CHIEF COMPLAINT: BRBPR

PRESENT ILLNESS: Mr. [**Known lastname 92234**] is a 82 year old Italian speaking man with ESRD
on HD, internal hemmorhoids, h/o colon CA s/p R colectomy,
complete heart block with dual-V pacer, CAD s/p NSTEMI in [**2150**]
who presents with 24 hours of BRBPR. The patient was stable and
recovering from two recent hospitalizations at home, doing well
until the AM of [**2-4**], when he had a large bloody bowel movement
with bright red blood and clots. At this time, he denied any
abdominal pain, chest pain, shortness of breath, n/v/d, f/c,
lightheadedness/dizziness. Later, in the evening, he had another
3 similar bowel movements with bright red blood and clots, and
then another bloody BM the next morning on the day of admission.
He then went to his HD session in the morning, when the staff
there noticed a change in his Hgb from 11 at his prior session
to 6.5. After HD, the patient appeared pale and tired to his
daughter and complained of not being able to stand because he
felt "weak". At that point, his family brought him to the [**Hospital1 18**]
ED. Of note, the patient has had an active recent medical
history, having been hospitalized from [**Date range (1) 28665**] for AMS
secondary to high dose Valtrex for shingles, and then another
hospitalization on [**3-20**] for dyspnea and fever, presumably
secondary to extreme herpetic neuralgia and pain.
.
In the ED, initial vs were: T 98.2 P 61 BP 105/31 RR 24 O2 100%
RA. The patient was hemodynamically stable, but had a Hct of
19.5 measured ([**1-24**] Hct 29.8). Two 18G PIVs were placed and
patient was transfused 1u PRBC's and given 1L fluids. Surgery
and GI were both consulted. On the floor, the patient was stable
and receiving a 2nd unit of PRBC's, but was quite restless from
post-herpetic pain and was requesting his lidocaine patches.
.
Review of systems:
(+) Abdominal/back pain and itching
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias.

MEDICAL HISTORY: -h/o chronic lymphocytic exudative pleural effusions
secondary to chronic uremic pleurisy
-Colonic adenoma with high grade dysplasia / intramucosal
carcinoma; no mucosal invasion, all LN negative, s/p right
colectomy [**3-22**]
-CAD: NSTEMI in [**2150**], no perfusion defects [**3-/2168**] MIBI.
-Mod Pulm HTN, EF >70% 3/09 Echo
-Complete Heart Block S/P [**Company 1543**] Sigma DR [**Last Name (STitle) 26019**] PPM
in [**6-/2167**]
-Left internal carotid artery stenosis: (Carotid US in [**3-19**]
showed a L ICA 70-79% stenosis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**]/LCCA index of 3.6, no
right ICA stenosis with a [**Country **]/RCCA index of 1. in [**2164**]) on
clopidogrel.
-ESRD: [**1-16**] HTN and diabetes, on HD, Receives hemodialysis on
Tuesday, Thursday and Saturday via a left AV fistula at [**Location (un) 1468**]
Dialysis Center.
-Type 2 DM: (last A1c 6% in [**7-22**]) on oral agents
-Hypertension
-Chronic anemia (baseline hct ~ 35)
-Hyperlipidemia
-Secondary hyperparathyroidism
-Bilateral cataracts s/p surgical intervention
-s/p ERCP for bile duct stenosis
-Mild dementia
-h/o urinary retention

MEDICATION ON ADMISSION: 1. simvastatin 10 mg PO DAILY
2. clopidogrel 75 mg Tablet PO DAILY
3. nifedipine 30 mg Tablet Extended Release PO BID
4. baclofen 10 mg PO DAILY PRN FOR PAIN AFTER DIALYSIS
5. metoprolol tartrate 25 mg PO BID
6. B complex-vitamin C-folic acid 1 mg Capsule PO DAILY
7. terazosin 2 mg PO HS
8. lidocaine 5 %(700 mg/patch) x2 DAILY PRN pain from zoster
(apply one to back and one to abdomen on site of zoster)
9. [patient doesn't take] tramadol 50 mg Tablet Sig: 0.5 Tablet
PO Q6H PRN
10. gabapentin 100 mg PO BID

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Zyprexa / Haldol / Morphine

PHYSICAL EXAM: Admission Exam:

FAMILY HISTORY: Non contributory.

SOCIAL HISTORY: Lives with wife.  One of his daughters is very involved in care,
also son [**Name (NI) **]. [**Name2 (NI) **] another son and daughter nearby. [**Name2 (NI) **] worked
as a bricklayer for many years. Reports a 45 pk/yr h/o tobacco
but quit over 20 yrs ago. Has glass of wine with lunch and
dinner occasionally. Occasional beer on a hot day.
Hemorrhage of gastrointestinal tract, unspecified,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Renal agenesis and dysgenesis,Herpes zoster with other nervous system complications,Diverticulosis of small intestine (without mention of hemorrhage),Hypovolemia,Atrial fibrillation,Cardiac pacemaker in situ,Diaphragmatic hernia without mention of obstruction or gangrene,Internal hemorrhoids without mention of complication,Personal history of malignant neoplasm of large intestine,Pure hypercholesterolemia,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Anemia, unspecified
Gastrointest hemorr NOS,End stage renal disease,Hyp kid NOS w cr kid V,Renal agenesis,H zoster nerv syst NEC,Dvrtclo sml int w/o hmrg,Hypovolemia,Atrial fibrillation,Status cardiac pacemaker,Diaphragmatic hernia,Int hemorrhoid w/o compl,Hx of colonic malignancy,Pure hypercholesterolem,DMII renl nt st uncntrld,Nephritis NOS in oth dis,Anemia NOS
Admission Date:  [**2171-2-5**]              Discharge Date:   [**2171-2-12**]

Date of Birth:  [**2088-10-27**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics) / Zyprexa / Haldol / Morphine

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
BRBPR

Major Surgical or Invasive Procedure:
colonoscopy
upper endoscopy

History of Present Illness:
Mr. [**Known lastname 92234**] is a 82 year old Italian speaking man with ESRD
on HD, internal hemmorhoids, h/o colon CA s/p R colectomy,
complete heart block with dual-V pacer, CAD s/p NSTEMI in [**2150**]
who presents with 24 hours of BRBPR. The patient was stable and
recovering from two recent hospitalizations at home, doing well
until the AM of [**2-4**], when he had a large bloody bowel movement
with bright red blood and clots. At this time, he denied any
abdominal pain, chest pain, shortness of breath, n/v/d, f/c,
lightheadedness/dizziness. Later, in the evening, he had another
3 similar bowel movements with bright red blood and clots, and
then another bloody BM the next morning on the day of admission.
He then went to his HD session in the morning, when the staff
there noticed a change in his Hgb from 11 at his prior session
to 6.5. After HD, the patient appeared pale and tired to his
daughter and complained of not being able to stand because he
felt "weak". At that point, his family brought him to the [**Hospital1 18**]
ED. Of note, the patient has had an active recent medical
history, having been hospitalized from [**Date range (1) 28665**] for AMS
secondary to high dose Valtrex for shingles, and then another
hospitalization on [**3-20**] for dyspnea and fever, presumably
secondary to extreme herpetic neuralgia and pain.
.
In the ED, initial vs were: T 98.2 P 61 BP 105/31 RR 24 O2 100%
RA. The patient was hemodynamically stable, but had a Hct of
19.5 measured ([**1-24**] Hct 29.8). Two 18G PIVs were placed and
patient was transfused 1u PRBC's and given 1L fluids. Surgery
and GI were both consulted. On the floor, the patient was stable
and receiving a 2nd unit of PRBC's, but was quite restless from
post-herpetic pain and was requesting his lidocaine patches.
.
Review of systems:
(+) Abdominal/back pain and itching
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias.


Past Medical History:
-h/o chronic lymphocytic exudative pleural effusions
secondary to chronic uremic pleurisy
-Colonic adenoma with high grade dysplasia / intramucosal
carcinoma; no mucosal invasion, all LN negative, s/p right
colectomy [**3-22**]
-CAD: NSTEMI in [**2150**], no perfusion defects [**3-/2168**] MIBI.
-Mod Pulm HTN, EF >70% 3/09 Echo
-Complete Heart Block S/P [**Company 1543**] Sigma DR [**Last Name (STitle) 26019**] PPM
in [**6-/2167**]
-Left internal carotid artery stenosis: (Carotid US in [**3-19**]
showed a L ICA 70-79% stenosis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**]/LCCA index of 3.6, no
right ICA stenosis with a [**Country **]/RCCA index of 1. in [**2164**]) on
clopidogrel.
-ESRD: [**1-16**] HTN and diabetes, on HD, Receives hemodialysis on
Tuesday, Thursday and Saturday via a left AV fistula at [**Location (un) 1468**]
Dialysis Center.
-Type 2 DM: (last A1c 6% in [**7-22**]) on oral agents
-Hypertension
-Chronic anemia (baseline hct ~ 35)
-Hyperlipidemia
-Secondary hyperparathyroidism
-Bilateral cataracts s/p surgical intervention
-s/p ERCP for bile duct stenosis
-Mild dementia
-h/o urinary retention

Social History:
Lives with wife.  One of his daughters is very involved in care,
also son [**Name (NI) **]. [**Name2 (NI) **] another son and daughter nearby. [**Name2 (NI) **] worked
as a bricklayer for many years. Reports a 45 pk/yr h/o tobacco
but quit over 20 yrs ago. Has glass of wine with lunch and
dinner occasionally. Occasional beer on a hot day.


Family History:
Non contributory.

Physical Exam:
Admission Exam:

Physical Exam:
Vitals: T: 98.7 BP: 134/49 P: 67 R: 18 O2: 98% RA
General: Alert, oriented, mildly agitated
HEENT: Sclera anicteric, MMM, poor dentition, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally but difficult to hear
with moaning sounds, no wheezes, rales, ronchi
CV: distant heart sounds, regular, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Herpetiform
purpuric purple rash on R abdominal wall and R lower back
GU: no foley
Ext: pulsatile L AVF without thrill; cool, well perfused, 2+
pulses, no clubbing, cyanosis or edema

Upon Discharge:
VS: 99% on RA at rest; desatted initially to mid 80s% on RA when
stood up but O2sat improved to 95% with deep breaths while
ambulating
LUNGS:  clear to auscultation
Ext: pulsatile bruit Left forearm AVF, dilated with proximal
thrill

Pertinent Results:
Admission Labs:

[**2171-2-5**] 04:15PM BLOOD WBC-4.5 RBC-1.88*# Hgb-6.8*# Hct-19.5*#
MCV-104* MCH-36.4* MCHC-35.2* RDW-14.5 Plt Ct-256#
[**2171-2-5**] 05:53PM BLOOD PT-12.9 PTT-28.1 INR(PT)-1.1
[**2171-2-5**] 04:15PM BLOOD Glucose-126* UreaN-27* Creat-2.8*# Na-141
K-3.8 Cl-98 HCO3-32 AnGap-15
[**2171-2-5**] 04:15PM BLOOD ALT-17 AST-26 CK(CPK)-32* AlkPhos-118
TotBili-0.3
[**2171-2-5**] 04:15PM BLOOD cTropnT-0.22*
[**2171-2-6**] 04:27AM BLOOD CK-MB-4 cTropnT-0.22*
[**2171-2-7**] 01:01PM BLOOD CK-MB-5 cTropnT-0.18*
[**2171-2-5**] 04:15PM BLOOD Albumin-3.0* Calcium-7.9* Phos-2.6*
Mg-2.2

Radiology:

TTE (Complete) Done [**2171-2-11**] at 3:56:46 PM

The left atrium is mildly dilated. The right atrial pressure is
indeterminate. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets are moderately thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.

IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Minimal aortic valve stenosis. Pulmonary artery systolic
hypertension. Incresaed PCWP.
Compared with the prior study (images reviewed) of [**2169-4-4**],
minimal aortic valve stenosis is now identified and the
estimated pulmonary artery systolic pressure is higher.


Brief Hospital Course:
82 year old man with ESRD on HD, colon CA s/p resection,
diverticulosis, CAD, CHB s/p pacer, Afib who presented with
massive GIB, requiring multiple transfusions, while on plavix,
source of bleed not determined but thought to be duodenal versus
diverticular.

#Bright Red Blood Per Rectum:
Patient with history of colon CA s/p R colectomy, known
diverticulosis and internal hemmorhoids, and anticoagulation
from Plavix. Transfused 4u PRBCS 19.5 --> 30.6. Plavix and ASA
held. Received another 3 units over the next 24+ hours.  On
[**2171-2-7**], GI scope showed red blood throughout the colon all the
way to ileocecal valve, likely [**1-16**] diverticular bleed, only 1
tic visualized due to blood. EGD was done as well, which showed
small amt coffee grounds but no clear upper source. Based on
bleeding during scope, patient underwent tagged RBC scan which
localized bleeding to RUQ, likely proximal small bowel (likely
duodenum).  Patient then went to angio with IR but they were
unable to localize bleed. The next day, patient started on
regular diet despite possible need for surgery due to family
requests (understood risks).  Patient then started to re-bleed
large amts of darker red blood.  IR recommended CTA abdomen
which showed colonic diverticula but no active bleeding.
Hematocrits have remained stable for past 48 hours prior to
being transferred to floor.

On the floor, patient's hematocrit remained stable with no
further transfusion requirement.  Definite source of bleed was
not clearly identified but thought to be duodenal and/or
diverticular, so patient was continued on pantoprazole on
discharge in setting of duodenal bleed and GERD symptoms.
Gastroenterology team felt that patient did not require
outpatient [**Month/Day (2) 4939**] with them at this time.  Patient will have
Hct drawn on Saturday at HD and have results faxed to PCP.
[**Name10 (NameIs) **] PCP appointment is on Tuesday (one week from discharge
date).  If patient were to re-bleed, he would likely require
surgical consultation, though he has already undergone Right
colectomy in the past.
.
#CAD:
Patient has TnT elevated beyond baseline to 0.22 in addition to
T-wave changes and ST depressions on his EKGs. This was thought
to be related to increased cardiac demand from hypovolemia in
addition to acute anemia decreasing myocardial oxygen delivery;
all in the setting of CAD.  CE x2 stable.  Metoprolol was held
initially in the setting of GI bleed but was restarted just
prior to discharge.  Plavix will be held indefinitely; decision
to restart plavix will be made by outpatient physician. [**Name10 (NameIs) **]
does not have history of coronary stents.
.
#Post-herpetic neuralgia:
Patient continues to have considerable pain from his recent
episode of shingles. Given lidocaine patches and Gabapentin
100mg [**Hospital1 **].
.
#ESRD:
On HD, with L AVF. Received HD as scheduled by renal while
hospitalized. Patient had missed appointment with transplant
surgery for narrowing fistula because of this hospitalization.
There was some concern by Renal team that he may have some
evidence of proximal stenosis with dilated fistula and venous
collaterals upstream, so his AVF was evaluated by NP [**First Name8 (NamePattern2) 5969**]
[**Last Name (NamePattern1) 15170**] and Dr. [**First Name (STitle) **] who felt that fistula was working well
enough at this time but would need to be followed in the future.
No signs of steal syndrome on exam prior to discharge.  No need
for fistulagram or intervention at this time.
.

#HTN:
Blood pressure medications were held in the setting of GI bleed.
 Metoprolol tartrate was restarted upon discharge.  Patient was
also restarted on home tamsulosin dose 2mg QHS upon discharge.
Blood pressures were up to 160s systolic prior to HD on day of
discharge, but improved to 120s post-HD.  Nifedipine ER was held
on discharge to avoid restarting too many antihypertensives
simultaneously and may be restarted by outpatient physician at
[**First Name (STitle) 4939**] appointment next week.  VNA will check blood pressures
and record them for PCP.
.
#HLD: Home simvastatin.
.
#DM: HbA1c in [**2167**] 6%. Off of oral agents, diet controlled.


Medications on Admission:
1. simvastatin 10 mg PO DAILY
2. clopidogrel 75 mg Tablet PO DAILY
3. nifedipine 30 mg Tablet Extended Release PO BID
4. baclofen 10 mg PO DAILY PRN FOR PAIN AFTER DIALYSIS
5. metoprolol tartrate 25 mg PO BID
6. B complex-vitamin C-folic acid 1 mg Capsule PO DAILY
7. terazosin 2 mg PO HS
8. lidocaine 5 %(700 mg/patch) x2 DAILY PRN pain from zoster
(apply one to back and one to abdomen on site of zoster)
9. [patient doesn't take] tramadol 50 mg Tablet Sig: 0.5 Tablet
PO Q6H PRN
10. gabapentin 100 mg PO BID


Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. baclofen 10 mg Tablet Sig: One (1) Tablet PO PRN DAILY () as
needed for after dialysis.
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
[**12-16**] Adhesive Patch, Medicateds Topical DAILY (Daily).
4. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Nephrocaps  Oral
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. terazosin 2 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
GI bleed, unknown source
Diverticulosis
HTN
Atrial Fibrillation
Complete Heart Block s/p Pacemaker
End stage renal disease.


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname 92234**],

You were admitted with a significant bleed in the
gastrointestinal tract. You were given seven units of blood and
dialyzed several times while you were in the hospital. We have
determined that it is safe for you to go home and be treated by
physical therapy while at home.

We have discontinued plavix indefinitely. Although this
medication protects you from stroke and heart attacks, we feel
that it is too dangerous for you to take at this time.  It could
potentially be restarted by one of your outpatient doctors in
the future.

We have taken tramadol off your medication list because you have
expressed to us that you do not take this medication.

The following changes have been made to your medications.
- Please STOP the plavix (as above) for now.
- Please also STOP your nifedipine for now -- this medication
may be restarted by your primary care doctor when you follow up
next week
- Please START pantoprazole 40mg daily.

Please have your visiting nurse check and record your blood
pressures, so that you may take this log of blood pressures into
your primary care physician's office at your appointment next
week.

You will need to have your blood counts drawn at Dialysis on
Saturday and have the results faxed to your primary care
physician's office.

[**Known lastname **] Instructions:
Please keep all of your [**Known lastname 4939**] appointments as listed below:

Department: [**Hospital1 18**] [**Location (un) 2352**]
When: TUESDAY [**2171-2-19**] at 10:10 AM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1579**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site

Department: RADIOLOGY
When: MONDAY [**2171-2-25**] at 9:50 AM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: RADIOLOGY
When: MONDAY [**2171-2-25**] at 10:30 AM
With: RADIOLOGY [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: MONDAY [**2171-3-11**] at 10:30 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
{'Hemorrhage of gastrointestinal tract, unspecified,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Renal agenesis and dysgenesis,Herpes zoster with other nervous system complications,Diverticulosis of small intestine (without mention of hemorrhage),Hypovolemia,Atrial fibrillation,Cardiac pacemaker in situ,Diaphragmatic hernia without mention of obstruction or gangrene,Internal hemorrhoids without mention of complication,Personal history of malignant neoplasm of large intestine,Pure hypercholesterolemia,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Anemia, unspecified'}


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: BRBPR

PRESENT ILLNESS: Mr. [**Known lastname 92234**] is a 82 year old Italian speaking man with ESRD
on HD, internal hemmorhoids, h/o colon CA s/p R colectomy,
complete heart block with dual-V pacer, CAD s/p NSTEMI in [**2150**]
who presents with 24 hours of BRBPR. The patient was stable and
recovering from two recent hospitalizations at home, doing well
until the AM of [**2-4**], when he had a large bloody bowel movement
with bright red blood and clots. At this time, he denied any
abdominal pain, chest pain, shortness of breath, n/v/d, f/c,
lightheadedness/dizziness. Later, in the evening, he had another
3 similar bowel movements with bright red blood and clots, and
then another bloody BM the next morning on the day of admission.
He then went to his HD session in the morning, when the staff
there noticed a change in his Hgb from 11 at his prior session
to 6.5. After HD, the patient appeared pale and tired to his
daughter and complained of not being able to stand because he
felt "weak". At that point, his family brought him to the [**Hospital1 18**]
ED. Of note, the patient has had an active recent medical
history, having been hospitalized from [**Date range (1) 28665**] for AMS
secondary to high dose Valtrex for shingles, and then another
hospitalization on [**3-20**] for dyspnea and fever, presumably
secondary to extreme herpetic neuralgia and pain.
.
In the ED, initial vs were: T 98.2 P 61 BP 105/31 RR 24 O2 100%
RA. The patient was hemodynamically stable, but had a Hct of
19.5 measured ([**1-24**] Hct 29.8). Two 18G PIVs were placed and
patient was transfused 1u PRBC's and given 1L fluids. Surgery
and GI were both consulted. On the floor, the patient was stable
and receiving a 2nd unit of PRBC's, but was quite restless from
post-herpetic pain and was requesting his lidocaine patches.
.
Review of systems:
(+) Abdominal/back pain and itching
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias.

MEDICAL HISTORY: -h/o chronic lymphocytic exudative pleural effusions
secondary to chronic uremic pleurisy
-Colonic adenoma with high grade dysplasia / intramucosal
carcinoma; no mucosal invasion, all LN negative, s/p right
colectomy [**3-22**]
-CAD: NSTEMI in [**2150**], no perfusion defects [**3-/2168**] MIBI.
-Mod Pulm HTN, EF >70% 3/09 Echo
-Complete Heart Block S/P [**Company 1543**] Sigma DR [**Last Name (STitle) 26019**] PPM
in [**6-/2167**]
-Left internal carotid artery stenosis: (Carotid US in [**3-19**]
showed a L ICA 70-79% stenosis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**]/LCCA index of 3.6, no
right ICA stenosis with a [**Country **]/RCCA index of 1. in [**2164**]) on
clopidogrel.
-ESRD: [**1-16**] HTN and diabetes, on HD, Receives hemodialysis on
Tuesday, Thursday and Saturday via a left AV fistula at [**Location (un) 1468**]
Dialysis Center.
-Type 2 DM: (last A1c 6% in [**7-22**]) on oral agents
-Hypertension
-Chronic anemia (baseline hct ~ 35)
-Hyperlipidemia
-Secondary hyperparathyroidism
-Bilateral cataracts s/p surgical intervention
-s/p ERCP for bile duct stenosis
-Mild dementia
-h/o urinary retention

MEDICATION ON ADMISSION: 1. simvastatin 10 mg PO DAILY
2. clopidogrel 75 mg Tablet PO DAILY
3. nifedipine 30 mg Tablet Extended Release PO BID
4. baclofen 10 mg PO DAILY PRN FOR PAIN AFTER DIALYSIS
5. metoprolol tartrate 25 mg PO BID
6. B complex-vitamin C-folic acid 1 mg Capsule PO DAILY
7. terazosin 2 mg PO HS
8. lidocaine 5 %(700 mg/patch) x2 DAILY PRN pain from zoster
(apply one to back and one to abdomen on site of zoster)
9. [patient doesn't take] tramadol 50 mg Tablet Sig: 0.5 Tablet
PO Q6H PRN
10. gabapentin 100 mg PO BID

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Zyprexa / Haldol / Morphine

PHYSICAL EXAM: Admission Exam:

FAMILY HISTORY: Non contributory.

SOCIAL HISTORY: Lives with wife.  One of his daughters is very involved in care,
also son [**Name (NI) **]. [**Name2 (NI) **] another son and daughter nearby. [**Name2 (NI) **] worked
as a bricklayer for many years. Reports a 45 pk/yr h/o tobacco
but quit over 20 yrs ago. Has glass of wine with lunch and
dinner occasionally. Occasional beer on a hot day. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Renal agenesis and dysgenesis,Herpes zoster with other nervous system complications,Diverticulosis of small intestine (without mention of hemorrhage),Hypovolemia,Atrial fibrillation,Cardiac pacemaker in situ,Diaphragmatic hernia without mention of obstruction or gangrene,Internal hemorrhoids without mention of complication,Personal history of malignant neoplasm of large intestine,Pure hypercholesterolemia,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Anemia, unspecified'}
