Blood in stool Anemia unspecified Gastric ulcer unspecified as acute or chronic without mention of hemorrhage or perforation without mention of obstruction Other specified gastritis without mention of hemorrhage Enthesopathy of hip region Long-term (current) use of aspirin
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
Melena, hematemesis
 
Major Surgical or Invasive Procedure:
___: EGD

 
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a h/o hip bursitis 
and hemorrhoids who presents with two days of black stool and 
hematemesis.  On ___, he began having loose, watery diarrhea 
that was "jet black" and several episodes of "black" emesis.  
Yesterday, he had two formed black BMs and no emesis.  Last BM 
was this morning and it remained black.  He denies hematochezia. 
 He reports headache, mild lightheadedness, and nausea but 
denies further emesis.  He denies fever/chills, anorexia, 
abdominal pain, chest pain, and shortness of breath.  Of note, 
___ has been taking 400-1200mg ibuprofen for the past week 
for his hip bursitis.  ___ went to his PCP ___ ___ and 
labs were notable for Hct 37.1 (down from 45 in ___.  Repeat 
Hct on ___ was 32, so he was told to go to the ED for 
evaluation.

In the ED, initial VS were T 99.8, HR 99, BP 136/79, RR 18, O2 
100% RA.  Labs were remarkable for Hct 34.5.  He was given 
pantoprazole 40mg IV and transferred to the medicine floor.
 
Past Medical History:
Hip bursitis - bilateral, on ibuprofen
Hemorrhoids - diagnosed by ___ in ___
 
Social History:
___
Family History:
Sister with ___ disease.
 
Physical Exam:
ADMISSION EXAM:
Vitals: T 98.2, BP 109/63, HR 67, RR 18, O2 100% RA  
General: AAOx3, pleasant, sitting comfortably in bed, NAD  
HEENT: Sclera anicteric, MMM, oropharynx clear  
Neck: Supple, JVP not elevated, no LAD  
Lungs: Breathing comfortably without accessory muscle use, clear 
to auscultation bilaterally, no wheezes, rales, rhonchi  
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
Abdomen: +BS, soft, non-tender, non-distended, bowel sounds 
present, no rebound tenderness or guarding, no organomegaly  
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Skin: No rashes or lesions noted  
Neuro:  CN II-XII intact, moving all extremities

DISCHARGE EXAM:
Vitals: T 98, BP 110/70, HR 72, RR 18, O2 99% RA  
General: AAOx3, pleasant, sitting comfortably in bed, NAD  
HEENT: Sclera anicteric, MMM, oropharynx clear  
Neck: Supple, JVP not elevated, no LAD  
Lungs: Breathing comfortably without accessory muscle use, clear 
to auscultation bilaterally, no wheezes, rales, rhonchi  
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
Abdomen: +BS, soft, non-tender, non-distended, bowel sounds 
present, no rebound tenderness or guarding, no organomegaly  
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Skin: No rashes or lesions noted  
Neuro:  CN II-XII intact, moving all extremities
 
Pertinent Results:
ADMISSION LABS:
___ 12:08PM BLOOD WBC-6.6 RBC-3.54* Hgb-11.5* Hct-34.5* 
MCV-98 MCH-32.5* MCHC-33.3 RDW-11.9 Plt ___
___ 12:08PM BLOOD Neuts-65.2 ___ Monos-5.0 Eos-6.7* 
Baso-0.9
___ 12:08PM BLOOD ___ PTT-29.4 ___
___ 12:08PM BLOOD Glucose-100 UreaN-21* Creat-0.8 Na-139 
K-4.1 Cl-106 HCO3-26 AnGap-11

DISCHARGE LABS:
___ 01:15PM BLOOD Hct-33.5*
___ 05:40AM BLOOD Glucose-93 UreaN-9 Creat-0.6 Na-141 K-4.2 
Cl-108 HCO3-24 AnGap-13
___ 05:40AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0

EGD ___:
Normal mucosa in the esophagus
Mild erythema and erosions in the stomach consistent with
gastritis (biopsy)
Clean-based gastric ulcer seen in the pyloric channel.
Re-bleeding rate within 30 days is less than 5%.
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum

 
Brief Hospital Course:
___ y/o M with hip bursitis and hemorrhoids who presents with two 
days of melena and hematemesis in the setting of excessive NSAID 
use.

# Upper GI bleed:  EGD was notable for a clean-based ulcer in 
the pyloric channel, most likely secondary to NSAID use.  
___ remained hemodynamically stable throughout 
hospitalization.  His hematocrit dropped slightly on day 2 (34.5 
to 31.7), but was stable thereafter.  ___ was started on 
pantoprazole 40mg IV bid, which was transitioned to omeprazole 
40mg po on discharge, and all NSAIDs were held.  He should 
continue high dose PPI for 8 weeks, at which point cessation can 
be considered.  H. pylori IgG was negative; gastric biopsies for 
H. pylori are pending.  Follow-up endoscopy is not required in 
the setting of a shallow pyloric ulcer with a clear cause.  
___ has follow-up appointment scheduled with GI on ___.

# Hip bursitis:  NSAIDs were held in the setting of GI bleed.  
His bursitis pain was controlled with tylenol and tramadol prn.  
___ was instructed to avoid NSAIDs/aspirin as these likely 
caused his ulcer.  Consider steroid injection in the future if 
needed for pain.

TRANSITIONAL ISSUES:
[ ] ___ should continue high dose PPI for 8 weeks, at which 
point cessation can be considered.  
[ ] Follow-up endoscopy is not required in the setting of a 
shallow pyloric ulcer with a clear cause.
[ ] Please recheck hematocrit at GI appointment on ___.
[ ] Pending results: gastric biopsies for H. pylori.
[ ] For PCP: ___ must avoid NSAIDs/aspirin.  He was started 
on tramadol for his bursitis pain. Consider steroid injection if 
needed for bursitis pain. 
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN pain 
2. Excedrin Migraine (aspirin-acetaminophen-caffeine) 250-250-65 
mg oral prn headache 
3. Multivitamins 1 TAB PO DAILY 

 
Discharge Medications:
1. Omeprazole 40 mg PO BID 
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60 
Capsule Refills:*0
2. Multivitamins 1 TAB PO DAILY 
3. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 
RX *tramadol 50 mg 1 tablet(s) by mouth q6h prn Disp #*40 Tablet 
Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary diagnosis:
Peptic ulcer disease

Secondary diagnosis:
Hip bursitis

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

 
Discharge Instructions:
Dear Mr. ___,

It was a pleasure caring for you during your stay at ___.  You 
were admitted for black stools.  An endoscopy showed an ulcer in 
the stomach, which was likely the source of bleeding.  There was 
no evidence of active bleeding and your blood counts remained 
stable. 

Please continue to take your medications as prescribed and keep 
your follow-up appointments.  It is very important that you STOP 
taking ibuprofen, aspirin, and NSAIDs, as this likely caused the 
ulcer.

-Your ___ Team
 
Followup Instructions:
___

{'melena': ['Peptic ulcer disease'], 'hematemesis': ['Peptic ulcer disease'], 'headache': [], 'lightheadedness': [], 'nausea': [], 'black stool': ['Peptic ulcer disease'], 'jet black emesis': ['Peptic ulcer disease'], 'formed black BMs': ['Peptic ulcer disease'], 'loose, watery diarrhea': [], 'denies hematochezia': [], 'denies fever/chills': [], 'anorexia': [], 'abdominal pain': [], 'chest pain': [], 'shortness of breath': [], 'hip bursitis': ['Enthesopathy of hip region'], 'hemorrhoids': []}