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EDILBERTO CRUZ 48-H by dredwardmark



Name: EDILBERTO CRUZ Hospital #: Age/Sex: 65 Address: Sta. Mesa Manila Date of admission: July 12,2007 Admitting Diagnosis: UGIB probobably secondary to GEV, CLD probably secondary to ALD, S/P RBL x 1 2006 Residents in charge: Dr.delos Reyes/Indon Intern-in-Chage: Dr. Maganda Clerk-in-Charge: Navarro/ Ponelas/ Reyes

48-HOUR HISTORY Patient is a diagnosed case of CLD secondary to CHLD Post hepatitis, S/P RBL, last May 2006. Maintained on Propanolol 10mg BID. History of Present Illness One day prior to admission, he had passage of tarry stool, and with vomited with a coffee ground appearance. It was associated with crampy abdominal pain, and no fever. Persistence of the mentioned symptoms prompted consult. Past Medical History (+) DM since 2006, unrecalled meds taken for only 1 month; no hypertension, no bronchial asthma, no PTB, no allergy S/P RBL x 1 at OMMC Family History Hypertension on mother side Personal and Social History Previous alcoholic beverage drinker, consumes 5-10 bottles x = 20 years, stopped last 2006 Previous smoker, 10 sticks/day x = 20 pack years, stopped last 2006 Review of Systems General: (-) fever, (-) anorexia, (-) weight loss HEENT: (-) dizziness, (-) blurring of vision Respiratory: (-) colds, (-) hemoptysis Cardiac: (-) PND Gastrointestinal: (+) crampy abdominal pain, (-) LBM, (+) bloody stool, onset unknown Neurologic: (-) seizure, (-) loss of consciousness Urinary: no dysuria, no oliguria Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Heumatology: no joint pains Physical Examination: conscious, coherent, not in cardio-respiratory distress o Vital Signs: BP: 110/70 HR: 80 RR: 20 Temp: 36.5 C HEENT: pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no cervical lymphadenopathies, (-) distended neck veins CHEST AND LUNGS: symmetrical chest expansion, no retraction, (-) crakles , (-) wheezes, (+) spider angiomata, no gynecomastia HEART: adynamic precordium, normal rate, regular rhythm, no murmur

ABDOMEN: flabby, normoactive bowel sound, soft, non-tender, liver span 7cm along RMCL, no splenomegaly, no caput medusae, (+) fluid wave EXTREMITIES: grossly normal, (+) Palmar erythema, with full and equal pulses Assessment: UGIB probobably secondary to GEV CLD probably secondary to ALD S/P RBL x 1 2006 PLAN: For admission Course in the wards. Upon admission, he was placed under the service of Drs. Delos Reyes, Filio and Indon. The patient was coherent, BP is 110/80, CR 80, RR 20, Temp 37degC, and has bleeding per NGT. The patient was maintained on NGT, and gastric lavage was done every 6 hours. Medications were Somatostatin 250mg on IV bolus, then250mg + 90cc D5W x 1 hour; Tranexamic acid 1g every 8 hours TIV, and Epinephrine solution, 2 amp and Vit K ampule. He was in moredate to high back rest. Vital signs, input and output, and neurological signs were monitored hourly; while CBG was monitored every 2 hours. July 13, 2007, vital signs were 140/80mmHg, PR was 60, RR 22cpm, temperature 36.6. The maintain was still maintained on NGT and still on gastric lavage every 6 hours. IVF was PNSS 1L x 8hour. He is for EGD with RBL. Vit K ampule, epinephrine solution + 10 cc NSS were given every 4 hours. Ranitidine 50mg every 12 hours and Famotidine 20mg every 12 hours were added to his medications. WOF: Active bleeding, Hypotension, and monitored every 1 hour, as well as urine output monitoring. On the second day of his admission, BP was 110/70, CR 78, RR 20 and temp 36.7. Nasogastric tube was removed, and he underwent EGD with RBL. Medications were continued, and he was placed on moderate to high back rest. He was monitored every hour and watched out for bleeding, hypotension and tachycardia. Gastro notes: S/P RBC/EGD, esophageal vessels large with RC signs, with severe portal gastropathy S/P ligation

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