CHIEF COMPLAINT: hematemesis

PRESENT ILLNESS: 86 yo F h/o HTN, sCHF, bleeding gastric ulcer s/p partial
gastrectomy [**2072**], sarcoidosis, afib not on coumadin, hematemesis
with anastamotic ulcer on EGD in [**2128**] p/w nausea and vomiting
last night.  She was in her usual state of health during the
day, went out for Chinese food for dinner around 5 pm.
Initially felt well afterwards, around 10 pm felt nauseated and
started vomiting.  Was up all night with abdominal pain and
nausea, vomited about five times last night.  This morning
around 6 am vomited bright red blood.  Not sure how much it was,
no coffee grounds.  Also may have had a dark stool this AM but
she is not sure.  Denies any diarrhea currently, but had
diarrhea last week.  She does get nauseated about once a week,
used to be followed in [**Hospital **] clinic for this and was thought to be
related to GERD and possible ulcer disease, has been on a [**Hospital1 **]
PPI and PRN promethazine at home, takes promethazine about
weekly.  Unable to take last night due to nausea.  No h/o liver
disease.  No h/o liver disease.  Denies chest pain, shortness of
breath, lightheadedness, joint pain, rashes, sick contacts.
.
In the ED, initial VS were HR 82, BP 162/98, RR 14, sat 99% 3L
NC.  EKG showed sinus rhythm 82 bpm, prolonged PR interval, PVCs
and new lateral ST depressions.  Pt given IV NS, protonix 80 mg
bolus and started on drip, zofran 4 mg, and morphine.  Pt
appeared dry on exam, rectal exam with no stool in the vault.
NG lavage not done given presence of bright red blood in vomit.
Hct 36 so no blood products were given, coags wnl. Access with
PIV x 2.  Received 2.5 L of IV NS.  GI called from [**Location **],
recommended EGD.  Admitted to ICU for active vomiting of blood
noted in ED.  VS on transfer temperature 97.8. HR 86 RR 20 BP
152/81, afib, sat 100% 2L.
.
On arrival to ICU, pt feels nauseated and abdominal pain in
lower part of abdomen which started last night as well,
nonradiating, feels like cramping.  No fever since episodes
started but did have a fever to 101 about 2 weeks ago for which
she was treated with amoxicillin.  Has had 4 episodes total of
blood in vomit, although unable to quantify amount of blood.
.
Review of systems:
(+) Per HPI, also + for cough for the last few weeks, recently
treated for presumed PNA with 10 day course of amoxicillin,
suspected that cough may be related to pulmonary sarcoidosis per
daughter
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, or wheezing. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
constipation.  Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.

MEDICAL HISTORY: 1. HTN
2. Hypercholesterolemia
3. systolic CHF, etiology unclear
4. Bleeding gastric ulcer s/p partial gastrectomy in [**2072**].
5. Hematemesis 6-7 years ago. No source was found on EGD.
6. Lap cholecystetomy in [**2124**] complicated by liver laceration
and PE
7. Post-op PE requiring brief intubation and s/p IVC filter and
anticoagulation in [**2124**]
8. S/p appendectomy
9. Iron deficiency anemia
10. OA of left knee requiring knee replacement
11. S/p fall complicated by displacement of anterior arch of C1

MEDICATION ON ADMISSION: alendronate 70 qweek
atenolol 25mg qam 50 qpm
dig 0.125 qd
lidoderm patch for back or knee
lisionpril 30mg qday
omeprazole 20mg [**Hospital1 **]
pravastatin 40mg qd
ropinirole 1mg qhs
effexor 150 mg qd
vit d
-allergies: ativan, compazine and advair

ALLERGIES: Ativan / Compazine

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: 98.7  HR 86 BP 143/74 sat 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, tacky mucous membranes, no
oropharyngeal lesions
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at bases bilaterally, no wheezes, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur best heard at apex
Abdomen: soft, mild ttp throughout, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Her father died of renal cancer; brother with lung cancer; no hx
of CAD; no hx of colon cancer.

SOCIAL HISTORY: - Tobacco: denies, prior 10 pack year history per OMR
- Alcohol:  denies currently, h/o EtOH abuse quit 35 years ago,
detox x 3 in the past
- Illicits:  pt denies, but per OMR h/o prescription drug abuse
(opiates)
Chronic or unspecified gastrojejunal ulcer with hemorrhage, without mention of obstruction,Acute posthemorrhagic anemia,Chronic systolic heart failure,Thrombocytopenia, unspecified,Dehydration,Sarcoidosis,Atrial fibrillation,Acquired absence of organ, stomach,Depressive disorder, not elsewhere classified,Unspecified essential hypertension,Dieulafoy lesion (hemorrhagic) of stomach and duodenum,Knee joint replacement,Swelling of limb,Long-term (current) use of steroids
Chr marginal ulcer w hem,Ac posthemorrhag anemia,Chr systolic hrt failure,Thrombocytopenia NOS,Dehydration,Sarcoidosis,Atrial fibrillation,Acq absence of stomach,Depressive disorder NEC,Hypertension NOS,Dieulafoy les,stom&duod,Joint replaced knee,Swelling of limb,Long-term use steroids
Admission Date:  [**2135-2-14**]              Discharge Date:   [**2135-2-20**]


Service: MEDICINE

Allergies:
Ativan / Compazine

Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
hematemesis

Major Surgical or Invasive Procedure:
EGD x3 with clipping


History of Present Illness:
86 yo F h/o HTN, sCHF, bleeding gastric ulcer s/p partial
gastrectomy [**2072**], sarcoidosis, afib not on coumadin, hematemesis
with anastamotic ulcer on EGD in [**2128**] p/w nausea and vomiting
last night.  She was in her usual state of health during the
day, went out for Chinese food for dinner around 5 pm.
Initially felt well afterwards, around 10 pm felt nauseated and
started vomiting.  Was up all night with abdominal pain and
nausea, vomited about five times last night.  This morning
around 6 am vomited bright red blood.  Not sure how much it was,
no coffee grounds.  Also may have had a dark stool this AM but
she is not sure.  Denies any diarrhea currently, but had
diarrhea last week.  She does get nauseated about once a week,
used to be followed in [**Hospital **] clinic for this and was thought to be
related to GERD and possible ulcer disease, has been on a [**Hospital1 **]
PPI and PRN promethazine at home, takes promethazine about
weekly.  Unable to take last night due to nausea.  No h/o liver
disease.  No h/o liver disease.  Denies chest pain, shortness of
breath, lightheadedness, joint pain, rashes, sick contacts.
.
In the ED, initial VS were HR 82, BP 162/98, RR 14, sat 99% 3L
NC.  EKG showed sinus rhythm 82 bpm, prolonged PR interval, PVCs
and new lateral ST depressions.  Pt given IV NS, protonix 80 mg
bolus and started on drip, zofran 4 mg, and morphine.  Pt
appeared dry on exam, rectal exam with no stool in the vault.
NG lavage not done given presence of bright red blood in vomit.
Hct 36 so no blood products were given, coags wnl. Access with
PIV x 2.  Received 2.5 L of IV NS.  GI called from [**Location **],
recommended EGD.  Admitted to ICU for active vomiting of blood
noted in ED.  VS on transfer temperature 97.8. HR 86 RR 20 BP
152/81, afib, sat 100% 2L.
.
On arrival to ICU, pt feels nauseated and abdominal pain in
lower part of abdomen which started last night as well,
nonradiating, feels like cramping.  No fever since episodes
started but did have a fever to 101 about 2 weeks ago for which
she was treated with amoxicillin.  Has had 4 episodes total of
blood in vomit, although unable to quantify amount of blood.
.
Review of systems:
(+) Per HPI, also + for cough for the last few weeks, recently
treated for presumed PNA with 10 day course of amoxicillin,
suspected that cough may be related to pulmonary sarcoidosis per
daughter
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, or wheezing. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
constipation.  Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.

Past Medical History:
1. HTN
2. Hypercholesterolemia
3. systolic CHF, etiology unclear
4. Bleeding gastric ulcer s/p partial gastrectomy in [**2072**].
5. Hematemesis 6-7 years ago. No source was found on EGD.
6. Lap cholecystetomy in [**2124**] complicated by liver laceration
and PE
7. Post-op PE requiring brief intubation and s/p IVC filter and
anticoagulation in [**2124**]
8. S/p appendectomy
9. Iron deficiency anemia
10. OA of left knee requiring knee replacement
11. S/p fall complicated by displacement of anterior arch of C1

one year ago; wore hard collar for one year and is now s/p
surgical fixation in [**7-11**] at [**Hospital3 **]
12. L TKR due to non [**Hospital1 **] of femur fx [**3-12**] at OSH
13. h/o depression
14. atrial fibrillation
15. hematemesis bleeding ulcer noted at billroth II anasthamosis
in [**2128**] (gastrin level wnl and H. pylori negative)
16. sarcoidosis dx [**2129**] with pulmonary symptoms and lymph node
bx

Social History:
- Tobacco: denies, prior 10 pack year history per OMR
- Alcohol:  denies currently, h/o EtOH abuse quit 35 years ago,
detox x 3 in the past
- Illicits:  pt denies, but per OMR h/o prescription drug abuse
(opiates)


Family History:
Her father died of renal cancer; brother with lung cancer; no hx
of CAD; no hx of colon cancer.


Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.7  HR 86 BP 143/74 sat 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, tacky mucous membranes, no
oropharyngeal lesions
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at bases bilaterally, no wheezes, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur best heard at apex
Abdomen: soft, mild ttp throughout, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
[**2135-2-14**] 07:05AM BLOOD WBC-15.5* RBC-4.02* Hgb-11.7* Hct-36.9
MCV-92 MCH-29.1 MCHC-31.6 RDW-14.9 Plt Ct-167
[**2135-2-14**] 12:55PM BLOOD WBC-10.6 RBC-2.90*# Hgb-8.7*# Hct-26.4*#
MCV-91 MCH-29.9 MCHC-32.9 RDW-15.0 Plt Ct-148*
[**2135-2-14**] 07:25PM BLOOD Hct-24.0*
[**2135-2-15**] 02:53AM BLOOD WBC-14.9* RBC-3.22* Hgb-9.6* Hct-28.8*
MCV-89 MCH-29.9 MCHC-33.5 RDW-14.8 Plt Ct-113*
[**2135-2-15**] 09:22AM BLOOD Hct-26.0*
[**2135-2-15**] 03:30PM BLOOD Hct-28.9*
[**2135-2-16**] 04:24AM BLOOD WBC-8.6 RBC-2.66*# Hgb-8.1*# Hct-23.6*#
MCV-89 MCH-30.3 MCHC-34.2 RDW-14.8 Plt Ct-84*
[**2135-2-14**] 07:05AM BLOOD PT-10.9 PTT-29.9 INR(PT)-1.0
[**2135-2-16**] 04:59AM BLOOD PT-13.1* PTT-29.2 INR(PT)-1.2*
[**2135-2-14**] 07:05AM BLOOD Fibrino-390
[**2135-2-14**] 07:05AM BLOOD Glucose-159* UreaN-17 Creat-0.7 Na-140
K-4.3 Cl-102 HCO3-25 AnGap-17
[**2135-2-15**] 02:53AM BLOOD Glucose-124* UreaN-25* Creat-0.6 Na-141
K-3.8 Cl-110* HCO3-22 AnGap-13
[**2135-2-16**] 04:24AM BLOOD Glucose-67* UreaN-21* Creat-0.5 Na-141
K-3.6 Cl-112* HCO3-21* AnGap-12
[**2135-2-14**] 07:05AM BLOOD ALT-20 AST-43* LD(LDH)-432* AlkPhos-120*
TotBili-0.3
[**2135-2-15**] 02:53AM BLOOD ALT-14 AST-24 AlkPhos-77
[**2135-2-14**] 07:05AM BLOOD Lipase-19
[**2135-2-14**] 07:05AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.8
[**2135-2-15**] 02:53AM BLOOD Calcium-7.1* Phos-2.5* Mg-1.9
[**2135-2-16**] 04:24AM BLOOD Calcium-6.5* Phos-2.6* Mg-1.7
[**2135-2-16**] 03:10AM BLOOD Digoxin-0.5*
[**2135-2-16**] 04:34AM BLOOD freeCa-1.00*
[**2135-2-14**] 08:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2135-2-14**] 08:00AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
[**2135-2-14**] 08:00AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1

MICRO:
Urine ([**2-14**]): no growth

EKG ([**2-14**]): Rate 82. Sinus rhythm. First degree A-V block.
Leftward axis. Poor R wave progression. Lateral ST-T wave
abnormalities. Compared to the previous tracing of [**2134-3-27**] first
degree A-V block is now present.

CXR ([**2-14**]):
IMPRESSION:
1. No evidence of intra-abdominal free air.
2. Stable cardiomegaly.
3. No evidence of decompensated congestive heart failure or
pneumonia.

Hand ([**2-16**]) Xray:
PND

EGD [**2-14**]:
Impression: Normal mucosa in the esophagus
Blood in the stomach body
Dieulafoy lesion in the Anastomotic site (endoclip)
Both the limbs were identified and no source of bleeding was
noticed in those.
Otherwise normal EGD to third part of the duodenum

Brief Hospital Course:
BRIEF HOSPITAL COURSE:
86 yo F h/o HTN, sCHF, bleeding gastric ulcer s/p partial
gastrectomy [**2072**], hematemesis in [**2128**] [**2-3**] anastamotic bleed,
afib not on coumadin p/w nausea and vomiting, hematemesis
.
ACTIVE ISSUES:
# Hematemesis/Acute blood loss Anemia:  Patient was initially
admitted to the ICU for frequent episodes of hematemesis with
stable blood pressures and heart rate in the ED.  Initially Hct
was 36 in setting of dehydration and decreased to 26 after fluid
repletion.  GI was consulted and EGD was done on day of
admission which showed likely Dieulafoy's lesion near
anastatmotic site from prior gastric bypass surgery, and three
clips were placed.  Followup Hct was 24 after EGD, transfused 2
units of PRBC.  She was scoped again the following day which
again showed bleeding Dieulafoy lesion and 2 clips were placed
and lesion injected.  Followup Hct suggested continued bleeding
so she was transfused 2 more units PRBC.  Third EGD was done on
[**2-16**] which showed no bleeding at anastamotic site and areas
suggestive of ischemia around the anastamotic site.  Patient was
evaluated by the surgical team who recommended no acute
intervention and transfusion goal of Hct >30 and platelets >70,
IR was made aware of patient who recommended no acute
intervention.  Throughout course in MICU patient's blood
pressure, urine output remained stable and patient was continued
on protonix 40 mg IV BID.  She received total of 6 units PRBC in
MICU and antihypertensives were held.  Her Hct remained stable
and she was transitioned to orals.  H. pylori was also sent and
was negative.
.
# Afib: Pt history with atrial fibrillation, not on coumadin.
At home she is on rate control with atenolol and on digoxin,
however this was held in setting of acute bleed.  She had one
episode of afib w/ RVR to 140s [**2-15**] around the EGD procedure.
The patient was given 2.5mg metoprolol IVx2 and 5mg IV x1. Pt
was otherwise in sinus during MICU stay.  Her digoxin was
continued.  Her beta blocker was started as Metoprolol on [**2-17**],
and she remained stable.  Aspirin is being held in light of GI
bleeding.
.
#Hand pain/ swelling: Patient has chronic pain at baseline, on
[**2-16**] noted to have swollen and tender MCP joints.  Pt with
history of sarcoidosis and inflammatory appearance of joints,
started short course of prednisone 20 mg x 4 days and standing
tylenol.  Pseudogout was also a consideration.  Hand xrays
ordered and showed nothing acute.
.
# Nausea/vomiting/abd pain:  Pt has had episodes in the past of
nausea and vomiting usually post-prandial and is on PPI [**Hospital1 **] as
symptoms thought to be [**2-3**] GERD or recurrence of ulcers in the
past, viral gastroenteritis was also on differential.  It is
possible that symptoms were also related to lesion at
anastamotic site.  Zofran and IV morphine given with symptomatic
improvement. This was transitioned to oral oxycodone, and then
this was weaned because of fall risk.  Abdominal exam remained
benign.

# leukocytosis:  Initally WBC 15.5, improved without
intervention. [**Month (only) 116**] have been in setting of stress vs
gastroenteritis given sx of nausea, vomiting.  No fevers during
stay in MICU, but was recently treated for cough and fever with
amoxicillin.

# Cough: has been ongoing for about 2 weeks, no change with
antibiotics and CXR with no acute process making PNA or CHF exac
less likely.  [**Month (only) 116**] be related to viral bronchitis vs re-occurance
of sarcoidosis (had pulmonary sarcoid in the past, follows in
pulmonology). Being worked up as outpatient

# HTN: Held atenolol, lisinopril in setting of acute bleed.
Restarted low dose BB first on [**2-17**].  ACE-I held and restarted
at a lower dose (10mg daily, instead of 30mg daily).  Should be
revaluated by PCP.
.
# chronic pain: pt with chronic pain in setting of multiple knee
and neck surgeries.  She is on an oxycodone regimen per her PCP,
[**Name10 (NameIs) **] IV morphine in ICU since pt had increased pain and was
NPO.  I did not give her more oxycodone since this increases
risk of falls, and she at times felt light-headed after taking
it when walking with walker (though proved to be stable on
evaluation). she was instructed not to drive on this medication.

# chronic systolic CHF: She appeared euvolemic on exam.  Most
recent EF is 50% from dobutamine stress test.  Beta blocker and
ACEI held in setting of bleed, but restarted gradually once her
bleeding resolved.

# depression: continued effexor

# Communication: Patient, daughter/hcp [**Name (NI) **] cell:[**Telephone/Fax (1) 106059**]
home: [**Telephone/Fax (1) 106060**]
# Code status: DNR, ok to intubate


Medications on Admission:
alendronate 70 qweek
atenolol 25mg qam 50 qpm
dig 0.125 qd
lidoderm patch for back or knee
lisionpril 30mg qday
omeprazole 20mg [**Hospital1 **]
pravastatin 40mg qd
ropinirole 1mg qhs
effexor 150 mg qd
vit d
-allergies: ativan, compazine and advair


Discharge Medications:
1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
4. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO DAILY (Daily).
5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
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:*2*
7. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
8. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Upper GI bleed due to gastric ulcer
Acute blood loss anemia
Atrial fibrillation
Hypertension

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:
You were admitted after vomiting blood.  You were found to have
a GI bleed with anemia.  In the ICU, you underwent EGD showing
bleeding ulcers.  These were successfully clipped.  After 6
blood transfusions your bleeding stopped.

It is very important that you take the twice daily Protonix to
prevent bleeding.

You were also found to have mild arthritis in your hand, most
likely felt to be "Pseudogout."  You completed a short course of
Prednisone.

Please see the medication sheet on discharge.  Please note that
your Lisinopril dose was decreased to 10mg daily.

Please minimize the use of any opiate medications you receive
from your physicians as this can cause an increased risk of
falls.  Oxycodone will only be prescribed by your PCP.

Followup Instructions:
PCP: [**Name10 (NameIs) 106056**],[**Name11 (NameIs) 1569**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 35502**]
- within 1 week

You should [**2135-2-22**] call to make an appointment for follow up.
{'Chronic or unspecified gastrojejunal ulcer with hemorrhage, without mention of obstruction,Acute posthemorrhagic anemia,Chronic systolic heart failure,Thrombocytopenia, unspecified,Dehydration,Sarcoidosis,Atrial fibrillation,Acquired absence of organ, stomach,Depressive disorder, not elsewhere classified,Unspecified essential hypertension,Dieulafoy lesion (hemorrhagic) of stomach and duodenum,Knee joint replacement,Swelling of limb,Long-term (current) use of steroids'}


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: hematemesis

PRESENT ILLNESS: 86 yo F h/o HTN, sCHF, bleeding gastric ulcer s/p partial
gastrectomy [**2072**], sarcoidosis, afib not on coumadin, hematemesis
with anastamotic ulcer on EGD in [**2128**] p/w nausea and vomiting
last night.  She was in her usual state of health during the
day, went out for Chinese food for dinner around 5 pm.
Initially felt well afterwards, around 10 pm felt nauseated and
started vomiting.  Was up all night with abdominal pain and
nausea, vomited about five times last night.  This morning
around 6 am vomited bright red blood.  Not sure how much it was,
no coffee grounds.  Also may have had a dark stool this AM but
she is not sure.  Denies any diarrhea currently, but had
diarrhea last week.  She does get nauseated about once a week,
used to be followed in [**Hospital **] clinic for this and was thought to be
related to GERD and possible ulcer disease, has been on a [**Hospital1 **]
PPI and PRN promethazine at home, takes promethazine about
weekly.  Unable to take last night due to nausea.  No h/o liver
disease.  No h/o liver disease.  Denies chest pain, shortness of
breath, lightheadedness, joint pain, rashes, sick contacts.
.
In the ED, initial VS were HR 82, BP 162/98, RR 14, sat 99% 3L
NC.  EKG showed sinus rhythm 82 bpm, prolonged PR interval, PVCs
and new lateral ST depressions.  Pt given IV NS, protonix 80 mg
bolus and started on drip, zofran 4 mg, and morphine.  Pt
appeared dry on exam, rectal exam with no stool in the vault.
NG lavage not done given presence of bright red blood in vomit.
Hct 36 so no blood products were given, coags wnl. Access with
PIV x 2.  Received 2.5 L of IV NS.  GI called from [**Location **],
recommended EGD.  Admitted to ICU for active vomiting of blood
noted in ED.  VS on transfer temperature 97.8. HR 86 RR 20 BP
152/81, afib, sat 100% 2L.
.
On arrival to ICU, pt feels nauseated and abdominal pain in
lower part of abdomen which started last night as well,
nonradiating, feels like cramping.  No fever since episodes
started but did have a fever to 101 about 2 weeks ago for which
she was treated with amoxicillin.  Has had 4 episodes total of
blood in vomit, although unable to quantify amount of blood.
.
Review of systems:
(+) Per HPI, also + for cough for the last few weeks, recently
treated for presumed PNA with 10 day course of amoxicillin,
suspected that cough may be related to pulmonary sarcoidosis per
daughter
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, or wheezing. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
constipation.  Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.

MEDICAL HISTORY: 1. HTN
2. Hypercholesterolemia
3. systolic CHF, etiology unclear
4. Bleeding gastric ulcer s/p partial gastrectomy in [**2072**].
5. Hematemesis 6-7 years ago. No source was found on EGD.
6. Lap cholecystetomy in [**2124**] complicated by liver laceration
and PE
7. Post-op PE requiring brief intubation and s/p IVC filter and
anticoagulation in [**2124**]
8. S/p appendectomy
9. Iron deficiency anemia
10. OA of left knee requiring knee replacement
11. S/p fall complicated by displacement of anterior arch of C1

MEDICATION ON ADMISSION: alendronate 70 qweek
atenolol 25mg qam 50 qpm
dig 0.125 qd
lidoderm patch for back or knee
lisionpril 30mg qday
omeprazole 20mg [**Hospital1 **]
pravastatin 40mg qd
ropinirole 1mg qhs
effexor 150 mg qd
vit d
-allergies: ativan, compazine and advair

ALLERGIES: Ativan / Compazine

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: 98.7  HR 86 BP 143/74 sat 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, tacky mucous membranes, no
oropharyngeal lesions
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at bases bilaterally, no wheezes, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur best heard at apex
Abdomen: soft, mild ttp throughout, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Her father died of renal cancer; brother with lung cancer; no hx
of CAD; no hx of colon cancer.

SOCIAL HISTORY: - Tobacco: denies, prior 10 pack year history per OMR
- Alcohol:  denies currently, h/o EtOH abuse quit 35 years ago,
detox x 3 in the past
- Illicits:  pt denies, but per OMR h/o prescription drug abuse
(opiates) 

### Response:
{'Chronic or unspecified gastrojejunal ulcer with hemorrhage, without mention of obstruction,Acute posthemorrhagic anemia,Chronic systolic heart failure,Thrombocytopenia, unspecified,Dehydration,Sarcoidosis,Atrial fibrillation,Acquired absence of organ, stomach,Depressive disorder, not elsewhere classified,Unspecified essential hypertension,Dieulafoy lesion (hemorrhagic) of stomach and duodenum,Knee joint replacement,Swelling of limb,Long-term (current) use of steroids'}
