CHIEF COMPLAINT: Here today for update after gastrointestinal bleeding and other issues.
SUBJECTIVE: Since last seen, the patient has felt well. He has had no abdominal pain at all. He has had no heartburn or indigestion. Yesterday, he had very dark, almost black stool once. This morning, brown stool with some blood streaking.
He will be out of breath if he runs up 2 flights of stairs but is not out of breath with standard everyday activities. At no point, has he had chest heaviness or tightness, pressure or palpitation. His most recent hemoglobin on MM/DD/YYYY was lower at 7.4, had been 8.8 prior. Another one drawn this morning, results not yet available. Recall he is thought to have chronic GI blood loss from AVM in the small intestine. There may be a component of portal hypertension.
When seen last time, he had superficial phlebitis to veins of the left leg. Those areas have improved. He was also found with an asymptomatic DVT in calf vein, left side.
Given the bleeding, anticoagulation was not offered. As mentioned, he has had no symptoms. Importantly, most recent venous Doppler studies showed some improvement. He has had no new symptoms in that leg. However, he just yesterday developed swelling and discomfort in the right upper extremity, especially proximal portion into axilla. Symptoms started at the site of a PICC line that was removed 10 days ago.
MEDICATIONS: Crestor 40 mg. Nasonex. Omeprazole 20 mg. Nadolol 20 mg.
ALLERGIES: DIOVAN, LISINOPRIL, and PENICILLIN.
OBJECTIVE: VITAL SIGNS: Weight is 231 pounds. Height is 66 inches. BMI above 30. BP 112/62. Pulse is 80 and regular. LUNGS: Clear. No wheezing or rhonchi. HEART: Regular rhythm. No gallop or murmur. EXTREMITIES: Upper extremity, there is obvious mild diffuse swelling of the proximal portion of the upper arm extending past the elbow into the mid forearm. He is mildly tender to palpation at the site of the PICC line in the medial distal upper arm. Pulses are felt. In lower extremities, no superficial tenderness and no edema noted.
ASSESSMENT:
1. Gastrointestinal bleeding, thought related to arteriovenous malformations. May have had a small bleed the last day or two.
2. Anemia secondary to gastrointestinal bleeding.
3. Possible portal hypertension, cause is not clear.
4. Clot in the calf vein of the left leg, improved when last checked.
5. New right upper extremity swelling, findings worrisome for clot in the brachial vein, part of the shoulder complex.
PLAN:
1. Await hemoglobin level today. May be a candidate for further transfusion.
2. Await further input from liver specialist regarding exact diagnosis, need for intervention.
3. Venous Doppler study of the right upper extremity.
4. If clot is present, then we will have to discuss with the specialist whether or not anticoagulation may be given, especially in light of possible recent active gastrointestinal bleeding.
5. Followup depends on the results of the labs and testing. May need to be seen within a few weeks.
6. Otherwise, we will follow up with him in 3 or 4 weeks.
