CHIEF COMPLAINT: upper GI Bleed

PRESENT ILLNESS: History of Present Illness: 61 female with history of HTN,
anemia, CKD who presents as a transfer from [**Hospital 8641**] Hospital for
ongoing workup of her gastrointestinal blood loss anemia.
Briefly, she had been referred for a GI evaluation of an anemia
that had been attributed to her CKD.  She had a colonoscopy
which was unrevealing.  She recently had an EGD which showed
non-bleeding gastric ulcer, duodenal diverticulum and esophageal
stricture.  There was also mention of gastric outlet
obstruction.  She was admitted several times to [**Hospital 8641**] Hospital
with falling hematocrit and no obvious source.  She had a
capsule study to evaluate the small intestine, which was not
effective as it was found in her stomach on repeat scope.
.
This last time she was admitted was after a syncopal episode
while having a melanotic stool on Friday. Head CT negative. She
was admitted and fluid resuscitated, and found to have a hct of
15%, which was from 30% one day prior.  She was admitted to
their ICU, placed on pantoprazole gtt, and had a repeat EGD.
This showed normal esophagus, clotted blood in the gastric
fundus, and partially obstructing gastric ulcers.  She had
recurrent bleeding episodes, mostly melanotic, and has received
7 units of packed red blood cells during admission.  She had a
bleeding scan which did not show any acute source of bleeding.
She had several episodes of crampy abdominal pain, nausea,
melanotic stool, and relative hypotension.  She was trasferred
for ongoing care.
.
Initial admission to the MICU: She had been transfused for a low
hematocrit.  She was evaluated by GI, and had an endoscopy.  She
had a large ulcer with two possible visible vessels.  She got
BICAP / electrocautery.  She also had a deformed pyloric
channel, and duodenal bulb diverticulum.  There was hemostasis
at the end of the procedure.  Surgery was consulted because of
concern for gastric outlet obstruction.  She was stable and
called out to the medical floor on [**2168-8-3**].
.
On the medical floor she had a stable hematocrit.  PT was done.
Surgery continued to follow her, and recommended a CT abd/pelvis
to evaluate for mass / cause of GOO.  She had a CT with oral
contrast this afternoon, and with drinking the contrast she
developed some abdominal discomfort and nausea.  She was given
zofran with good result.  Approximately 8 hours after her CT
scan, she felt the need to move her bowels, and was feeling
lightheaded and shaky.  With assistance, she started to ambulate
to the bathroom, but had a pre-syncopal event and fell to her
knees.  She was placed in bed, with her BP noted 85/58, tachy to
120's, and feeling dizzy.  She was given IVF bolus, and her BP
improved and HR returned toward normal.  She then had a
melanotic stool.  She had a STAT hematocrit that was 19% from
29% at 6am.  A unit of packed cells was orderd, and she was
transferred to the MICU for closer monitoring and possible
endoscopy.

MEDICAL HISTORY: - s/p cardiac arrest
- cardiomyopathy
- s/p PPM
- memory deficits
- hypertension
- migraine headaches
- CKD
- constipation

MEDICATION ON ADMISSION: Medications at home. Importantly, this list may be equivocal as
the patient cannot recall for certain her medication list in its
entirety. Moreover, she is seen by multiple specialists, and
after a conversation with her PCP, [**Name10 (NameIs) **] were unable to elucidate
her regimen. The following list is what we have based on our
information:
- metoprolol 50 [**Hospital1 **]
- asa 81 daily
- elavil 50 tid
- folic acid dailiy
- boniva monthly
- ferrous sulfate 325 [**Hospital1 **]
- pravastatin 20 daily
- pantoprazole
- trazodone hs prn
- tylenol #3 prn
.
Medication on transfer:
- pantoprazole 40 IV twice daily
- Pravastatin 20 daily
- folic acid 1 daily
- MVI
- metoprolol 15 twice daily with holding parameters
- trazodone 150 qhs prn
- morphine prn
- percocet prn pain
- zofran q6h

ALLERGIES: Sulfa (Sulfonamides) / Atorvastatin / Fenofibrate

PHYSICAL EXAM: Vs- 99.9  130/70  85  12  97%ra
Gen- Middle aged female, frail, appears older than stated age,
pleasant, interactive, NAD
Heent- MMM, beefy red tongue, anicteric, pale mucus membranes
Neck- supple, jvp flat, radiating cardiac murmur
Cor- regular rate and rhythm, audible S1 and S2, holosystolic
murmur heard at USB radiating to cartotids
Chest- clear bilaterally
Abd- soft, mild TTP LUQ and RLQ.  Positive bowel sounds.  No
guarding or rebound tenderness.  Rectal defferd.  No
organomegaly.
Ext- no c/c/e.
Neuro- AAO x 3, some difficulty with recall of recent events.
MAE.
Skin- Pale, delayed cap refill, cool hands.
Msk- Normal

FAMILY HISTORY: Father with [**Name2 (NI) 499**] cancer in 60s. Mother with CAD, anemia.  No
history of bleeding disorders or diabetes.

SOCIAL HISTORY: Married, lives with husband and two dogs.  No tobacco and EtOH
use.  Retired LPN.
Acute gastric ulcer with hemorrhage, with obstruction,Pressure ulcer, lower back,Acute posthemorrhagic anemia,Other primary cardiomyopathies,Urinary tract infection, site not specified,Diverticulosis of colon with hemorrhage,Other specified disorders of esophagus,Other constipation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage II (mild),Syncope and collapse,Other persistent mental disorders due to conditions classified elsewhere,Other and unspecified hyperlipidemia,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Cardiac pacemaker in situ,Family history of malignant neoplasm of gastrointestinal tract,Family history of ischemic heart disease
Ac stomac ulc w hem-obst,Pressure ulcer, low back,Ac posthemorrhag anemia,Prim cardiomyopathy NEC,Urin tract infection NOS,Dvrtclo colon w hmrhg,Other dsrders esophagus,Constipation NEC,Hy kid NOS w cr kid I-IV,Chro kidney dis stage II,Syncope and collapse,Mental disor NEC oth dis,Hyperlipidemia NEC/NOS,Migrne unsp wo ntrc mgrn,Status cardiac pacemaker,Family hx-gi malignancy,Fam hx-ischem heart dis
Admission Date:  [**2168-8-2**]              Discharge Date:   [**2168-8-10**]

Date of Birth:  [**2106-11-13**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides) / Atorvastatin / Fenofibrate

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
upper GI Bleed

Major Surgical or Invasive Procedure:
Endoscopic Gastroduodenoscopy with Electrocaudery followed by
subsequent Endoscopic Gastroduodenoscopy


History of Present Illness:
History of Present Illness: 61 female with history of HTN,
anemia, CKD who presents as a transfer from [**Hospital 8641**] Hospital for
ongoing workup of her gastrointestinal blood loss anemia.
Briefly, she had been referred for a GI evaluation of an anemia
that had been attributed to her CKD.  She had a colonoscopy
which was unrevealing.  She recently had an EGD which showed
non-bleeding gastric ulcer, duodenal diverticulum and esophageal
stricture.  There was also mention of gastric outlet
obstruction.  She was admitted several times to [**Hospital 8641**] Hospital
with falling hematocrit and no obvious source.  She had a
capsule study to evaluate the small intestine, which was not
effective as it was found in her stomach on repeat scope.
.
This last time she was admitted was after a syncopal episode
while having a melanotic stool on Friday. Head CT negative. She
was admitted and fluid resuscitated, and found to have a hct of
15%, which was from 30% one day prior.  She was admitted to
their ICU, placed on pantoprazole gtt, and had a repeat EGD.
This showed normal esophagus, clotted blood in the gastric
fundus, and partially obstructing gastric ulcers.  She had
recurrent bleeding episodes, mostly melanotic, and has received
7 units of packed red blood cells during admission.  She had a
bleeding scan which did not show any acute source of bleeding.
She had several episodes of crampy abdominal pain, nausea,
melanotic stool, and relative hypotension.  She was trasferred
for ongoing care.
.
Initial admission to the MICU: She had been transfused for a low
hematocrit.  She was evaluated by GI, and had an endoscopy.  She
had a large ulcer with two possible visible vessels.  She got
BICAP / electrocautery.  She also had a deformed pyloric
channel, and duodenal bulb diverticulum.  There was hemostasis
at the end of the procedure.  Surgery was consulted because of
concern for gastric outlet obstruction.  She was stable and
called out to the medical floor on [**2168-8-3**].
.
On the medical floor she had a stable hematocrit.  PT was done.
Surgery continued to follow her, and recommended a CT abd/pelvis
to evaluate for mass / cause of GOO.  She had a CT with oral
contrast this afternoon, and with drinking the contrast she
developed some abdominal discomfort and nausea.  She was given
zofran with good result.  Approximately 8 hours after her CT
scan, she felt the need to move her bowels, and was feeling
lightheaded and shaky.  With assistance, she started to ambulate
to the bathroom, but had a pre-syncopal event and fell to her
knees.  She was placed in bed, with her BP noted 85/58, tachy to
120's, and feeling dizzy.  She was given IVF bolus, and her BP
improved and HR returned toward normal.  She then had a
melanotic stool.  She had a STAT hematocrit that was 19% from
29% at 6am.  A unit of packed cells was orderd, and she was
transferred to the MICU for closer monitoring and possible
endoscopy.

Past Medical History:
- s/p cardiac arrest
- cardiomyopathy
- s/p PPM
- memory deficits
- hypertension
- migraine headaches
- CKD
- constipation


Social History:
Married, lives with husband and two dogs.  No tobacco and EtOH
use.  Retired LPN.


Family History:
Father with [**Name2 (NI) 499**] cancer in 60s. Mother with CAD, anemia.  No
history of bleeding disorders or diabetes.


Physical Exam:
Vs- 99.9  130/70  85  12  97%ra
Gen- Middle aged female, frail, appears older than stated age,
pleasant, interactive, NAD
Heent- MMM, beefy red tongue, anicteric, pale mucus membranes
Neck- supple, jvp flat, radiating cardiac murmur
Cor- regular rate and rhythm, audible S1 and S2, holosystolic
murmur heard at USB radiating to cartotids
Chest- clear bilaterally
Abd- soft, mild TTP LUQ and RLQ.  Positive bowel sounds.  No
guarding or rebound tenderness.  Rectal defferd.  No
organomegaly.
Ext- no c/c/e.
Neuro- AAO x 3, some difficulty with recall of recent events.
MAE.
Skin- Pale, delayed cap refill, cool hands.
Msk- Normal


Pertinent Results:
EKG [**8-3**]: Sinus rhythm. Atrial sensed and ventricular paced
rhythm with capture. No previous tracing available for
comparison.
Rate PR QRS QT/QTc P QRS T
72 0 144 424/445 0 -62 64
.
CXR [**8-3**]: The left costophrenic angle has been cropped from this
image. Cardiac silhouette is within normal limits and there is
no evidence of vascular congestion, pleural effusion, or acute
pneumonia. Dual-channel cardiac pacemaker device is in place. No
evidence of pneumonia.
.
EGD [**8-3**]: The antrum and pyloric channel were deformed. There
was a large ulcer with 2 possible visible vessels in what
appeared to be a large duodenal bulb diverticulum. The duodenum
was intubated with difficulty due to edema causing partial
obstruction. The post-bulbar duodenum appeared normal. (thermal
therapy). Otherwise normal small bowel enteroscopy to third part
of the duodenum.
.
CT ABD/PELVIS [**8-5**]: 1. Marked wall thickening of the 2nd portion
of the duodenum, with an ulcer crater located extremely close to
the GDA. If there is ongoing bleeding from the ulcer, consider
communication with GDA. However, no pseudoaneurysm is currently
visualized. No focal pancreatic mass is identified.
2. Small bilateral pleural effusions (poorly defined 4-mm
ground-glass nodule is present within the right lower lobe,
incompletely visualized).
3. Right adnexal cyst measuring up to 3.2 cm. Further evaluation
can be obtained with pelvic ultrasound once clinically stable.
.
EGD [**8-6**]: Erosion in the gastroesophageal junction. The pyloric
channel was deformed as noted in the previous EGD. There was a
large ~2cm clean based ulcer that appeared to be in the channel
just proximal to a duodenal bulb diverticulum (on the previous
EGD the ulcer appeared to be in the diverticulum and the precise
location remains in question because of the anatomic distortion
and edema surrounding the ulcer). The duodenum was intubated and
the post-bulbar duodenum appeared normal. Otherwise normal EGD
to second part of the duodenum.
.
[**2168-8-10**] 11:00AM BLOOD Hct-31.1*
[**2168-8-10**] 05:40AM BLOOD WBC-6.3 RBC-3.08* Hgb-9.6* Hct-27.8*
MCV-90 MCH-31.2 MCHC-34.5 RDW-14.6 Plt Ct-286
[**2168-8-9**] 05:40AM BLOOD WBC-7.7# RBC-3.28* Hgb-9.8* Hct-29.6*
MCV-90 MCH-29.7 MCHC-33.0 RDW-14.6 Plt Ct-280
[**2168-8-8**] 03:35PM BLOOD Hct-35.3*
[**2168-8-6**] 08:03AM BLOOD Hct-26.1*
[**2168-8-6**] 02:43AM BLOOD WBC-7.4 RBC-3.07*# Hgb-9.4*# Hct-27.6*#
MCV-90 MCH-30.7 MCHC-34.1 RDW-15.2 Plt Ct-229
[**2168-8-5**] 09:21PM BLOOD WBC-9.2# RBC-2.14*# Hgb-6.5*# Hct-19.5*#
MCV-91 MCH-30.4 MCHC-33.3 RDW-15.9* Plt Ct-338
[**2168-8-5**] 05:10AM BLOOD Hct-28.0*
[**2168-8-4**] 06:55AM BLOOD WBC-7.3 RBC-3.39* Hgb-10.3* Hct-30.2*
MCV-89 MCH-30.3 MCHC-34.0 RDW-16.4* Plt Ct-241
[**2168-8-4**] 01:50AM BLOOD Hct-29.2*
[**2168-8-3**] 01:22PM BLOOD Hct-33.9*
[**2168-8-3**] 05:03AM BLOOD WBC-8.4 RBC-3.43* Hgb-10.8* Hct-30.1*
MCV-88 MCH-31.4 MCHC-35.8* RDW-16.2* Plt Ct-175
[**2168-8-2**] 05:21PM BLOOD WBC-12.2* RBC-3.94* Hgb-12.3 Hct-35.8*
MCV-91 MCH-31.2 MCHC-34.3 RDW-15.9* Plt Ct-307
[**2168-8-10**] 05:40AM BLOOD Plt Ct-286
[**2168-8-7**] 03:42AM BLOOD PT-14.1* PTT-27.9 INR(PT)-1.2*
[**2168-8-4**] 06:55AM BLOOD PT-13.5* PTT-28.1 INR(PT)-1.2*
[**2168-8-3**] 09:13AM BLOOD Plt Ct-219
[**2168-8-2**] 05:21PM BLOOD PT-12.6 PTT-26.4 INR(PT)-1.1
[**2168-8-2**] 05:21PM BLOOD Plt Ct-307
[**2168-8-3**] 01:22PM BLOOD FDP-0-10
[**2168-8-3**] 09:13AM BLOOD Ret Aut-3.70*
[**2168-8-10**] 05:40AM BLOOD Glucose-78 UreaN-17 Creat-1.4* Na-143
K-4.6 Cl-112* HCO3-29 AnGap-7*
[**2168-8-8**] 05:50AM BLOOD Glucose-78 UreaN-18 Creat-1.3* Na-144
K-3.9 Cl-115* HCO3-25 AnGap-8
[**2168-8-4**] 06:55AM BLOOD Glucose-88 UreaN-50* Creat-1.3* Na-144
K-4.4 Cl-112* HCO3-21* AnGap-15
[**2168-8-2**] 05:21PM BLOOD Glucose-99 UreaN-60* Creat-1.5* Na-141
K-4.6 Cl-110* HCO3-24 AnGap-12
[**2168-8-9**] 05:40AM BLOOD Amylase-33
[**2168-8-6**] 02:43AM BLOOD ALT-16 AST-17 LD(LDH)-183 AlkPhos-49
TotBili-0.3
[**2168-8-3**] 05:03AM BLOOD ALT-10 AST-14 AlkPhos-40 TotBili-0.6
[**2168-8-9**] 05:40AM BLOOD Lipase-23
[**2168-8-9**] 05:40AM BLOOD Calcium-7.8* Mg-2.1
[**2168-8-8**] 05:50AM BLOOD Phos-3.6 Mg-2.1
[**2168-8-7**] 03:42AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.6
[**2168-8-6**] 02:43AM BLOOD Albumin-1.9* Calcium-6.9* Phos-3.1
Mg-1.5*
[**2168-8-3**] 05:03AM BLOOD Albumin-1.9* Calcium-7.6* Phos-3.7 Mg-1.8
[**2168-8-2**] 05:21PM BLOOD Iron-14*
[**2168-8-3**] 09:13AM BLOOD Hapto-148
[**2168-8-2**] 05:21PM BLOOD calTIBC-179* VitB12-533 Hapto-213*
Ferritn-398* TRF-138*
[**2168-8-7**] 11:45AM BLOOD GASTRIN-Test
[**2168-8-3**] 03:07PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2168-8-3**] 03:07PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2168-8-3**] 03:07PM URINE RBC-[**7-19**]* WBC-[**12-29**]* Bacteri-MANY
Yeast-FEW Epi-0
.
Urine culture - URINE CULTURE (Final [**2168-8-5**]):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------     4 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
.
HPylori -   HELICOBACTER PYLORI ANTIBODY TEST (Final [**2168-8-5**]):
      NEGATIVE BY EIA. (Reference Range-Negative).

Brief Hospital Course:
61 female with h/o HTN, CMP, CKD, memory difficulties
transferred from OSH after an episode of LGIB and EGD c/w
multiple gastroduodenal ulcers. Now s/p EGDx2 with
electrocautery with recurrence of bleed during this
hospitalization, who was sent to MICU, but then was stable with
HCT around 31 for 3days on general medicine floor.

1. PUD with GI Bleed/Acute Blood Loss Anemia: Had EGD x2 with
electrocautery performed on duodenal ulcer initially and no
intervention on second EGD (second scope was performed in the
setting of rebleed and transfer back to the ICU).  CT
abdomen/pelvis was performed for concern for outflow obstruction
at pylorus and duodenal ulcer was noted to abut gastroduodenal
artery.  Surgery was consulted who felt that surgical treatment
was only indicated if angiography was positive in the setting of
acute rebleed.  Interventional radiology was consulted who
recommended no prophylactic intervention.  Her hct was monitored
and she was transfused a total of 5 units prbcs with
stabilization of her hct to 31, which was her value upon
discharge.  She was continued on Nexium and sucralate at time of
discharge, H. pylori negative on this admission.  Her diet was
advanced slowly, per GI recommendations.  EGD needed in [**7-17**]
weeks as per GI recs. She left the hospital with some mild
abdominal cramps and LUQ/RUQ tenderness to palpation that was
felt to be stable given she was tolerating a normal adult diet.
- Importantly, the patient's fasting gastrin level returned
after discharge, and it was determined to be elevated at 157 (nl
0-99). This may represent long-term PPI use, which can be
associated with gastric polyps and elevated gastrin (note, on
EGD a duodenal bulb diverticulum was appreciated). Elevated
gastrin may also occur in less common entities such as
gastrinoma, multiple endocrine neoplasia, pernicious anemia,
carcinoid, and occult GI malignancies ([**Date Range 499**], pancreatic);
however, the pt has had a recent negative colonoscopy in [**Month (only) 116**] and
does not raise high concern for these other conditions. If the
pt develops symptoms or raises clinical concern, these disorders
and others may be further investigated.
.
2. HTN: Her antihypertensives were held in the setting of GI
bleed; however, her metoprolol 50 [**Hospital1 **] was resumed before she was
discharged. Importantly, her home medication regimen was not
fully elucidated since she herself has memory deficits, and her
PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], who we communicated with was also not totally
sure of her meds since she is followed by multiple specialists
(cardiology, nephrology). Her medications for HTN, CKD, etc,
should be reconciled as an outpatient.
.
3. CKD: Stage 2 with apparent baseline creatinine of 1.3.  Renal
function near baseline throughout admission.
.
4. Hyperlipidemia: Pravastatin was held initially in the setting
of her active bleeding. It was not resumed. Importantly,
although the history is not clear, there appears to be a history
of allergies towards "statins" resulting in rhabdo. Please check
this history before resuming pravastatin.
.
5. Cardiomyopathy:  Per medical history however no cardiac
studies in our system.  She tolerated both prbc transfusions and
IVFs without any decompensation and appeared euvolemic to
slightly dry during her stay although she does have a baseline
III/VI sys murmur at the RUSB.
.
6. Complete Heart Block S/P Pacemaker: No active issues during
hospitalization.
.
7. Memory deficits: stable, but difficult to get a comprehensive
history at times.
.
8. Migraine Headaches: Continued elavil. Pt typically takes
Tylenol3 at home, however, codeine can cause dyspepsia so given
the pt's ulcers, we recommend tylenol alone. The pt had
difficulty with this in that her headaches were [**11-18**] pain on
tylenol alone. Noting this, please f/u with patient to determine
best treatment for the headaches.
.
9. E coli UTI: Treated with Ciprofloxacin for full course.
.
10. Rt adnexal cyst (3.2cm) was incidentally found on pelvic CT.
Recommend followup with pelvic ultrasound as outpt.
.
11. Incidentally, there was a poorly characterized ground-glass
4mm RLL nodule, for which no specific follow-up is recommended
since this lesion was poorly visualized since the study was an
abdominal CT with limited examination of the chest. We will
leave it at the disgression of the PCP to determine whether CT
followup in 3 months should be performed for solitary pulmonary
nodule workup.
.

Medications on Admission:
Medications at home. Importantly, this list may be equivocal as
the patient cannot recall for certain her medication list in its
entirety. Moreover, she is seen by multiple specialists, and
after a conversation with her PCP, [**Name10 (NameIs) **] were unable to elucidate
her regimen. The following list is what we have based on our
information:
- metoprolol 50 [**Hospital1 **]
- asa 81 daily
- elavil 50 tid
- folic acid dailiy
- boniva monthly
- ferrous sulfate 325 [**Hospital1 **]
- pravastatin 20 daily
- pantoprazole
- trazodone hs prn
- tylenol #3 prn
.
Medication on transfer:
- pantoprazole 40 IV twice daily
- Pravastatin 20 daily
- folic acid 1 daily
- MVI
- metoprolol 15 twice daily with holding parameters
- trazodone 150 qhs prn
- morphine prn
- percocet prn pain
- zofran q6h


Discharge Medications:
1. Trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Multivitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
6. Boniva 3 mg/3 mL Syringe Kit Sig: One (1) INJECTION
Intravenous once a month.
7. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO at bedtime.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
1. Peptic Ulcer Disease
2. Upper GI Bleed
3. Blood Loss Anemia
4. E Coli Urinary Tract Infection
.
Secondary:
HTN
CAD
Cardiomyopathy, s/p Cardiac Arrest '[**62**]
Dementia
Complete Heart Block S/P Pacemaker Placement
Anemia [**3-12**] CKD
CKD
Migraine Headaches
Chronic Constipation


Discharge Condition:
Stable, ambulatory, vital signs stable, tolerating PO feeds.


Discharge Instructions:
You were treated for bleeding from an ulcer in your stomach with
a procedure called an EGD.

Please go to the emergency room immediately if you notice blood
in your stools, very black stools, or if you feel dizzy, faint,
chest pain, or short of breath.

Followup Instructions:
Please see our Gastroenterologists here at [**Hospital1 18**] for a follow-up
appt within the next 6 weeks - please speak with your PCP about
the timing of this study.  You will need a repeat EGD within the
next 6-8 weeks.  The number is ([**Telephone/Fax (1) 2233**], please schedule
with Dr. [**Last Name (STitle) **]. Please let them know that Dr. [**Last Name (STitle) **] did your
last EGD.





Name:  [**Known lastname 12652**],[**Known firstname **]                    Unit No:   [**Numeric Identifier 12653**]

Admission Date:  [**2168-8-2**]              Discharge Date:   [**2168-8-10**]

Date of Birth:  [**2106-11-13**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides) / Atorvastatin / Fenofibrate

Attending:[**First Name3 (LF) 342**]
Addendum:
Patient had a Stage I pressure ulcer during her stay that was
treated with barrier cream and duoderm bandages.  The pressure
ulcer resolved by the time of discharge.

Discharge Disposition:
Home

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 347**] MD [**MD Number(1) 348**]

Completed by:[**2168-9-7**]
{'Acute gastric ulcer with hemorrhage, with obstruction,Pressure ulcer, lower back,Acute posthemorrhagic anemia,Other primary cardiomyopathies,Urinary tract infection, site not specified,Diverticulosis of colon with hemorrhage,Other specified disorders of esophagus,Other constipation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage II (mild),Syncope and collapse,Other persistent mental disorders due to conditions classified elsewhere,Other and unspecified hyperlipidemia,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Cardiac pacemaker in situ,Family history of malignant neoplasm of gastrointestinal tract,Family history of ischemic heart disease'}


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: upper GI Bleed

PRESENT ILLNESS: History of Present Illness: 61 female with history of HTN,
anemia, CKD who presents as a transfer from [**Hospital 8641**] Hospital for
ongoing workup of her gastrointestinal blood loss anemia.
Briefly, she had been referred for a GI evaluation of an anemia
that had been attributed to her CKD.  She had a colonoscopy
which was unrevealing.  She recently had an EGD which showed
non-bleeding gastric ulcer, duodenal diverticulum and esophageal
stricture.  There was also mention of gastric outlet
obstruction.  She was admitted several times to [**Hospital 8641**] Hospital
with falling hematocrit and no obvious source.  She had a
capsule study to evaluate the small intestine, which was not
effective as it was found in her stomach on repeat scope.
.
This last time she was admitted was after a syncopal episode
while having a melanotic stool on Friday. Head CT negative. She
was admitted and fluid resuscitated, and found to have a hct of
15%, which was from 30% one day prior.  She was admitted to
their ICU, placed on pantoprazole gtt, and had a repeat EGD.
This showed normal esophagus, clotted blood in the gastric
fundus, and partially obstructing gastric ulcers.  She had
recurrent bleeding episodes, mostly melanotic, and has received
7 units of packed red blood cells during admission.  She had a
bleeding scan which did not show any acute source of bleeding.
She had several episodes of crampy abdominal pain, nausea,
melanotic stool, and relative hypotension.  She was trasferred
for ongoing care.
.
Initial admission to the MICU: She had been transfused for a low
hematocrit.  She was evaluated by GI, and had an endoscopy.  She
had a large ulcer with two possible visible vessels.  She got
BICAP / electrocautery.  She also had a deformed pyloric
channel, and duodenal bulb diverticulum.  There was hemostasis
at the end of the procedure.  Surgery was consulted because of
concern for gastric outlet obstruction.  She was stable and
called out to the medical floor on [**2168-8-3**].
.
On the medical floor she had a stable hematocrit.  PT was done.
Surgery continued to follow her, and recommended a CT abd/pelvis
to evaluate for mass / cause of GOO.  She had a CT with oral
contrast this afternoon, and with drinking the contrast she
developed some abdominal discomfort and nausea.  She was given
zofran with good result.  Approximately 8 hours after her CT
scan, she felt the need to move her bowels, and was feeling
lightheaded and shaky.  With assistance, she started to ambulate
to the bathroom, but had a pre-syncopal event and fell to her
knees.  She was placed in bed, with her BP noted 85/58, tachy to
120's, and feeling dizzy.  She was given IVF bolus, and her BP
improved and HR returned toward normal.  She then had a
melanotic stool.  She had a STAT hematocrit that was 19% from
29% at 6am.  A unit of packed cells was orderd, and she was
transferred to the MICU for closer monitoring and possible
endoscopy.

MEDICAL HISTORY: - s/p cardiac arrest
- cardiomyopathy
- s/p PPM
- memory deficits
- hypertension
- migraine headaches
- CKD
- constipation

MEDICATION ON ADMISSION: Medications at home. Importantly, this list may be equivocal as
the patient cannot recall for certain her medication list in its
entirety. Moreover, she is seen by multiple specialists, and
after a conversation with her PCP, [**Name10 (NameIs) **] were unable to elucidate
her regimen. The following list is what we have based on our
information:
- metoprolol 50 [**Hospital1 **]
- asa 81 daily
- elavil 50 tid
- folic acid dailiy
- boniva monthly
- ferrous sulfate 325 [**Hospital1 **]
- pravastatin 20 daily
- pantoprazole
- trazodone hs prn
- tylenol #3 prn
.
Medication on transfer:
- pantoprazole 40 IV twice daily
- Pravastatin 20 daily
- folic acid 1 daily
- MVI
- metoprolol 15 twice daily with holding parameters
- trazodone 150 qhs prn
- morphine prn
- percocet prn pain
- zofran q6h

ALLERGIES: Sulfa (Sulfonamides) / Atorvastatin / Fenofibrate

PHYSICAL EXAM: Vs- 99.9  130/70  85  12  97%ra
Gen- Middle aged female, frail, appears older than stated age,
pleasant, interactive, NAD
Heent- MMM, beefy red tongue, anicteric, pale mucus membranes
Neck- supple, jvp flat, radiating cardiac murmur
Cor- regular rate and rhythm, audible S1 and S2, holosystolic
murmur heard at USB radiating to cartotids
Chest- clear bilaterally
Abd- soft, mild TTP LUQ and RLQ.  Positive bowel sounds.  No
guarding or rebound tenderness.  Rectal defferd.  No
organomegaly.
Ext- no c/c/e.
Neuro- AAO x 3, some difficulty with recall of recent events.
MAE.
Skin- Pale, delayed cap refill, cool hands.
Msk- Normal

FAMILY HISTORY: Father with [**Name2 (NI) 499**] cancer in 60s. Mother with CAD, anemia.  No
history of bleeding disorders or diabetes.

SOCIAL HISTORY: Married, lives with husband and two dogs.  No tobacco and EtOH
use.  Retired LPN. 

### Response:
{'Acute gastric ulcer with hemorrhage, with obstruction,Pressure ulcer, lower back,Acute posthemorrhagic anemia,Other primary cardiomyopathies,Urinary tract infection, site not specified,Diverticulosis of colon with hemorrhage,Other specified disorders of esophagus,Other constipation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage II (mild),Syncope and collapse,Other persistent mental disorders due to conditions classified elsewhere,Other and unspecified hyperlipidemia,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Cardiac pacemaker in situ,Family history of malignant neoplasm of gastrointestinal tract,Family history of ischemic heart disease'}
