CHIEF COMPLAINT: Melena, hematocrit drop

PRESENT ILLNESS: 75 yo male with ESRD on HD, trach for resp failure who presents
from [**Hospital **] rehab with a hematocrit drop and melena in his
rectal tube. Per notes he had HD yesterday and received 2 units
PRBCS during HD and hct was 35 during HD. Today hct was
re-checked and was 19. Stools were noted to guaiac positive. INR
was noted to be 4.3 , so pt received 5 mg of vitamin K. VS at NH
were T 97.5 HR 104 BP 108/59 and sats of 98%.
.
In the ER he was noted to have melena in his rectal tube. Hs HR
was initialy in the 90s with BP 108/53. He had a lavage of his
g-tube that was clear and received protonix 40 IV x2. He
received an additional 5 mg of vitamin K and 2 units of FFP
here. He received ~1.5 L of fluid and had starte receiving 1
back of PRBCs prior to txfr to the ICU. While in the ER his SBPs
dropped to the 80s-90s.
.
Upon arrival to the floor, the pt's initial SBP was in the 70s,
with HR in the 120s. This improved to SBP of 90s. The pt
appeared comfortable and denied abdominal pain, chest pain,
lightheadedness or nausea. Said he had fevers several weeks ago
and one recent episode of emesis. He thinks he may have had
black stool for weeks.
.
Of note, pt recently admitted [**Date range (1) 77791**] for new atrial
fibrillation, septic shock (urosepsis), and acute on chronic
renal failure now requiring dialysis and was discharged to
[**Hospital1 **].

MEDICAL HISTORY: # DM2
# CRI (baseline 2.5)- recently started on HD
# CHF
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia

MEDICATION ON ADMISSION: Insulin SS
lantus 48 units qhs
Simvastatin 10 mg daily
ASA 81 mg daily
Metoprolol 50 mg TID
Citalopram 20 mg daily
Lansoprazole 30 mg daily
Coumadin
Silver Sulfadiazine 1%
Epoetin 1000 units with HD
Acetaminophen 650 q6 hours prn
clonazepam 0.5 mg tid prn
trazodone 50 mg hs prn

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: VS: T:  HR: 120s BP: SBP 70s-90s  RR:  O2 sat:
Gen: obese male, mentating appropriately, NAD, pale
HEENT: anicteric sclera, dry MM
Neck: supple, dialysis line in place
Cardio: distant heart sounds, tachycardic, no murmur appreciated
Pulm: CTAB anteriorly, no w/r/g
Abd: soft, obese, NT, ND, +BS, G tube in place
Ext: hyperpigmentation on shins, 1+ peripheral edema, 1+ DP
pulses b/l
Neuro: Alert, awake, mentating appropriately and responding to
commands. Moves all extremities
Skin: hyperpigmentation on shins, dry gauze wrapped on both
shins

FAMILY HISTORY: N/C

SOCIAL HISTORY: Used to live with wife, who is HCP. Now at [**Hospital1 **].
Other gastrostomy complications,Acute kidney failure, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,End stage renal disease,Urinary tract infection, site not specified,Other and unspecified infection due to central venous catheter,Bacteremia,Pressure ulcer, buttock,Chronic diastolic heart failure,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Monoclonal paraproteinemia,Morbid obesity
Gastrostomy comp NEC,Acute kidney failure NOS,Gastrointest hemorr NOS,Ac posthemorrhag anemia,End stage renal disease,Urin tract infection NOS,Oth/uns inf-cen ven cath,Bacteremia,Pressure ulcer, buttock,Chr diastolic hrt fail,Klebsiella pneumoniae,Atrial fibrillation,DMII wo cmp nt st uncntr,Monoclon paraproteinemia,Morbid obesity
Admission Date:  [**2150-4-2**]              Discharge Date:   [**2150-4-22**]

Date of Birth:  [**2075-1-1**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Melena, hematocrit drop

Major Surgical or Invasive Procedure:
EGD
Tunneling of temporary HD line


History of Present Illness:
75 yo male with ESRD on HD, trach for resp failure who presents
from [**Hospital **] rehab with a hematocrit drop and melena in his
rectal tube. Per notes he had HD yesterday and received 2 units
PRBCS during HD and hct was 35 during HD. Today hct was
re-checked and was 19. Stools were noted to guaiac positive. INR
was noted to be 4.3 , so pt received 5 mg of vitamin K. VS at NH
were T 97.5 HR 104 BP 108/59 and sats of 98%.
.
In the ER he was noted to have melena in his rectal tube. Hs HR
was initialy in the 90s with BP 108/53. He had a lavage of his
g-tube that was clear and received protonix 40 IV x2. He
received an additional 5 mg of vitamin K and 2 units of FFP
here. He received ~1.5 L of fluid and had starte receiving 1
back of PRBCs prior to txfr to the ICU. While in the ER his SBPs
dropped to the 80s-90s.
.
Upon arrival to the floor, the pt's initial SBP was in the 70s,
with HR in the 120s. This improved to SBP of 90s. The pt
appeared comfortable and denied abdominal pain, chest pain,
lightheadedness or nausea. Said he had fevers several weeks ago
and one recent episode of emesis. He thinks he may have had
black stool for weeks.
.
Of note, pt recently admitted [**Date range (1) 77791**] for new atrial
fibrillation, septic shock (urosepsis), and acute on chronic
renal failure now requiring dialysis and was discharged to
[**Hospital1 **].


Past Medical History:
# DM2
# CRI (baseline 2.5)- recently started on HD
# CHF
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia

Social History:
Used to live with wife, who is HCP. Now at [**Hospital1 **].

Family History:
N/C

Physical Exam:
VS: T:  HR: 120s BP: SBP 70s-90s  RR:  O2 sat:
Gen: obese male, mentating appropriately, NAD, pale
HEENT: anicteric sclera, dry MM
Neck: supple, dialysis line in place
Cardio: distant heart sounds, tachycardic, no murmur appreciated
Pulm: CTAB anteriorly, no w/r/g
Abd: soft, obese, NT, ND, +BS, G tube in place
Ext: hyperpigmentation on shins, 1+ peripheral edema, 1+ DP
pulses b/l
Neuro: Alert, awake, mentating appropriately and responding to
commands. Moves all extremities
Skin: hyperpigmentation on shins, dry gauze wrapped on both
shins

Pertinent Results:
Admission labs:
[**2150-4-1**] 11:05PM   WBC-12.0* RBC-2.01* HGB-5.8* HCT-18.6* MCV-92
MCH-28.9 MCHC-31.3 RDW-20.0*
[**2150-4-1**] 11:05PM   NEUTS-77.0* BANDS-0 LYMPHS-16.4* MONOS-3.7
EOS-2.7 BASOS-0.2
[**2150-4-1**] 11:05PM   PLT SMR-NORMAL PLT COUNT-162
[**2150-4-1**] 11:05PM   GLUCOSE-127* UREA N-99* CREAT-3.5* SODIUM-140
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
[**2150-4-1**] 11:05PM   CALCIUM-8.1* PHOSPHATE-3.4 MAGNESIUM-2.8*
[**2150-4-1**] 11:05PM   ALT(SGPT)-6 AST(SGOT)-13 ALK PHOS-121* TOT
BILI-0.2
[**2150-4-1**] 11:05PM   LIPASE-52
[**2150-4-1**] 11:05PM   PT-24.5* PTT-36.1* INR(PT)-2.4*
.
Studies:
ECG Study Date of [**2150-4-1**]
Rate PR QRS QT/QTc P QRS T
117 0 124 346/445 0 20 0
Baseline artifact. Probable atrial fibrillation with rapid
ventricular
response. However, there are periods of regularization but no
discernible
flutter waves. There is right bundle-branch block. Since the
previous tracing of [**2150-3-15**] the ventricular response is more
regular.
.
CHEST (PORTABLE AP)  [**2150-4-2**]
Tracheostomy tube tip terminates about 9 cm above the carina,
and the cuff is overdistended, as communicated by telephone to
Dr. [**Last Name (STitle) **] on [**2150-4-2**]. Heart is enlarged, pulmonary
vascularity is engorged, and there is bilateral perihilar
haziness attributed to pulmonary edema. More confluent left
retrocardiac opacification is present, likely a combination of
atelectasis and moderate effusion, but underlying infectious
consolidation is not excluded. Small right pleural effusion is
also evident.
.
EGD [**2150-4-2**]
Impression: Internal bumper of the recently placed PEG tube was
seen in place. There was a blood clot underneath the bumper
suggesting a site of bleed. It was washed, and did not reveal
any visible vessel or active bleeding.
There was no fresh or old blood (except the clot under the
bumper) seen in the stomach.
There was no fresh or old blood in the duodenum.
Erythema in the first and 2nd part of the duodenum
Otherwise normal EGD to second part of the duodenum
Recommendations:
- Bleeding likely to be from the site of the internal bumper of
the PEG in the setting of high INR, but seems to have stopped
now.
- PPI [**Hospital1 **]
- Watch Hct
.
TTE (Complete) Done [**2150-4-4**]
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is low normal (LVEF 50-55%). The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. There is no aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: poor technical quality due to patient's body
habitus. Moderately dilated left ventricular cavity. Left
ventricular function is probably low-normal, a focal wall motion
abnormality cannot be fully excluded. The right ventricle is not
well seen. Thickened aortic leaflets without frank stenosis.
Pulmonary artery systolic pressure could not be determined.
.
RENAL U.S. PORT  [**2150-4-13**]
IMPRESSION: No hydronephrosis. No collections identified. Thin
cortex bilaterally consistent with chronic interstitial disease.
.
CHEST (PORTABLE AP)  [**2150-4-17**]
FINDINGS: The image did not include the lung bases; however,
there is opacification in the right lung base secondary to
atelectasis and effusion. The left lung base cannot be
evaluated. The heart size is mildly enlarged and stable. More
opacification adjacent to the left heart border may indicate
left lower lobe atelectasis. A double-lumen central line tip is
in the proximal-to-mid one-third of the SVC. The tracheostomy
tube projects approximately 5 cm from the carina, unchanged.

Brief Hospital Course:
75 year old male with h/o ESRD on HD, tracheostomy who initally
presented with anemia and melena.  The patient was recently
discharged from [**Hospital1 18**] to rehab.  At rehab, he was found to have
a drop in his hematocrit from 35 to 18.6 associated with
hypotension and tachycardia.
.
# GI Bleed:  On admission, he had melena in his rectal tube and
gtube lavage was reportedly negative. His melena at that time
was felt most likely to LGIB, in the setting of recent
initiation of anticoagulation and supratherapeutic INR.  ASA and
coumadin were held on admission as well as his BB.  The patient
had a tagged red blood cell scan to identify the source of
bleeding, which was negative.  GI was consulted and performed
EGD on admission which demonstrated the source of bleeding to be
most likely from the site of the internal bumper of the PEG in
the setting of high INR, with no active bleeding noted.  Aspirin
and coumadin were held in the setting of active GI bleeding.  He
was transfused 8 units of PRBCs as well as 2 units of FFP on day
of admission, and his HCT remained stable above 30.  Although
his HCT remained stable, he continued to be guaiac positive.  He
was a second EGD on [**4-20**], which showed no source of bleeding.
His ASA and coumadin were restarted.
.
# Acute blood loss anemia:  As above.
.
# Hypotension, Hemorrhagic, Hypovolemic and Septic:  Pt was
initially hypotensive, likely hemorrhagic [**1-17**] GI bleed.  With
aggressive IVF resuscitation and transfusions on admission,
patient became volume overloaded.  With CVVH, over 40L of fluids
were removed.  However, in the setting of diuresis, the patient
dropped his blood pressures and required Neo to maintain SBP
over 90 and MAP greater than 55.  Neo was able to be weaned off
with IVF boluses.  He was also treated for UTI and bacteremia.
At discharge, his SBP ranged at 100s-110s.
.
# Relative adrenal insufficiency:  Pt was started on a course of
stress dose steroids after [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test had a less than
target range increase after cosyntropin was administered.  This
was discontinued after 6 days as he was not displaying other
signs of adrenal insufficiency.
.
# Chronic kidney disease, stage V:  The patient was started on
dialysis for renal insufficiency during his previous admission.
He was seen by renal while in the hospital, who felt he could
benefit from CVVH while in the intensive care unit to help
mobilize some of his fluid overload.  He was on CVVH initially
and then transitioned to HD 3x/week.  Throughout his course of
stay, he was negative 29L at discharge; weight at time of
discharge is 147 kg.  His temporary line was also tunneled in IR
during this admission without complication.  However, the
insertion site became infected; catheter tip culture has no
growth to time of discharge.  A second tunneled line was placed
by IR on [**4-20**].  He was started on midodrine to support his BP
during dialysis.
.
# Atrial fibrillation with RVR:  On admission, the patient was
in afib with RVR. His beta blocker and anticoagulation was
initially held in the setting of his GIB.  He was restarted on
his BB as tolerated by his BP.  He was also transiently on
digoxin for improved rate control while on CVVH; this was
discontinued as his HR came under better control with BB.  HR on
discharge was in the 50-60s.
.
# UTI:  Pt was found to have pan-resistant Klebsiella UTI and
received a 10 day course of Meropenam.
.
# Bacteremia:  Pt was found to have 2/2 bottles of coag.
negative Staph from the arterial line.  The line was pulled and
a new one place.  The catheter tip culture has no growth to time
of discharge.  Pt was treated with a 14 day course of Vancomycin
given his hypotension, tachycardia, and elevated WBC at the
time.
.
# Respiratory failure:  Pt has a tracheostomy and initially
required vent support.  With mobilization of his excess fluid,
the patient was weaned to a trach mask while in the hospital.
On [**4-20**] he desatted to 80%, in the setting of having increased
volume (7L positive in the last two days).  He had HD, where 3L
were removed and his sats did not improve significantly.  He was
requiring .7% FiO2, CXR showed partial collapse of his left
lung.  Mechanical ventilation was restarted and he was
maintained on this until discharge.  Sputum culture from [**4-8**]
showed acinetobacter and stenotrophomonas, initially not treated
because it was felt these could be colonizers.  However, in the
context of his increased oxygen requirement and cxr findings he
was started on tobramycin and was already on vanc for a presumed
line infection (positive blood cultures).  He underwent a BAL on
[**4-21**] and results are pending.  He will need to have his
tobramycin and vancomycin dosed at HD.  Please give 80 mg of IV
tobramycin after HD and check level prior to HD.  If tobramycin
level is >2, dose will required adjustment.  IV vancomycin
should also be dosed after HD with levels drawn prior to HD.
Results of the BAL should be followed up and if pt has
clinically improved the antibiotics should be discontinued.
.
# ?MGUS:  Pt had an elevated kappan and lambda.  Heme/onc was
consulted and performed a bone marrow biopsy.  Preliminary
results suggest MGUS.  Heme/onc had recommended outpatient
follow up in Benign [**Hospital **] Clinic in [**1-19**] weeks.
.
# DM2:  Pt was covered with a sliding scale for his Type II
Diabetes.
.
# Hyperlipidemia:  Pt was continued on his simvastation.
.
# FEN:  Pt received tube feeds via G-tube at goal.
# FULL CODE
# HCP:  [**Name (NI) 77789**] [**Name (NI) 77792**] (wife) [**Telephone/Fax (1) 77790**]

Medications on Admission:
Insulin SS
lantus 48 units qhs
Simvastatin 10 mg daily
ASA 81 mg daily
Metoprolol 50 mg TID
Citalopram 20 mg daily
Lansoprazole 30 mg daily
Coumadin
Silver Sulfadiazine 1%
Epoetin 1000 units with HD
Acetaminophen 650 q6 hours prn
clonazepam 0.5 mg tid prn
trazodone 50 mg hs prn

Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Insulin Glargine 100 unit/mL Solution Sig: Fifty Two (52)
units Subcutaneous once a day.
4. Insulin Regular Human 100 unit/mL Solution Sig: 0-18 units
Injection four times a day: As directed by sliding scale.
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
8. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day) as needed.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 4 PM).
16. Tobramycin in NS 80 mg/100 mL Piggyback Sig: Eighty (80) mg
Intravenous QHD (each hemodialysis) for 10 days: Please dose
after HD.  Please call [**Hospital1 18**] to follow up BAL results from [**4-21**],
if no growth and pt clinically improving can d/c anitbiotics.
17. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
18. Vancomycin 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y
(750) mg Intravenous HD PROTOCOL (HD Protochol) for 10 days.
19. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
20. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]

Discharge Diagnosis:
Primary:
upper GI bleed
urosepsis with ESBL
Volume overload
Hypotension
.
Secondary:
ESRD on dialysis
Atrial fibrillation
Urinary tract infection
Bacteremia
Monoclonal gammopathy of undetermined significance
Hyperlipidemia
Type II Diabetes


Discharge Condition:
Stable, afebrile


Discharge Instructions:
You were admitted to the hospital with a drop in your blood
counts and melena (or blood in your stool).  While you were in
the hospital, an EGD showed a clot around your PEG tube site,
which likely contributed to your bleeding. Your INR was also
high, which was a contributing factor.  While in the hostpial
you had an infection of your urinary tract that was treated,
your blood pressure was also low.  You had alot of fluid removed
in dialysis and your current weight, which is your dry weight is
147 kg.
GI reevaluated your upper GI tract and found no source of
bleeding, you were restarted on warfarin.
At the time of discharge your blood level (hematocrit) was
stable, and should be checked in 3 days.
.
You were also on CVVH, a type of dialysis, while you were in the
hospital to help remove some of the excess fluid in your
tissues.  During work up of causes of renal failure, you were
noted to have abnormal blood tests leading to a bone marrow
biopsy.  You were diagnosed with possible MGUS (monoclonal
gammopathy of undetermined significance).  You will see a
hematologist as an outpatient for this.
.
For a brief time, you needed medications to help support your
blood pressure.  Your blood pressure is now fine off the
medications.
.
You were also treated for a urinary tract infection and bacteria
in your blood with antibiotics.  In addition you were started on
tobramycin for acetinobacter and stentrophomonas in your sputum
when your oxygen requirement increased.  A BAL was done [**4-21**],
with no growth to date.  This will need to be followed up.
.
Please continue to take your medications as directed.
.
Please keep your follow up appointments.
.
If you have more bleeding from the rectum, vomiting of blood,
abdominal pain, lightheadedness, palpitations, chest discomfort,
shortness of breath, or any other concerning symptoms, please
call your primary care provider or go to the Emergency
Department.

Followup Instructions:
Please follow up with your PCP within two weeks of discharge.
.
Please also follow up with the Benign [**Hospital **] Clinic in [**1-19**] months
regarding the diagnosis of MGUS.  The clinic number is
[**Telephone/Fax (1) 68451**].



Completed by:[**2150-5-5**]
{"Other gastrostomy complications,Acute kidney failure, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,End stage renal disease,Urinary tract infection, site not specified,Other and unspecified infection due to central venous catheter,Bacteremia,Pressure ulcer, buttock,Chronic diastolic heart failure,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Monoclonal paraproteinemia,Morbid obesity"}


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, hematocrit drop

PRESENT ILLNESS: 75 yo male with ESRD on HD, trach for resp failure who presents
from [**Hospital **] rehab with a hematocrit drop and melena in his
rectal tube. Per notes he had HD yesterday and received 2 units
PRBCS during HD and hct was 35 during HD. Today hct was
re-checked and was 19. Stools were noted to guaiac positive. INR
was noted to be 4.3 , so pt received 5 mg of vitamin K. VS at NH
were T 97.5 HR 104 BP 108/59 and sats of 98%.
.
In the ER he was noted to have melena in his rectal tube. Hs HR
was initialy in the 90s with BP 108/53. He had a lavage of his
g-tube that was clear and received protonix 40 IV x2. He
received an additional 5 mg of vitamin K and 2 units of FFP
here. He received ~1.5 L of fluid and had starte receiving 1
back of PRBCs prior to txfr to the ICU. While in the ER his SBPs
dropped to the 80s-90s.
.
Upon arrival to the floor, the pt's initial SBP was in the 70s,
with HR in the 120s. This improved to SBP of 90s. The pt
appeared comfortable and denied abdominal pain, chest pain,
lightheadedness or nausea. Said he had fevers several weeks ago
and one recent episode of emesis. He thinks he may have had
black stool for weeks.
.
Of note, pt recently admitted [**Date range (1) 77791**] for new atrial
fibrillation, septic shock (urosepsis), and acute on chronic
renal failure now requiring dialysis and was discharged to
[**Hospital1 **].

MEDICAL HISTORY: # DM2
# CRI (baseline 2.5)- recently started on HD
# CHF
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia

MEDICATION ON ADMISSION: Insulin SS
lantus 48 units qhs
Simvastatin 10 mg daily
ASA 81 mg daily
Metoprolol 50 mg TID
Citalopram 20 mg daily
Lansoprazole 30 mg daily
Coumadin
Silver Sulfadiazine 1%
Epoetin 1000 units with HD
Acetaminophen 650 q6 hours prn
clonazepam 0.5 mg tid prn
trazodone 50 mg hs prn

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: VS: T:  HR: 120s BP: SBP 70s-90s  RR:  O2 sat:
Gen: obese male, mentating appropriately, NAD, pale
HEENT: anicteric sclera, dry MM
Neck: supple, dialysis line in place
Cardio: distant heart sounds, tachycardic, no murmur appreciated
Pulm: CTAB anteriorly, no w/r/g
Abd: soft, obese, NT, ND, +BS, G tube in place
Ext: hyperpigmentation on shins, 1+ peripheral edema, 1+ DP
pulses b/l
Neuro: Alert, awake, mentating appropriately and responding to
commands. Moves all extremities
Skin: hyperpigmentation on shins, dry gauze wrapped on both
shins

FAMILY HISTORY: N/C

SOCIAL HISTORY: Used to live with wife, who is HCP. Now at [**Hospital1 **]. 

### Response:
{"Other gastrostomy complications,Acute kidney failure, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,End stage renal disease,Urinary tract infection, site not specified,Other and unspecified infection due to central venous catheter,Bacteremia,Pressure ulcer, buttock,Chronic diastolic heart failure,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Monoclonal paraproteinemia,Morbid obesity"}
