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85y/o m w/ hx AD, diverticulosis, recently dx colon ca
s.p hemicolectomy p/w dark stools and dropping Hct (30
-->26-->23).
NG lavage was negative in ED, however, pt with duodenal ulcer
on EGD [**7-2**]. Possibly recent PUD vs anastomotic site vs [**1-26**] colon ca vs
diverticulosis.
Review of systems:
Constitutional: No(t) Fever
Cardiovascular: No(t) Chest pain, No(t) Palpitations
Respiratory: No(t) Cough, No(t) Dyspnea
Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,
No(t) Diarrhea, No(t) Constipation
Since 12 AM
Tmax: 37.3 C (99.2
Tcurrent: 37.3 C (99.2
HR: 69 (64 - 78) bpm
BP: 150/73(91) {128/39(65) - 150/99(103)} mmHg
RR: 16 (16 - 24) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
O2 Delivery Device: None
SpO2: 100%
ABG: ////
Physical Examination
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), RRR
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Tender: ,
healing colectomy scar, no erythema, tenderness, bleeding, oozing.
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): only new year and thought he was at [**Hospital1 947**],
Alzheimer's: pt with baseline dementia. Pt oriented to self, but not
time or place.
Movement: Purposeful, Tone: Normal
Labs / Radiology
WBC
9.7
Hct
24.0
Plt
593
Other labs: PT / PTT / INR:14.4/27.2/1.3"