Medical Transcription Services Company

DATE OF ADMISSION:  1/31/99

CHIEF COMPLAINT:
The patient is a 92 year-old woman admitted for evaluation and treatment of acute GI bleed.

HISTORY OF PRESENT ILLNESS:
The patient is a nursing home resident with a history of organic brain syndrome, blindness, deafness, and dementia. She is fed by a percutaneous G - tube. There is no history of upper GI disease according to her current medical records including peptic ulcer disease, liver disease, esophageal varices, etc. There is no history of aspirin or NSAID use according to her chart or from nursing home records. Her recent stools have been dark, but not bloody. Today she was observed to have a large emesis mixed with blood and was referred for evaluation.

PAST MEDICAL HISTORY:
Past medical history, social history, family history, and review of systems were extensively reviewed on her last admission 12/23/96. Please see that record. In brief, the patient has a history of aspiration pneumonia, organic brain syndrome, urinary tract infections, and bilateral fractured hips with chronic contractures. She has no chronic medications according to her nursing home record.

PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly female, talking loudly when disturbed.
VITAL SIGNS: Blood pressure 69/72, heart rate 95, respirations 18,temperature 99.2 rectally.
HEENT: The eyes cannot be examined due to non cooperation by the patient. She appears to have a cataract OD and an iridectomy OS.
NECK: The neck appears to be supple.
CHEST: Unremarkable.
LUNGS: Clear to auscultation and percussion.
CARDIOVASCULAR: Veins the jugular venous pulse is normal. Arteries central and peripheral pulses are difficult to palpate. Cor first and second heart tones are normal. Soft 5-4 gallop and soft nonspecific systolic murmur present.
ABDOMEN: Diffuse guarding with no palpable masses. Bowel sounds are slightly diminished.
EXTREMITIES: Bilateral leg contractures in the "fetal position." Upper extremities are non contracted and are mobile. No ulcers, sores, or deceit are evident.
NEUROLOGIC: No focal abnormalities are apparent; the patient is uncooperative with the examination.

LABORATORY:
CBC and chemistry profiles are not available at the time of admission. Guaiac of G - tube aspiration is positive with yellow material. Stool is black, but is guaiac negative.

IMPRESSION:

• History of vomiting with hematemesis; ?oral ?esophageal? gastric origin.
• Guaiac negative melanotic stool; ? iron ? bismuth ?
• Organic brain syndrome including unoffending, blink, deaf, demented individual with chronic contractures.
• The patient is DNI/DNR (do not intubate, do not resuscitate) statue per the nursing home.
• History of recurrent urinary tract infections.
• History of bilateral fractured hips and postoperative surgery with chronic contractures.

PLAN:
The patient will be admitted for observation. conservative management is planned. Invasive procedures will not be performed. Type and cross and trasfusion not planned. Compassionate care and comfort measures, however, will be instituted in full.

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