CHIEF COMPLAINT: bloody emesis

PRESENT ILLNESS: History of Present Illness (source - patient who is tangential,
though oriented): 86 y.o. male with PMHx of atrial fibrillation
on Coumadin, COPD, DM, colon CA s/p left colectomy and iron
deficiency anemia who presents to the ED with a chief complaint
of vomiting blood. Patient reports a history of 4 days of
antibiotics (Augmentin) for a foot infection. He had been
experiencing foot pain for appoximately 2 weeks prior to the
initiation of antibioitics and for this, he was taking Advil [**Hospital1 **]
every day. He reports experiencing some dark stools throughout
this time and on the day of presentation, experienced an episode
of hematemesis for which he presented to the ED. He denies
abdominal pain, fevers/chills, chest pain, shortness of breath,
palpitations. He does also note some drops of blood in the
toilet, but no frank hematochezia.
.
In the ED, initial vitals were: T - 97.7, BP - 131/45, HR - 77,
RR - 16, O2 - 97% RA. Hct was low at 15, down from baseline of
low 20s and INR was elevated to 8.3. NG lavage showed coffee
grounds which did not clear with 500ccs and rectal exam revealed
black stool that was frankly guaiac positive. GI was consulted
and planned for EGD once admitted. Patient was ordered for 10 mg
of vitamin K as well as 2 units of FFP and PRBCs. Patient's labs
were also notable for acute on chronic renal failure with
BUN/creatinine of 124/3.6 (creatinine up from baseline of 1.5 -
2.0). In the setting of this acute renal failure, troponin was
elevated to 0.13 without ischemic changes on EKG. Patient was
thus admitted to the MICU for further management of his severe
anemia with renal failure and a troponin leak.
.
Upon arrival to the ICU, patient was interactive and in no acute
distress with stable vitals.

MEDICAL HISTORY: DM2
Paroxysmal Atrial Fibrillation on anticoagulation
CRI- baseline Cr 1.5 - 2.0
HTN
Gout
COPD
OA
h/o GIB ([**2198**]; found to have gastritis, ulcerations, no active
bleeding, and angioectasia in colon)
h/o hip fx s/p ORIF/IM nail R hip, L hip [**2201**]
[**Name (NI) 3674**] unclear etiology, previously treated with regular
transfusions, now on procrit, baseline 30
h/o pericardial effusion in setting of AF with RVR, CHF, pleural
effusions ([**2198**])
s/p TURP for prostate enlargement and urinary retention
h/o sigmoid colon ca s/p sigmoid colectomy [**2192**]
right cheek SCC s/p skin graft
Diastolic CHF

MEDICATION ON ADMISSION: Ipratropium-Albuterol
Lisinopril 10 mg PO QD
Montelukast 10 mg PO QD
Pantoprazole 40 mg PO QD
Rosiglitazone 4 mg PO QD
Coumadin 4 mg PO QD
Iron 325 mg PO QD
MVI

ALLERGIES: Percocet / Tylenol

PHYSICAL EXAM: On Admission
Vitals: T: 99.2, BP: 119/38, P: 76, R: 22, O2: 96% RA
General: Awake,alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: Deferred as bed with frank melena
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient denies tobacco or illicit drugs. He reports occasional
alcohol consumption.
Angiodysplasia of stomach and duodenum with hemorrhage,Acute kidney failure, unspecified,Chronic diastolic heart failure,Acute osteomyelitis, ankle and foot,Acute posthemorrhagic anemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Chronic obstructive asthma, unspecified,Atrial fibrillation,Gout, unspecified,Osteoarthrosis, unspecified whether generalized or localized, other specified sites,Personal history of malignant neoplasm of large intestine,Long-term (current) use of anticoagulants
Angio stm/dudn w hmrhg,Acute kidney failure NOS,Chr diastolic hrt fail,Ac osteomyelitis-ankle,Ac posthemorrhag anemia,DMII wo cmp nt st uncntr,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Chronic obst asthma NOS,Atrial fibrillation,Gout NOS,Osteoarthro NOS-oth site,Hx of colonic malignancy,Long-term use anticoagul
Admission Date:  [**2203-6-10**]              Discharge Date:   [**2203-6-21**]


Service: MEDICINE

Allergies:
Percocet / Tylenol

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
bloody emesis

Major Surgical or Invasive Procedure:
Debridement of right 3rd toe and excision of the distal phalanx.
PICC line placed.


History of Present Illness:
History of Present Illness (source - patient who is tangential,
though oriented): 86 y.o. male with PMHx of atrial fibrillation
on Coumadin, COPD, DM, colon CA s/p left colectomy and iron
deficiency anemia who presents to the ED with a chief complaint
of vomiting blood. Patient reports a history of 4 days of
antibiotics (Augmentin) for a foot infection. He had been
experiencing foot pain for appoximately 2 weeks prior to the
initiation of antibioitics and for this, he was taking Advil [**Hospital1 **]
every day. He reports experiencing some dark stools throughout
this time and on the day of presentation, experienced an episode
of hematemesis for which he presented to the ED. He denies
abdominal pain, fevers/chills, chest pain, shortness of breath,
palpitations. He does also note some drops of blood in the
toilet, but no frank hematochezia.
.
In the ED, initial vitals were: T - 97.7, BP - 131/45, HR - 77,
RR - 16, O2 - 97% RA. Hct was low at 15, down from baseline of
low 20s and INR was elevated to 8.3. NG lavage showed coffee
grounds which did not clear with 500ccs and rectal exam revealed
black stool that was frankly guaiac positive. GI was consulted
and planned for EGD once admitted. Patient was ordered for 10 mg
of vitamin K as well as 2 units of FFP and PRBCs. Patient's labs
were also notable for acute on chronic renal failure with
BUN/creatinine of 124/3.6 (creatinine up from baseline of 1.5 -
2.0). In the setting of this acute renal failure, troponin was
elevated to 0.13 without ischemic changes on EKG. Patient was
thus admitted to the MICU for further management of his severe
anemia with renal failure and a troponin leak.
.
Upon arrival to the ICU, patient was interactive and in no acute
distress with stable vitals.

Past Medical History:
DM2
Paroxysmal Atrial Fibrillation on anticoagulation
CRI- baseline Cr 1.5 - 2.0
HTN
Gout
COPD
OA
h/o GIB ([**2198**]; found to have gastritis, ulcerations, no active
bleeding, and angioectasia in colon)
h/o hip fx s/p ORIF/IM nail R hip, L hip [**2201**]
[**Name (NI) 3674**] unclear etiology, previously treated with regular
transfusions, now on procrit, baseline 30
h/o pericardial effusion in setting of AF with RVR, CHF, pleural
effusions ([**2198**])
s/p TURP for prostate enlargement and urinary retention
h/o sigmoid colon ca s/p sigmoid colectomy [**2192**]
right cheek SCC s/p skin graft
Diastolic CHF

Social History:
Patient denies tobacco or illicit drugs. He reports occasional
alcohol consumption.

Family History:
NC

Physical Exam:
On Admission
Vitals: T: 99.2, BP: 119/38, P: 76, R: 22, O2: 96% RA
General: Awake,alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: Deferred as bed with frank melena
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
Labs on admission:
[**2203-6-10**] 10:45AM BLOOD WBC-7.4 RBC-1.82*# Hgb-4.8*# Hct-15.6*#
MCV-86 MCH-26.5* MCHC-30.9* RDW-19.6* Plt Ct-245
[**2203-6-10**] 10:45AM BLOOD Glucose-175* UreaN-124* Creat-3.6*#
Na-142 K-4.5 Cl-106 HCO3-25 AnGap-16
[**2203-6-10**] 10:45AM BLOOD PT-67.8* PTT-37.0* INR(PT)-8.3*
.
HCT trend [**6-10**] 15.6 -> [**6-10**] 16 -> [**6-11**] 20 -> [**6-11**] 22 -> [**6-11**]
23.6 -> [**6-12**] 25 -> [**6-21**] 28.3
.
INR trend [**6-10**] 8.3 -> [**6-10**] 2.2 -> [**6-10**] 1.6 -> [**6-11**] 1.3 -> [**6-12**]
1.2 -> [**6-21**] 1.8
.
[**2203-6-19**] 05:19AM BLOOD Glucose-115* UreaN-23* Creat-1.3* Na-140
K-4.7 Cl-108 HCO3-24 AnGap-13
[**2203-6-17**] 07:20PM BLOOD Vanco-15.1
.
Urine cx [**2203-6-10**]: negative
.
[**2203-6-13**] 4:50 pm SWAB      Source: right foot.

                            **FINAL REPORT [**2203-6-17**]**

   GRAM STAIN (Final [**2203-6-13**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI IN
PAIRS.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   WOUND CULTURE (Final [**2203-6-16**]):
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations
Rifampin
         should not be used alone for therapy.
      CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).    MODERATE
GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S

   ANAEROBIC CULTURE (Final [**2203-6-17**]):    NO ANAEROBES ISOLATED.

.
[**2203-6-14**] 12:56 pm TISSUE      RT 3RD TOE.

                            **FINAL REPORT [**2203-8-15**]**

   GRAM STAIN (Final [**2203-6-14**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   TISSUE (Final [**2203-6-18**]):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 273-9328S [**2203-6-13**].


   ANAEROBIC CULTURE (Final [**2203-6-18**]):    NO ANAEROBES ISOLATED.


   ACID FAST SMEAR (Final [**2203-6-15**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

   ACID FAST CULTURE (Final [**2203-8-15**]):    NO MYCOBACTERIA
ISOLATED.

   FUNGAL CULTURE (Final [**2203-6-30**]):    NO FUNGUS ISOLATED.
.
CXR [**2203-6-10**]:
SINGLE PORTABLE UPRIGHT CHEST RADIOGRAPH: There are low lung
volumes.
Mediastinal and hilar contours are unchanged. There is left
basilar
atelectasis. There is no right effusion or pneumothorax.
Pulmonary
vasculature is normal. Osseous structures are grossly normal.
IMPRESSION: Left basilar likely atelectasis.
.
X-rays of right toes [**2203-6-17**]:
FINDINGS: There is abnormal soft tissue swelling and ulceration
in the distal aspect of the right third toe. There appears to be
exposed bone, as well as gas at the distal tip of the third toe,
highly suspicious for osteomyelitis.
The cortical definition of the third distal to until [**Hospital1 **] is
also irregular consistent with cortical destruction. There is
extensive osteopenia. Vascular calcifications are present. There
is cortical thickening along several of the metatarsal shafts,
likely chronic.
.
Right third toe debridement [**2203-6-14**]:
Acute osteomyelitis.
.
Fundoscopic mucosa biopsy [**2203-6-16**]:
Gastric fundic mucosa, biopsy:  Focal foveolar hyperplasia.
.
DUPLEX DOP ABD/PELVIS LIMITED & Abd ultrasound complete [**2203-6-17**]:
FINDINGS: There is somewhat limited evaluation of the liver due
to body
habitus and inability to suspend respiration. No intrahepatic
biliary ductal dilatation is seen. On dedicated Doppler
interrogation, there is normal flow and waveforms within the
portal and hepatic veins, as questioned. The proximal common
duct measures 3 mm in diameter. There is significantly limited
visualization of the pancreas. There is limited visualization of
theaorta. The gallbladder is normal. The right kidney is normal
in size, measuring 9.6 cm, containing a simple, 3.7-cm cyst at
the lower pole. The spleen is normal, measuring 11.7 cm. The
left kidney is normal in size, measuring 11.0 cm, containing
cysts, one of which had a punctate wall calcification. On
Doppler interrogation, no images of the hepatic artery were
obtained due to technical factors.
IMPRESSION: Normal portal vein flow, as questioned. Somewhat
limited
evaluation of the liver with no intra- or extra-hepatic biliary
ductal
dilatation. Bilateral renal cysts.
.
CXR [**2203-6-18**]:
One AP portable view. Comparison with the prior study. Lung
volumes are
somewhat low. Streaky density at the lung bases consistent with
subsegmental atelectasis and possibly retrocardiac consolidation
persists. There is blunting of the left costophrenic sulcus
consistent with a small effusion, not apparent previously. A
PICC line has been inserted on the left and terminates in the
region of the mid superior vena cava.
IMPRESSION: Evidence for small left pleural effusion. PICC line
in place. No other significant change.

Brief Hospital Course:
Assessment and Plan: Mr. [**Known lastname 1968**] is a 86 year old male with
history of GIBs, colon CA s/p colectomy, atrial fibrillation on
coumadin and DM who presents with Hct of 15, hematemesis and
melena in the setting of a supratherapeutic INR found to have
AVM s/p clipping. Pt also s/p right distal toe amuptation.
.
# GIB: The patient presented to the ED with bloody emesis. NG
lavage showed coffee grounds which did not clear with 500ccs and
rectal exam revealed black stool that was frankly guaiac
positive on arrival. In the ED GI was consulted and the pt
received 10 mg of vitamin K as well as 2 units of FFP for INR of
8.3 (in the setting of being on amoxicillin/clavulanate for his
toe) and his HCT was 15.  He received 6 units of blood in the
ICU and his HCT increased to 28 which was above his baseline of
25. He was plaved on an IV PPI and his ASA, CCB, and ACE were
held.  During his admission he required 2 EGDs.  The first
showed an area of eythema with an overlying clot in the fundus
with question of AVM below. The clot was unable to be suctioned
off.  A single red non bleeding angioexctasia was seen in the
fundus and was thought to be the source of his bleeding given
that his INR was supratherapeutic on admission.  Three endoclips
were placed.  The EGD was also notable for varices at the
gastroesophageal junction, an esophageal ring, and a small
hiatal hernia. His second EGD was notable for a 1 cm X 2 cm area
of localized nodularity of the mucosa of the fundus which was
biopsied and showed focal foveolar hyperplasia and no evidence
of malignancy. The previously placed clips were present in the
gastric junction and a dilated vein was noted at the GE
junction.  He was discharged on a po PPI.  His calcium dose was
increased and changed to calcitrol since it is better absorbed
when taking protonix.
.
# Likely osteomyelitis of right middle toe: During his admission
he required debridement of right 3rd toe and excision of the
distal phalanx. Tissue cx grew MRSA and CORYNEBACTERIUM. The
patient was started on vancomycin, flagyl, and cipro. A PICC
line was placed and the patient was discharged with VNA on long
term vancomycin with last dose planned for [**2203-7-25**].   He was
discharged with lab checks (CBC AST, ALT, A ph, Tbili Chem 7) q
Friday as well as a vanco trough check on [**2203-6-24**]. His wound was
dressed with betadine dressing. A special brace was obtained as
patient needed to be able to ambulate and even do some stairs at
home. Rehab was offered but patient declined for social reasons.
 He was discharged on calcium and vitamin D.
.
# A fib with RVR: The patient had an episode of A fib with RVR
on [**2203-6-20**] and received diltiazem 10 IV x2, lopressor 10 IVx1,
and an additional dose of diltiazem 60mg po. Of note his
diltiazem had been held earlier in the day. His diltiazem dose
was increased to 240mg daily which was his previous home dose.
His coumadin was restarted prior to discharge as his [**Country **] score
was 3. At the time of discharge his INR was subtherapeutic at
1.8.  He was discharged with plan for INR check on [**2203-6-24**] and to
have this result faxed to his PCP.
.
#. Iron deficiency anemia: His HCT was above his baseline of 25
at the time of discharge. He is being continued on his home iron
supplementation. He is on epogen at home.
.
# Acute Renal Failure: On admission his creatinine was initially
elevated to 3.6 from baseline of 1.5 - 2.0. The ARF was likely
secondary to inadequate renal perfusion secondary to blood loss.
His creatinine was 1.3 at discharge.
.
#. HTN: He was discharged on his home lisinopril and CCB.
.
# COPD: Patient had intermittent wheezes in the beginning of his
hospitalization. He was treated with prn nebs. Albuterol prn for
SOB or wheeze was added to his home regimen of medications
including ipratropium inh, fluticasone inh, and montelukast.
.
# Gout: His allopurinol was renally dosed during his ARF. He was
discharged on his home allopurinol. His colchicine was
discontinued as he was doing well off this medication.
.
#. Psych: His home dose of buproprion was continued.
.
#. DM: He was discharged on his rosiglitazone and was maintained
on a diabetic diet while in the hospital.
.
#. Diastolic CHF: He lasix was originally held in the setting of
decreased UOP due to GI bleed and in the setting of ARF.  He was
discharged on his home lasix.
.
# PPx: pneumoboots, sc heparin, PPI PO
.
# Code: Full
.
# Emergency contact: [**Name (NI) **] and [**First Name5 (NamePattern1) **] [**Name (NI) **] [**Telephone/Fax (1) 111706**] (friends-
pt has no family)

Medications on Admission:
Ipratropium-Albuterol
Lisinopril 10 mg PO QD
Montelukast 10 mg PO QD
Pantoprazole 40 mg PO QD
Rosiglitazone 4 mg PO QD
Coumadin 4 mg PO QD
Iron 325 mg PO QD
MVI

Discharge Medications:
1. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*0*
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 5 weeks: last dose
[**2203-7-25**].
Disp:*qs * Refills:*2*
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) puff Inhalation twice a day.
Disp:*1 inh* Refills:*2*
10. Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
12. Calcium Citrate 250 mg Tablet Sig: Two (2) Tablet PO twice a
day.
Disp:*120 Tablet(s)* Refills:*0*
13. Multivitamin     Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-21**]  Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*0*
15. Outpatient Lab Work
Please have the folllowing labs drawn every Friday and have them
faxed to your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 12227**]
CBC
AST, ALT, A ph, Tbili
Chem 7
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
17. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
18. Outpatient Lab Work
INR check on Friday [**2203-6-24**] and fax to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 12227**]
19. Outpatient Lab Work
Check vancomycin trough on [**2203-6-24**] and fax to Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 12227**].
20. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*0*
21. Epogen 10,000 unit/mL Solution Sig: One (1) ml sc Injection
once a week: on Fridays.
Disp:*qs * Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary:
1) Upper GI bleed
2) Toe osteomyelitis
.
Secodary:
1) DM2
2) Paroxysmal Atrial Fibrillation on anticoagulation
3) CRI- baseline Cr 1.5 - 2.0
4)HTN
5) Gout
6) COPD
7) OA
8) h/o GIB ([**2198**]; found to have gastritis, ulcerations, no
active
bleeding, and angioectasia in colon)
9) h/o hip fx s/p ORIF/IM nail R hip, L hip [**2201**]
10) [**Name (NI) 3674**] unclear etiology, previously treated with regular
transfusions, now on procrit, baseline 30
11) h/o pericardial effusion in setting of AF with RVR, CHF,
pleural
effusions ([**2198**])
12) s/p TURP for prostate enlargement and urinary retention
13) h/o sigmoid colon ca s/p sigmoid colectomy [**2192**]
14) right cheek SCC s/p skin graft
15) Diastolic CHF


Discharge Condition:
Stable on Vancomycin IV for osteomyelitis.
INR subtherapeutic at 1.8.


Discharge Instructions:
You were admitted to the hospital for an upper gastrointestinal
bleed. A source of bleeding was found in your stomach and it was
clipped. You received blood transfusions and now your blood
count is stable. While in the hospital you were also found to
have osteomyelitis in your toe which is an infection of the
bone. You were started on a long-term IV antibiotic called
vancomycin.  You stayed in the hospital for one day longer than
expected because your heart was in atrial fibrillation and
beating quickly.  We restarted your diltiazem at it's previous
dose.
.
The following changes were made to your medications:
-vancomycin was started for your osteomyelitis
-albuterol was added to be taken as needed for shortness of
breath or wheeze
-colchicine was discontinued since you are doing well off of it
-your calcium dose was increased and changed to calcitrol since
it is better absorbed when you are taking protonix
.
No other changes were made to your medications.  You should take
all medications as detailed on the attached sheets.
.
You should return to the emergency room if you develop any of
the following:
- vomiting of blood or coffee grounds like substance
- black tarry stools
- lightheadedness or palpitations
- chest pain
- shortness of breath
- persistent fever > 100.4
- worsening pain or redness/blackness around the toe

Followup Instructions:
Please call Dr.[**Name (NI) 14868**] [**Telephone/Fax (1) 543**] office and make an
appointment for 2 weeks from now for podiatry
.
Please call Dr.[**Name (NI) 12755**] office and make a follow up appointment
for sometime in the next 1-2 weeks [**Last Name (LF) 7476**],[**First Name3 (LF) **] [**Telephone/Fax (1) 7477**].
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**], MD Phone:[**Telephone/Fax (1) 7477**] Date/Time:[**2203-8-10**]
8:00
Provider: [**Known firstname 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 6742**]
Date/Time:[**2203-10-4**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2203-10-21**] 10:00



Completed by:[**2204-1-7**]
{'Angiodysplasia of stomach and duodenum with hemorrhage,Acute kidney failure, unspecified,Chronic diastolic heart failure,Acute osteomyelitis, ankle and foot,Acute posthemorrhagic anemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Chronic obstructive asthma, unspecified,Atrial fibrillation,Gout, unspecified,Osteoarthrosis, unspecified whether generalized or localized, other specified sites,Personal history of malignant neoplasm of large intestine,Long-term (current) use of anticoagulants'}


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: bloody emesis

PRESENT ILLNESS: History of Present Illness (source - patient who is tangential,
though oriented): 86 y.o. male with PMHx of atrial fibrillation
on Coumadin, COPD, DM, colon CA s/p left colectomy and iron
deficiency anemia who presents to the ED with a chief complaint
of vomiting blood. Patient reports a history of 4 days of
antibiotics (Augmentin) for a foot infection. He had been
experiencing foot pain for appoximately 2 weeks prior to the
initiation of antibioitics and for this, he was taking Advil [**Hospital1 **]
every day. He reports experiencing some dark stools throughout
this time and on the day of presentation, experienced an episode
of hematemesis for which he presented to the ED. He denies
abdominal pain, fevers/chills, chest pain, shortness of breath,
palpitations. He does also note some drops of blood in the
toilet, but no frank hematochezia.
.
In the ED, initial vitals were: T - 97.7, BP - 131/45, HR - 77,
RR - 16, O2 - 97% RA. Hct was low at 15, down from baseline of
low 20s and INR was elevated to 8.3. NG lavage showed coffee
grounds which did not clear with 500ccs and rectal exam revealed
black stool that was frankly guaiac positive. GI was consulted
and planned for EGD once admitted. Patient was ordered for 10 mg
of vitamin K as well as 2 units of FFP and PRBCs. Patient's labs
were also notable for acute on chronic renal failure with
BUN/creatinine of 124/3.6 (creatinine up from baseline of 1.5 -
2.0). In the setting of this acute renal failure, troponin was
elevated to 0.13 without ischemic changes on EKG. Patient was
thus admitted to the MICU for further management of his severe
anemia with renal failure and a troponin leak.
.
Upon arrival to the ICU, patient was interactive and in no acute
distress with stable vitals.

MEDICAL HISTORY: DM2
Paroxysmal Atrial Fibrillation on anticoagulation
CRI- baseline Cr 1.5 - 2.0
HTN
Gout
COPD
OA
h/o GIB ([**2198**]; found to have gastritis, ulcerations, no active
bleeding, and angioectasia in colon)
h/o hip fx s/p ORIF/IM nail R hip, L hip [**2201**]
[**Name (NI) 3674**] unclear etiology, previously treated with regular
transfusions, now on procrit, baseline 30
h/o pericardial effusion in setting of AF with RVR, CHF, pleural
effusions ([**2198**])
s/p TURP for prostate enlargement and urinary retention
h/o sigmoid colon ca s/p sigmoid colectomy [**2192**]
right cheek SCC s/p skin graft
Diastolic CHF

MEDICATION ON ADMISSION: Ipratropium-Albuterol
Lisinopril 10 mg PO QD
Montelukast 10 mg PO QD
Pantoprazole 40 mg PO QD
Rosiglitazone 4 mg PO QD
Coumadin 4 mg PO QD
Iron 325 mg PO QD
MVI

ALLERGIES: Percocet / Tylenol

PHYSICAL EXAM: On Admission
Vitals: T: 99.2, BP: 119/38, P: 76, R: 22, O2: 96% RA
General: Awake,alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: Deferred as bed with frank melena
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient denies tobacco or illicit drugs. He reports occasional
alcohol consumption. 

### Response:
{'Angiodysplasia of stomach and duodenum with hemorrhage,Acute kidney failure, unspecified,Chronic diastolic heart failure,Acute osteomyelitis, ankle and foot,Acute posthemorrhagic anemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Chronic obstructive asthma, unspecified,Atrial fibrillation,Gout, unspecified,Osteoarthrosis, unspecified whether generalized or localized, other specified sites,Personal history of malignant neoplasm of large intestine,Long-term (current) use of anticoagulants'}
