CHIEF COMPLAINT: Left leg pain and syncope

PRESENT ILLNESS: Briefly this is an 88 year old male with hypertension, atrial
fibrillation s/p pacemaker placement, GI bleeding, prostate
cancer MGUS and chronic renal insufficiency who presented from
home with left knee pain and syncope. The patient reports that
he was in his usual state of health prior to admission.  On the
day of presentation he woke up with significant pain in his
right knee with swelling.  It made it difficult for him to
ambulate.  Later in the morning the patient was sitting on the
comode when he began to "act funny" and subsequently "blacked
out."  He does not rememeber this event well but says that his
daughters were present. He does not report any head trauma.  He
does note that the week prior to this event he was experiencing
black stools.  He also experienced non-bloody emesis x 1 on the
day of presentation.  He had had multiple admissions in the past
for dizziness and melena.  He was brought to the emergency room
for further evaluation.

MEDICAL HISTORY: 1. Prostate cancer dx'd [**2179**]- maintained on lupron (no
surgery/xrt).
2. Hypertension
3. Aortic insufficiency (2+).
3. Paroxysmal atrial fibrillation (not on anticoagulation)
4. Sick sinus syndrome s/p PPM for symptomatic bradycardia, [**5-18**]

MEDICATION ON ADMISSION: 1. Quetiapine 25 mg 0.5 Tablet PO QD ().
2. Donepezil 5 mg PO HS (at bedtime).
3. Atorvastatin 10 mg PO DAILY (Daily).
4. Calcitriol 0.5 mcg PO DAILY (Daily).
5. Lactulose (30) ML PO TID (3 times a day).
6. Fluticasone 50 mcg Nasal DAILY (Daily).
7. Darbepoetin Alfa qoweek ().
8. Pantoprazole 40 mg PO Q24H (every 24 hours).
9. Amlodipine 5 mg PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg PO TID (3 times a day).

ALLERGIES: Percocet / Simvastatin

PHYSICAL EXAM: Vitals: T: 97.3 BP: 164/63 HR: 80 RR: 20 O2: 96% on RA
GENERAL - NAD, pleasant, lying in bed, no acute distress
HEENT - PERRL, sclerae anicteric; partial ptosis R (old)
NECK - supple. no JVD, right IJ in place
RESP - clear to auscultation bilaterally, no wheezes, rales,
ronchi
CARDIAC - paced rhythm. Normal S1/S2; [**2-16**] Diastolic murmur at
LUSB
EXT - 2+ ankle edema bilaterally; Left knee effusion without
tenderness, mildly decreased range of motion
NEURO - Alert and oriented x 3, able to move all extremities.

FAMILY HISTORY: There is no history of premature CAD, HTN. One daughter who died
with ESRD.

SOCIAL HISTORY: Pt lives with his wife, his daughter [**Name (NI) 2048**] is the HCP.  Remote
smoking history, no ETOH, and no illicit drug use
Angiodysplasia of intestine with hemorrhage,Acute kidney failure, unspecified,Defibrination syndrome,Chronic kidney disease, Stage IV (severe),Urinary tract infection, site not specified,Secondary hyperparathyroidism (of renal origin),Iron deficiency anemia secondary to blood loss (chronic),Thrombocytopenia, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Atrial fibrillation,Contusion of knee,Unspecified fall,Hypoxemia,Aortic valve disorders,Other persistent mental disorders due to conditions classified elsewhere,Other chronic pulmonary heart diseases,Osteoarthrosis, localized, not specified whether primary or secondary, lower leg,Gout, unspecified,Other and unspecified hyperlipidemia,Nonspecific low blood pressure reading,Late effect of internal injury to chest,Residual foreign body in soft tissue,Late effects of injury, undetermined whether accidentally or purposely inflicted,Unspecified hemorrhoids without mention of complication,Cardiac pacemaker in situ,Personal history of malignant neoplasm of prostate
Angio intes w hmrhg,Acute kidney failure NOS,Defibrination syndrome,Chr kidney dis stage IV,Urin tract infection NOS,Sec hyperparathyrd-renal,Chr blood loss anemia,Thrombocytopenia NOS,Hy kid NOS w cr kid I-IV,Atrial fibrillation,Contusion of knee,Fall NOS,Hypoxemia,Aortic valve disorder,Mental disor NEC oth dis,Chr pulmon heart dis NEC,Loc osteoarth NOS-l/leg,Gout NOS,Hyperlipidemia NEC/NOS,Low blood press reading,Late eff int injur chest,Old FB in soft tissue,Late eff inj-undet circ,Hemorrhoids NOS,Status cardiac pacemaker,Hx-prostatic malignancy
Admission Date:  [**2185-4-5**]              Discharge Date:   [**2185-4-12**]


Service: MEDICINE

Allergies:
Percocet / Simvastatin

Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
Left leg pain and syncope

Major Surgical or Invasive Procedure:
Small Bowel Enteroscopy
Right Internal Jugular Vein Catheterization
Left Knee Arthrocentesis


History of Present Illness:
Briefly this is an 88 year old male with hypertension, atrial
fibrillation s/p pacemaker placement, GI bleeding, prostate
cancer MGUS and chronic renal insufficiency who presented from
home with left knee pain and syncope. The patient reports that
he was in his usual state of health prior to admission.  On the
day of presentation he woke up with significant pain in his
right knee with swelling.  It made it difficult for him to
ambulate.  Later in the morning the patient was sitting on the
comode when he began to "act funny" and subsequently "blacked
out."  He does not rememeber this event well but says that his
daughters were present. He does not report any head trauma.  He
does note that the week prior to this event he was experiencing
black stools.  He also experienced non-bloody emesis x 1 on the
day of presentation.  He had had multiple admissions in the past
for dizziness and melena.  He was brought to the emergency room
for further evaluation.

In the ED, his VS were 96.7, 59, 111/33, 19, 98%RA. He was
guaiac negative on exam. An old facial droop on the right was
noted. EKG showed v-paced rhythm. Trop was 0.14 around his
baseline with CRI. NH4 was 99 around his baseline. No asterixis.
He was given 1L NS, ASA 325mgX1 and admitted for further workup.


On admission the floor the patient was noted to be hypotensive
with systolic blood pressures in the 60s with altered mental
status.  He was not noted to have any melena or hematochezia.
His hematocrit on presentation was 32 but the following morning
it had decreased to 22. He received a liter of IVF, one unit of
O negative blood while awaiting type and cross with subsequent
improvement in his blood pressure and mental status.  He was
subsequently transferred to the MICU.

In the MICU, hypotension was felt to have been most likely from
GIB. Also found to have hemarthrosis of the left knee which was
not felt to be contributing significantly to his decreased
hematocrit.  He had no signs of infection, no EKG changes, TnT
stable with ARF, improving. Got vitamin K and FFP on admit to
ICU. Small bowel enteroscopy showed no active bleeding or AVMs,
only small erosion in antrum. He received a total of 8 units
PRBCs in the MICU with stabilization of his hematocrit in the
range of 28 to 30.  Of note he also developed laboratory
abnormalities consistent with low grade DIC with
thrombocytopenia, decreased fibrinogen at 64 and elevated fibrin
degredation products of 160-320.  He received one dose of
cryoprecipitate with improvement.  He was transferred to the
floor in stable condition.

Of note- MICU team spoke with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5717**] whom discussed his
prior 6 GIB with similar presentations with a dramatic HCT drop
in absence of melena/hematochezia, no other sx other than HCT
drop. Melena or guaiac + stools appear ~2 days later. He is
unaware that family declines endoscopies. He also noted that pt
has known severe DJD/arthritis of knees and stated that if knee
effusion was asymmetric then most certainly sustained trauma to
knee although has close to 24hour supervision. Pt has underlying
dementia w/waxing & [**Doctor Last Name 688**] change in AMS. Pt never received
anticoagulation for AF due to severe GIB risk. He is not on
ASA/NSAIDs for same reason.

On re-transfer to the floor, the patient was hemodynamically
stable.  He currently denies specific complaints including
fevers, chills, lightheadedness, dizzines, chest pain, shortness
of breath, nausea, vomiting, abdominal pain, dysuria, hematuria,
leg pain or swelling. No bowel movements over a 24 hour period.
All other review of systems negative in detail.


Past Medical History:
1. Prostate cancer dx'd [**2179**]- maintained on lupron (no
surgery/xrt).
2. Hypertension
3. Aortic insufficiency (2+).
3. Paroxysmal atrial fibrillation (not on anticoagulation)
4. Sick sinus syndrome s/p PPM for symptomatic bradycardia, [**5-18**]

5. Iron deficiency anemia/ anemia of chronic disease
6. Chronic Renal Failure
7. Pulmonary Hypertension (TTE [**10-17**] PASP 38mmhg)
8. Secondary hyperparathyroidism (low 25-hydroxyvitamin D, s/p
tx)
9. MGUS, IgG monoclonal gammopathy
10. s/p GSW with retained pleural fragment
11. s/p pacemaker placement.
12. Severe bilateral DJD of the knees
13. Gout
14. Refractory UGIB from jejunal AVMs, diagnosed in [**7-/2180**], and
duodenal ulcers, diagnosed in [**4-/2183**]
15. Encephalopathy and hyperammonemia without evidence of
hepatic
dysfunction.


Social History:
Pt lives with his wife, his daughter [**Name (NI) 2048**] is the HCP.  Remote
smoking history, no ETOH, and no illicit drug use


Family History:
There is no history of premature CAD, HTN. One daughter who died
with ESRD.


Physical Exam:
Vitals: T: 97.3 BP: 164/63 HR: 80 RR: 20 O2: 96% on RA
GENERAL - NAD, pleasant, lying in bed, no acute distress
HEENT - PERRL, sclerae anicteric; partial ptosis R (old)
NECK - supple. no JVD, right IJ in place
RESP - clear to auscultation bilaterally, no wheezes, rales,
ronchi
CARDIAC - paced rhythm. Normal S1/S2; [**2-16**] Diastolic murmur at
LUSB
EXT - 2+ ankle edema bilaterally; Left knee effusion without
tenderness, mildly decreased range of motion
NEURO - Alert and oriented x 3, able to move all extremities.


Pertinent Results:
Chemistries:
[**2185-4-5**] 07:30AM   GLUCOSE-133* UREA N-34* CREAT-2.4* SODIUM-143
POTASSIUM-3.9 CHLORIDE-112* TOTAL CO2-19* ANION GAP-16
[**2185-4-5**] 07:30AM   ALT(SGPT)-7 AST(SGOT)-20 LD(LDH)-253*
CK(CPK)-84 ALK PHOS-60 TOT BILI-0.8
[**2185-4-5**] 07:30AM   ALBUMIN-2.5* CALCIUM-8.9 PHOSPHATE-3.7
MAGNESIUM-1.9
[**2185-4-5**] 07:30AM   VIT B12-1313* FOLATE-9.1
[**2185-4-5**] 07:30AM   TSH-2.6
[**2185-4-5**] 12:30AM   AMMONIA-99*
[**2185-4-5**] 10:29PM   LD(LDH)-260* TOT BILI-0.9 DIR BILI-0.3 INDIR
BIL-0.6
[**2185-4-5**] 03:48PM   HAPTOGLOB-96
[**2185-4-5**] 03:48PM   FDP-160-320*
[**2185-4-5**] 03:48PM   FIBRINOGE-64*
[**2185-4-11**] 06:34AM BLOOD Glucose-97 UreaN-45* Creat-2.7* Na-143
K-3.5 Cl-112* HCO3-21* AnGap-14
[**2185-4-9**] 05:48AM BLOOD Fibrino-222
[**2185-4-7**] 03:41AM BLOOD PSA-1.2
[**2185-4-7**] 03:41AM BLOOD PEP-TRACE ABNO

Hematology:
[**2185-4-5**] 12:30AM   WBC-6.6 RBC-3.20* HGB-10.6* HCT-32.0*
MCV-100* MCH-33.0* MCHC-33.0 RDW-15.7*
[**2185-4-5**] 12:30AM   NEUTS-73.2* LYMPHS-20.3 MONOS-4.9 EOS-1.5
BASOS-0.1
[**2185-4-5**] 12:30AM   PLT COUNT-86*#
[**2185-4-5**] 07:30AM   WBC-5.9 RBC-2.23*# HGB-7.1*# HCT-22.1*#
MCV-99* MCH-31.9 MCHC-32.2 RDW-15.6*
[**2185-4-5**] 07:30AM   PLT COUNT-91*
[**2185-4-5**] 07:30AM   PT-19.6* PTT-55.5* INR(PT)-1.8*
[**2185-4-11**] 06:34AM BLOOD WBC-8.5 RBC-3.40* Hgb-10.4* Hct-31.0*
MCV-91 MCH-30.5 MCHC-33.5 RDW-17.9* Plt Ct-154

Cardiac Enzymes:
[**2185-4-5**] 12:30AM BLOOD CK(CPK)-40 cTropnT-0.14*
[**2185-4-5**] 07:30AM BLOOD CK(CPK)-84 CK-MB-NotDone cTropnT-0.12*
[**2185-4-5**] 03:48PM BLOOD CK(CPK)-53 CK-MB-NotDone cTropnT-0.12*

Urinalysis:
[**2185-4-9**] 12:54AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2185-4-9**] 12:54AM URINE Blood-LGE Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2185-4-9**] 12:54AM URINE RBC->50 WBC-21-50* Bacteri-FEW Yeast-NONE
Epi-1

[**2185-4-7**] 03:41AM URINE Hours-RANDOM Creat-173 Na-22 TotProt-61
Prot/Cr-0.4*
[**2185-4-7**] 03:41AM URINE U-PEP-AWAITING F IFE-PND Osmolal-333

EKG: Regular ventricular paced rhythm. Underlying atrial rhythm
is probably atrial fibrillation. Since the previous tracing of
[**2184-12-30**] no significant change.

Imaging:

HIP UNILAT MIN 2 VIEWS LEFT PORT  [**2185-4-5**] 2:19 PM
No comparisons. No acute fracture or dislocation is seen. No
lucent or sclerotic lesion is noted. Atherosclerotic vascular
calcification is seen. Soft tissues are otherwise unremarkable.
Severe degenerative changes of the left knee are noted, and
there is a large knee joint effusion. These are unchanged
compared to the previous examination.

FEMUR (AP & LAT) LEFT PORT; HIP UNILAT MIN 2 VIEWS LEFT PO
No comparisons. No acute fracture or dislocation is seen. No
lucent or sclerotic lesion is noted. Atherosclerotic vascular
calcification is seen. Soft tissues are otherwise unremarkable.
Severe degenerative changes of the left knee are noted, and
there is a large knee joint effusion. These are unchanged
compared to the previous examination.

CHEST (PORTABLE AP)  [**2185-4-5**] 9:59 AM
In comparison with the study of [**2184-12-30**], there is no
significant change. Again there is persistent extension of
intra-abdominal bowel loops into the right hemithorax with known
bullet fragment. Pacemaker device is again seen and there is
stable appearance of the heart and lungs.

KNEE (2 VIEWS) LEFT  [**2185-4-5**] 12:48 AM
There is severe tricompartmental joint disease with osteophyte
formation and loss of the normal joint space in addition to
regions of subchondral sclerosis. The severe underlying
degenerative changes limits the ability for subtle fractures;
however, no obvious displaced fractures are identified. There is
a slight irregularity in the region of the tibial tubercle and
at the insertion of the quadriceps tendon. Marked vascular
calcification is noted, and there is a moderate-to-large a
suprapatellar joint effusion.

ECHOCARDIOGRAM [**2185-4-6**]:
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is mild global left ventricular hypokinesis
(LVEF = 45 %). There is no ventricular septal defect. Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Moderate (2+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2184-6-21**],
the overall LVEF is slightly lower.

Microbiology:

[**2185-4-5**] 7:30 am SEROLOGY/BLOOD
RAPID PLASMA REAGIN TEST (Final [**2185-4-6**]): NONREACTIVE.

JOINT FLUID LEFT KNEE.
GRAM STAIN (Final [**2185-4-6**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2185-4-9**]):    NO GROWTH.

[**2185-4-7**] 4:55 pm STOOL
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2185-4-8**]): FECES
NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.

[**2185-4-9**] 12:54 am URINE
URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000
ORGANISMS/ML.


Brief Hospital Course:
88 year old male with hypertension, atrial fibrillation s/p
pacemaker placement, GI bleeding, prostate cancer MGUS and
chronic renal insufficiency who presented from home with left
knee pain and syncope.

Syncopal episode:  The patient has a history of multiple
syncopal episodes.  The differential diagnosis considered
included vasovagal, cardiac, hypovolemic and neurologic causes
of syncope.  The event happened while the patient was sitting on
the comode which argues for a vasovagal etiology.  Hypovolemia
also likely contributed as on presentation the patient had
evidence of gastrointestinal bleeding.  On presentation he had
evidence of confusion which improved dramatically once he was
resuscitated with blood products for his bleeding.  At the time
of discharge he denied lightheadedness or dizziness. He was
monitored on telemetry throughout his stay with evidence of
atrial fibrillation which was well rate controlled.  He is
scheduled for pacemaker interrogation in one week.  No further
workup was pursued.

Gastrointestinal Bleeding: The patient has a history of 6 prior
episodes of gastrointestinal bleeding from small bowel AVMs.
His most recent bleeding episode occurred three months ago.  The
patient reports developing black stools three days prior to
presentation.  His hematocrit was within his baseline on
presentation but dropped 10 points within the first 24 hours of
this admission with associated hypotension to the 60s systolic
and altered mental status.  He received 7 units of packed RBCs
in total from his bleeding.  He was transferred to the MICU
where he underwent small bowel enteroscopy which demonstrated
AVMs but no active bleeding.  At the time of discharge his
hematocrit had been stable for over 48 hours.  His blood
pressures were stable.  He was tolerating a regular diet.
Further workup with a double balloon enteroscopy was considered
but deferred at this time.

Left Knee Effusion:  On presentation the patient was complaining
of left knee pain with associated knee swelling.  Xray from the
emergency room showed a large effusion with evidence of
osteoarthritis.  He underwent arthrocentesis which showed
evidence of hemearthrosis.  He subsequently underwent hip and
femur films which were negative for fracture.  He was seen by
the orthopedic surgery service who recommended conservative
management with tylenol for pain. He did not receive NSAIDs
given his history of gastronitestinal bleeding.  It was not
thought that the bleeding in his knee was sufficient to account
for his decreased hematocrit and hypotension.

Thrombocytopenia:  On presentation his platelet count was 86
from a baseline of 150 to 200.  The etiology of this finding on
presentation is unclear but there was concern for low grade DIC.
 He had a low fibrinogen at 64 and fibrin degredation products
of 160-320.  The hematology service was consulted who
recommended following the patient clinically.  He received one
dose of cryoprecipitate.  His platelet count slowly improved to
154 on the day of discharge.  He will follow up with his primary
hematologist Dr. [**Last Name (STitle) **].

Urinary Tract Infection: Urine culture on [**2185-4-9**] grew > 100,000
e. coli.  He was started on ciprofloxacin with plans to complete
a 7 day course.  On discharge he was on day [**3-18**].

Atrial Fibrillation/Sick Sinus Syndrome:  The patient has
evidence of an irregular, wide complex rhythm and is status
post-pacemaker placement.  He has known atrial fibrillation and
sick sinus syndrome and is followed here by electrophysiology.
At the time of discharge he was taking his home dose of
metoprolol.   He will follow up in device clinic in one week for
pacemaker interrogation.

Anemia:  The patient's baseline hematocrit ranges from 28 to 32.
 During this admission he had a normal B12 and hematocrit.  He
also has known MGUS with concern for decreased marrow
production.  He also likely has chronic gastrointestinal
bleeding from AVMs.  As above, he required 7 units of PRBCs
during this admission for gastrointestinal bleeding.  On
discharge his hematocrit was 31.0.  Further workup for his
gastrointestinal bleeding would be limited to a double balloon
enteroscopy vs. allowing for periodic transfusions.  At this
time, further endoscopy was deferred.  He will follow up in
hematology clinic.

Stage 4 Chronic Kidney Disease: the patient's baseline
creatinine ranges between [**2-13**].  In the setting of
gastrointestinal bleeding his creatinine increased to 3.6. After
resuscitation his creatinine quickly improved to baseline and
was 2.7 on the day of discharge.  His medications were renally
dosed.  He was continued on his home dose of calcitriol.  He
will follow up with his nephrologist Dr. [**Last Name (STitle) 4090**].

Dementia:  No active inpatient issues.  He was continued on his
home donepazil and quetiapine.

Hypertension:  As above, the patient presented with syncope,
likely in the setting of gastrointestinal bleeding.  On hospital
day two his blood pressures dropped into the 60s systolic.  His
antihypertensive medications were held in this setting.  At the
time of discharge he was tolerating his home antihypertensive
regimen which includes metoprolol and amlodipine.

Hyperlipidemia - The patient has an allergy to simvastatin
reported in the online medical record.  On admission he was
taking atorvastatin.  This medication was continued as he
appears to be tolerting it well.

Prophylaxis: He received subcutaneous heparin for DVT
prophylaxis, and IV protonix given his gastrointestinal
bleeding.  He also received an aggressive bowel regimen.

Code: Full Code

Communication: Daughters [**Name (NI) 2155**] [**Telephone/Fax (1) 104517**]; [**Name2 (NI) 2048**]
[**Telephone/Fax (1) 104518**]

Disposition:  To rehab

Medications on Admission:
1. Quetiapine 25 mg 0.5 Tablet PO QD ().
2. Donepezil 5 mg PO HS (at bedtime).
3. Atorvastatin 10 mg PO DAILY (Daily).
4. Calcitriol 0.5 mcg PO DAILY (Daily).
5. Lactulose (30) ML PO TID (3 times a day).
6. Fluticasone 50 mcg Nasal DAILY (Daily).
7. Darbepoetin Alfa qoweek ().
8. Pantoprazole 40 mg PO Q24H (every 24 hours).
9. Amlodipine 5 mg PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg PO TID (3 times a day).


Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Aranesp SureClick -Polysorbate 60 mcg/0.3 mL Pen Injector
Sig: One (1)  Subcutaneous every other week .
7. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 672**] Hospital

Discharge Diagnosis:
Primary:
Gastrointestinal Bleeding
Left Knee Effusion
Atrial Fibrillation
Sick sinus syndrome
Chronic Anemia
Acute on chronic renal failure

Secondary:
Aortic Insufficiency
MGUS
Encephalopathy


Discharge Condition:
Stable.  Oriented to person, hospital and [**2185**].  Ambulating with
significant assistance.  Breathing comfortably on room air.


Discharge Instructions:
You were seen and evaluated for your knee pain and your
lightheadedness.  You were found to have swelling of your knee
and when a sample of this fluid was taken you were found to have
blood.  It was thought that this was secondary to
osteoarthritis.  You also had a low blood count and underwent
upper endoscopy.  You required 7 units of blood to control this
gastrointestinal bleeding.

Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please take ciprofloxacin 750 mg daily for 7 more days
2. Please take tylenol 325-650 mg every six hours as needed for
pain

Please keep all your follow up appointments.

Please seek immediate medical attention if you experience any
lightheadedness, dizziness, chest pain, shortness of breath,
worsening abdominal pain, black or red stools, falls at home or
any other concerning symptoms.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2185-4-19**] 9:40

Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2185-4-21**] 8:00

Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2185-4-21**]
9:00

Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Phone [**Telephone/Fax (1) 250**] Date/Time:
[**2185-6-2**]  09:00a

Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] Date/Time: [**2185-4-28**]  04:00p
{'Angiodysplasia of intestine with hemorrhage,Acute kidney failure, unspecified,Defibrination syndrome,Chronic kidney disease, Stage IV (severe),Urinary tract infection, site not specified,Secondary hyperparathyroidism (of renal origin),Iron deficiency anemia secondary to blood loss (chronic),Thrombocytopenia, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Atrial fibrillation,Contusion of knee,Unspecified fall,Hypoxemia,Aortic valve disorders,Other persistent mental disorders due to conditions classified elsewhere,Other chronic pulmonary heart diseases,Osteoarthrosis, localized, not specified whether primary or secondary, lower leg,Gout, unspecified,Other and unspecified hyperlipidemia,Nonspecific low blood pressure reading,Late effect of internal injury to chest,Residual foreign body in soft tissue,Late effects of injury, undetermined whether accidentally or purposely inflicted,Unspecified hemorrhoids without mention of complication,Cardiac pacemaker in situ,Personal history of malignant neoplasm of prostate'}


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: Left leg pain and syncope

PRESENT ILLNESS: Briefly this is an 88 year old male with hypertension, atrial
fibrillation s/p pacemaker placement, GI bleeding, prostate
cancer MGUS and chronic renal insufficiency who presented from
home with left knee pain and syncope. The patient reports that
he was in his usual state of health prior to admission.  On the
day of presentation he woke up with significant pain in his
right knee with swelling.  It made it difficult for him to
ambulate.  Later in the morning the patient was sitting on the
comode when he began to "act funny" and subsequently "blacked
out."  He does not rememeber this event well but says that his
daughters were present. He does not report any head trauma.  He
does note that the week prior to this event he was experiencing
black stools.  He also experienced non-bloody emesis x 1 on the
day of presentation.  He had had multiple admissions in the past
for dizziness and melena.  He was brought to the emergency room
for further evaluation.

MEDICAL HISTORY: 1. Prostate cancer dx'd [**2179**]- maintained on lupron (no
surgery/xrt).
2. Hypertension
3. Aortic insufficiency (2+).
3. Paroxysmal atrial fibrillation (not on anticoagulation)
4. Sick sinus syndrome s/p PPM for symptomatic bradycardia, [**5-18**]

MEDICATION ON ADMISSION: 1. Quetiapine 25 mg 0.5 Tablet PO QD ().
2. Donepezil 5 mg PO HS (at bedtime).
3. Atorvastatin 10 mg PO DAILY (Daily).
4. Calcitriol 0.5 mcg PO DAILY (Daily).
5. Lactulose (30) ML PO TID (3 times a day).
6. Fluticasone 50 mcg Nasal DAILY (Daily).
7. Darbepoetin Alfa qoweek ().
8. Pantoprazole 40 mg PO Q24H (every 24 hours).
9. Amlodipine 5 mg PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg PO TID (3 times a day).

ALLERGIES: Percocet / Simvastatin

PHYSICAL EXAM: Vitals: T: 97.3 BP: 164/63 HR: 80 RR: 20 O2: 96% on RA
GENERAL - NAD, pleasant, lying in bed, no acute distress
HEENT - PERRL, sclerae anicteric; partial ptosis R (old)
NECK - supple. no JVD, right IJ in place
RESP - clear to auscultation bilaterally, no wheezes, rales,
ronchi
CARDIAC - paced rhythm. Normal S1/S2; [**2-16**] Diastolic murmur at
LUSB
EXT - 2+ ankle edema bilaterally; Left knee effusion without
tenderness, mildly decreased range of motion
NEURO - Alert and oriented x 3, able to move all extremities.

FAMILY HISTORY: There is no history of premature CAD, HTN. One daughter who died
with ESRD.

SOCIAL HISTORY: Pt lives with his wife, his daughter [**Name (NI) 2048**] is the HCP.  Remote
smoking history, no ETOH, and no illicit drug use 

### Response:
{'Angiodysplasia of intestine with hemorrhage,Acute kidney failure, unspecified,Defibrination syndrome,Chronic kidney disease, Stage IV (severe),Urinary tract infection, site not specified,Secondary hyperparathyroidism (of renal origin),Iron deficiency anemia secondary to blood loss (chronic),Thrombocytopenia, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Atrial fibrillation,Contusion of knee,Unspecified fall,Hypoxemia,Aortic valve disorders,Other persistent mental disorders due to conditions classified elsewhere,Other chronic pulmonary heart diseases,Osteoarthrosis, localized, not specified whether primary or secondary, lower leg,Gout, unspecified,Other and unspecified hyperlipidemia,Nonspecific low blood pressure reading,Late effect of internal injury to chest,Residual foreign body in soft tissue,Late effects of injury, undetermined whether accidentally or purposely inflicted,Unspecified hemorrhoids without mention of complication,Cardiac pacemaker in situ,Personal history of malignant neoplasm of prostate'}
