Cirrhosis of liver without mention of alcohol Esophageal varices in diseases classified elsewhere with bleeding Congenital factor VIII disorder Asymptomatic human immunodeficiency virus [HIV] infection status Chronic hepatitis C without mention of hepatic coma
 
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
Dark stools
 
Major Surgical or Invasive Procedure:
___: endoscopic banding and injection of sodium laurate by 
GI
 
History of Present Illness:
Mr. ___ is a ___ year old male with history of hemophilia, 
HepC and HIV contracted from clotting factor transfusions in 
1990s, HepC cirrhosis with known varices who presents with dark 
stools beginning this am. He is otherwise without complaint. He 
was recently admitted ___ with complaints of melena 
in the setting of recent variceal bleeding requiring banding 
while in ___ one month prior. On his last admission, he had 
not been taking his prescribed PPI. During his last admission he 
received an octreotide gtt x 24 hours and EGD found that one of 
the previously placed bands had fallen off but there was no 
active bleeding at the site. He was discharged on an H2B in 
place of a PPI due to interactions with HAART. He was scheduled 
to have a repeat EGD with banding on ___ but given new dark 
stools he decided to present to the ED.  
.  
In the ED, T was 98.5, HR 100, BP 109/60, RR 16, O2 sat 100% on 
RA. Labs remarkable for Hct of 19.1 (28.9 ___ and slightly 
elevated AST 54. PTT 57.2, INR 1.4. GI was consulted who 
recommended octreotide bolus and gtt and Heme consult. Heme also 
evaluated patient and recommended factor VIII bolus to be 
followed by BID dosing. He received Protonix 40 mg IV, 
octreotide 50 mcg bolus followed by 50 mcg/hr gtt, and was 
scheduled to get factor VIII 50U/kg bolus but did not receive 
this in the ED before arriving in the ICU. He also received 500 
mg of IV levofloxacin and 2 mg of Zofran.  

 
Past Medical History:
1. Hemophilia. 
2. HIV- Dx ___ contracted from clotting factor; ___ VL 51 and 
CD4 264
3. HCV- Dx ___ treated with pegylated interferon and ribavirin 
for three months, stopped early due to failure to achieve any 
viral response and anemia; now on maintenance pegasysis 
4. WPW tachycardia. 
5. Hypertriglyceridemia. 
 
Social History:
___
Family History:
His brother died of complications of hemophilia  in ___. He 
died from HCV. No other family history of lymphoma or 
malignancies. 

 
Physical Exam:
: 99.1 BP: 129/81 HR: 88 RR: 24 O2 100% RA  
Gen: Pleasant, well appearing, although somnolent from sedation 
given during EGD  
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.  
NECK: Supple, No LAD, No JVD.  
CV: RRR. nl S1, S2. No murmurs, rubs ___  
LUNGS: CTAB, good BS ___, No W/R/C  
ABD: NABS. Soft, NT, ND. No HSM  
EXT: WWP, NO CCE. 2+ DP pulses ___  
SKIN: No rashes/lesions, ecchymoses.  
NEURO: A&Ox3. Appropriate. Neuro exam unable to be completed due 
to somnolence from sedation given during EGD.  
PSYCH: Listens and responds to questions appropriately, pleasant 
 

 
Pertinent Results:
On Admission:
___ 02:35PM   ___ PTT-57.2* ___
___ 02:35PM   PLT SMR-NORMAL PLT COUNT-201#
___ 02:35PM   HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL 
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ STIPPLED-1+
___ 02:35PM   NEUTS-65 BANDS-0 ___ MONOS-8 EOS-2 
BASOS-2 ___ MYELOS-0 NUC RBCS-1*
___ 02:35PM   WBC-7.0# RBC-1.82*# HGB-6.9*# HCT-19.1*# 
MCV-105* MCH-37.7* MCHC-35.9* RDW-15.6*
___ 02:35PM   ALT(SGPT)-35 AST(SGOT)-54* ALK PHOS-57 TOT 
BILI-1.1
___ 02:35PM   estGFR-Using this
___ 02:35PM   GLUCOSE-108* UREA N-29* CREAT-0.6 SODIUM-138 
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-25 ANION GAP-10
.
On Discharge:
___ 05:35AM BLOOD WBC-2.4* RBC-2.54* Hgb-8.8* Hct-24.2* 
MCV-95 MCH-34.5* MCHC-36.3* RDW-20.0* Plt Ct-89*
___ 05:35AM BLOOD ___
___ 05:35AM BLOOD Plt Ct-89*
___ 05:35AM BLOOD Glucose-92 UreaN-16 Creat-0.6 Na-139 
K-3.7 Cl-110* HCO3-25 AnGap-8
___ 05:35AM BLOOD ALT-31 AST-47* AlkPhos-52 TotBili-0.6
___ 05:35AM BLOOD Calcium-7.6* Phos-3.5 Mg-1.9 Iron-20*
___ 05:35AM BLOOD calTIBC-439 Ferritn-33 TRF-338
.
Please see OMR for EGD report. 

 
Brief Hospital Course:
___ year old male with hemophilia, HIV, and Hep C cirrhosis with 
known varices who presents with recurrent melena and HCT 19.
.
# Acute upper GI bleed: Due to recurrent variceal bleeding. Was 
last banded ~5 wks ago in ___, then repeat banding during last 
hospitalization at end of ___. Was scheduled for repeat 
banding procedure ___, however presented to ER due to dark 
stools. Complicated by h/o Hemophilia. Received octreotide bolus 
and factor VIII bolus in ER. Admitted to MICU for urgent EGD 
which demonstrated 2 cords of grade II varices in the lower 
third of the esophagus. 1 band was placed just distal to the 
area of clot/ulceration and area injected with sodium morrhuate. 
Pt had poor response to first two units PRBC, however HCT bumped 
appropriately with 2 additional units to 25.4. Did not need 
further Factor 8. Patient transferred to floor. Monitored on 
octreotide ggt. Advanced to regular diet and demonstrated stable 
crit. Patient discharged on ciprofloxacin and Sucralfate for a 7 
day course. Patient instructed to take Pantoprazole 40 mg 12 
hours apart from Atazinavir. Later was called by pharmacy - 
switched pantoprazole to omeprazole for insurance purposes. 
Continued Propranolol 60 mg for varices. 
- Patient will require repeat banding in 2 weeks
. 
# Hemophilia: Received factor 8 in ER when acutely bleeding. To 
follow up with heme. 
. 
# HIV: Continued HAART meds, Bactrim prophylaxis. Patient 
instructed to take ppi 12 hours apart from Atainavir. 
.
# HepC: Continued peg-interferon

 
Medications on Admission:
Ritonavir 100 mg PO DAILY  
Atazanavir 150 mg PO DAILY  
Emtricitabine-Tenofovir 200-300 mg One Tablet PO DAILY  
Zidovudine 300 mg PO BID  
Peginterferon Alfa-2a 90 mcg 1X/WEEK (FR)  
Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY  
Sucralfate 1 gram three times a day for 2 weeks: At 8am, Noon 
and 4pm daily x 2 weeks.  
Ranitidine HCl 150 mg PO once a day as needed for indigestion 
for 2 weeks: Take 12 hours apart from Atazanavir .  
Ciprofloxacin 250 mg PO BID  

 
Discharge Medications:
1. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY 
(Daily).  
2. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet 
PO DAILY (Daily).  
3. Atazanavir 150 mg Capsule Sig: One (1) Capsule PO DAILY 
(Daily): Separate from Protonix by 12 hours.  
4. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO BID (2 
times a day).  
5. Peginterferon Alfa-2a 180 mcg/mL Solution Sig: 90 mcg  
Subcutaneous 1X/WEEK (FR): 180 mcg/0.5 mL Kit 
Inject 90mcg .  
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
7. Propranolol 60 mg Capsule,Sustained Action 24 hr Sig: One (1) 
Capsule,Sustained Action 24 hr PO once a day.
Disp:*30 Capsule,Sustained Action 24 hr(s)* Refills:*2*
8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times 
a day) for 4 days: Take for ___ay 7 ___. .
Disp:*16 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): 
Separate 12 hours from atazinavir  .
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a 
day for 4 days: Take for ___ay 7 ___
.
Disp:*8 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Acute upper GI bleed
Esophageal varices and ulcer
Anemia from blood loss
Hemophilia A
HCV cirrhosis
HIV

 
Discharge Condition:
Good, ambulating, HCT stable

 
Discharge Instructions:
You were admitted for anemia due to bleeding from your 
esophagus.  You had an upper endoscopy which demonstrated an 
oozing esophageal ulcer and varices (1 varix was banded). You 
received factor 8 for your hemophilia and blood for the anemia. 
.
Please take all your medications as directed.  You will be given 
a prescription for ciprofloxacin, an antibiotic, which you 
should take for 4 more days to help prevent an infection 
following your esophageal bleed.
You will also be given a prescription for a medication called 
sucralfate, which you should take for 4 more days.  This 
medication will help your esophagus heal following the bleeding. 

It is important to take your Pantoprazole 12 hours apart from 
Atazanavir. 
. 
Attend all your follow-up appointments.  Please have you blood 
count checked at your appointment next week with your 
hematologist.
. 
Return to the ER if you experience dark black stool, 
lightheadness, dizziness, bleeding, shortness of breath, fever, 
chills, nausea, vomiting or any other concerning symptoms. 
 
Followup Instructions:
___

{'dark stools': ['Esophageal varices in diseases classified elsewhere', 'Cirrhosis of liver without mention of alcohol'], 'HIV': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'hemophilia': ['Congenital factor VIII disorder'], 'HepC': ['Chronic hepatitis C without mention of hepatic coma']}