HISTORY: The patient had a gastric bypass surgery on 04/12/2006, complicated by GI bleeding postoperatively for which he needed 11 units of blood. He had 3 episodes of endoscopy. We never saw active bleeding but several areas of potential bleeding, including a visible vessel at the gastrojejunostomy, were either clipped or cauterized. He left the hospital on the sixth postoperative day, went home for 1 day, had some blood per rectum and was readmitted just for 1 day of observation, which did not reveal any active bleeding but old bleeding. His hematocrit was stable. He now is feeling well. He has good energy. He has no pain. He is taking liquids well, urinating well and moving his bowels well without blood.
OBJECTIVE: On physical exam, his weight is 254 pounds. His preop weight was 289. His BMI is now 38. His pulse is 72. Blood pressure is 122/90, respirations 14, temperature 36.5. He appears absolutely well. He has good color. Conjunctivae are pink. The abdomen is flat, soft and nontender. The staples were removed last week.
IMPRESSION: The patient is now doing very well. There is no evidence of further bleeding.
PLAN: I have told him to continue Nexium for another 2 weeks. He is back on his high blood pressure medicine, Monopril, as well. I have told him to begin a stage 3 diet, and we explained him how to do that. He should start exercising gradually. He may drive, and he should come back and see us in 3 months.
Posts
No comments:
Post a Comment