CHIEF COMPLAINT: melena/BRBPR

PRESENT ILLNESS: 47 year old male with history of AVR w/ St. Jude's valve (in
[**2173**]) on coumadin, CHF, HLD, OSA on BiPAP, asthma, recent
admission for Asthma flare and low hemoglobin at [**Hospital 27217**]
Hospital, presents with four episodes of bright red bloody
stools.
.
Patient reports an episode of melena at 8am today.  He had a
subsequent large volume liquid bowel movement that was bright
red two hours later, and two further episodes.  He complains of
nausea earlier with the bowel movements as well as LUQ abdominal
cramps.  He denies shortness of breath, lightheadedness, chest
pain, nausea, vomiting, and hematemesis.  He presented initially
to [**Hospital3 26615**].  His labs were notable for INR: 3.8, Hct 31
(down from prior 41, one week ago).  He received 10 vit K, 40 MG
protonix, and 2 units of FFP.  He was transferred to [**Hospital1 18**] for
further management.
.
At [**Hospital1 18**] ED, his initial VS were: T 99.7, HR 78, BP 136/71, RR
18, O2 98%.  On exam he was guaiac +.  His labs were notable
for: Hct 27.5 (MCV 74), WBC 8.5, Plt 330, INR 2.4, Na 141, K
3.8, Cl 104, HCO3 29, BUN 20, Cr 0.9.  He was started on a
protonix gtt, tylenol x1 for h/a, 1L NS, and was written for
2units pRBC which he has not received yet.  His VS remained
stable HR 70-80s, SBP 120s-130s.  GI and cardiology were
consulted in the ED.  Plan was to admit to MICU for further work
up of GI bleed, likely colonoscopy in the AM, and to start
heparin gtt when INR<2.  On transfer, he has 2 18g pivs and 1
20g piv.  He is full code.
.
Of note, patient states that he recently had an asthma flare,
requiring frequent albuterol rescue inhalers as well as steroid
taper.  He went to [**Hospital 27217**] Hospital for this and was found to
have a hemoglobin of 6.  He was transfused a total of 4units of
pRBC.  He had a CT head/abd/pelvis that were negative.  He had a
colonoscopy that showed AVMs, not felt to be the source of
bleeding.  He had an EGD that was normal, and was discharged
with a plan for capsule endoscopy as an outpatient.  Of note, he
recently cracked a tooth and had an extraction.  He had been
taking 800mg ibuprofen tid for 14 days.
.
Currently, patient c/o anxiety and headache.

MEDICAL HISTORY: Microcytic anemia
CAD s/p St. [**Male First Name (un) 923**] mechanical AVR in [**2173**] (on coumadin) and 1v
CABG (LIMA to LAD) in [**2175**] on coumadin
CHF- had recent echo at [**Hospital 27217**] hospital; had recent stress
test and cardiac catheterization w/in past 6months that was
negative
Asthma- s/p recent flare on steroids, admitted to [**Hospital 27217**]
hospital 2 weeks ago, has never been intubated
OSA on BiPap
DM, controlled with diet
HTN
HLD
Recent dental extraction
Anxiety, depression

MEDICATION ON ADMISSION: Coumadin 5mg daily
Nexium 40mg daily
Crestor 40mg daily
Lasix 40mg daily
Vesicare 10mg 4 tablets daily
Celexa 40mg daily
Dulera 100mcg-5mcg daily
Albuterol 90 mcg q4-6hours
Iron

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMISSION EXAM
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Opening click, normal S1 + S2, regular
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, mildly-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, gait deferred

FAMILY HISTORY: Mother: had chron's disease passed away of lymphoma
Father: passed away, had dementia
Sister: bicuspid aortic valve
Grandmother with Crohns and brother with unspecified IBD

SOCIAL HISTORY: Works as a manager for [**Company **]
- Tobacco:  quit 3 yrs ago, used to smoke <1ppd for 20 years
- Alcohol:  social, weekends only
- Illicits:  none
Angiodysplasia of intestine with hemorrhage,Acute posthemorrhagic anemia,Hypovolemia,Heart valve replaced by other means,Long-term (current) use of anticoagulants,Benign neoplasm of colon,Iron deficiency anemia secondary to blood loss (chronic),Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Asthma, unspecified type, unspecified,Aortocoronary bypass status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of tobacco use,Anticoagulants causing adverse effects in therapeutic use
Angio intes w hmrhg,Ac posthemorrhag anemia,Hypovolemia,Heart valve replac NEC,Long-term use anticoagul,Benign neoplasm lg bowel,Chr blood loss anemia,Hyperlipidemia NEC/NOS,Obstructive sleep apnea,Asthma NOS,Aortocoronary bypass,DMII wo cmp nt st uncntr,Hypertension NOS,History of tobacco use,Adv eff anticoagulants
Admission Date:  [**2187-4-1**]              Discharge Date:   [**2187-4-4**]

Date of Birth:  [**2139-7-21**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
melena/BRBPR

Major Surgical or Invasive Procedure:
Colonoscopy
Capsule endoscopy

History of Present Illness:
47 year old male with history of AVR w/ St. Jude's valve (in
[**2173**]) on coumadin, CHF, HLD, OSA on BiPAP, asthma, recent
admission for Asthma flare and low hemoglobin at [**Hospital 27217**]
Hospital, presents with four episodes of bright red bloody
stools.
.
Patient reports an episode of melena at 8am today.  He had a
subsequent large volume liquid bowel movement that was bright
red two hours later, and two further episodes.  He complains of
nausea earlier with the bowel movements as well as LUQ abdominal
cramps.  He denies shortness of breath, lightheadedness, chest
pain, nausea, vomiting, and hematemesis.  He presented initially
to [**Hospital3 26615**].  His labs were notable for INR: 3.8, Hct 31
(down from prior 41, one week ago).  He received 10 vit K, 40 MG
protonix, and 2 units of FFP.  He was transferred to [**Hospital1 18**] for
further management.
.
At [**Hospital1 18**] ED, his initial VS were: T 99.7, HR 78, BP 136/71, RR
18, O2 98%.  On exam he was guaiac +.  His labs were notable
for: Hct 27.5 (MCV 74), WBC 8.5, Plt 330, INR 2.4, Na 141, K
3.8, Cl 104, HCO3 29, BUN 20, Cr 0.9.  He was started on a
protonix gtt, tylenol x1 for h/a, 1L NS, and was written for
2units pRBC which he has not received yet.  His VS remained
stable HR 70-80s, SBP 120s-130s.  GI and cardiology were
consulted in the ED.  Plan was to admit to MICU for further work
up of GI bleed, likely colonoscopy in the AM, and to start
heparin gtt when INR<2.  On transfer, he has 2 18g pivs and 1
20g piv.  He is full code.
.
Of note, patient states that he recently had an asthma flare,
requiring frequent albuterol rescue inhalers as well as steroid
taper.  He went to [**Hospital 27217**] Hospital for this and was found to
have a hemoglobin of 6.  He was transfused a total of 4units of
pRBC.  He had a CT head/abd/pelvis that were negative.  He had a
colonoscopy that showed AVMs, not felt to be the source of
bleeding.  He had an EGD that was normal, and was discharged
with a plan for capsule endoscopy as an outpatient.  Of note, he
recently cracked a tooth and had an extraction.  He had been
taking 800mg ibuprofen tid for 14 days.
.
Currently, patient c/o anxiety and headache.

Past Medical History:
Microcytic anemia
CAD s/p St. [**Male First Name (un) 923**] mechanical AVR in [**2173**] (on coumadin) and 1v
CABG (LIMA to LAD) in [**2175**] on coumadin
CHF- had recent echo at [**Hospital 27217**] hospital; had recent stress
test and cardiac catheterization w/in past 6months that was
negative
Asthma- s/p recent flare on steroids, admitted to [**Hospital 27217**]
hospital 2 weeks ago, has never been intubated
OSA on BiPap
DM, controlled with diet
HTN
HLD
Recent dental extraction
Anxiety, depression

Social History:
Works as a manager for [**Company **]
- Tobacco:  quit 3 yrs ago, used to smoke <1ppd for 20 years
- Alcohol:  social, weekends only
- Illicits:  none


Family History:
Mother: had chron's disease passed away of lymphoma
Father: passed away, had dementia
Sister: bicuspid aortic valve
Grandmother with Crohns and brother with unspecified IBD

Physical Exam:
ADMISSION EXAM
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Opening click, normal S1 + S2, regular
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, mildly-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, gait deferred

DISCHARGE EXAM
Vitals: T: m98.6, c97.8, BP: 132/88 P: 63 R: 18 O2: 95%RA
General: sleeping with BiPap on, drowsy, but arousable and A&Ox3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: short neck with significant adipose tissue, supple, JVP
could not be evaluated, no LAD
CV: RRR, Opening click loudest at LLSB, normal S1 + S2, III/VI
systolic murmur best over RUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: obese, soft, non-tender, nondistended, 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, gait normal

Pertinent Results:
Admission Labs:
[**2187-4-1**] 09:12PM BLOOD WBC-8.5 RBC-3.74* Hgb-8.2* Hct-27.5*
MCV-74* MCH-22.1* MCHC-29.9* RDW-22.8* Plt Ct-330
[**2187-4-1**] 09:12PM BLOOD Neuts-69.1 Bands-0 Lymphs-21.5 Monos-6.4
Eos-2.2 Baso-0.9
[**2187-4-1**] 09:12PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL
[**2187-4-1**] 09:12PM BLOOD PT-24.9* PTT-41.5* INR(PT)-2.4*
[**2187-4-1**] 09:12PM BLOOD Glucose-137* UreaN-20 Creat-0.9 Na-141
K-3.8 Cl-104 HCO3-29 AnGap-12
[**2187-4-1**] 09:12PM BLOOD ALT-55* AST-36 LD(LDH)-406* AlkPhos-96
TotBili-0.2
[**2187-4-2**] 04:42AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.0
[**2187-4-2**] 04:42AM BLOOD Hapto-18*

CBC trend:
[**2187-4-1**] 09:12PM BLOOD WBC-8.5 RBC-3.74* Hgb-8.2* Hct-27.5*
MCV-74* MCH-22.1* MCHC-29.9* RDW-22.8* Plt Ct-330
[**2187-4-2**] 04:42AM BLOOD WBC-7.6 RBC-4.02* Hgb-9.3* Hct-30.2*
MCV-75* MCH-23.1* MCHC-30.7* RDW-22.3* Plt Ct-282
[**2187-4-2**] 10:16AM BLOOD Hct-29.6*
[**2187-4-2**] 07:29PM BLOOD WBC-9.9 RBC-4.10* Hgb-9.4* Hct-31.5*
MCV-77* MCH-22.9* MCHC-29.7* RDW-22.7* Plt Ct-329
[**2187-4-3**] 12:01AM BLOOD Hgb-9.8* Hct-32.8*
[**2187-4-3**] 05:35AM BLOOD WBC-7.9 RBC-4.00* Hgb-9.3* Hct-30.9*
MCV-77* MCH-23.2* MCHC-30.0* RDW-22.8* Plt Ct-333
[**2187-4-3**] 12:45PM BLOOD Hgb-9.5* Hct-32.5*
[**2187-4-3**] 09:18PM BLOOD Hgb-9.1* Hct-30.1*
[**2187-4-4**] 05:40AM BLOOD WBC-8.0 RBC-3.98* Hgb-9.4* Hct-31.1*
MCV-78* MCH-23.5* MCHC-30.0* RDW-22.9* Plt Ct-377

INR Trend:
[**2187-4-1**] 09:12PM BLOOD PT-24.9* PTT-41.5* INR(PT)-2.4*
[**2187-4-2**] 04:42AM BLOOD PT-29.3* PTT-91.7* INR(PT)-2.8*
[**2187-4-2**] 10:16AM BLOOD PT-25.8* PTT-37.6* INR(PT)-2.5*
[**2187-4-3**] 05:35AM BLOOD PT-20.3* INR(PT)-1.9*
[**2187-4-3**] 12:45PM BLOOD PT-18.8* INR(PT)-1.8*
[**2187-4-4**] 05:40AM BLOOD PT-17.1* PTT-33.1 INR(PT)-1.6*

TTg:
[**2187-4-3**] 12:01AM BLOOD tTG-IgA-3

Discharge labs:
[**2187-4-4**] 05:40AM BLOOD WBC-8.0 RBC-3.98* Hgb-9.4* Hct-31.1*
MCV-78* MCH-23.5* MCHC-30.0* RDW-22.9* Plt Ct-377
[**2187-4-4**] 05:40AM BLOOD PT-17.1* PTT-33.1 INR(PT)-1.6*
[**2187-4-4**] 05:40AM BLOOD Glucose-124* UreaN-8 Creat-0.8 Na-139
K-4.3 Cl-102 HCO3-30 AnGap-11
[**2187-4-4**] 05:40AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.2

[**2187-4-1**] ECG:Normal sinus rhythm. Left bundle-branch block.
Non-specific ST-T wave No previous tracing available for
comparison.  Read by: [**Last Name (LF) **], [**First Name3 (LF) **] P.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 156 154 420/446 63 97 -48

[**2187-4-2**]: Colonoscopy
Impression: Polyp in the sigmoid colon
Angioectasias in the cecum and sigmoid colon
Otherwise normal colonoscopy to cecum

[**2187-4-3**] Capsule Endoscopy - pending on discharge. Prelim report
showed AVM and angioectasias without blood in lumen

Brief Hospital Course:
47 year old male with history of AVR w/ St. Jude's valve (in
[**2173**]) on coumadin, CHF, HLD, OSA on BiPAP, asthma, recent
admission for asthma flare and low hemoglobin (suspected GIB) at
[**Hospital 27217**] Hospital, presents with melena followed by bright red
bloody stool.

# Gastrointestinal bleed: Given FFP and vitamin K at OSH, prior
to transfer. Patient was stablized with 2 units of pRBCs at
[**Hospital1 18**], and remained hemodynamically stable throughout the
admission. Colonoscopy showed 1 polyp and several angioectasias
throughout the colon. Capsule endoscopy final report was pending
at discharge, however preliminary report showed an AVM,
angioectasias and no evidence of blood in the small bowel. Acute
GI bleed was felt to be due to bleeding from AVM in the setting
of an elevated INR.
.
# Microcytic Anemia: MCV 75. This was felt to be due to chronic
gastrointestinal bleeding, likely from anticoagulation and
multiple AVMs, worsened acutely by significant GI bleed. Patient
had evidence of minimal intravascular hemolysis with an elevated
LDH and low haptoglobin, which was felt to be a result of being
given PRBCs. The patient received 2units of pRBCs on admission.
He was restarted on his home iron supplementation once work up
for GI bleed was complete. He will have a follow up CBC in
several days to ensure that his blood count is stable.
.
# Colonic Polyp: Single sessile 6 mm polyp of benign appearance
seen on colonoscopy, not intervened upon given high INR. Plan is
for patient for have a repeat colonoscopy in the next 6-12months
off warfarin and bridged with lovenox. Patient has GI followup
later this month.
.
# Aortic Valve Replacement: S/p [**Hospital3 **] prosthetic valve, on
Coumadin at home, and supratherapeutic INR on presentation to
OSH (which often fluctuates, per patient).  Goal INR ideally
[**2-16**]. Cardiology was consulted and felt that given valve location
(aortic) and type (bileaflet), it was appropriate not bridge
with heparin and permit INR to drift down in setting of a GI
bleed, with the thought that once the INR was <1.7, we could
start a heparin drip if still concerned for bleeding. Given the
patient was stable x2days without further signs of bleeding, he
was restarted on his home dose of warfarin on HD#2. He was
discharged with a Levonox bridge given subtherapeutic INR of
1.6. Dr. [**Last Name (STitle) **] will resume warfarin management and the patient
was instructed to have his INR checked 2 and 5 days
post-discharge.
.
# CHF: Echo at [**Location (un) 12918**] earlier this month showed EF 40-45% and
impaired LV relaxation. On admission, patient was hypovolemic
and showed no signs of volume overload after 2units of PRBCs. He
showed no signs of CHF during his hospitalization, thus his
Lasix was held. His lasix was not restarted on discharge, as he
did not appear to be requiring it.

# Asthma: Recent exacerbation, s/p prednisone taper. We
continued his home inhalers and he remained asymptomatic in the
hospital.

TRANSITIONS OF CARE ISSUES:
1. We discontinued the Lasix given clinical stability and no
signs of volume overload
2. Capsule endoscopy final report pending at discharge
3. Patient will need continued outpatient management of his INR
and warfarin dosing, as well as a follow up CBC which will be
drawn on [**2187-4-9**] and faxed to his PCP.
4. His PCP's office will call him with an appointment in the
next couple days. He knows to call Dr.[**Name (NI) 110211**] office if they do
not contact him in the next day.

Medications on Admission:
Coumadin 5mg daily
Nexium 40mg daily
Crestor 40mg daily
Lasix 40mg daily
Vesicare 10mg 4 tablets daily
Celexa 40mg daily
Dulera 100mcg-5mcg daily
Albuterol 90 mcg q4-6hours
Iron


Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours) as needed for shortness of breath or wheezing.
2. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. Dulera 200-5 mcg/actuation HFA Aerosol Inhaler Sig: One (1)
Inhalation Inhalation [**Hospital1 **] (2 times a day).
5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Outpatient Lab Work
Please check CBC and INR on [**2187-4-6**] and [**2187-4-9**] and fax
results to Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office (Phone: [**Telephone/Fax (1) 10508**]; Fax:
[**Telephone/Fax (1) 110212**])

8. enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg (1
syringe) Subcutaneous Q12H (every 12 hours).
Disp:*14 syringes* Refills:*0*
9. Ativan 1 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as
needed for anxiety: Do not drive or operate heavy machinery when
taking this medication.
Disp:*5 Tablet(s)* Refills:*0*
10. Vesicare 10 mg Tablet Sig: Four (4) Tablet PO once a day.
11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Lower Gastrointestinal bleed
Angioectasias in Colon
Anemia, Iron deficiency
Mechanical Aortic Valve


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


Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your stay at [**Hospital 61**] Hospital. You were admitted for anemia and blood in your
stool. You underwent a colonoscopy and a capsule endoscopy to
identify the source of the bleeding. No active bleeding was seen
however, a polyp and some vascular malformations were seen which
could be the cause of your bleeding. The bleeding stopped on its
own and your blood counts remained stable.

Please have your INR checked on Friday, [**4-6**] and [**4-9**] and send the results to Dr. [**Last Name (STitle) **], who will resume
management of your warfarin dosing and INR levels.

The following changes were made to your medications
1. We STOPPED your lasix as you did not need it. Please follow
up with your primary care doctor.
2. You were given 5 tablets of ativan for anxiety. Please take 1
tablet no more than every 6 hours as needed for anxiety. Do not
drive or operate heavy machinery when taking this medication.
3. START lovenox injections twice daily until your primary care
provider instructs you to stop.

Followup Instructions:
If you would like to receive you primary care at [**Hospital1 **], call #[**Telephone/Fax (1) 2010**]. This is the scheduling number for
[**Hospital6 733**] ([**Company 191**]). Let them know you are a new
patient and would like to establish care within the [**Hospital1 **] system.

*** Dr. [**Last Name (STitle) **] is working on an appointment for you. His office
staff will contact you at home to schedule an appointment. If by
tomorrow afternoon, you have not heard from Dr.[**Name (NI) 110211**] office
concerning an appointment date and time, please call them and
have them schedule you for an appointment within the next
week.***
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: THE MEDICAL GROUP
Address: [**Last Name (un) 15488**] [**Apartment Address(1) 31103**], [**Hospital1 420**],[**Numeric Identifier 15489**]
Phone: [**Telephone/Fax (1) 10508**]

Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2187-4-25**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 22337**], MD [**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
{'Angiodysplasia of intestine with hemorrhage,Acute posthemorrhagic anemia,Hypovolemia,Heart valve replaced by other means,Long-term (current) use of anticoagulants,Benign neoplasm of colon,Iron deficiency anemia secondary to blood loss (chronic),Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Asthma, unspecified type, unspecified,Aortocoronary bypass status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of tobacco use,Anticoagulants causing adverse effects in therapeutic use'}


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: melena/BRBPR

PRESENT ILLNESS: 47 year old male with history of AVR w/ St. Jude's valve (in
[**2173**]) on coumadin, CHF, HLD, OSA on BiPAP, asthma, recent
admission for Asthma flare and low hemoglobin at [**Hospital 27217**]
Hospital, presents with four episodes of bright red bloody
stools.
.
Patient reports an episode of melena at 8am today.  He had a
subsequent large volume liquid bowel movement that was bright
red two hours later, and two further episodes.  He complains of
nausea earlier with the bowel movements as well as LUQ abdominal
cramps.  He denies shortness of breath, lightheadedness, chest
pain, nausea, vomiting, and hematemesis.  He presented initially
to [**Hospital3 26615**].  His labs were notable for INR: 3.8, Hct 31
(down from prior 41, one week ago).  He received 10 vit K, 40 MG
protonix, and 2 units of FFP.  He was transferred to [**Hospital1 18**] for
further management.
.
At [**Hospital1 18**] ED, his initial VS were: T 99.7, HR 78, BP 136/71, RR
18, O2 98%.  On exam he was guaiac +.  His labs were notable
for: Hct 27.5 (MCV 74), WBC 8.5, Plt 330, INR 2.4, Na 141, K
3.8, Cl 104, HCO3 29, BUN 20, Cr 0.9.  He was started on a
protonix gtt, tylenol x1 for h/a, 1L NS, and was written for
2units pRBC which he has not received yet.  His VS remained
stable HR 70-80s, SBP 120s-130s.  GI and cardiology were
consulted in the ED.  Plan was to admit to MICU for further work
up of GI bleed, likely colonoscopy in the AM, and to start
heparin gtt when INR<2.  On transfer, he has 2 18g pivs and 1
20g piv.  He is full code.
.
Of note, patient states that he recently had an asthma flare,
requiring frequent albuterol rescue inhalers as well as steroid
taper.  He went to [**Hospital 27217**] Hospital for this and was found to
have a hemoglobin of 6.  He was transfused a total of 4units of
pRBC.  He had a CT head/abd/pelvis that were negative.  He had a
colonoscopy that showed AVMs, not felt to be the source of
bleeding.  He had an EGD that was normal, and was discharged
with a plan for capsule endoscopy as an outpatient.  Of note, he
recently cracked a tooth and had an extraction.  He had been
taking 800mg ibuprofen tid for 14 days.
.
Currently, patient c/o anxiety and headache.

MEDICAL HISTORY: Microcytic anemia
CAD s/p St. [**Male First Name (un) 923**] mechanical AVR in [**2173**] (on coumadin) and 1v
CABG (LIMA to LAD) in [**2175**] on coumadin
CHF- had recent echo at [**Hospital 27217**] hospital; had recent stress
test and cardiac catheterization w/in past 6months that was
negative
Asthma- s/p recent flare on steroids, admitted to [**Hospital 27217**]
hospital 2 weeks ago, has never been intubated
OSA on BiPap
DM, controlled with diet
HTN
HLD
Recent dental extraction
Anxiety, depression

MEDICATION ON ADMISSION: Coumadin 5mg daily
Nexium 40mg daily
Crestor 40mg daily
Lasix 40mg daily
Vesicare 10mg 4 tablets daily
Celexa 40mg daily
Dulera 100mcg-5mcg daily
Albuterol 90 mcg q4-6hours
Iron

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMISSION EXAM
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Opening click, normal S1 + S2, regular
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, mildly-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, gait deferred

FAMILY HISTORY: Mother: had chron's disease passed away of lymphoma
Father: passed away, had dementia
Sister: bicuspid aortic valve
Grandmother with Crohns and brother with unspecified IBD

SOCIAL HISTORY: Works as a manager for [**Company **]
- Tobacco:  quit 3 yrs ago, used to smoke <1ppd for 20 years
- Alcohol:  social, weekends only
- Illicits:  none 

### Response:
{'Angiodysplasia of intestine with hemorrhage,Acute posthemorrhagic anemia,Hypovolemia,Heart valve replaced by other means,Long-term (current) use of anticoagulants,Benign neoplasm of colon,Iron deficiency anemia secondary to blood loss (chronic),Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Asthma, unspecified type, unspecified,Aortocoronary bypass status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of tobacco use,Anticoagulants causing adverse effects in therapeutic use'}
