CHIEF COMPLAINT: GIB

PRESENT ILLNESS: 50 yo M with CAD s/p multiple PCI, CHF, AFIB on coumadin, and
active cocaine use presented to the ED this morning c/o 3 days
of epigastric pain and melanotic stools. He was discharged from
the medicine service at [**Hospital1 18**] on [**2180-5-18**]. The reason for this
prior admission was initially chest pain, which was thought to
be non-cardiac, but his hospitalization was prolonged by severe
knee pain.  Despite the absence of crystals on joint aspiration,
he was empirically treated for gout and started on prednisone
20mg daily, allopurinol, colchicine, and pantoprazole; his
ranitidine was stopped. He was discharged on a lovenox bridge
for 2 doses but never received it.
.
Per patient, the day after discharge, he developed diffuse
abdominal pain and noted black stools. The consistency of the
stool varied between soft to hard. Denied BRBPR. He also
experienced some dizziness and substern chest pressure, but no
chest pain similar to prior MI. He endorses using cocaine on the
day prior to admission. Otherwise denied alcohol or tobacco use
or any ingestions.
.
In the ED, initial vs were: T 97.1, P 72, BP 102/76, R 22, O2
sat 100% RA. Initial Hct was 39.6, down slightly from his
baseline in the low 40's. BUN was elevated to 40s from a
baseline of 10, and Cr to 1.3 from a baseline of ~1.0. Abd CT
with po/IV contrast done as the ED staff was concerned for
mesenteric ischemia given the epigastric pain in the setting of
recent cocaine use--CT Abd preliminary read unremarkable. NG
lavage was notable for "specks" or BRB which cleared after
500cc. Rectal exam notable for melena.
.
He was given morphine 4mg IV twice for epigastric pain in
addition to zofran. GI was consulted and he was given 10mg IV
vit K + 2u FFP for INR 1.7.  He developed a diffuse urticarial
rash after receiving FFP for which he received 50mg of benadryl.
 During the initial 6 hours of his ED stay, he received 1L NS.
Immediately prior to transfer: HR= 108, BP= 132/68 and a second
liter of NS was started.
.
On the floor, patient was slightly tachycardic and complaining
of diffuse abdminal, shoulder, leg pain. He reported nausea but
no vomiting.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: - CAD s/p MI x2 in setting of cocaine, BMS to mid-RCA
- Dilater cardiomyopathy with CHF (LVEF 15-20%)
- Paroxysmal atrial fibrillation on coumadin
- DM-II
- Dyslipidemia
- Hypertension
- Bronchitis / asthma
- Cocaine abuse
- Gout
- Morbid obesity
- Depression
- Obstructive sleep apnea
- Herniated disc, orthopedic problems of the shoulder
- h/o E.coli bacteremia
- h/o Nephrolithiasis
- s/p cholecystecomy
- h/o PNAs

MEDICATION ON ADMISSION: (from [**2180-5-18**] discharge summary):
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for
SOB/wheeze.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY
4. colchicine 0.6 mg PO BID
5. digoxin 250 mcg Tablet PO DAILY
6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN Chest pain.
7. spironolactone 25 mg Tablet PO DAILY
8. simvastatin 20 mg PO DAILY
9. furosemide 40 mg PO BID
10. lisinopril 40 mg Tablet PO DAILY
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr PO
qd
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation every 4-6 hours
as needed for shortness of breath or wheezing.
13. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation every six (6) hours as needed for shortness of breath

ALLERGIES: Motrin / Shellfish

PHYSICAL EXAM: Physical Exam on Arrival to [**Hospital Unit Name 153**]
Vitals: T: 97.8 BP:124/80 P:111 R:21 18 O2:100% 2L NC
General: Obese man, lying flat in bed, in mild pain
HEENT: Sclera anicteric,  pupils 2 mm, symmetric, reactive MMM,
oropharynx clear
Neck: supple, no LAD, JVP difficult to appreciate due to body
habitus
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, non-distended, bowel sounds present. diffuse
tenderness on palpation, no rebound
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
right knee intact passive range of motion. Slight warmth and
effusion noted.

FAMILY HISTORY: Mother 78 with several heart attacks. Father had psychiatric
issues. One brother, six sisters; some of them with diabetes.

SOCIAL HISTORY: Had been living alone in an apartment, but now his sister and
her children are staying with him. He is a former veteran in the
navy and supports himself with SSDI, is single. Divorced and
having stress because he is paying his [**Social Security Number 71948**]social security check for
child support despite the children being in their 20s. Reports
extreme cocaine abuse with the last usage in [**2173**]. Reports that
at its peak, he was using up to $1600 worth of cocaine per day
(smoked it), has been homeless in the past. Reports using
marijuana intermittently, but with no recent usage for the last
several decades. Denies any other illicit drug use, no smoking
history. Drinks alcohol rarely.
Blood in stool,Acute kidney failure, unspecified,Other primary cardiomyopathies,Acute posthemorrhagic anemia,Chronic diastolic heart failure,Orthostatic hypotension,Atrial fibrillation,Acute gouty arthropathy,Cocaine abuse, unspecified,Morbid obesity,Duodenitis, without mention of hemorrhage,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Old myocardial infarction,Long-term (current) use of anticoagulants,Percutaneous transluminal coronary angioplasty status,Salicylates causing adverse effects in therapeutic use,Other agents affecting blood constituents causing adverse effects in therapeutic use
Blood in stool,Acute kidney failure NOS,Prim cardiomyopathy NEC,Ac posthemorrhag anemia,Chr diastolic hrt fail,Orthostatic hypotension,Atrial fibrillation,Acute gouty arthropathy,Cocaine abuse-unspec,Morbid obesity,Duodenitis w/o hmrhg,DMII wo cmp nt st uncntr,Asthma NOS,Old myocardial infarct,Long-term use anticoagul,Status-post ptca,Adv eff salicylates,Adv eff blood agent NEC
Admission Date:  [**2180-5-20**]              Discharge Date:   [**2180-5-28**]

Date of Birth:  [**2130-2-15**]             Sex:   M

Service: MEDICINE

Allergies:
Motrin / Shellfish

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
GIB

Major Surgical or Invasive Procedure:
None

History of Present Illness:
50 yo M with CAD s/p multiple PCI, CHF, AFIB on coumadin, and
active cocaine use presented to the ED this morning c/o 3 days
of epigastric pain and melanotic stools. He was discharged from
the medicine service at [**Hospital1 18**] on [**2180-5-18**]. The reason for this
prior admission was initially chest pain, which was thought to
be non-cardiac, but his hospitalization was prolonged by severe
knee pain.  Despite the absence of crystals on joint aspiration,
he was empirically treated for gout and started on prednisone
20mg daily, allopurinol, colchicine, and pantoprazole; his
ranitidine was stopped. He was discharged on a lovenox bridge
for 2 doses but never received it.
.
Per patient, the day after discharge, he developed diffuse
abdominal pain and noted black stools. The consistency of the
stool varied between soft to hard. Denied BRBPR. He also
experienced some dizziness and substern chest pressure, but no
chest pain similar to prior MI. He endorses using cocaine on the
day prior to admission. Otherwise denied alcohol or tobacco use
or any ingestions.
.
In the ED, initial vs were: T 97.1, P 72, BP 102/76, R 22, O2
sat 100% RA. Initial Hct was 39.6, down slightly from his
baseline in the low 40's. BUN was elevated to 40s from a
baseline of 10, and Cr to 1.3 from a baseline of ~1.0. Abd CT
with po/IV contrast done as the ED staff was concerned for
mesenteric ischemia given the epigastric pain in the setting of
recent cocaine use--CT Abd preliminary read unremarkable. NG
lavage was notable for "specks" or BRB which cleared after
500cc. Rectal exam notable for melena.
.
He was given morphine 4mg IV twice for epigastric pain in
addition to zofran. GI was consulted and he was given 10mg IV
vit K + 2u FFP for INR 1.7.  He developed a diffuse urticarial
rash after receiving FFP for which he received 50mg of benadryl.
 During the initial 6 hours of his ED stay, he received 1L NS.
Immediately prior to transfer: HR= 108, BP= 132/68 and a second
liter of NS was started.
.
On the floor, patient was slightly tachycardic and complaining
of diffuse abdminal, shoulder, leg pain. He reported nausea but
no vomiting.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.


Past Medical History:
- CAD s/p MI x2 in setting of cocaine, BMS to mid-RCA
- Dilater cardiomyopathy with CHF (LVEF 15-20%)
- Paroxysmal atrial fibrillation on coumadin
- DM-II
- Dyslipidemia
- Hypertension
- Bronchitis / asthma
- Cocaine abuse
- Gout
- Morbid obesity
- Depression
- Obstructive sleep apnea
- Herniated disc, orthopedic problems of the shoulder
- h/o E.coli bacteremia
- h/o Nephrolithiasis
- s/p cholecystecomy
- h/o PNAs


Social History:
Had been living alone in an apartment, but now his sister and
her children are staying with him. He is a former veteran in the
navy and supports himself with SSDI, is single. Divorced and
having stress because he is paying his [**Social Security Number 71948**]social security check for
child support despite the children being in their 20s. Reports
extreme cocaine abuse with the last usage in [**2173**]. Reports that
at its peak, he was using up to $1600 worth of cocaine per day
(smoked it), has been homeless in the past. Reports using
marijuana intermittently, but with no recent usage for the last
several decades. Denies any other illicit drug use, no smoking
history. Drinks alcohol rarely.

Family History:
Mother 78 with several heart attacks. Father had psychiatric
issues. One brother, six sisters; some of them with diabetes.


Physical Exam:
Physical Exam on Arrival to [**Hospital Unit Name 153**]
Vitals: T: 97.8 BP:124/80 P:111 R:21 18 O2:100% 2L NC
General: Obese man, lying flat in bed, in mild pain
HEENT: Sclera anicteric,  pupils 2 mm, symmetric, reactive MMM,
oropharynx clear
Neck: supple, no LAD, JVP difficult to appreciate due to body
habitus
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, non-distended, bowel sounds present. diffuse
tenderness on palpation, no rebound
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
right knee intact passive range of motion. Slight warmth and
effusion noted.

Pertinent Results:
Labs on Admission:
[**2180-5-20**] 10:25AM BLOOD WBC-13.6* RBC-4.71 Hgb-13.0* Hct-39.6*
MCV-84 MCH-27.6 MCHC-32.8 RDW-14.9 Plt Ct-615*
[**2180-5-20**] 07:25PM BLOOD Hct-33.7*
[**2180-5-20**] 10:25AM BLOOD Neuts-64.2 Lymphs-29.2 Monos-4.8 Eos-0.9
Baso-1.0
[**2180-5-20**] 10:25AM BLOOD PT-19.1* PTT-24.0 INR(PT)-1.7*
[**2180-5-20**] 10:25AM BLOOD Glucose-187* UreaN-46* Creat-1.3* Na-138
K-4.4 Cl-102 HCO3-21* AnGap-19
[**2180-5-20**] 10:25AM BLOOD ALT-44* AST-26 AlkPhos-46 TotBili-0.3
[**2180-5-20**] 10:25AM BLOOD Lipase-33
[**2180-5-20**] 10:25AM BLOOD cTropnT-0.02*
[**2180-5-20**] 07:25PM BLOOD CK-MB-4 cTropnT-0.01
[**2180-5-20**] 10:25AM BLOOD Digoxin-0.5*
[**2180-5-20**] 12:03PM BLOOD Lactate-3.6*

Pertinent Labs:
[**2180-5-21**] 04:42AM BLOOD WBC-10.1 RBC-3.76* Hgb-10.5* Hct-32.0*
MCV-85 MCH-27.9 MCHC-32.7 RDW-14.2 Plt Ct-458*
[**2180-5-21**] 10:25AM BLOOD Hct-31.3*
[**2180-5-21**] 03:21PM BLOOD Hct-31.4*
[**2180-5-21**] 09:34PM BLOOD Hct-30.1*
[**2180-5-21**] 03:15PM BLOOD Lactate-1.1

Labs on Discharge:

Imaging:
[**2180-5-20**]
- CXR: The cardiac silhouette is upper limits of normal. The
lungs are
grossly clear without focal consolidation, pleural effusions, or
pulmonary
edema. Bony structures are intact.
- CT abd/pelvis: The visualized lung bases demonstrate slight
atelectasis but no masses, nodules or pleural effusions. The
spleen, adrenals, pancreas, and liver appear within normal
limits. Patient is status post cholecystectomy with clips in the
gallbladder fossa. Kidneys enhance and excrete contrast
symmetrically without solid masses or hydronephrosis.
Hypodensities in the mid pole of the left kidney (2:32) is too
small to characterize but is likely a cyst. No free air or free
fluid or adenopathy is present. Incidental note is made of a
circumaortic left renal vein but the aorta and its mesenteric
branches are patent. Stomach and bowel appear normal.  PELVIS:
Bowel loops appear normal including a normal visualized
appendix.  The bladder is normal in appearance. No free air or
free fluid or adenopathy is present.  BONE WINDOWS: No
suspicious bone lesions are present. Degenerative changes are
present in the lumbar spine.
IMPRESSION:
No acute findings in the abdomen or pelvis to explain patient's
symptoms.

[**2180-5-21**]
- KUB: The cardiac silhouette is upper limits of normal. The
lungs are
grossly clear without focal consolidation, pleural effusions, or
pulmonary
edema. Bony structures are intact.

Brief Hospital Course:
50 yo M with CAD s/p multiple PCI, CHF, AFIB on coumadin, and
active cocaine use, presents with 3 days of epigastric pain and
melanotic stools, concerning for GI bleed.

# GI bleed: Patient noted to have occult positive stool,
however, NG lavage only borderline positive.  Hct is stable at
39 though lower than baseline of mid-40s. Most likely etiology
of GI bleed is from medications, which includes prednisone
(recently started), baseline aspirin, plavix, coumadin, and
lovenox.  H2-blocker was also recently stopped and patient
transitioned to PPI.  All of these medications would make the
patient more prone to bleed.  On presentation, he was slighly
tachycardic with HR in the 100s, most likely from not receiving
home diltiazem and metoprolol.  He was started with IV
pantoprazole gtt.  Coumadin, Lovenox and Plavix were held.  His
initial q6h Hct series remained stable.  GI evaluated him and
did EGD which showed no lesions.  His bleeding stopped.  His
hematocrit remained stable.  Anticoagulation was resumed and he
was observed for recurrence in the hospital.  Bleeding did not
recur.

# Dilated cardiomyopathy with CHF: Chronic issue and patient
followed closely by Dr. [**First Name (STitle) 437**]. Echocardiogram on [**2180-5-11**] showed
moderately dilated left ventricle with severe systolic
dysfunction and LVEF of 15-20%. In the context of the GI bleed
and fluid resuscitation, will monitor closely for signs of fluid
overload. CXR on admission does not show pleural effusion or
pulmonary edema and patient has good O2 sat on 2L NC, which he
was able to be weaned off.  He continued with metoprolol and
digoxin.  Lisinopril, spironolactone, and furosemide were held
temporarily given ARF in the setting of GIB; these were resumed
without difficulty.

# Acute renal failure.  On admission, Cr 1.3 compared to
baseline 0.9-1.1. Most likely from decreased po intake leading
to pre-renal process.  He completed IVF from the ED.  His
creatinine improved.

# Coronary artery disease: Patient has history of multiple MIs
in the context of cocaine abuse. He has BMS to mid-RCA placed
here in [**1-20**] and reported another DES to LAD: this was confirmed
to have been done [**3-/2180**] Hosptial, for a 70%
LAD lesion, with good result.

# Paroxysmal atrial fibrillation.  He continued to be in Afib
while in the ICU with rate mostly in the 80s-100s.  Last dose of
Lovenox was [**2180-5-18**] when INR was 1.4.  He was continued on
digoxine and metoprolol.  Coumadin and Lovenox were held
temporarily given GIB and pending EGD procedure; these were
resumed without incident.

# DM2, and gout were stable.

Medications on Admission:
(from [**2180-5-18**] discharge summary):
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for
SOB/wheeze.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY
4. colchicine 0.6 mg PO BID
5. digoxin 250 mcg Tablet PO DAILY
6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN Chest pain.
7. spironolactone 25 mg Tablet PO DAILY
8. simvastatin 20 mg PO DAILY
9. furosemide 40 mg PO BID
10. lisinopril 40 mg Tablet PO DAILY
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr PO
qd
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation every 4-6 hours
as needed for shortness of breath or wheezing.
13. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation every six (6) hours as needed for shortness of breath

or wheezing.
14. glyburide 5 mg PO BID
15. warfarin 5 mg PO QD
16. allopurinol 300 mg PO DAILY
17. prednisone 20 mg Tablet PO QD for 7 days ([**2180-5-18**] - [**2180-5-24**])
18. oxycodone-acetaminophen 10-325 mg Tablet Sig: One (1) Tablet

PO Q4H (every 4 hours).
19. Lovenox 150 mg [**Hospital1 **]
20. pantoprazole 40 mg Tablet, Delayed Release (E.C.) PO QD

Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-12**] puff Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

10. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
13. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
15. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Lower GI bleeding (melena)

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Go to [**Hospital3 3383**] [**Hospital3 **] on [**Hospital3 **] [**2180-5-29**]
to have your INR level checked.  When you left [**Hospital1 18**] it was in
range at 2.2, with your daily dosing regimen of 5 mg daily

Department: RHEUMATOLOGY
When: FRIDAY [**2180-6-2**] at 4:30 PM
With: [**Name6 (MD) 3712**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2180-6-5**] at 3:50 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 69643**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: PODIATRY
When: [**Hospital Ward Name **] [**2180-7-10**] at 1 PM
With:  [**Hospital 1947**] CLINIC (SB) [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage




Name:  [**Known lastname **],[**Known firstname **] [**Initials (NamePattern4) **] [**Known lastname **]              Unit No:   [**Numeric Identifier 12189**]

Admission Date:  [**2180-5-20**]              Discharge Date:   [**2180-5-28**]

Date of Birth:  [**2130-2-15**]             Sex:   M

Service: MEDICINE

Allergies:
Motrin / Shellfish

Attending:[**First Name3 (LF) 3046**]
Addendum:
At time of initial discharge, patient complained of feeling
dizzy with standing. Orthostatics were negative, vital signs
were normal, and there were no signs of recurrent bleeding

PT worked with the patient after after an additional day his
symptoms improved and he was stable for discharge.

Discharge Disposition:
Home With Service

Facility:
[**Hospital 136**] Homecare

                             [**First Name11 (Name Pattern1) 394**] [**Last Name (NamePattern4) 3047**] MD [**MD Number(2) 3048**]

Completed by:[**2180-5-28**]
{'Blood in stool,Acute kidney failure, unspecified,Other primary cardiomyopathies,Acute posthemorrhagic anemia,Chronic diastolic heart failure,Orthostatic hypotension,Atrial fibrillation,Acute gouty arthropathy,Cocaine abuse, unspecified,Morbid obesity,Duodenitis, without mention of hemorrhage,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Old myocardial infarction,Long-term (current) use of anticoagulants,Percutaneous transluminal coronary angioplasty status,Salicylates causing adverse effects in therapeutic use,Other agents affecting blood constituents causing adverse effects in therapeutic use'}


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: GIB

PRESENT ILLNESS: 50 yo M with CAD s/p multiple PCI, CHF, AFIB on coumadin, and
active cocaine use presented to the ED this morning c/o 3 days
of epigastric pain and melanotic stools. He was discharged from
the medicine service at [**Hospital1 18**] on [**2180-5-18**]. The reason for this
prior admission was initially chest pain, which was thought to
be non-cardiac, but his hospitalization was prolonged by severe
knee pain.  Despite the absence of crystals on joint aspiration,
he was empirically treated for gout and started on prednisone
20mg daily, allopurinol, colchicine, and pantoprazole; his
ranitidine was stopped. He was discharged on a lovenox bridge
for 2 doses but never received it.
.
Per patient, the day after discharge, he developed diffuse
abdominal pain and noted black stools. The consistency of the
stool varied between soft to hard. Denied BRBPR. He also
experienced some dizziness and substern chest pressure, but no
chest pain similar to prior MI. He endorses using cocaine on the
day prior to admission. Otherwise denied alcohol or tobacco use
or any ingestions.
.
In the ED, initial vs were: T 97.1, P 72, BP 102/76, R 22, O2
sat 100% RA. Initial Hct was 39.6, down slightly from his
baseline in the low 40's. BUN was elevated to 40s from a
baseline of 10, and Cr to 1.3 from a baseline of ~1.0. Abd CT
with po/IV contrast done as the ED staff was concerned for
mesenteric ischemia given the epigastric pain in the setting of
recent cocaine use--CT Abd preliminary read unremarkable. NG
lavage was notable for "specks" or BRB which cleared after
500cc. Rectal exam notable for melena.
.
He was given morphine 4mg IV twice for epigastric pain in
addition to zofran. GI was consulted and he was given 10mg IV
vit K + 2u FFP for INR 1.7.  He developed a diffuse urticarial
rash after receiving FFP for which he received 50mg of benadryl.
 During the initial 6 hours of his ED stay, he received 1L NS.
Immediately prior to transfer: HR= 108, BP= 132/68 and a second
liter of NS was started.
.
On the floor, patient was slightly tachycardic and complaining
of diffuse abdminal, shoulder, leg pain. He reported nausea but
no vomiting.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: - CAD s/p MI x2 in setting of cocaine, BMS to mid-RCA
- Dilater cardiomyopathy with CHF (LVEF 15-20%)
- Paroxysmal atrial fibrillation on coumadin
- DM-II
- Dyslipidemia
- Hypertension
- Bronchitis / asthma
- Cocaine abuse
- Gout
- Morbid obesity
- Depression
- Obstructive sleep apnea
- Herniated disc, orthopedic problems of the shoulder
- h/o E.coli bacteremia
- h/o Nephrolithiasis
- s/p cholecystecomy
- h/o PNAs

MEDICATION ON ADMISSION: (from [**2180-5-18**] discharge summary):
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for
SOB/wheeze.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY
4. colchicine 0.6 mg PO BID
5. digoxin 250 mcg Tablet PO DAILY
6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN Chest pain.
7. spironolactone 25 mg Tablet PO DAILY
8. simvastatin 20 mg PO DAILY
9. furosemide 40 mg PO BID
10. lisinopril 40 mg Tablet PO DAILY
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr PO
qd
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation every 4-6 hours
as needed for shortness of breath or wheezing.
13. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation every six (6) hours as needed for shortness of breath

ALLERGIES: Motrin / Shellfish

PHYSICAL EXAM: Physical Exam on Arrival to [**Hospital Unit Name 153**]
Vitals: T: 97.8 BP:124/80 P:111 R:21 18 O2:100% 2L NC
General: Obese man, lying flat in bed, in mild pain
HEENT: Sclera anicteric,  pupils 2 mm, symmetric, reactive MMM,
oropharynx clear
Neck: supple, no LAD, JVP difficult to appreciate due to body
habitus
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, non-distended, bowel sounds present. diffuse
tenderness on palpation, no rebound
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis.
right knee intact passive range of motion. Slight warmth and
effusion noted.

FAMILY HISTORY: Mother 78 with several heart attacks. Father had psychiatric
issues. One brother, six sisters; some of them with diabetes.

SOCIAL HISTORY: Had been living alone in an apartment, but now his sister and
her children are staying with him. He is a former veteran in the
navy and supports himself with SSDI, is single. Divorced and
having stress because he is paying his [**Social Security Number 71948**]social security check for
child support despite the children being in their 20s. Reports
extreme cocaine abuse with the last usage in [**2173**]. Reports that
at its peak, he was using up to $1600 worth of cocaine per day
(smoked it), has been homeless in the past. Reports using
marijuana intermittently, but with no recent usage for the last
several decades. Denies any other illicit drug use, no smoking
history. Drinks alcohol rarely. 

### Response:
{'Blood in stool,Acute kidney failure, unspecified,Other primary cardiomyopathies,Acute posthemorrhagic anemia,Chronic diastolic heart failure,Orthostatic hypotension,Atrial fibrillation,Acute gouty arthropathy,Cocaine abuse, unspecified,Morbid obesity,Duodenitis, without mention of hemorrhage,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Old myocardial infarction,Long-term (current) use of anticoagulants,Percutaneous transluminal coronary angioplasty status,Salicylates causing adverse effects in therapeutic use,Other agents affecting blood constituents causing adverse effects in therapeutic use'}
