H&P #3

Identifying Data

Full Name: J. G.

Sex: Male

DOB: xx/xx/69

Date & Time: August 30, 2023

Location: New York Presbyterian Queens

Religion: Unknown

Source of Information: Self

Reliability: Reliable

Source of referral: Self

 

Chief Complaint: “blood in stool” x 3 hours

 

History of Present Illness:

54 y/o M with PMHx HTN presents to ED c/o 1 episode of grossly bloody loose stool at around 10pm while at work (works as a restaurant waiter). Patient reports stool was malodorous and states the toilet bowl was filled with red blood. Denies inciting event, states he had a typical home cooked meal about 3 hours prior to symptom onset. Patient denies prior similar episodes. Positive family history of colon cancer in paternal uncle diagnosed around age 60. Patient denies abdominal pain, nausea, vomiting, fever, chills, trauma, changes in dietary habits, dizziness, lightheadedness, weight loss, changes in appetite. No reported recent travel, alcohol use, NSAID use, or sick contacts. Patient has no prior history of colonoscopy or EGD.

On arrival to ED vital signs were stable. CBC unremarkable with Hgb 14.3. BMP significant for BUN 30.1, Cr 1.7. LFTs unremarkable. CT reveals diverticulosis. While in ED patient had an additional 4 episodes of bloody stool, consistent with prior reported data.

 

Differential diagnosis:

  1. GI bleed – lower
  2. Diverticulosis
  3. Hemorrhoids
  4. Peptic ulcer
  5. Colon cancer

 

Past Medical History:

Medical History:

  • Hypertension

Medications:

  • Amlodipine 10 mg tablet QD PO
  • Lisinopril 10 mg tablet QD PO
  • Denies current OTC medications.
  • Denies herbal supplement use.

Surgical History:

  • No past surgical history

Allergies:

  • No known drug/food/environmental allergies

Family History:

  • Mother: Alive, age 79, PMHx HTN, T2DM, HLD, COPD.
  • Father: Deceased age 81 from CVA.
  • Paternal uncle: colorectal cancer (around age 60)
  • 2 daughters, ages 34 and 32, alive and well

Social History:

  • Smoking: Nonsmoker.
  • Alcohol: Denies alcohol use.
  • Denies past or current illicit drug use
  • Marital History: Married for 15 years.
  • Language: English. Able to read and write.
  • Education: Some college
  • Occupational History: Restaurant waiter
  • Travel: No recent travel
  • Home situation: Lives with wife in apartment.
  • Sleep: Patient states he sleeps about 6-7 hours per night
  • Exercise: Denies regular exercising
  • Diet: carbohydrate heavy diet
  • Caffeine: denies caffeine use

 

ROS:

  • General:. Denies fever, fatigue, chills, night sweats, weight loss, changes in appetite.
  • Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
  • HEENT: Denies vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies chest pain, palpitations, leg swelling
  • Gastrointestinal: Admits to hematochezia. Denies abdominal pain, constipation, N/V.
  • Genitourinary: Denies urgency, frequency, incontinence, hesitancy, dribbling.
  • Musculoskeletal: Denies muscle pain, joint pain, arthritis, or swelling.
  • Nervous system: Denies headache, loss of strength, change in cognition/mental status/memory.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
  • Endocrine: Denies polydipsia, heat or cold intolerance, excessive sweating.
  • Psychiatric: Denies depression or anxiety.

 

Physical Exam:

Vitals:

  • Weight: 174 lb Height: 61 inches       BMI: 30.82 kg/m2
  • BP: 130/88, left arm sitting
  • RR: 18
  • HR: 96 bpm
  • Temp: 98.9 F oral
  • SpO2: 99% room air

General: 54-year-old male who is speaking in full sentences on room air, lying in bed and appears in no acute distress. AO x 3.

HEENT: Normocephalic & atraumatic; PERRL; EOM intact; nares patent B/L; Pharynx non-erythematous. No exudates present.

Neck: Trachea midline. Neck supple and non-tender. No lymphadenopathy present.

Heart: Regular rate and rhythm. S1 & S2 distinct with no murmurs or gallops.

Lungs: Clear to auscultation B/L. No adventitious sounds noted.

Abdominal: Abdomen symmetric and non-distended, with no scars. Normoactive bowel sounds in all 4 quadrants. Non-tender to palpation and tympanic throughout with no guarding or rebound.

Musculoskeletal: FROM, no cyanosis, no peripheral edema, intact distal pulses.

Rectal: Gross red blood on DRE. No tenderness, no masses, no external hemorrhoids visualized, no anal fissures. Normal sphincter tone.

Chaperone present – X.X, RN.

 

Labs:

CBC: HGB 14.3; Crit 44.0, PLT 214, WBC 9.89

BMP: Na 142, K 4.7, Cl 109, CO2 20, BUN 30.1, Cr 1.70, Glu 109, Anion gap 13, Ca 9.3

Hepatic panel: TP 6.3, ALB 4.5, SGOT 17, SGPT 18, TBILI 0.2, DBILI 0.1, ALK 83

APTT: 33.7; INR 0.92

 

Imaging:

CTA abdomen/pelvis: No evidence of active GI bleed. Colonic diverticulosis without evidence of active diverticulitis. Enlarged prostate.

 

Assessment/Plan:

J. G. is a 54 y/o M w/ PMHx HTN presenting to the ED with hematochezia. Patient has no prior history of colonoscopy or EGD. CBC unremarkable. BMP shows elevated BUN/Cr 30.1/1.70. CTA abdomen pelvis reveals colonic diverticulosis.

 

#Hematochezia

-Monitor/trend CBC q8h

-Maintain Hgb above 7

-Transfusion threshold: Hgb < 7, Plt < 50

-GI consult for colonoscopy

-Active type & screen

-IVF for now (LR 75mL/hr)

-Clear liquids for now

-Monitor BMs

 

#AKI – Creatinine 1.7, unclear pt baseline

-IV hydration

-Trend Cr down

-Monitor electrolytes

 

#Hypertension

-Hold lisinopril 10 mg due to AKI

-Continue amlodipine 10 mg

 

#Obesity – BMI 30.82

-Lifestyle and dietary modifications

 

Diet: carbohydrate controlled diet

DVT ppx: SCDs

Code status: full

 

Patient Education:

A gastrointestinal bleed occurs when any of the organs that are part of the digestive tract start to bleed. The GI bleed can be a lower GI bleed – meaning the large intestine is affected or an upper GI bleed – which can include the esophagus, stomach or small intestine. Bloody bowel movements are more commonly associated with lower GI bleeds. Other symptoms you may experience can include weakness, stomach pain, diarrhea, pale skin or a sensation that your heart is racing.

Causes of a GI bleed can include things such as ulcers, diverticulosis, irritable bowel disease, hemorrhoids, anal fissures, polyps, cancer, etc.

Blood tests will be completed to monitor your blood cell count to make sure it does not drop too low. If it drops below a certain level you may need a blood transfusion.

You will likely be scheduled for a colonoscopy. You will receive medicine to help you relax and make you sleepy for it to be performed. Then a tube is inserted through the anus that allows medical providers to look inside the colon with a camera.

To help prevent GI bleeds, NSAID use should be limited as these can increase the risk of bleeding.

Treatment will depend on the source of the bleeding.