CHIEF COMPLAINT: GI bleeding

PRESENT ILLNESS: This is a 69 year-old Female with a PMH significant for chronic
obstructive pulmonary disease (on home oxygen supplementation),
coronary artery disease (s/p silent MI previosuly), non-insulin
dependent diabetes mellitus, peripheral artery disease and
diverticulosis, known hiatal hernia who presents with bright red
blood per rectum.
.
The patinent presented to [**Hospital3 **] 1-week prior with the
onset of shortness of breath. She was initially presumed to be
having a COPD exacerbation and recveived steroids, nebulizers
and oxygen treatments with subsequent improvement and discharge
to a skilled nursing facility. At the facility, she was noted to
have grossly blood stools mixed with melena in the AM on [**2161-8-14**]
(at 2AM) associated with hypotension. She denied
lightheadedness, dizziness or palpitations. She had no nausea,
emesis or abdominal pain. She had no cough, respiratory symptoms
or hematemesis. She returned to the [**Hospital3 **] ED and was
noted to have a hemoglobin of 7.2 g/dL (significant decline from
baseline). She recived 1 unit of packed red cells and 1.5L of
normal saline prior to transfer. She has been on prophylactic
Lovenox and ASA. She denies recent NSAID use.
.
Of note, her last colonoscopy and EGD were 1-year prior and at
that time noted evidence of diverticulosis. She reports that she
has been admitted to [**Hospital3 **] almost annually with
similar bleeding concerns and each endoscopy reveals resolved
bleeding with a presumed divericular source.
.
In the [**Hospital1 18**] ED upon transfer, initial VS 100.0 56 98/42 16 96%
RA. Her exam was notable for a moderate amount of maroon colored
diarrhea per rectum. Laboratory data noted a WBC 6.9, hemoglobin
9.5, hematocrit 30.9%, platelets 204 and INR 1.2. LFTs were
reassuring. A 22-gauge, 20-gauge and two 18-gauge peripherals
were established for IV access. She received 1L NS x 1 in the ED
and 1 unit of pRBCs. GI and General Surgery were consulted and
agreed with MICU transfer.
.
On arrival to the MICU, she was mentating well without abdominal
pain and appears stable. She was treated and stabilized in the
ICU before being transitioned to the hospital medicine service
for ongoing management.  She underwent an attempt at
colonoscopy, although the preparation was not felt to be
adequate to effectively rule out focal GI pathology. No upper GI
pathology was noted on endoscopy.

MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease (on 2L NC home oxygen)
2. Coronary artery disease (status-post silent MI without
stenting; on ASA for secondary prevention; had MI over 15 years
prior and recent pharmacologic stress testing was reassuring)
3. History of hiatal hernia
4. History of diverticulosis
5. Peripheral artery disease
6. Non-insulin dependent diabetes mellitus
7. Hyperlipidemia
8. GERD, reflux esophagitis

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Atenolol 25 mg PO DAILY
2. Pregabalin 150 mg PO BID
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Simvastatin 40 mg PO HS
5. Tiotropium Bromide 1 CAP IH DAILY
6. Aspirin 81 mg PO QPM
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
9. Ranitidine 150 mg PO HS
10. Omeprazole 20 mg PO DAILY
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
12. calcium polycarbophil *NF* 1300  Oral [**Hospital1 **]
13. Requip *NF* (rOPINIRole) 3 mg Oral [**Hospital1 **]
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
every 5 minutes
15. Isosorbide Mononitrate 30 mg PO DAILY

ALLERGIES: tetnus / Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: #ADMISSION PHYSICAL EXAM
VITALS:  98.0  59  113/52  16  97% 2L NC
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD unable to assess given
habitus.
CVS: Regular rate and rhythm, II/VI early systolic murmur,
without rubs or gallops. S1 and S2 normal.
RESP: End expiratory wheezing in the bilateral bases. No rhonchi
or crackles. Stable inspiratory effort.
ABD: soft, obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; bilateral 1+ edema to the
mid-shins, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally, sensation grossly
intact. Gait deferred.
RECTAL: external peri-anal region without lesions, skin tags or
fissures. Digital exam reveals normal tone. No masses or
internal hemorrhoids. Bleeding noted on finger mixed with
melenic maroon-colored stool.

FAMILY HISTORY: Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Mother died of
liver cancer at age 63 years.

SOCIAL HISTORY: Patient lives at home with her husband and has 6 children.
Denies tobacco use currently (quit 6 days prior); prior to that
has a 50 pack-year history; denies alcohol use; no recreational
substance use. Patient is independent in ADLs and ambulates
unassisted. Worked at Stop-and-Shop as a cashier.
Diverticulosis of colon with hemorrhage,Chronic airway obstruction, not elsewhere classified,Other dependence on machines, supplemental oxygen,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Other and unspecified hyperlipidemia,Diaphragmatic hernia without mention of obstruction or gangrene,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Peripheral vascular disease, unspecified,Esophageal reflux
Dvrtclo colon w hmrhg,Chr airway obstruct NEC,Depend-supplement oxygen,Crnry athrscl natve vssl,Old myocardial infarct,Hyperlipidemia NEC/NOS,Diaphragmatic hernia,DMII wo cmp nt st uncntr,Periph vascular dis NOS,Esophageal reflux
Admission Date:  [**2161-8-14**]              Discharge Date:   [**2161-8-18**]

Date of Birth:  [**2091-12-8**]             Sex:   F

Service: MEDICINE

Allergies:
tetnus / Sulfa(Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
GI bleeding

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is a 69 year-old Female with a PMH significant for chronic
obstructive pulmonary disease (on home oxygen supplementation),
coronary artery disease (s/p silent MI previosuly), non-insulin
dependent diabetes mellitus, peripheral artery disease and
diverticulosis, known hiatal hernia who presents with bright red
blood per rectum.
.
The patinent presented to [**Hospital3 **] 1-week prior with the
onset of shortness of breath. She was initially presumed to be
having a COPD exacerbation and recveived steroids, nebulizers
and oxygen treatments with subsequent improvement and discharge
to a skilled nursing facility. At the facility, she was noted to
have grossly blood stools mixed with melena in the AM on [**2161-8-14**]
(at 2AM) associated with hypotension. She denied
lightheadedness, dizziness or palpitations. She had no nausea,
emesis or abdominal pain. She had no cough, respiratory symptoms
or hematemesis. She returned to the [**Hospital3 **] ED and was
noted to have a hemoglobin of 7.2 g/dL (significant decline from
baseline). She recived 1 unit of packed red cells and 1.5L of
normal saline prior to transfer. She has been on prophylactic
Lovenox and ASA. She denies recent NSAID use.
.
Of note, her last colonoscopy and EGD were 1-year prior and at
that time noted evidence of diverticulosis. She reports that she
has been admitted to [**Hospital3 **] almost annually with
similar bleeding concerns and each endoscopy reveals resolved
bleeding with a presumed divericular source.
.
In the [**Hospital1 18**] ED upon transfer, initial VS 100.0 56 98/42 16 96%
RA. Her exam was notable for a moderate amount of maroon colored
diarrhea per rectum. Laboratory data noted a WBC 6.9, hemoglobin
9.5, hematocrit 30.9%, platelets 204 and INR 1.2. LFTs were
reassuring. A 22-gauge, 20-gauge and two 18-gauge peripherals
were established for IV access. She received 1L NS x 1 in the ED
and 1 unit of pRBCs. GI and General Surgery were consulted and
agreed with MICU transfer.
.
On arrival to the MICU, she was mentating well without abdominal
pain and appears stable. She was treated and stabilized in the
ICU before being transitioned to the hospital medicine service
for ongoing management.  She underwent an attempt at
colonoscopy, although the preparation was not felt to be
adequate to effectively rule out focal GI pathology. No upper GI
pathology was noted on endoscopy.

Past Medical History:
1. Chronic obstructive pulmonary disease (on 2L NC home oxygen)
2. Coronary artery disease (status-post silent MI without
stenting; on ASA for secondary prevention; had MI over 15 years
prior and recent pharmacologic stress testing was reassuring)
3. History of hiatal hernia
4. History of diverticulosis
5. Peripheral artery disease
6. Non-insulin dependent diabetes mellitus
7. Hyperlipidemia
8. GERD, reflux esophagitis


Social History:
Patient lives at home with her husband and has 6 children.
Denies tobacco use currently (quit 6 days prior); prior to that
has a 50 pack-year history; denies alcohol use; no recreational
substance use. Patient is independent in ADLs and ambulates
unassisted. Worked at Stop-and-Shop as a cashier.

Family History:
Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Mother died of
liver cancer at age 63 years.

Physical Exam:
#ADMISSION PHYSICAL EXAM
VITALS:  98.0  59  113/52  16  97% 2L NC
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD unable to assess given
habitus.
CVS: Regular rate and rhythm, II/VI early systolic murmur,
without rubs or gallops. S1 and S2 normal.
RESP: End expiratory wheezing in the bilateral bases. No rhonchi
or crackles. Stable inspiratory effort.
ABD: soft, obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; bilateral 1+ edema to the
mid-shins, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally, sensation grossly
intact. Gait deferred.
RECTAL: external peri-anal region without lesions, skin tags or
fissures. Digital exam reveals normal tone. No masses or
internal hemorrhoids. Bleeding noted on finger mixed with
melenic maroon-colored stool.

#DISCHARGE PHYSICAL EXAM:
VITALS:  T 99.1, HR 62, BP 118/52, RR 22, O2 sat 93% 2L NC.
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD unable to assess given
habitus.
CVS: Regular rate and rhythm, II/VI early systolic murmur,
without rubs or gallops. S1 and S2 normal.
RESP: End expiratory wheezing in the bilateral bases. No rhonchi
or crackles. Stable inspiratory effort.
ABD: soft, obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; bilateral 1+ edema to the
mid-shins, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally, sensation grossly
intact. Gait deferred.


Pertinent Results:
#ADMISSION LABS:
[**2161-8-14**] 02:12PM   PT-12.5 PTT-23.8* INR(PT)-1.2*
[**2161-8-14**] 02:12PM   PLT COUNT-204
[**2161-8-14**] 02:12PM   NEUTS-82.1* LYMPHS-13.9* MONOS-3.8 EOS-0.2
BASOS-0.1
[**2161-8-14**] 02:12PM   WBC-6.9 RBC-3.39* HGB-9.5* HCT-30.9* MCV-91
MCH-28.1 MCHC-30.8* RDW-16.3*
[**2161-8-14**] 02:12PM   ALBUMIN-2.7*
[**2161-8-14**] 02:12PM   ALT(SGPT)-18 AST(SGOT)-13 LD(LDH)-136 ALK
PHOS-30* TOT BILI-0.3
[**2161-8-14**] 08:23PM   PLT COUNT-235
[**2161-8-14**] 08:23PM   WBC-11.2*# RBC-3.82* HGB-10.4* HCT-34.1*
MCV-89 MCH-27.2 MCHC-30.5* RDW-16.7*
[**2161-8-14**] 08:23PM   CALCIUM-7.5* PHOSPHATE-3.3 MAGNESIUM-1.8
[**2161-8-14**] 08:23PM   estGFR-Using this
[**2161-8-14**] 08:23PM   GLUCOSE-79 UREA N-41* CREAT-0.9 SODIUM-144
POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-32 ANION GAP-7*

#PERTINENT/DISCHARGE LABS:
[**2161-8-18**] 01:00PM BLOOD WBC-12.6* RBC-3.48* Hgb-9.6* Hct-31.4*
MCV-90 MCH-27.7 MCHC-30.7* RDW-17.2* Plt Ct-214
[**2161-8-18**] 06:10AM BLOOD WBC-12.3* RBC-3.47* Hgb-9.5* Hct-31.3*
MCV-90 MCH-27.5 MCHC-30.5* RDW-17.1* Plt Ct-195
[**2161-8-17**] 02:27AM BLOOD WBC-12.1* RBC-3.67* Hgb-10.2* Hct-32.8*
MCV-89 MCH-27.9 MCHC-31.2 RDW-16.7* Plt Ct-193
[**2161-8-16**] 02:00AM BLOOD WBC-11.7* RBC-3.77* Hgb-10.3* Hct-33.2*
MCV-88 MCH-27.4 MCHC-31.1 RDW-16.7* Plt Ct-202
[**2161-8-15**] 08:50AM BLOOD Neuts-70.8* Lymphs-24.7 Monos-3.9 Eos-0.4
Baso-0.2
[**2161-8-17**] 02:27AM BLOOD PT-11.9 PTT-25.6 INR(PT)-1.1
[**2161-8-16**] 02:00AM BLOOD PT-11.4 INR(PT)-1.1
[**2161-8-15**] 08:50AM BLOOD PT-11.9 PTT-20.3* INR(PT)-1.1
[**2161-8-18**] 06:10AM BLOOD Glucose-90 UreaN-12 Creat-0.6 Na-145
K-3.9 Cl-103 HCO3-34* AnGap-12
[**2161-8-17**] 02:27AM BLOOD Glucose-110* UreaN-19 Creat-0.8 Na-145
K-4.1 Cl-105 HCO3-36* AnGap-8
[**2161-8-16**] 02:00AM BLOOD Glucose-89 UreaN-32* Creat-0.9 Na-145
K-4.2 Cl-108 HCO3-35* AnGap-6*
[**2161-8-16**] 02:00AM BLOOD ALT-19 AST-15 AlkPhos-34* TotBili-0.4
[**2161-8-18**] 06:10AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.9
[**2161-8-17**] 02:27AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.8
[**2161-8-16**] 02:00AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.9

#MICROBIOLOGY:
[**2161-8-14**] 6:32 pm MRSA SCREEN      Source: Nasal swab.
                            **FINAL REPORT [**2161-8-17**]**
   MRSA SCREEN (Final [**2161-8-17**]):    No MRSA isolated.

#IMAGING:
[]CXR [**2161-8-15**]: The lungs are hyperinflated, consistent with COPD.
 The heart is likely enlarged.  The aorta is calcified and
unfolded.  There is upper zone redistribution, but I doubt overt
CHF.  No gross effusion.  No frank consolidation.  Probable
minimal atelectasis at both bases.

[]TTE [**2161-8-17**]: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is high (>4.0L/min/m2). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild
pulmonary artery hypertension. Dilated ascending aorta.

#PROCEDURES:
[][**2161-8-17**] EGD
Findings: Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Recommendations: Follow-up with the inpatient GI team for
further recommendations.


Brief Hospital Course:
[]BRIEF CLINICAL HISTORY:
69 yo F with a PMH significant for obstructive pulmonary disease
(on home oxygen supplementation), coronary artery disease (s/p
silent MI previosuly), non-insulin dependent diabetes mellitus,
peripheral artery disease and diverticulosis, known hiatal
hernia who presents with hematochezia mixed with melena and
symptomatic anemia, who improved after 2U blood transfusion.
She had a brief stay in the MICU for GIB and hypotension to ~80s
systolic.  While in the MICU she had a TTE and an EGD done, both
normal.  Her hematocrit stabilized and she was transferred to
the inpatient medicine floor.  Patient had an attempt at
colonoscopy in house to evaluate for presumed diverticulosis,
but following an inadequate preparation for the first attempt,
she deferred further attempts during this admission. As she had
stopped actively bleeding, this was felt to be a reasonable
option, and she was encouraged to pursue a formal repeat
colonoscopy as an outpatient through her outpatient team.

[]ACTIVE ISSUES:
# GASTROINTESTINAL BLEEDING - Patient presents with known
history of diverticulosis on prior colonoscopy and hiatal hernia
on ASA for secondary prevention of MI and now presenting with
acute onset of bright red blood per rectum with melanotic stools
with subsequent hemodynamic instability. A lower GI source is
suspected at this time. Etiologies would include diverticular
bleeding, angiodysplasia or vascular malformations, malignancy
(although prior colonoscopy was 1-year prior makes this less
likely), or colonic ischemia. Of note, she has multiple prior
admissions to OSH for diverticular bleeding seen on colonoscopy.
No significant abdominal pain, NSAID use, nausea or emesis to
point towards an upper GI source. NG lavage deferred in the ED.
Patient had EGD on [**2161-8-17**], normal, no biopsies were done.
.
# CHRONIC OBSTRUCTIVE PULMONARY DISEASE - Stable COPD with home
oxygen requirement. Recent acute exacerbation with resolution.
Lungs stable on exam with end expiratory wheezing; oxygen status
stable. Home regimen includes nebulizers, albuterol and
tiotropium inhalers with fluticasone-salmeterol. CXR from [**2161-8-14**]
c/w COPD with hyperinflated lungs, no evidence of consolidation
or overt CHF. The patient was kept on 2L O2 NC which is her
baseline O2 requirement, and we continued her home nebulizer
treatments along with inhalers. She had a mild minimally
productive cough that was treated symptomatically with
robitussin and showed no evidence of acute pulmonary infection.

.
# NON-INSULIN DEPENDENT DIABETES MELLITUS - Carries a diagnosis
of diabets mellitus, on oral hypoglycemics. No history of
retinopathy, nephropathy or neuropathy.  During her
hospitalization, her home oral hypoglycemics were held and she
was kept on an insulin sliding scale.  She required modest
amounts of insulin and had no hypo or hyperglycemic events.
.
# CORONARY ARTERY DISEASE - Remote history of silent MI without
recent cardiac cath or stenting intervention; pharmcologic
stress testing reassuring in the past year, per report. No acute
anginal symptoms in the setting of this GI bleeding episode.
Denies chest pain or exertional dyspnea. Her ASA and atenolol
were held on admission in the setting of a GI bleed, in addition
to her isosorbide mononitrate.  Prior to discharge, we restarted
her ASA given the stability in her blood counts and discussion
with GI, as well as cardiac risk factors.

# GERD, ESOHPAGEAL REFLUX - we continued the patient on home
regimen of Omeprazole and Ranitidine.
.
# HYPERLIPIDEMIA - We continued the patient on her home dose of
Simvastatin 40 mg PO daily.

[]TRANSITIONAL ISSUES:
-patient restarted on atenolol and ASA; VNA will monitor
hemodynamics and consult with PCP if there are any issues.
-patient will follow up with PCP and GI later this month; plan
for f/u colonoscopy as an outpatient, as the patient deferred
further inpatient procedures at this time following the initial
attempt.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Atenolol 25 mg PO DAILY
2. Pregabalin 150 mg PO BID
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Simvastatin 40 mg PO HS
5. Tiotropium Bromide 1 CAP IH DAILY
6. Aspirin 81 mg PO QPM
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
9. Ranitidine 150 mg PO HS
10. Omeprazole 20 mg PO DAILY
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
12. calcium polycarbophil *NF* 1300  Oral [**Hospital1 **]
13. Requip *NF* (rOPINIRole) 3 mg Oral [**Hospital1 **]
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
every 5 minutes
15. Isosorbide Mononitrate 30 mg PO DAILY


Discharge Medications:
1. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
3. Omeprazole 20 mg PO DAILY
4. Pregabalin 150 mg PO BID
5. Ranitidine 150 mg PO HS
6. Requip *NF* (rOPINIRole) 3 mg Oral [**Hospital1 **]
7. Simvastatin 40 mg PO HS
8. Tiotropium Bromide 1 CAP IH DAILY
9. Furosemide 20 mg PO QAM
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
11. calcium polycarbophil *NF* 1300  Oral [**Hospital1 **]
12. Isosorbide Mononitrate 30 mg PO DAILY
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
every 5 minutes
15. Aspirin 81 mg PO QPM
16. Atenolol 25 mg PO DAILY


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Diverticulosis


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Mrs. [**Known lastname **],

It was a pleasure taking care of you.

You were admitted to the [**Hospital1 69**]
for blood in your stools.  You were seen by the
gastro-intestinal doctors and the [**Name5 (PTitle) **] surgery doctors and it
was felt that you would do best with more intensive monitoring
in the ICU.  You were given intravenous fluids, a unit of blood,
and you were stabilized before being transfered to the regular
medicine inpatient unit.  You had an ultrasound of your heart,
and the GI doctors looked in the top of your gastro intestinal
tract with a scope and found nothing abnormal.  You will follow
up with the GI doctors with the [**Name5 (PTitle) **] to do a colonoscopy as an
outpatient.  We wish you and your family the best.

Followup Instructions:
Name: [**Last Name (LF) 61898**],[**First Name3 (LF) 278**] T.
Specialty: Primary Care
When: Wednesday [**9-1**] at 2pm
Location: COMMUNITY PHYSICIANS ASSOCIATES, INC.
Address: [**Street Address(2) 4472**] [**Apartment Address(1) 19251**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 61899**]

Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD
Specialty: Gastroenterology
When: Tuesday [**9-8**] at 2:15pm
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 682**]
{'Diverticulosis of colon with hemorrhage,Chronic airway obstruction, not elsewhere classified,Other dependence on machines, supplemental oxygen,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Other and unspecified hyperlipidemia,Diaphragmatic hernia without mention of obstruction or gangrene,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Peripheral vascular disease, unspecified,Esophageal reflux'}


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: GI bleeding

PRESENT ILLNESS: This is a 69 year-old Female with a PMH significant for chronic
obstructive pulmonary disease (on home oxygen supplementation),
coronary artery disease (s/p silent MI previosuly), non-insulin
dependent diabetes mellitus, peripheral artery disease and
diverticulosis, known hiatal hernia who presents with bright red
blood per rectum.
.
The patinent presented to [**Hospital3 **] 1-week prior with the
onset of shortness of breath. She was initially presumed to be
having a COPD exacerbation and recveived steroids, nebulizers
and oxygen treatments with subsequent improvement and discharge
to a skilled nursing facility. At the facility, she was noted to
have grossly blood stools mixed with melena in the AM on [**2161-8-14**]
(at 2AM) associated with hypotension. She denied
lightheadedness, dizziness or palpitations. She had no nausea,
emesis or abdominal pain. She had no cough, respiratory symptoms
or hematemesis. She returned to the [**Hospital3 **] ED and was
noted to have a hemoglobin of 7.2 g/dL (significant decline from
baseline). She recived 1 unit of packed red cells and 1.5L of
normal saline prior to transfer. She has been on prophylactic
Lovenox and ASA. She denies recent NSAID use.
.
Of note, her last colonoscopy and EGD were 1-year prior and at
that time noted evidence of diverticulosis. She reports that she
has been admitted to [**Hospital3 **] almost annually with
similar bleeding concerns and each endoscopy reveals resolved
bleeding with a presumed divericular source.
.
In the [**Hospital1 18**] ED upon transfer, initial VS 100.0 56 98/42 16 96%
RA. Her exam was notable for a moderate amount of maroon colored
diarrhea per rectum. Laboratory data noted a WBC 6.9, hemoglobin
9.5, hematocrit 30.9%, platelets 204 and INR 1.2. LFTs were
reassuring. A 22-gauge, 20-gauge and two 18-gauge peripherals
were established for IV access. She received 1L NS x 1 in the ED
and 1 unit of pRBCs. GI and General Surgery were consulted and
agreed with MICU transfer.
.
On arrival to the MICU, she was mentating well without abdominal
pain and appears stable. She was treated and stabilized in the
ICU before being transitioned to the hospital medicine service
for ongoing management.  She underwent an attempt at
colonoscopy, although the preparation was not felt to be
adequate to effectively rule out focal GI pathology. No upper GI
pathology was noted on endoscopy.

MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease (on 2L NC home oxygen)
2. Coronary artery disease (status-post silent MI without
stenting; on ASA for secondary prevention; had MI over 15 years
prior and recent pharmacologic stress testing was reassuring)
3. History of hiatal hernia
4. History of diverticulosis
5. Peripheral artery disease
6. Non-insulin dependent diabetes mellitus
7. Hyperlipidemia
8. GERD, reflux esophagitis

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Atenolol 25 mg PO DAILY
2. Pregabalin 150 mg PO BID
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Simvastatin 40 mg PO HS
5. Tiotropium Bromide 1 CAP IH DAILY
6. Aspirin 81 mg PO QPM
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
9. Ranitidine 150 mg PO HS
10. Omeprazole 20 mg PO DAILY
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
12. calcium polycarbophil *NF* 1300  Oral [**Hospital1 **]
13. Requip *NF* (rOPINIRole) 3 mg Oral [**Hospital1 **]
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
every 5 minutes
15. Isosorbide Mononitrate 30 mg PO DAILY

ALLERGIES: tetnus / Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: #ADMISSION PHYSICAL EXAM
VITALS:  98.0  59  113/52  16  97% 2L NC
GENERAL: Appears in no acute distress. Alert and interactive.
Well nourished appearing.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD unable to assess given
habitus.
CVS: Regular rate and rhythm, II/VI early systolic murmur,
without rubs or gallops. S1 and S2 normal.
RESP: End expiratory wheezing in the bilateral bases. No rhonchi
or crackles. Stable inspiratory effort.
ABD: soft, obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; bilateral 1+ edema to the
mid-shins, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally, sensation grossly
intact. Gait deferred.
RECTAL: external peri-anal region without lesions, skin tags or
fissures. Digital exam reveals normal tone. No masses or
internal hemorrhoids. Bleeding noted on finger mixed with
melenic maroon-colored stool.

FAMILY HISTORY: Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Mother died of
liver cancer at age 63 years.

SOCIAL HISTORY: Patient lives at home with her husband and has 6 children.
Denies tobacco use currently (quit 6 days prior); prior to that
has a 50 pack-year history; denies alcohol use; no recreational
substance use. Patient is independent in ADLs and ambulates
unassisted. Worked at Stop-and-Shop as a cashier. 

### Response:
{'Diverticulosis of colon with hemorrhage,Chronic airway obstruction, not elsewhere classified,Other dependence on machines, supplemental oxygen,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Other and unspecified hyperlipidemia,Diaphragmatic hernia without mention of obstruction or gangrene,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Peripheral vascular disease, unspecified,Esophageal reflux'}
