Name: ………………………………………………….….

……..
DOB: ………………………………. Gender:
…………….
MRN: …………………………….. NOG:
…………………
Resident Admission Note Adm. Date: …………………… Bed:

DATE: Thursday, September 17, 2020 TIME: 3:36 PM

CHIEF COMPLAINT: Anemia, Hematochezia
HISTORY: Case of 42 year old man presenting for Hematochezia and Anemia.
History goes back to 1 week prior to presentation when the patient went to his Nephrologist for follow up and a
drop in hb was noticed. FO3 x3 were ordered and found to be positive. He reports 1 episode of Hematochezia
yesterday associated with severe diffuse abdominal pain more prominent on the left side. He has generalized
fatigue and lightheadedness. No chest pain, dyspnea or palpitations. No fever or chills. Weight loss of 3 kg in 1
month.
To note patient had severe watery diarrhea non mucoid non bloody for 2 days that resolved on its owns 1 week
prior to presentation.

PMH:
- HTN
-ESRD (at age 17 years old due to Renal Hypoplasia s/p Bilateral Nephrectomy and 1.5 year before Kidney
Transplant)

PSH:
-Bilateral Nephrectomy
-Kidney Transplant (1996)
-Right testicle hydrocele
-Hiatal Hernia repair complicated by Esophageal Tear 2004

Allergies: Keflex (cefalexin)

Medications:
Rapamune (sirolimus) 1mg 2tabs daily
Cellcept (mycophenolate mofetil) 500mg BID
Prednisone 7.5mg OD
PPI 20mg TID
Maltofer OD
Doxazosin 4mg half tab OD
Concor 2.5 mg OD
Approvel (irbisartan) 150 OD
Folic Acid 5mg OD

TEMPERATURE: 37.2 SPO2: 100% PULSE: 55 BP: 110/70 HEIGHT: WEIGHT:

GENERAL APPEARANCE: Not in distress

NEURO: Alert & oriented x 3,
HEENT/NECK: Norm cephalic, atraumatic, Nose normal. Neck- normal range of motion
LUNGS/HEART:GBAE, RRR
ABDOMEN: +BS, Soft abdomen with left sided tenderness to palpation. Surgical scar noted
SKIN: On the back an elevated nevus with irregular border. Warm, no erythema, no rash
Lower Limbs: Right Lower Limb edema

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 Name: ………………………………………………….….
……..
DOB: ………………………………. Gender:
…………….
MRN: …………………………….. NOG:
…………………
Adm. Date: …………………… Bed:

DIAGNOSTIC TESTS:
UA negative
WBC: 6.9, Hgb:9.2, HCT:27.9, Na:142, K:5.1, CL-:107, HCO3:25, Urea:84, Cr:2.13, INR:1.05, PTT:28

IMPRESSION and PLAN:

This is the case of a of 42 years old man known to have HTN, ESRD s/p Kidney transplant, presenting for
Hematochezia of 1 week duration.
Please admit this patient under care of dr Rajaa Chatila
C:Stable
A:as tolerated
D:clear liquid, no jillo
IV 500NSS Q24h
HGT once daily
No anticoagulation
C/S Dr.Hala Kilani
C.diff antigen toxin tests
Endoscopy after 48 hours
R/O colon CA, R/O diverticulosis, R/O IBD, R/O internal hemorrhoids, R/O anal fissure: colonoscopy
R/O upper gastric bleed: gastroscopy
Resume home medications

RESIDENT NAME & SIGNATURE: Mohamad Khalifeh , PGY1 DATE 9/17/2020 TIME:3:36 PM

ATTENDING NAME & SIGNATURE: DATE TIME

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