SUBJECTIVE: The patient is doing well this morning. She had 2 bowel movements overnight. She had spots of blood in the first one, no blood in the second. The spots of blood in the first one were consistent with the amount that I saw on the toilet yesterday. It seems this is consistent with her previous hemorrhoidal bleeding, status post her dearterialization procedure. She denies any fevers, chills, chest pain, shortness of breath, vomiting or diarrhea. She does admit to some nausea, which was controlled with Zofran.
Additionally, she does have some pain, which is currently controlled with her current regimen. She is tolerating her liquid diet well. Her oral ulcers are not causing her problem at the moment. Her Magic mouthwash has been controlling her oral discomfort. Otherwise, she has no other complaints. No swelling, headache. She slept well last night. She actually reports that her energy is improved. She feels mildly confident that she can go home today.
OBJECTIVE:
VITAL SIGNS: Temperature is 98.2, blood pressure 112/64, pulse 69, respirations 18. She is saturating 100% on room air.
GENERAL: The patient is awake, alert and oriented x3. She is sitting up in bed, conversant appropriately and responding appropriately to questions. She is in no apparent distress.
HEENT: Sclerae are anicteric. Mucous membranes are moist. Oral lesions do persist. They are unchanged. No jugular venous distention or physical pulsations appreciated on exam. No masses.
HEART: Normal S1, S2. Did not appreciate any murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rales or rhonchi.
ABDOMEN: Soft, nondistended, nontender to palpation. Bowel sounds are present in all quadrants.
EXTREMITIES: No peripheral edema appreciated. Dorsalis pedis pulse is 2+/4 bilaterally, symmetrical.
LABORATORY DATA: BMP demonstrates glucose 100, BUN 21, creatinine 1.12, sodium 140, potassium 4.7, chloride 107, carbon dioxide 26, calcium 8.2. CBC demonstrates white count 4.0, hemoglobin 10.6, hematocrit 32.2, MCV 80.3, platelets 91. She has a normal differential.
The hemoglobin reported on the CBC was drawn at 5:30 this morning. She had a hemoglobin drawn last night as well with a hemoglobin of 10.7. She is maintaining her blood counts.
ASSESSMENT AND PLAN:
1. Acute blood loss anemia secondary to internal hemorrhoids. The patient has had no more bloody bowel movements since being transferred from the ICU. She does have some mild spotting with 1 bowel movement, but this is not the volume reported upon presentation. Colorectal surgery is coming by to evaluate. Gastroenterology has also been made aware of her readmission.
2. Presyncope secondary to acute blood loss anemia. The patient has had no more presyncopal symptoms. She denies any lightheadedness or dizziness upon standing. She has ambulated to the bathroom without difficulty.
3. Hepatocellular carcinoma with metastases to lung. The patient continues to receive Avastin monthly. She has been continuing her erlotinib p.o. daily. She does not have any currently, but her son is bringing her some today.
4. Internal hemorrhoids, status post transanal hemorrhoidal dearterialization. Colorectal is evaluating the patient. Her bleeding is stable. She is using Proctofoam 3 times daily as needed.
5. Insulin-dependent diabetes mellitus. The patient’s sugars are controlled. Continue her basal and sliding scale insulin per her home regimen.
6. Essential hypertension. Her blood pressure is controlled. Continue current management.
7. Dyslipidemia. Continue her statin.
8. Oropharyngeal mucositis secondary to her chemotherapy. Continue Magic mouthwash as needed. Acute pain controlled on the current regimen.
9. Nausea. She says she has controlled with the Zofran sublingually. Continue.
10. Portal hypertensive esophageal varices, nonbleeding.
11. Deep venous thrombosis prophylaxis. Continue PCDs.
12. Code status. The patient still is a full code.
