CHIEF COMPLAINT: GI bleed
Respiratory distress

PRESENT ILLNESS: (History obtained from son and OSH record)
76 yo F with history of CKD recently started on hemodialysis (2
cycles as of [**7-20**]), h/o CVA x2, h/o RCC s/p nephrectomy, and
recent known [**Hospital **] transferred from the OSH to the ICU for planned
GI work-up; however, was in respiratory distress requiring
intubation in the [**Hospital1 **] ED.
.
Per the son, she has been having increased lethargy, decreased
energy, as well as LE swelling.  Patient reported having had at
least 1 week of melena and 1 day of hematemesis on [**2129-7-15**].
This led to her admission to [**Hospital **] Hospital on [**2129-7-15**].
At the OSH ED, she was noteded to have BRBPR and initial Hct of
25.3 from 30.5 on [**7-12**] and 34.4 on [**6-7**].  Per OSH record, her NG
lavage in the ED was negative.  Her hemodynamics remained
stable.  Subsequently, she was on Protonix gtt and IV hydration
with GI consult.  Her plavix was held.  She apparently underwent
an endoscopy by DR. [**Last Name (STitle) 30885**], which showed a bleeding friable
large pyloric channel stalk polyp 4-5 cm as well as gastric
mucosal friability.  Per discharge summary, patient vomited
blood on [**7-19**] and received DDAVP.  During her time in the OSH,
she was initiated on hemodialysis per her nephrologist's
recommendations.  Per the son, patient was supposed to be
transferred over on [**7-19**] but did not get here until [**7-20**].
.
Per the son, she had a colonoscopy that was not remarkable,
except for polyps, last year.
.
Patient received a cycle of dialysis today before transfer.
.
Per ED report, patient became hypoxic en route to the 70s to
endoscopy, so was rerouted to the ED.  At triage, HR 69, BP
167/66, RR 25, O2Sat 85% on BiPAP.  There was concern of
pneumonia vs. fluid overload.  She was placed on BiPAP then was
intubated for hypoxic respiratory distress on fentanyl and
propofol.  Apparently, OG tube lavage did not show blood.  Per
ED report, patient had a living will from [**2117**] with DNR/DNI, but
this was discussed with patient prior to intubation, and she
agreed to it.  She was given protonix 80 mg IV 1x, vancomycin,
levofloxacin, and zosyn.  Nephrology and GI were made aware of
her.  Bedside echocardiogram showed small pericardial effusion
with left sided pleural effusion.  Upon transfer, HR 58, BP
142/58, RR 16, O2Sat 100% on FiO2 80%, TV 400, RR set 18, and
PEEP of 10 with fentanyl and propofol for sedation.
.
In the [**Hospital Unit Name 153**], she was quickly extubated without complication on
[**7-21**] after HD ultrafiltration. She has been on 2L NC since. Echo
showed EF 50% with apical hypokinesis attributed NSTEMI during
this admission although trop elevations are only modest
considering renal function and CK/MB not elevated. EKG notable
for non-specific t-wave changes. She is on plavix as an outpt
for hx of CVA, but this has been held in setting of GIB.
.
In terms of her GI bleed, she was found to have a large polyp
leading to obstruction of pylorus. She was transfused [**2129-7-23**] 1
unit of pRBCs. Patient also noted to have bleeding [**Doctor First Name **]-[**Doctor Last Name **]
tear on EGD on Monday [**2129-7-25**], after which she had 20 cc
hematemesis but has had none since and has been hemodynamically
stable the entire hospitalization throughout [**Hospital Unit Name 153**] stay. She has
been on [**Hospital1 **] IV PPI, transitioned to PO PPI today and tolerating
po intake. Her last transfusion was today [**7-27**] with HD, at which
time she got 1 unit PRBC. She has received total 2 units (one
today, one on [**7-23**]).
.
Her course was also complicated by MSSA bacteremia and a
hematoma next to her AV fistula. Blood cultures drawn on
admission to [**Hospital1 18**] grew MSSA, one out of four bottles. She is on
cefazolin with Hemodialysis (2/2/3 g after HD on M/W/F, today
day 7 of 14 - last day [**8-3**]). Initial concern for infected
fistula given mild tenderness but ultrasound ok and vascular
felt it was very unlikely (no graft). Subsequent cultures x 6
days no growth to date.
.
She also had thrombocytopenia and Plt 142 on presentation, that
decreased to nadir of 69. Patient has not been on heparin at
[**Hospital1 18**], but unclear if received at OSH or with hemodialysis. PF4
neg. Plts since rose to 110.
In terms of ESRD, patient received HD session prior to transfer
to the floor.
Vitals in [**Hospital Unit Name 153**] prior to transfer to floor were as follows: T
98.7, BP 128/64, P 70, RR 14, O2sat 99% 2L. Pt arrived at the
floor with no complaint of pain.

MEDICAL HISTORY: (per [**Hospital **] Hospital record)
- Upper GIB from bleeding large pyloric channel stalk polyp with
diffuse gastric friability
- Lower GIB
- history of CVAs x2, was on plavix (until OSH admission.
Initially on ASA-> Plavix.  Did not tolerate Aggrenox per OSH
record)
- CKD stage 4, on dialysis (2 cycles as of [**7-20**])
- h/o renal cell cancer s/p nephrectomy
- HTN
- HLD
- Anemia of chronic disease

MEDICATION ON ADMISSION: Upon transfer from [**Hospital **] Hospital:
- labetolol 100 mg po BID
- Crestor 40 mg daily
- Vitamin B12 1000 mcg po daily
- Renvela 800 mg with meals TID
- Sodium bicarb 648 mg po TID
- Prilosec 20 mg po BID
- nephrocaps 1 cap daily
- Tylenol 650 mg q6h prn
- Ambien 5 mg po qHS prn
- Zofran 4 mg IV q6h prn
.
Home medications (per OSH record)
- labetolol 200 mg [**Hospital1 **]
- Crestor 40 mg daily
- Plavix 75 mg daily
- Calcitriol 0.25 mcg daily
- B12 1000 mcg daily

ALLERGIES: Hydralazine / Heparin,Porcine

PHYSICAL EXAM: On admission:
Vitals: T:97.1 BP:109/67 P:77 R:17 O2: 97%, CMV Vt450, PEEP 10,
RR set at 18
General: intubated
HEENT: Sclera anicteric, MMM
Neck: supple, no LAD
Lungs: bronchial breath sounds, clear to auscultation, no w/c/r
appreciated
CV: RRR, normal S1 and S2, soft [**2-10**] holosystolic and diastolic
murmur, no rub or gallops
Abd: soft, NT, ND, BS present, no guarding, no organomegaly, +
old scar
GU: Foley draining clear urine
Ext: Cool extremities, 1+ edema to the thighs, 2+ DP and radial
pulses bilaterally, no clubbing or cyanosis.

FAMILY HISTORY: - father deceased at 66 with MI
- mother deceased at 91 to colon cancer
- 1 sister is in good health

SOCIAL HISTORY: - lived at home with son
- has 3 grown children: son [**Name (NI) **], daughter [**Name (NI) **] and another
daughter
- no tobacco or alcohol use per son
- has been physically inactive for at least 1 year
- stays at home most of the time, but has a good friend that she
talks to twice a day
Acute respiratory failure,Acute diastolic heart failure,End stage renal disease,Bacteremia,Acute posthemorrhagic anemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Benign neoplasm of stomach,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Renal dialysis status,Personal history of malignant neoplasm of kidney,Other specified cardiac dysrhythmias,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Acute respiratry failure,Ac diastolic hrt failure,End stage renal disease,Bacteremia,Ac posthemorrhag anemia,Hyp kid NOS w cr kid V,Benign neoplasm stomach,Mth sus Stph aur els/NOS,Thrombocytopenia NOS,Renal dialysis status,Hx of kidney malignancy,Cardiac dysrhythmias NEC,Hx TIA/stroke w/o resid
Admission Date:  [**2129-7-20**]              Discharge Date:   [**2129-8-3**]

Date of Birth:  [**2052-11-25**]             Sex:   F

Service: MEDICINE

Allergies:
Hydralazine / Heparin,Porcine

Attending:[**First Name3 (LF) 603**]
Chief Complaint:
GI bleed
Respiratory distress

Major Surgical or Invasive Procedure:
Ultrafiltration
Hemodialysis

History of Present Illness:
(History obtained from son and OSH record)
76 yo F with history of CKD recently started on hemodialysis (2
cycles as of [**7-20**]), h/o CVA x2, h/o RCC s/p nephrectomy, and
recent known [**Hospital **] transferred from the OSH to the ICU for planned
GI work-up; however, was in respiratory distress requiring
intubation in the [**Hospital1 **] ED.
.
Per the son, she has been having increased lethargy, decreased
energy, as well as LE swelling.  Patient reported having had at
least 1 week of melena and 1 day of hematemesis on [**2129-7-15**].
This led to her admission to [**Hospital **] Hospital on [**2129-7-15**].
At the OSH ED, she was noteded to have BRBPR and initial Hct of
25.3 from 30.5 on [**7-12**] and 34.4 on [**6-7**].  Per OSH record, her NG
lavage in the ED was negative.  Her hemodynamics remained
stable.  Subsequently, she was on Protonix gtt and IV hydration
with GI consult.  Her plavix was held.  She apparently underwent
an endoscopy by DR. [**Last Name (STitle) 30885**], which showed a bleeding friable
large pyloric channel stalk polyp 4-5 cm as well as gastric
mucosal friability.  Per discharge summary, patient vomited
blood on [**7-19**] and received DDAVP.  During her time in the OSH,
she was initiated on hemodialysis per her nephrologist's
recommendations.  Per the son, patient was supposed to be
transferred over on [**7-19**] but did not get here until [**7-20**].
.
Per the son, she had a colonoscopy that was not remarkable,
except for polyps, last year.
.
Patient received a cycle of dialysis today before transfer.
.
Per ED report, patient became hypoxic en route to the 70s to
endoscopy, so was rerouted to the ED.  At triage, HR 69, BP
167/66, RR 25, O2Sat 85% on BiPAP.  There was concern of
pneumonia vs. fluid overload.  She was placed on BiPAP then was
intubated for hypoxic respiratory distress on fentanyl and
propofol.  Apparently, OG tube lavage did not show blood.  Per
ED report, patient had a living will from [**2117**] with DNR/DNI, but
this was discussed with patient prior to intubation, and she
agreed to it.  She was given protonix 80 mg IV 1x, vancomycin,
levofloxacin, and zosyn.  Nephrology and GI were made aware of
her.  Bedside echocardiogram showed small pericardial effusion
with left sided pleural effusion.  Upon transfer, HR 58, BP
142/58, RR 16, O2Sat 100% on FiO2 80%, TV 400, RR set 18, and
PEEP of 10 with fentanyl and propofol for sedation.
.
In the [**Hospital Unit Name 153**], she was quickly extubated without complication on
[**7-21**] after HD ultrafiltration. She has been on 2L NC since. Echo
showed EF 50% with apical hypokinesis attributed NSTEMI during
this admission although trop elevations are only modest
considering renal function and CK/MB not elevated. EKG notable
for non-specific t-wave changes. She is on plavix as an outpt
for hx of CVA, but this has been held in setting of GIB.
.
In terms of her GI bleed, she was found to have a large polyp
leading to obstruction of pylorus. She was transfused [**2129-7-23**] 1
unit of pRBCs. Patient also noted to have bleeding [**Doctor First Name **]-[**Doctor Last Name **]
tear on EGD on Monday [**2129-7-25**], after which she had 20 cc
hematemesis but has had none since and has been hemodynamically
stable the entire hospitalization throughout [**Hospital Unit Name 153**] stay. She has
been on [**Hospital1 **] IV PPI, transitioned to PO PPI today and tolerating
po intake. Her last transfusion was today [**7-27**] with HD, at which
time she got 1 unit PRBC. She has received total 2 units (one
today, one on [**7-23**]).
.
Her course was also complicated by MSSA bacteremia and a
hematoma next to her AV fistula. Blood cultures drawn on
admission to [**Hospital1 18**] grew MSSA, one out of four bottles. She is on
cefazolin with Hemodialysis (2/2/3 g after HD on M/W/F, today
day 7 of 14 - last day [**8-3**]). Initial concern for infected
fistula given mild tenderness but ultrasound ok and vascular
felt it was very unlikely (no graft). Subsequent cultures x 6
days no growth to date.
.
She also had thrombocytopenia and Plt 142 on presentation, that
decreased to nadir of 69. Patient has not been on heparin at
[**Hospital1 18**], but unclear if received at OSH or with hemodialysis. PF4
neg. Plts since rose to 110.
In terms of ESRD, patient received HD session prior to transfer
to the floor.
Vitals in [**Hospital Unit Name 153**] prior to transfer to floor were as follows: T
98.7, BP 128/64, P 70, RR 14, O2sat 99% 2L. Pt arrived at the
floor with no complaint of pain.

Past Medical History:
(per [**Hospital **] Hospital record)
- Upper GIB from bleeding large pyloric channel stalk polyp with
diffuse gastric friability
- Lower GIB
- history of CVAs x2, was on plavix (until OSH admission.
Initially on ASA-> Plavix.  Did not tolerate Aggrenox per OSH
record)
- CKD stage 4, on dialysis (2 cycles as of [**7-20**])
- h/o renal cell cancer s/p nephrectomy
- HTN
- HLD
- Anemia of chronic disease


Social History:
- lived at home with son
- has 3 grown children: son [**Name (NI) **], daughter [**Name (NI) **] and another
daughter
- no tobacco or alcohol use per son
- has been physically inactive for at least 1 year
- stays at home most of the time, but has a good friend that she
talks to twice a day


Family History:
- father deceased at 66 with MI
- mother deceased at 91 to colon cancer
- 1 sister is in good health


Physical Exam:
On admission:
Vitals: T:97.1 BP:109/67 P:77 R:17 O2: 97%, CMV Vt450, PEEP 10,
RR set at 18
General: intubated
HEENT: Sclera anicteric, MMM
Neck: supple, no LAD
Lungs: bronchial breath sounds, clear to auscultation, no w/c/r
appreciated
CV: RRR, normal S1 and S2, soft [**2-10**] holosystolic and diastolic
murmur, no rub or gallops
Abd: soft, NT, ND, BS present, no guarding, no organomegaly, +
old scar
GU: Foley draining clear urine
Ext: Cool extremities, 1+ edema to the thighs, 2+ DP and radial
pulses bilaterally, no clubbing or cyanosis.

On discharge:
Vitals: T:98.9 BP:164/70 P:72 R:20 95% on 2L O2
General: Pleasant, older woman in NAD. Friendly, cooperative.
AAOx3
HEENT: Sclera anicteric, MMM
Neck: supple, no LAD
Lungs: breaths slightly shallow but unlabored, good air
movement, no use of supplementary muscles, clear to auscultation
bilaterally, no w/c/r appreciated
CV: RRR, normal S1 and S2, no murmur, rub, or gallops
Abd: soft, NT, ND, BS present, no guarding, no organomegaly, +
old scar
Ext: Warm extremities, minimal edema to the thighs, 2+ DP and
radial pulses bilaterally, no clubbing or cyanosis.


Pertinent Results:
1. Labs on admission:
[**2129-7-20**] 01:55PM BLOOD WBC-10.9 RBC-4.35 Hgb-13.3 Hct-38.9
MCV-89 MCH-30.5 MCHC-34.1 RDW-17.2* Plt Ct-138*
[**2129-7-20**] 01:55PM BLOOD Neuts-83.4* Lymphs-10.0* Monos-4.7
Eos-1.1 Baso-0.8
[**2129-7-20**] 01:55PM BLOOD PT-11.7 PTT-21.7* INR(PT)-1.0
[**2129-7-20**] 01:55PM BLOOD Glucose-54* UreaN-27* Creat-2.8* Na-144
K-4.1 Cl-106 HCO3-26 AnGap-16
[**2129-7-20**] 01:55PM BLOOD ALT-23 AST-35 LD(LDH)-291* CK(CPK)-141
AlkPhos-86 TotBili-0.6
[**2129-7-20**] 01:55PM BLOOD CK-MB-10 MB Indx-7.1* proBNP-[**Numeric Identifier 88886**]*
[**2129-7-20**] 01:55PM BLOOD cTropnT-0.20*
[**2129-7-20**] 09:22PM BLOOD CK-MB-11* MB Indx-8.3* cTropnT-0.28*
[**2129-7-21**] 05:44AM BLOOD CK-MB-9 cTropnT-0.22*
[**2129-7-20**] 09:22PM BLOOD Calcium-7.2* Phos-3.7 Mg-1.8
[**2129-7-21**] 05:44AM BLOOD Triglyc-150*
[**2129-7-21**] 05:44AM BLOOD TSH-51*
.
2. Labs on discharge:
Test Name Value Reference Range Units
[**2129-8-3**] 07:30
COMPLETE BLOOD COUNT
White Blood Cells 7.6 4.0 - 11.0 K/uL
Red Blood Cells 3.26* 4.2 - 5.4 m/uL
Hemoglobin 10.0* 12.0 - 16.0 g/dL
Hematocrit 29.6* 36 - 48 %
MCV 91 82 - 98 fL
MCH 30.5 27 - 32 pg
MCHC 33.6 31 - 35 %
RDW 15.9* 10.5 - 15.5 %
Platelet Count [**Telephone/Fax (3) 88887**] K/uL

[**2129-8-3**] 07:30
RENAL & GLUCOSE
Glucose 138* 70 - 100 mg/dL
  IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
Urea Nitrogen 44* 6 - 20 mg/dL
Creatinine 3.8* 0.4 - 1.1 mg/dL
Sodium 138 133 - 145 mEq/L
Potassium 3.4 3.3 - 5.1 mEq/L
Chloride 101 96 - 108 mEq/L
Bicarbonate 26 22 - 32 mEq/L
Anion Gap 14 8 - 20 mEq/L
Calcium, Total 7.9* 8.4 - 10.3 mg/dL
Phosphate 2.5* 2.7 - 4.5 mg/dL
Magnesium 2.3 1.6 - 2.6 mg/dL

.
3. Imaging/diagnostics:
- CXR ([**2129-7-20**]):
1. Enlarged cardiac silhouette, may be due to pericardial
effusion and/or
cardiomyopathy, not optimally evaluated due to the bibasilar
opacities.
2. Bilateral mid-to-lower lung opacities likely represent
layering bilateral pleural effusions with overlying atelectasis,
underlying consolidation cannot be excluded.
.
- CXR ([**2129-7-22**]):
.
- Echocardiogram ([**2129-7-21**]):
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with distal
septal/anterior/apical hypokinesis. The remaining segments
contract normally (LVEF = 50%). No masses or thrombi are seen in
the left ventricle. The right ventricular cavity is mildly
dilated with focal hypokinesis of the apical free wall. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.

IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Moderate aortic regurgitation. Mild mitral
regurgitation. Small circumferential pericardial effusion
without signs of tamponade. Bilateral pleural effusions with
atelectatic lung.
.
- Upper extremity ultrasound ([**2129-7-22**]):
Extensive soft tissue edema, without focal fluid collection.
These findings could reflect cellulitis. Clinical correlation is
advised.
.
- CXR ([**2129-7-25**]):
In comparison with the study of [**7-24**], there is no evidence of
pneumomediastinum or pneumothorax. Bibasilar opacification is
consistent with pleural effusions, compressive atelectasis, and
increased pulmonary venous pressure or pulmonary edema. Some of
the diffuse opacification could represent aspiration.
.
- EGD ([**2129-7-25**]):
A 4cm pedunculated gastric polyp was found at the pylorus,
prolapsing into duodenum. The tip of the polyp was erythematous
and ulcerated. An endoloop was placed at the base of the polyp
and the polyp was pulled into the stomach for better
visualization.
A single-piece polypectomy was then performed using a hot snare
in the gastric polyp. The polyp was completely removed. There
was no evidence of bleeding from the polypectomy site.
Two additional smalll polyps (<1cm) were found in the stomach
body.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear was seen at the GE junction, continuing
into the cardia.  There was no evidence of bleeding initially,
however at the end of the procedure, there was a moderate amount
of fresh blood seen arising from the GE junction.  The area was
flushed with water vigorously, and the bleeding appeared to stop
spontaneously.
Otherwise normal EGD to 3rd portion of duodenum.


Brief Hospital Course:
76 yo F with CKD on HD, h/o CVA, h/o RCC s/p nephroctomy
presents after recently initiating hemodialysis with GI bleed
transferred to [**Hospital Unit Name 153**] for hypoxic respiratory failure requiring
intubation, found to have troponin leak, also found to have
profound hypothyroidism and ?MSSA bacteremia.

# Hypoxic respiratory failure.
CXR on admission to [**Hospital1 18**] most consistent with fluid overload,
potentially from flash pulmonary edema in the setting of demand
ischemia. Echocardiogram showed pericardial effusion without
tamponade. Ultrafiltration and hemodialysis performed with
marked improvement in respiratory status. Patient successfully
extubated without complication.  She continued to have large
pleural effusions and oxygen requirement of 3L NC on the floor.
Ultrafiltration was limited by blood pressures; because pt's
blood pressures could not tolerate pulling off significant
volume, she will require rehabilitation stay for period of time
until enough fluid is removed to decrease oxygen requirement
back to baseline.  Pt does not require oxygen at home.

# ?NSTEMI vs Demand Ischemia
Cardiac enzymes elevated with troponin 0.22 on admission and
downtrended slowly, likely secondary to demand ischemia in
setting of GI bleed.  She may have otherwise had an NSTEMI prior
to presentation. Echocardiogram showed mild regional left
ventricular systolic dysfunction with distal
septal/anterior/apical hypokinesis. EKG was noted for anterior
Qs in V1 V2 and TWI in V1-V4. Patient was asymptomatic.  Patient
was not given ASA or heparin in setting of her GIB.  Beta
blocker (metoprolol) and captopril were started.  She continued
on home rosuvastatin.  Aspirin 81mg and Plavix 75mg were held
temporarily due to the risk of reemergent GI bleed. Per GI
recommendations, the patient was started on Aspirin 81mg daily
[**7-29**], while hematocrit continued to be stable, and she was
transitioned from Aspirin 81mg to Plavix 75mg on [**8-2**]. She was
also transitioned from captopril as an inpatient to lisinopril
as an outpatient as its long half-life allows for once-daily
dosing.

# GI bleed.
Patient was transfered to [**Hospital1 18**] from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in setting of
GI bleed with known gastric polyp.  Gastric polyp and pyloric
channel polyp biopsied at OSH, with pathology result showing
tublar adenoma. Patient was hemodynamically stable throughout
without bleeding. Maintained on IV pantoprazole 40 mg [**Hospital1 **].
Required 1 unit of pRBC transfusion for Hct drop of ~ [**10-15**]
points over the course of [**2-6**] days but no obvious melena or
BRBPR.  GI was consulted and performed EGD with removal of
polyp. Patient also noted to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear at the GE
junction which was bleeding when endoscope was removed. Patient
had one episode of hematemesis after EGD but stayed
hemodynamically stable. Tranfused a total of 2 units pRBC during
dialysis. Plavix 75mg was restarted in [**8-2**] for stroke risk.

# MSSA Bacteremia/hypotension:
[**2-8**] Blood cultures on presentation to [**Hospital1 18**] grew Methicillin
Sensitive Staph Aureus.  Patient was recently initiated on
hemodialysis through left arm fistula, although transplant
surgery does not believe the site to be infected.  U/S of the
extremity showed edema but no abscess.  Echocardiogram showed AR
and MR, but there is no history of echocardiogram at PCP's
office for comparison.  No blood culture was done in the OSH.
She was initially started on vancomycin for presumed MRSA, which
then transitioned to cefazolin for MSSA and ease of dosing with
dialysis.  ID was consulted and recommended 2-week course.
Cefazolin was dosed at dialysis as follows: 2g IV Mondays after
HD, 2g IV Wednesdays after HD, 3g IV on Fridays after HD.  The
course was completed with the last dose of cefazolin was given
[**2129-8-3**].

# Hypothyroidism
Patient was found to have TSH>50, for which she was started on
levothyroxine 50mcg daily.  TFTs should be rechecked in 5 weeks
as an outpatient.

# Thrombocytopenia.
She was noted to have an acute drop of platelets by half in the
MICU since her admission to the hospital.  Patient did not
receive heparin products while in this hospital given her GIB.
Per nephrology, heparin was not being used with her
ultrafiltration.  It is unclear if she got heparin at the OSH.
Medications such as vancomycin and PPI could also potentially
cause thrombocytopenia, and patient is now on Cefazolin.  PPI
was continued in setting of her GI bleed. Anti-PF4 antibody was
negative and platelet counts improved spontaneously.

# Chronic/End-stage renal failure on Hemodialysis.
Patient was recently started on dialysis (2 session) by the time
of her transfer to the ICU. Outpatient nephrologist reported
recent [**Doctor First Name **]/ANCA nephropathy from ?hydralazine. Baseline
creatinine 8.5. Renal team was consulted and started
hemodialysis Monday/Wednesday/Friday.  Epo was held off given
the history of renal cell carcinoma.  PPD was placed and read as
negative, and patient was set up for outpatient hemodialysis on
M/W/F schedule in [**Hospital1 **].  She does have a left arm hematoma
near the site of her AV fistula which has been stable and does
not disrupt use of the fistula for hemodialysis.

# H/o CVA.
Continued on Rosuvastatin Calcium 40 mg po daily and held off on
plavix in the setting of the GI bleed.  Plavix was restarted on
[**8-2**].

# HTN.
As her clinical pictures, her SBP also improved, requiring
reinitiation of the beta blocker.  She was started on metoprolol
as well as captopril, and will switch from captopril to
lisinopril at discharge.

# CODE STATUS:

# Health Care Proxy = son [**Name (NI) **] [**Name (NI) 54371**] [**Telephone/Fax (1) 88888**]

Transition of Care Issues:
[ ] Discuss epo with outpatient nephrologist
[ ] Need TSH/T3/free T4 checked in 5 weeks
[ ] Taper PPI after 8 weeks at 40mg [**Hospital1 **]
[ ] Repeat EGD in 3 months to confirm adequate removal of polyp
[ ] Pathology report from gastric polyp

Medications on Admission:
Upon transfer from [**Hospital **] Hospital:
- labetolol 100 mg po BID
- Crestor 40 mg daily
- Vitamin B12 1000 mcg po daily
- Renvela 800 mg with meals TID
- Sodium bicarb 648 mg po TID
- Prilosec 20 mg po BID
- nephrocaps 1 cap daily
- Tylenol 650 mg q6h prn
- Ambien 5 mg po qHS prn
- Zofran 4 mg IV q6h prn
.
Home medications (per OSH record)
- labetolol 200 mg [**Hospital1 **]
- Crestor 40 mg daily
- Plavix 75 mg daily
- Calcitriol 0.25 mcg daily
- B12 1000 mcg daily


Discharge Medications:
1. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for SOB.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation every 4-6 hours as needed
for SOB.
8. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Outpatient Lab Work
Please check CBC, Chem-10 daily while on hemodialysis.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)

Discharge Diagnosis:
Primary Diagnoses:
End Stage Renal Disease on Hemodialysis
Demand Ischemia
Upper Gastrointestinal Bleed secondary to gastric polyp
Pleural Effusions




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


Discharge Instructions:
Dear Ms. [**Known lastname 54371**],
You were admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital to start
hemodialysis, but there you started bleeding from your gastric
polyp, so they transfered you to the [**Hospital1 18**].  Here, you were
having significant difficulty breathing in the Emergency [**Hospital1 **],
so you were intubated and placed on a ventilator machine for one
day in the medical intensive care unit.  With another round of
hemodialysis, they were able to take off enough fluid to make
your breathing better, so the tube could be removed without any
difficulties.

You also had an endoscopy in the intensive care unit during
which we removed a large bleeding polyp in your stomach.  You
were also found to have a tear in your esophageal mucosa, called
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear, which could have also caused some of the
bleeding.   You were given two units of blood transfusion.
Your blood counts have been stable.

Dear Ms. [**Known lastname 54371**],
You were admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital to start
hemodialysis, but there you started bleeding from your gastric
polyp, so they transfered you to the [**Hospital1 18**].  Here, you were
having significant difficulty breathing in the Emergency [**Hospital1 **],
so you were intubated and placed on a ventilator machine for one
day in the medical intensive care unit.  With another round of
hemodialysis, they were able to take off enough fluid to make
your breathing better, so the tube could be removed without any
difficulties.

In evaluation of your gastrointestinal bleed an endoscopy was
performed in the intensive care unit during which we removed a
large bleeding polyp in your stomach.  You were also found to
have a tear in your esophageal mucosa, called [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]
tear, which could have also caused some of the bleeding.   You
were transfused two units of blood after which your blood counts
have been stable.

There is some question of whether or not you had a small heart
attack before you came into our hospital.  You should have your
primary care doctor set you up with a cardiologist after you go
home.

The following changes have been made to your medications:
1. please stop your labetalol
2. please stop your calcitriol
3. please start protonix (pantoprazole) 40 mg every 12 hours
4. please start metoprolol tartrate 37.5mg every 12 hours
  *** please hold metoprolol on mornings before dialysis ***
5. please start lisinopril 10 mg once daily
6. please start levothyroxine 50 micrograms daily (please take
this medication on an empty stomach an hour prior to taking your
other medications)
.
Again it was a pleasure taking care of you. Please contact with
questions or concerns.


Followup Instructions:
Please be sure to keep all of your followup appointments.
You will be discharged to Rehab, but after you return home,
please set up an appointment with your primary care physician,
[**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as soon as possible.
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 13553**]

Please also have your primary care physician set you up with a
cardiologist after you are discharged.

Please also be sure to follow up with AV Care for your fistula.
You may have an area of narrowing with part of your fistula, so
you will need a study called a fistulagram to further evaluate
whether or not you will need a procedure to fix it.
Please follow up with AV care within the next month:
([**Telephone/Fax (1) 87407**]

FMC - [**Location (un) 1121**] Dialysis Center
[**Street Address(2) 88889**]
[**Hospital1 **] [**Numeric Identifier 26668**]
Phone: [**Telephone/Fax (1) 30127**]
Nephrologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Outpt hd schedule will be every Mon, Wed & Fri at 5:00pm

Department: DIV. OF GASTROENTEROLOGY
When: THURSDAY [**2129-9-8**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage



Completed by:[**2129-8-6**]
{'Acute respiratory failure,Acute diastolic heart failure,End stage renal disease,Bacteremia,Acute posthemorrhagic anemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Benign neoplasm of stomach,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Renal dialysis status,Personal history of malignant neoplasm of kidney,Other specified cardiac dysrhythmias,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}


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 bleed
Respiratory distress

PRESENT ILLNESS: (History obtained from son and OSH record)
76 yo F with history of CKD recently started on hemodialysis (2
cycles as of [**7-20**]), h/o CVA x2, h/o RCC s/p nephrectomy, and
recent known [**Hospital **] transferred from the OSH to the ICU for planned
GI work-up; however, was in respiratory distress requiring
intubation in the [**Hospital1 **] ED.
.
Per the son, she has been having increased lethargy, decreased
energy, as well as LE swelling.  Patient reported having had at
least 1 week of melena and 1 day of hematemesis on [**2129-7-15**].
This led to her admission to [**Hospital **] Hospital on [**2129-7-15**].
At the OSH ED, she was noteded to have BRBPR and initial Hct of
25.3 from 30.5 on [**7-12**] and 34.4 on [**6-7**].  Per OSH record, her NG
lavage in the ED was negative.  Her hemodynamics remained
stable.  Subsequently, she was on Protonix gtt and IV hydration
with GI consult.  Her plavix was held.  She apparently underwent
an endoscopy by DR. [**Last Name (STitle) 30885**], which showed a bleeding friable
large pyloric channel stalk polyp 4-5 cm as well as gastric
mucosal friability.  Per discharge summary, patient vomited
blood on [**7-19**] and received DDAVP.  During her time in the OSH,
she was initiated on hemodialysis per her nephrologist's
recommendations.  Per the son, patient was supposed to be
transferred over on [**7-19**] but did not get here until [**7-20**].
.
Per the son, she had a colonoscopy that was not remarkable,
except for polyps, last year.
.
Patient received a cycle of dialysis today before transfer.
.
Per ED report, patient became hypoxic en route to the 70s to
endoscopy, so was rerouted to the ED.  At triage, HR 69, BP
167/66, RR 25, O2Sat 85% on BiPAP.  There was concern of
pneumonia vs. fluid overload.  She was placed on BiPAP then was
intubated for hypoxic respiratory distress on fentanyl and
propofol.  Apparently, OG tube lavage did not show blood.  Per
ED report, patient had a living will from [**2117**] with DNR/DNI, but
this was discussed with patient prior to intubation, and she
agreed to it.  She was given protonix 80 mg IV 1x, vancomycin,
levofloxacin, and zosyn.  Nephrology and GI were made aware of
her.  Bedside echocardiogram showed small pericardial effusion
with left sided pleural effusion.  Upon transfer, HR 58, BP
142/58, RR 16, O2Sat 100% on FiO2 80%, TV 400, RR set 18, and
PEEP of 10 with fentanyl and propofol for sedation.
.
In the [**Hospital Unit Name 153**], she was quickly extubated without complication on
[**7-21**] after HD ultrafiltration. She has been on 2L NC since. Echo
showed EF 50% with apical hypokinesis attributed NSTEMI during
this admission although trop elevations are only modest
considering renal function and CK/MB not elevated. EKG notable
for non-specific t-wave changes. She is on plavix as an outpt
for hx of CVA, but this has been held in setting of GIB.
.
In terms of her GI bleed, she was found to have a large polyp
leading to obstruction of pylorus. She was transfused [**2129-7-23**] 1
unit of pRBCs. Patient also noted to have bleeding [**Doctor First Name **]-[**Doctor Last Name **]
tear on EGD on Monday [**2129-7-25**], after which she had 20 cc
hematemesis but has had none since and has been hemodynamically
stable the entire hospitalization throughout [**Hospital Unit Name 153**] stay. She has
been on [**Hospital1 **] IV PPI, transitioned to PO PPI today and tolerating
po intake. Her last transfusion was today [**7-27**] with HD, at which
time she got 1 unit PRBC. She has received total 2 units (one
today, one on [**7-23**]).
.
Her course was also complicated by MSSA bacteremia and a
hematoma next to her AV fistula. Blood cultures drawn on
admission to [**Hospital1 18**] grew MSSA, one out of four bottles. She is on
cefazolin with Hemodialysis (2/2/3 g after HD on M/W/F, today
day 7 of 14 - last day [**8-3**]). Initial concern for infected
fistula given mild tenderness but ultrasound ok and vascular
felt it was very unlikely (no graft). Subsequent cultures x 6
days no growth to date.
.
She also had thrombocytopenia and Plt 142 on presentation, that
decreased to nadir of 69. Patient has not been on heparin at
[**Hospital1 18**], but unclear if received at OSH or with hemodialysis. PF4
neg. Plts since rose to 110.
In terms of ESRD, patient received HD session prior to transfer
to the floor.
Vitals in [**Hospital Unit Name 153**] prior to transfer to floor were as follows: T
98.7, BP 128/64, P 70, RR 14, O2sat 99% 2L. Pt arrived at the
floor with no complaint of pain.

MEDICAL HISTORY: (per [**Hospital **] Hospital record)
- Upper GIB from bleeding large pyloric channel stalk polyp with
diffuse gastric friability
- Lower GIB
- history of CVAs x2, was on plavix (until OSH admission.
Initially on ASA-> Plavix.  Did not tolerate Aggrenox per OSH
record)
- CKD stage 4, on dialysis (2 cycles as of [**7-20**])
- h/o renal cell cancer s/p nephrectomy
- HTN
- HLD
- Anemia of chronic disease

MEDICATION ON ADMISSION: Upon transfer from [**Hospital **] Hospital:
- labetolol 100 mg po BID
- Crestor 40 mg daily
- Vitamin B12 1000 mcg po daily
- Renvela 800 mg with meals TID
- Sodium bicarb 648 mg po TID
- Prilosec 20 mg po BID
- nephrocaps 1 cap daily
- Tylenol 650 mg q6h prn
- Ambien 5 mg po qHS prn
- Zofran 4 mg IV q6h prn
.
Home medications (per OSH record)
- labetolol 200 mg [**Hospital1 **]
- Crestor 40 mg daily
- Plavix 75 mg daily
- Calcitriol 0.25 mcg daily
- B12 1000 mcg daily

ALLERGIES: Hydralazine / Heparin,Porcine

PHYSICAL EXAM: On admission:
Vitals: T:97.1 BP:109/67 P:77 R:17 O2: 97%, CMV Vt450, PEEP 10,
RR set at 18
General: intubated
HEENT: Sclera anicteric, MMM
Neck: supple, no LAD
Lungs: bronchial breath sounds, clear to auscultation, no w/c/r
appreciated
CV: RRR, normal S1 and S2, soft [**2-10**] holosystolic and diastolic
murmur, no rub or gallops
Abd: soft, NT, ND, BS present, no guarding, no organomegaly, +
old scar
GU: Foley draining clear urine
Ext: Cool extremities, 1+ edema to the thighs, 2+ DP and radial
pulses bilaterally, no clubbing or cyanosis.

FAMILY HISTORY: - father deceased at 66 with MI
- mother deceased at 91 to colon cancer
- 1 sister is in good health

SOCIAL HISTORY: - lived at home with son
- has 3 grown children: son [**Name (NI) **], daughter [**Name (NI) **] and another
daughter
- no tobacco or alcohol use per son
- has been physically inactive for at least 1 year
- stays at home most of the time, but has a good friend that she
talks to twice a day 

### Response:
{'Acute respiratory failure,Acute diastolic heart failure,End stage renal disease,Bacteremia,Acute posthemorrhagic anemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Benign neoplasm of stomach,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Renal dialysis status,Personal history of malignant neoplasm of kidney,Other specified cardiac dysrhythmias,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}
