CHIEF COMPLAINT: GIB

PRESENT ILLNESS: 78 yo F with hypertension, diabetes mellitus type II, chronic
kidney disease admitted for deep venous thrombosis and probable
pulmonary embolism on [**11-9**]. During admission patient also noted
to have malalignment of her previous left hip repair and
underwent
revision. Seen in ortho clinic [**11-27**], had oozing from hip wound,
patched.
.
Today at rehab, pt reported dizziness on standing and diffuse
abd pain, 1x episode of non bloody non bilious emesis. Also had
semi urgent BM that was normal in consistency, no blood, no
melena. At rehab labs were checekd, INR was 3.0, hgb 5, bun cr
67/1.7. Sent to ED for anemia.
.
On arrival to the ED VS were T 99.1 HR 97 BP 149/79 RR 16 SpO2
95%/RA.  She was noted to have melena in her diaper.  Had one
episode of dark emesis in the ED, guaiac positive.  Labs
significant for Hct 16.8, INR 3.2 BUN/Cr 71/1.7, trop 0.04. EKG
showed ST segment depression in anterolateral leads (V4/5/6, I,
avl).  Given 2L NS, 1 U FFP, 1 U PRBC, 2nd unit PRBC hung.  2 x
20g IVs placed.  GI consulted, plan for am EGD.  Protonix 80 +
8/hr.  VS on transfer Temp: 98.1, Pulse: 87, RR: 18, BP: 117/86,
O2Sat: 99, O2Flow: 2L, Pain:
.
On arrival to the MICU,
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: Diabetes
hypertension
history of stroke
shingles
depression
dementia
renal insufficiency
adnexal masses
endometrial thickening
glaucoma

MEDICATION ON ADMISSION: 1. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units
Subcutaneous every morning.
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: Diabetes Mellitus (one brother died of diabetes, other brother
currently has diabetes)
No history of blood disorders, hypercoagulability, heart disease
.

SOCIAL HISTORY: Smoked for 10 years, quit in [**2114**]. Husband died of lung cancer.
Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Other acute and subacute forms of ischemic heart disease, other,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity,Chronic kidney disease, Stage III (moderate),Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Unspecified glaucoma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Dementia, unspecified, without behavioral disturbance,Leukocytosis, unspecified,Depressive disorder, not elsewhere classified,Hypotension, unspecified,Hypovolemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of tobacco use,Aftercare for healing traumatic fracture of hip,Long-term (current) use of insulin,Anticoagulants causing adverse effects in therapeutic use,Salicylates causing adverse effects in therapeutic use
Chr duoden ulcer w hem,Ac ischemic hrt dis NEC,Acute kidney failure NOS,Ac posthemorrhag anemia,Ch DVT/embl prox low ext,Chr kidney dis stage III,Stomach ulcer NOS,Hy kid NOS w cr kid I-IV,Glaucoma NOS,DMII wo cmp nt st uncntr,Demen NOS w/o behv dstrb,Leukocytosis NOS,Depressive disorder NEC,Hypotension NOS,Hypovolemia,Hx TIA/stroke w/o resid,History of tobacco use,Aftrcre traumatic fx hip,Long-term use of insulin,Adv eff anticoagulants,Adv eff salicylates
Admission Date:  [**2130-12-8**]              Discharge Date:   [**2130-12-14**]

Date of Birth:  [**2052-6-6**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
GIB

Major Surgical or Invasive Procedure:
[**2130-12-6**]: esophagogastro duodenoscopy

History of Present Illness:
78 yo F with hypertension, diabetes mellitus type II, chronic
kidney disease admitted for deep venous thrombosis and probable
pulmonary embolism on [**11-9**]. During admission patient also noted
to have malalignment of her previous left hip repair and
underwent
revision. Seen in ortho clinic [**11-27**], had oozing from hip wound,
patched.
.
Today at rehab, pt reported dizziness on standing and diffuse
abd pain, 1x episode of non bloody non bilious emesis. Also had
semi urgent BM that was normal in consistency, no blood, no
melena. At rehab labs were checekd, INR was 3.0, hgb 5, bun cr
67/1.7. Sent to ED for anemia.
.
On arrival to the ED VS were T 99.1 HR 97 BP 149/79 RR 16 SpO2
95%/RA.  She was noted to have melena in her diaper.  Had one
episode of dark emesis in the ED, guaiac positive.  Labs
significant for Hct 16.8, INR 3.2 BUN/Cr 71/1.7, trop 0.04. EKG
showed ST segment depression in anterolateral leads (V4/5/6, I,
avl).  Given 2L NS, 1 U FFP, 1 U PRBC, 2nd unit PRBC hung.  2 x
20g IVs placed.  GI consulted, plan for am EGD.  Protonix 80 +
8/hr.  VS on transfer Temp: 98.1, Pulse: 87, RR: 18, BP: 117/86,
O2Sat: 99, O2Flow: 2L, Pain:
.
On arrival to the MICU,
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
Diabetes
hypertension
history of stroke
shingles
depression
dementia
renal insufficiency
adnexal masses
endometrial thickening
glaucoma


Social History:
Smoked for 10 years, quit in [**2114**]. Husband died of lung cancer.


Family History:
Diabetes Mellitus (one brother died of diabetes, other brother
currently has diabetes)
No history of blood disorders, hypercoagulability, heart disease
.

Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

DISCHARGE FEX
99.0 150/63 58 18 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Sutures over left hip c/d/i wihtout erythema or drainage.

Neuro: CNII-XII intact, grossly normal sensation, gait deferred,
finger-to-nose intact


Pertinent Results:
LABS: See below.
Notable for HCT 16.8([**12-8**])-->27.1([**12-9**])-->24.3([**12-9**])-->29.4
([**12-10**])-->29.4 ([**12-11**])-->32.9-->35.9
.
MICROBIOLOGY:
[**2130-12-10**]  SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY
TEST-FINAL Negative
[**2130-12-8**]  URINE URINE CULTURE-FINAL No growth
.
STUDIES:
EGD [**2130-12-8**]:
3 ulcers seen in stomach, duodenal bulb and D2. D2 lesion most
likely culprit for significant bleed. No active bleed at the
time of endoscopy. Recommend PPI gtt to continue, NPO. Please
reverse INR. If re-bleeds IR, surgery and GI consultation.
Potential embolization of GDA likely as great difficulty with
endoscopic intervention given size, location.
.
LENI [**12-9**]:
Persistent partially occlusive deep venous thrombosis in the
left
mid superficial femoral and popliteal veins. Left calf veins are
not
visualized. No DVT in the right lower extremity.
.
Hip Plain Films [**12-11**]
In comparison with study of [**11-27**], there is little overall
change
in the appearance of the metallic fixation device about
previously described fracture of the proximal femur. Lesser
trochanteric fracture fragment remains ununited with the
fracture mass.
Continued moderate joint space narrowing in both hip joints with
degenerative changes in the lower lumbar spine.
.
IVC Filter placement [**12-12**]:
1. Single patent IVC.
2. Two left renal veins.
3. Infrarenal IVC diameter measured about 7 mm.
4. Successful placement of G2 IVC filter in the infrarenal IVC.
.
CHEMISTRY

[**2130-12-8**] 03:20PM BLOOD WBC-15.4* RBC-1.75*# Hgb-5.2*# Hct-16.8*#
MCV-96# MCH-29.6# MCHC-30.8* RDW-23.9* Plt Ct-416
[**2130-12-8**] 10:12PM BLOOD WBC-11.0 RBC-2.47*# Hgb-7.5*# Hct-22.4*#
MCV-91 MCH-30.3 MCHC-33.5 RDW-19.1* Plt Ct-251
[**2130-12-9**] 04:29AM BLOOD WBC-10.7 RBC-3.19*# Hgb-9.9*# Hct-27.1*
MCV-85 MCH-31.1 MCHC-36.6* RDW-20.3* Plt Ct-226
[**2130-12-9**] 06:25PM BLOOD Hct-27.1*
[**2130-12-10**] 01:29AM BLOOD WBC-9.3 RBC-3.42* Hgb-10.1* Hct-29.4*
MCV-86 MCH-29.4 MCHC-34.2 RDW-21.0* Plt Ct-240
[**2130-12-11**] 03:48AM BLOOD WBC-7.3 RBC-3.34* Hgb-9.9* Hct-29.4*
MCV-88 MCH-29.8 MCHC-33.9 RDW-21.2* Plt Ct-267
[**2130-12-12**] 06:40AM BLOOD WBC-7.5 RBC-3.73* Hgb-10.9* Hct-32.9*
MCV-88 MCH-29.2 MCHC-33.2 RDW-20.7* Plt Ct-319
[**2130-12-13**] 07:35AM BLOOD WBC-8.2 RBC-3.95* Hgb-11.7* Hct-35.9*
MCV-91 MCH-29.7 MCHC-32.6 RDW-20.1* Plt Ct-347
[**2130-12-8**] 03:20PM BLOOD Neuts-63.9 Lymphs-30.8 Monos-4.1 Eos-0.8
Baso-0.3
[**2130-12-8**] 03:20PM BLOOD PT-33.4* PTT-58.4* INR(PT)-3.2*
[**2130-12-9**] 06:49AM BLOOD PT-19.5* PTT-29.7 INR(PT)-1.8*
[**2130-12-10**] 01:29AM BLOOD PT-16.2* PTT-31.0 INR(PT)-1.5*
[**2130-12-12**] 06:40AM BLOOD PT-14.9* PTT-29.8 INR(PT)-1.4*
[**2130-12-13**] 07:35AM BLOOD PT-14.5* PTT-30.4 INR(PT)-1.4*
[**2130-12-8**] 02:50PM BLOOD Glucose-184* UreaN-71* Creat-1.8* Na-134
K-4.8 Cl-104 HCO3-21* AnGap-14
[**2130-12-11**] 03:48AM BLOOD Glucose-106* UreaN-37* Creat-1.3* Na-142
K-3.5 Cl-109* HCO3-28 AnGap-9
[**2130-12-13**] 07:35AM BLOOD Glucose-76 UreaN-18 Creat-1.3* Na-137
K-4.1 Cl-106 HCO3-24 AnGap-11
[**2130-12-8**] 03:20PM BLOOD CK(CPK)-26*
[**2130-12-8**] 10:12PM BLOOD CK(CPK)-32
[**2130-12-9**] 04:29AM BLOOD CK(CPK)-28*
[**2130-12-8**] 03:20PM BLOOD cTropnT-0.04*
[**2130-12-8**] 10:12PM BLOOD CK-MB-1 cTropnT-0.03*
[**2130-12-9**] 04:29AM BLOOD CK-MB-1 cTropnT-0.03*
[**2130-12-8**] 03:20PM BLOOD Lipase-50
[**2130-12-8**] 03:20PM BLOOD Calcium-9.9 Phos-4.4# Mg-2.0
[**2130-12-9**] 04:29AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.9
[**2130-12-10**] 01:29AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.8
[**2130-12-11**] 03:48AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.7
[**2130-12-12**] 06:40AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.6
[**2130-12-13**] 07:35AM BLOOD Calcium-9.7 Phos-2.4* Mg-1.8
[**2130-12-8**] 03:40PM BLOOD Hgb-5.4* calcHCT-16

URINE
[**2130-12-8**] 05:30PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.011
[**2130-12-8**] 05:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2130-12-8**] 05:30PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
[**2130-12-8**] 05:30PM URINE CastGr-9* CastHy-3*

Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
Ms. [**Known lastname **] is a 78 year old female with recent left hip surgery
complicated by deep venous thomrbosis (DVT) of the left leg and
suspected pulmonary embolus (PE) treated with warfarin who was
found to have melena at her nursing home and anemia in the ED.
.
# Gastrointestinal Bleed (GIB):  She presented with melena and
so there was concern for upper GI source.  She underwent an EGD
which found 3 ulcers--1 pre-pyloric which was not bleeding, and
2 duodenal which both had evidence of fresh clots.  The GI team
injected epinephrine into each of these ulcers but were unable
to perform other interventions due to the size and location of
the ulcers.  She tested negative for H. pylori.  She was
maintained on a pantoprazole drip for a few days and then later
transitioned to twice daily oral pantoprazole.  She required 5
units of packed RBCs and vitamin K with 2 units of FFP to
reverse her INR.  Also, her anticoagulation was stopped (see
below).
.
# DVT/PE:  No current leg swelling but still has persistent left
deep vein thrombosis found on repeat doppler.  Because the GI
team felt that she was a very high risk of rebleeding in the
ulcers, further anticoagulation was held.  Instead, an IVC
filter was placed while her ulcers had time to heal over.
Interventional radiology was consulted and placed the filter on
[**2130-12-12**] without incident.
.
# Chest pain/EKG changes: Her chest pain on admission was likely
due to demand ischemia given her profound anemia (hematocrit of
16.8) on admission. Alternitively, it may have been due to
irritation of suspected PE.  Her troponins were mildly elevated
and decreased. Her chest pain resolved with blood transfusion.
Cardiology follow up as outpatient for further testing and/or
possible revascularization could be considered.
.
# Hypertension: Originally, her anti-hypertensives were held due
to concern for large volume GIB and hypotension.  However, she
was restarted sequentially on her home amlodipine, metoprolol,
HCTZ, and lisinopril.
.
# Diabetes mellitus:  Continued home lantus, half dose for NPO,
covered with sliding scale humalog, qid fingersticks.  Held
metformin. Due to low blood glucose. Lantus dose was decreased
to 24 units qpm.
.
# h/o hip arthroplasty:  Patient had flawed hip arthroplasty in
the [**Country 13622**] Republic, revised here in [**2130-10-24**].  Still
has staples in right incision, orthopedics consulted to remove
the staples.  Plain film Xrays showed little change from [**11-27**]
films, but did note persistent lesser trochanteric fragment
nonunion. Films were reviewed by orthopedic staff to their
satisfaction.
.
TRANSITIONAL ISSUES:
- Please give education on avoiding NSAIDs, steroids, etc to
prevent further ulcers
- Will set up cardiology follow up to evaluate need for further
testing/management due to demand ischemia noted on presentation.
- Patient will need to follow up with GI in [**3-29**] weeks to arrange
repeat EGD to assess healing of ulcers. At that time,
reinitiation of coumadin and aggrenox should be considered. If
she is to be anticoagulated, would consider removal of IVC
filter.


Medications on Admission:
1. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units
Subcutaneous every morning.
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
6. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

8. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)

as needed for anxiety.
10. dipyridamole-aspirin 200-25 mg Cap, ER Multiphase 12 hr Sig:

One (1) Cap PO DAILY (Daily).
11. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
12. multivitamin     Tablet Sig: 1-2 Tablets PO DAILY (Daily).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
15. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
16. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
17. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6

hours) as needed for pain, fever.
18. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
19. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
20. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
21. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO

Q8H (every 8 hours) as needed for nausea.
22. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).

23. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).


Discharge Medications:
1. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units
Subcutaneous qpm: or as otherwise directed.
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for anxiety.
9. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
10. multivitamin,tx-minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QAM (once a day (in the
morning)).
13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
14. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
15. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
17. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
18. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
19. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]

Discharge Diagnosis:
PRIMARY DIAGNOSIS
Pyloric ulcers
deep vein thrombosis


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms. [**Known lastname **],
.
You were admitted to the hospital because you were having dark
colored stools which is a sign that you were bleeding in your
stomach.  You had an EGD where the GI doctors looked down your
throat with a camera and found 3 ulcers in your stomach which
were bleeding. They used medications to stop the bleeding and
you received several units of blood.  You should avoid taking
pain medications such as Motrin and Advil because these can
cause ulcers.
.
Also, you still have a clot in your leg where they did the
surgery.  Because you cannot take blood thinning medication
right now due to ulcers, you had a filter placed in your veins
to stop this clot from moving to your lungs.
.
The following changes were made to your medications:
STOP warfarin, aggrenox, miconazole, oxycodone, prochlorperazine
START omeprazole 40mg tablet twice daily
DECREASE lantus to 24 units daily
.
No other changes were made to your medications.
.
It is very important that you keep all of the follow-up
appointments listed below.
.
It was a pleasure taking care of you in the hospital!

Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2131-1-9**] at 1 PM
With: [**Name6 (MD) 11170**] [**Last Name (NamePattern4) 11171**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage

Department: CARDIAC SERVICES
When: WEDNESDAY [**2131-1-10**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15553**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Other acute and subacute forms of ischemic heart disease, other,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity,Chronic kidney disease, Stage III (moderate),Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Unspecified glaucoma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Dementia, unspecified, without behavioral disturbance,Leukocytosis, unspecified,Depressive disorder, not elsewhere classified,Hypotension, unspecified,Hypovolemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of tobacco use,Aftercare for healing traumatic fracture of hip,Long-term (current) use of insulin,Anticoagulants causing adverse effects in therapeutic use,Salicylates causing adverse effects in therapeutic use'}


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: GIB

PRESENT ILLNESS: 78 yo F with hypertension, diabetes mellitus type II, chronic
kidney disease admitted for deep venous thrombosis and probable
pulmonary embolism on [**11-9**]. During admission patient also noted
to have malalignment of her previous left hip repair and
underwent
revision. Seen in ortho clinic [**11-27**], had oozing from hip wound,
patched.
.
Today at rehab, pt reported dizziness on standing and diffuse
abd pain, 1x episode of non bloody non bilious emesis. Also had
semi urgent BM that was normal in consistency, no blood, no
melena. At rehab labs were checekd, INR was 3.0, hgb 5, bun cr
67/1.7. Sent to ED for anemia.
.
On arrival to the ED VS were T 99.1 HR 97 BP 149/79 RR 16 SpO2
95%/RA.  She was noted to have melena in her diaper.  Had one
episode of dark emesis in the ED, guaiac positive.  Labs
significant for Hct 16.8, INR 3.2 BUN/Cr 71/1.7, trop 0.04. EKG
showed ST segment depression in anterolateral leads (V4/5/6, I,
avl).  Given 2L NS, 1 U FFP, 1 U PRBC, 2nd unit PRBC hung.  2 x
20g IVs placed.  GI consulted, plan for am EGD.  Protonix 80 +
8/hr.  VS on transfer Temp: 98.1, Pulse: 87, RR: 18, BP: 117/86,
O2Sat: 99, O2Flow: 2L, Pain:
.
On arrival to the MICU,
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: Diabetes
hypertension
history of stroke
shingles
depression
dementia
renal insufficiency
adnexal masses
endometrial thickening
glaucoma

MEDICATION ON ADMISSION: 1. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units
Subcutaneous every morning.
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: Diabetes Mellitus (one brother died of diabetes, other brother
currently has diabetes)
No history of blood disorders, hypercoagulability, heart disease
.

SOCIAL HISTORY: Smoked for 10 years, quit in [**2114**]. Husband died of lung cancer. 

### Response:
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Other acute and subacute forms of ischemic heart disease, other,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity,Chronic kidney disease, Stage III (moderate),Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Unspecified glaucoma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Dementia, unspecified, without behavioral disturbance,Leukocytosis, unspecified,Depressive disorder, not elsewhere classified,Hypotension, unspecified,Hypovolemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of tobacco use,Aftercare for healing traumatic fracture of hip,Long-term (current) use of insulin,Anticoagulants causing adverse effects in therapeutic use,Salicylates causing adverse effects in therapeutic use'}
