allergies: patient recorded as having no known allergies to drugs attending: chief complaint: loss of consciousness/melenic stools major surgical or invasive procedure: ercp history of present illness: hpi: mr. is a 44 year old male with a history of hcv/etoh cirrhosis s/p olt . he was brought to the ed following a syncopal episode. he reports that he has been having black, tarry stools for the last 3 days that became heavy today. there is no bright red blood. he has been nauseous since last night, but has not vomited. he has become progressively more fatigued and weak over the past few days. this morning, he was too tired to walk to the bathroom. he stood to use his urinal, became dizzy, fainted, and fell to the ground. he landed on his left wrist and ankle, which are painful now. he is also complaining of headache, but it is unknown if he hit his head as the fall was not witnessed. he does not have abdominal pain. he underwent egd in , which demonstrated mild portal gastropathy and grade 1 nonbleeding varices. past medical history: - transjugular liver biopsy in - h/o sbp -> on prophylaxis - h/o encephalopathy - h/o ascites - jaundice starting in - ? no etoh since to , h/o cocaine in -olt c/b ha stenosis, stented - admit to hospital for rehab/?depression - candidiasis - syncopal episode attributed to ugi bleeding social history: lives with mother in . denies etoh, drugs disabled chem engineer family history: nc physical exam: t98 bp100/61 hr105 rr17 gen: pale, appears tired, speaking slowly heent: no icterus, dry mucous membranes pulm: clear to auscultation bilaterally cvs: tachycardic, regular rhythm, no murmurs/rubs/gallops abd: soft, nontender, nondistended, +bowel sounds, well-healed subcostal incisions, guiaic positive as per ed, ng lavage not grossly bloody ext: no edema, no clubbing, no cyanosis pertinent results: 12:20pm wbc-5.5 rbc-2.07*# hgb-6.7*# hct-19.6*# mcv-95 mch-32.5* mchc-34.3 rdw-20.0* 12:20pm alt(sgpt)-60* ast(sgot)-38 alk phos-75 amylase-13 tot bili-0.2 12:20pm albumin-3.6 calcium-9.4 phosphate-4.9* magnesium-1.4* 12:20pm lipase-7 12:20pm plt count-160 12:20pm pt-11.5 ptt-23.4 inr(pt)-1.0 06:25am blood wbc-3.8* rbc-3.27* hgb-10.7* hct-30.8* mcv-94 mch-32.6* mchc-34.7 rdw-19.5* plt ct-89* 06:25am blood plt ct-89* 06:25am blood glucose-117* urean-26* creat-1.3* na-144 k-4.8 cl-111* hco3-26 angap-12 06:25am blood alt-42* ast-30 alkphos-62 totbili-0.3 03:37am blood fk506->30.0 05:45am blood fk506-30.0* 06:10am blood fk506-19.9 06:25am blood fk506-10.2 brief hospital course: an ng was placed while in the ed for lavage. no blood was detected. he received 2 units of prbc while in the ed for a hct of 19.6. hct increased to 23.6. an egd was performed with no active bleeding noted. serial hematocrits were done. he was transferred to the sicu for management until . another 2 units of prbc were given with hct increase to 31.8. a ct without contrast revealed gaseous distention of the small and large bowel consistent with recent egd procedure. no evidence of perforation or free fluid collections within the abdominal cavity. submillimeter nonobstructive right renal calculi or vascular calcification was noted. asa and plavix (for hepatic artery stent) were held. on potassium was 6.7. repeat k+ was 5.7. iv lasix, saline, insulin and bicarb were given. k+_decreased to 4.8. a ct of the head showed no acute intracranial pathology. ekg was normal. a ct of the left ankle and left wrist were negative for fractures. ortho was consulted for persistent left foot pain. pt was consulted and recommended crutches for foot pain limiting ambulation. iv protonix was started . fluconazole was started for esophageal candidiasis. consequently, prograf levels increased to 30. prograf was held for elevated levels since fluconazole was started on . on , his fk level was 10.2. he was discharged on fk of 3mg q 12 hours with strict instructions to follow up on and have an fk level drawn, as well as a cbc and chem-7. of note, a ct scan from was negative for any source of gi bleeding, such as pseudoaneurysm. medications on admission: colace 100", prednisone 12.5', plavix 75', asa 325', gemfibrozil 600", bactrim, mmf 500", valcyte 900', protonix 40', prograf 6", insulin sliding scale, nph 10u qam discharge disposition: home with service facility: homecare discharge diagnosis: ugi bleeding l foot synovial injury discharge condition: good discharge instructions: please call the transplant office if you experience fevers, chills, nausea, vomiting, black or bloody stools, abdominal pain, jaundice, too low or too high glucoses, dizziness or any concerns. Procedure: Transfusion of packed cells Diagnoses: Chronic hepatitis C without mention of hepatic coma Alcoholic cirrhosis of liver Iron deficiency anemia secondary to blood loss (chronic) Blood in stool Liver replaced by transplant Syncope and collapse Other and unspecified alcohol dependence, continuous Candidal esophagitis