CHIEF COMPLAINT: Chest pain and anemia

PRESENT ILLNESS: 70 year old man with afib on coumadin, insulin dependent DM,
obseity, systolic and diastolic heart failure LVEF 40-45%, CAD
s/p CABG '[**93**], PTCA'[**15**], STEMI with BMS to the SVG-OM graft
[**2118-4-8**], presents with fatigue and dyspnea on exertion over past
week.  He was initially feeling well after discharge [**3-/2117**] and
began exercising and losing weight.  However, this past week
dyspnea increased and exertional capacity decreased.  He called
his cardiologist who thought he might be overdiuresed, therefore
his lasix and spironolactone were reduced to half prior doses.
Dyspnea worsened despite this change.  Then on the day of
admission he had 2 bowel movements, the second of which was dark
black.  The bowel movement was preceeded by crampy abdominal
pain.  He attempted to walk from the bathroom to the kitchen but
because acutely dyspneic.  He sat down and then developed chest
pain, took a nitro with relief.  Tried to walk again but the
chest pain returned, thus called EMS and was brought to an OSH.
There his chest pain was relieved by repeated nitroglycerin and
he was eventually started on a nitroglycerin drip.  Labs at OSH
were notable for HCT 25, INR 3.7, K 7.  Enroute to [**Hospital1 18**], his
SBP dropped with increasing nitro drip doses.

MEDICAL HISTORY: CAD s/p CABG in [**2093**], s/p cath in [**2103**] wiuth BMS to Lcx, [**2113**]
revealing a severe stenosis in the SVG to the OM s/p BMS x 3,
[**2115**] at [**Hospital1 112**] (patient says stent but unknown location)
IDDM
morbid obesity
COPD
sleep apnea on BiPAP
CHF, diastolic, with EF 71% per OSH reports
afib
HTN
CVA with right sided numbness
history of rheumatic fever

MEDICATION ON ADMISSION: 1. aspirin 325 mg DAILY
2. nitroglycerin 0.4 mg q5min PRN
3. furosemide 40 mg PO daily
4. lisinopril 10 mg PO DAILY
5. atorvastatin 80 mg PO DAILY
6. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: One Hundred (100) units Subcutaneous twice a day.
7. metformin 500 mg PO daily
8. venlafaxine 75 mg PO DAILY
9. warfarin 5 mg PO once a day.
10. pantoprazole 40 mg PO once a day.
12. ranolazine 1,000 mg PO twice a day.
13. clopidogrel 75 mg PO daily
14. isosorbide mononitrate 60 mg PO once a day.
15. metoprolol succinate 200 mg PO once a day.
16. spironolactone 25 mg PO once a day.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission exam:
Vitals: 98F 108/44 71 9 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation

FAMILY HISTORY: Adopted, unknown

SOCIAL HISTORY: Lives with wife and four children.  Worked as a carpenter.  No
tob/ETOH/IVDA.
Other specified gastritis, with hemorrhage,Acute kidney failure, unspecified,Other and unspecified coagulation defects,Acute on chronic systolic heart failure,Other acute and subacute forms of ischemic heart disease, other,Acute posthemorrhagic anemia,Atrial fibrillation,Hyperpotassemia,Chronic airway obstruction, not elsewhere classified,Morbid obesity,Long-term (current) use of anticoagulants,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Old myocardial infarction,Unspecified essential hypertension,Other late effects of cerebrovascular disease,Disturbance of skin sensation,Helicobacter pylori [H. pylori],Constipation, unspecified,Leukocytosis, unspecified,Other left bundle branch block,Diverticulosis of colon (without mention of hemorrhage),Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified
Oth spf gastrt w hmrhg,Acute kidney failure NOS,Coagulat defect NEC/NOS,Ac on chr syst hrt fail,Ac ischemic hrt dis NEC,Ac posthemorrhag anemia,Atrial fibrillation,Hyperpotassemia,Chr airway obstruct NEC,Morbid obesity,Long-term use anticoagul,DMII wo cmp nt st uncntr,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Old myocardial infarct,Hypertension NOS,Late effect CV dis NEC,Skin sensation disturb,Helicobacter pylori,Constipation NOS,Leukocytosis NOS,Left bb block NEC,Dvrtclo colon w/o hmrhg,Obstructive sleep apnea,Depressive disorder NEC
Admission Date:  [**2118-5-7**]              Discharge Date:   [**2118-5-19**]

Date of Birth:  [**2047-9-30**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Chest pain and anemia


Major Surgical or Invasive Procedure:
Colonoscopy and Upper Endoscopy

History of Present Illness:
70 year old man with afib on coumadin, insulin dependent DM,
obseity, systolic and diastolic heart failure LVEF 40-45%, CAD
s/p CABG '[**93**], PTCA'[**15**], STEMI with BMS to the SVG-OM graft
[**2118-4-8**], presents with fatigue and dyspnea on exertion over past
week.  He was initially feeling well after discharge [**3-/2117**] and
began exercising and losing weight.  However, this past week
dyspnea increased and exertional capacity decreased.  He called
his cardiologist who thought he might be overdiuresed, therefore
his lasix and spironolactone were reduced to half prior doses.
Dyspnea worsened despite this change.  Then on the day of
admission he had 2 bowel movements, the second of which was dark
black.  The bowel movement was preceeded by crampy abdominal
pain.  He attempted to walk from the bathroom to the kitchen but
because acutely dyspneic.  He sat down and then developed chest
pain, took a nitro with relief.  Tried to walk again but the
chest pain returned, thus called EMS and was brought to an OSH.
There his chest pain was relieved by repeated nitroglycerin and
he was eventually started on a nitroglycerin drip.  Labs at OSH
were notable for HCT 25, INR 3.7, K 7.  Enroute to [**Hospital1 18**], his
SBP dropped with increasing nitro drip doses.

Upon arrival to [**Hospital1 18**], he was chest pain free with VS 97.6
99/56, 74 16 97% 2L.  ECG showed a new LBBB, trop negative.
Labs notable for K 7.2 (not hemolyzed) and thus he received
calcium, D50/insulin, and kayexalate.  INR was 4.9.  GI was
called given HCT drop from 31 to 25 and made plans to scope in
the morning.  Rectal exam notable for brown stool guaiac
positive with specks of black stool.  Nitroglycerin drip was
stopped and his pain was controlled with morphine PRN.  He
received 1L NS.  Vitals prior to transfer 98.1 69 109/41 16 99%
RA pain 0.

On arrival to the MICU, he was initially comfortable, but then
developed chest pain prompting morphine 2mg x3 without relief.
SL nitro was given with improvement in pain.  ECG showed narrow
complex sinus rhythm with ST depressions in I, V4-V6.  He later
had another episode of pain relieved by SL nitroglycerin.

Past Medical History:
CAD s/p CABG in [**2093**], s/p cath in [**2103**] wiuth BMS to Lcx, [**2113**]
revealing a severe stenosis in the SVG to the OM s/p BMS x 3,
[**2115**] at [**Hospital1 112**] (patient says stent but unknown location)
IDDM
morbid obesity
COPD
sleep apnea on BiPAP
CHF, diastolic, with EF 71% per OSH reports
afib
HTN
CVA with right sided numbness
history of rheumatic fever

Social History:
Lives with wife and four children.  Worked as a carpenter.  No
tob/ETOH/IVDA.


Family History:
Adopted, unknown


Physical Exam:
Admission exam:
Vitals: 98F 108/44 71 9 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation

Discharge exam:
VS - 98.0, 98.6, 96/49 (94-145/48-71), 71 (52-81), 20, 100RA
GENERAL - Obese late-middle aged man in NAD. Oriented x3.
HEENT - NCAT. Oropharynx clear
NECK - Supple, unable to assess JVD due to habitus
CARDIAC -  RRR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS - CTAB, no crackles, wheezes or rhonchi.
ABDOMEN - Soft, obese NTND. No HSM or tenderness.
EXTREMITIES - WWP, no LE edema, no clubbing
SKIN - Multiple scars across lower extremities from vein
harvesting, some chronic stasis changes

Pertinent Results:
Admission Labs:
===============
[**2118-5-6**] 11:55PM BLOOD WBC-11.2* RBC-2.82* Hgb-8.0* Hct-24.7*
MCV-87 MCH-28.3 MCHC-32.3 RDW-19.2* Plt Ct-178
[**2118-5-6**] 11:55PM BLOOD Neuts-85.1* Lymphs-10.4* Monos-3.0
Eos-1.3 Baso-0.2
[**2118-5-6**] 11:55PM BLOOD PT-49.3* PTT-56.2* INR(PT)-4.9*
[**2118-5-6**] 11:55PM BLOOD Glucose-187* UreaN-78* Creat-1.9* Na-131*
K-7.2* Cl-99 HCO3-22 AnGap-17
[**2118-5-7**] 03:20AM BLOOD Calcium-9.6 Phos-4.1 Mg-2.6

Pertinent Labs:
===============
[**2118-5-6**] 11:55PM BLOOD cTropnT-<0.01
[**2118-5-7**] 03:20AM BLOOD CK-MB-4 cTropnT-0.02*
[**2118-5-7**] 08:55AM BLOOD CK-MB-5 cTropnT-0.04*
[**2118-5-7**] 10:58PM BLOOD CK-MB-4 cTropnT-0.05*
[**2118-5-12**] 10:50AM BLOOD Hapto-164
[**2118-5-12**] 10:50AM BLOOD LD(LDH)-195 TotBili-2.0* DirBili-0.5*
IndBili-1.5

HELICOBACTER PYLORI ANTIBODY TEST: POSITIVE BY EIA.
Urine culture [**5-9**]- no growth

Discharge Labs:
===============
[**2118-5-19**] 06:35AM BLOOD Hct-29.5*
[**2118-5-17**] 11:00AM BLOOD PT-11.9 PTT-33.3 INR(PT)-1.1
[**2118-5-18**] 11:10AM BLOOD Glucose-108* UreaN-21* Creat-1.1 Na-136
K-4.6 Cl-100 HCO3-28 AnGap-13
[**2118-5-18**] 11:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-3.2*

Micro/Path:
===========
URINE CULTURE (Final [**2118-5-10**]):    NO GROWTH.
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2118-5-9**]): POSITIVE BY
EIA.
MRSA SCREEN (Final [**2118-5-9**]):    No MRSA isolated.

Imaging/Studies:
================
CXR [**5-9**]- Status post sternotomy, with mild prominence of the
cardiomediastinal silhouette.  There is upper zone
re-distribution without overt CHF.  There is minimal atelectasis
at both bases.  No frank consolidation or effusion.

EKG [**5-9**]-  LBBB -> sinus rhythm narrow complex, ST depressions
V4-V6 and I, avL

EGD [**5-9**]- Nodularity in the whole stomach compatible with
nodular gastritis. Normal EGD to third part of the duodenum.

CT abd/pelvis [**5-12**]-
1.  No evidence of retroperitoneal bleed or acute
intra-abdominal process.
2.  Fatty infiltration of the liver.
3.  Cholelithiasis.
4.  Right renal cyst.

Colonoscopy [**2118-5-18**]:
Impression:
Grade 1 internal hemorrhoids
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum

Brief Hospital Course:
70 year old man with afib on coumadin, insulin dependent DM,
obseity, systolic and diastolic heart failure LVEF 40-45%, CAD
s/p CABG '[**93**], PTCA'[**15**], STEMI with BMS to the SVG-OM graft
[**2118-4-8**], presents with fatigue and dyspnea on exertion, found to
have hematocrit drop secondary to GI bleed.

ACTIVE DIAGNOSES:
=================
# Chest Pain: Demand ischemia in setting of GI bleed. He has
known coronary vascular disease with refractory angina that is
not amenable to intervention per cardiology team. No evidence of
consolidation or PTX on CXR to suggest pulmonary cause. Patient
was transfused a total of 8 units pRBCs; hematocrit initially
stabilized and when heparin gtt and coumadin were re-started,
hematocrit dropped again and chest pain returned without EKG
changes. He was continued on aspirin, plavix, and ranolazine.
Imdur was started at a lower dose than home dose given concern
for hypotension in setting of bleeding, but BP remained stable
so imdur was titrated up to his home dose. He then had return of
chest pain, with dynamic ST changes in V3-V5 and I/avL,
consistent with known non-intervenable areas of disease.  His
imdur was increased to 240mg and metoprolol was increased to
tartrate 150mg PO BID without further episodes of chest pain.

# UGIB/H.Pylori + Nodular Gastritis: On EGD, patient had
evidence of nodular gastritis with superficial erosions.
H.pylori returned positive and patient began triple therapy with
amoxicillin (not candidate for clarithromycin given interaction
with ranolazine), metronidazole and pantoprazole.  Coumadin was
held and INR was reversed with vitamin K.  Patient had ongoing
hematocrit drop without obvious bleeding once heparin drip was
restarted, so both coumadin and heparin were stopped.  Patient
will complete 2 weeks of triple therapy, then continue [**Hospital1 **]
pantoprazole.  He does not require GI follow-up or test of cure.
He also underwent colonoscopy which did not reveal an additional
or alternative source of his bleeding. If he continues to bleed,
the next step would be a capsule endoscopy. He will have a [**Hospital1 **]
check prior to his PCP appointment to assess his hematocrit.

# Acute blood loss anemia: Source suspected to be gastritis as
above. Coumadin was held on admission to the ICU and reversed
with vitamin K and FFP.  He was transfused a total of 8 units
during admission; initially 4 units in the ICU as he had an
inappropriate response to blood, then again on the floor as with
initiation of coumadin and bridge with heparin drip, patient's
hematocrit drifted down.  Haptoglobin and LDH were normal, and
indirect bilirubin was only slightly elevated (and was post
transfusion) so low suspicion for hemolysis.  With
discontinuation of heparin drip and coumadin, hematocrit
stabilized and patient did not require transfusion for >72 hours
prior to discharge.

# Constipation: Significantly constipated during admission.
Required 2 days of prep prior to his colonoscopy.  Patient
discharged on senna/colace/miralax to prevent further
constipation.

# Acute on chronic systolic heart failure:  On admission,
patient had mild pulmonary edema secondary to decreased lasix
and spironolactone dose over past week prior to admission.
Patient was diuresed in the ICU, and was euvolemic on transfer
to the floor. He was continued on home lasix 40mg daily, with
extra doses with transfusions. He had a few episodes of
orthostatic hypotension prompting decrease of his lasix dose to
20mg PO daily. Patient was euvolemic at the time of discharge,
and weight was stable at 120 kg.

# Hyperkalemia: 7.2 on admission likely secondary to ARF,
spironolactone, and lisinopril.  ECG improved to narrow complex
once potassium normalized. Potassium remained stable for
remainder of admission.  Spironolactone was not restarted, and
lisinopril was restarted at lower dose of 5mg PO daily.

# LBBB: Suspect metabolic etiology given improved with K
correction.  Trop negative suggesting against acute coronary
syndrome.  LBBB resolved after correction of K.

# Acute renal failure: Likely secondary to systolic CHF with
poor forward flow with second hit of poor perfusion due to acute
GIB. Patient's creatinine trended down and was 1.1 on day of
discharge.

# Leukocytosis: Unclear etiology, but may be due to stress of
GIB.  No evidence of infectious colitis, UA without evidence of
infection and no consolidation seen on CXR.  White count
resolved and remained normal for remainder of admission.

CHRONIC DIAGNOSES:
==================

# HLD: continued atorvastatin

# Depression: continued venlafaxine

# DMII: Blood sugar well controlled during admission.

Transitional issues:
# Spironolactone held on discharge given hyperkalemia to 7.2 on
admission.

# Coumadin held on discharge -> we anticipate holding this
medication for about a month while his gastritis heals with
protection against stroke with aspirin 325mg and plavix 75mg in
the interim.

# Lisinopril decreased to 5mg daily to prevent hyperkalemia and
increase pressure room to uptitrate Imdur to 240mg PO daily and
metoprolol to 150mg tartrate [**Hospital1 **]

# H.pylori triple therapy treatment to continue through [**2118-5-23**]

# Hematocrit and electrolytes should be rechecked by PCP at
[**Name9 (PRE) 702**] appointment, he has a script for this.

# Insulin decreased to 70/30 mix 80 units daily given in-house
hypoglycemia. We suggest setting him up with [**Last Name (un) **] for further
diabetes management but wanted him to discuss this with his PCP
[**Name Initial (PRE) **].

# Weight on discharge 120kg, discharged on furosemide 20mg
daily.

Medications on Admission:
1. aspirin 325 mg DAILY
2. nitroglycerin 0.4 mg q5min PRN
3. furosemide 40 mg PO daily
4. lisinopril 10 mg PO DAILY
5. atorvastatin 80 mg PO DAILY
6. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: One Hundred (100) units Subcutaneous twice a day.
7. metformin 500 mg PO daily
8. venlafaxine 75 mg PO DAILY
9. warfarin 5 mg PO once a day.
10. pantoprazole 40 mg PO once a day.
12. ranolazine 1,000 mg PO twice a day.
13. clopidogrel 75 mg PO daily
14. isosorbide mononitrate 60 mg PO once a day.
15. metoprolol succinate 200 mg PO once a day.
16. spironolactone 25 mg PO once a day.

Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ranolazine 500 mg Tablet Extended Release 12 hr Sig: Two (2)
Tablet Extended Release 12 hr PO BID (2 times a day).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
[**Name Initial (PRE) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.

7. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days.
[**Name Initial (PRE) **]:*12 Tablet(s)* Refills:*0*
9. amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 4 days.
[**Name Initial (PRE) **]:*16 Tablet(s)* Refills:*0*
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
[**Name Initial (PRE) **]:*30 Capsule(s)* Refills:*2*
12. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO
twice a day.
[**Name Initial (PRE) **]:*180 Tablet(s)* Refills:*2*
14. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Eighty (80) units Subcutaneous twice a day.
15. Imdur 60 mg Tablet Extended Release 24 hr Sig: Four (4)
Tablet Extended Release 24 hr PO once a day.
16. Miralax 17 gram Powder in Packet Sig: One (1)  PO once a
day.
[**Name Initial (PRE) **]:*30 packets* Refills:*2*
17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0*
18. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0*
19. Outpatient [**Name Initial (PRE) **] Work
Please obtain CBC, Chem 7 prior to your appointment.
Have the results communicated to your PCP:
[**Name Initial (NameIs) 7274**]: [**Name Initial (NameIs) **],[**Name Initial (NameIs) **]
Address: [**Hospital1 29147**], [**Location (un) **],[**Numeric Identifier 29160**]
Phone: [**Telephone/Fax (1) 29149**]
Fax: [**Telephone/Fax (1) 29155**]


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Primary diagnosis:
# Unstable Angina
# H. pylori + nodular gastritis with erosions
# Blood loss anemia

Secondary diagnosis:
# Coronary artery disease
# Atrial Fibrillation


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


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

It was a pleasure taking care of you! You were admitted to [**Hospital1 18**]
for evaluation and treatment of chest pain, shortness of breath,
and GI bleeding. You were found to have a low blood count likely
due to a slow bleed in your GI tract related to all of your
blood thinners and gastritis with erosions from H. pylori (a
bacteria that pre-disposes to gastritis and ulcers).  You were
started on a medication to protect your GI tract, treatment for
your infection, and you were given blood transfusions to improve
your blood counts. You underwent an upper endoscopy which showed
the inflammation of the stomach and erosions and a colonoscopy
which was without source of bleeding.

You also had an elevation in your potassium level, so your
spironolactone was discontinued.

We attempted re-starting anticoagulation but you began to bleed
again. As a result, your coumadin is being held until resolution
of your gastritis. We suggesting waiting a month or so until
resuming coumadin and would like to re-assure you that you are
recieving protection against stroke from your afib from your
aspirin and plavix.

The following changes were made to your medication regimen:
- START Metronidazole three times day through Monday [**2118-5-23**] to treat the infection in your stomach
- START Amoxicillin twice a day through Monday [**2118-5-23**] to
treat the infection in your stomach
- INCREASE pantoprazole to twice a day to protect your stomach
lining
- INCREASE Imdur to 240mg by mouth daily
- CHANGE to Metoprolol Tartrate 150mg by mouth twice daily
- DECREASE Lisinopril to 5mg daily
- DECREASE Lasix to 20mg daily
- DECREASE Insulin 70/30 to 80 units twice daily
- STOP Spironolactone
- STOP Coumadin -> you will have to discuss with your primary
care doctor restarting this medication about a month from now
once your gastritis has healed
- START Senna and Colace twice a day as needed for constipation
- START Miralax once daily as needed for constipation

Please follow up as suggested below.

Followup Instructions:
Name:[**Name6 (MD) **] [**Name8 (MD) **],MD
Specialty: Primary Care
Address: [**Hospital1 29147**], [**Location (un) **],[**Numeric Identifier 29160**]
Phone: [**Telephone/Fax (1) 29149**]
When: Tuesday, [**5-24**] at 3:15pm

-Please have your labs checked prior to this appointment, on
discharge your hematocrit was 29.5

Department: CARDIAC SERVICES
When: THURSDAY [**2118-5-26**] at 9:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2118-5-20**]
{'Other specified gastritis, with hemorrhage,Acute kidney failure, unspecified,Other and unspecified coagulation defects,Acute on chronic systolic heart failure,Other acute and subacute forms of ischemic heart disease, other,Acute posthemorrhagic anemia,Atrial fibrillation,Hyperpotassemia,Chronic airway obstruction, not elsewhere classified,Morbid obesity,Long-term (current) use of anticoagulants,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Old myocardial infarction,Unspecified essential hypertension,Other late effects of cerebrovascular disease,Disturbance of skin sensation,Helicobacter pylori [H. pylori],Constipation, unspecified,Leukocytosis, unspecified,Other left bundle branch block,Diverticulosis of colon (without mention of hemorrhage),Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified'}


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: Chest pain and anemia

PRESENT ILLNESS: 70 year old man with afib on coumadin, insulin dependent DM,
obseity, systolic and diastolic heart failure LVEF 40-45%, CAD
s/p CABG '[**93**], PTCA'[**15**], STEMI with BMS to the SVG-OM graft
[**2118-4-8**], presents with fatigue and dyspnea on exertion over past
week.  He was initially feeling well after discharge [**3-/2117**] and
began exercising and losing weight.  However, this past week
dyspnea increased and exertional capacity decreased.  He called
his cardiologist who thought he might be overdiuresed, therefore
his lasix and spironolactone were reduced to half prior doses.
Dyspnea worsened despite this change.  Then on the day of
admission he had 2 bowel movements, the second of which was dark
black.  The bowel movement was preceeded by crampy abdominal
pain.  He attempted to walk from the bathroom to the kitchen but
because acutely dyspneic.  He sat down and then developed chest
pain, took a nitro with relief.  Tried to walk again but the
chest pain returned, thus called EMS and was brought to an OSH.
There his chest pain was relieved by repeated nitroglycerin and
he was eventually started on a nitroglycerin drip.  Labs at OSH
were notable for HCT 25, INR 3.7, K 7.  Enroute to [**Hospital1 18**], his
SBP dropped with increasing nitro drip doses.

MEDICAL HISTORY: CAD s/p CABG in [**2093**], s/p cath in [**2103**] wiuth BMS to Lcx, [**2113**]
revealing a severe stenosis in the SVG to the OM s/p BMS x 3,
[**2115**] at [**Hospital1 112**] (patient says stent but unknown location)
IDDM
morbid obesity
COPD
sleep apnea on BiPAP
CHF, diastolic, with EF 71% per OSH reports
afib
HTN
CVA with right sided numbness
history of rheumatic fever

MEDICATION ON ADMISSION: 1. aspirin 325 mg DAILY
2. nitroglycerin 0.4 mg q5min PRN
3. furosemide 40 mg PO daily
4. lisinopril 10 mg PO DAILY
5. atorvastatin 80 mg PO DAILY
6. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: One Hundred (100) units Subcutaneous twice a day.
7. metformin 500 mg PO daily
8. venlafaxine 75 mg PO DAILY
9. warfarin 5 mg PO once a day.
10. pantoprazole 40 mg PO once a day.
12. ranolazine 1,000 mg PO twice a day.
13. clopidogrel 75 mg PO daily
14. isosorbide mononitrate 60 mg PO once a day.
15. metoprolol succinate 200 mg PO once a day.
16. spironolactone 25 mg PO once a day.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission exam:
Vitals: 98F 108/44 71 9 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation

FAMILY HISTORY: Adopted, unknown

SOCIAL HISTORY: Lives with wife and four children.  Worked as a carpenter.  No
tob/ETOH/IVDA. 

### Response:
{'Other specified gastritis, with hemorrhage,Acute kidney failure, unspecified,Other and unspecified coagulation defects,Acute on chronic systolic heart failure,Other acute and subacute forms of ischemic heart disease, other,Acute posthemorrhagic anemia,Atrial fibrillation,Hyperpotassemia,Chronic airway obstruction, not elsewhere classified,Morbid obesity,Long-term (current) use of anticoagulants,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Old myocardial infarction,Unspecified essential hypertension,Other late effects of cerebrovascular disease,Disturbance of skin sensation,Helicobacter pylori [H. pylori],Constipation, unspecified,Leukocytosis, unspecified,Other left bundle branch block,Diverticulosis of colon (without mention of hemorrhage),Obstructive sleep apnea (adult)(pediatric),Depressive disorder, not elsewhere classified'}
