CHIEF COMPLAINT: bright red blood per rectum

PRESENT ILLNESS: 77 y.o female with extensive pmhx including afib not on
coumaidn, chf, ckd, mpd, hemorrhoidectomy in [**6-/2139**], lower GIB
in [**7-/2139**] s/p 19 units of pRBCs and superior rectal artery
embolization, now with recurrent lower GI bleeding.  Patient
fell at home on [**2140-1-5**] fracturing her right hip.  She underwent
total hip replacement on [**2140-1-8**] and since that time has been at
rehab.  She was started on coumadin post surgery for DVT
prophylaxis.  She has some epistaxis at [**Hospital3 **] and was
seen by ENT.  The epistaxis resolved with packing.  At rehab her
HCT was 28.8 on [**1-13**].5 on [**1-14**].6 on [**1-18**], and 27.8 on
[**1-19**].  Her rehab course was complicated by c. diff for which she
is currently taking PO vancomycin.  Four days ago she had a
bloodly bowel movement and anticoagulation was stopped.
Throughout the day today she was not feeling well and had chills
all day long.  Today at 7pm she started having large bloody
bowel movements with clots (500 cc of blood per reports).  She
did not have any abdominal pain, nausea, vomiting, hematemesis.
She has been having ongoing diarreha over the past several weeks
and has been diagnosed with c. diff.  Given BRBPR, pt was
started on IVF (NS at 60 cc per hour) was sent from rehab to
[**Hospital3 **].
.
At [**Hospital3 **] patient was tachycardiac to 140, had systolic
blood pressure of 130.  Her HCT was 25.5 at [**Hospital3 4107**].
She received 2L NS and 1 unit pRBCs prior to transfer.
.
On arrival to [**Hospital1 18**], BP was 118/61, HR 132. HCT was 25.  Exam
was notable for large blood clots per rectum. Patient received
1L NS, 2 units of FFP, and started 2 units pRBCs.  ED called
gastroenterology,
surgery and interventional radidology.  Patient with iodine
contrast allergy, so IR recommended tagged RBC scan overnight
with possible angio by IR in the morning.  Patient was started
on PPI drip and received solumedrol 125 mg IV x1 as part of
pre-medication for contrast administration given allergy.
Patient spiked fever to 100.5 in the ED.  Throughout ED course
HR ranged 120s - 160s (a. fib) and systolic blood pressure
ranged 110s - 130s.  Vitals on transfer are 136 131/56 23 99%
2L.
.
On arrival to the MICU, patient continues to pass clots of
bright red blood.  She denies abdominal pain.  She complains of
pain on her back at the site of her ulcer.  No nausea, vomiting.
 She complains that she feels short of breath and has orthopnea
(pt sleeps with 6 pillows at baseline), but thinks dyspnea is
slightly worse. Pt complains of fevers and chills.

MEDICAL HISTORY: CAD s/p RCA stent [**2-/2136**]
HTN
Hyperlipidemia
Afib off coumadin x 2 years due to bleeding
Chronic kidney disease
CHF with diastolic dysfunction but normal EF
GERD
pericardial effusion
pulmonary hypertension - right heart cath in [**2136**]
s/p TIA
depression
angina
pneumonia/bronchitis
gout
Anemia
Arthritis
Irritable Bowel Syndrome
Chronic Kidney Disease
OSA
Myeloproliferative disorder with leukocytosis
s/p TAH//BSO - reports R ovary explosion
s/p CCY and appendectomry
bilateral cataract surgery
left hip fracture s/p total hip replacement in [**1-17**]

MEDICATION ON ADMISSION: Vitamin b complex/vitamin c/folic acid 1 tab daily
allopurinol 300 mg PO daily
metoprolol tartrate 37.5 mg PO Q8H
atorvastatin 40 mg PO qHS
aspirin 81 mg daily
trazodone 25 mg PO QHS PRN
Ferrous sulfate 30 mg PO daily
Sevelamer 400 mg PO daily
Lidocaine 5% patch daily
Hydrocorticosone acetate 25 mg daily
magnesium hydroxide 30 mL daily PRN
Hydroxyurea 500 mg MWF
Vitamin d 800 units daily
Tiotropium bromide 18 mcg daily
Albuterol sulfate nebs Q6H PRN
Camphor/menthol Q8H apply to back
Ascorbic acid 500 mg daily
acetaminophen 975 mg TID
zinc sulfate 220 mg daily
lidocaine 2% jelly Q8H
Miconazole nitrate 2% Q8H apply to buttox
Vancomycin 250 mg Q6H (started [**1-19**])
Saccharomyces boulardii 500 mg [**Hospital1 **]
Trazodone 25 mg Q6H PRN
Fluoxetine 20 mg daily
esomeprazole 40 mg daily

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Codeine / Diazepam /
Benzodiazepines / Iodine

PHYSICAL EXAM: Vitals: T: 96.8 P: 156 P: 124/75 R: 29 O2: 91% on 3L
General: Alert & oriented x3, comfortable, tearful at times
HEENT: Sclera anicteric, pale conjunctiva, slightly dry mucus
membranes, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to mandible
CV: Tachy, irregular, S1, S2
Lungs: Clear to auscultation anteriorally
Abdomen: Soft, non-tender, non-distended, no rebound/guarding,
no masses
GU: foley catheter in place
Ext: warm, well perfused, left lower extremtiy shortened and
externally rotated, left calf wrapped in dressing which is
clean/dry/intact, no edema.
Neuro: CNII-XII intact

FAMILY HISTORY: Father had colitis. Granddaughter with ulcerative colitis.

SOCIAL HISTORY: Widowed and lives alone in [**Hospital3 4634**] in [**Location (un) 5110**], MA. In
rehab follolwing surgery for hip fracture repair on [**2140-1-8**]. 6
children and 17 grandchildren. Tobacco: [**1-8**] cig/day x 30 years,
quit many years ago. EtOH: social Illicits: none
Infection and inflammatory reaction due to internal joint prosthesis,Other septicemia due to gram-negative organisms,Acute kidney failure, unspecified,Toxic encephalopathy,Intestinal infection due to Clostridium difficile,Pressure ulcer, lower back,Acute on chronic diastolic heart failure,Severe sepsis,Hemorrhage of gastrointestinal tract, unspecified,Urinary tract infection, site not specified,Acute posthemorrhagic anemia,Paroxysmal ventricular tachycardia,Chronic airway obstruction, not elsewhere classified,Myelodysplastic syndrome, unspecified,Percutaneous transluminal coronary angioplasty status,Hip joint replacement,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Carrier or suspected carrier of other specified infectious organism,Other chronic pulmonary heart diseases,Other and unspecified angina pectoris
React-inter joint prost,Gram-neg septicemia NEC,Acute kidney failure NOS,Toxic encephalopathy,Int inf clstrdium dfcile,Pressure ulcer, low back,Ac on chr diast hrt fail,Severe sepsis,Gastrointest hemorr NOS,Urin tract infection NOS,Ac posthemorrhag anemia,Parox ventric tachycard,Chr airway obstruct NEC,Myelodysplastic synd NOS,Status-post ptca,Joint replaced hip,Abn react-artif implant,Carrier NEC,Chr pulmon heart dis NEC,Angina pectoris NEC/NOS
Admission Date:  [**2140-1-22**]              Discharge Date:   [**2140-2-4**]

Date of Birth:  [**2061-10-28**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Diazepam /
Benzodiazepines / Iodine

Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
bright red blood per rectum

Major Surgical or Invasive Procedure:
Peripherally inserted central catheter
.
1. Irrigation and debridement of left hip wound and the deep
tissue (soft tissue and muscle).
2. Aspiration of left hip (arthrocentesis).
3. Revision left hip hemiarthroplasty.
4. Wound revision left hip with complicated closure.
5. Application of negative pressure dressing (20 sq cm).

History of Present Illness:
77 y.o female with extensive pmhx including afib not on
coumaidn, chf, ckd, mpd, hemorrhoidectomy in [**6-/2139**], lower GIB
in [**7-/2139**] s/p 19 units of pRBCs and superior rectal artery
embolization, now with recurrent lower GI bleeding.  Patient
fell at home on [**2140-1-5**] fracturing her right hip.  She underwent
total hip replacement on [**2140-1-8**] and since that time has been at
rehab.  She was started on coumadin post surgery for DVT
prophylaxis.  She has some epistaxis at [**Hospital3 **] and was
seen by ENT.  The epistaxis resolved with packing.  At rehab her
HCT was 28.8 on [**1-13**].5 on [**1-14**].6 on [**1-18**], and 27.8 on
[**1-19**].  Her rehab course was complicated by c. diff for which she
is currently taking PO vancomycin.  Four days ago she had a
bloodly bowel movement and anticoagulation was stopped.
Throughout the day today she was not feeling well and had chills
all day long.  Today at 7pm she started having large bloody
bowel movements with clots (500 cc of blood per reports).  She
did not have any abdominal pain, nausea, vomiting, hematemesis.
She has been having ongoing diarreha over the past several weeks
and has been diagnosed with c. diff.  Given BRBPR, pt was
started on IVF (NS at 60 cc per hour) was sent from rehab to
[**Hospital3 **].
.
At [**Hospital3 **] patient was tachycardiac to 140, had systolic
blood pressure of 130.  Her HCT was 25.5 at [**Hospital3 4107**].
She received 2L NS and 1 unit pRBCs prior to transfer.
.
On arrival to [**Hospital1 18**], BP was 118/61, HR 132. HCT was 25.  Exam
was notable for large blood clots per rectum. Patient received
1L NS, 2 units of FFP, and started 2 units pRBCs.  ED called
gastroenterology,
surgery and interventional radidology.  Patient with iodine
contrast allergy, so IR recommended tagged RBC scan overnight
with possible angio by IR in the morning.  Patient was started
on PPI drip and received solumedrol 125 mg IV x1 as part of
pre-medication for contrast administration given allergy.
Patient spiked fever to 100.5 in the ED.  Throughout ED course
HR ranged 120s - 160s (a. fib) and systolic blood pressure
ranged 110s - 130s.  Vitals on transfer are 136 131/56 23 99%
2L.
.
On arrival to the MICU, patient continues to pass clots of
bright red blood.  She denies abdominal pain.  She complains of
pain on her back at the site of her ulcer.  No nausea, vomiting.
 She complains that she feels short of breath and has orthopnea
(pt sleeps with 6 pillows at baseline), but thinks dyspnea is
slightly worse. Pt complains of fevers and chills.


Past Medical History:
CAD s/p RCA stent [**2-/2136**]
HTN
Hyperlipidemia
Afib off coumadin x 2 years due to bleeding
Chronic kidney disease
CHF with diastolic dysfunction but normal EF
GERD
pericardial effusion
pulmonary hypertension - right heart cath in [**2136**]
s/p TIA
depression
angina
pneumonia/bronchitis
gout
Anemia
Arthritis
Irritable Bowel Syndrome
Chronic Kidney Disease
OSA
Myeloproliferative disorder with leukocytosis
s/p TAH//BSO - reports R ovary explosion
s/p CCY and appendectomry
bilateral cataract surgery
left hip fracture s/p total hip replacement in [**1-17**]


Social History:
Widowed and lives alone in [**Hospital3 4634**] in [**Location (un) 5110**], MA. In
rehab follolwing surgery for hip fracture repair on [**2140-1-8**]. 6
children and 17 grandchildren. Tobacco: [**1-8**] cig/day x 30 years,
quit many years ago. EtOH: social Illicits: none


Family History:
Father had colitis. Granddaughter with ulcerative colitis.


Physical Exam:
Vitals: T: 96.8 P: 156 P: 124/75 R: 29 O2: 91% on 3L
General: Alert & oriented x3, comfortable, tearful at times
HEENT: Sclera anicteric, pale conjunctiva, slightly dry mucus
membranes, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to mandible
CV: Tachy, irregular, S1, S2
Lungs: Clear to auscultation anteriorally
Abdomen: Soft, non-tender, non-distended, no rebound/guarding,
no masses
GU: foley catheter in place
Ext: warm, well perfused, left lower extremtiy shortened and
externally rotated, left calf wrapped in dressing which is
clean/dry/intact, no edema.
Neuro: CNII-XII intact


Pertinent Results:
TTE [**1-23**]: Cardiac rhythm is atrial fibrillation with an
uncontrolled ventricular rate. The left atrium is markedly
dilated. The right atrium is markedly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
small. LV function appears depressed due to uncontrolled
ventricular rate (the left ventricular ejection fraction during
beats following a normal diastolic filling period is normal).
There is beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated with borderline normal free wall function. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension. A
very small pericardial effusion is present (no tamponade).

Compared with the findings of the prior study (images reviewed)
of [**2137-5-2**], the pericardial effusion is smaller. Multiple
other significant structural and functional cardiac lesions
persist as noted above.
.
Tagged RBC Scan [**1-23**]: Hemorrhage beginning at 8 minutes. Oblique
positioning limits differentiation between sigmoid and cecum
however movement of tracer is suggestive of sigmoid colon.
.
IR Procedure [**1-23**]: 1. Unremarkable selective superior and
inferior mesenteric arteriograms.
2. Specifically, no angiographic evidence of active arterial
bleeding.


Brief Hospital Course:
77 y.o female with extensive pmhx including afib recently
anticoagulated s/p L hip replacement on [**1-8**], chf, ckd, mpd,
hemorrhoidectomy in [**6-/2139**], lower GIB in [**7-/2139**] s/p superior
rectal artery embolization, now with lower GI bleeding, Cdiff
infection, UTI and hip infection.
.
# Goals of care: Pt was transferred to the ICU on [**2140-2-2**] for
worsening altered mental status. Goals of care discussion was
addressed with the family prior to transfer, and pt was made
DNR/DNI, and transferred mostly for nursing care. On the morning
of [**2140-2-3**], the ICU team continued goals of care discussion.
Based on her progressive decline, and likely irreversibility of
her multiple conditions, family meeting was held with the pt's
son on [**2140-2-3**] with [**First Name5 (NamePattern1) 636**] [**Last Name (NamePattern1) 29286**] present. The decision was made
to focus on comfort, and pt was made CMO. Most medications,
including antibiotics, were discontinued, with only continuation
of medications for comfort, including antiemetics, pain
medications.  She was transferred back to the floor, and
remained on comfort-based medications with apparent good effect
until her passing on the evening of [**2140-2-4**].
.
The acute medical issues during her hospitalization were as
follows:
# GI Bleeding: Patient presented with massive amount of lower GI
bleeding, passing massive amount of large bright red clots.
Patient had a history of diverticular disease and known
hemorrhoidal disease as well as a lower GIB in [**2139-7-6**]
requiring a total of 18 units pRBCs. At that time she underwent
coiling of her right superior rectal artery with resolution of
bleeding. Patient underwent tagged RBC scan which identified the
source of the bleeding as the sigmoid colon but no bleeding was
seen on subsequent IR imaging so no interventions were
performed. Her bleeding improved and her stools became dark
indicating old blood. She required a total of 9 units of blood
during this hospital stay. Patient remained hemodynamically
stable throughout her bleeding episode, never requiring
pressors. Protonix gtt was discontinued as her bleeding source
was almost definitively from a lower source. She had no further
episodes of acute bleeding during her stay and her hematocrits
remained stable
.
# Hip Infection: Patient underwent left-sided hip replacement on
[**1-8**] at [**Hospital3 **]. Swelling at the surgical site had been
noted at rehab and was again noted here. The wound looked
infected and was healing poorly so she was taken to the OR on
[**1-24**] for wound dehiscence and two infected collections were
seen, one superficial and one deep. Vacs were applied and the
prosthesis was changed. Both were found to be growing Proteus
and Enterococcus (same organisms as the urine). Infectious
disease was consulted who recommended IV ceftriaxone and IV
vancomycin, which was later narrowed to ampcillin monotherapy.
.
# Lethargy: Patient's mental status on transfer out of the MICU
was interactive, awake, and generally oriented x3.  During her
stay on the floor, her mental status deteriorated to the point
of unresponsiveness on [**2-2**], despite not having been given any
sedating medications for several days.  CT head was negative,
and VBG did not reveal significant hypercapnia.  Toxic metabolic
insults such as [**Last Name (un) **], multiple infections, and persistent
tachycardia for days were thought to be potential precipitants
for somnolence.  She developed signs of respiratory depression
and hypopnea, which prompted transfer to the MICU.  From there,
her goals of care were transitioned to comfort-focused care, as
discussed above.
.
# C. diff infection: Patient with report of c. diff infection
from rehab.  Has had ongoing diarrhea over the past several
weeks.  Started on PO vancomycin on [**2140-1-19**], which was continued
during her stay. Patient was passing pseudomembranes in stool
here so was started on IV flagyl on [**1-23**]. IV flagyl was d/c'ed
for one day with return of her diarrhea so she was continued on
double therapy through [**1-30**]. Course will be for at least two
weeks after patient is off antibiotic therapy for her hip
infection.  Flexiseal was removed, then later replaced on [**2-1**],
when diarrhea became less formed and more liquid, to help
protect the patient's unstageable decubitus ulcer.
.
# Atrial fibrillation with RVR: Patient with baseline heart
rates in the 110s but were more elevated here, persistently in
the 120s - 140s. Triggers felt to be infection, bleed, and
hypovolemia. After initial bleed subsided, she was restarted on
her home beta-blocker and her rates were well-controlled for
some time.  on [**4-8**], her tachycardia to 140s became more
persistent, and pt required frequent bolus doses of IV
metoprolol to keep her HR below 130s.  She was kept off
anticoagulation during her stay, given her GI bleed.
.
# Urinary Tract Infection: Patient had no complaints of dysuria
but had a history of Proteus UTI at rehab. Found to have proteus
and enterococcus in her urine here. Per ID, her skin is likely
colonized with these organisms. Antibiotics discussed above.
.
# [**Last Name (un) **]: Creatinine fluctuated early in hospitalization, then
later steadily trended upwards.  Her creatinine worsened with
both volume resuscitation and diuresis.  Urine lytes were
consistent with intravascular volume depletion.
.
# Diastolic CHF: Patient with history of diastolic CHF,
previously on 120 mg of lasix daily, but has not been on lasix
as per rehab records.  Patient initially very symptomatic from
CHF with dyspnea and orthopnea. TTE during this admission showed
severe MR [**First Name (Titles) **] [**Last Name (Titles) **], and likely depressed systolic function, which
was difficult to quantify, given rapid heart rate. She was
gently diuresed as her blood pressures would tolerate.
.
# Leukocytosis: Patient with known MDS and baseline WBC ranging
between 10 - 20,000.  Patient with leukocytosis to 40,000 on
admission, neutrophil predominant that rose to 50,000 during
this hospital stay before trending down. Leukocytosis was
attributed to patient's many sources of infection including
ongoing C.diff, UTI, and hip infection.
.
# CAD: Pt with known CAD s/p RCA stent. Patient complained of
chest pain on [**1-26**] and [**1-27**] without concurrent EKG changes.
Patient stated the pain was similar to her "heart attack" pain.
She responded to SL nitro and morphine. Her troponin was
slightly elevated from baseline (0.05) but CK and CK MB remained
flat and serial enzymes showed downtrending troponin. She was
continued on atorvastatin 40 mg PO and restarted her daily baby
aspirin.
.
# COPD: Continue tiotropium bromide 18 mcg daily and Albuterol
sulfate nebs Q6H PRN.
.
# MDS:  Continue Hydroxyurea 500 mg MWF
.
# Depression: Pt was continued on fluoxetine 20 mg daily

Medications on Admission:
Vitamin b complex/vitamin c/folic acid 1 tab daily
allopurinol 300 mg PO daily
metoprolol tartrate 37.5 mg PO Q8H
atorvastatin 40 mg PO qHS
aspirin 81 mg daily
trazodone 25 mg PO QHS PRN
Ferrous sulfate 30 mg PO daily
Sevelamer 400 mg PO daily
Lidocaine 5% patch daily
Hydrocorticosone acetate 25 mg daily
magnesium hydroxide 30 mL daily PRN
Hydroxyurea 500 mg MWF
Vitamin d 800 units daily
Tiotropium bromide 18 mcg daily
Albuterol sulfate nebs Q6H PRN
Camphor/menthol Q8H apply to back
Ascorbic acid 500 mg daily
acetaminophen 975 mg TID
zinc sulfate 220 mg daily
lidocaine 2% jelly Q8H
Miconazole nitrate 2% Q8H apply to buttox
Vancomycin 250 mg Q6H (started [**1-19**])
Saccharomyces boulardii 500 mg [**Hospital1 **]
Trazodone 25 mg Q6H PRN
Fluoxetine 20 mg daily
esomeprazole 40 mg daily


Discharge Medications:
n/a - deceased

Discharge Disposition:
Expired

Discharge Diagnosis:
Lower intestinal bleed, clostridium difficile infection. septic
left hip joint


Discharge Condition:
deceased

Discharge Instructions:
deceased

Followup Instructions:
deceased
{'Infection and inflammatory reaction due to internal joint prosthesis,Other septicemia due to gram-negative organisms,Acute kidney failure, unspecified,Toxic encephalopathy,Intestinal infection due to Clostridium difficile,Pressure ulcer, lower back,Acute on chronic diastolic heart failure,Severe sepsis,Hemorrhage of gastrointestinal tract, unspecified,Urinary tract infection, site not specified,Acute posthemorrhagic anemia,Paroxysmal ventricular tachycardia,Chronic airway obstruction, not elsewhere classified,Myelodysplastic syndrome, unspecified,Percutaneous transluminal coronary angioplasty status,Hip joint replacement,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Carrier or suspected carrier of other specified infectious organism,Other chronic pulmonary heart diseases,Other and unspecified angina pectoris'}


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: bright red blood per rectum

PRESENT ILLNESS: 77 y.o female with extensive pmhx including afib not on
coumaidn, chf, ckd, mpd, hemorrhoidectomy in [**6-/2139**], lower GIB
in [**7-/2139**] s/p 19 units of pRBCs and superior rectal artery
embolization, now with recurrent lower GI bleeding.  Patient
fell at home on [**2140-1-5**] fracturing her right hip.  She underwent
total hip replacement on [**2140-1-8**] and since that time has been at
rehab.  She was started on coumadin post surgery for DVT
prophylaxis.  She has some epistaxis at [**Hospital3 **] and was
seen by ENT.  The epistaxis resolved with packing.  At rehab her
HCT was 28.8 on [**1-13**].5 on [**1-14**].6 on [**1-18**], and 27.8 on
[**1-19**].  Her rehab course was complicated by c. diff for which she
is currently taking PO vancomycin.  Four days ago she had a
bloodly bowel movement and anticoagulation was stopped.
Throughout the day today she was not feeling well and had chills
all day long.  Today at 7pm she started having large bloody
bowel movements with clots (500 cc of blood per reports).  She
did not have any abdominal pain, nausea, vomiting, hematemesis.
She has been having ongoing diarreha over the past several weeks
and has been diagnosed with c. diff.  Given BRBPR, pt was
started on IVF (NS at 60 cc per hour) was sent from rehab to
[**Hospital3 **].
.
At [**Hospital3 **] patient was tachycardiac to 140, had systolic
blood pressure of 130.  Her HCT was 25.5 at [**Hospital3 4107**].
She received 2L NS and 1 unit pRBCs prior to transfer.
.
On arrival to [**Hospital1 18**], BP was 118/61, HR 132. HCT was 25.  Exam
was notable for large blood clots per rectum. Patient received
1L NS, 2 units of FFP, and started 2 units pRBCs.  ED called
gastroenterology,
surgery and interventional radidology.  Patient with iodine
contrast allergy, so IR recommended tagged RBC scan overnight
with possible angio by IR in the morning.  Patient was started
on PPI drip and received solumedrol 125 mg IV x1 as part of
pre-medication for contrast administration given allergy.
Patient spiked fever to 100.5 in the ED.  Throughout ED course
HR ranged 120s - 160s (a. fib) and systolic blood pressure
ranged 110s - 130s.  Vitals on transfer are 136 131/56 23 99%
2L.
.
On arrival to the MICU, patient continues to pass clots of
bright red blood.  She denies abdominal pain.  She complains of
pain on her back at the site of her ulcer.  No nausea, vomiting.
 She complains that she feels short of breath and has orthopnea
(pt sleeps with 6 pillows at baseline), but thinks dyspnea is
slightly worse. Pt complains of fevers and chills.

MEDICAL HISTORY: CAD s/p RCA stent [**2-/2136**]
HTN
Hyperlipidemia
Afib off coumadin x 2 years due to bleeding
Chronic kidney disease
CHF with diastolic dysfunction but normal EF
GERD
pericardial effusion
pulmonary hypertension - right heart cath in [**2136**]
s/p TIA
depression
angina
pneumonia/bronchitis
gout
Anemia
Arthritis
Irritable Bowel Syndrome
Chronic Kidney Disease
OSA
Myeloproliferative disorder with leukocytosis
s/p TAH//BSO - reports R ovary explosion
s/p CCY and appendectomry
bilateral cataract surgery
left hip fracture s/p total hip replacement in [**1-17**]

MEDICATION ON ADMISSION: Vitamin b complex/vitamin c/folic acid 1 tab daily
allopurinol 300 mg PO daily
metoprolol tartrate 37.5 mg PO Q8H
atorvastatin 40 mg PO qHS
aspirin 81 mg daily
trazodone 25 mg PO QHS PRN
Ferrous sulfate 30 mg PO daily
Sevelamer 400 mg PO daily
Lidocaine 5% patch daily
Hydrocorticosone acetate 25 mg daily
magnesium hydroxide 30 mL daily PRN
Hydroxyurea 500 mg MWF
Vitamin d 800 units daily
Tiotropium bromide 18 mcg daily
Albuterol sulfate nebs Q6H PRN
Camphor/menthol Q8H apply to back
Ascorbic acid 500 mg daily
acetaminophen 975 mg TID
zinc sulfate 220 mg daily
lidocaine 2% jelly Q8H
Miconazole nitrate 2% Q8H apply to buttox
Vancomycin 250 mg Q6H (started [**1-19**])
Saccharomyces boulardii 500 mg [**Hospital1 **]
Trazodone 25 mg Q6H PRN
Fluoxetine 20 mg daily
esomeprazole 40 mg daily

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Codeine / Diazepam /
Benzodiazepines / Iodine

PHYSICAL EXAM: Vitals: T: 96.8 P: 156 P: 124/75 R: 29 O2: 91% on 3L
General: Alert & oriented x3, comfortable, tearful at times
HEENT: Sclera anicteric, pale conjunctiva, slightly dry mucus
membranes, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to mandible
CV: Tachy, irregular, S1, S2
Lungs: Clear to auscultation anteriorally
Abdomen: Soft, non-tender, non-distended, no rebound/guarding,
no masses
GU: foley catheter in place
Ext: warm, well perfused, left lower extremtiy shortened and
externally rotated, left calf wrapped in dressing which is
clean/dry/intact, no edema.
Neuro: CNII-XII intact

FAMILY HISTORY: Father had colitis. Granddaughter with ulcerative colitis.

SOCIAL HISTORY: Widowed and lives alone in [**Hospital3 4634**] in [**Location (un) 5110**], MA. In
rehab follolwing surgery for hip fracture repair on [**2140-1-8**]. 6
children and 17 grandchildren. Tobacco: [**1-8**] cig/day x 30 years,
quit many years ago. EtOH: social Illicits: none 

### Response:
{'Infection and inflammatory reaction due to internal joint prosthesis,Other septicemia due to gram-negative organisms,Acute kidney failure, unspecified,Toxic encephalopathy,Intestinal infection due to Clostridium difficile,Pressure ulcer, lower back,Acute on chronic diastolic heart failure,Severe sepsis,Hemorrhage of gastrointestinal tract, unspecified,Urinary tract infection, site not specified,Acute posthemorrhagic anemia,Paroxysmal ventricular tachycardia,Chronic airway obstruction, not elsewhere classified,Myelodysplastic syndrome, unspecified,Percutaneous transluminal coronary angioplasty status,Hip joint replacement,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Carrier or suspected carrier of other specified infectious organism,Other chronic pulmonary heart diseases,Other and unspecified angina pectoris'}
