AG

74/F
Roman Catholic
Married

HISTORY OF PRESENT ILLNESS 

1 day prior, noted difficulty defecating, able to pass dark-colored but formed stools after straining. No consult consult or
intervention done.
Few hours prior, at around 5am, he suddenly felt weak after urinating, causing him to almost fall on the floor if not for his wife
assisting him. He was subsequently brought to a chair to rest, noting slight relief of weakness. In the interim, he was still able to
perform his usual activities (chores) but with observed exertional dyspnea and easy fatigability, relieved temporarily with rest.
Persistence prompted ER consult.
ROS: Frequent bouts of knee pain for which he would take indomethacin for relief

PAST MEDICAL HISTORY 

Hypertension x 4 years, usual BP 130/80, highest BP 140/100
Type 2 diabetes mellitus x 4 years, no CBG monitoring, no recent HBA1c
Kidney disease? (Was previously told he had elevated creatinine)
No surgeries or allergies
Maintenance medications: ​Sodium bicarbonate 650mg OD, Sitagliptin 50mg OD, Telmisartan amlodipine 40/10mg OD,
Febuxostat 40mg

FAMILY HISTORY: ​type 2 diabetes mellitus, hypertension, stomach cancer

PERSONAL AND SOCIAL HISTORY: ​80 pack year smoker, stopped 10 years ago, occasional alcohol drinker, retired office
worker

At the ER: 
Awake, not in distress
BP 110/80 HR 93 RR 20 T 36.7
(+) Pale conjunctiva, no icteresia
Normal rate, regular rhythm, no murmur
Crackles on the mid lung field, right; clear on the left; no wheezing
SpO2 98% at room air
Abdomen soft, nondistended, nontender; no organomegaly
Full and equal pulses, no pedal edema
DRE: empty rectal vault, no masses, (+) non-thrombosed grade 3 hemorrhoids, (+) minimal black stools on examining finger
Baseline CBG: 182 mg/dL (last meal: 2 hours prior)

Baseline laboratory results: 

CBC: Hgb 78 Hct 0.23 RBC 2.59 WBC 12.99 MCH 30 MCHC 0.34 MCV 89 RDW 12.7
Bands 0 Neutrophils 0.84 Lymphocytes 0.11 Monocyte 0.05 Eosinophil 0 Basophil 0

Crea 1.36 mg/dL eGFR 50

Na 139 K 4.50 iCa 4.92 Mg 1.95 NT-pro BNP 73.75
CXR:

Consolidation in the right mid/lower zone with effacement of the right heart border. The right hemidiaphragm silhouette is clearly
outlined. Left lung is clear.

*Silhouette sign​ in this case identifying a right middle lobe pneumonia. The right heart border is effaced indicative of
consolidation in the medial segment of the right middle lobe.
12-L ECG
OTHERS: 
On the 3rd hospital day, was scheduled for EGD
Intraoperative findings: (+) Gastric ulcer antrum) Forrest III; (+) Duoedenal ulcers (D1, D2), Forrest III