CHIEF COMPLAINT: GI bleed

PRESENT ILLNESS: This is a 69-year-old man with COPD, HTN, a. fib on enoxaparin
and coumadin, PE, and recent admission for sternal wound
infection s/p multiple debridements presents from OSH with
unstable upper GI hemorrhage.  Per report, patient developed
episodes of hematemesis and melena yesterday at [**Hospital **] rehab.
He was transferred to [**Hospital3 7362**] where he underwent emergent
EGD overnight.  He was found to have a distal esophageal ulcer
that was clipped x5.  Patient was also started on a PPI and
octreotide drip, given 9 units of PRBCs, 7 units of FFP, 20mg of
IV vitamin K, and protamine.  He was also started on a levophed
gtt for persistent hypotension. After EGD, hct was still ~20,
and patient continued to have copious amounts of melena.
Patient was apparently seen by IR at [**Hospital1 3597**], who did not feel
comfortable intervening with this sort of bleed, and surgery who
did not feel that patient would survive a distal esophagectomy.
As such, Mr. [**Known lastname 63108**] was transferred to [**Hospital1 18**] for further
treatment.

MEDICAL HISTORY: - h/o atrial Fibrillation
- s/p Pacer ([**Company 1543**] DDD)
- COPD
- Hypertension
- PVD s/p Aortobifemoral bypass
- Hyperlipidemia
- Chronic liver disease [**2-22**] EtOH (sober now)
- Anemia: h/o maroon stools; colonoscopy in [**2146**] with
hemorrhoids, colon polyps, adenoma
- h/o epistaxis
- history of AAA that was repaired in 07
- h/o PE ~2-3 months ago per pt. Notes from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] mention
PE and imaging from today mentions stable PE. However, no
records at [**Hospital1 18**] mention PE.
- Wedge fractures - Noted in lumbar region on CT scan
- prolonged hospitalization at [**Hospital1 18**] in [**8-30**] for epiglottitis
requiring cric/trach, with hospital course complicated by GI
bleeding and pseudonomas bacteremia

MEDICATION ON ADMISSION: digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY
midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID
tamsulosin 0.4 mg Capsule daily
simvastatin 40 mg Tablet daily
citalopram 20 mg Tablet daily
vancomycin 125 mg Capsule PO Q6H for 14 days treatment
clonazepam 0.5 mg Tablet [**Hospital1 **] PRN
ceftazidime 2 gram Q8H (every 8 hours): plan for 6-8 weeks total
Percocet 5-325 mg Q4H PRN pain
aspirin 81 mg Tablet daily
warfarin 1 mg Tablet Sig: 0.5mg daily for 2 weeks, INR goal [**2-23**]
for afib/PE (patient very sensitive to coumadin).
Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days, then taper to 40 mg daily
alum-mag hydroxide-simeth 200-200-20 mg/5 mL QID (4 times a day)
as needed for gas pain.
fluticasone-salmeterol 250-50 mcg/dose [**1-22**] puff Inhalation [**Hospital1 **]
potassium chloride 20 mEq Tab Sust.Rel daily
Wellbutrin SR 150 mg Tablet Sustained Release Sig: One Tablet
Sustained Release PO once a day: 150mg daily for 3 days, then
increase to [**Hospital1 **] for smoking cessation
ipratropium bromide 0.02 % Solution Sig: Two (2) Q6H PRN
wheezing
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **] PRN
Coumadin 0.5mg QD

ALLERGIES: Seroquel / Fentanyl / Flagyl

PHYSICAL EXAM: Physical Exam on Discharge:
O: Tc 98, Tm 98.6, BP 100/59 (94-127/59-78), HR 90 (83-101), RR
20 (18-22), O2Sat 96% 3L
I/O: 1790/975 over last 24 hours, 100/460 over last 8 hours
HEENT: NC AT
Chest: Healing sternotomy. Improved airway sounds, coarse
rhonchi in the bases but cleared with coughing, no wheeze or
crackles
CV: Heart sound distant, difficult to hear with also coarse
rhonchi.  Does have a [**3-26**] holosystolic murmur present when
patient holds breath for a second (this valvular disease is
known, evident by based on available echo)
Abd: soft, NT, mildly distended, BS present
Ext: no edema, 2+ DP bilaterally, no asterixis
Neuro: AAOx3

FAMILY HISTORY: Father and mother both died of CAD, dad died after age >50

SOCIAL HISTORY: Unemployed. Used to work in the stockroom at the [**Location (un) **]
Corportation. Lives alone. Has a scooter at home.  Health care
proxy is his friend [**Name (NI) 892**] [**Name (NI) 16471**], (c) [**Telephone/Fax (1) 106834**], (h)
[**Telephone/Fax (1) 106835**].  Tobacco: used to smoke 1.5 ppd x ~50 years. Quit
6 months ago.  Alcohol: per records, hx of heavy EtOH use. Quit
9 months ago.  Illicits: none
Ulcer of esophagus with bleeding,Acute respiratory failure,Other shock without mention of trauma,Intestinal infection due to Clostridium difficile,Other postoperative infection,Unspecified pleural effusion,Unspecified disease of pericardium,Hyposmolality and/or hyponatremia,Acute posthemorrhagic anemia,Other ascites,Unspecified disease of pancreas,Alcoholic cirrhosis of liver,Loss of weight,Unspecified essential hypertension,Atrial fibrillation,Other emphysema,Aortocoronary bypass status,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Cardiac pacemaker in situ
Ulcer esophagus w bleed,Acute respiratry failure,Shock w/o trauma NEC,Int inf clstrdium dfcile,Other postop infection,Pleural effusion NOS,Pericardial disease NOS,Hyposmolality,Ac posthemorrhag anemia,Ascites NEC,Pancreatic disease NOS,Alcohol cirrhosis liver,Abnormal loss of weight,Hypertension NOS,Atrial fibrillation,Emphysema NEC,Aortocoronary bypass,Abn react-anastom/graft,Status cardiac pacemaker
Admission Date:  [**2147-1-16**]              Discharge Date:   [**2147-1-28**]

Date of Birth:  [**2078-1-10**]             Sex:   M

Service: MEDICINE

Allergies:
Seroquel / Fentanyl / Flagyl

Attending:[**First Name3 (LF) 1945**]
Chief Complaint:
GI bleed

Major Surgical or Invasive Procedure:
EGD x 2
arterial line placement

History of Present Illness:
This is a 69-year-old man with COPD, HTN, a. fib on enoxaparin
and coumadin, PE, and recent admission for sternal wound
infection s/p multiple debridements presents from OSH with
unstable upper GI hemorrhage.  Per report, patient developed
episodes of hematemesis and melena yesterday at [**Hospital **] rehab.
He was transferred to [**Hospital3 7362**] where he underwent emergent
EGD overnight.  He was found to have a distal esophageal ulcer
that was clipped x5.  Patient was also started on a PPI and
octreotide drip, given 9 units of PRBCs, 7 units of FFP, 20mg of
IV vitamin K, and protamine.  He was also started on a levophed
gtt for persistent hypotension. After EGD, hct was still ~20,
and patient continued to have copious amounts of melena.
Patient was apparently seen by IR at [**Hospital1 3597**], who did not feel
comfortable intervening with this sort of bleed, and surgery who
did not feel that patient would survive a distal esophagectomy.
As such, Mr. [**Known lastname 63108**] was transferred to [**Hospital1 18**] for further
treatment.

Patient was recently admitted to the cardiothoracic surgery
service for reucrrent sternal wound infections in setting of
CABG.  Mr. [**Known lastname 63108**] was maintained on vancomycin and ceftaz at
rehab.  He also has a history of C.diff for which he is on po
vancomycin.

Upon arrival to ICU, vitals were: HR 107, BP 96/61 on 16mcg of
levophed, SP02 100% on CMV fi02 60%, PEEP 5, tidal volume 500.
Patient has a non-functioning PICC and a left IJ placed at
outside facility.  Gastroenterology, thoracic surgery, and
interventional radiology were called.


Past Medical History:
- h/o atrial Fibrillation
- s/p Pacer ([**Company 1543**] DDD)
- COPD
- Hypertension
- PVD s/p Aortobifemoral bypass
- Hyperlipidemia
- Chronic liver disease [**2-22**] EtOH (sober now)
- Anemia: h/o maroon stools; colonoscopy in [**2146**] with
hemorrhoids, colon polyps, adenoma
- h/o epistaxis
- history of AAA that was repaired in 07
- h/o PE ~2-3 months ago per pt. Notes from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] mention
PE and imaging from today mentions stable PE. However, no
records at [**Hospital1 18**] mention PE.
- Wedge fractures - Noted in lumbar region on CT scan
- prolonged hospitalization at [**Hospital1 18**] in [**8-30**] for epiglottitis
requiring cric/trach, with hospital course complicated by GI
bleeding and pseudonomas bacteremia

Social History:
Unemployed. Used to work in the stockroom at the [**Location (un) **]
Corportation. Lives alone. Has a scooter at home.  Health care
proxy is his friend [**Name (NI) 892**] [**Name (NI) 16471**], (c) [**Telephone/Fax (1) 106834**], (h)
[**Telephone/Fax (1) 106835**].  Tobacco: used to smoke 1.5 ppd x ~50 years. Quit
6 months ago.  Alcohol: per records, hx of heavy EtOH use. Quit
9 months ago.  Illicits: none

Family History:
Father and mother both died of CAD, dad died after age >50

Physical Exam:
Physical Exam on Discharge:
O: Tc 98, Tm 98.6, BP 100/59 (94-127/59-78), HR 90 (83-101), RR
20 (18-22), O2Sat 96% 3L
I/O: 1790/975 over last 24 hours, 100/460 over last 8 hours
HEENT: NC AT
Chest: Healing sternotomy. Improved airway sounds, coarse
rhonchi in the bases but cleared with coughing, no wheeze or
crackles
CV: Heart sound distant, difficult to hear with also coarse
rhonchi.  Does have a [**3-26**] holosystolic murmur present when
patient holds breath for a second (this valvular disease is
known, evident by based on available echo)
Abd: soft, NT, mildly distended, BS present
Ext: no edema, 2+ DP bilaterally, no asterixis
Neuro: AAOx3


Pertinent Results:
[**2147-1-16**] 12:05PM   PT-17.5* PTT-34.8 INR(PT)-1.6*
[**2147-1-16**] 12:05PM   PLT SMR-NORMAL PLT COUNT-310
[**2147-1-16**] 12:05PM   HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+
SCHISTOCY-OCCASIONAL ENVELOP-OCCASIONAL ACANTHOCY-1+
[**2147-1-16**] 12:05PM   NEUTS-88* BANDS-2 LYMPHS-6* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2147-1-16**] 12:05PM   WBC-24.7*# RBC-2.52* HGB-8.1* HCT-21.6*
MCV-86 MCH-32.1*# MCHC-37.3*# RDW-16.5*
[**2147-1-16**] 12:05PM   DIGOXIN-0.4*
[**2147-1-16**] 12:05PM   ALBUMIN-2.9* CALCIUM-7.7* PHOSPHATE-3.4
MAGNESIUM-1.6
[**2147-1-16**] 12:05PM   CK-MB-6 cTropnT-0.02*
[**2147-1-16**] 12:05PM   ALT(SGPT)-29 AST(SGOT)-105* CK(CPK)-68 ALK
PHOS-68 TOT BILI-3.4* DIR BILI-0.8* INDIR BIL-2.6
[**2147-1-16**] 12:05PM   estGFR-Using this
[**2147-1-16**] 12:05PM   GLUCOSE-150* UREA N-44* CREAT-1.1 SODIUM-140
POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-21* ANION GAP-13
[**2147-1-16**] 12:33PM   LACTATE-1.7
[**2147-1-16**] 12:33PM   TYPE-MIX PO2-39* PCO2-44 PH-7.32* TOTAL
CO2-24 BASE XS--3
[**2147-1-16**] 03:25PM URINE  AMORPH-FEW
[**2147-1-16**] 03:25PM URINE  RBC-[**3-25**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2147-1-16**] 03:25PM URINE  [**Month/Day/Year 3143**]-LG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2147-1-16**] 03:25PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2147-1-16**] 03:26PM   FIBRINOGE-221
[**2147-1-16**] 03:26PM   PT-17.3* PTT-33.0 INR(PT)-1.5*
[**2147-1-16**] 03:26PM   PLT COUNT-325
[**2147-1-16**] 03:26PM   WBC-24.0* RBC-3.31*# HGB-9.9* HCT-28.1*#
MCV-85 MCH-29.9 MCHC-35.2* RDW-17.0*
[**2147-1-16**] 03:26PM   CALCIUM-8.0* PHOSPHATE-3.1 MAGNESIUM-1.6
[**2147-1-16**] 03:26PM   GLUCOSE-140* UREA N-42* CREAT-0.9 SODIUM-141
POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-21* ANION GAP-14
[**2147-1-16**] 07:54PM   LACTATE-1.4
[**2147-1-16**] 07:54PM   TYPE-ART PO2-128* PCO2-37 PH-7.36 TOTAL
CO2-22 BASE XS--3
[**2147-1-16**] 09:08PM   CK-MB-8 cTropnT-0.02*
[**2147-1-16**] 09:08PM   CK(CPK)-98
[**2147-1-16**] 09:09PM   HCT-29.4*
[**2147-1-16**] 09:22PM   freeCa-1.08*
[**2147-1-16**] 09:22PM   TYPE-[**Last Name (un) **] PH-7.35
[**2147-1-17**] 12:00AM   HCT-27.4*
.
EGD [**1-16**]
[**Month/Year (2) **] in the whole Esophagus
5 previously placed endoclips visualized in linear fashion in
distal esophagus terminating at the GE junction. Appearance of
potential ulceration beneath.
[**Month/Year (2) **] in the whole stomach
Red [**Month/Year (2) **], less than seen in stomach and esophagus visualized in
duodenum. No active bleeding source identified.
Otherwise normal EGD to second part of the duodenum
.
EGD [**1-17**]
Five endoclips in a linear pattern from 41 to 45 cm from the
incisors were noted in the esophagus. It is unclear what the
clips were overlying but one clip was positioned over a
protuberance that was suspicious for a varix. There was also
[**Month/Year (2) **] throughout the esophagus without obvious source but likely
emanating from the stomach.
[**Month/Year (2) **] throughout the stomach with a large clot in the cardia and
fundus overlying active oozing of unclear source
[**Name (NI) **] in the visualized portions of the duodenum
Otherwise normal EGD to second part of the duodenum
.
[**1-18**] CT abdomen/pelvis
1. No evidence of active extravasation. High-attenuation
material in the
stomach could be consistent with hemorrhagic products.
2. Multiple enlarged intra-abdominal lymph nodes, with 3.6-cm
heterogeneous and centrally necrotic mass near pancreatic head.
Following resolution of patient's acute GI bleed, this could be
further investigated by FDG-PET or endoscopic ultrasound-guided
aspiration.
3. Aorto-biiliac stent graft, with no evidence of endoleak or
aortoenteric
fistula.
4. Increased bilateral pleural effusions and trace ascites.
5. New loculated pericardial fluid collection, compressing right
atrium and ventricle.

[**1-27**] EUS:
Salmon colored mucosa in a localized pattern suggestive of
Barrett's Esophagus, 3 hemostatic clips found in distal
esophagus.  Biopsies done in the stomach.  Diffuse continuous
nodularity of the mucosa without bleeding in the stomach.  A
large peri-pancreatic LN was noted near the head of the pancreas
about 3 cm in max diameter s/p FNA.  Fluid collection (?
necrotic) adjacent to the lower third of the CBD near the
pancreatic head.  Apparent infiltrative process in the stomach
manifest by thickened gastric walls (particularly in the body)
suggestive of intestinal metaplasia or less likely lymphoma or
linitis plastica.


Brief Hospital Course:
This is a 69-year-old gentleman with a pmhx. significant for
afib, PE (on coumadin and now lovenox), CAD s/p recent CABG,
c.diff infection, who is transferred here from [**Hospital3 7362**]
with continued GI bleed despite placement of 5 clips in lower
esophageal ulcer.
.
# UGI BLEED/Mass near pancreas:  Patient underwent endoscopy at
OSH and s/p clips to esophageal ulcers.  He was transferred to
[**Hospital1 18**] ICU [**1-16**].  He underwent EGD [**1-16**] that showed: [**Month/Year (2) **] in
the esophagus and stomach, 5 previously placed endoclips,
potential ulceration beneath and no active bleeding source
identified.  The following day [**1-17**], he underwent repeat EGD
that showed: suspicion for varix underlying esophageal clip,
[**Month/Year (2) **] throughout the esophagus without obvious source but likely
emanating from the stomach and [**Month/Year (2) **] throughout the stomach with
a large clot in the cardia and fundus overlying active oozing of
unclear source.  CT abdomen showed: enlarged abdominal
lymphnodes and necrotic mass near pancreatic head.  This mass
was biopsied and pathology pending from EGD/EUS on [**1-27**].  While
in the ICU, patient required pRBC, but on transfer to medicine
floor remained stable w/ hcts in the low 30s.  He was
transitioned from iv ppi to po ppi.  Palliative care was
consulted while on the floor as patient expressed that he was
uncertain if he wanted further work up.  He expressed that he
wanted to be DNR/DNI.  Goals of care discussion held with him
and HCP.  [**Name (NI) **] decided to undergo further work up, and as
stated had a biopsy of the mass.  He will follow up with
gastroenterology for biopsies and will need oncology referral if
malignancy.  He was started on morphine for pain.  Of note given
his CHADS score, discussion with GI, he was restarted on low
dose of ASA 81 mg daily with PPI and follow-up with
gastroenterology.
- Check Hct on [**2147-1-31**].  Transfuse for hct <25.
.
# HYPOTENSION: Secondary to hypovolemia, with high CVP and low
lactate.  Responded to ivf's and pRBC in the ICU.  BP on the
floor remained in 90s.  He was restarted on lasix for diuresis
(see below) and tolerated this.
.
# PLEURAL EFFUSION:  Bilateral effusions noted on CT imaging.
Patient diuresed w/ iv lasix while on the floor and then
switched to po.  On discharge patient sating in mid 90s on RA.
- If patient develops worsening dyspnea or edema, can increase
lasix from 40mg daily to [**Hospital1 **].
.
# PERICARDIAL EFFUSION: Secondary to h/o surgeries.
[**Hospital1 **] done that showed no tamponade physiology, but was
notable for severe TR and depressed RV function.
.
# CIRHOSIS: Found to have cirrhosis on imaging, likely related
to ETOH.  Possible varix on EGD.  Patient will follow up with GI
as an outpatient, will need referal to Liver.
.
# STERNAL WOUND INFECTION:  Patient with recent CABG and
subsequent sternal wound infection that grew out pseudomonas.
Has been on vanc and ceftaz at rehab and this was continued on
this hospitalization.  Patient will follow up with [**Hospital **] clinic on
discharge.
-Continue ceftaz
-Continue dry dressings
.
# CDIFF: Continued po vanc while on ceftaz.
.
# CAD s/p CABG:  PAtient was continued on his statin and lasix
restarted.  Aspirin was held in the setting of GI bleed.
-Do not restart aspirin until patient follows up with GI as an
outpatient.
.
# AFIB:  Continued digoxin for atrial fibrillation.  Coumadin
was held in the setting of bleed and should not be restarted
until patient follows up as outpatient with GI and cardiology.
.
# COPD:  Continued inhalers/nebs.
.
# BPH:  Restarted tamsulosin when stable.  Okay to continue.


Medications on Admission:
digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY
midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID
tamsulosin 0.4 mg Capsule daily
simvastatin 40 mg Tablet daily
citalopram 20 mg Tablet daily
vancomycin 125 mg Capsule PO Q6H for 14 days treatment
clonazepam 0.5 mg Tablet [**Hospital1 **] PRN
ceftazidime 2 gram Q8H (every 8 hours): plan for 6-8 weeks total
Percocet 5-325 mg Q4H PRN pain
aspirin 81 mg Tablet daily
warfarin 1 mg Tablet Sig: 0.5mg daily for 2 weeks, INR goal [**2-23**]
for afib/PE (patient very sensitive to coumadin).
Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days, then taper to 40 mg daily
alum-mag hydroxide-simeth 200-200-20 mg/5 mL QID (4 times a day)
as needed for gas pain.
fluticasone-salmeterol 250-50 mcg/dose [**1-22**] puff Inhalation [**Hospital1 **]
potassium chloride 20 mEq Tab Sust.Rel daily
Wellbutrin SR 150 mg Tablet Sustained Release Sig: One Tablet
Sustained Release PO once a day: 150mg daily for 3 days, then
increase to [**Hospital1 **] for smoking cessation
ipratropium bromide 0.02 % Solution Sig: Two (2) Q6H PRN
wheezing
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **] PRN
Coumadin 0.5mg QD

Discharge Medications:
1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for gas.
8. ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours).
9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
10. Wellbutrin SR 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1)  Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
13. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
14. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
15. morphine 10 mg/5 mL Solution Sig: One (1)  PO Q4H (every 4
hours) as needed for pain.


Discharge Disposition:
Extended Care

Facility:
Maplewood Care & Rehabilitation Center - [**Location (un) 32944**]

Discharge Diagnosis:
Necrotic mass near the pancrease
Upper GI bleed
Pleural effusion


Discharge Condition:
A&Ox3
Ambulate with assistance.


Discharge Instructions:
Dear Mr. [**Known lastname 63108**],
You were admitted to the hospital because you were vomiting
[**Known lastname **].  At [**Hospital3 7362**] you had an upper endoscopy and had
clips placed to prevent further bleeding.  You were transferred
to [**Hospital1 18**] for further work up.  While you were here you had
repeat endoscopies, that showed [**Hospital1 **] in the esophagus and the
stomach.  You required [**Hospital1 **] transfusions while you were here,
but your repeat hematocrits have been stable.  On imaging it
appeared that you had a mass close to the pancreas, and so you
had a biopsy to evaluate the mass.  We continued you on your
antibiotics for your sternal wound and c diff.

For your follow up you will need to see the gastroenterology
team to find the final results of your biopsy.  You should also
continue to see the infectious disease doctor regarding your
sternal wound and cardiac surgery.

We have made the following changes to your medications:
1. Stop aspirin.  This is a [**Hospital1 **] thinner and you have had a
recent upper gastrointestinal bleed.  Do not restart this until
you have seen the gastroenterologist in follow up.  Please
discuss restarting this medication with your gastroenterologist
and cardiologist.
2. Stop coumadin.  This is also a [**Hospital1 **] thinner.  Do not restart
this until you have seen the gastroenterologist in follow up.
Please discuss restarting this medication with your
gastroenterologist and cardiologist.
3. Start morphine for pain.  This is a sedating medication,
please take only as directed.  DO NOT TAKE WITH ALCOHOL OR WHILE
OPERATING A MOTOR VEHICLE.
4. Stop citalopram, you are on wellbutrin.
5. Stop potassium chloride, you have not required
supplementation while you have been here.
6. Stop midodrine.
7. Stop percocet, you were started on morphine instead.


Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2147-2-7**] at 2:30 PM
With: [**Name6 (MD) 11170**] [**Last Name (NamePattern4) 11171**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage

Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2147-2-8**] at 11:30 AM
With: [**Known firstname **] [**Last Name (NamePattern4) 13896**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: CARDIAC SURGERY
When: MONDAY [**2147-2-13**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST     Best Parking: [**Doctor First Name **]. GARAGE
{'Ulcer of esophagus with bleeding,Acute respiratory failure,Other shock without mention of trauma,Intestinal infection due to Clostridium difficile,Other postoperative infection,Unspecified pleural effusion,Unspecified disease of pericardium,Hyposmolality and/or hyponatremia,Acute posthemorrhagic anemia,Other ascites,Unspecified disease of pancreas,Alcoholic cirrhosis of liver,Loss of weight,Unspecified essential hypertension,Atrial fibrillation,Other emphysema,Aortocoronary bypass status,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Cardiac pacemaker in situ'}


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: GI bleed

PRESENT ILLNESS: This is a 69-year-old man with COPD, HTN, a. fib on enoxaparin
and coumadin, PE, and recent admission for sternal wound
infection s/p multiple debridements presents from OSH with
unstable upper GI hemorrhage.  Per report, patient developed
episodes of hematemesis and melena yesterday at [**Hospital **] rehab.
He was transferred to [**Hospital3 7362**] where he underwent emergent
EGD overnight.  He was found to have a distal esophageal ulcer
that was clipped x5.  Patient was also started on a PPI and
octreotide drip, given 9 units of PRBCs, 7 units of FFP, 20mg of
IV vitamin K, and protamine.  He was also started on a levophed
gtt for persistent hypotension. After EGD, hct was still ~20,
and patient continued to have copious amounts of melena.
Patient was apparently seen by IR at [**Hospital1 3597**], who did not feel
comfortable intervening with this sort of bleed, and surgery who
did not feel that patient would survive a distal esophagectomy.
As such, Mr. [**Known lastname 63108**] was transferred to [**Hospital1 18**] for further
treatment.

MEDICAL HISTORY: - h/o atrial Fibrillation
- s/p Pacer ([**Company 1543**] DDD)
- COPD
- Hypertension
- PVD s/p Aortobifemoral bypass
- Hyperlipidemia
- Chronic liver disease [**2-22**] EtOH (sober now)
- Anemia: h/o maroon stools; colonoscopy in [**2146**] with
hemorrhoids, colon polyps, adenoma
- h/o epistaxis
- history of AAA that was repaired in 07
- h/o PE ~2-3 months ago per pt. Notes from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] mention
PE and imaging from today mentions stable PE. However, no
records at [**Hospital1 18**] mention PE.
- Wedge fractures - Noted in lumbar region on CT scan
- prolonged hospitalization at [**Hospital1 18**] in [**8-30**] for epiglottitis
requiring cric/trach, with hospital course complicated by GI
bleeding and pseudonomas bacteremia

MEDICATION ON ADMISSION: digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY
midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID
tamsulosin 0.4 mg Capsule daily
simvastatin 40 mg Tablet daily
citalopram 20 mg Tablet daily
vancomycin 125 mg Capsule PO Q6H for 14 days treatment
clonazepam 0.5 mg Tablet [**Hospital1 **] PRN
ceftazidime 2 gram Q8H (every 8 hours): plan for 6-8 weeks total
Percocet 5-325 mg Q4H PRN pain
aspirin 81 mg Tablet daily
warfarin 1 mg Tablet Sig: 0.5mg daily for 2 weeks, INR goal [**2-23**]
for afib/PE (patient very sensitive to coumadin).
Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days, then taper to 40 mg daily
alum-mag hydroxide-simeth 200-200-20 mg/5 mL QID (4 times a day)
as needed for gas pain.
fluticasone-salmeterol 250-50 mcg/dose [**1-22**] puff Inhalation [**Hospital1 **]
potassium chloride 20 mEq Tab Sust.Rel daily
Wellbutrin SR 150 mg Tablet Sustained Release Sig: One Tablet
Sustained Release PO once a day: 150mg daily for 3 days, then
increase to [**Hospital1 **] for smoking cessation
ipratropium bromide 0.02 % Solution Sig: Two (2) Q6H PRN
wheezing
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **] PRN
Coumadin 0.5mg QD

ALLERGIES: Seroquel / Fentanyl / Flagyl

PHYSICAL EXAM: Physical Exam on Discharge:
O: Tc 98, Tm 98.6, BP 100/59 (94-127/59-78), HR 90 (83-101), RR
20 (18-22), O2Sat 96% 3L
I/O: 1790/975 over last 24 hours, 100/460 over last 8 hours
HEENT: NC AT
Chest: Healing sternotomy. Improved airway sounds, coarse
rhonchi in the bases but cleared with coughing, no wheeze or
crackles
CV: Heart sound distant, difficult to hear with also coarse
rhonchi.  Does have a [**3-26**] holosystolic murmur present when
patient holds breath for a second (this valvular disease is
known, evident by based on available echo)
Abd: soft, NT, mildly distended, BS present
Ext: no edema, 2+ DP bilaterally, no asterixis
Neuro: AAOx3

FAMILY HISTORY: Father and mother both died of CAD, dad died after age >50

SOCIAL HISTORY: Unemployed. Used to work in the stockroom at the [**Location (un) **]
Corportation. Lives alone. Has a scooter at home.  Health care
proxy is his friend [**Name (NI) 892**] [**Name (NI) 16471**], (c) [**Telephone/Fax (1) 106834**], (h)
[**Telephone/Fax (1) 106835**].  Tobacco: used to smoke 1.5 ppd x ~50 years. Quit
6 months ago.  Alcohol: per records, hx of heavy EtOH use. Quit
9 months ago.  Illicits: none 

### Response:
{'Ulcer of esophagus with bleeding,Acute respiratory failure,Other shock without mention of trauma,Intestinal infection due to Clostridium difficile,Other postoperative infection,Unspecified pleural effusion,Unspecified disease of pericardium,Hyposmolality and/or hyponatremia,Acute posthemorrhagic anemia,Other ascites,Unspecified disease of pancreas,Alcoholic cirrhosis of liver,Loss of weight,Unspecified essential hypertension,Atrial fibrillation,Other emphysema,Aortocoronary bypass status,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Cardiac pacemaker in situ'}
