history of present illness: the patient is a 54-year-old woman with a past medical history significant for migraine headaches, anemia, and gastroesophageal reflux disease who presented to the emergency department on with coffee-grounds emesis, melena, and weakness. ms. was in her usual state of health until waking on and finding herself weak. that morning she had black/tarry stool and several episodes of nausea and vomiting with emesis described as dark and coffee-grounds like. she reported increased thirst, mild dyspnea, abdominal pain, and significant dizziness. she reports she might have syncopized several times, but it was not clear about what actually happened. she was able to manage to call her husband who came home and called emergency medical technicians immediately. upon arriving, the emergency medical technicians found ms. to have a systolic blood pressure of 70, a heart rate of 140, and a respiratory rate of 20 to 24. they administered 3 liters of intravenous fluids, and the patient's blood pressure responded into the 120s. the patient was taken to the emergency department where a nasogastric lavage was administered, clearing with 500 cc. a chest x-ray was negative for dissection, and an electrocardiogram was normal. the patient had a hematocrit of 22.8; down from her baseline of around 26. three large-bore intravenous lines were placed, and the patient was transferred directly to the medical intensive care unit where she was transfused a total of 2 units of packed red blood cells and aggressively hydrated. her hematocrit responded 26.1, and her blood pressure remained stable with a systolic blood pressure in the 110s; although she remained tachycardic in the 90s to 100. the gastrointestinal service was consulted and performed an esophagogastroduodenoscopy which showed no active bleed but ulcers in the prepyloric area, submucosal hematomas/angiomas in the fundus, and a small hiatal hernia. the gastrointestinal service felt that the lesions could be consistent with nonsteroidal antiinflammatory drug induced gastropathy. upon questioning, the patient reported that she took at least 100 excedrin pills and some aleve during the last month for her migraine headaches. she had a remote history of gastric ulcers in and a history of gastroesophageal reflux disease with a protonix prescription, but she was not taking the proton pump inhibitor regularly. the patient was started on protonix 40 mg by mouth twice per day, and a helicobacter pylori antibody was sent. the patient was transferred from the medical intensive care unit to the general medicine floor with a stable hematocrit in the high 20s and a stable blood pressure with a systolic blood pressure in the 110s. past medical history: 1. peptic ulcer disease in . 2. migraine headaches. 3. gastroesophageal reflux disease. 4. anemia of unknown origin. 5. cervical spondylosis/radiculopathy. 6. osteoarthritis. 7. depression. 8. hypercholesterolemia. 9. obstructive sleep apnea. 10. history of diverticulitis times one. 11. hypertension. 12. status post carpal tunnel surgery. 13. status post cesarean section. medications on admission: 1. atorvastatin 10 mg by mouth once per day. 2. mirapex 0.125 mg by mouth q.h.s. 3. imitrex 50 mg by mouth q.6h. as needed (for headache). 4. atenolol. allergies: compazine (causes dystonia). social history: the patient is married with three children. she is a dental hygienist. she reports increased stress on the job recently. she reports occasional alcohol. no tobacco. no intravenous drug abuse. family history: father has alzheimer's disease. sister has depression. brother has psychosis. review of systems: the patient reports that she is premenopausal and has experienced increased vaginal bleeding in the last several months. menses have occurred roughly twice per month and have been heavier than normal. physical examination on presentation: physical examination on admission to the medicine service revealed the patient's temperature was 97.6, pulse was 78, blood pressure was 108/44, and oxygen saturation was 99% on room air. in general, the patient was in no apparent distress. alert and oriented times three. good skin color. good skin turgor. head, eyes, ears, nose, and throat examination revealed extraocular muscles were intact. pupils were equal, round, and reactive to light. the mucous membranes were moist. no lymphadenopathy. the oropharynx was clear. the chest was clear to auscultation bilaterally. no wheezes. cardiovascular examination revealed a regular rate and rhythm. no murmurs, rubs, or gallops. abdominal examination revealed the abdomen was soft, nontender, and nondistended. normal active bowel sounds. no hepatosplenomegaly appreciated. extremities were warm and well perfused. no clubbing, cyanosis, or edema. neurologic examination revealed cranial nerves ii through xii were grossly intact. strength was throughout. no gross sensory deficits. pertinent laboratory values on presentation: the patient's laboratories on admission to the medicine service revealed her white blood cell count was 7.7, her hematocrit was 28.4, and her platelets were 246. sodium was 141, potassium was 3.7, chloride was 109, bicarbonate was 24, blood urea nitrogen was 7, creatinine was 0.5, and her blood glucose was 113. calcium was 8.3, magnesium was 1.9, and phosphorous was 2.7. albumin was 2.9. cardiac enzymes were negative times three. pertinent radiology/imaging: a chest x-ray was negative. esophagogastroduodenoscopy showed submucosal hematomas/angiomas, prepyloric ulcers, and a small hiatal hernia. concise summary of hospital course by issue/system: 1. upper gastrointestinal bleed issues: the patient's blood pressure and pulse stabilized after 2 units of packed red blood cells administered in the medical intensive care unit along with generous intravenous hydration. esophagogastroduodenoscopy was negative for an active bleed but was positive for changes most likely caused by nonsteroidal antiinflammatory drug use. the patient was started on protonix 40 mg by mouth twice per day and quickly advanced her diet to a full house diet. after the transfusion, the patient's hematocrit remained stable in the upper 20s. on the day of discharge, her last hematocrit was 29.7; which was actually above the patient's baseline. a second esophagogastroduodenoscopy was performed on and again showed no active bleed, and the same nonsteroidal antiinflammatory drug induced gastropathy seen in the first scoping. the patient was discharged with instructions to take protonix 40 mg by mouth once per day for at least the next six weeks and to follow up by calling gastroenterologist dr. in one week's time. she was also asked to stay away from nonsteroidal antiinflammatory drugs at least until after seeing her gastroenterologist. an helicobacter pylori antibody was sent and was still pending at the time of discharge. 2. anemia issues: the patient's baseline hematocrit was roughly 26. there had been an outpatient workup, which did not reveal a cause of this anemia. the patient's acute gastrointestinal bleed which brought her in on this admission was probably not related to her baseline anemia. the patient did report increased menses recently, which certainly could be contributing to her baseline anemia. she was asked to follow up with her outpatient gynecologist after discharge. the patient was also asked to follow up with her primary care provider for evaluation of her chronic anemia. 3. hypertension issues: the patient had been taking atenolol for hypertension at home. however, the atenolol was held during her hospital stay due to hypotension following the acute bleed and then her blood pressure stable in the 100 to 110s/50s the rest of the hospital stay. she was discharged without atenolol, and the patient was asked to follow up with her primary care provider for possible restarting of this medication in the future. 4. fluids/electrolytes/nutrition issues: the patient was made nothing by mouth upon admission to the hospital for gastrointestinal bleed, but after esophagogastroduodenoscopy showed no active bleeding, her diet was slowly advanced. she was tolerating a full house diet by the day of discharge. her electrolytes were monitored and repleted when necessary. she was given generous intravenous fluids until she was eating well. 5. migraine headache issues: the patient was continued on imitrex for her migraines with tylenol, but no nonsteroidal antiinflammatory drugs available. she was discharged with a prescription for imitrex on the same dose she came in on. 6. obstructive sleep apnea issues: the patient reported that she did not use continuous positive airway pressure consistently at home and refused to use this during her hospital stay. she reported no symptoms of obstructive sleep apnea. condition at discharge: the patient's condition on discharge was good. primary discharge diagnoses: (her discharge diagnoses were) 1. upper gastrointestinal bleed. 2. nonsteroidal antiinflammatory drug-induced nephropathy. 3. anemia. secondary discharge diagnoses: 1. gastroesophageal reflux disease. 2. migraine headaches. 3. depression. 4. hypertension. 5. hypercholesterolemia. 6. history of diverticulitis. medications on discharge: (her discharge medications were) 1. atorvastatin 10 mg by mouth once per day. 2. mirapex 0.125 mg by mouth q.h.s. 3. protonix 40 mg by mouth once per day. 4. imitrex 50 mg by mouth q.6h. as needed (for migraine headaches); take two doses separated by one hour, maximum of two doses per 24 hours. discharge instructions/followup: 1. the patient was asked to follow up by calling her gastroenterologist (dr. in one week. 2. the patient was also asked to follow up with her primary care provider (dr. in the next several days. dr. was expected to evaluate ms. chronic anemia and consider restarting her atenolol as an outpatient. 3. the patient was also instructed to make an appointment with her gynecologist within the next several weeks for evaluation of her recent heavy menses. , m.d. dictated by: medquist36 Procedure: Other endoscopy of small intestine Esophagogastroduodenoscopy [EGD] with closed biopsy Diagnoses: Esophageal reflux Pure hypercholesterolemia Unspecified essential hypertension Iron deficiency anemia secondary to blood loss (chronic) Diaphragmatic hernia without mention of obstruction or gangrene Unspecified sleep apnea Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus