Oropharyngeal Bleeding H and P Sample Report

DATE OF ADMISSION: MM/DD/YYYY

CHIEF COMPLAINT: Oropharyngeal bleeding.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male on cardiopulmonary support following non-ST-elevation MI with ejection fraction of 60%. Of note, he is on heparin as well and has low platelets of 70,000. He was seen yesterday by Dr. John Doe, and both nasal cavities were packed as well as his oral cavity, as he was found to have an abrasion/laceration of the soft palate as well. We were called to the ICU by the patient’s nurse with complaints of severe continued oropharyngeal bleeding.

PAST MEDICAL HISTORY: Atherosclerosis of aorta, arteriosclerotic heart disease, cardiomyopathy, chronic kidney disease, epistaxis, hyperlipidemia, oropharyngeal laceration, palpitations, peripheral vascular disease, polyneuropathy, and spinal stenosis.

MEDICATIONS: Heparin, Ancef, as well as multiple other medications.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient denies alcohol, drugs, tobacco usage.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: A complete 12-point review of systems is otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 37.6, pulse 94, blood pressure 98/62.
GENERAL: The patient is sedated and intubated.
HEENT: There is a Rhino Rocket in the right nasal cavity with no active bleeding. There is Merocel in the left nasal cavity with no active bleeding noted. Merocel appears to be dry. Oral cavity reveals an extremely large packing above the indwelling endotracheal tube and orogastric tube. This appears to be saturated with blood clot and bright red blood as well. The packing was removed and an abrasion/small laceration was seen in the soft palate area, which appears to be actively bleeding.
NECK: Supple. Full range of motion. No lymphadenopathy or masses.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended. Normoactive bowel sounds.
EXTREMITIES: No cyanosis, clubbing or edema.
NEUROLOGIC: Grossly nonfocal.

LABORATORY DATA: Reveal a white blood cell count of 11.6, hematocrit 26.2, and platelet count of 74,000. Packed red blood cells and platelets are currently being transfused. Sodium is 140 and potassium 4.2.

PROCEDURE: Control of oropharyngeal bleeding was done at the bedside. A large oral cavity packing consisting of 4 x 4s and Xeroform as well as Surgicel was removed. No active bleeding was seen in the hard palate. An approximately 1.5 cm partial thickness laceration avulsion was seen of the left soft palate with active bleeding. FloSeal hemostatic sealant was placed in this area with direct pressure over this area for approximately 5 minutes. The area was re-examined and found to be free from any further bleeding. Large clots were removed from the oronasopharynx. No active bleeding was seen from the nasopharynx. No other bleeding was seen.

IMPRESSION: Oropharyngeal hemorrhage in a patient on cardiopulmonary support, on heparin.

PLAN: We recommend the nasal packing and 4 x 4 in the mouth, to be left in until Sunday or Monday. The patient is to be continued on Ancef. The platelets should be transfused to keep the platelet count around 100,000. If possible, we would recommend minimizing the patient’s heparin drip, if okay with Cardiac Surgery.


5s8fox8