allergies: actos / hydrocodone / oxycodone / codeine / celexa attending: chief complaint: gi bleed major surgical or invasive procedure: egd with variceal banding history of present illness: hpi: 64 y.o. f with previously diagnosed cirrhosis (biopsy ) due to nash, and previously known grade 1 varices seen on egd in , and confirmed again in who presents with 6-7 episodes of hematemesis. patient states her vomiting started suddenly today at 7:30 am and continued until 11 am. the nausea is resolved upon interviewing in ed @ 2 pm. patient also reported associated lightheadedness, diaphoresis and became pale. she denied any hemoptysis, no cough, no chest or abdominal pain, no palpitations. no fevers/chills. patient also reported a single episode of melana this morning. she states yesterday she had a normal bowel movement which was brown. she denied any occult blood, no history of lgib or melana. no history of hematemesis or hemoptosis in the past as well. patient reports mild persistent swelling of lower extremities, she also reports mild abdominal girth increase. however she does not way herself at night. she denies any pnd, no orthopnea, she has been compliant with her diuretics. . in ed: patient given, protonix iv, ciprofloxacin, and writen for octreotide; zofran for nausea; past medical history: dm on insulin htn cirrhosis - liver u/s with cirrhosis and no focal lesions , endoscopy with grade i and ii esophageal varices in colonoscopy with adenoma in nash anemia - baseline hct 35 atrophic vaginitis social history: 2 siblings with dm, mother with liver ca, sister with breast ca, no cad . family history: lives at home with husband, no etoh or alcohol, no other drugs. physical exam: 98.2 68 141/53 100ra gen: overweight, pleasant female, nad, speaking in full sentences, comfortable. heent: anicteric sclera, eomsi, clear op - no evidence of thrush or recent bleeding, spiting clear saliva cv: rrr, nl s1, s2, no m/r/g lungs: ctab/l, no w/r/r abd: nt, nd, +bs, no organomegaly, no evidence of spider angiomas ext: wwp x 4 w/o c/c/e or rashes . pertinent results: 11:50am blood wbc-3.9* rbc-3.46* hgb-9.0* hct-27.7* mcv-80* mch-26.0* mchc-32.5 rdw-17.7* plt ct-108* 06:00pm blood hct-25.2* 12:17am blood hct-24.9* 05:41am blood wbc-2.6* rbc-2.89* hgb-7.6* hct-23.6* mcv-82 mch-26.3* mchc-32.1 rdw-18.4* plt ct-86* 05:55pm blood hct-28.0* 04:43am blood wbc-6.2# rbc-3.60* hgb-9.7*# hct-29.2* mcv-81* mch-26.9* mchc-33.1 rdw-18.6* plt ct-139*# 11:50am blood glucose-297* urean-24* creat-0.7 na-137 k-4.9 cl-106 hco3-25 angap-11 egd on : esophagus: protruding lesions 1 cords of grade ii varices and 2 cords of grade 1 varicies were seen in the esophagus. there were stigmata of recent bleeding on the grade 2 varix. 1 band was successfully placed. stomach: contents: clotted blood was seen in the stomach. mucosa: granularity, erythema and congestion of the mucosa were noted in the stomach consistant with portal gastropathy. duodenum: contents: clotted blood was seen in the duodenum. brief hospital course: variceal bleed- banding completed on egd. received 1 unit prbc, and subsequenty hematocrits have been stable. patient's diet was advanced, and she tolerated po's well, and was therefore discharged. . # thrombocytopenia/pancytopenia- has been attributed to her cirrhosis and been seen in hematology/oncology as outpatient. stable throughout duration of hospitalization. . # cirrhosis - continued nadolol and furosemide and spironolactone restarted. started cipro for sbp prophylaxis given variceal bleed. . # dm 2 - restarted metformin 500 . medications on admission: ultram 50 mg aldactone 25 mg lasix 40 mg po qd prilosec 20 mg otc nadolol 20 mg qd humalog glucophage 500 mg asa 81mg discharge medications: 1. sucralfate 1 g tablet sig: one (1) tablet po qid (4 times a day). disp:*120 tablet(s)* refills:*2* 2. metformin 500 mg tablet sig: one (1) tablet po bid (2 times a day). 3. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 4. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). disp:*60 tablet, delayed release (e.c.)(s)* refills:*2* 6. ciprofloxacin 250 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*30 tablet(s)* refills:*2* 7. insulin nph human recomb 100 unit/ml suspension sig: take 54 u in the am 16 u at 5 pm and 34 u at 10 pm subcutaneous three times a day. 8. humalog 100 unit/ml solution sig: based on sliding scale used at home previously subcutaneous qachs. 9. spironolactone 25 mg tablet sig: one (1) tablet po twice a day. discharge disposition: home discharge diagnosis: variceal bleed secondary diagnoses: cirrhosis diabetes mellitus discharge condition: hematocrit and vital signs stable. discharge instructions: you were admitted for bleeding and vomitting. you had an endoscopy procedure to see where you were bleeding from, and then the bleeding was treated by tying of the sites of bleeding, and also with medication and blood transfusion. please call your physician if you experiencing worsening severe dizziness, lightheadedness, blood in vomit, blood in stool, black stools, abdominal pain, or any other concerning symptoms. followup instructions: you have an appointment with your liver doctor, dr. on tuesday :15 pm. please call ( with any questions, concerns, or to change your appointment Procedure: Endoscopic excision or destruction of lesion or tissue of esophagus Diagnoses: Unspecified essential hypertension Cirrhosis of liver without mention of alcohol Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Long-term (current) use of insulin Esophageal varices in diseases classified elsewhere, with bleeding Other chronic nonalcoholic liver disease