Melena - Differential diagnosis includes peptic ulcer, esophagitis, and arteriovenous malformation. Risks/benefits of Esophagogastroduodenoscopy discussed with patient[] including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy.
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[] []male presented with []. Denies hematemesis, hematochezia, or melena. Acute blood loss anemia - probable iron deficiency anemia. Differential diagnosis includes gastric ulcer, gastritis, esophagitis,[] and less likely colon cancer. Risks/benefits of EGD discussed with patient[] including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy. Ordered iron studies.
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Melena -
Differential diagnosis includes gastric ulcer and esophageal varices.
Risks/benefits of EGD with possible variceal banding discussed with patient[] including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy.
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Melena - Differential diagnosis includes peptic ulcer, esophagitis, and arteriovenous malformation. Risks/benefits of Esophagogastroduodenoscopy discussed with patient[] including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy.
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[] []male presented with []. Denies hematemesis, hematochezia, or melena. Acute blood loss anemia - probable iron deficiency anemia. Differential diagnosis includes gastric ulcer, gastritis, esophagitis,[] and less likely colon cancer. Risks/benefits of EGD discussed with patient[] including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy. Ordered iron studies. Transfuse to hemoglobin of 8.
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REVIEW OF SYSTEMS
-CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue.
-HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears,
Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
-SKIN: No rash or itching.
-CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No
palpitations or edema.
-RESPIRATORY: No shortness of breath, cough or sputum.
-GASTROINTESTINAL: Per HPI. No hematemesis, hematochezia, or melena.
-GENITOURINARY: No burning on urination.
-NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia,
numbness or tingling in the extremities. No change in bowel or bladder control.
-MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
-HEMATOLOGIC/LYMPHATICS: No anemia, bleeding or bruising. No enlarged nodes. No history of
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ICD 10 Diagnosis for Gastroenterology. Inpatient Gastroenterology. Hematemesis, hematochezia, melena, acute blood loss anemia, elevated liver enzymes, dysphagia esophagopharyngeal, epigastric abdominal pain, right upper quadrant abdominal pain, left upper quadrant abdominal pain, right lower quadrant abdominal pain, abnormal CT, ascites, hepatic encephalopathy, alcoholic cirrhosis, non-alcoholic cirrhosis, C. difficile diarrhea, acute pancreatitis, chronic pancreatitis, biliary pancreatitis, cannabis hyperemesis syndrome, cyclic vomiting syndrome, abnormal intraoperative cholangiogram.
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Patient denies jaundice, scleral icterus, pale stools, dark urine. No reports of hematochezia or melena. No recent trauma or falls. When asked, patient denies any recent weight loss or gain. No dizziness, SOB, or chest pain reported. No recent diarrhea or constipation. Denies hx of hemorrhoids.
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