CHIEF COMPLAINT: Diarrhea, abdominal pain, upper GI bleed

PRESENT ILLNESS: 82 y/o F w/ dementia, CAD s/p CABGx3 [**7-/2158**], DM2 and HTN w/ recent
admit to [**Hospital 882**] Hospital for UTI, and discharged from [**Hospital1 18**] on
[**1-31**] after treatment for [**Last Name (un) **] who now returns with 3 days of abd
pain, green, loose stool and emesis x1. Of note, per last d/c
summary, she was treated fort 4 days with levaquin for a UTI at
[**Hospital 882**] Hospital.
.
In the ED, VS: CBC with leukocytosis to 22. Cr 1.3 (bl 1.2),
hyponateremia, hypocalcemia. UA negative. CT showing sigmoid
colitis. Treated with iv flagyl, IVF, zofran and dilaudid. No
cdiff sent. Also had urinary retention with 600cc out after
foley placement.
.
On arrival to the floor, daughter reported patient is tolerating
po's.
.
ROS: Per daughter, pt unable to give history.
+ per HPI. No fever, chills, SOB, cough, CP, palpitations,
myalgias or arthralgias, headache, change in vision or depressed
mood.
.

MEDICAL HISTORY: diabetes mellitus type II
s/p coronary artery bypass graft
h/o coronary artery disease x 3 in 7/92
vasculopathy
status post laminectomy at L4-L5 for spinal stenosis on
[**2166-6-7**]
ventral hernia since [**2159**] s/p repair in 6/93
Hashimoto's hypothyroidism
HTN
s/p appendectomy
cholecystectomy via paramedial incision
s/p total abdominal hysterectomy via the same paramedial
incision
s/p bilateral salpingo-oophorectomy via midline incision
osteoarthritis
irritable bowel syndrome
esophageal stricture s/p dilation times one
s/p benign polypectomy
right nephrolithiasis.

MEDICATION ON ADMISSION: allopurinol 100 mg qd
aspirin 325 mg qd
Ca/Vit D
carvedilol 3.125 mg [**Hospital1 **]
donepezil 10 mg qd
ezetimibe 10 mg qd
furosemide 20 mg qd
glipizide 2.5 mg QPM.
glipizide 5 mg QAM.
levothyroxine 100 mcg qd
lisinopril 10 mg qd
memantine 10 mg [**Hospital1 **]
metformin 500 mg [**Hospital1 **]
multivitamin 1 qd
pravastatin 40 mg qd

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / Cephalexin /
Cefazolin / Opioids-Morphine & Related

PHYSICAL EXAM: VS: 98 156/76 101 15 97% RA
GEN: well appearing F in NAD
HEENT: EOMI, dry mucous membraines, cracked lips
CV: regular rate, 3/6 SEM with radiation to carotids
Lungs: CTAB, no wheezes
ABD: hyperactive BS, soft but diffusely TTP throughout, no R/G
RECTAL: deferred
EXT: 1+ [**Location (un) **]
NEURO: altert, oriented only to self

FAMILY HISTORY: mom MI at 74.  dad cancer at 79.  3 brothers with MI in 40-50s.
Sister MI [**16**].

SOCIAL HISTORY: remote tobacco history, no etoh, lives with husband in [**Name (NI) 3786**].
Daughter and son very involved in her care.
Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Bacteremia,Other and unspecified noninfectious gastroenteritis and colitis,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Other esophagitis,Other persistent mental disorders due to conditions classified elsewhere,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Hypocalcemia,Retention of urine, unspecified,Other specified cardiac dysrhythmias,Other and unspecified hyperlipidemia,Ventral, unspecified, hernia without mention of obstruction or gangrene,Other and unspecified special symptoms or syndromes, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled
Chr duoden ulcer w hem,Ac on chr syst hrt fail,Acute kidney failure NOS,Hyposmolality,Bacteremia,Noninf gastroenterit NEC,Other staphylococcus,Stomach ulcer NOS,Other esophagitis,Mental disor NEC oth dis,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Hypocalcemia,Retention urine NOS,Cardiac dysrhythmias NEC,Hyperlipidemia NEC/NOS,Ventral hernia NOS,Special symptom NEC/NOS,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,DMII wo cmp uncntrld
Admission Date:  [**2177-2-5**]              Discharge Date:   [**2177-2-19**]

Date of Birth:  [**2095-1-5**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Cephalexin /
Cefazolin / Opioids-Morphine & Related

Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Diarrhea, abdominal pain, upper GI bleed

Major Surgical or Invasive Procedure:
Endoscopy


History of Present Illness:
82 y/o F w/ dementia, CAD s/p CABGx3 [**7-/2158**], DM2 and HTN w/ recent
admit to [**Hospital 882**] Hospital for UTI, and discharged from [**Hospital1 18**] on
[**1-31**] after treatment for [**Last Name (un) **] who now returns with 3 days of abd
pain, green, loose stool and emesis x1. Of note, per last d/c
summary, she was treated fort 4 days with levaquin for a UTI at
[**Hospital 882**] Hospital.
.
In the ED, VS: CBC with leukocytosis to 22. Cr 1.3 (bl 1.2),
hyponateremia, hypocalcemia. UA negative. CT showing sigmoid
colitis. Treated with iv flagyl, IVF, zofran and dilaudid. No
cdiff sent. Also had urinary retention with 600cc out after
foley placement.
.
On arrival to the floor, daughter reported patient is tolerating
po's.
.
ROS: Per daughter, pt unable to give history.
+ per HPI. No fever, chills, SOB, cough, CP, palpitations,
myalgias or arthralgias, headache, change in vision or depressed
mood.
.

Past Medical History:
diabetes mellitus type II
s/p coronary artery bypass graft
h/o coronary artery disease x 3 in 7/92
vasculopathy
status post laminectomy at L4-L5 for spinal stenosis on
[**2166-6-7**]
ventral hernia since [**2159**] s/p repair in 6/93
Hashimoto's hypothyroidism
HTN
s/p appendectomy
cholecystectomy via paramedial incision
s/p total abdominal hysterectomy via the same paramedial
incision
s/p bilateral salpingo-oophorectomy via midline incision
osteoarthritis
irritable bowel syndrome
esophageal stricture s/p dilation times one
s/p benign polypectomy
right nephrolithiasis.

Social History:
remote tobacco history, no etoh, lives with husband in [**Name (NI) 3786**].
Daughter and son very involved in her care.


Family History:
mom MI at 74.  dad cancer at 79.  3 brothers with MI in 40-50s.
Sister MI [**16**].

Physical Exam:
VS: 98 156/76 101 15 97% RA
GEN: well appearing F in NAD
HEENT: EOMI, dry mucous membraines, cracked lips
CV: regular rate, 3/6 SEM with radiation to carotids
Lungs: CTAB, no wheezes
ABD: hyperactive BS, soft but diffusely TTP throughout, no R/G
RECTAL: deferred
EXT: 1+ [**Location (un) **]
NEURO: altert, oriented only to self

Pertinent Results:
Labs on Admission:
[**2177-2-5**] 05:49PM   LACTATE-1.8
[**2177-2-5**] 05:45PM   GLUCOSE-85 UREA N-50* CREAT-1.3* SODIUM-129*
POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-20* ANION GAP-21*
[**2177-2-5**] 05:45PM   estGFR-Using this
[**2177-2-5**] 05:45PM   ALT(SGPT)-11 AST(SGOT)-26 ALK PHOS-81 TOT
BILI-0.2
[**2177-2-5**] 05:45PM   ALBUMIN-2.7*
[**2177-2-5**] 05:45PM   WBC-22.8*# RBC-3.59* HGB-10.8* HCT-33.2*
MCV-93 MCH-30.2 MCHC-32.6 RDW-14.6
[**2177-2-5**] 05:45PM   NEUTS-85.8* LYMPHS-9.7* MONOS-3.1 EOS-0.8
BASOS-0.6
[**2177-2-5**] 05:45PM   PLT COUNT-633*#
[**2177-2-5**] 05:45PM   PT-12.2 PTT-32.8 INR(PT)-1.0
[**2177-2-5**] 04:58PM   PH-7.44
[**2177-2-5**] 04:58PM   GLUCOSE-118* LACTATE-1.7 NA+-130* K+-5.4*
CL--96*
[**2177-2-5**] 04:58PM   HGB-11.6* calcHCT-35
[**2177-2-5**] 04:58PM   freeCa-1.00*
[**2177-2-5**] 04:00PM URINE  [**Year/Month/Day 3143**]-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2177-2-5**] 04:00PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018

Labs on Discharge:
139  101  25
--------------<120
4.1  32  0.8

Ca: 8.9 Mg: 2.2 P: 4.8

Source: Line-PICC
    9.8
9.8>---<378
    29.2

PT: 13.1  PTT: 28.1  INR: 1.1

Microbiology:
[**2177-2-5**] 4:00 pm URINE  - NO GROWTH.

[**2177-2-5**] 5:45 [**Year/Month/Day **] Culture, Routine (Final [**2177-2-11**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    FINAL
SENSITIVITIES.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPHYLOCOCCUS, COAGULASE NEGATIVE
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------<=0.25 S
TETRACYCLINE----------     4 S
VANCOMYCIN------------     1 S

[**2177-2-5**] 6:34 pm [**Year/Month/Day 3143**] CULTURE

                            **FINAL REPORT [**2177-2-8**]**

   [**Month/Day/Year **] Culture, Routine (Final [**2177-2-8**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    FINAL
SENSITIVITIES.
         COAG NEG STAPH does NOT require contact precautions,
regardless of
         resistance.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPHYLOCOCCUS, COAGULASE NEGATIVE
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------     2 S

[**Month/Day/Year **] cultures from 1/14,15,17,18,20/11 Negative FINAL

[**Month/Day/Year **] cultures from 1/21-22/11 PENDING

[**2177-2-9**] 12:07 am STOOL     CONSISTENCY: SOFT

                            **FINAL REPORT [**2177-2-11**]**

   FECAL CULTURE (Final [**2177-2-11**]):
      NO ENTERIC GRAM NEGATIVE RODS FOUND.
      NO SALMONELLA OR SHIGELLA FOUND.

   CAMPYLOBACTER CULTURE (Final [**2177-2-11**]):    NO CAMPYLOBACTER
FOUND.

   FECAL CULTURE - R/O VIBRIO (Final [**2177-2-11**]):    NO VIBRIO
FOUND.

   FECAL CULTURE - R/O YERSINIA (Final [**2177-2-11**]):    NO YERSINIA
FOUND.

   FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2177-2-11**]):
      NO E.COLI 0157:H7 FOUND.

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2177-2-9**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).

1/16,17,19/11 C. Diff [**Doctor First Name **] NEGATIVE

[**2177-2-14**] HELICOBACTER PYLORI ANTIBODY TEST (Final [**2177-2-14**]):
NEGATIVE BY EIA.

[**2177-2-13**] 3:04 pm URINE  - NGTD

Imaging:

- ECG	Study Date of [**2177-2-5**]  3:43:54 PM
Sinus bradycardia with left bundle-branch block and secondary
ST-T wave
abnormalities with occasional premature ventricular
contractions. Compared to the previous tracing of [**2177-1-27**] the
occasional ventricular premature beats are new. Clinical
correlation is suggested.

- CT ABD & PELVIS WITH CONTRAST	Study Date of [**2177-2-5**] 3:52 PM
IMPRESSION:
1. Thickened, enhancing wall of the sigmoid colon concerning for
colitis;
infectious or inflammatory causes most likely, less likely
ischemic
2. Hyperemic small bowel, in some places may be minmally
thickened, with
normal caliber IVC, may indicate enteritis less likely sequela
of hypovolemia.
3. Mildly thickened, hyperemic gastric wall, may be due to
gastritis.
Recommend clinical correlation and consider endoscopy if not
performed
recently to exclude a more aggressive process.
4. 24 x 15 mm hypodensity near the pancreatic head, difficult to
discern
whether pancreatic in origin vs duodenal/gastric diverticulum vs
biliary(if
there is a history of prior pancreatitis, pseudocyst would be
another
consideration). Second hypodensity in the pancreatic body may be
a cystic
neoplasm (IMPN). Recommend MRCP for further evaluation.
5. Ventral wall hernia without evidence of obstruction, but with
small amout of fluid in hernia sac, new since the prior study,
may be reactive

- CHEST (PA & LAT)	Study Date of [**2177-2-5**] 4:26 PM
FINDINGS: Frontal and lateral views of the chest are obtained.
No focal
consolidation, pleural effusion, or pneumothorax is seen. The
patient is
status post median sternotomy and CABG. Aorta is calcified and
tortuous. The cardiac silhouette is top normal.

- CHEST (PA & LAT)	Study Date of [**2177-2-9**] 12:00 N
IMPRESSION: No active disease.

- TTE ([**2177-2-12**]): The left atrium is moderately dilated. Left
ventricular wall thicknesses and cavity size are normal. Overall
left ventricular systolic function is severely depressed (LVEF=
25-30 %). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are moderately thickened.
No masses or vegetations are seen on the aortic valve, but
cannot be fully excluded due to suboptimal image quality. There
is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. No masses or vegetations are seen on the tricuspid
valve, but cannot be fully excluded due to suboptimal image
quality. There is no pericardial effusion.

- CXR ([**2177-2-15**]): As compared to the previous radiograph, the
bilateral parenchymal pulmonary opacities are of unchanged
extent and severity. Unchanged mild cardiomegaly, unchanged
blunting of the left costophrenic sinus, potentially suggesting
a small pleural effusion. No newly occurred focal parenchymal
opacities. Unchanged monitoring and support devices.

- CXR ([**2177-2-16**]): Report PENDING

- CHEST PORT. LINE PLACEMENT Study Date of [**2177-2-17**] 9:16 AM
IMPRESSION: PICC line should be retracted by 4 cm.

- VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2177-2-17**] 2:02 PM
Penetration to thin liquids and nectar. For full details, please
refer to
speech and swallow division note in OMR.

- CHEST (PORTABLE AP) Study Date of [**2177-2-17**] 5:37 PM
FINDINGS: The PICC line has been pulled back to either the left
brachiocephalic vein or the junction with the superior vena
cava.
Retrocardiac opacification persists, as does the apparent
elevation of
pulmonary venous pressure.

- UNILAT LOWER EXT VEINS LEFT Study Date of [**2177-2-18**] 1:16 PM
IMPRESSION: No evidence of deep vein thrombosis in the left leg.





Brief Hospital Course:
82 F with dementia with recent admission here for acute renal
failure and abdominal pain and found to have Coag Negative Staph
Bacteremia, as well as an upper GI bleed.

# Upper GI Bleed: On admission, the patient was noted to have
abdominal pain, but stable HCTs around 30. Overnight from
[**Date range (1) 19674**], the patient HCT was noted to drop from 28.5 to 22.9;
this was not a spurious value, as on repeat it was 21.6. The
patient's lisinopril was decreased to 2.5 mg, the patient given
2 large bore IV access, and gastric lavage was performed, which
revealed Gastroccult positive findings. The patient was started
on a PPI gtt, and was transfused with 2 uPRBC. In Heparin and
Aspirin were discontinued, and pneumoboots were started. The
patient was placed on telemetry. Patient was transferred to the
MICU, where she was transfused another 4 units of packed red
[**Date range (1) **] cells over 36 hours with esophagogastroduodenoscopy
performed by gastroenterology showing giant duodenal ulcer in
bulb which was not actively bleeding and no visible vessel was
seen. H. Pylori antibody was negative. Her hematocrit has
remained stable around 29 with last transfusion being on
[**2177-2-13**]. She was continued on IV pantoprazole, which was
ultimately switched to dissolvable lansoprasole 30 mg [**Hospital1 **].
Family would not want surgical intervention but are still ok
with temporary reversal of DNR/DNI for endoscopy with GI or IR
intervention should she have an upper GI bleed in the past. She
was restarted on her home dose of aspirin, and will likely
require lifetime proton-pump inhibitor therapy, although this
may be able to be titrated downward in the future. Additionally,
the patient was given a prescription for sucralfate for ulcer
coating as well. GI had asked for a gastrin level to be sent to
assess for possible ZE Syndrome, and this was still pending at
the time of discharge.

# Abdominal Pain: On admission, the patent was found to have a
leukocytosis, abdominal pain, and reported history of diarrhea,
all of which were consistent with C. Difficile. A CT scan of the
abdomen also reported sigmoid colonic inflammation,  also in
keeping with C. Diff (see report for full detail). Additionally,
the patient has received Levaquin recently in the past for a
urinary tract infection. Given the clinical picture, the patient
was started on PO Vancomycin, which for 1 day was broadened to
include IV Cipro/Flagyl (but these medications were subsequently
DC'ed following ID consult). ID was consulted, and also felt
this picture was most consistent with C. Diff; microbiology
specimen of the stool, however, for C. Diff toxin was negative x
3. PO Vancomycin was DC'ed after a total course of 7 days. The
patient's sigmoid colitis was presumed to be secondary to
ischemia from a small upper GI bleed, given the localization of
the colitis and the lack of findings from C. Diff analysis.

# Bacteremia: The patient was found to have 3/4 bottles with
CoNS. Per ID, the patient was started on a 7 day course of IV
Vancomycin. Unknown source but urine is possibility as urine
culture from [**2177-1-31**] showed Alpha hemolytic colonies consistent
with alpha streptococcus or lactobacillus. However, urine on
this admission was clean; it was although though that the CoNS
might represent contamination of [**Month/Day/Year **] samples drawn in the
emergency department. Regardless, IV Vancomycin therapy was
initiated, and the patient was placed in cue for a TTE to rule
out the possibility of endocarditis. TTE showed LVEF of 20-25%
but no vegetation.  She completed 7 days of IV Vancomycin on
[**2177-2-13**]. ID has recommended that she have repeat [**Year (4 digits) **]
cultures two weeks after the discontinuation of her antibiotics
to ensure that she remains without bacteremia.

# Nutrition/DMII: The patient was initially able to tolerate
solid foods on her admission. After her transfer to the ICU, she
was evaluated by speech and swallow, who did not feel
comfortable clearing her from an aspiration risk standpoint. A
video swallow study was performed after a few more days of
medical management, and S&S cleared the patient for swallowing.
However, nutrition was also consulted on the Patein, and
indicated that the patient was not taking in enough via PO to
sustain her nutritionally. The family was made aware of this
finding, but elected to carefully monitor the patient's intake
upon her discharge, writing down all foods that she takes for
the next four days until she sees a nutritionist. At that time,
the nutritionist will re-evaluate if the patient is taking an
appropriate amount in by mouth, and recommend for or against PEG
tube placement. In house, our nutritionists have recommended a
PEG tube placement. The patient in the ICU was started on TPN
given her NPO status, but her TPN was discontinued on the day of
her discharge, as was her PICC line. The patient's sliding scale
was adjusted appropriately in house, and the patient was DC'ed
on her home insulin regimen.

# Acute renal failure: On presentation, Cr was 1.3. However,
given likely poor PO intake and slow IVF resuscitation secondary
to concerns of the patent's' newly understood and diagnosed
heart failure, the patient's creatinine increased to 1.9 during
admission. IVF were administered more aggressively, and the
Creatinine improved to 0.8 on discharge. During acute kidney
injury, the patient's allopurinol, furosemide, and lisinopril
were held, but as the acute kidney injury improved, these
medications were subsequently added back on. Additionally, the
patient required diuresis post-ICU transfer as she received a
great deal of [**Year (4 digits) **] and fluid, and given her decreased EF.

# Systolic congestive heart failure: Patient has a known TTE
with EF 25-30%, during the course of her hospitalization was
volume overloaded after tranfusion with 6 u PRBC. She was
diuresed with Lasix, and was discharged on a home regimen of a
BB, Statin, ASA, Furosemide and ACE-I.

# Supraventricular tachycardia: During the patient's drop in
HCT, she was on telemetry and was noted to have SVTs. Patient
was started on prior admission on 3.125 mg Carvedilol, and was
transitioned to IV metoprolol during her ICU stay. She was
transitioned back to PO Metoprolol upon discharge.

# Anion gap metabolic acidosis: On admission, the patient had an
AG acidosis at 20, which was presumed to be secondary to acute
renal injury, as the remaining MUDPILES differential were worked
up, without any obvious source. The patient did not have an
elevated serum osm, leading away from ethylene glycol or
methanol toxicity, uremia was not particularly high, other
ingested medications did not appear to pay a role, and the
patient's lactic acid was only 1.8 on admission. The patient's
AG resolved to normal after the administration of aggressive
IVF.

# Hyponatremia: Resolved with IVF, and with urine lytes was
found to be pre-renal, and so most likely hypovolemic
hyponatremia. This improved with aggressive IVF.

# LLE swelling: patient noted on prior admission and though old
notes to have L > R lower extremity edema, on last admission had
DVT U/S of that extremity that was negative. DVT U/S from
yesterday is also negative.
# CAD: No active issues in the hospital. Low concern for ACS.
Continue home BB, statin.

# Dementia: Continued Aricept; we also used Tylenol PRN for pain
control, as we tried to avoid masking a fever that might
indicate further infection.

# HLD: Home pravastatin, Zetia

# CODE STATUS - Patient was DNR/DNI per HCP daughter [**Name (NI) 717**].

# PENDING RESULTS
- Gastrin level

# PCP [**Name9 (PRE) **] ISSUES
- Optimize sCHF failure regimen
- TTE in 4 weeks per cardiology recs
- Consider hospice care; discuss with patient the benefits and
risks of ICD placement post TTE findings
- Please follow up Gastrin level from our hospital records to
assess for ZE Syndrome
- Please discuss the risks/benefits of a PEG tube placement;
thus far, family has been reluctant to pursue, but nutritionist
appointment shortly should help clarify matters
- Please discuss the need for possible PT rehabilitation at a
dedicated facility; understandably the family does not want
their mother to leave home, but she may ultimately benefit from
more close and intensive therapy than can be provided at home.
- Please have your PCP draw [**Name9 (PRE) **] cultures [**2177-2-27**] to see if
there are still any bacteria in your [**Last Name (LF) **], [**First Name3 (LF) **] our infectious
disease team's recommendation


Medications on Admission:
allopurinol 100 mg qd
aspirin 325 mg qd
Ca/Vit D
carvedilol 3.125 mg [**Hospital1 **]
donepezil 10 mg qd
ezetimibe 10 mg qd
furosemide 20 mg qd
glipizide 2.5 mg QPM.
glipizide 5 mg QAM.
levothyroxine 100 mcg qd
lisinopril 10 mg qd
memantine 10 mg [**Hospital1 **]
metformin 500 mg [**Hospital1 **]
multivitamin 1 qd
pravastatin 40 mg qd

Discharge Medications:
1. allopurinol 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.

2. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
3. carvedilol 3.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a
day.
4. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet [**Hospital1 **]: One (1)
Tablet PO once a day.
5. metformin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
6. donepezil 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
7. ezetimibe 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
8. furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
9. glipizide 2.5 mg Tablet Extended Rel 24 hr [**Hospital1 **]: One (1)
Tablet Extended Rel 24 hr PO at bedtime.
10. glipizide 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO QAM.
11. levothyroxine 100 mcg Tablet [**Hospital1 **]: One (1) Tablet PO once a
day.
12. lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
13. memantine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
14. multivitamin     Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
15. pravastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.

16. acetaminophen 650 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
17. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*0*
18. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Primary Diagnosis:
- Upper GI Bleed
- Urinary Retention
Secondary Diagnosis:
- Systolic Heart Failure
- Type II Diabetes
- Hashimoto's hypothyroidism
- Hypertension
- Hypertension

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


Discharge Instructions:
Ms. [**Known lastname 19672**], it was a pleasure taking care of you in the hospital.
You were admitted because you had been having some nausea,
vomiting, and diarrhea. You came to our emergency room, where a
CT scan of your abdomen showed that you had some inflammation in
your large intestine. It also showed some areas of irritation in
an area of your stomach, which was likely the source of your
pain. We started to treat you with antibiotics for what we
presumed was an infection in your colon. In addition, during
your hospitalization we discovered that you were growing
bacteria in your [**Last Name (LF) **], [**First Name3 (LF) **] we started you on antibiotics for
this as well. You completed antibiotic courses for both of these
infections.

During your hospital stay, your [**First Name3 (LF) **] count had dropped very
low, and you were found to have [**First Name3 (LF) **] in your stool. This
bleeding was so severe that it required you to receive 6 units
of [**First Name3 (LF) **], as well as for you to be transferred to the intensive
care unit. Our GI doctors looked with a camera into your stomach
and saw that you had an ulcer, which was likely the source of
your bleeding, in addition to the source of your pain. We
started you on two medications which should lessen the risk of
your ulcer re-bleeding.

You came back to the medical floor, and our speech and swallow
team and nutritionist evaluated you. Our speech and swallow team
felt safe with your swallowing, but your nutritionists were
concerned that you were not taking enough food in by mouth, and
that this was affecting your nutritional status. After speaking
with your family, we agreed that your family would monitor your
intake over the next few days by writing down exactly what you
eat every day, and you have an appointment with the
nutritionists to see if you still require a PEG tube, which is
what our nutritionists have recommended you have placed. A PEG
tube is a tube from the skin to the stomach which allows a
person to be fed without giving food through the mouth.

Finally, our physical therapists evaluated you as well, and
agreed that you were somewhat weaker than you had been on your
previous admission; they recommended that you go to
rehabilitation or have 24 hour care and PT at home in order to
get stronger. After discussion with your family, we agreed to
have you evaluated at home.

When you leave the hospital:
- START Tylenol 650 mg every 6 hours as needed for pain
- START Lansoprazole 30 mg twice a day
- START Sucralfate 1 gm by mouth four times a day

We did not make any other changes to your medications, so please
continue to take them as you normally do.

Please have your primary care physician [**Name9 (PRE) 702**] two laboratory
values which are still pending at the time of your discharge
- Gastrin level
- Please have your PCP draw [**Name9 (PRE) **] cultures on [**2177-2-27**] to see if
there are still any bacteria in your [**Last Name (LF) **], [**First Name3 (LF) **] our infectious
disease team's recommendation
- Please have your PCP check [**Initials (NamePattern4) **] [**1-31**] 2:00pm
in order to make sure that your electrolytes are stable

Followup Instructions:
You have an appointment with your primary care doctor, as below
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Hospital1 641**]
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1701**]
Appointment: Friday [**2177-2-21**] 2:00pm

You have an appointment with the nutritionists, as below
Department: BE WELL CENTER
When: TUESDAY [**2177-2-25**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 8826**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 8021**], RD [**Telephone/Fax (1) 3681**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Hospital 1422**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Bacteremia,Other and unspecified noninfectious gastroenteritis and colitis,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Other esophagitis,Other persistent mental disorders due to conditions classified elsewhere,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Hypocalcemia,Retention of urine, unspecified,Other specified cardiac dysrhythmias,Other and unspecified hyperlipidemia,Ventral, unspecified, hernia without mention of obstruction or gangrene,Other and unspecified special symptoms or syndromes, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled'}


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: Diarrhea, abdominal pain, upper GI bleed

PRESENT ILLNESS: 82 y/o F w/ dementia, CAD s/p CABGx3 [**7-/2158**], DM2 and HTN w/ recent
admit to [**Hospital 882**] Hospital for UTI, and discharged from [**Hospital1 18**] on
[**1-31**] after treatment for [**Last Name (un) **] who now returns with 3 days of abd
pain, green, loose stool and emesis x1. Of note, per last d/c
summary, she was treated fort 4 days with levaquin for a UTI at
[**Hospital 882**] Hospital.
.
In the ED, VS: CBC with leukocytosis to 22. Cr 1.3 (bl 1.2),
hyponateremia, hypocalcemia. UA negative. CT showing sigmoid
colitis. Treated with iv flagyl, IVF, zofran and dilaudid. No
cdiff sent. Also had urinary retention with 600cc out after
foley placement.
.
On arrival to the floor, daughter reported patient is tolerating
po's.
.
ROS: Per daughter, pt unable to give history.
+ per HPI. No fever, chills, SOB, cough, CP, palpitations,
myalgias or arthralgias, headache, change in vision or depressed
mood.
.

MEDICAL HISTORY: diabetes mellitus type II
s/p coronary artery bypass graft
h/o coronary artery disease x 3 in 7/92
vasculopathy
status post laminectomy at L4-L5 for spinal stenosis on
[**2166-6-7**]
ventral hernia since [**2159**] s/p repair in 6/93
Hashimoto's hypothyroidism
HTN
s/p appendectomy
cholecystectomy via paramedial incision
s/p total abdominal hysterectomy via the same paramedial
incision
s/p bilateral salpingo-oophorectomy via midline incision
osteoarthritis
irritable bowel syndrome
esophageal stricture s/p dilation times one
s/p benign polypectomy
right nephrolithiasis.

MEDICATION ON ADMISSION: allopurinol 100 mg qd
aspirin 325 mg qd
Ca/Vit D
carvedilol 3.125 mg [**Hospital1 **]
donepezil 10 mg qd
ezetimibe 10 mg qd
furosemide 20 mg qd
glipizide 2.5 mg QPM.
glipizide 5 mg QAM.
levothyroxine 100 mcg qd
lisinopril 10 mg qd
memantine 10 mg [**Hospital1 **]
metformin 500 mg [**Hospital1 **]
multivitamin 1 qd
pravastatin 40 mg qd

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / Cephalexin /
Cefazolin / Opioids-Morphine & Related

PHYSICAL EXAM: VS: 98 156/76 101 15 97% RA
GEN: well appearing F in NAD
HEENT: EOMI, dry mucous membraines, cracked lips
CV: regular rate, 3/6 SEM with radiation to carotids
Lungs: CTAB, no wheezes
ABD: hyperactive BS, soft but diffusely TTP throughout, no R/G
RECTAL: deferred
EXT: 1+ [**Location (un) **]
NEURO: altert, oriented only to self

FAMILY HISTORY: mom MI at 74.  dad cancer at 79.  3 brothers with MI in 40-50s.
Sister MI [**16**].

SOCIAL HISTORY: remote tobacco history, no etoh, lives with husband in [**Name (NI) 3786**].
Daughter and son very involved in her care. 

### Response:
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Bacteremia,Other and unspecified noninfectious gastroenteritis and colitis,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Other esophagitis,Other persistent mental disorders due to conditions classified elsewhere,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Hypocalcemia,Retention of urine, unspecified,Other specified cardiac dysrhythmias,Other and unspecified hyperlipidemia,Ventral, unspecified, hernia without mention of obstruction or gangrene,Other and unspecified special symptoms or syndromes, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled'}
