CHIEF COMPLAINT: Melena, Chest Pain

PRESENT ILLNESS: 87 [**Female First Name (un) **] old male with history of coronary artery disease with
drug eluding stents, chronic obstructive pulmonary disease, type
II diabetes, h/o diverticulosis, now presenting with 3-4 days of
melena and left sided chest pain. Patient initially presented
this AM to [**Hospital6 **] after noting dark stools
for the last few days. Patient states that a few days ago, he
felt that his gout had been acting up in his right arm and hand,
and his PCP prescribed him allopurinol. Shortly after starting
the medication, he noted dark stools and called his PCP. [**Name10 (NameIs) **]
dose was decreased from 300 mg daily to 200 mg daily, but he
continued to have dark stools. He then stopped the medication 2
nights ago because he was concerned from the melena. He
continued to note a few more dark stools, the last of which was
at 6 AM this morning, which prompted him to go to [**Hospital 31145**]. At the OSH, they felt he was slightly volume
overloaded, and he was given lasix for diuresis. He was also
having chest pain, and ECG had TWIs, changed from prior, so he
was transferred to [**Hospital1 18**] for further evaluation. The patient's
chest pain is not different than his usual pain. He states that
over the last few weeks, he's noted a few more episodes per week
of a chest "discomfort". He cannot fully characterize the pain,
but thinks it may be more like a "pressure". He denies radiation
of the pain, nausea, or vomiting. He usually takes 1 NTG which
resolved the pain. This AM, he also took 1 NTG which resolved
the pain as well.

MEDICAL HISTORY: -chronic obstructive pulmonary disease
-Coronary artery disease s/p PCI with LAD stent [**2126**], [**2129**].
Cypher stent to the  ostial CX in 06, chronically occluded RCA.
Circumflex received a  DES in 07. 2 DES to LAD in [**11-10**]
-Type II Diabetes
-Hypertension
-Hyperlipidemia
-Diverticulosis
-peripherial vascular disease

MEDICATION ON ADMISSION: Clopidogrel 75 mg PO DAILY
Aspirin 325 mg Tablet PO DAILY
Albuterol 90 mcg 1-2 Puffs IH Q6H PRN
Ipratropium Bromide 17 mcg 2 IH QID
Metoprolol Succinate 100 mg PO DAILY
Isordil 30 mg PO daily
Simvastatin 80 mg PO DAILY
Nitroglycerin 0.4 mg PRN
Lisinopril 10 mg PO DAILY
Furosemide 40 mg PO daily
Bumetanide 1 mg PO daily
Allopurinol 200 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 96.3 82 101/57 22 100% 2LNC
GEN: WDWN elderly male, NAD, appropriate, pleasant
HEENT: MMM, no epistaxis
CV: RRR, 1/6 systolic murmur at LUSB
LUNGS: bilateral crackles [**2-6**] posterior lung fields; no rhonci,
no wheezes
ABDOMEN: soft, NT, obese. normal BS. no HSM appreciated. Rectal
deferred- guaiac + in ED
EXT: [**2-4**]+ BLE edema; chronic venous stasis changes, pulses 1+ in
LE and 2+ UE
NEURO: A/O x 3; moves all extremities

FAMILY HISTORY: Brother with hemorrhagic CVA [**3-7**] aneurysm; father with HTN;
brother had "[**Last Name **] problem", sister had ovarian cancer.

SOCIAL HISTORY: Retired gunsmith. Lives with wife on MV. Prior alcoholic, last
drink 2-3 years ago. Smoked 2 ppd x 50 years; quit 15 years
prior. No IVDU.
Subendocardial infarction, initial episode of care,Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute on chronic systolic heart failure,Other bilateral bundle branch block,Acute posthemorrhagic anemia,Helicobacter pylori [H. pylori],Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Diverticulosis of colon (without mention of hemorrhage),Other chronic pulmonary heart diseases,Gout, unspecified,Other and unspecified hyperlipidemia,Mitral valve disorders,Family history of malignant neoplasm of ovary
Subendo infarct, initial,Chr stomach ulc w hem,Ac on chr syst hrt fail,Bilat bb block NEC,Ac posthemorrhag anemia,Helicobacter pylori,Crnry athrscl natve vssl,Status-post ptca,Chr airway obstruct NEC,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,DMII wo cmp nt st uncntr,Dvrtclo colon w/o hmrhg,Chr pulmon heart dis NEC,Gout NOS,Hyperlipidemia NEC/NOS,Mitral valve disorder,Fm hx ovary malignancy
Admission Date:  [**2139-8-9**]              Discharge Date:   [**2139-8-15**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Melena, Chest Pain

Major Surgical or Invasive Procedure:
Cardiac Catheterization with PTCA to the left circumflex and
Vision BMS to the LAD


History of Present Illness:
87 [**Female First Name (un) **] old male with history of coronary artery disease with
drug eluding stents, chronic obstructive pulmonary disease, type
II diabetes, h/o diverticulosis, now presenting with 3-4 days of
melena and left sided chest pain. Patient initially presented
this AM to [**Hospital6 **] after noting dark stools
for the last few days. Patient states that a few days ago, he
felt that his gout had been acting up in his right arm and hand,
and his PCP prescribed him allopurinol. Shortly after starting
the medication, he noted dark stools and called his PCP. [**Name10 (NameIs) **]
dose was decreased from 300 mg daily to 200 mg daily, but he
continued to have dark stools. He then stopped the medication 2
nights ago because he was concerned from the melena. He
continued to note a few more dark stools, the last of which was
at 6 AM this morning, which prompted him to go to [**Hospital 31145**]. At the OSH, they felt he was slightly volume
overloaded, and he was given lasix for diuresis. He was also
having chest pain, and ECG had TWIs, changed from prior, so he
was transferred to [**Hospital1 18**] for further evaluation. The patient's
chest pain is not different than his usual pain. He states that
over the last few weeks, he's noted a few more episodes per week
of a chest "discomfort". He cannot fully characterize the pain,
but thinks it may be more like a "pressure". He denies radiation
of the pain, nausea, or vomiting. He usually takes 1 NTG which
resolved the pain. This AM, he also took 1 NTG which resolved
the pain as well.

In the ED, vitals were 98.1, 108/68, 81, 18, 98% 3L. NGL was
done without any blood/coffee ground. Patient's SBP was as low
as 88 at one point, but for the most part was in the 100s/110s.
He continued to have mild CP of [**4-13**], which improved with NG.
There was evidence of TWIs which seemed new, but in the setting
of a known RBBB. Dr.[**Name (NI) 5452**] coverage, Dr. [**Last Name (STitle) 16794**] was contact[**Name (NI) **],
and the [**Name (NI) **] resident was instructed to stop clopedigrel, but
start [**Name (NI) **] 81 mg daily. He had no further episodes of melena in
the ED. His hematocrit in the ED was stable compared to his
earlier hematocrit at the OSH. GI was consulted, and would do
EGD in AM unless he became hemodynamically stable overnight. 2
large bore IVs were started prior to transfer to the MICU.

Of note, the patient has not had previous EGD, but has had
c-scope in the past which showed some diverticuli, but otherwise
reportedly normal.


Past Medical History:
-chronic obstructive pulmonary disease
-Coronary artery disease s/p PCI with LAD stent [**2126**], [**2129**].
Cypher stent to the  ostial CX in 06, chronically occluded RCA.
Circumflex received a  DES in 07. 2 DES to LAD in [**11-10**]
-Type II Diabetes
-Hypertension
-Hyperlipidemia
-Diverticulosis
-peripherial vascular disease


Social History:
Retired gunsmith. Lives with wife on MV. Prior alcoholic, last
drink 2-3 years ago. Smoked 2 ppd x 50 years; quit 15 years
prior. No IVDU.


Family History:
Brother with hemorrhagic CVA [**3-7**] aneurysm; father with HTN;
brother had "[**Last Name **] problem", sister had ovarian cancer.

Physical Exam:
VS: 96.3 82 101/57 22 100% 2LNC
GEN: WDWN elderly male, NAD, appropriate, pleasant
HEENT: MMM, no epistaxis
CV: RRR, 1/6 systolic murmur at LUSB
LUNGS: bilateral crackles [**2-6**] posterior lung fields; no rhonci,
no wheezes
ABDOMEN: soft, NT, obese. normal BS. no HSM appreciated. Rectal
deferred- guaiac + in ED
EXT: [**2-4**]+ BLE edema; chronic venous stasis changes, pulses 1+ in
LE and 2+ UE
NEURO: A/O x 3; moves all extremities


Pertinent Results:
Labs-

[**2139-8-9**] 03:00PM BLOOD WBC-8.2 RBC-3.55* Hgb-9.9*# Hct-31.3*#
MCV-88 MCH-27.7 MCHC-31.4 RDW-18.2* Plt Ct-278
[**2139-8-9**] 09:21PM BLOOD Hct-27.1*
[**2139-8-10**] 02:45AM BLOOD WBC-7.5 RBC-3.31* Hgb-9.9* Hct-29.6*
MCV-89 MCH-29.8 MCHC-33.4 RDW-17.7* Plt Ct-187
[**2139-8-11**] 02:36AM BLOOD WBC-7.8 RBC-3.79* Hgb-11.2* Hct-33.7*
MCV-89 MCH-29.4 MCHC-33.1 RDW-17.7* Plt Ct-192
[**2139-8-11**] 02:36AM BLOOD WBC-7.8 RBC-3.79* Hgb-11.2* Hct-33.7*
MCV-89 MCH-29.4 MCHC-33.1 RDW-17.7* Plt Ct-192
[**2139-8-11**] 02:36AM BLOOD WBC-7.8 RBC-3.79* Hgb-11.2* Hct-33.7*
MCV-89 MCH-29.4 MCHC-33.1 RDW-17.7* Plt Ct-192
[**2139-8-12**] 05:25AM BLOOD WBC-6.5 RBC-3.95* Hgb-11.6* Hct-36.4*
MCV-92 MCH-29.4 MCHC-31.9 RDW-17.4* Plt Ct-168
[**2139-8-13**] 05:30AM BLOOD WBC-7.9 RBC-3.88* Hgb-11.4* Hct-35.5*
MCV-92 MCH-29.5 MCHC-32.2 RDW-18.7* Plt Ct-178
[**2139-8-15**] 05:55AM BLOOD WBC-7.4 RBC-3.78* Hgb-11.1* Hct-33.8*
MCV-90 MCH-29.5 MCHC-32.9 RDW-17.8* Plt Ct-188
[**2139-8-9**] 03:00PM BLOOD Neuts-81.4* Lymphs-13.0* Monos-4.0
Eos-1.4 Baso-0.2
[**2139-8-15**] 05:55AM BLOOD Plt Ct-188
[**2139-8-15**] 05:55AM BLOOD PT-14.2* PTT-29.4 INR(PT)-1.2*
[**2139-8-9**] 03:00PM BLOOD PT-14.2* PTT-25.9 INR(PT)-1.2*
[**2139-8-15**] 05:55AM BLOOD Glucose-124* UreaN-35* Creat-1.7* Na-144
K-4.1 Cl-102 HCO3-31 AnGap-15
[**2139-8-14**] 05:20AM BLOOD Glucose-139* UreaN-34* Creat-1.6* Na-141
K-4.4 Cl-101 HCO3-30 AnGap-14
[**2139-8-9**] 03:00PM BLOOD Glucose-119* UreaN-92* Creat-1.5* Na-145
K-4.7 Cl-105 HCO3-31 AnGap-14
[**2139-8-14**] 05:20AM BLOOD CK(CPK)-45
[**2139-8-12**] 05:25AM BLOOD CK(CPK)-143
[**2139-8-11**] 09:52PM BLOOD CK(CPK)-218*
[**2139-8-11**] 05:49AM BLOOD CK(CPK)-285*
[**2139-8-10**] 10:43AM BLOOD CK(CPK)-57
[**2139-8-9**] 03:00PM BLOOD CK(CPK)-43
[**2139-8-13**] 05:30AM BLOOD CK-MB-NotDone cTropnT-1.58*
[**2139-8-12**] 05:25AM BLOOD CK-MB-27* MB Indx-18.9* cTropnT-1.21*
[**2139-8-11**] 05:49AM BLOOD CK-MB-60* MB Indx-21.1* cTropnT-0.60*
proBNP-[**Numeric Identifier 23911**]*
[**2139-8-10**] 10:17PM BLOOD CK-MB-42* MB Indx-20.8* cTropnT-0.36*
[**2139-8-9**] 09:21PM BLOOD CK-MB-6 cTropnT-0.09*
[**2139-8-9**] 03:00PM BLOOD cTropnT-0.06*
[**2139-8-15**] 05:55AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.2
[**2139-8-10**] 02:45AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.4
[**2139-8-13**] 01:06PM BLOOD Type-ART pO2-173* pCO2-56* pH-7.31*
calTCO2-30 Base XS-0 Intubat-NOT INTUBA
.
Studies-
EKG [**2139-8-9**]
Compared to the previous tracing the rhythm remains sinus at 81
with
clearcut first degree A-V block and left atrial abnormality.
There is
right bundle-branch block/left anterior hemiblock with
intraventricular
conduction delay and marked ST segment depression laterally
consistent
with lateral ischemia. Lateral myocardial infarction cannot be
excluded in lead V6, possibly acute.
TRACING #2


Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
82 232 136 424/462 4 -59 -159
.
CXR [**2139-8-10**]
FINDINGS: The heart is enlarged. There are ECG leads projected
over the
chest. There is atelectasis versus infection at the lung bases
and a follow- up PA and lateral chest rediograph is advised for
further evaluation.
The study and the report were reviewed by the staff radiologist.

.
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is mild to moderate regional left ventricular systolic
dysfunction with akinesis of the inferolateral wall, and
hypokinesis of the basal to mid inferior wall. The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate ([**2-4**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. No
pericardial effusion. EF=40%

IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional left ventricular systolic dysfunction consistent with
coronary artery disease. Mild to moderate mitral regurgitation.
Moderate pulmonary hypertension.

Compared with the prior study (images reviewed) of [**2137-2-7**],
regional left ventricular systolic function is new. The severity
of mitral regurgitation has increased. Estimated pulmonary
artery pressures are higher.
.
cxr [**2139-8-11**]
FINDINGS: As compared to the previous radiograph, there is no
major change.  The moderate hilar enlargement and the subtle
perihilar opacities on the right are unchanged. Also unchanged
is the extent of the partial retrocardiac atelectasis. Unchanged
size of the cardiac silhouette, with moderate tortuosity of the
thoracic aorta. No extent of newly occurred parenchymal
opacities, no pleural effusion.
.
EKG [**2139-8-14**]
Sinus rhythm. Bifascicular block. Occasional ventricular
premature beats.
Compared to the previous tracing no change.
TRACING #3


Read by: [**Last Name (LF) **],[**First Name3 (LF) **]

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
97 [**Telephone/Fax (3) 39561**]/438 82 -81 95
.
Cardiac Cath [**2139-8-13**]- "prelim" report
Right dominant coronary angiography
LMCA- minimal disease
LAD- 70%ostial prior to prior stents, PTCA and BMS
LCX- 100% in stent ostial/PTCA 3.0 with good result
RCA- known 100% via prior cath








Brief Hospital Course:
87 yo male with history of coronary artery disease, who
presented with melena, and was found to have an NSTEMI (chest
pain, ECG changes, and elevated cardiac enzymes were present).

#. Melena: Patient was initially admitted to the MICU given ECG
changes and melanotic stools with 10 pt hematocrit drop from
baseline.  Initial hematocrit in ED was same as outside
hospital.  Re-check that same evening was decreased to 27, and
he received 2 units pRBC.  Re-check after that was 29, so he
received 2 more units given his chest pain, and slightly
elevated cardiac enzymes and ECG changes.  GI was consulted and
performed an EGD.  EGD showed small ulcers and erosions, no
active bleed.  At that point his PPI was switched from IV to PO
BID.  hematocrit increased to 35 and remained stable through the
rest of his admission, it was monitored every 8 hours and then
every 12 until stable at 33-34.  His stool started to normalize
with minimal melanotic stool before transfer from the ICU to the
floor.

#. NSTEMI: The patient had chest discomfort initially, but by
the time he was transferred to the floor he was chest pain free.
 On admission, he had anterolateral TWI as well as significant
2-[**Street Address(2) 2051**] depressions in the lateral leads.  This was thought to
be demand ischemia secondary to his hematocrit less than 30,
which was then transfused to >30.  His cardiac enzymes continued
to trend upwards, at which time it he was diagnosed with an
NSTEMI.  Cardiology was notified.  He was started on [**Street Address(2) **] 325,
and [**Street Address(2) **] 75 mg, but heparin was not started because of his
risk of bleeding.  ECG changes persisted at the time of transfer
from ICU to cardiology service.  An ECHO was performed which
showed depressed EF to 40% with new wall motion abnormalities,
LV systolic dysfunction, worsening MR, and increase in artery
pressures. Patient was put on metoprolol 12.5 [**Hospital1 **] for NSTEMI.
His cardiac enzymes and EKG were closely monitored. He had a
cardiac catheterization which showed 100% occlusion of stent in
LCX ostial- which was treated with PTCA with good results. Also
he had 70% occlusion of the ostial LAD which was treated with
BMS. He tolerated the procedure well, and is to continue on
aspirin, [**Hospital1 **], stain, beta blocker and ace-inhibitor.
.

#. acute on chronic kidney disease, CKD3: Creatinine recently
seemed to fluctuate between 1.3-1.7. still near baseline at
discharge. Creatinine initially had risen with diuresis, but
improved during his admission. Patient was given pre-cath
hydration. His volume and kidney status were closely monitored.
Once renal function had improved captopril was restarted,
(initially held due to acute renal failure)
.
#. Hypoxia/Dyspnea/acute on chronic systolic heart failure:
likely all components of patient's volume overload; he received
4 units pRBC as well as saline due to GI bleed which eventually
led to oxygen requirement.  His chest film was consistent with
mild volume overload.  Repeat ECHO shows depressed EF to 40%,
but last EF >55%.  BNP was greater than 10K. Also his CHF was
worsened with his pre-cath hydration given for renal protection,
at which time in addition to receiving fluids his Lasix was
temporarily held as creatinine was elevated. After cath patient
still was on 3L nasal canula when he ambulated, and by discharge
did not need oxygen at rest. Patient was given home oxygen to
use when short of breath with activity. Post cath he was
restarted on his Lasix, which improved his fluid status and
decreased his oxygen therapy need. He was kept in house until
his fluid status improved post procedure. Patient was also given
albuterol PRN with standing Atrovent, and instructed how to use
his inhalers. For his heart failure, patient was on a beta
blocker, ACEI, and aspirin. He was also instructed about fluid
restriction to 1.5 liters and a low salt diet. He was
recommended to have out patient cardiac rehab to increase his
endurance.

Medications on Admission:
Clopidogrel 75 mg PO DAILY
Aspirin 325 mg Tablet PO DAILY
Albuterol 90 mcg 1-2 Puffs IH Q6H PRN
Ipratropium Bromide 17 mcg 2 IH QID
Metoprolol Succinate 100 mg PO DAILY
Isordil 30 mg PO daily
Simvastatin 80 mg PO DAILY
Nitroglycerin 0.4 mg PRN
Lisinopril 10 mg PO DAILY
Furosemide 40 mg PO daily
Bumetanide 1 mg PO daily
Allopurinol 200 mg daily


Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO at bedtime:
for cholesterol.
Disp:*60 Tablet(s)* Refills:*2*
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day): for your lungs.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): For
your stomach.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): To prevent closure of your heart stents.
Disp:*60 Tablet(s)* Refills:*6*
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed: for your lungs.
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): For your heart
stents.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Every 6 hours as needed as needed for wheezing: For your lungs.

8. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day): For your heart.
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): For your blood pressure and heart.
Disp:*60 Tablet(s)* Refills:*2*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Outpatient Occupational Therapy
Please have cadiac physical therapy rehab, goals of walking 300+
feet and to improve endurance


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 4298**]  VNA

Discharge Diagnosis:
Primary-
-Coronary Artery Disease, now status post Non-ST elevation
myocardial infarction (NSTEMI)
-Small ulcers and erosions of the stomach, status post upper
Gastrointestial Bleed
-Chronic systolic Congestive heart failure with EF of 40%

Secondary
-Chronic Obstructive Pulmonary Disease
-Kidney disease, chronic, stage 3, est GFR 38
-Diabetes Mellitus Type II
-Hypertension
-Hyperlipidemia
-Diverticulosis


Discharge Condition:
Hemodynamically stable, afebrile, able to ambulate. Requires 2
liters of oxygen with a nasal canula when he ambulates for
extended periods. No oxygen therapy required at rest.


Discharge Instructions:
You were admitted to the hospital due to blood in your stool,
which was caused by small uclers in your stomach. This was seen
by an endoscopy study. You also had chest pain that was due to a
heart attack. Once you were no longer having bleeding, you had a
cardiac catheterization which showed blockages of your heart
stents. The left circumflex artery was opened with a balloon
angioplasty, and a bare metal stent was placed in your Left
anterior descending artery. You tolerated the procedure well.
.
Your medication changes were as follows: Your medication are the
same except your lisinopril and isordil was stopped, and you
were started on pantoprazole for your stomach, captopril for
your heart, and oxygen for your lungs. Your dose of lasix was
increased.
.
Please seek medical attention or go to the ER if you have chest
pain, shortness of breath, palpitations, leg swelling, blood in
your stool, or black tarry stools or any other concerning
symtoms.
.
Please keep your follow up appointments.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases by 3
lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: Do not drink more than 1.5 liters of fluids
per day
.
Physical therapy recommended that you have out patient thearpy
to increase your strength and mobility.


Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 29822**] Date/Time: Thursday [**8-20**] at 11am. Please discuss your stay with him and let him
review your medicaions. Please evaluate if you still need oxygen
at home.

Provider: [**Last Name (NamePattern4) **].[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]:[**Telephone/Fax (1) 7960**].  Date/Time: [**9-2**] at
11:30am at [**Hospital6 **] (Dr. [**Last Name (STitle) **] is not available at the
[**Location (un) **] until [**Month (only) **])



Completed by:[**2139-8-19**]
{'Subendocardial infarction, initial episode of care,Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute on chronic systolic heart failure,Other bilateral bundle branch block,Acute posthemorrhagic anemia,Helicobacter pylori [H. pylori],Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Diverticulosis of colon (without mention of hemorrhage),Other chronic pulmonary heart diseases,Gout, unspecified,Other and unspecified hyperlipidemia,Mitral valve disorders,Family history of malignant neoplasm of ovary'}


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: Melena, Chest Pain

PRESENT ILLNESS: 87 [**Female First Name (un) **] old male with history of coronary artery disease with
drug eluding stents, chronic obstructive pulmonary disease, type
II diabetes, h/o diverticulosis, now presenting with 3-4 days of
melena and left sided chest pain. Patient initially presented
this AM to [**Hospital6 **] after noting dark stools
for the last few days. Patient states that a few days ago, he
felt that his gout had been acting up in his right arm and hand,
and his PCP prescribed him allopurinol. Shortly after starting
the medication, he noted dark stools and called his PCP. [**Name10 (NameIs) **]
dose was decreased from 300 mg daily to 200 mg daily, but he
continued to have dark stools. He then stopped the medication 2
nights ago because he was concerned from the melena. He
continued to note a few more dark stools, the last of which was
at 6 AM this morning, which prompted him to go to [**Hospital 31145**]. At the OSH, they felt he was slightly volume
overloaded, and he was given lasix for diuresis. He was also
having chest pain, and ECG had TWIs, changed from prior, so he
was transferred to [**Hospital1 18**] for further evaluation. The patient's
chest pain is not different than his usual pain. He states that
over the last few weeks, he's noted a few more episodes per week
of a chest "discomfort". He cannot fully characterize the pain,
but thinks it may be more like a "pressure". He denies radiation
of the pain, nausea, or vomiting. He usually takes 1 NTG which
resolved the pain. This AM, he also took 1 NTG which resolved
the pain as well.

MEDICAL HISTORY: -chronic obstructive pulmonary disease
-Coronary artery disease s/p PCI with LAD stent [**2126**], [**2129**].
Cypher stent to the  ostial CX in 06, chronically occluded RCA.
Circumflex received a  DES in 07. 2 DES to LAD in [**11-10**]
-Type II Diabetes
-Hypertension
-Hyperlipidemia
-Diverticulosis
-peripherial vascular disease

MEDICATION ON ADMISSION: Clopidogrel 75 mg PO DAILY
Aspirin 325 mg Tablet PO DAILY
Albuterol 90 mcg 1-2 Puffs IH Q6H PRN
Ipratropium Bromide 17 mcg 2 IH QID
Metoprolol Succinate 100 mg PO DAILY
Isordil 30 mg PO daily
Simvastatin 80 mg PO DAILY
Nitroglycerin 0.4 mg PRN
Lisinopril 10 mg PO DAILY
Furosemide 40 mg PO daily
Bumetanide 1 mg PO daily
Allopurinol 200 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 96.3 82 101/57 22 100% 2LNC
GEN: WDWN elderly male, NAD, appropriate, pleasant
HEENT: MMM, no epistaxis
CV: RRR, 1/6 systolic murmur at LUSB
LUNGS: bilateral crackles [**2-6**] posterior lung fields; no rhonci,
no wheezes
ABDOMEN: soft, NT, obese. normal BS. no HSM appreciated. Rectal
deferred- guaiac + in ED
EXT: [**2-4**]+ BLE edema; chronic venous stasis changes, pulses 1+ in
LE and 2+ UE
NEURO: A/O x 3; moves all extremities

FAMILY HISTORY: Brother with hemorrhagic CVA [**3-7**] aneurysm; father with HTN;
brother had "[**Last Name **] problem", sister had ovarian cancer.

SOCIAL HISTORY: Retired gunsmith. Lives with wife on MV. Prior alcoholic, last
drink 2-3 years ago. Smoked 2 ppd x 50 years; quit 15 years
prior. No IVDU. 

### Response:
{'Subendocardial infarction, initial episode of care,Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute on chronic systolic heart failure,Other bilateral bundle branch block,Acute posthemorrhagic anemia,Helicobacter pylori [H. pylori],Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Diverticulosis of colon (without mention of hemorrhage),Other chronic pulmonary heart diseases,Gout, unspecified,Other and unspecified hyperlipidemia,Mitral valve disorders,Family history of malignant neoplasm of ovary'}
