented with BP of 199/103 that increased to 211/106. Given 20 mg IV hydralazine in
the ED.
- Resume home lisinopril.
2. Acute CHF I50.9, Acute CHF I50.9 Likely in the setting of hypertensive emergency. Appears
euvolemic on exam. pro-BNP 6307, troponin peaked at 0.051. Chest x-ray demonstrates
interstitial lung markings, however they are described as being chronic, also cardiomegaly and
emphysematous changes.
- Received furosemide 60mg IV in the ED. We will not give additional diuresis at this time as
she appears euvolemic.
- Echocardiogram pending
3. COPD exacerbation J44.1 Patient presenting with shortness of breath, increased sputum
production and cough. No concern for infection at this time as she does not have fevers/chills,
WBC count is normal.
In the ED received duo nebs, 125 mg methylprednisolone.
- Duonebs
- O2 as needed for O2 between 88-93%
- BiPAP as needed
- Will not start antibiotics at this time
4. HTN (hypertension) I10, HTN (hypertension) I10 History of hypertension, lisinopril at home.
Has not been adherent to her medications in the past 3-4 weeks.
5. COPD (chronic obstructive pulmonary disease) J44.9 History of COPD. Follows with Dr.
Sloane. Last time she was hospitalized was sent home on oxygen. Has not followed up as
outpatient.
6. Tobacco user Z72.0 History of cigarette smoking.
- Nicotine patch
7. Substance abuse F19.10 Endorses cocaine use. States she wants to go to rehab. SBIRT
evaluated her in the ED and will follow up during hospitalization.
8. Pre-diabetes R73.03 HbA1c in Nov 2017 was 6.1, glucose in BMPs have been within normal
limits. Will not start sliding scale at this time.
Problem List/Past Medical History Ongoing Chronic back pain COPD (chronic obstructive
pulmonary disease) Diabetes mellitus HTN (hypertension) Obesity Substance abuse Tobacco
user Medications Inpatient
No active inpatient medications Home albuterol-ipratropium 2.5 mg-0.5 mg/3 mL NEB, 3 mL,
Neb, q6h, PRN, 3 refills Asmanex HFA 200 mcg/inh inhalation aerosol, Inhalation lisinopril 40
mg oral tablet, 40 mg= 1 tab, PO, Daily, Not taking oxyCODONE 5 mg oral TABLET, 5 mg= 1
tab, PO, q8h, PRN pravastatin 40 mg oral tablet, 40 mg= 1 tab, PO, Daily, Not taking
predniSONE 20 mg oral tablet, 40 mg= 2 tab, PO, Daily Stiolto Respimat 2.5 mcg-2.5 mcg
inhalation aerosol, 2 puff, Inhalation, q24h-int Allergies penicillin G sodium Social History
Recreational drugs: Cocaine, last time on Monday, uses 2-3 times per week. Started at age 23.
Was in Turk House, Marion House, graduated in 2013. Was clean for 4 years, relapsed in 2015.
Tobacco: 3 cigarettes while not high, if high with cocaine she smokes about 2-3 packs per day.
Started at age 12
Alcohol: wine coolers every other day. Last drink 5/9/18 PM. No history of alcohol withdrawal.
Family History Diabetes mellitus: Mother. Lab Results CBC
WBC: 6.2 k/uL (05/10/18 11:29:00 EDT)
Hgb: 15.6 gm/dL High (05/10/18 11:29:00 EDT)
Hct: 50.1 % High (05/10/18 11:29:00 EDT)
Platelet: 233 k/uL (05/10/18 11:29:00 EDT)

BMP
Sodium Lvl: 142 mmol/L (05/10/18 11:29:00 EDT)
Potassium Lvl: 3.9 mmol/L (05/10/18 11:29:00 EDT)
Chloride: 107 mmol/L (05/10/18 11:29:00 EDT)
CO2: 31 mmol/L High (05/10/18 11:29:00 EDT)
BUN: 15 mg/dL (05/10/18 11:29:00 EDT)
Creatinine: 0.9 mg/dL (05/10/18 11:29:00 EDT)
Glucose Lvl Random: 101 mg/dL (05/10/18 11:29:00 EDT)
Calcium Lvl: 8.3 mg/dL Low (05/10/18 11:29:00 EDT)

Troponin-I: 0.044 ng/mL (05/10/18 15:01:00 EDT)

Troponin-I: 0.051 ng/mL High (05/10/18 11:29:00 EDT)

Chief Complaint

History of Present Illness

65 YO male is on the floor for past 10 days with history of decompensated alcoholic cirrhosis
with ascites, multiple hospitalizations for anemia, Lower GI bleeding,got 7 blood transfusions at
floor and last was yesterday after that his Hb improved from 6.5 to 10 also got one platelet
transfusion before colonoscopy. EGD showed no varices . In colonoscopy mild oozing in the
sigmoid colon with friability and telangiectasias . His last colonoscopy in 2016 is positive for
multiple AVMs. Pt had episode of delirium 3 days back at night with delusions and hallucination
which was controlled by 1mg of Haldol. Yesterday during rounds he was really confused they
ordered Ammonia and it was high 35 and it was raised and lactulose 20mg/30ml was ordered for
this after this he had three bowel movements with no blood in it.ss

Around 7 PM yesterday he had bp of 193/94.They gave him nifedipine 30 mg followed by

hydralazine 20mg IV and again repeated nifedipine again and blood pressure dropped to 160 by
12:15am.At about 1230, a code stroke was called.At that time patient was encephalopathic and
not really responding and he was not able to follow command. he was having R sided shaky
movements of body with L eye turned medially and fixed and also she passed urine.Duration is 3
mins and resolved before they gave him 1 dose of Ativan. At that time his bp is in 197/101and
he became unconscious.Therefore an NIH score was not done. They called neurology and
CT scan was done and it revealed subarachnoid hemorrhage. After this Patient has been
transferred to the ICU.

Review of Systems

As above.

Physical Exam
Vitals & Measurements
T: 35.1 °C (Oral) TMIN: 35.1 °C (Oral) TMAX: 36.8 °C (Oral) HR: 57(Monitored) RR: 24
BP: 129/74 SpO2: 99% WT: 90.3 kg

Oxygen Delivery Device: Nasal cannula (06/28/18 01:00:00 EDT)

Oxygen Flow Rate: 2 L/min (06/28/18 01:00:00 EDT)

Pain Assessment
Primary: Numeric Pain Score: 0 (06/27/18 20:00:00 EDT) Non-Verbal Pain Scale: Score: 0
(06/28/18 00:50:00 EDT)
Pain Present: No actual or suspected pain (06/28/18 00:50:00 EDT)

General: Unconscious pt not oriented in time,place and person.

Eye: Pupils round, equal and reactive to light bilaterally. Conjunctiva is pale.
Neck: Supple, no carotid bruits, no JVD, no lymphadenopathy.
Lungs: No respiratory distress. Lungs are clear to auscultation and percussion with good air
exchange. Non-labored respiration. No crackles, no wheeze
Heart or Cardiovascular: Normal rate, regular rhythm, no murmur, gallop or rub. There is no
peripheral edema. No jugular venous distension. Distal pulses strong and equal in all limbs.
Abdomen: Soft, supple, non-distended. No tenderness to palpation. Bowel sounds are present
and normal. No masses or organomegaly noted.
Musculoskeletal: No gross deformity of extremities. no tenderness or swelling.
Skin: Skin is warm, dry and pale. No rashes or lesions.
Neurologic: AAO X 0. NIH =30, GCS 6-7, Not opening his eyes,corneal reflex and gag reflex
present,responding inconsistently to pain, flaccid body .

Assessment/Plan
1.Subarachnoid Hemrrhage:
Patient is Hypertensive and thrombocytopenic along with decompensated alcoholic
cirrhosis,anemia, and lower GI Bleeding.

Plan :
Ordered prolactin level, lactic acid 2.5, CPK, Ammonia 39, CMP.
Monitor bp countinously.
Frequent neuro checks.
Transfused platelets.
Started Narcan drip with goal of 125.
Consult NEUROSURGERY.
MRI planned.
2. Lower GI bleed K92.2
Resolved. No further episodes of GI bleeding over the past 24 hours. Most likely in setting of
cirrhosis and portal HTN. Multiple episodes of melena and bright blood in stool in this
admission. Colonoscopy: showed mild oozing in the sigmoid colon with friability and
telangiectasias, with prior colonoscopy in 2016 demonstrating multiple AVMs.

Plan:
-Continue to serially monitor CBC
-GI was consulted:
Capsule endoscopy with indication of Hgb drop. Patient was scheduled for tomorrow.
Continue nadolol
check INR daily

2. Hepatic encephalopathy K72.90

New. Patient is disoriented and having disorganized behavior. Given his cirrhosis and ammonia
of 59 (6/25). Asterixis is present.

Plan:
-monitor level of consciousness
-Lactulose 20 mg tid titrate to 2-3 loose bowel movement

3. Symptomatic anemia D64.9

Stable. Most likely due to GI bleeding. Also hypersplenism in the setting of cirrhosis and
chronic disease anemia are considered. Right now patient does not have symptoms attributable to
anemia.

-Serially monitor CBC

-Drop in Hgb 7.5 --> 6.5. One unit of pack cell was infused. Hbg after transfusion= 6.7 and in
morning it was 10.
-check for symptoms chest pain, dyspnea, weakness
-Transfuse pRBC in case of Hbg<7 or symptomatic blood loss, 2 units of FFP, 1 unit of platelet

4. Anasarca R60.1
Resolving. Generalized edema secondary to decompensated cirrhosis.

Plan:
Decrease Lasix dose to 40mg p.o. daily
sprinolactone 50mg daily
strict I/Os control (last fluid balance: -633cc)
daily weights
Check Bun/Cr daily

5. Stage 3 chronic kidney disease N18.3

Stable. Based on previous records from VA the average of Cr is 1.8-2. Cr has not increased in
this admission.