Hematemesis Opioid dependence uncomplicated Alcohol abuse uncomplicated Homelessness Other specified soft tissue disorders Nicotine dependence cigarettes uncomplicated
 
Name:  ___             Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
vancomycin / Thorazine / contact metal agent
 
Attending: ___.
 
Chief Complaint:
Hematemesis
 
Major Surgical or Invasive Procedure:
NONE
 
History of Present Illness:
___ undomiciled man with a history of hepatitis C, 
opioid use disorder, alcohol abuse who presented to the ED with 
1 day history of hematemesis. The patient reports one episode 2 
days prior of a couple tablespoons of blood which then occurred 
again morning of admission. He denies any blood in his stool or 
melena. He denies any chest or abdominal pain. He denies any 
shortness of breath. He also reports some bilateral leg swelling 
without pain, warmth, fevers which has been present for several 
weeks for which another hospital prescribed him Bactrim. 
  
In the ED, initial vitals were: 9 98.9 81 129/100 18 98% RA. 
Exam was notable for brown stool, guaiac negative, lower 
extremities with 2+ pitting edema and excoriations. Minimal 
erythema, no warmth. EKG SR, NA, NI, new TWI V4-V6.  Labs 
without significant anemia and overall stable. While there were 
no red flags in the ED, with stable VS, labs and no hematemesis 
in the ED given pulmonary vascular congestion on CXR, EKG 
changes compared with prior and no documented history of CHF, he 
was admitted for further workup. 
    
On the floor, he was initially ornery and requesting to leave 
AMA because he needed to use. He arrived in dirty urine and 
stool covered clothing and he was cleaned up. He reports feeling 
unwell, "like my body is deteriorating"
 
Review of systems:  
(+) Per HPI  
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies headache, sinus tenderness, rhinorrhea or 
congestion. Denies cough, shortness of breath. Denies chest pain 
or tightness, palpitations. Denies diarrhea, constipation or 
abdominal pain. No dysuria. Denies arthralgias or myalgias. 
Otherwise ROS is negative.

 
Past Medical History:
HCV
Bipolar disorder
Opioid Use Disorder with active IV heroin use (last used a few 
hours prior to admission) sometimes sniffs 
ETOH active

Surgical history:
Incision, drainage, and packing of left forearm abscess. ___
Lt tibial and Rt shoulder Fixation BWH ___

 
Social History:
___
Family History:
Unknown
 
Physical Exam:
ADMISSION PHYSICAL EXAM:  
Vitals: 98.2 PO 158 / 84 70 20 98 Ra  
Pain Scale: ___ 
General: Patient appears dishelved, unkempt and foul smelling. 
Alert, oriented and in no acute distress  
HEENT: Sclera anicteric, poor dentition
Neck: supple, JVP low, no LAD appreciated
Lungs: Clear to auscultation bilaterally, moving air well and 
symmetrically, no wheezes, rales or rhonchi appreciated  
CV: Regular rate and rhythm, S1 and S2 clear and of good 
quality, no murmurs, rubs or gallops appreciated
Abdomen: soft, non-tender, non-distended, normoactive bowel 
sounds throughout, no rebound or guarding
Ext: Bilateral ___ pitting up to knees 
Neuro: CN2-12 grossly in tact, motor and sensory function 
grossly intact in bilateral UE and ___, symmetric. Nodding off 
during exam
  
DISCHARGE PHYSICAL EXAM
General: Alert, oriented and in no acute distress  
HEENT: Sclera anicteric, poor dentition
Neck: supple, JVP low, no LAD appreciated
Lungs: Clear to auscultation bilaterally, moving air well and 
symmetrically, no wheezes, rales or rhonchi appreciated  
CV: Regular rate and rhythm, S1 and S2 clear and of good 
quality, no murmurs, rubs or gallops appreciated
Abdomen: soft, non-tender, non-distended, normoactive bowel 
sounds throughout, no rebound or guarding
Ext: Bilateral ___ pitting up to knees R > L.  Minimal / 
resolving erythema RLE, several scabbed over excoriations
Neuro: CN2-12 grossly intact, motor and sensory function grossly 
intact in bilateral UE and ___, symmetric. 
 
Pertinent Results:
Admission Labs:
___ 11:55PM BLOOD WBC-6.0 RBC-3.38* Hgb-11.4* Hct-33.8* 
MCV-100* MCH-33.7* MCHC-33.7 RDW-14.8 RDWSD-54.7* Plt ___
___ 11:55PM BLOOD Neuts-45.6 ___ Monos-12.7 Eos-1.7 
Baso-0.8 Im ___ AbsNeut-2.73# AbsLymp-2.33 AbsMono-0.76 
AbsEos-0.10 AbsBaso-0.05
___ 11:55PM BLOOD ___ PTT-33.9 ___
___ 11:55PM BLOOD Glucose-127* UreaN-11 Creat-0.6 Na-135 
K-3.5 Cl-96 HCO3-26 AnGap-17
___ 11:55PM BLOOD Lipase-28
___ 11:55PM BLOOD Albumin-3.6
___ 11:55PM BLOOD proBNP-140*
 
Imaging:
___ CHEST X-RAY: Low lung volumes, mild cardiomegaly, and 
central pulmonary vascular 
congestion. Right apical airspace opacity appears modestly more 
conspicuous as compared to the prior examination, and could be 
further evaluated by apical lordotic views if clinically 
indicated. 

___ CHEST X-RAY
FINDINGS:  
  
The previously described opacity at the right lung apex appears 
less 
conspicuous on apical lordotic views.  Some of the abnormality 
is due to 
deformity of the right clavicular head, and there may be 
additional bony 
deformity of the adjacent manubrium. 
  
IMPRESSION:  
No good evidence for clinically significant pulmonary or pleural 
abnormality 
at the right apex. 
  

 
Brief Hospital Course:
___ undomiciled man with a history of hepatitis C, 
opioid use disorder, alcohol abuse who presented to the ED with 
1 day history of hematemesis, one week history of R > L 
bilateral lower extremity edema, rib pain after sustaining rib 
fractures in assault, and hemoptysis. 

  
# Hematemesis vs Hemoptysis
Patient did not give a clear history - he reported vomiting up 
blood, but while inpatient, RN observed hemoptysis.  He reports 
a history of rib fractures secondary to assault.  He denies 
fevers, chills, weight loss, night sweats.  Because he also had 
concomitant R > L lower extremity edema, pulmonary embolism is 
possible.  Pulmonary infection, trauma, malignancy are also 
possibilities. I discussed this with the patient and ordered 
lower extremity ultrasound and CTA to evaluate further the 
source of bleeding.  He left the hospital against medical advice 
before this could be obtained.
  
# Bilateral lower extremity edema, R > L
Unclear etiology as well, while there is pulmonary vascular 
congestion on admission CXR his proBNP is normal and he has no 
symptoms of CHF.  Apparently had recent diagnosis of cellulitis 
and started treatment with antibiotics prescribed at ___.  
Patient reports negative LENIs.  Severe onycomycosis and 
excoriations from scratching on bilateral lower extremities 
predisposing to cellulitis.  As above, ordered LENIs, but 
patient left against medical advice before this could be 
obtained.

# Opioid Use Disorder
Unable to confirm methadone dose with Addiction ___ 
___ (___) before he left against medical advice.  He 
indicates 73mg Po Daily.
Patient reports ongoing daily heroin use, occasionally snorting 
heroin, despite being enrolled in methadone program.  Social 
work was consulted but was unable to see him before he left 
against medical advice

I had a frank discussion with the patient regarding his ongoing 
drug abuse - he stated he was interested in drug rehabilitation, 
and agreed to stay for further workup as outlined above.  
Shortly after our discussion, he told his nurse he was leaving 
against medical advice, and he walked out of the hospital before 
I could re-assess him and have a discussion of risks
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 73 mg PO DAILY 
(unable to verify with Addiction Treatment ___ 
- ___, where he reportedly obtains methadone)
 
Discharge Medications:
1.  Methadone 73 mg PO DAILY  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
OPIOD USE DISORDER
 
Discharge Condition:
LEFT AGAINST MEDICAL ADVICE
 
Discharge Instructions:
LEFT AGAINST MEDICAL ADVICE
 
Followup Instructions:
___

{'hematemesis': ['Hematemesis'], 'opioid use disorder': ['Opioid dependence', 'uncomplicated'], 'alcohol abuse': ['Alcohol abuse', 'uncomplicated'], 'homelessness': ['Homelessness'], 'soft tissue disorders': ['Other specified soft tissue disorders'], 'nicotine dependence': ['Nicotine dependence', 'cigarettes', 'uncomplicated']}