Diagnostics

ECG:
Chest X-ray:
CBC: February 13, 2019 February 15, 2019 February 17, 2019
WBC 10.7 H 9.8 9.2
RBC 4.51 4.41 L 5.07
Hemoglobin 7.90 L 7.80 L 10.00 L
Hematocrit 29.3 L 28.9 L 34.3 L
MCV 65.0 L 65.5 L 67.7 L
MCH 17.5 L 17.7 L 19.7 L
MCHC 27.0 L 27.0 L 29.2 L
RDW-CV 20.0 H 22.1 H 25.0 H
Platelet Count 651 551 438
Differential Count
Neutrophil 65 H 60 59
Lymphocytes 20 20 21
Monocytes 4 6 6
Eosinophil 10 H 14 H 13 H
Basophil 1 0 1
Urinalysis:Urine Flowcytometry
Red Cells 1.00
Pus Cells 4.7
Epithelial Cells 1.0
Bacteria 1.0
Color Light Yellow
Transparency Clear
pH 7.0
Specific Gravity 1.010
Blood Negative
Leukocyte Negative
Glucose Negative
Nitrite Negative
Protein Negative
Urobilinogen Normal
Ketones Negative
Bilirubin Negative
Blood Chemistry:

Creatinine 58.4 umol/L

Sodium 149.9 mmol/L

Potassium 4.29 mmol/L

Ionized Calcium 1.28 mmol/L

Ionized Magnesium 0.56 mmol/L

CBS 137 mg/dL

Protime 12.1 seconds

INR 1.02

APTT 33.9 seconds

Differential Diagnosis
Rule In Rule Out
Rule In Rule Out
Rule In Rule Out
Course in the ward:
• Patient came in at the ER due to dizziness, initial assessment done
revealing a vital signs of: BP- , HR- , RR- , T- . History and Physical
examinations were obtained with a pertinent finding of
hematochezia, headache, melena, pale palpebral conjunctiva,
tenderness at epigastric area, and presence of fresh blood on
examining finger after digital rectal exam.
• The following labs were ordered: CBC which revealed a WBC of 10.7,
RBC of 4.51, Hemoglobin of 7.90, Hematocrit of 29.3 and Platelet of
651. Urinalysis which revealed red cells/HPF of 1.00, Pus cells/HPF of
4.7, Epithelial cells/HPF of 1.0 and Bacteria of 1.0. Creatinine of 58.4
umol/L, Sodium of 149.9, Potassium of 4.29, Ionized Calcium of 1.28,
Ionized Magnesium of 0.56, Protime of 12.1 seconds and APTT of 33.9
seconds. 12 leads ECG showed a normal sinus rhythm and a Chest X-
ray which revealed normal chest findings.
• Patient was then advised for admission, Venoclysis was started with
PNSS 1L at 30 gtts/min. Patient was placed on NPO. Medication given
was Omeprazole 80mg via IVTT. Patient was then transported to the
ward.
Hospital day 1:
• Patient still with pallor, occasional dizziness, and episodes of
headache. No melena, no hematochezia.
• Patient was seen awake, conscious and coherent, with anicteric
sclerae and pale palpebral conjunctiva, with clear breath sounds and
distinct heart sounds, tenderness was noted at epigastric area.
• Patient was otherwise stable.
• Plan: Patient was placed on soft diet.
Hospital day 2
• Patient still with pallor, occasional dizziness, and episodes of
headache. No melena, no hematochezia.
• Patient was seen awake, conscious and coherent, with anicteric
sclerae and pale palpebral conjunctiva, with clear breath sounds and
distinct heart sounds, tenderness was noted at epigastric area.
• Patient was otherwise stable.
• Plan: Patient was ordered with repeat CBC
Hospital day 3:
• Patient still with pallor, no dizziness, with no headache. No melena, no
hematochieza.
• Patient was seen awake, conscious and coherent, with anicteric sclerae
and pale palpebral conjunctiva, with clear breath sounds and distinct
heart sounds, tenderness was noted at epigastric area.
• Patient was otherwise stable. Repeat CBC result revealed: WBC of 9.8,
RBC of 4.41, Hemoglobin of 7.80, Hematocrit of 28.9 and platelet of 551.
• Plan: Facilitate Blood Transfusion of 1 ‘’U’’ PRBC of patients blood type
properly screened and crossmatched. For repeat CBC post Blood
Transfusion.
Hospital day 4:
• Patient without any subjective complaints, no pallor, no dizziness, no
headache, no melena, no hematochezia.
• Patient was seen awake, conscious and coherent, with anicteric
sclerae and pale palpebral conjunctiva, with clear breath sounds and
distinct heart sounds, tenderness was noted at epigastric area.
• Patient was otherwise stable. Repeat CBC post Blood Transfusion
result revealed: WBC of 9.2, RBC of 5.07, Hemoglobin of 10.00,
Hematocrit of 34.3 and platelet of 438.
• Plan: Continue current medication and management, Monitor Vital
Signs q4h, Refer for any unsualities.
Hospital day 5:
• Patient without any subjective complaints, no pallor, no dizziness, no
headache, no melena, no hematochezia.
• Patient was seen awake, conscious and coherent, with anicteric
sclerae and pale palpebral conjunctiva, with clear breath sounds and
distinct heart sounds, tenderness was noted at epigastric area.
• Patient was otherwise stable.
• Plan: May go home. Take home meds: Omeprazole 40mg/cap, 1 cap
OD ACBF for 14 days. For EGD as an outpatient. For CBC as an
outpatient. Follow-up on 03/07/19 with EGD and CBC result.
• Patient progressively improved clinically throughout his hospital stay
and was eventually discharged. BP- , HR- , RR- , T- ,.