CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: This is an 81-year-old gentleman with a past medical history of
CAD s/p MI, MDS on cycle 2 Vidaza, anemia, severe COPD baseline
home oxygen 2.5 L , hypertension, hyperlipidemia,also with
bladder cancer status post TURBT and BCG treatment in [**2135**]
presenting with retroperitoneal bleed. He presented to [**Location (un) 620**]
ED this afternoon with left sided abdominal pain radiating to
his left thigh. He had previously been hospitalized there from
[**Date range (1) 3462**] for SOB and tachycardia during which he was found to
have a PE and PNA and discharged to rehab on lovenox bridge to
coumadin and levfloxacin. CT at [**Location (un) 620**] showed active
extravasation on CTA abd/pelvis. HCT 23.9, received 1U PRBC and
10mg vitamin K and transferred to [**Hospital1 18**].
.
On arrival to the ED his VS were T 97.6 HR 122 bp 126/66 RR 20
100% ON 5L NC. HCT at 24.3 from 30.5 on discharge [**2140-8-9**] (after
transfusion). In ED Became hypotensive to 59/44 with 1U PRBC
given, 1 U FFP, improving to 111/50 HR in 100s. ED EKG showed
sinus tachycardia. Increasing pain ? tamponading vs worse
managed with fentanyl boluses. Surgery consulted, noted LLQ/L
groin pain c/w location of RP bleed on CT scan, recommended
consulting interventional radiology for possible intervention
and continued transfusion, resuscitation with plan to follow. IR
consulted for angio,felt risks of angio outweighed benefits of
resuscitation, watching.

MEDICAL HISTORY: - Retroperitoneal bleed s/p L hypogastric coil embolization
- Removable IVC filter placed [**8-/2140**] (to be removed 6 months
later)
- DVT / PE ([**7-/2140**])
- MDS on Vidaza
- CAD s/p MI
- COPD on 2L NC
- GI bleed [**2132**]
- Bladder ca s/p BCG [**2135**]
- HTN
- HLD
- AAA repair [**2120**]

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from  team census.
1. Enoxaparin Sodium 80 mg SC Q12H
2. Warfarin 5 mg PO DAILY16
3. Levofloxacin 500 mg PO Q24H
4. PredniSONE 10 mg po  daily Duration: 2 Days
5. PredniSONE 5 mg  po daily Duration: 2  Days Start: After 10
mg tapered dose.
6. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
7. Albuterol-Ipratropium [**12-14**] PUFF IH Q6H:PRN wheeze
8. Omeprazole 20 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Benzonatate 200 mg PO TID
11. Docusate Sodium 100 mg PO BID
12. Senna 1 TAB PO BID
13. Diltiazem Extended-Release 120 mg PO DAILY
Hold for SBP < 100
14. Atorvastatin 40 mg PO HS
15. Bisacodyl 10 mg PO HS:PRN constipation
16. Ensure *NF* (food supplement, lactose-free) 120 ml Oral [**Hospital1 **]
17. Acidophilus *NF* (L.acidoph &
sali-B.bif-S.therm;<br>lactobacillus acidophilus) 175 mg Oral
[**Hospital1 **]
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation

ALLERGIES: Sulfa(Sulfonamide Antibiotics) / Zocor / aspirin

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: BP: 144/80 P: 133 R: 18 O2: 96%
General: Alert, oriented, no acute distress,
HEENT: pale Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL

FAMILY HISTORY: No family history of bledding disorders.

SOCIAL HISTORY: Lives with wife.  Retired [**Name2 (NI) 3455**] [**Doctor Last Name 3456**].  Quit tobacco in [**2120**]
with 2-3 ppd hx for over 50 years.  No etoh or illicits.
Hemorrhage, unspecified,Hemoperitoneum (nontraumatic),Other pulmonary embolism and infarction,Pneumonia, organism unspecified,Dissection of aorta, thoracic,Unspecified vascular insufficiency of intestine,Acute posthemorrhagic anemia,Alkalosis,Aneurysm of iliac artery,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Chronic airway obstruction, not elsewhere classified,Other dependence on machines, supplemental oxygen,Myelodysplastic syndrome, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of bladder,Anticoagulants causing adverse effects in therapeutic use,Hypotension, unspecified,Nonspecific abnormal results of function study of liver,Esophageal reflux,Accidents occurring in residential institution,Personal history of other diseases of circulatory system,Edema
Hemorrhage NOS,Hemoperitoneum,Pulm embol/infarct NEC,Pneumonia, organism NOS,Dsct of thoracic aorta,Vasc insuff intest NOS,Ac posthemorrhag anemia,Alkalosis,Iliac artery aneurysm,Old myocardial infarct,Crnry athrscl natve vssl,Chr airway obstruct NEC,Depend-supplement oxygen,Myelodysplastic synd NOS,Hypertension NOS,Hyperlipidemia NEC/NOS,Hx of bladder malignancy,Adv eff anticoagulants,Hypotension NOS,Abn liver function study,Esophageal reflux,Accid in resident instit,Hx-circulatory dis NEC,Edema
Admission Date:  [**2140-8-19**]              Discharge Date:   [**2140-8-29**]

Date of Birth:  [**2058-12-14**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfa(Sulfonamide Antibiotics) / Zocor / aspirin

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
[**2140-8-20**] OPERATIONS PERFORMED:

1. Infrarenal inferior vena cava filter.
2. Coil embolization of branches of the left hypogastric artery.


History of Present Illness:
 This is an 81-year-old gentleman with a past medical history of
CAD s/p MI, MDS on cycle 2 Vidaza, anemia, severe COPD baseline
home oxygen 2.5 L , hypertension, hyperlipidemia,also with
bladder cancer status post TURBT and BCG treatment in [**2135**]
presenting with retroperitoneal bleed. He presented to [**Location (un) 620**]
ED this afternoon with left sided abdominal pain radiating to
his left thigh. He had previously been hospitalized there from
[**Date range (1) 3462**] for SOB and tachycardia during which he was found to
have a PE and PNA and discharged to rehab on lovenox bridge to
coumadin and levfloxacin. CT at [**Location (un) 620**] showed active
extravasation on CTA abd/pelvis. HCT 23.9, received 1U PRBC and
10mg vitamin K and transferred to [**Hospital1 18**].
.
On arrival to the ED his VS were T 97.6 HR 122 bp 126/66 RR 20
100% ON 5L NC. HCT at 24.3 from 30.5 on discharge [**2140-8-9**] (after
transfusion). In ED Became hypotensive to 59/44 with 1U PRBC
given, 1 U FFP, improving to 111/50 HR in 100s. ED EKG showed
sinus tachycardia. Increasing pain ? tamponading vs worse
managed with fentanyl boluses. Surgery consulted, noted LLQ/L
groin pain c/w location of RP bleed on CT scan, recommended
consulting interventional radiology for possible intervention
and continued transfusion, resuscitation with plan to follow. IR
consulted for angio,felt risks of angio outweighed benefits of
resuscitation, watching.

On arrival to the MICU patient denied pain. SOB with nasal
canula and atrovent nebulizers given. Tachycardia to 140s. IVF
bolus given. 2 18 guage peripherals in place.

Review of systems:
(+) Per HPI
(-) 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, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
- Retroperitoneal bleed s/p L hypogastric coil embolization
- Removable IVC filter placed [**8-/2140**] (to be removed 6 months
later)
- DVT / PE ([**7-/2140**])
- MDS on Vidaza
- CAD s/p MI
- COPD on 2L NC
- GI bleed [**2132**]
- Bladder ca s/p BCG [**2135**]
- HTN
- HLD
- AAA repair [**2120**]

Social History:
Lives with wife.  Retired [**Name2 (NI) 3455**] [**Doctor Last Name 3456**].  Quit tobacco in [**2120**]
with 2-3 ppd hx for over 50 years.  No etoh or illicits.


Family History:
No family history of bledding disorders.

Physical Exam:
Admission Physical Exam:
Vitals: T: BP: 144/80 P: 133 R: 18 O2: 96%
General: Alert, oriented, no acute distress,
HEENT: pale Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL

Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, dis non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

Discharge Physical Exam:
VS Tc 97.8 Tm 98.0 HR 84-101 BP 137/67 (120s-150s/60s-70s) RR
18-20 O2 99-100% 2L NC (home O2 is 2.5 L)
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Diminished air movement, improved from prior, otherwise
clear, no wheezes, rales, ronchi
CV RRR normal S1/S2, distant heart sounds, no mrg
ABD firm abdomen (not rigid) - consistent with exam throughout
the week, NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, pitting edema in hands
improved to baseline, 3+ lower extremity peripheral edema
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions, large ecchymosis on left flank


Pertinent Results:
Admission labs:
[**2140-8-19**] 08:24PM BLOOD WBC-1.5*# RBC-2.51*# Hgb-8.1* Hct-24.3*
MCV-97 MCH-32.4* MCHC-33.4 RDW-19.4* Plt Ct-319
[**2140-8-19**] 08:24PM BLOOD Neuts-71* Bands-0 Lymphs-24 Monos-4 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2*
[**2140-8-19**] 08:24PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Target-OCCASIONAL Stipple-OCCASIONAL
[**2140-8-19**] 11:13PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Burr-1+ Tear Dr[**Last Name (STitle) 833**]
[**2140-8-19**] 08:24PM BLOOD PT-24.3* PTT-40.8* INR(PT)-2.3*
[**2140-8-19**] 08:24PM BLOOD PT-24.3* PTT-40.8* INR(PT)-2.3*
[**2140-8-20**] 10:15AM BLOOD Fibrino-165*
[**2140-8-19**] 08:24PM BLOOD Glucose-167* UreaN-25* Creat-0.9 Na-137
K-5.0 Cl-103 HCO3-30 AnGap-9
[**2140-8-20**] 04:20AM BLOOD Calcium-7.1* Phos-5.9*# Mg-1.9
[**2140-8-20**] 10:20AM BLOOD Type-ART Temp-36 Rates-/12 Tidal V-500
FiO2-100 pO2-475* pCO2-51* pH-7.37 calTCO2-31* Base XS-3
AADO2-186 REQ O2-40 Intubat-INTUBATED
[**2140-8-20**] 10:20AM BLOOD Type-ART Temp-36 Rates-/12 Tidal V-500
FiO2-100 pO2-475* pCO2-51* pH-7.37 calTCO2-31* Base XS-3
AADO2-186 REQ O2-40 Intubat-INTUBATED
[**2140-8-20**] 10:20AM BLOOD Glucose-129* Lactate-2.0 Na-135 K-4.1
Cl-103 calHCO3-31*
[**2140-8-20**] 10:20AM BLOOD freeCa-0.87*
[**2140-8-19**] 08:42PM BLOOD Hgb-8.2* calcHCT-25

Discharge Labs:
[**2140-8-29**] 07:15AM BLOOD WBC-3.0* RBC-3.33* Hgb-10.6* Hct-33.8*
MCV-101* MCH-31.8 MCHC-31.4 RDW-19.1* Plt Ct-405
[**2140-8-29**] 07:15AM BLOOD PT-13.1* PTT-94.3* INR(PT)-1.2*
[**2140-8-29**] 07:15AM BLOOD Glucose-96 UreaN-17 Creat-0.8 Na-136
K-4.5 Cl-99 HCO3-34* AnGap-8
[**2140-8-29**] 07:15AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.0
[**2140-8-21**] 05:33PM BLOOD freeCa-1.12

Studies:
[**2140-8-20**] CHEST PORT. LINE PLACEM
In comparison with the earlier study of this date, there is now
a
right jugular sheath in place without evidence of pneumothorax.
Endotracheal
tube tip lies approximately 8 cm above the carina.

Little overall change in the appearance of the heart and lungs.

[**2140-8-20**] CT ABD & PELVIS W/O CONTRAST
Interval increase of left retroperitoneal hematoma, now with
decompression
into the peritoneal cavity.  Small amounts of blood tracking
around the liver,
both paracolic gutters, and into the pelvis.


[**2140-8-20**] CHEST (PORTABLE AP)
In comparison with the study of [**8-13**], there is continued
hyperexpansion of the lungs consistent with chronic pulmonary
disease.  There
is associated decrease in markings at the apices with coarse
interstitial
markings in the lower lung zones.  The possibility of
supervening pneumonia
would have to be considered in the appropriate clinical setting.


Micro:
[**2140-8-19**] Urine culture, final: negative
[**2140-8-20**] MRSA screen x 2, final: negative


Brief Hospital Course:
81M with CAD s/p MI, severe COPD (home oxygen 2.5 L), HTN, HL,
MDS (on cycle 2 Vidaza), and bladder cancer (s/p TURBT and BCG
treatment in [**2135**] was transferred from [**Hospital1 **] [**Location (un) **] [**2140-8-19**] with
retroperitoneal bleed and is now s/p coil embolizatoin of left
hypogastric artery and IVC filter placement. He remained
hemodynamically stable post-operatively and has was called out
of the CV ICU to the medicine floor.

# Retroperitoneal bleed: Atraumatic bleed in the setting of
anticoagulation for provoked DVT/PE with INR in therapeutic
range of 2.3 at presentation. Initially presented to [**Location (un) 620**]
where CT showed active extravasation on CTA abd/pelvis. HCT
23.9, INR 1.8, received 1U PRBC and 10mg vitamin K and
transferred to [**Hospital1 18**]. Transferred to MICU for hypotension. In
the MICU, IR was consulted and then vascular surgery. Iliac
aneurysm was found and patient transferred to vascular surgery.
He was continuing to have expansion of the RP hematoma. Had CT
scan at 5am on [**8-20**] which showed expansion with decompression of
peritoneal cavity and his hypogastric artery was coil embolized,
achieving hemostasis. The bleeding was not related to his iliac
aneurysm. He was then brought to the CV ICU post-operatively.
Arbitrary transfusion goal of 30 (was in 28 range before this
acute illness due to MDS). Only got 2 units in CV ICU. In total
he was transfused 10 units since arrival to [**Hospital1 18**] (6 peri
operatively) Last transfusion [**2140-8-21**] at 9pm with HCT 25 -> 30.
Throughout his stay in the CVICU, he did not require pressors
and has been hypertensive today with SBP~150. Peripheral access
was obtained in the CV ICU and his cortis was pulled.
Transferred from CV ICU to medicine on [**8-22**] and he remained
hemodynamically stable with stable hematocrit in the 28-33
range.

# PE: Diagnosed [**2140-8-13**] by CTA revealing subsegmental right lower
lobe pulmonary embolus. Was anticoagulated with INR 2.3 on
admission, and is now s/p reversal given RP bleed coil of
hypogastric artery. On heparin drip bridging to coumadin.
Started coumadin 5 mg daily on [**8-26**]. No evidence of bleeding and
stable hematocrits. He had an IVC filter placed [**2140-8-20**] (Cook
Select Filter). He will require a total of 6 months of
anticoagulation and will follow up with his Hematologist for
ongoing management of his DVT/PE. At the time of discahrge he
was satting 99% on his home O2 (2L NC).

# Elevated Bicarb: Bicarb peaked at 43. Likely multifactorial
due to COPD with chronic renal compensation and retention of
bicarb. Also likely component of contraction alkalosis secondary
to aggressive diuresis. Started acetazolamide [**8-25**] through [**8-28**].
Bicarb was 34 at the time of discharge. His HCO3 should continue
to be monitored as long as he is being actively diuresed.

# LE edema: Patient with continued marked lower extremity edema
likely from iatrogenic volume overload due to transfusion of 10U
pRBCs. He was diuresed with Lasix 20mg IV qday for the duration
of his course with marked improvement in his volume overload. He
should continue to have his legs elevated at night and
throughout the day when recumbent in bed. He should also
continue Lasix 40mg PO qday for 3 days. He should have his
electrolytes checked twice daily while receiving Lasix.

# COPD: Patient has a history severe COPD with FEV1 of
approximately 0.7 on 2.5L NC at home. His home medications were
continued and there was no e/o COPD flare on this admission. At
the time of discharge he was satting well on his home O2.

# Ischemic Colitis: Diagnosed [**Hospital1 **] CT [**8-4**], involving
descending/sigmoid colon area. Initially presumed infectious s/p
10 day course cipro/flagyll but in context of atherosclerotic
disease and large volume bleed, ischemic seemed more likely. Pt
was transfused per above and was having normal non bloody BMs at
the time of discharge.

# MDS: He is s/p Vidaza with continued pancytopenia. In
consultation with outpatient oncologist, will hold off on
additional chemotherapy for MDS at this time. He will f/u with
his outpatient Oncologist for ongoing management of MDS.

# Liver and renal hypodensities: seen on CT scan last [**Hospital1 **]
admission likely cysts vs hemangiomas.
- outpatient MRI/renal US to further evaluate

# CAD s/p MI: His home Atorvastatin and Diltiazem were continued
throughout his course. He is allergic to ASA.

# GERD: His home omeprazole 20 mg PO daily was continued.

# Hyperlipidemia: His home Atorvastatin 40mg PO daily was
continued.

# Transitional issues:
- Patient will need IV heparin bridge to Coumadin (INR goal [**1-15**]
for 6 months)
- Will need daily INR checks until therapeutic
- Patient scheduled for follow up with Vascular Surgery (Dr.
[**Last Name (STitle) **]
- Please ensure the patient follows up for interval IVC filter
removal.  The filter is a Cook Celect filter.
- Patient scheduled for follow up with [**Name (NI) 3463**] [**Name (NI) 2274**]
- Pt will need his Na, Cl, K, Cr and Mg checked twice daily for
3 days while being diuresed with Lasix.
- Pt will need outpatient MRI/renal US to evaluate liver and
renal hypodensities seen on CT

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from  team census.
1. Enoxaparin Sodium 80 mg SC Q12H
2. Warfarin 5 mg PO DAILY16
3. Levofloxacin 500 mg PO Q24H
4. PredniSONE 10 mg po  daily Duration: 2 Days
5. PredniSONE 5 mg  po daily Duration: 2  Days Start: After 10
mg tapered dose.
6. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
7. Albuterol-Ipratropium [**12-14**] PUFF IH Q6H:PRN wheeze
8. Omeprazole 20 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Benzonatate 200 mg PO TID
11. Docusate Sodium 100 mg PO BID
12. Senna 1 TAB PO BID
13. Diltiazem Extended-Release 120 mg PO DAILY
Hold for SBP < 100
14. Atorvastatin 40 mg PO HS
15. Bisacodyl 10 mg PO HS:PRN constipation
16. Ensure *NF* (food supplement, lactose-free) 120 ml Oral [**Hospital1 **]
17. Acidophilus *NF* (L.acidoph &
sali-B.bif-S.therm;<br>lactobacillus acidophilus) 175 mg Oral
[**Hospital1 **]
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation


Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Senna 1 TAB PO BID
3. Albuterol-Ipratropium [**12-14**] PUFF IH Q6H:PRN wheeze
4. Benzonatate 200 mg PO TID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
8. Warfarin 5 mg PO DAILY16
9. Heparin IV Sliding Scale
10. Diltiazem Extended-Release 120 mg PO DAILY
Hold for SBP < 100
11. Atorvastatin 40 mg PO HS
12. Acidophilus *NF* (L.acidoph &
sali-B.bif-S.therm;<br>lactobacillus acidophilus) 175 mg Oral
[**Hospital1 **]
13. Bisacodyl 10 mg PO HS:PRN constipation
14. Ensure *NF* (food supplement, lactose-free) 120 ml Oral [**Hospital1 **]
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary Diagnoses:
- Left Retroperitoneal Hematoma / expanding
- Anemia requiring transfusion
- Pulmonary emobolism / recent
- Left Iliac Artery Aneurysm

Secondary diagnoses: Severe COPD on home O2, coronary artery
disease status post MI, hyperlipidemia, myelodysplastic
syndrome, and bladder cancer status post TURBT


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 3457**],

You were admitted to the hospital because you were bleeding
internally (retroperitoneal hemeorrhage).  You were given
multiple blood transfusions.  You required an endovascular
procedure to stop the bleeding as well as to prevent a future
blood clot in your lungs. Due to the recent blood clots in your
leg and lungs, you were restarted on blood thinners (Heparin and
Coumadin) and you should continue taking Coumadin as prescribed
following discharge.  You will need to have your blood drawn
often to determine how much Coumadin you will need to take.

Below are the instructions and expectations following the
procedure:

MEDICATION:
??????	Take Aspirin 325mg (enteric coated) once daily
??????	If instructed, take Plavix (Clopidogrel) 75mg once daily
??????	Continue all other medications you were taking before surgery,
unless otherwise directed
??????	You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort

WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
??????	Elevate your leg above the level of your heart with pillows
every 2-3 hours throughout the day and night
??????	Avoid prolonged periods of standing or sitting without your
legs elevated
??????	It is normal to feel tired and have a decreased appetite, your
appetite will return with time
??????	Drink plenty of fluids and eat small frequent meals
??????	It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
??????	To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication

ACTIVITIES:
??????	When you go home, you may walk and use stairs
??????	You may shower (let the soapy water run over groin incision,
rinse and pat dry)
??????	Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
??????	No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
??????	After 1 week, you may resume sexual activity
??????	After 1 week, gradually increase your activities and distance
walked as you can tolerate
??????	No driving until you are no longer taking pain medications

CALL THE OFFICE FOR: [**Telephone/Fax (1) 3464**]
??????	Numbness, coldness or pain in lower extremities
??????	Temperature greater than 101.5F for 24 hours
??????	New or increased drainage from incision or white, yellow or
green drainage from incisions
??????	Bleeding from groin puncture site

SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
??????	Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.

You will need to have the IVC filter removed after you complete
your course of blood thinners.  This should be scheduled through
the office of Dr. [**Last Name (STitle) **] who placed the filter.

Followup Instructions:
You will also need to follow up with vascular surgery (Dr.
[**Last Name (STitle) **] for removal of your IVC filter when you finish
your course of blood thinners (6 months from discharge).

Name: [**Name6 (MD) 3465**] [**Last Name (NamePattern4) 3466**], MD
Specialty: Hematology/Oncology
When: Thursday [**2140-9-1**] at 12:30pm
Location: [**Hospital1 641**]
Address: [**Street Address(2) 3467**], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3468**]
This appointment was already scheduled for you to see Dr.
[**First Name (STitle) 3459**].

Department: VASCULAR SURGERY
When: WEDNESDAY [**2140-9-28**] at 2:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Name: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3453**], MD
Specialty: Primary Care
Location: [**Location (un) 2274**] [**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 3472**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.



Completed by:[**2140-8-29**]
{'Hemorrhage, unspecified,Hemoperitoneum (nontraumatic),Other pulmonary embolism and infarction,Pneumonia, organism unspecified,Dissection of aorta, thoracic,Unspecified vascular insufficiency of intestine,Acute posthemorrhagic anemia,Alkalosis,Aneurysm of iliac artery,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Chronic airway obstruction, not elsewhere classified,Other dependence on machines, supplemental oxygen,Myelodysplastic syndrome, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of bladder,Anticoagulants causing adverse effects in therapeutic use,Hypotension, unspecified,Nonspecific abnormal results of function study of liver,Esophageal reflux,Accidents occurring in residential institution,Personal history of other diseases of circulatory system,Edema'}


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: Hypotension

PRESENT ILLNESS: This is an 81-year-old gentleman with a past medical history of
CAD s/p MI, MDS on cycle 2 Vidaza, anemia, severe COPD baseline
home oxygen 2.5 L , hypertension, hyperlipidemia,also with
bladder cancer status post TURBT and BCG treatment in [**2135**]
presenting with retroperitoneal bleed. He presented to [**Location (un) 620**]
ED this afternoon with left sided abdominal pain radiating to
his left thigh. He had previously been hospitalized there from
[**Date range (1) 3462**] for SOB and tachycardia during which he was found to
have a PE and PNA and discharged to rehab on lovenox bridge to
coumadin and levfloxacin. CT at [**Location (un) 620**] showed active
extravasation on CTA abd/pelvis. HCT 23.9, received 1U PRBC and
10mg vitamin K and transferred to [**Hospital1 18**].
.
On arrival to the ED his VS were T 97.6 HR 122 bp 126/66 RR 20
100% ON 5L NC. HCT at 24.3 from 30.5 on discharge [**2140-8-9**] (after
transfusion). In ED Became hypotensive to 59/44 with 1U PRBC
given, 1 U FFP, improving to 111/50 HR in 100s. ED EKG showed
sinus tachycardia. Increasing pain ? tamponading vs worse
managed with fentanyl boluses. Surgery consulted, noted LLQ/L
groin pain c/w location of RP bleed on CT scan, recommended
consulting interventional radiology for possible intervention
and continued transfusion, resuscitation with plan to follow. IR
consulted for angio,felt risks of angio outweighed benefits of
resuscitation, watching.

MEDICAL HISTORY: - Retroperitoneal bleed s/p L hypogastric coil embolization
- Removable IVC filter placed [**8-/2140**] (to be removed 6 months
later)
- DVT / PE ([**7-/2140**])
- MDS on Vidaza
- CAD s/p MI
- COPD on 2L NC
- GI bleed [**2132**]
- Bladder ca s/p BCG [**2135**]
- HTN
- HLD
- AAA repair [**2120**]

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from  team census.
1. Enoxaparin Sodium 80 mg SC Q12H
2. Warfarin 5 mg PO DAILY16
3. Levofloxacin 500 mg PO Q24H
4. PredniSONE 10 mg po  daily Duration: 2 Days
5. PredniSONE 5 mg  po daily Duration: 2  Days Start: After 10
mg tapered dose.
6. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation [**Hospital1 **]
7. Albuterol-Ipratropium [**12-14**] PUFF IH Q6H:PRN wheeze
8. Omeprazole 20 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. Benzonatate 200 mg PO TID
11. Docusate Sodium 100 mg PO BID
12. Senna 1 TAB PO BID
13. Diltiazem Extended-Release 120 mg PO DAILY
Hold for SBP < 100
14. Atorvastatin 40 mg PO HS
15. Bisacodyl 10 mg PO HS:PRN constipation
16. Ensure *NF* (food supplement, lactose-free) 120 ml Oral [**Hospital1 **]
17. Acidophilus *NF* (L.acidoph &
sali-B.bif-S.therm;<br>lactobacillus acidophilus) 175 mg Oral
[**Hospital1 **]
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation

ALLERGIES: Sulfa(Sulfonamide Antibiotics) / Zocor / aspirin

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: BP: 144/80 P: 133 R: 18 O2: 96%
General: Alert, oriented, no acute distress,
HEENT: pale Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL

FAMILY HISTORY: No family history of bledding disorders.

SOCIAL HISTORY: Lives with wife.  Retired [**Name2 (NI) 3455**] [**Doctor Last Name 3456**].  Quit tobacco in [**2120**]
with 2-3 ppd hx for over 50 years.  No etoh or illicits. 

### Response:
{'Hemorrhage, unspecified,Hemoperitoneum (nontraumatic),Other pulmonary embolism and infarction,Pneumonia, organism unspecified,Dissection of aorta, thoracic,Unspecified vascular insufficiency of intestine,Acute posthemorrhagic anemia,Alkalosis,Aneurysm of iliac artery,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Chronic airway obstruction, not elsewhere classified,Other dependence on machines, supplemental oxygen,Myelodysplastic syndrome, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of bladder,Anticoagulants causing adverse effects in therapeutic use,Hypotension, unspecified,Nonspecific abnormal results of function study of liver,Esophageal reflux,Accidents occurring in residential institution,Personal history of other diseases of circulatory system,Edema'}
