Gastroesophageal laceration-hemorrhage syndrome Other shock without mention of trauma Intestinal disaccharidase deficiencies and disaccharide malabsorption Tobacco use disorder
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
Hematemesis
 
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy (EGD)
 
History of Present Illness:
Mr. ___ is a ___ year old male with lactose intolerance who 
presented to ED with abdominal pain and hematemesis since the 
night prior to admission. He reports that he ate ___ food 
and a slice of pizza on ___ at ~5pm. At ~10 pm he reports 
onset of crampy epigastric pain with occasional epigastric 
burning pain that was relieved only by laying on his side. He 
took peptobismol which improved the pain, and had a normal bowel 
movement. At ~1am he woke up and had an episode of forceful 
vomiting during which he vomited ___ times, the last time he 
vomited about ___ cup of bright red blood. He went back to bed 
and woke up hours later and drank water because he felt 
dehydrated, and this caused him to vomit again, this time his 
vomited had dried blood more similar to coffee grounds. At this 
time he also had a loose, brown, non-bloody bowel movement. 
Finally, at ~5am he again drank water which prompted a third 
episode of vomiting coffee ground material. Patient endorses 
drinking coffee, and having ___ drinks of alcohol approximately 
twice per week. He denies recent NSAID use, and reports using 
NSAIDs ___ month about 2 pills each time.

In the ED, initial VS were 99.2 122 153/90 16. Received 2L NS 
with improvement noted in his tachycardia, NG lavage showed 
bright red blood and clots which did not clear after >300cc 
output. He additionally received a DRE which was heme negative. 
NG tube was removed while in the ED. Patient was started on IV 
PPI and GI was consulted. Patient was transferred to floor 
pending GI consult. Transfer VS 97.7 89 142/70 16 100%RA

One review of systems, he endorsed abdominal pain, nausea, 
vomiting, hematemesis and diarrhea as detailed in HPI.
He denied fever, chills, night sweats, headache, vision changes, 
rhinorrhea, congestion, cough, shortness of breath, chest pain,  
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.  
All other 10-system review negative in detail. 

On arrival to the floor, patient reports mild ongoing abdominal 
pain. Denies lightheadedness or palpitations. No additional 
acute symptoms.

 
Past Medical History:
- Lactose intolerance (keeps a lactose free diet) 
- Tonsillectomy and arytenoidectomy ___ years old)
- Wisdom tooth extraction ___ years old)
 
Social History:
___
Family History:
-Father, aged ___, suffers from Diverticular Disease for ___ years 
which has been refractory with well maintained diet and 
hydration. Gallbladder removed for unspecified reasons.
-Mother, aged ___, suffers from GERD and "thyroid problems." Has 
had recurrence of breast cancer 3 times with 2x being treated 
with chemotherapy and radiation and the ___ recurrence being 
treated with full mastectomy, all in same breast.
-Grandmother (maternal) Passed from stomach cancer in early ___
-Grandfather: died from myocardial infarction
-2 Brothers, aged ___ and ___, no medical conditions
No family history of bleeding disorders. 
 
Physical Exam:
ADMISSION PHYSICAL EXAM:  
VS 98.9   130/80   96(up to 120s on tele when ambulatory)   18  
97%RA
GEN Alert, oriented, no acute distress  
HEENT NCAT MMM EOMI sclera anicteric, OP clear  
NECK supple, no JVD, no LAD  
PULM Good aeration, CTAB no wheezes, rales, ronchi  
CV RRR normal S1/S2, no mrg  
ABD soft NT ND normoactive bowel sounds, no r/g  
EXT WWP 2+ pulses palpable bilaterally, no c/c/e  
NEURO CNs2-12 intact, motor function grossly normal  
SKIN no ulcers or lesions  

DISCHARGE PHYSICAL EXAM
Tmax 100.0 Tc 99.0 BP 120/73 (117-160/63-80) HR 83 (83-97) RR 20 
(___) O2sat 99%RA (97-99%RA)
General: Alert, oriented, cooperative, in no acute distress  
HEENT: NCAT, MMM, PERRLA, EOMI, anicteric sclerae, OP clear  
Neck: supple, no JVD, no palpable lymphadenopathy  
Pulm: Good aeration, CTAB without wheezes, rales, or ronchi  
Cor: RRR, normal S1, S2, no MRG  
Abdomen: soft, non-tender, non-distended, no rebound or 
guarding, no palpable hepatosplenomegaly, positive bowel sounds
Extremities: WWP, 2+ radial and dorsalis pedis pulses 
bilaterally, no C/C/E  
Skin: No ulcers or lesions noted

 
Pertinent Results:
___ 07:25AM BLOOD WBC-6.1 RBC-4.70 Hgb-14.6 Hct-42.0 MCV-89 
MCH-31.0 MCHC-34.7 RDW-12.5 Plt ___
___ 03:35PM BLOOD WBC-9.0 RBC-4.39* Hgb-13.8* Hct-39.3* 
MCV-90 MCH-31.4 MCHC-35.1* RDW-12.4 Plt ___
___ 10:00AM BLOOD WBC-13.4* RBC-4.90 Hgb-15.3 Hct-43.5 
MCV-89 MCH-31.2 MCHC-35.1* RDW-12.6 Plt ___
___ 06:00AM BLOOD WBC-12.2* RBC-5.08 Hgb-16.0 Hct-44.2 
MCV-87 MCH-31.6 MCHC-36.2* RDW-12.3 Plt ___

___ 06:00AM BLOOD Neuts-90.8* Lymphs-3.8* Monos-4.1 Eos-0.8 
Baso-0.4

___ 06:00AM BLOOD ___ PTT-27.7 ___

___ 07:25AM BLOOD Glucose-94 UreaN-6 Creat-0.8 Na-139 K-3.6 
Cl-102 HCO3-27 AnGap-14
___ 06:00AM BLOOD Glucose-127* UreaN-15 Creat-0.9 Na-137 
K-4.2 Cl-102 HCO3-25 AnGap-14

___ 06:00AM GFR = >75 

___ 03:35PM BLOOD ALT-44* AST-23 LD(LDH)-130 AlkPhos-61 
TotBili-1.1

___ 07:25AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9

___ 03:35PM BLOOD Albumin-3.9

___ CHEST (PA & LAT): FINDINGS:  PA and lateral radiographs 
of the chest demonstrate clear lungs without focal consolidation 
concerning for pneumonia, pleural effusion or pneumothorax.  The 
pulmonary vasculature is not engorged.  The cardiac silhouette 
is normal in size.  The mediastinal and hilar contours are 
within normal limits.  There is no evidence of 
pneumomediastinum.  The trachea is midline.  The visualized 
upper abdomen is unremarkable. IMPRESSION:  No acute 
cardiopulmonary pathology, specifically no evidence of 
pneumomediastinum. 

___ 11:30:00 AM EGD Report: IMPRESSION: Localized 
erythema in the gastroesophageal junction possibly consistent 
with healed erosion or MW tear(biopsy). Erythema in the fundus 
compatible with gastritis. Mild erythema in the antrum 
compatible with gastritis (biopsy). Normal mucosa in the whole 
duodenum. Otherwise normal EGD to third part of the duodenum. 
RECOMMENDATIONS: Follow up biopsy results from antrum and 
esophagus. Hematemesis most likely related to ___ tear 
from retching. Would recommend daily PPI, advancing diet as 
tolerated, and observation. Continue recs of inpatient consult 
team.

___ Pathology Tissue: GI BX'S (2 JARS): A. Gastroesophageal 
junction biopsy: Squamous epithelium, no diagnostic 
abnormalities recognized. Gastric type mucosa, no intestinal 
metaplasia identified. 
B. Antrum biopsy: No diagnostic abnormalities recognized.

 
Brief Hospital Course:
___ male presents with acute onset of abdominal pain, 
nausea, vomiting, diarrhea and hematemesis.

#Hematemesis:
He does not have clear risk factors for upper GI bleed. He 
reports drinking normal amounts of coffee, denies recent or 
heavy NSAID use, although he does report drinking ___ drinks 
approximately twice a week. There was no history or symptoms 
consistent with PUD, GERD, or H. pylori as the presentation 
appears to have been acute over one to two days. He denies 
family history of bleeding or clotting disorders. Differential 
considered included bleeding ulcer ___ tear vs AVM. 
Given the extent of blood loss with evidence of early 
hemorrhagic shock including tachycardia on presentation, GI was 
consulted and performed an urgent EGD for evaluation which 
showed localized erythema in the gastroesophageal junction 
consistent with healed erosion or ___ tear, erythema 
consistent with gastritis in the antrum and fundus, and 
otherwise wnl to third part of duodenum. History and EGD 
findings were most consistent with ___ tear. Biopsies 
from antrum and GE junction returned grossly normal without 
diagnostic abnormalities. Patient received Pantoprazole 40 mg IV 
while in ED. He was kept on IV pantoprazole and switched to 
omeprazole 40 mg PO daily the evening after EGD. His diet was 
advanced following the procedure, and he tolerated a regular 
diet well prior to discharge. His vital signs remained normal 
and stable throughout his hospitalization, and he did not 
experience any further episodes of vomiting or hematemesis. Per 
GI recs, we discharged him on a two week course of omeprazole 40 
mg PO daily. We set up follow-up with his PCP in two weeks. 
Patient was advised to avoid fatty foods, caffeine, alcohol, 
spicy foods and anything that could irritate his stomach.

#Hemorrhagic shock - no hypotension
He presented with tachycardia and orthostatic symptoms without 
blood pressure drop (headache, mild dizziness on rising from 
bed). He received 2L NS in ED with good heart rate response. 
Upon arrival to floor heart rate was trending back up and 
increased >120 with standing on several occassions. He underwent 
urgent EGD which did not reveal active bleeding. He received an 
additional 1L bolus of NS on transfer to the floor, and was 
maintained on ___ continuous at 75-125 ml/hr while he diet 
was advanced to a regular diet. He was maintained on telemetry, 
which was only notable for several non-sustained, asymptomatic 
episodes of tachycardia upon standing and walking. His vital 
signs were monitored throughout and he never developed 
hypotension, or other signs or symptoms of hypovolemia. 
Hematocrit was trended 44.2-->43.5-->39.3-->42.0 on ___, 
___, and ___ respectively. Two 18 gauge 
peripheral IVs were maintained throughout his hospitalization, 
as well as active type and crossmatch.
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY 

 
Discharge Medications:
1. Omeprazole 40 mg PO DAILY Duration: 14 Days 
RX *omeprazole 40 mg 1 capsule(s) by mouth Daily Disp #*14 
Capsule Refills:*0
2. Multivitamins 1 TAB PO DAILY 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
___ Tear
Upper GI Bleed

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Dear Mr. ___,

You were treated in the hospital for bleeding your GI tract. You 
underwent endoscopy of your upper GI tract which showed evidence 
of irritation of the stomach lining. There was an area of 
irritation where the stomach and esophagus meet which was most 
likely the source of your bleeding.  You have been placed on a 
medicine to suppress acid production in your stomach. You should 
continue to take this until your follow up appointment with your 
new primary care physician in two weeks.  You had biopsies taken 
from your stomach during the endoscopy. The results of your 
biopsies were normal without diagnostic abnormalities. You can 
follow up with your primary care physician regarding the 
results.
 
Followup Instructions:
___

{'Abdominal pain': ['Gastroesophageal laceration-hemorrhage syndrome'], 'Hematemesis': ['Gastroesophageal laceration-hemorrhage syndrome'], 'Nausea': ['Gastroesophageal laceration-hemorrhage syndrome'], 'Vomiting': ['Gastroesophageal laceration-hemorrhage syndrome'], 'Tachycardia': ['Other shock without mention of trauma'], 'Orthostatic symptoms': ['Other shock without mention of trauma'], 'Lactose intolerance': ['Intestinal disaccharidase deficiencies and disaccharide malabsorption'], 'Alcohol use': ['Tobacco use disorder']}