CHIEF COMPLAINT: Transfer for GI bleed

PRESENT ILLNESS: 58 yo M with hx of HIV who was transfered from [**Hospital3 **]
for initial presentation of COPD exacerbation and who then
developed a massive GI bleed. Per OSH DC summary, he was
admitted on [**2-18**] for a COPD exacerbation. COPD improved on nebs,
IV steroids and IV antibiotics. Within 2-3 days of admission,
patient developed a GI bleed, which started as a combination of
melena and hematochezia. Felt likely UGIB and GI was consulted.
Had an EGD which was negative. During course of bowel prep for
colonoscopy he developed massive rectal bleeding. Colonoscopy
was defered because GI was concerned about not being able to
visualize anything given bleeding. Patient subsequently went
into hypovolemic and hemorrhagic shock and was transferred to
the ICU where he received continuous blood transfusions and
fluid resuscitation. He remained persistently hypotensive and
continued to bleed so he was started on pressors on [**2-23**]. GI
continued to defer colonoscopy. IR was consulted and a bleeding
scan was done which was nondiagnostic. He continued to bleed and
require transfusions.
.
Per DC summary, on the day of transfer GI decided to do a
colonoscopy despite the persistent bleeding. They were unable to
clearly visualize any bleeding because the entire colon (from
the cecum to rectum) was full of blood. The scope was sent right
midway into the ileum where there was also blood suggesting a
mid-point GI bleed, however GI was unable to locate a specific
area. IR was reconsulted to consider angiographic embolization
but was not comfortable performing this procedure. Entire team
agreed that best course was transfer to tertiary care facility
for possible IR embolectomy. He had received a total of ~14
units of packed red cells across his admission.
.
Other complications during his hospital course included a left
iliac partial thrombosis. Also developed rising creatinine to
~1.3 and consulted renal who felt likely HIV nephropathy.
Consulted ID for possible of PCP pneumonia and per ID note he
was ruled out by sputums.
.
At the time of transfer to [**Hospital Unit Name 153**] at [**Hospital1 18**], his VS were stable on
1.5 mcg/kg of neo. He was noted to still be sleepy from sedation
for his scope (done at 4pm on day of transfer). He was
comfortable and in NAD. Abdomen noted to be firm and distended.
He subsequently became very tachycardic and hypotensive, and was
found to have large mealonic stool. He was intubated for
respiratory distress, and received 6 U PRBC, 4 U plts, and 4 U
FFP during the [**Hospital Unit Name 153**] stay. He underwent a CTA, which showed
active bleeding in a loop of mid-to-distal ileum situated within
the right hemipelvis. Unfortunately, once he went down to IR on
the [**Hospital Ward Name **], they were unable to find anything. IR did say,
however, that the patient might have better luck with an IR
machine on the [**Hospital Ward Name **], and so he was being transferred West
for this.
.
In the MICU, patient has had several more episodes of BRBPR,
last one on [**3-1**] at 3pm. Patient had a second CTA on [**2-28**], but
no active bleed was identified. On [**3-1**], patietn had tagged red
cell scan done which was negative as well. Mr. [**Known lastname 26211**] also
experienced some respiratory distress and pulmonary edema
requiring 2 days of intubation. He was diuresed with Lasix IV
and responded well. Patient was extubated on [**3-1**]. Solumedrol,
which was started at OSH for COPD exacerbation, was tapered from
40mg IV bid to 40mg IV qd.
He has not received blood transfusion since [**96**] hours prior to
transfer to the floor. He has been transfused a total of 11
units pRBCs since admission to [**Hospital1 18**].. HCT increased from 32->
39, and has remained stable. At this point, GI may attempt push
enteroscopy. Surgery has requested to maintain hct >30, plts
>100, fibrinogen >100 (ICU has been doing plts >50). Of note,
TSH was checked and found to be 0.89, Free-T4:0.59 (low).
Difficult to interpret in setting of acute illness, can
re-evaluate as outpatient.
.
Today, patient states that he feels "ehh." Denies any sob,
abdominal pain, nausea. States he has not had any BRBPR or
melena today.
.
Review of sytems: positive as per above

MEDICAL HISTORY: HIV: on HAART, reports excellent compliance, per pt last CD4
~200 and VL undetectable, sexually acquired
COPD/emphysema: unclear hx (per one report no prior dx, per
another has history of severe emphysema), continues to smoke 1
PPD, improved at OSH with steroids and nebs
Osteoporosis
Remote history of unspecified hematuria
Hyperlipidemia
History of KS of the skin
Weight loss with low BMI and failure to thrive
History of syphilis
.

MEDICATION ON ADMISSION: Medications on Transfer (per DC summary):
Azithromycin 500mg MWF
Dapsone 50mg PO daily
Lactiobacillus 1 tablet PO BID with meals
Fluconazole 200mg IV daily
Benzonatate 100mg PO TID prn
Norvir 100mg PO daily at 6PM
Reyetax 300mg PO q6pm
Truvada 1 tablet daily
Atrovent 0.5mg/2.5ml inhaled q4h prn
Solumedrol 40mg by mouth Q8H IV (sic)
Neosynephrine gtt 60mg in 250ml titrate SBP < 95
Albuterol suffate nebs Q4H
Fat emulsion 20% 100ml IV daily except sunday
Pantopraziole 40mg IV BID
TPN
nicotine patch 14mg/24hr

ALLERGIES: Sulfa(Sulfonamide Antibiotics) / pentamidine isethionate

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: T: 96.0 BP:96/80 P: 105 R: 22 O2: 94/4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, faint sparse scattered
wheezes, no rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Physical Exam on Discharge:
Vitals: T 98 BP 132/90 P 80 R 16 O2 90% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, thrush on
lateral aspects of tongue
Neck: supple, JVP not elevated, no LAD
Lungs: clear to ausculation b/l except for several scattered
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis;
edema in UEs b/l is resolved
Neuro: CNs2-12 intact, motor function grossly normal

FAMILY HISTORY: Unknown

SOCIAL HISTORY: - Tobacco: 1 PPD
- Alcohol: rare
- Illicits: none
Lives alone. MSM.
Blood in stool,Acute respiratory failure,Human immunodeficiency virus [HIV] disease,Acute and subacute necrosis of liver,Acidosis,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Obstructive chronic bronchitis with (acute) exacerbation,Pulmonary congestion and hypostasis,Tobacco use disorder,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Personal history of other malignant neoplasm of skin,Thrombocytopenia, unspecified
Blood in stool,Acute respiratry failure,Human immuno virus dis,Acute necrosis of liver,Acidosis,Acute kidney failure NOS,Ac posthemorrhag anemia,Obs chr bronc w(ac) exac,Pulm congest/hypostasis,Tobacco use disorder,Hyperlipidemia NEC/NOS,Osteoporosis NOS,Hx-skin malignancy NEC,Thrombocytopenia NOS
Admission Date:  [**2190-2-26**]              Discharge Date:   [**2190-3-8**]

Date of Birth:  [**2132-1-13**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfa(Sulfonamide Antibiotics) / pentamidine isethionate

Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Transfer for GI bleed

Major Surgical or Invasive Procedure:
Angiogram
RIJ line placement
PICC line placement


History of Present Illness:
58 yo M with hx of HIV who was transfered from [**Hospital3 **]
for initial presentation of COPD exacerbation and who then
developed a massive GI bleed. Per OSH DC summary, he was
admitted on [**2-18**] for a COPD exacerbation. COPD improved on nebs,
IV steroids and IV antibiotics. Within 2-3 days of admission,
patient developed a GI bleed, which started as a combination of
melena and hematochezia. Felt likely UGIB and GI was consulted.
Had an EGD which was negative. During course of bowel prep for
colonoscopy he developed massive rectal bleeding. Colonoscopy
was defered because GI was concerned about not being able to
visualize anything given bleeding. Patient subsequently went
into hypovolemic and hemorrhagic shock and was transferred to
the ICU where he received continuous blood transfusions and
fluid resuscitation. He remained persistently hypotensive and
continued to bleed so he was started on pressors on [**2-23**]. GI
continued to defer colonoscopy. IR was consulted and a bleeding
scan was done which was nondiagnostic. He continued to bleed and
require transfusions.
.
Per DC summary, on the day of transfer GI decided to do a
colonoscopy despite the persistent bleeding. They were unable to
clearly visualize any bleeding because the entire colon (from
the cecum to rectum) was full of blood. The scope was sent right
midway into the ileum where there was also blood suggesting a
mid-point GI bleed, however GI was unable to locate a specific
area. IR was reconsulted to consider angiographic embolization
but was not comfortable performing this procedure. Entire team
agreed that best course was transfer to tertiary care facility
for possible IR embolectomy. He had received a total of ~14
units of packed red cells across his admission.
.
Other complications during his hospital course included a left
iliac partial thrombosis. Also developed rising creatinine to
~1.3 and consulted renal who felt likely HIV nephropathy.
Consulted ID for possible of PCP pneumonia and per ID note he
was ruled out by sputums.
.
At the time of transfer to [**Hospital Unit Name 153**] at [**Hospital1 18**], his VS were stable on
1.5 mcg/kg of neo. He was noted to still be sleepy from sedation
for his scope (done at 4pm on day of transfer). He was
comfortable and in NAD. Abdomen noted to be firm and distended.
He subsequently became very tachycardic and hypotensive, and was
found to have large mealonic stool. He was intubated for
respiratory distress, and received 6 U PRBC, 4 U plts, and 4 U
FFP during the [**Hospital Unit Name 153**] stay. He underwent a CTA, which showed
active bleeding in a loop of mid-to-distal ileum situated within
the right hemipelvis. Unfortunately, once he went down to IR on
the [**Hospital Ward Name **], they were unable to find anything. IR did say,
however, that the patient might have better luck with an IR
machine on the [**Hospital Ward Name **], and so he was being transferred West
for this.
.
In the MICU, patient has had several more episodes of BRBPR,
last one on [**3-1**] at 3pm. Patient had a second CTA on [**2-28**], but
no active bleed was identified. On [**3-1**], patietn had tagged red
cell scan done which was negative as well. Mr. [**Known lastname 26211**] also
experienced some respiratory distress and pulmonary edema
requiring 2 days of intubation. He was diuresed with Lasix IV
and responded well. Patient was extubated on [**3-1**]. Solumedrol,
which was started at OSH for COPD exacerbation, was tapered from
40mg IV bid to 40mg IV qd.
He has not received blood transfusion since [**96**] hours prior to
transfer to the floor. He has been transfused a total of 11
units pRBCs since admission to [**Hospital1 18**].. HCT increased from 32->
39, and has remained stable. At this point, GI may attempt push
enteroscopy. Surgery has requested to maintain hct >30, plts
>100, fibrinogen >100 (ICU has been doing plts >50). Of note,
TSH was checked and found to be 0.89, Free-T4:0.59 (low).
Difficult to interpret in setting of acute illness, can
re-evaluate as outpatient.
.
Today, patient states that he feels "ehh." Denies any sob,
abdominal pain, nausea. States he has not had any BRBPR or
melena today.
.
Review of sytems: positive as per above


Past Medical History:
HIV: on HAART, reports excellent compliance, per pt last CD4
~200 and VL undetectable, sexually acquired
COPD/emphysema: unclear hx (per one report no prior dx, per
another has history of severe emphysema), continues to smoke 1
PPD, improved at OSH with steroids and nebs
Osteoporosis
Remote history of unspecified hematuria
Hyperlipidemia
History of KS of the skin
Weight loss with low BMI and failure to thrive
History of syphilis
.


Social History:
- Tobacco: 1 PPD
- Alcohol: rare
- Illicits: none
Lives alone. MSM.

Family History:
Unknown

Physical Exam:
Physical Exam on Admission:
Vitals: T: 96.0 BP:96/80 P: 105 R: 22 O2: 94/4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, faint sparse scattered
wheezes, no rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Physical Exam on Discharge:
Vitals: T 98 BP 132/90 P 80 R 16 O2 90% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, thrush on
lateral aspects of tongue
Neck: supple, JVP not elevated, no LAD
Lungs: clear to ausculation b/l except for several scattered
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis;
edema in UEs b/l is resolved
Neuro: CNs2-12 intact, motor function grossly normal


Pertinent Results:
Labs on Admission:

[**2190-2-26**] 10:23PM   WBC-31.9* RBC-4.28* HGB-13.1* HCT-35.1*
MCV-82 MCH-30.6 MCHC-37.4* RDW-15.4
[**2190-2-26**] 10:23PM   NEUTS-94* BANDS-0 LYMPHS-0 MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-8*
[**2190-2-26**] 10:23PM   HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-2+
OVALOCYT-1+ SCHISTOCY-OCCASIONAL BURR-OCCASIONAL
STIPPLED-OCCASIONAL
[**2190-2-26**] 10:23PM   PT-14.0* PTT-29.6 INR(PT)-1.3*
[**2190-2-26**] 10:23PM   ALT(SGPT)-1685* AST(SGOT)-249* LD(LDH)-323*
ALK PHOS-68 TOT BILI-3.2* DIR BILI-0.4* INDIR BIL-2.8
[**2190-2-26**] 10:23PM   ALBUMIN-2.2* CALCIUM-6.4* PHOSPHATE-4.2
MAGNESIUM-2.1
[**2190-2-26**] 10:23PM   GLUCOSE-131* UREA N-49* CREAT-1.3*
SODIUM-146* POTASSIUM-3.6 CHLORIDE-120* TOTAL CO2-20* ANION
GAP-10
.
Relevant Labs:
.

[**2190-2-28**] 02:03AM BLOOD  WBC-13.9* Lymph-2* Abs [**Last Name (un) **]-278 CD3%-51
Abs CD3-142* CD4%-18 Abs CD4-51* CD8%-32 Abs CD8-89*
CD4/CD8-0.6*
[**2190-3-1**] 05:03AM BLOOD Ret Aut-1.8
[**2190-3-5**] 06:01AM BLOOD Hapto-<5*
[**2190-2-26**] 10:23PM BLOOD Hapto-33 Ferritn-1693*
[**2190-3-2**] 03:51AM BLOOD TSH-0.89
[**2190-3-2**] 03:51AM BLOOD T3-39* Free T4-0.59*
[**2190-2-26**] 10:23PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2190-2-26**] 10:23PM BLOOD HCV Ab-NEGATIVE
.
Microbiology:
.
[**2190-3-2**] 3:51 am Blood (Toxo)      CHEM# [**Serial Number 92433**]G [**3-2**].

                            **FINAL REPORT [**2190-3-5**]**

   TOXOPLASMA IgG ANTIBODY (Final [**2190-3-5**]):
      EQUIVOCAL FOR TOXOPLASMA IgG ANTIBODY BY EIA.
      4.0 IU/ML.
      Reference Range:  Negative < 4 IU/ml, Positive >= 8 IU/ml.


   TOXOPLASMA IgM ANTIBODY (Final [**2190-3-5**]):
      NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
.
[**2190-3-3**] 5:59 pm SPUTUM      Source: Induced.

                            **FINAL REPORT [**2190-3-4**]**

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2190-3-4**]):    NEGATIVE for Pneumocystis jirovecii
(carinii).
.
Imaging:
.
Imaging at OSH:
1. Nuclear medicine GI bleeding scan [**2190-2-25**]: essentially
negative GI bleeding study wuithout evidence of active GI
bleeding during the 1 hr scan
2. CT Abdomen/Pelvis w/Contrast [**2190-2-25**]: Fluid-filled colon.
No mass lesion. Moderate abdominal and pelvic ascites with
mesenteric edema. Left internal iliac artery partially
thrombosed aneurysm with diffuse aortoiliac athersclerotic
vascular disease. Cholelithiasis, no intra- or extra-hepatic
biliary ductal dilatation.
3. Renal US [**2-25**]: unremarkable
4. CXR: no acute process
.
Chest x-ray [**2190-2-26**]:
The lungs are hyperinflated. The heart is not enlarged. The
aorta is
minimally unfolded. There is no CHF, frank consolidation, or
gross effusion. However, there is minimal irregular opacity at
the right costophrenic angle, ? related to localized scarring
and/or pleural thickening. There are also smaller irregular
opacities at the left costophrenic angle, biapical pleural
thickening, and right apical linear scarring.
.
There is mildly distended transverse colon (6.6 cm), near the
splenic flexure. A curvilinear sliver of gas projecting above
the left hemidiaphragm likely represents an artifact due to
superimposition of bowel loops, rather than free air.
.
CT abdomen/pelvis [**2-27**]:
1. Findings consistent with active small-bowel
hemorrhage/extravasation.
2. Free fluid in the abdomen and pelvis.
3. Diffuse atherosclerotic disease with ectatic left common
iliac artery and right common iliac pseudoaneurysm and
thrombosed left internal iliac aneurysm with distal retrograde
filling.
4. Left lung base ill-defined opacity could be infectious or
inflammatory, to be followed.
5. Subcentimeter liver lesion, too small to fully characterize.
.
Mesenteric angiogram [**2-27**]:
1. Right femoral arteriogram demonstrated access of the right
common femoral artery.
2. SMA-gram demonstrated no active extravasation. Normal
branching vessels seen.
3. Angiograms from ileal branches and subsequently ileocolic
branch did not demonstrate active extravasation, pseudoaneurysm
or early draining vein.
4. A nuclear RBC scan is recommended to see if there is
persistent bleeding.
IMPRESSION: Uncomplicated fluoroscopy-guided mesenteric
angiogram.
.
CTA abdomen/pelvis [**2-28**] (wet read):
No active bleed at this time. However study somewhat limited by
contrast filling the entire large bowel (likely from prior
bleed). No bleed seen at the distal small bowel site, as seen
previously. Mild increase in the abdominal- pelvic free fluid
and anasarca. Stable findings include abdominal aorta
atherosclerotic disease, celiac stenosis, R CIA pseudoaneurysm,
thrombosed left internal iliac aneurysm. Bilateral moderate
simple pleural effusions with
basal atelectasis, slightly larger since prior study of [**2-27**].
Foley cath in place, with bulb in the bladder. A taggedRBC study
may be helpful to localize the bleed.
.
Tagged RBC study [**3-1**]:
Normal study with no evidence of GI bleeding during the time of
study.
.
Chest x-ray [**3-2**]:
Moderately severe pulmonary edema is new, accompanied by small
bilateral pleural effusion, but heart size and mediastinal
vascular caliber are normal. This could be due to transient
effects of transfusion, either increased osmotic load alone, or
in combination with TRALI. Close followup advised.
.
TTE [**2190-3-4**]:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). Doppler parameters are most consistent
with normal left ventricular diastolic function. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Small LV cavity size with hyperdynamic LV systolic
function. No pathologic valvular abnormality seen.
.
Labs on Discharge:

[**2190-3-7**] 06:45AM BLOOD Hct-42.5
[**2190-3-8**] 06:55AM BLOOD ALT-144* AST-46* AlkPhos-109 TotBili-9.3*
DirBili-0.6* IndBili-8.7

Brief Hospital Course:
58M HIV+ who was hospitalized at OSH for COPD exacerbation where
he developed massive LGIB with negative colonoscopy, transferred
to [**Hospital1 18**] for possible IR embolization.
.
# Gastrointestinal bleeding: Patient developed massive LGIB at
OSH, requiring large volume RBC transfusions.  At OSH, patient
had negative EGD. Multiple unsuccessful attempts at
colonoscopies secondary to ongoing bleeding at OSH. Patient was
transferred for possible IR embolization. He does have history
of hemorrhoids, but no history of diverticulosis. Per patient,
last colonoscopy 8 months ago was normal. Patient has required
massive transfusion, a total of 25 units of pRBCs. Continued to
bleed intermittently, unclear why. On CTA, there was bleeding
visualized in a loop of mid-to-distal ileum situated within the
right hemipelvis. However, attempt to [**Hospital1 92434**] and embolize was
not successful. Repeat attempt was planned, but next CTA did not
localize a bleed. General surgery was following, but did not
require emergent surgery.  Patient's hct stabilized.  He had a
capsule study which was normal and did not show any bleeding.
After discharge, patient should follow up with gastroenterology.
.
# HIV: CD4 count 51 this admission, on HAART. Because patient
was on liquid diet, he was on liquid Emtricitabine. However,
liquid form has lower bioavailability thus patient was likely
subtherapeutic. Additionally, he was on a PPI which interacts
with retrovirals. Per outside records, patient patient was on
dapsone 15mg daily for PCP [**Name9 (PRE) **], though this dose sounds too low.
Given this and subtherapeutic HAART, there was some concern for
PCP [**Name Initial (PRE) 1064**]. Sputum PCP x1 was negative.  During this
admission, G6PD was checked and was normal, thus restarted on
Dapsone 100mg qd. As outpatient, [**Name8 (MD) **] RN at his ID physician's
office, he was on Dapsone 50mg daily which is below recommended
ppx dose.  This was most likely secondary to rising LFTs in
setting of Dapsone.  When Dapsone 100mg qd was started, Tbili
trended up, peaking at 9.5.  Thus, Dapsone was discontinued.
Discussed with patient monthly inhaled pentamadine vs.
atovaquone, and decided to do pentamadine.  Unfortunately, when
patient received pentamadine treatment, he went into respiratory
distress and required solumedrol.  He should not ever again
receive pentamadine.  On discharge, patient was started on
atovaquone for PCP [**Name Initial (PRE) 1102**].  Also, continued home HAART:
truvada, retonavir 100mg qd, atazanavir 300 mg PO qd.
.
# COPD/Repiratory Failure: Originally admitted to OSH for COPD
exacerbation. Patient was intubated shortly after arrival in ICU
for airway protection in setting of massive bleeding,
hypotension, and tachycardia. Per report, has never had
diagnosis of COPD until this admission.  However, based on
imaging, as well as on smoking history, likely has COPD. Also
had some pulmonary edema on chest x-ray and was diuresed with
Lasix.  Unclear why he had pulmonary edema, probably because of
fluid overload given massive transfusions. TTE with small LV (no
hypertrophy) and hyperdynamic EF. As patient was started on high
dose steroids at OSH for COPD exacerbation, he was discharged on
2 week predisone taper. As outpatient, he will need PFTs to
further evaluate for COPD.
.
# Hypotension: Likely secondary to GI bleed as has resolved with
appropriate transfusions. On admission, patient was afebrile,
but did have a WBC count, highly neutrophilic without bandemia,
more suggestive of WBC count from steroids than infection. Off
pressors and maintaining his pressures several days into the
admission.
.
# Leukocytosis: Likely secondary to steroids. Patient had BCx,
UCx, and C. Diff all of which were negative. Patient was started
on steroids for COPD exacerbation on [**2-18**]
.
# Transaminitis: Notable for elevations in ALT, AST, bilirubin.
Given trended down without alternative intervention besides
hemodynamic stability, likely some element of hepatic shock. Hep
A antibody positive, but otherwise hep serologies are negative.
Most likely secondary to hypoperfusion.
.
TRANSITIONS OF CARE:
-code: full
-f/u with gastroenterology
-f/u with pulmonary for PFTs
-re-check LFTs/bilirubin


Medications on Admission:
Medications on Transfer (per DC summary):
Azithromycin 500mg MWF
Dapsone 50mg PO daily
Lactiobacillus 1 tablet PO BID with meals
Fluconazole 200mg IV daily
Benzonatate 100mg PO TID prn
Norvir 100mg PO daily at 6PM
Reyetax 300mg PO q6pm
Truvada 1 tablet daily
Atrovent 0.5mg/2.5ml inhaled q4h prn
Solumedrol 40mg by mouth Q8H IV (sic)
Neosynephrine gtt 60mg in 250ml titrate SBP < 95
Albuterol suffate nebs Q4H
Fat emulsion 20% 100ml IV daily except sunday
Pantopraziole 40mg IV BID
TPN
nicotine patch 14mg/24hr

Discharge Medications:
1. atazanavir 300 mg Capsule Sig: One (1) Capsule PO once a day.

2. ritonavir 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 9 days: Please take daily while taking prednisone;
then you can STOP this medications.
Disp:*9 Tablet(s)* Refills:*0*
5. prednisone 10 mg Tablet Sig: see below Tablet PO once a day
for 9 days: -Take 30 mg (3 tabs) on [**3-9**]/7,[**3-11**]
-Take 20mg (2 tabs) on [**3-12**]/10,[**3-14**]
-Take 10mg (1 tab) on [**3-15**]/13,[**3-17**]
-After [**3-17**], STOP taking prednisone.
Disp:*18 Tablet(s)* Refills:*0*
6. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
Disp:*450 ML(s)* Refills:*2*
7. atovaquone 750 mg/5 mL Suspension Sig: One (1)  PO DAILY
(Daily).
Disp:*30 tabs* Refills:*2*
8. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): Please do NOT smoke when you have the
patch on as this can be dangerous.
Disp:*30 Patch 24 hr(s)* Refills:*2*
9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1)  Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]

Discharge Diagnosis:
Primary:
Lower GI bleed
Possible COPD
HIV


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 Mr. [**Known lastname 26211**],

You were initially admitted to an outside hospital initially
with trouble breathing.  During the hospitalization, you
developed profuse bleeding from your gastrointestinal tract and
were transferred to [**Hospital3 **] Medical Center for further care.
 First you were admitted to the intensive care unit.  You had an
imaging study which showed the location of your bleed.  The
interventional radiology doctors tried to [**Name5 (PTitle) 92434**] and stop it
but were unable to.  Plans were made for a repeat attempt, but
repeat imaging no longer showed the location of the bleed.  You
also had a capsule study in which you swallowed a camera.  The
video of your intestines was normal, confirming that you no
longer were bleeding. During the admission, you required
multiple transfusions of blood products.  By discharge, you were
no longer having bloody bowel movements and your blood counts
were stable.  After discharge, you should follow up with a
gastroenterology doctor.  It is very important that you follow
up given how massive your bleeding was. Please ask your primary
care physician to set you up with the specialist.
.
During the admission, you had a chest x-ray which showed that
your lungs were quite inflated suggestive of COPD (chronic
obstructive pulmonary disease) which is caused by an extensive
smoking history.  You should see a pulmonologist (lung doctor)
for further evaluation, including pulmonary function tests.
Please ask your primary care physician to set you up with the
specialist. In the mean time, if you feel short of breath, you
should use the albuterol inhaler as included in the
prescriptions below.
.
During the admission, we also saw that your Dapsone was at a
dose somewhat lower than ideal for PCP [**Name Initial (PRE) 1102**].  We
increased your dose, but, this caused some blood test
abnormalities suggesting that this medicine was causing your
blood cells to [**Doctor Last Name **].  Thus, we stopped your Dapsone.  We
discussed two alternative medications, Atovaquone which could be
expensive and inhaled Pentamidine monthly.  We spoke with you
and you preferred the inhaled Pentamidine.  Unfortunately, when
you received the treatment, you had an allergic reaction and had
strouble breathing.  You were treated with IV steroids and
nebulizers and responded well.  In the future, you cannot use
pentamidine again. Given your allergy to pentamidine, you should
take the Atovaquone instead.  A prescription is included.
.
We have made the following changes to your medications:
*START Prednisone taper (it is important that you decrease the
dose gradually as it is dangerous to stop it abruptly):
-Take 30 mg (3 tabs) on [**3-9**]/7,[**3-11**]
-Take 20mg (2 tabs) on [**3-12**]/10,[**3-14**]
-Take 10mg (1 tab) on [**3-15**]/13,[**3-17**]
-After [**3-17**], STOP taking prednisone
*START Ranitidine 150mg daily while you are taking the
prednisone.  Once you finish the prednisone, you can stop the
ranitidine.
*START Atovaquone 1500mg daily (this will replace the Dapsone)
*START Nystatin 5mL mouth swish 3 times per day for thrush
*START Nicotine patch daily to help you quit smoking.  It is
important that you DO NOT smoke while wearing the patch as that
can be dangerous.
*START Albuterol inhaler as needed for shortness of breath.
.
Please follow up with your primary care physician and infectious
disease doctor.  Also, please ask your primary care physician to
set you up with appointments to see a pulmonologist and a
gastroenterologist.
.
It was a pleasure taking care of you, we wish you all the best!

Followup Instructions:
***It is recommended you follow up with a Gastroenterologist and
a Pulmonologist within 2-4 weeks from discharge.  Please discuss
booking these appts during your follow up appt on Friday with
[**First Name9 (NamePattern2) 92435**] [**Doctor Last Name **]:
.
Name: NP, [**First Name8 (NamePattern2) 3742**] [**Last Name (NamePattern1) **] (works with Dr [**Last Name (STitle) **])
Location: [**Hospital 46644**] MEDICAL AT RIVERWALK
Address: [**Location (un) 46645**], [**Hospital1 **],[**Numeric Identifier 46646**]
Phone: [**Telephone/Fax (1) 34574**]
Appt:  [**3-12**] at 9:50am
.
Name: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital 46644**] MEDICAL AT RIVERWALK
Address: [**Location (un) 46645**], [**Hospital1 **],[**Numeric Identifier 46646**]
Phone: [**Telephone/Fax (1) 34574**]
Appt:  [**3-19**] at 11am



Completed by:[**2190-3-17**]
{'Blood in stool,Acute respiratory failure,Human immunodeficiency virus [HIV] disease,Acute and subacute necrosis of liver,Acidosis,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Obstructive chronic bronchitis with (acute) exacerbation,Pulmonary congestion and hypostasis,Tobacco use disorder,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Personal history of other malignant neoplasm of skin,Thrombocytopenia, unspecified'}


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: Transfer for GI bleed

PRESENT ILLNESS: 58 yo M with hx of HIV who was transfered from [**Hospital3 **]
for initial presentation of COPD exacerbation and who then
developed a massive GI bleed. Per OSH DC summary, he was
admitted on [**2-18**] for a COPD exacerbation. COPD improved on nebs,
IV steroids and IV antibiotics. Within 2-3 days of admission,
patient developed a GI bleed, which started as a combination of
melena and hematochezia. Felt likely UGIB and GI was consulted.
Had an EGD which was negative. During course of bowel prep for
colonoscopy he developed massive rectal bleeding. Colonoscopy
was defered because GI was concerned about not being able to
visualize anything given bleeding. Patient subsequently went
into hypovolemic and hemorrhagic shock and was transferred to
the ICU where he received continuous blood transfusions and
fluid resuscitation. He remained persistently hypotensive and
continued to bleed so he was started on pressors on [**2-23**]. GI
continued to defer colonoscopy. IR was consulted and a bleeding
scan was done which was nondiagnostic. He continued to bleed and
require transfusions.
.
Per DC summary, on the day of transfer GI decided to do a
colonoscopy despite the persistent bleeding. They were unable to
clearly visualize any bleeding because the entire colon (from
the cecum to rectum) was full of blood. The scope was sent right
midway into the ileum where there was also blood suggesting a
mid-point GI bleed, however GI was unable to locate a specific
area. IR was reconsulted to consider angiographic embolization
but was not comfortable performing this procedure. Entire team
agreed that best course was transfer to tertiary care facility
for possible IR embolectomy. He had received a total of ~14
units of packed red cells across his admission.
.
Other complications during his hospital course included a left
iliac partial thrombosis. Also developed rising creatinine to
~1.3 and consulted renal who felt likely HIV nephropathy.
Consulted ID for possible of PCP pneumonia and per ID note he
was ruled out by sputums.
.
At the time of transfer to [**Hospital Unit Name 153**] at [**Hospital1 18**], his VS were stable on
1.5 mcg/kg of neo. He was noted to still be sleepy from sedation
for his scope (done at 4pm on day of transfer). He was
comfortable and in NAD. Abdomen noted to be firm and distended.
He subsequently became very tachycardic and hypotensive, and was
found to have large mealonic stool. He was intubated for
respiratory distress, and received 6 U PRBC, 4 U plts, and 4 U
FFP during the [**Hospital Unit Name 153**] stay. He underwent a CTA, which showed
active bleeding in a loop of mid-to-distal ileum situated within
the right hemipelvis. Unfortunately, once he went down to IR on
the [**Hospital Ward Name **], they were unable to find anything. IR did say,
however, that the patient might have better luck with an IR
machine on the [**Hospital Ward Name **], and so he was being transferred West
for this.
.
In the MICU, patient has had several more episodes of BRBPR,
last one on [**3-1**] at 3pm. Patient had a second CTA on [**2-28**], but
no active bleed was identified. On [**3-1**], patietn had tagged red
cell scan done which was negative as well. Mr. [**Known lastname 26211**] also
experienced some respiratory distress and pulmonary edema
requiring 2 days of intubation. He was diuresed with Lasix IV
and responded well. Patient was extubated on [**3-1**]. Solumedrol,
which was started at OSH for COPD exacerbation, was tapered from
40mg IV bid to 40mg IV qd.
He has not received blood transfusion since [**96**] hours prior to
transfer to the floor. He has been transfused a total of 11
units pRBCs since admission to [**Hospital1 18**].. HCT increased from 32->
39, and has remained stable. At this point, GI may attempt push
enteroscopy. Surgery has requested to maintain hct >30, plts
>100, fibrinogen >100 (ICU has been doing plts >50). Of note,
TSH was checked and found to be 0.89, Free-T4:0.59 (low).
Difficult to interpret in setting of acute illness, can
re-evaluate as outpatient.
.
Today, patient states that he feels "ehh." Denies any sob,
abdominal pain, nausea. States he has not had any BRBPR or
melena today.
.
Review of sytems: positive as per above

MEDICAL HISTORY: HIV: on HAART, reports excellent compliance, per pt last CD4
~200 and VL undetectable, sexually acquired
COPD/emphysema: unclear hx (per one report no prior dx, per
another has history of severe emphysema), continues to smoke 1
PPD, improved at OSH with steroids and nebs
Osteoporosis
Remote history of unspecified hematuria
Hyperlipidemia
History of KS of the skin
Weight loss with low BMI and failure to thrive
History of syphilis
.

MEDICATION ON ADMISSION: Medications on Transfer (per DC summary):
Azithromycin 500mg MWF
Dapsone 50mg PO daily
Lactiobacillus 1 tablet PO BID with meals
Fluconazole 200mg IV daily
Benzonatate 100mg PO TID prn
Norvir 100mg PO daily at 6PM
Reyetax 300mg PO q6pm
Truvada 1 tablet daily
Atrovent 0.5mg/2.5ml inhaled q4h prn
Solumedrol 40mg by mouth Q8H IV (sic)
Neosynephrine gtt 60mg in 250ml titrate SBP < 95
Albuterol suffate nebs Q4H
Fat emulsion 20% 100ml IV daily except sunday
Pantopraziole 40mg IV BID
TPN
nicotine patch 14mg/24hr

ALLERGIES: Sulfa(Sulfonamide Antibiotics) / pentamidine isethionate

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: T: 96.0 BP:96/80 P: 105 R: 22 O2: 94/4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, faint sparse scattered
wheezes, no rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Physical Exam on Discharge:
Vitals: T 98 BP 132/90 P 80 R 16 O2 90% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, thrush on
lateral aspects of tongue
Neck: supple, JVP not elevated, no LAD
Lungs: clear to ausculation b/l except for several scattered
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis;
edema in UEs b/l is resolved
Neuro: CNs2-12 intact, motor function grossly normal

FAMILY HISTORY: Unknown

SOCIAL HISTORY: - Tobacco: 1 PPD
- Alcohol: rare
- Illicits: none
Lives alone. MSM. 

### Response:
{'Blood in stool,Acute respiratory failure,Human immunodeficiency virus [HIV] disease,Acute and subacute necrosis of liver,Acidosis,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Obstructive chronic bronchitis with (acute) exacerbation,Pulmonary congestion and hypostasis,Tobacco use disorder,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Personal history of other malignant neoplasm of skin,Thrombocytopenia, unspecified'}
