Acute duodenal ulcer with hemorrhage without mention of obstruction Other shock without mention of trauma Nonunion of fracture Thrombocytopenia unspecified Acute posthemorrhagic anemia Other and unspecified alcohol dependence continuous Other chronic nonalcoholic liver disease Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Tobacco use disorder
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
___
 
Attending: ___.
 
Chief Complaint:
Bleeding duodenal ulcer
 
Major Surgical or Invasive Procedure:
Laparotomy, oversewing of the duodenal ulcer, truncal vagotomy, 
liver biopsy and pyloroplasty.

 
History of Present Illness:
___ year old male with a history of alcoholism and more recently, 
binge drinking, who was brought to the emergency room after 
experiencing abdominal pain x 1 week, followed by dark stools 
and lightheartedness. Patient reportedly had syncope at home 
today, landing on his left chest with subsequent pain. He was 
evaluated in the ED for the aforementioned symptoms and his dark 
stools
progressed to bright red blood per rectum. An NGT was placed and 
approximately 350 ccs of bright red blood was removed. GI was 
consulted for concern of acute upper GI bleed and given the 
history of excessive alcohol intake along with a transaminatis 
and bilirubin of 2, he was started on Octreotide for concern for
a variceal bleed. He was reportedly also started on a PPI drip. 
SBP intermittently dropped to ___ and thus over the course of 
his time in the ER, he was given 4 units of PRBCs and 5 liters 
of saline with transient improvement. Given chest pain s/p fall, 
a CXR was ordered which showed no fractures. EKG was also 
unremarkable and troponin x 1 was negative. Patient was then 
admitted to the MICU for further management of his GIB. Of note, 
patient has a history of excessive alcohol use for years, but 
more recently has been drinking heavily because of grief with 
his father's death.
 
Past Medical History:
Right Distal Humeral Fracture in ___  
Alcoholism  

 
Social History:
___
Family History:
Non-contributory  
 
Physical Exam:
Vital signs stable, afebrile.
No oropharyngeal erythema or exudate.  No scleral icterus.
Regular rate and rhythm; no murmurs, rubs or gallops.
Lungs with minimal wheezes anteriorly.
+BS.  NTND.  No ascites. 
No c/c/e.  No peripheral stigmata of liver disease.

 
Pertinent Results:
___ 07:12AM BLOOD WBC-6.0 RBC-3.03* Hgb-10.1* Hct-29.2* 
MCV-97 MCH-33.4* MCHC-34.6 RDW-20.2* Plt ___
___ 09:48AM BLOOD ___ PTT-29.3 ___
___ 04:50AM BLOOD Glucose-66* UreaN-8 Creat-0.7 Na-134 
K-3.9 Cl-97 HCO3-28 AnGap-13
___ 04:50AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.5*

EGD (___): Large cratered bleeding ulcer in the duodenal bulb 
[apex]- this was treated with injection and cautery. Otherwise 
normal EGD to second part of the duodenum.
 
Brief Hospital Course:
___: Admitted with GI bleed and GI consulted.
___: Scoped and to OR for procedure as described in Operative 
Note, transferred uneventfully to SICU, extubated successfully.  

___: Transferred to floor. Placed on PCA for pain.
___: NGT and Foley removed. CVL removed.
___: Diet advanced to sips.
___: Diet advanced to full liquids. Hep locked and placed on po 
meds.
___: Diet advanced to regular diet.
___: Pt. discharged with instructions for followup as medically 
stable.

 
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 
hours) as needed for pain.
Disp:*55 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours).  
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Medications
Please continue all other home medications as directed by your 
primary care provider.
5. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Tablet PO 
DAILY (Daily).  
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 
6 hours).
Disp:*28 Capsule(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Bleeding duodenal ulcer

 
Discharge Condition:
Stable.

 
Discharge Instructions:
Resume all home medications. Seek immediate medical attention 
for fever >101.5, chills, increased redness, swelling, bleeding 
or discharge from incision, chest pain, shortness of breath, 
difficulty breathing, severe headache, increasing neurological 
deficit, or anything else that is troubling you. No strenuous 
exercise or heavy lifting until follow up appointment, at least. 
Do not drive or drink alcohol while taking narcotic pain 
medications. Call your surgeon to make follow up appointment. 
 
Followup Instructions:
___

{'abdominal pain': ['Acute duodenal ulcer with hemorrhage'], 'dark stools': ['Acute duodenal ulcer with hemorrhage'], 'lightheartedness': ['Acute duodenal ulcer with hemorrhage'], 'syncope': ['Acute duodenal ulcer with hemorrhage'], 'bright red blood per rectum': ['Acute duodenal ulcer with hemorrhage'], 'chest pain': ['Other shock without mention of trauma'], 'fall': ['Nonunion of fracture'], 'alcoholism': ['Other and unspecified alcohol dependence', 'continuous'], 'transaminatis': ['Other chronic nonalcoholic liver disease', 'Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH]']}