Gastroenterology case study

DISCHARGE SUMMARY

IDENTIFYING DATA

This 72-year-old white female was admitted through the emergency room with coffee-grounds emesis, hemoglobin of 9.5, complaining of left upper quadrant discomfort.

LABORATORY DATA

On admission patient’s hemoglobin was 9.5, white count 8.1, platelet count 208,000, and normal BUN and creatinine.  Urinalysis was normal, serum gastrin levels normal at 43.  Chemistry panel was normal with the exception of a globulin of 1.6, albumin 3.2, total protein 4.8.  Prothrombin time and PTT normal, serum iron 117, and low hemoglobin to 8.5.  Hemoglobin at discharge 10.3.  Chest x-ray reveals no acute process.  Abdominal film nonspecific.

           

HOSPITAL COURSE

Patient was admitted with GI bleed, generally inactive at time of admission in that she had no significant orthostatic changes.  She was placed on IV Zantac, and an emergency endoscopy done showed an erosion at the gastroesophageal junction, a 1.5-cm benign-appearing anterior wall antral ulcer with hemorrhagic speck near its margin, and slight oozing from the margin after endoscopy.  There was moderate antral edema and scarring as well.  The duodenal bulb was scarred as well.

She showed no further signs of active bleeding, but needed
5 units of blood to maintain her hemoglobin greater than 10.

DISCHARGE DIAGNOSES

1. Upper gastrointestinal bleed secondary to gastric ulcer.

2. Anemia secondary to #1.

DISCHARGE MEDICATIONS

Zantac 300 mg q.h.s., Carafate 1 g p.o. t.i.d. 1 hour before meals.

FOOTNOTE

Line 8 (Page 1).  A was added to avoid beginning the sentence with a numeral.

Line 9 (Page 1).  Although coffee-ground emesis was dictated, the correct term is coffee-grounds emesis.

Line 13 (Page 1).  Was added to improve grammar.

Line 15 (Page 1).  The dictated comma after 43 was changed to a period to improve sentence structure.

Line 16 (Page 1).  Chem panel was expanded to chemistry panel.

Line 17 (Page 1).  And was added to separate pro time (prothrombin time) and PTT (partial thromboplastin time).

Line 25 (Page 1).  Alternative:  I.V.

Line 36 (Page 1).  GI was expanded to gastrointestinal in the diagnosis.

Line 39 (Page 1).  Med was expanded to medications.