Medical record # :Q000099956
Admitted: 03/01/2009.
Telemetry Floor: placed on monitor.
Robert Johnson Yetund.
Admitting Diagnosis:Upper GIB,Aspiration pneumonia, NSTEMI,Homeless.
PMH:Heroine abuse,Hep C, Asthma,EGD 05/2009(Large gastric Varies)On 05/05/2009 EGD done found large gastric esophageal, scheduled for colonoscopy on 05/06/2009. Patient remain noncompliance with plan of care.Left and came back two days later with swelling of bilateral lower extremities, fatigue and abdominal pain.
GCS = 15.
Height: 5ft 8inches
Weight: 166lbs.
Chest xray showed pulmonary edema.
Patient had nstemi.(Non S .T.sgment elevation.
Troponin 5.2
Patient had black/Tarry stools x3 days.
Hgb= 5.4.
Attending Doctor : Dr. Too Much.
Plan intervention:
Transfuse: 4units of PRBC.
Diuretic given
Nebulizer.
Protonix intravenously to help stop the bleeding.
Allergy: NKDA.
Diet :Regular diet.
Language: English speaking.
H/H after blood transfusions 8.2/25.8
PLAN:
Transfer to SNF when there is accepting SNF
No accepting SNF.
Declined by Rosemead FANS SNF.
Nurses You Move Me 