allergies: patient recorded as having no known allergies to drugs attending: chief complaint: fatigue, melena major surgical or invasive procedure: egd angiography with chemoembolization to l gastric artery history of present illness: 87 yo f with h/o cad s/p mi , chf ef 30-40%, ar, mr, tr, gerd, remote history of breast cancer who presented with 4 episodes of melena. the patient reported feeling fatigued for several days, and then having first episode of melena on the evening of and then had additional 3 episodes. she denies any prior episodes of melena or bright red blood per rectum. on presentation, vital signs were stable and the patient's initial hematocrit was 26.6. ng lavage did not clear with 1000 cc ns, clots present. she denied nausea, vomiting and abdominal pain. she also denied any nsaid use or additional aspirin use (takes 1 full dose aspirin/day). past medical history: 1. cad, qwmi . subsequent p-mibi with slightly rev t in distal anterior/inferior walls and apex. ef 30-40% at that time. 2. mr, tr, ai 3. breast cancer s/p excision/radiation/tamoxifen 4. depression 5. gout social history: widow. lives in . family history: non-contributory pertinent results: 01:30am blood wbc-15.7*# rbc-2.69* hgb-8.5* hct-26.7* mcv-99* mch-31.8 mchc-32.1 rdw-17.1* plt ct-295 01:30am blood plt ct-295 01:30am blood neuts-76.6* bands-0 lymphs-18.8 monos-3.3 eos-0.8 baso-0.4 01:30am blood pt-13.2 ptt-22.7 inr(pt)-1.1 01:30am blood glucose-155* urean-57* creat-0.9 na-142 k-4.5 cl-106 hco3-23 angap-18 01:30am blood ck(cpk)-42 01:30am blood ck-mb-notdone ctropnt-<0.01 06:00am blood calcium-8.0* phos-3.9 mg-1.7 01:30am blood vitb12-435 folate-greater th ekg: normal sinus rhythm. q waves in leads v1-v3 suggest prior anterior myocardial infarction. q waves in leads iii and avf consistent with prior inferior myocardial infarction. non-specific st-t wave flattening. compared to the previous tracing of the st segment elevations in leads v2-v3 are no longer present. otherwise, no diagnostic interval change. brief hospital course: 87 yo female with history of cad, htn, chf and breast cancer admitted with melena. 1. ugib- the patient presented with fatigue and melena. her initial hematocrit was 26. an ng lavage in the ed did not clear with >1 liter saline. gi and surgery were consulted and recommended urgent egd. her initial egd showed diffuse red blood in the fundus and body of the stomach with no identifiable source. she was then taken emergently to ir for angiography. angiogram showed no obvious source of bleeding; however, the left gastric artery was prophylactically emoblized with gel foam. the patient subsequently had no further bleeding episodes and her hematocrit stablilized. her aspirin was discontinued. she received a total of 4units of prbcs and was started on protonix. an h.pylori was sent and is pending at the time of discharge. she had a re-look egd on which showed severe diffuse gastritis with contact bleeding. she will need outpatient gi follow-up. 2. cad: the patient denied chest pain however given her history of cad she was ruled out for mi with serial cardiac enzymes. she had no events on telemetry. her aspirin and beta blocker were held on admission; however, once her hematocrit stabilized her beta blocker was restarted. 3. htn: restarted on beta blocker. 4. depression: the patient was continued on celexa and remeron with trazadone prn at night. 5. access: 2 large bore ivs were maintained at all times. 6. px- pneumoboots, ppi 7. code: full, hcp: daughter- . 8. dispo: she is being discharged to home with pcp and gi . vna services have been arranged for a hematocrit check 2-3 days after discharge. medications on admission: lopressor 25 lasix 20 every other day ecasa 325 daily mvi celexa 20 daily remeron 15 daily trazadone 25 daily discharge medications: 1. citalopram hydrobromide 20 mg tablet sig: one (1) tablet po hs (at bedtime). 2. mirtazapine 15 mg tablet sig: one (1) tablet po hs (at bedtime). 3. allopurinol 100 mg tablet sig: two (2) tablet po qd (once a day). 4. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po every twelve (12) hours. disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 5. trazodone hcl 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed. 6. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). discharge disposition: home with service facility: family & services discharge diagnosis: primary diagnosis: ugib secondary diagnosis: cad depression htn discharge condition: no further episodes of melena. hd stable. hct stable x 48 hours. discharge instructions: please take your medications as prescribed and keep all scheduled appointments. call your doctor or return to the er if you experience worsening fatigue, abdominal pain, chest pain, black stools or bloody stools. do not take any aspirin or nsaids until further notice. followup instructions: provider: , where: date/time: 1:30 Procedure: Other endoscopy of small intestine Other endoscopy of small intestine Injection or infusion of other therapeutic or prophylactic substance Arteriography of other intra-abdominal arteries Transfusion of packed cells Diagnoses: Coronary atherosclerosis of native coronary artery Esophageal reflux Acute posthemorrhagic anemia Personal history of malignant neoplasm of breast Mitral valve insufficiency and aortic valve insufficiency Depressive disorder, not elsewhere classified Rheumatic heart failure (congestive) Old myocardial infarction Diseases of tricuspid valve Acute gastritis, with hemorrhage