Admission Note for GI Bleed

DATE: .................

CHIEF COMPLAINT: GI bleeding x ....... hours/days/months

HISTORY OF PRESENT ILLNESS:

Site -
Onset -
Character -
Alleviating factors -
Time course -
Exacerbating factors -
Severity -
Similar symptoms before -
Nausea -
Vomiting -
Diarrhea -
Constipation -
Loss of appetite -
Black/bloody stools - , Rectal pain -
Abdominal pain -
Sick contacts - , Suspicious food consumed -
Fever/chills - , SOB - , Chest pain - , Headache -
Lightheaded - , Passed out -
Weakness - , Blurred vision -
Cough - , Chest pain - , Dysuria -

ER Tx given -

PAST MEDICAL HISTORY: (circle all that apply)
PUD Gallstones Kidney stones UTIs MI CAD HTN DM Pancreatitis
GI bleeding Hemorrhoids Diverticulitis Cirrhosis
Stroke CA PVD DVT COPD Asthma
EGD -
Colonoscopy -

PAST SURGICAL HISTORY: (circle all that apply)
Cholecystectomy Hernia Appendectomy Hysterectomy

MEDICATIONS:

ALLERGY: NKDA

FMH: (circle all that apply)
CAD DM Stroke HTN CA

SOCIAL HISTORY: (circle all that apply)
 Independent NH Lives w spouse son daughter
Alcohol - no heavy occasional last drink
Smoker: no
Illicit drugs - no cocaine heroin marijuana

REVIEW OF SYSTEMS: unremarkable apart from above symptoms

PHYSICAL EXAM:
VITALS: Orthostatics -
SpO2 - Initial vitals -

GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD +JVD
LUNGS: CTA (B) crackles L R B wheezing
HEART: Clear S1S2, RRR irregular murmur S D /6 S3
ABDOMEN: Soft, NT, ND, +BS
Rectal exam:
EXTREMITIES: no edema +edema
PERIPHERAL VASCULAR: palpable nonpalpable Doppler
NEURO:
AAO x 3, CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B), SENSATION: nonfocal
DTR: ++, CEREBELLAR: non focal

LABS:

N= B= L=AG= LFT
Amylase Lipase
CXR:
KUB:
EKG:

ASSESSMENT:
- GI bleeding due to
*Gastroenteritis
*Gastritis
*PUD
*Hemorrhoids
*Divericulitis
*Esophageal varices
*Mallory Weiss syndrome
*IBD

PLAN:
- IVF
- NPO
- H/H now and q 8 hr
- Type and screen 2 U PRBC
- Protonix 40 mg IV QD/BID
- GI consult-> EGD/Colonoscopy
- Octeotride 50 mcg IV bolus & then 50 mcg/hr IV drip
- O2 to keep SpO2 > 92%
- CBCD, BMP, INR/PTT in AM
- Compression stocking BLE for DVT prophylaxis

Signature:


Published: 02/05/005
Updated: 03/08/2009