CHIEF COMPLAINT: Bleeding from colostomy and foley

PRESENT ILLNESS: 84 year old male with multiple co-morbidities including rectal
cancer s/p resection and radiation in [**2157**] now with colostomy,
coronary artery disease s/p stents, systolic CHF, dilated
cardiomyopathy, atrial fibrillation not on [**Year (4 digits) **], cardiac
arrest and complete heart block s/p AICD/pacemaker, recent
trach/peg after prolonged hospitalization for rib
fractures/flail chest s/p fall who presents with large amount of
bleeding from colostomy and Foley. The patient also endorsed
increased shortness of breath, weakness and fatigue. The patient
had been recently admitted 8/21-25/[**2163**] to the [**Hospital1 18**] MICU for
pneumonia and MRSA bacteremia/sepsis and had been discharged on
Vancomycin and baby aspirin (for his atrial fibrillation and
coronary artery disease).
.
In the [**Hospital1 18**] ED, initial vital signs were: Afebrile, HR70,
BP107/53, RR24, 91% on trach vent. Given his tender abdomen,
there was initial concern for an intrabdominal event.
ACS/General Surgery was consulted and CT abdomen/pelvis was
performed. As the imaging was negative, there were no acute
surgical concerns; ACS recommended tagged RBC if he continued to
bleed. GI was also consulted and recommended two units pRBC for
Hct 22, IV PPI initiation. The patient also underwent PEG lavage
which was clear but was passing small amounts of maroon colored
stools. There was also initial concern for DIC but labs not
suggestive of this (the patient has history of heparin induced
thrombocytopenia but platelets normal). The patient has had
hematuria in the past, with three-way foley in place.
.
Upon arrival to the MICU, the patient was resting comfortably in
bed with trach/PEG, endorsing fatigue and abdominal pain. Per
the patient's wife, the patient looked good on discharge two
days ago but seemed under the weather on arrival to [**Hospital 100**]
Rehab. When she saw him at 6pm yesterday evening, he was stable
without signs of bleeding.
.
Review of systems:
(+) Per HPI
(-) [**Hospital 4273**] fever, headache, cough, shortness of breath, or
wheezing. [**Hospital 4273**] chest pain, chest pressure, palpitations, or
weakness. [**Hospital 4273**] nausea, vomiting.

MEDICAL HISTORY: - Rectal cancer s/p excision and XRT ([**2157**])
- CAD s/p stents (?[**2159**])
- CVA in [**2150**] with residual right hand dysthesia
- Complete heart block s/p pacemaker
- h/o cardiac arrest (now with AICD)
- GI bleed secondary to angiectasias in the duodenum ([**1-/2162**])
s/p cauterization via EGD
- Atrial fibrillation
- Systolic CHF (EF 40-45%)
- s/p Fall with multiple rib fractures ([**2163-6-23**])
- MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from
trach
- Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **]

MEDICATION ON ADMISSION: * Acetaminophen 325 mg Tablet [**Date Range **]: Two (2) Tablet PO Q4H PRN
* Lidocaine 5 %(700 mg/patch) daily
* Trazodone 25 mg Tablet qHS
* Citalopram 20 mg daily
* Docusate 10mL twice daily
* Ferrous sulfate 300mg daily
* Folic acid 1mg daily
* Multivitamin daily
* Omeprazole 20 mg daily
* Albuterol inhaler 2 puffs q4 hours PRN
* Simethicone 80mg three times daily
* Miconazole nitrate 2% powder qHS
* Oxycodone 5-10mg q4 hours PRN
* Aspirin 81mg daily
* Lasix 40mg daily
* Carvedilol 6.25mg twice daily
* Vancomycin 750mg twice daily X 13 more days

ALLERGIES: Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

PHYSICAL EXAM: ADMISSION:
Vitals: T: 98.9 BP: 115/54 P: 71 R: 16 O2: 99%  (FiO2 35%, Tv
450, RR12, PEEP5)
General: Alert, oriented, no acute distress, pale, breathing
comfortably via trach
HEENT: PERRL, pale conjunctiva, normocephalic, poor dentition,
clear oropharynx
Neck: Soft, supple, trach in place with minimal secretions
Lungs: Mild rhonchi in all lung fields, no wheezing/rales; mild
bibasilar crackels
CV: Regular rate and rhythm, normal S1 + S2, no rubs or gallops,
[**3-20**] holosystolic murmur
Abdomen: Soft, non-tender, non-distended, positive bowel sounds,
no rebound tenderness or guarding, maroon streaked stool in
colostomy
GU: Three way foley with dark pink urine in collection bag
Ext: Warm, well perfused, +pulses, bilateral upper extremity
edema, L>R; bilateral anterior shin hemosiderin changes
.
DISCHARGE:
VS: 98.7 70 111/49 17 96% (Pressure Support 12, PEEP 5, FiO2
35%)
General: Comfortable, no acute distress
HEENT: PERRL, EOMI, MMM, poor dentition
Cardiovascular: RRR, II/VI systolic murmur
Respiratory / Chest: CTA bilaterally, no wheezes/rales/ronchi
Abdominal: Soft, nontender/nondistended, naBS, ostomy c/d/i
Extremities: WWP, 2+ lower extremity edema, 2+ upper extremity
edema L>R (chronic), 2+PT/DP/radial pulses
Neurologic: Attentive, moving all extremities

FAMILY HISTORY: Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures

SOCIAL HISTORY: Resident of [**Hospital 100**] Rehab w plans to return home; previously had
lived in [**Location 745**] with his wife, now w some depression about
moving out of their 42 year home. Has two children. Retired
computer science professor.
- Tobacco:  5 cigars daily for 30 years, quit [**2150**] s/p CVA
- Alcohol:  Previously [**1-16**] glasses/week, generally per wife
"affects him quite a bit," changing his mood and making him sick
- Illicits: [**Month/Day (2) 4273**]
Angiodysplasia of stomach and duodenum with hemorrhage,Pressure ulcer, stage IV,Attention to gastrostomy,Chronic systolic heart failure,Other primary cardiomyopathies,Hematuria, unspecified,Atrial fibrillation,Automatic implantable cardiac defibrillator in situ,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Personal history of sudden cardiac arrest,Personal history of traumatic fracture,History of fall,Percutaneous transluminal coronary angioplasty status,Personal history of irradiation, presenting hazards to health,Tracheostomy status
Angio stm/dudn w hmrhg,Pressure ulcer, stage IV,Atten to gastrostomy,Chr systolic hrt failure,Prim cardiomyopathy NEC,Hematuria NOS,Atrial fibrillation,Status autm crd dfbrltr,Hx-rectal & anal malign,Hx sudden cardiac arrest,Hx traumatic fracture,Personal history of fall,Status-post ptca,Hx of irradiation,Tracheostomy status
Admission Date:  [**2163-9-10**]              Discharge Date:   [**2163-9-12**]

Date of Birth:  [**2079-1-17**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Bleeding from colostomy and foley


Major Surgical or Invasive Procedure:
none

History of Present Illness:
84 year old male with multiple co-morbidities including rectal
cancer s/p resection and radiation in [**2157**] now with colostomy,
coronary artery disease s/p stents, systolic CHF, dilated
cardiomyopathy, atrial fibrillation not on [**Year (4 digits) **], cardiac
arrest and complete heart block s/p AICD/pacemaker, recent
trach/peg after prolonged hospitalization for rib
fractures/flail chest s/p fall who presents with large amount of
bleeding from colostomy and Foley. The patient also endorsed
increased shortness of breath, weakness and fatigue. The patient
had been recently admitted 8/21-25/[**2163**] to the [**Hospital1 18**] MICU for
pneumonia and MRSA bacteremia/sepsis and had been discharged on
Vancomycin and baby aspirin (for his atrial fibrillation and
coronary artery disease).
.
In the [**Hospital1 18**] ED, initial vital signs were: Afebrile, HR70,
BP107/53, RR24, 91% on trach vent. Given his tender abdomen,
there was initial concern for an intrabdominal event.
ACS/General Surgery was consulted and CT abdomen/pelvis was
performed. As the imaging was negative, there were no acute
surgical concerns; ACS recommended tagged RBC if he continued to
bleed. GI was also consulted and recommended two units pRBC for
Hct 22, IV PPI initiation. The patient also underwent PEG lavage
which was clear but was passing small amounts of maroon colored
stools. There was also initial concern for DIC but labs not
suggestive of this (the patient has history of heparin induced
thrombocytopenia but platelets normal). The patient has had
hematuria in the past, with three-way foley in place.
.
Upon arrival to the MICU, the patient was resting comfortably in
bed with trach/PEG, endorsing fatigue and abdominal pain. Per
the patient's wife, the patient looked good on discharge two
days ago but seemed under the weather on arrival to [**Hospital 100**]
Rehab. When she saw him at 6pm yesterday evening, he was stable
without signs of bleeding.
.
Review of systems:
(+) Per HPI
(-) [**Hospital 4273**] fever, headache, cough, shortness of breath, or
wheezing. [**Hospital 4273**] chest pain, chest pressure, palpitations, or
weakness. [**Hospital 4273**] nausea, vomiting.


Past Medical History:
- Rectal cancer s/p excision and XRT ([**2157**])
- CAD s/p stents (?[**2159**])
- CVA in [**2150**] with residual right hand dysthesia
- Complete heart block s/p pacemaker
- h/o cardiac arrest (now with AICD)
- GI bleed secondary to angiectasias in the duodenum ([**1-/2162**])
s/p cauterization via EGD
- Atrial fibrillation
- Systolic CHF (EF 40-45%)
- s/p Fall with multiple rib fractures ([**2163-6-23**])
- MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from
trach
- Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **]


Social History:
Resident of [**Hospital 100**] Rehab w plans to return home; previously had
lived in [**Location 745**] with his wife, now w some depression about
moving out of their 42 year home. Has two children. Retired
computer science professor.
- Tobacco:  5 cigars daily for 30 years, quit [**2150**] s/p CVA
- Alcohol:  Previously [**1-16**] glasses/week, generally per wife
"affects him quite a bit," changing his mood and making him sick
- Illicits: [**Month/Day (2) 4273**]


Family History:
Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures

Physical Exam:
ADMISSION:
Vitals: T: 98.9 BP: 115/54 P: 71 R: 16 O2: 99%  (FiO2 35%, Tv
450, RR12, PEEP5)
General: Alert, oriented, no acute distress, pale, breathing
comfortably via trach
HEENT: PERRL, pale conjunctiva, normocephalic, poor dentition,
clear oropharynx
Neck: Soft, supple, trach in place with minimal secretions
Lungs: Mild rhonchi in all lung fields, no wheezing/rales; mild
bibasilar crackels
CV: Regular rate and rhythm, normal S1 + S2, no rubs or gallops,
[**3-20**] holosystolic murmur
Abdomen: Soft, non-tender, non-distended, positive bowel sounds,
no rebound tenderness or guarding, maroon streaked stool in
colostomy
GU: Three way foley with dark pink urine in collection bag
Ext: Warm, well perfused, +pulses, bilateral upper extremity
edema, L>R; bilateral anterior shin hemosiderin changes
.
DISCHARGE:
VS: 98.7 70 111/49 17 96% (Pressure Support 12, PEEP 5, FiO2
35%)
General: Comfortable, no acute distress
HEENT: PERRL, EOMI, MMM, poor dentition
Cardiovascular: RRR, II/VI systolic murmur
Respiratory / Chest: CTA bilaterally, no wheezes/rales/ronchi
Abdominal: Soft, nontender/nondistended, naBS, ostomy c/d/i
Extremities: WWP, 2+ lower extremity edema, 2+ upper extremity
edema L>R (chronic), 2+PT/DP/radial pulses
Neurologic: Attentive, moving all extremities

Pertinent Results:
Blood Counts
[**2163-9-9**] 10:15PM BLOOD WBC-8.1 RBC-2.55* Hgb-7.3* Hct-22.4*
MCV-88 MCH-28.7 MCHC-32.6 RDW-16.3* Plt Ct-105*
[**2163-9-11**] 01:56AM BLOOD WBC-8.0 RBC-3.06* Hgb-9.2*# Hct-26.3*
MCV-86 MCH-29.9 MCHC-34.8 RDW-16.5* Plt Ct-120*
[**2163-9-12**] 04:39AM BLOOD WBC-6.9 RBC-3.06* Hgb-8.9* Hct-26.6*
MCV-87 MCH-29.0 MCHC-33.5 RDW-16.6* Plt Ct-132*

Chemistry
[**2163-9-9**] 10:15PM BLOOD Glucose-108* UreaN-49* Creat-1.1 Na-139
K-4.0 Cl-103 HCO3-29 AnGap-11

ABx
[**2163-9-12**] 06:51AM BLOOD Vanco-24.2*
.
IMAGING:
[**2163-9-9**] CXR:
IMPRESSION: Blunting of the left costophrenic angle and left
base opacities consistent with left pleural effusion with
overlying atelectasis, underlying consolidation cannot be
entirely excluded. Cardiomegaly and prominent right hilum again
seen. Mild pulmonary vascular congestion, improved.
.
CT ABD and PELVIS:
1. Ascites is new since most recent exams dating back to [**2161**],
likely
correlating with diffuse anasarca.
2. Slight increase in size of 9-mm enhancing left liver lobe
lesion which is incompletely characterized on this exam. This
might be a flash filling
hemangioma or focal nodular hyperplasia. No other acute
intra-abdominal
process. If more definitive characterization is desired,
multiphasic CT of
the liver could be considered.
.

Brief Hospital Course:
HOSPITAL COURSE
84yo M PMHx CAD s/p stenting, systolic CHF (EF40-45%), atrial
fibrillation, recent hospitalization for MRSA bacteremia of
respiratory source, who represented from MACU with hematuria and
blood in colostomy bag, thought to be secondary to recent
initiation of ASA, now resolved after holding ASA,
hemodynamically stable x multiple days, being discharged to
MACU.
.
ACTIVE
# Blood in Ostomy: Patient w/ history of UGIB secondary to
angiectasias in the duodenum who presented w/ trace blood in his
ostomy; patient remaining hemodynamically stable w/ PEG lavage
negative; Trace blood in his colostomy bag suggests lower GI
bleed; given temporal relationship to initiation of ASA, this
was felt to most likely be an exacerbation of underlying issue;
bleeding resolved with holding of ASA.  He received 2 units of
pRBC on the day of admission.  His hemoglobin/hematocrit was
thereafter stable.  Patient/family have declined scoping at this
time but may be amenable to this as an outpatient (of note,
colonoscopy in [**2160**] was normal).  Continued patient's home
omeprazole; held ASA (see below).  His cardiologist was notified
because the patient is now no longer on aspirin or [**Year (4 digits) **], but
bleeding risk strongly outweighs stroke risk at this time.
Patient will need to readdress issue of colonoscopy as an
outpatient with outpatient providers.  Scheduled follow up with
Dr. [**Last Name (STitle) 1940**] on [**10-31**].  Please call Dr. [**Last Name (STitle) 1940**] office to see if
can get EGD sooner.
.
# Hematuria: Patient with a history of hematuria of uncertain
etiology who presents w recurrence of bleeding, thought to be
secondary recent initiation of ASA; holding of ASA resolved
bleeding issue; patient will need to have outpatient follow-up
with urology for discussion of cystoscopy; (appt was not yet
scheduled).  PATIENT WITH FIRM FOLEY CATHETER WITH 30CC balloon.
 Sending extra replacements with the patient.  Please be aware
if removing.

.
# MRSA bacteremia: Pt w recent admission notable for MRSA
bacteremia w/o TTE evidence of valvular involvement; continued
vancomycin treatment course (last day is [**2163-9-18**]); level was
supratherapeutic during this hospitalization; adjusted dosing to
500mg [**Hospital1 **].  Patient will need Vancomycin trough on morning of
[**2163-9-14**] and adjust dose as necessary.
.
# Chronic Diastolic CHF: Patient w EF 55-60% ([**2163-9-8**])
appearing fluid overloaded on admission; restarted patient's
home diuresis with good urine output.  Continued home
carvedilol.  Continued to hold lisinopril (had been held during
recent admission) given normotensive without.  Could consider
restarting as outpatient if he became hypertensive.
.
# Sacral decubitus ulcer: Stage IV, significant. Appropriate
wound care.  Continued oxycodone, lidocaine. Patient became
loopy receiving oxycodone 5mg Q4H.  Is written for 5-10mg
Q4H:PRN for pain, but will need to be assessed prior to
medication to make sure not continuing to get loopy.  Please
assess at MACU and continue to turn the patient regularly
minimizing weight bearing to that area.
.
# Atrial fibrillation: CHADS4 but off
anticoagulation/antiplatelet secondary to history of GI bleeds,
hemothorax in 6/[**2163**]. Given bleeding on this admission he will
likely be a poor candidate for ASA in the future.  Alerted
outpatient cardiologist Dr. [**Last Name (STitle) **] regarding this issue.  He
has follow up with Dr. [**Last Name (STitle) **] on [**9-28**] and we will contact him
as well on the day of discharge.
.
TRANSITIONAL
- PATIENT WITH FIRM FOLEY CATHETER WITH 30CC balloon.  Sending
extra replacements with the patient.  Please be aware if
removing.
- Scheduled for follow-up with cardiologist
- Scheduled follow up with gastroenterologist, please call to
see if can get EGD sooner than schedule appt.
- If has continued hematuria, will need urology follow up for
cystoscopy.
- Continue vancomycin for MRSA bactermia until [**2163-9-18**], next
traough needs to be morning of [**9-14**].  Goal level 15-20.
- Wean off vent to trach mask, plan to diurese to dry weight to
aid in weaning process
- Holding lisinopril given stable, BP, but can restart if
becomes hypertensive.

Medications on Admission:
* Acetaminophen 325 mg Tablet [**Date Range **]: Two (2) Tablet PO Q4H PRN
* Lidocaine 5 %(700 mg/patch) daily
* Trazodone 25 mg Tablet qHS
* Citalopram 20 mg daily
* Docusate 10mL twice daily
* Ferrous sulfate 300mg daily
* Folic acid 1mg daily
* Multivitamin daily
* Omeprazole 20 mg daily
* Albuterol inhaler 2 puffs q4 hours PRN
* Simethicone 80mg three times daily
* Miconazole nitrate 2% powder qHS
* Oxycodone 5-10mg q4 hours PRN
* Aspirin 81mg daily
* Lasix 40mg daily
* Carvedilol 6.25mg twice daily
* Vancomycin 750mg twice daily X 13 more days

Discharge Medications:
1. acetaminophen 325 mg Tablet [**Date Range **]: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Date Range **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on and 12 hours off.
3. trazodone 50 mg Tablet [**Date Range **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
4. citalopram 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).

5. docusate sodium 50 mg/5 mL Liquid [**Date Range **]: One (1)  PO BID (2
times a day): Hold for loose stools.
6. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Date Range **]: One (1)
PO DAILY (Daily).
7. folic acid 1 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).

8. multivitamin     Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).

9. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Date Range **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Date Range **]:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for sob,
wheeze.
11. simethicone 80 mg Tablet, Chewable [**Date Range **]: One (1) Tablet,
Chewable PO TID (3 times a day).
12. miconazole nitrate 2 % Powder [**Date Range **]: One (1) Appl Topical HS
(at bedtime).
13. oxycodone 5 mg Tablet [**Date Range **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: PLease evaluate pt and hold for
RR<12, sedation or if the patient appears loopy.
14. Lasix 40 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
15. vancomycin 500 mg Recon Soln [**Date Range **]: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours) for 11 days: 500mg started on
[**9-12**], please get trough morning of [**9-14**].
16. psyllium     Packet [**Date Range **]: One (1) Packet PO TID (3 times a
day) as needed for low ostomy output: low ostomy output.
17. sucralfate 1 gram Tablet [**Date Range **]: One (1) Tablet PO QID (4 times
a day).
18. carvedilol 6.25 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2
times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Primary Diagnosis:
GI bleed
.
Secondary Diagnosis:
CAD
A-fib
s/p cardiac arrest and AICD pacemaker


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You are being dishcarged from [**Hospital1 1170**].  You were re-admitted to the hospital for bleeding from
your ostomy as well as your Foley catheter.  We felt this was
because your aspiring was continued.  We held your aspirin, gave
you one unit of blood and you have been doing well since.  You
will go back to the MACU and will have follow up with GI and
Cardiology for further management of these issues.

The following medication was STOPPED:
Aspirin 81mg Daily
.
Please continue to HOLD lisinopril 2.5mg PO Daily
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2163-9-28**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: WEDNESDAY [**2163-9-28**] at 11:30 AM
With:  DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**2163-10-31**] 1:15pm
[**Last Name (NamePattern1) 13209**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1983**]
Fax: [**Telephone/Fax (1) 20601**]
{'Angiodysplasia of stomach and duodenum with hemorrhage,Pressure ulcer, stage IV,Attention to gastrostomy,Chronic systolic heart failure,Other primary cardiomyopathies,Hematuria, unspecified,Atrial fibrillation,Automatic implantable cardiac defibrillator in situ,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Personal history of sudden cardiac arrest,Personal history of traumatic fracture,History of fall,Percutaneous transluminal coronary angioplasty status,Personal history of irradiation, presenting hazards to health,Tracheostomy status'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Bleeding from colostomy and foley

PRESENT ILLNESS: 84 year old male with multiple co-morbidities including rectal
cancer s/p resection and radiation in [**2157**] now with colostomy,
coronary artery disease s/p stents, systolic CHF, dilated
cardiomyopathy, atrial fibrillation not on [**Year (4 digits) **], cardiac
arrest and complete heart block s/p AICD/pacemaker, recent
trach/peg after prolonged hospitalization for rib
fractures/flail chest s/p fall who presents with large amount of
bleeding from colostomy and Foley. The patient also endorsed
increased shortness of breath, weakness and fatigue. The patient
had been recently admitted 8/21-25/[**2163**] to the [**Hospital1 18**] MICU for
pneumonia and MRSA bacteremia/sepsis and had been discharged on
Vancomycin and baby aspirin (for his atrial fibrillation and
coronary artery disease).
.
In the [**Hospital1 18**] ED, initial vital signs were: Afebrile, HR70,
BP107/53, RR24, 91% on trach vent. Given his tender abdomen,
there was initial concern for an intrabdominal event.
ACS/General Surgery was consulted and CT abdomen/pelvis was
performed. As the imaging was negative, there were no acute
surgical concerns; ACS recommended tagged RBC if he continued to
bleed. GI was also consulted and recommended two units pRBC for
Hct 22, IV PPI initiation. The patient also underwent PEG lavage
which was clear but was passing small amounts of maroon colored
stools. There was also initial concern for DIC but labs not
suggestive of this (the patient has history of heparin induced
thrombocytopenia but platelets normal). The patient has had
hematuria in the past, with three-way foley in place.
.
Upon arrival to the MICU, the patient was resting comfortably in
bed with trach/PEG, endorsing fatigue and abdominal pain. Per
the patient's wife, the patient looked good on discharge two
days ago but seemed under the weather on arrival to [**Hospital 100**]
Rehab. When she saw him at 6pm yesterday evening, he was stable
without signs of bleeding.
.
Review of systems:
(+) Per HPI
(-) [**Hospital 4273**] fever, headache, cough, shortness of breath, or
wheezing. [**Hospital 4273**] chest pain, chest pressure, palpitations, or
weakness. [**Hospital 4273**] nausea, vomiting.

MEDICAL HISTORY: - Rectal cancer s/p excision and XRT ([**2157**])
- CAD s/p stents (?[**2159**])
- CVA in [**2150**] with residual right hand dysthesia
- Complete heart block s/p pacemaker
- h/o cardiac arrest (now with AICD)
- GI bleed secondary to angiectasias in the duodenum ([**1-/2162**])
s/p cauterization via EGD
- Atrial fibrillation
- Systolic CHF (EF 40-45%)
- s/p Fall with multiple rib fractures ([**2163-6-23**])
- MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from
trach
- Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **]

MEDICATION ON ADMISSION: * Acetaminophen 325 mg Tablet [**Date Range **]: Two (2) Tablet PO Q4H PRN
* Lidocaine 5 %(700 mg/patch) daily
* Trazodone 25 mg Tablet qHS
* Citalopram 20 mg daily
* Docusate 10mL twice daily
* Ferrous sulfate 300mg daily
* Folic acid 1mg daily
* Multivitamin daily
* Omeprazole 20 mg daily
* Albuterol inhaler 2 puffs q4 hours PRN
* Simethicone 80mg three times daily
* Miconazole nitrate 2% powder qHS
* Oxycodone 5-10mg q4 hours PRN
* Aspirin 81mg daily
* Lasix 40mg daily
* Carvedilol 6.25mg twice daily
* Vancomycin 750mg twice daily X 13 more days

ALLERGIES: Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

PHYSICAL EXAM: ADMISSION:
Vitals: T: 98.9 BP: 115/54 P: 71 R: 16 O2: 99%  (FiO2 35%, Tv
450, RR12, PEEP5)
General: Alert, oriented, no acute distress, pale, breathing
comfortably via trach
HEENT: PERRL, pale conjunctiva, normocephalic, poor dentition,
clear oropharynx
Neck: Soft, supple, trach in place with minimal secretions
Lungs: Mild rhonchi in all lung fields, no wheezing/rales; mild
bibasilar crackels
CV: Regular rate and rhythm, normal S1 + S2, no rubs or gallops,
[**3-20**] holosystolic murmur
Abdomen: Soft, non-tender, non-distended, positive bowel sounds,
no rebound tenderness or guarding, maroon streaked stool in
colostomy
GU: Three way foley with dark pink urine in collection bag
Ext: Warm, well perfused, +pulses, bilateral upper extremity
edema, L>R; bilateral anterior shin hemosiderin changes
.
DISCHARGE:
VS: 98.7 70 111/49 17 96% (Pressure Support 12, PEEP 5, FiO2
35%)
General: Comfortable, no acute distress
HEENT: PERRL, EOMI, MMM, poor dentition
Cardiovascular: RRR, II/VI systolic murmur
Respiratory / Chest: CTA bilaterally, no wheezes/rales/ronchi
Abdominal: Soft, nontender/nondistended, naBS, ostomy c/d/i
Extremities: WWP, 2+ lower extremity edema, 2+ upper extremity
edema L>R (chronic), 2+PT/DP/radial pulses
Neurologic: Attentive, moving all extremities

FAMILY HISTORY: Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures

SOCIAL HISTORY: Resident of [**Hospital 100**] Rehab w plans to return home; previously had
lived in [**Location 745**] with his wife, now w some depression about
moving out of their 42 year home. Has two children. Retired
computer science professor.
- Tobacco:  5 cigars daily for 30 years, quit [**2150**] s/p CVA
- Alcohol:  Previously [**1-16**] glasses/week, generally per wife
"affects him quite a bit," changing his mood and making him sick
- Illicits: [**Month/Day (2) 4273**] 

### Response:
{'Angiodysplasia of stomach and duodenum with hemorrhage,Pressure ulcer, stage IV,Attention to gastrostomy,Chronic systolic heart failure,Other primary cardiomyopathies,Hematuria, unspecified,Atrial fibrillation,Automatic implantable cardiac defibrillator in situ,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Personal history of sudden cardiac arrest,Personal history of traumatic fracture,History of fall,Percutaneous transluminal coronary angioplasty status,Personal history of irradiation, presenting hazards to health,Tracheostomy status'}
