1. colonoscopy to see where the blood is coming from  

2. endoscopy to see if there is a stomach ulcer causing the bleeding 

3. Stop hydrochlorothiazide to hold more sodium and give fluids

4. work up anemia to see if we can find possible cause 

5. stop aspirin due to bleeding 

6. UA- look for any blood, infections 

7. get CMP to look at liver function 

CC: 81 YO F c/o weakness and lightheadedness x 1 week as well as occasional palpitations. 

RBC indices: for further details regarding low Hgb. 

Wt bearing XRay of knees: evaluate arthritis advancements. 

Holter Monitor: to assess possible timing/etiology of palpitations. 

PT consult: she’s very independent, so PT to work on strength and mobility. 

UA: examine urine for possible protein, glucose, WBC, etc. 

Clonidine: potentially D/C due to possible contribution to recent lightheadedness 

Ibuprofen: patient education for NSAID use. (kidney toxicity)

CC: 81 year old female c/o “nearly fell last week…I feel dizzy sometimes”.  Patient positive for orthostatic hypotension and she complains of her heart “skips a beat” occasionally.  Patient is anemic upon CBC analysis and positive for occult blood in stool. 

 

1.     CBC with diff (Identify MCV for possible causes of anemia) 

2.     Holter monitor (Near syncopal episode for complaint of “heart skipping a beat” and normal EKG) 

3.     UA (High creat – rule out UTI and analyze kidney function) 

4.     Reevalute hypertension medications (Experiencing orthostatic hypotension, under goal, and on multiple medications [4]) 

5.     Colonoscopy (Evaluate for GI bleed) 

6.     Ibuprofen use (Education on adverse effects and consider alternative pain management) 

7.     Reevaluate high dose aspirin (Identify reason for current high dose and consider switching to low dose) 

81 year old female presents with complain of near syncope and recent diarrhea.  

1.      Abdominal CT po contrast to evaluate for GI bleed 

2.      Rehydrate with fluids to address orthostasis and hyponatremia 

3.      Discontinue aspirin and ibuprofen to decrease bleeding risk 

4.      Fecal occult blood test 

5.      d/c clonidine 

6.      d/c glyburide 

7.      Reevaluate HTN meds- not on ACE, on diuretic and also med for incontinence, BB could mask hypoglycemia 
8. Endoscopy/colonoscopy for possible bleed

81 y/o female c/o dizziness 

·       Orthostasis 

·       Side effects of multiple drugs 

o   Solifenacin (is it appropriate?) 

·       Anemia 

o   Possibly from GI bleed (positive blood in stool) 

o   Endoscopy to rule out GI bleed? 

o   Iron studies (to rule out iron deficiency) 

·       “A couple” ibuprofen + full dose aspirin 

·       Dehydration 

o   Loss of thirst reflex 

o   Recommend fluid replacement 

·       Low sodium 

o   Could be result of Hydrochlorothiazide + possible dehydration 

·       Acute renal injury 

o   Increased serum creatinine 

o   Monitor output 

o   U/A with culture (look at protein and glucose and to rule out possible UTI) 

1.     CBC w/ diff (to see if there is an infection, and to see if microcytic/macrocytic/normocytic) 

2.     Iron Studies (for anemia) 

3.     CBC, Serum chemistries, Coag studies, and liver studies (To assess for Acute lower GI bleed). 

4.     Start Lisinopril 5 mg and STOP Metoprolol and hydrochlorothiazide (Due to low Sodium and Orthostasis; starting Lisinopril due to Kidney protection and DM) 

5.     Stop Aspirin (Due to GI bleed) 

6.     Start IV fluids (fluid resuscitation of NS for hyponatremia) 

7.     Council about ibuprofen and have her stop taking NSAIDs 

8.     Pharmacological Stress test (Heart palpitations; exercise not warranted) 

81-year-old female presents with a CC of “I nearly fell last week. Even now I feel dizzy sometimes.” PMH of osteoporosis, HTN, DM, hyperlipidemia, Alzheimer’s, urinary incontinence, and depression. ROS includes palpitations, upset stomach, diarrhea, and arthritis. Vitals: low BP when standing. Blood in stool. Slightly anemic. Trouble affording meds. Hyponatremic. Creatinine elevated. 

·       Dizziness – HTN polypharmacy 

·       Anemia – GI bleed from too many NSAIDs or from alendronate 

·       Palpitations – clonidine 

·       Hyponatremia – from loss of fluids, diuretic 

·       Renal function – NSAIDs and metformin 

·       Weakness – statin therapy 

 

1.      Evaluate meds for HTN. 

2.      Order colonoscopy. 

3.      Administer normal saline. 

4.      Holter monitor for palpitations. 

5.      Consult nutritionist. 

6.      Evaluate DM meds – sulfonylurea. 

7.      Social history evaluation. 

8.      Total medication review with pharmacy. 

-       Occult Stool Sample: Look for possible cause of slight anemia. She is on Ibuprofen and could have GI bleed.

-       Holter Monitor: Monitor possible arrhythmia causing near-syncopal episodes 

-       Further Anemia Studies: obtain Iron studies, retic,

-       Assess DM control: On Metformin, and Glyburide. Sulfonylurea is known to cause hypoglycemia 

-       Add a UA: Assess anemia, kidney function

-       OT/PT consult: for updated ADL/iADLs, Assessment for arthritis in her knees

81 y/o female c/o a near syncopal event last week and currently feeling dizzy. Pt denies falling. 

1.     Endoscopy R/O stomach or upper GI bleed 

2.     Colonoscopy R/O lower GI bleed and cancer 

3.     Red blood cell indices R/O etiologies of anemia 

4.     Medication eval 

a.     Donepezil – dizziness 

b.     Hydrochlorothiazide – hypotensive 

c.      Clonidine – dizziness 

5.     Head MRI R/O brain pathology 

6.     Stool O&P R/O infection or parasite 

7.     Eval aspirin use in accordance with Ibuprofen could relate to GI bleed