Name: ………………………………………………….….……..

DOB: ………………………………. Gender: …………….

MRN: …………………………….. NOG: …………………
Adm. Date: …………………… Bed: …………….......
Physician: …………………………………………………..….
Coverage: ……………………………………………………...
Resident Admission Note
DATE: Thursday, September 17, 2020 TIME: 15:36 a9/p9
CHIEF COMPLAINT: Coffee ground emesis of 1 day duration
HISTORY: Case of 77 years old male known to have BPPV, Aortic stenosis s/p aortic ballooning (1975), hx of
right sided CVA (2006) with no residual weakness, paroxysmal afib on sintrom only, CAD? , presented with
above chief complaint. Patient reports 2 episodes of coffee ground emesis , with 2 episodes of melena with
loose stool , he also reports dizziness today, no weakness , no paresthesia, no abdominal pain .
He reports burning epigastric pain from time to time , no recent nsaid use , no weight loss , no decrease in
appetite , reports occasional dysphagia on solids, no dyspnea , no cough, no change in bowel habis, no other
complaint.
Travel hx : cotonou 1 month ago
Last TTE(13/05/2019): EF: 60-65% , Mild AS, Mild MR, Mild MS, mild Pulmo HTN, moderate to severe AR
PMH: BPPV
Aortic stenosis s/p aortic ballooning (1975)
right sided CVA (2006),
paroxysmal afib
CAD?
PSH: Bilateral inguinal hernia
Bilateral Cataract
Left leg nerve release?
Aortic ballooning
Allergies: none
Medications:
Betaserc 16mg Bid
Sintrom 4mg ¾ OD
Sigmart 10mg bid
Simvastatin 20mg OD

SH: Past smoker

Non alcoholic
ROS:
Constitutional: Denies fever, chills, weight loss or weakness
HENT:  Denies sore throat or ear pain
Respiratory: Chronic whitish sputum , no shortness of breath
Cardiovascular: Denies chest pain, palpitations or swelling
GI: Denies abdominal pain, nausea.
GU:  Denies dysuria, polyuria, hematuria, flank pain
Neurologic: Denies headache, focal weakness or sensory changes

TEMPERATURE: 37.1 SPO2: 98% PULSE: 95 BP:117/60 HEIGHT: WEIGHT: 73

GENERAL APPEARANCE: Normal, not in distress

NEURO: Alert & oriented x 3, normal motor function, normal sensory function, no focal deficits noted.
HEENT/NECK: Norm cephalic, atraumatic, oropharynx moist, no oral exudates, Nose normal. Neck- normal range of motion
Pale conjuctiva
LUNGS/HEART: Irregular S1S2, 2/6 systolic murmur ,no rubs, no gallops. GBAE , fine bibasilar crackles
ABDOMEN: Bowel sounds normal, Soft, Mild LLQ tenderness, no masses, no pulsatile masses./DRE: melena

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MR F-10 Ed.7
 Name: ………………………………………………….….……..
GENITO-URINARY: No CVA tenderness DOB: ………………………………. Gender: …………….
MRN: …………………………….. NOG: …………………
SKIN: Warm, dry, no erythema, no rash
Adm. Date: …………………… Bed: …………….......
OTHERS: Trace bilateral pitting edema , positive peripheral pulses
Physician: …………………………………………………..….
Coverage: ……………………………………………………...

Resident Admission Note (Continued)

DIAGNOSTIC TESTS:
WBC 9.45
RBC 3.59
HGB 10.6
HCT 32.3
MCV 90.1
MCH 29.7
MCHC 33
CHCM 32.4
RDW 14.9
HDW 2.43
PLT 189
MPV 8.1
%NEUT 87.3
SODIUM 138
POTASSIUM 4.8
CHLORIDE 102
CO2 24
UREA 121
CREATININE 1.03
CPK 61
CKMB 2
TROPONIN T 0.019
INR 4.07
PTT PATIENT 38
IMPRESSION: Case of 77 years old male known to have BPPV, Aortic stenosis s/p aortic ballooning (1975), hx of right
sided CVA (2006) with no residual weakness, paroxysmal afib on sintrom only, CAD? , presented with Coffee ground
emesis and melena:
r/o Upper gi bleed
R/o PUD
R/o polyps/ tumor
MANAGEMENT PLAN:
IV Hydration
Repeat CBCD at 6 PM
Skip sintrom today
Nexium iv BID
Clear fluid diet + keep npo after midnight tomorrow EGD
Repeat CBCD INR Tomorrow
Monitor Vitals frequently

RESIDENT NAME & SIGNATURE: Ali Dakroub PGY1 DATE 9/17/2020 TIME:15:36 a9/p9

ATTENDING NAME & SIGNATURE: DATE TIME

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MR F-10 Ed.7