CHIEF COMPLAINT: GI Bleed

PRESENT ILLNESS: In brief, Ms. [**Known lastname **] is an 83-year-old female with multiple
medical problems including ESRD on HD (MWF), DM2, PVD, Afib,
severe AS s/p mAVR (St. [**Known lastname 923**]'s valve), recurrent GIB [**2-10**]
diverticulosis s/p colectomy and [**Doctor Last Name **] procedure in [**2162**] with
continued GIBs, recently d/c'd from [**Hospital1 18**] after bleeding from
ostomy, now transfered from [**Hospital 1263**] Hospital after presenting
from rehab with approx ~1L of frank blood from ileostomy. Pt
noticed blood in ileostomy bag morning of presentation and
dropped SBPs into 80s (baseline 110-130s). Pt denies ever having
any abdominal pain, no pain around ileostomy site. Denies any
increased ileostomy output. Denies lightheadedness, weakness,
abd pain, CP, nausea, vomiting, fevers or chills.
.
Of note, most recent prior admission, pt was bleeding from
ostomy and found to have supratherapeutic INR of 6.6. After this
admission, INR goal changed to 2.5-3.0.
.
In the ED, initial VS were 98.1 84 102/52 16 100%RA. Received
3.5L NS and started receiving 1st unit PRBC. In the ED, SBPs
responded to fluids. Labs: INR 4.1, hematocrit 26.8 (similar to
baseline), plt 159. Cr 5.3 (ESRD on HD MWF, was 5.6 on [**9-13**]). GI
and colorectal surgery were consulted in the ED. VS on transfer
were 78, 115/73, 20, 98%RA.
.
During her ICU stay, pt was given 2U FFP and received 5U PRBC
total. EGD that showed gastritis, and colonoscopy that showed
diverticulosis in transverse and ascending colon, without a
specific source identified. However, likely bleed [**2-10**]
diverticuli as per GI. She was initially on protonix drip and
was later switched to daily PPIs.
.
The patient was also found to be hypocalcemic and given calcium
gluconate. Day 2 MICU patient spiked temp 101-102 and she became
hypotensive and associated AMS with hypotension, BPs minimally
responsive to 2.5 L IVF. She was started on Levo for <24hours,
she has poor peripheral access, unable to get CVL so Levo
administered through tunneled cath. Zosyn/Vanc started for
possible line infection, cultures negative and she remained
hemodynamically stable off pressors so ABx stopped, she was
given ABx for 3 days. Fever likely associated with transfusions.
AMS Required pressors <24hours. Unclear infection source,
patient Cdiff negative, blood cx still pending.
.
Upon transfer to the medicine floor, VSS with no acute bleeding.

MEDICAL HISTORY: 1. history of repeated GI bleeds: past work up revealing various
potential sources along her GI tract including small bowl AVM's,
colonic polyps, ascending and transverse colon diverticulosis.
Had L hemicolectomy with transverse colostomy and [**Doctor Last Name 3379**]
pouch in [**10/2162**] with pathology examination revealing
diverticulosis as the source of bleed.
2. Diastolic CHF (EF 65-75%) on 2L O2 at home
3. Severe AS s/p mechanical [**Year (4 digits) 1291**] [**12-14**], [**Hospital3 9642**]
4. HLD
5. ESRD on HD (MWF)
6. Hypothyroidism
7. Atrial fibrillation on amiodarone and coumadin
8. PVD
9. Diabetes Mellitus
10. HTN
11. [**2168-1-27**]: Stenting of left superficial femoral
artery/above-knee popliteal artery transition
12. [**2168-1-28**]: Left Calf Ulcer Debridement
13. [**2168-2-26**]: Left lower extremity wound debridement
14. [**2168-3-8**]: Split thickness skin graft from right thigh to left
lower calf
15. [**2168-4-19**]: left lower extremity angioplasty
16. [**2168-4-27**]: Debridement of eschar and bone from the posterior
aspect of the left heel
17. Bilateral TKR
18. Open cholecystectomy
[**76**]. ORIF right periprosthetic femur fracture with RLE plate [**2164**]
20. Left upper arm radiocephalic AV fistula [**2164**] , Left upper
arm arteriovenous graft angioplasty , L upper arm AV graft [**2165**]

MEDICATION ON ADMISSION: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY
5. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous
ASDIR (AS DIRECTED): As per sliding scale.
6. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS
7. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
9. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM

ALLERGIES: Protamine

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: She is an only child. Grandfather died of cancer but son is not
sure of what type. Three sons with htn.  Pt. denies any other
history of CA, DM, or HTN in her parents.

SOCIAL HISTORY: Denies tobacco, drug or illicit drug use. Discharged [**9-13**] to
rehab. Lives at home with husband and 53 year old son who
prepares her medications. Has been in the hospital or at rehab
for last 5 mos, Other sons lives in [**Name (NI) 47**] and [**Name (NI) 4565**],
daughter lives in [**Name (NI) 669**]. Pt is a retired work supervisor at
Veteran's Hospital in JP. Retired about 10 years ago.
Diverticulosis of colon with hemorrhage,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic diastolic heart failure,Compression of vein,Other colostomy and enterostomy complication,Acute posthemorrhagic anemia,Hypotension, unspecified,Febrile nonhemolytic transfusion reaction,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Peripheral vascular disease, unspecified,Abnormal coagulation profile,Thrombocytopenia, unspecified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypocalcemia,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Acquired absence of intestine (large) (small),Renal dialysis status,Heart valve replaced by other means,Other dependence on machines, supplemental oxygen,Knee joint replacement,Other postprocedural status,Personal history of colonic polyps,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Dvrtclo colon w hmrhg,End stage renal disease,Hyp kid NOS w cr kid V,Chr diastolic hrt fail,Compression of vein,Colstmy/enteros comp NEC,Ac posthemorrhag anemia,Hypotension NOS,Feb nonhemo transf react,Gstr/ddnts NOS w/o hmrhg,Periph vascular dis NOS,Abnrml coagultion prfile,Thrombocytopenia NOS,Atrial fibrillation,DMII wo cmp nt st uncntr,Hypocalcemia,Hypothyroidism NOS,Hyperlipidemia NEC/NOS,Acquire absnce intestine,Renal dialysis status,Heart valve replac NEC,Depend-supplement oxygen,Joint replaced knee,Post-proc states NEC,Prsnl hst colonic polyps,Abn react-procedure NEC
Admission Date:  [**2168-9-29**]              Discharge Date:   [**2168-10-12**]

Date of Birth:  [**2084-10-17**]             Sex:   F

Service: MEDICINE

Allergies:
Protamine

Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
GI Bleed

Major Surgical or Invasive Procedure:
Upper Endoscopy [**2168-9-30**]
Colonoscopy [**2168-9-30**]
Angiography- IR guided PICC line placement and HD Line change


History of Present Illness:
In brief, Ms. [**Known lastname **] is an 83-year-old female with multiple
medical problems including ESRD on HD (MWF), DM2, PVD, Afib,
severe AS s/p mAVR (St. [**Known lastname 923**]'s valve), recurrent GIB [**2-10**]
diverticulosis s/p colectomy and [**Doctor Last Name **] procedure in [**2162**] with
continued GIBs, recently d/c'd from [**Hospital1 18**] after bleeding from
ostomy, now transfered from [**Hospital 1263**] Hospital after presenting
from rehab with approx ~1L of frank blood from ileostomy. Pt
noticed blood in ileostomy bag morning of presentation and
dropped SBPs into 80s (baseline 110-130s). Pt denies ever having
any abdominal pain, no pain around ileostomy site. Denies any
increased ileostomy output. Denies lightheadedness, weakness,
abd pain, CP, nausea, vomiting, fevers or chills.
.
Of note, most recent prior admission, pt was bleeding from
ostomy and found to have supratherapeutic INR of 6.6. After this
admission, INR goal changed to 2.5-3.0.
.
In the ED, initial VS were 98.1 84 102/52 16 100%RA. Received
3.5L NS and started receiving 1st unit PRBC. In the ED, SBPs
responded to fluids. Labs: INR 4.1, hematocrit 26.8 (similar to
baseline), plt 159. Cr 5.3 (ESRD on HD MWF, was 5.6 on [**9-13**]). GI
and colorectal surgery were consulted in the ED. VS on transfer
were 78, 115/73, 20, 98%RA.
.
During her ICU stay, pt was given 2U FFP and received 5U PRBC
total. EGD that showed gastritis, and colonoscopy that showed
diverticulosis in transverse and ascending colon, without a
specific source identified. However, likely bleed [**2-10**]
diverticuli as per GI. She was initially on protonix drip and
was later switched to daily PPIs.
.
The patient was also found to be hypocalcemic and given calcium
gluconate. Day 2 MICU patient spiked temp 101-102 and she became
hypotensive and associated AMS with hypotension, BPs minimally
responsive to 2.5 L IVF. She was started on Levo for <24hours,
she has poor peripheral access, unable to get CVL so Levo
administered through tunneled cath. Zosyn/Vanc started for
possible line infection, cultures negative and she remained
hemodynamically stable off pressors so ABx stopped, she was
given ABx for 3 days. Fever likely associated with transfusions.
AMS Required pressors <24hours. Unclear infection source,
patient Cdiff negative, blood cx still pending.
.
Upon transfer to the medicine floor, VSS with no acute bleeding.

Patient is an 83-year-old female with multiple medical problems
including ESRD on HD (MWF), DM2, PVD, Afib, severe AS s/p mAVR
(St. [**Month/Day (2) 923**]'s valve), recurrent GIB treated with colectomy and
[**Doctor Last Name **] procedure in [**2162**] with continued GIBs after the
procedures who was transferred from [**Hospital 1263**] Hospital where she
presented from rehab with approx ~1L of frank blood from
ileostomy. Patient's pressures at rehab had been SBP 110-130s
until this morning when she first noted bleeding from ostomy;
changed the bag once at 11 am. SBP reportedly dropped to 80s.
Blood has since pooled while she was in the ED. Denies
lightheadedness, weakness, abd pain, CP, nausea, vomiting,
fevers or chills.

.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.

Past Medical History:
1. history of repeated GI bleeds: past work up revealing various
potential sources along her GI tract including small bowl AVM's,
colonic polyps, ascending and transverse colon diverticulosis.
Had L hemicolectomy with transverse colostomy and [**Doctor Last Name 3379**]
pouch in [**10/2162**] with pathology examination revealing
diverticulosis as the source of bleed.
2. Diastolic CHF (EF 65-75%) on 2L O2 at home
3. Severe AS s/p mechanical [**Year (4 digits) 1291**] [**12-14**], [**Hospital3 9642**]
4. HLD
5. ESRD on HD (MWF)
6. Hypothyroidism
7. Atrial fibrillation on amiodarone and coumadin
8. PVD
9. Diabetes Mellitus
10. HTN
11. [**2168-1-27**]: Stenting of left superficial femoral
artery/above-knee popliteal artery transition
12. [**2168-1-28**]: Left Calf Ulcer Debridement
13. [**2168-2-26**]: Left lower extremity wound debridement
14. [**2168-3-8**]: Split thickness skin graft from right thigh to left
lower calf
15. [**2168-4-19**]: left lower extremity angioplasty
16. [**2168-4-27**]: Debridement of eschar and bone from the posterior
aspect of the left heel
17. Bilateral TKR
18. Open cholecystectomy
[**76**]. ORIF right periprosthetic femur fracture with RLE plate [**2164**]
20. Left upper arm radiocephalic AV fistula [**2164**] , Left upper
arm arteriovenous graft angioplasty , L upper arm AV graft [**2165**]

Angioplasty/fistulogram [**2166**] x 5 and [**2167**] x3

Social History:
Denies tobacco, drug or illicit drug use. Discharged [**9-13**] to
rehab. Lives at home with husband and 53 year old son who
prepares her medications. Has been in the hospital or at rehab
for last 5 mos, Other sons lives in [**Name (NI) 47**] and [**Name (NI) 4565**],
daughter lives in [**Name (NI) 669**]. Pt is a retired work supervisor at
Veteran's Hospital in JP. Retired about 10 years ago.


Family History:
She is an only child. Grandfather died of cancer but son is not
sure of what type. Three sons with htn.  Pt. denies any other
history of CA, DM, or HTN in her parents.


Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Discharge Physical Exam:
Afebrile, Hemodynamically stable with SBPs in 120s-130s
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, Non-tender, no lymphadenopathy
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - Mechanical heart sounds heard throughout precordium.
Holosytolic murmur heard throughout precordium heard best over
apex. RRR no rubs or gallops otherwise
ABDOMEN - Obese, Ostomy bag in place with green stool free of
blood or melena evident. NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - Chronic venous changes in LE bilaterally with
evidence of multiple vascular surgeries. WWP, no c/c/e, 2+
peripheral pulses. She has evidence of a RUE hand tremor
SKIN - no rashes or lesions other than chronic changes
NEURO - awake, A&Ox3, CNs II-XII grossly intact

Pertinent Results:
Admission Labs:

[**2168-9-29**] 07:40PM BLOOD WBC-3.7* RBC-3.13* Hgb-8.9* Hct-26.8*
MCV-86 MCH-28.5 MCHC-33.2 RDW-17.4* Plt Ct-159
[**2168-9-29**] 07:40PM BLOOD Neuts-41.5* Lymphs-48.9* Monos-5.3
Eos-3.7 Baso-0.5
[**2168-9-29**] 07:40PM BLOOD PT-40.1* PTT-32.7 INR(PT)-4.1*
[**2168-9-29**] 07:40PM BLOOD Glucose-97 UreaN-32* Creat-5.3* Na-135
K-4.4 Cl-101 HCO3-27 AnGap-11
[**2168-9-29**] 11:14PM BLOOD Calcium-7.5* Phos-3.3 Mg-1.8

BCx Negative x2
C.Diff Toxin negative x2

[**2168-9-30**] Colonoscopy: Multiple non-bleeding diverticula with
mixed openings were seen in the transverse colon and ascending
colon. Diverticulosis appeared to be of moderate severity.
Throughout the colon red flecks consistent with old blood was
noted in the colon.
Impression: Diverticulosis of the transverse colon and ascending
colon
Otherwise normal colonoscopy to cecum

[**2168-9-30**] EGD: Normal mucosa in the whole esophagus
Erythema in the whole stomach compatible with gastritis
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum

Discharge Labs:

[**2168-10-12**] 07:50AM BLOOD WBC-3.4* RBC-2.54* Hgb-7.4* Hct-23.8*
MCV-94 MCH-29.0 MCHC-30.9* RDW-17.0* Plt Ct-182
[**2168-10-12**] 07:50AM BLOOD PT-21.4* PTT-116.6* INR(PT)-2.0*
[**2168-10-12**] 08:32AM BLOOD Glucose-84 UreaN-38* Creat-3.0*# Na-136
K-4.5 Cl-101 HCO3-26 AnGap-14
[**2168-10-12**] 08:32AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.0

INR Trend
[**2168-10-12**] 07:50AM BLOOD PT-21.4* PTT-116.6* INR(PT)-2.0*
[**2168-10-11**] 09:00AM BLOOD PT-18.8* PTT-79.7* INR(PT)-1.7*
[**2168-10-11**] 06:40AM BLOOD PT-18.4* PTT-83.5* INR(PT)-1.6*
[**2168-10-10**] 05:50AM BLOOD PT-15.6* INR(PT)-1.4*
[**2168-10-9**] 06:38AM BLOOD PT-13.5* PTT-72.6* INR(PT)-1.2*
[**2168-10-7**] 05:46AM BLOOD PT-13.3 PTT-67.4* INR(PT)-1.1

Labs of Note:
[**2168-10-11**] 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
HBV Viral Load Pending

Brief Hospital Course:

83 year old female with multiple medical problems including ESRD
on HD (MWF), DM2, PVD, Afib, severe AS s/p mAVR (St. [**Month/Day/Year 923**]'s
valve), multiple GIB treated with colectomy and [**Doctor Last Name **]
procedure in [**2162**], continued GIBs after the procedures now
presents with bleeding from ileostomy.Colonoscopy and EGD showed
no active bleeding but evidence of diverticulosis and evidence
of prior GIB.


#. GI bleed: Resolved, most likely diverticular in origin
considering significant past history of diverticular bleeds and
evidence on colonoscopies. Each of these past bleeds have
occurred in the setting of supratherapeutic INRs, consistent
with this admission.  Stable Hct and no GI complaints. Patient
requires a total colectomy for definative treatment of her
recurrent bleeds, though patient does not want surgery because
complicated post-op course last time. Her Coumadin appears to be
therapeutic when she is at home but at rehab center she became
supratherapeutic. She will likely benefit long term from having
a home INR monitor to prevent future episodes. GIB did not recur
after Coumadin/Heparin bridge was started. Her Hct trended down
to 23.8 on discharge without gross bleeding. This information
was shared with the accepting physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12879**], at [**Hospital 100**]
Rehab MACU where they will monitor her Hct and potentially
provide transfusions as needed.


#. Subtherapeutic INR: Patient continued to be subtherapeutic
despite titrating up Coumadin to 10mg Daily. Her INR started
uptrending after 10mg were given and she was tapered down to
7.5mg and down again to 4mg on day of discharge when her INR was
2.0. Likely related to large doses of Vitmain K given in MICU.
Given active bleeding and concern for hemodynamic instability
for now will aim for lower end of therapeutic range (goal INR
2.5-3.0). Heparin drip should be continued until she is
therapeutic. Discharged on Coumadin 4mg home dose.

#. Hypotension and Fever: Septic etiology was entertained
initially in MICU.  The patient was started on ceftazidime and
vancomycin.  This was discontinued in MICU prior to transfer to
floor. The patient was also worked up for Clostridium difficile
infection, despite her lack of diarrhea. Patient was started on
empiric P.o. Flagyl, this was also discontinued.  Pt's blood
culture and C.diff screening remained negative. This was most
likely tranfusion related rather than an active infection as
fever/hypotension occured following 5 units PRBCs and 2 units
FFP.

#. [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] mechanical aortic valve: Given the concern for
active hemorrhage, we were judicious with the use of heparin.
The patient initially came in supratherapeutic, and throughout
her stay her INR is monitored. After Coumadin was held some time
her INR became sub-therapeutic and she was bridged to Heparin
(see above).

# Thrombocytopenia: Her platelets downtrended during her stay
but stablizes around 112. Uunclear etiology, ddx abx related vs
consumptive. low suspicion for HIT. It was monitored and she
continued uptrending after transfer out of MICU.

#. Goals of Care: She was seen by Palliative Care during
hospitalization. Patient aware of her prognosis but enjoys
living and expects to live past her 84th birthday. Pal Care
initiated conversations which can be addressed again in the
future but for now she remains FC. Pal care continues to follow.

CHRONIC STABLE CONDITIONS:

#. ESRD on HD: No urgent indication for HD. The patient was
continued on a regular hemodialysis schedule.  Her dialysis
access was used to draw laboratory tests, and infuse
antibiotics.

#. Afib: In sinus rhythm during admission. Continue amiodarone.

#. Hypothyroidism: Continued levothyroxine.

#. Hyperlipidemia: Continued pravastatin.

#. DM: HISS

#. Diastolic Heart Failure: Chronic, well compensated. Last Echo
[**2165**] LVEF >55% on 2L NC home O2. Continued Oxygen and home meds.

#. FEN: PRBC transfusion prn, replete lytes prn, NPO for now

Transitional Issues:
- Continue Heparin Drip until INR becomes therapeutic
- Monitor Hct as she has had borderline low Hct and has a
history of GIBs. She has not had any melena or BRB per ostomy.
She has not required PRBCs since transfer out of MICU.
- She should be set up with a home INR monitor to prevent future
admissions for GIBs
- Goals of Care discussion was initiated by our Palliative Care
department. She remains full code which has been confirmed with
family and outpatient providers. If she is hospitalized again
for GIB and requires significant resucitation this should be
readdressed.
- Of note she had hepatitis panel and HIV drawn because an
interventional radiologist had a needle stick during procedure.
HbSAg and HbCAg were positive, HBV viral load still pending on
discharge. HIV never came back but patient was consented by
blood bank.
- PICC line is not completely central but is superior to SVC and
so is okay to use for labs and heparin drip. Angio tried to
advance but she has some subclavian stenosis and so unable.

Medications on Admission:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY
5. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous
ASDIR (AS DIRECTED): As per sliding scale.
6. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS
7. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
9. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM


Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. insulin lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED): Continue to use your home
Insulin Sliding Scale as prescribed.
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day.
9. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: Coumadin dosing should be titrated by your [**Hospital 197**] Clinic
for an INR goal 2.5-3.5.
10. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: Six [**Age over 90 1230**]y (650) units Intravenous QHR:
Please continue Heparin Drip until INR therapeutic (2.5-3.5).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Active:
- GI Bleed
- Diverticulosis

Chronic:
- Chronic Diastolic Heart Failure (LVEF >55%)
- Severe Aortic Stenosis s/p St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**]
- HLD
- ESRD on HD (MWF)
- Hypothyroidism
- A.Fib on Amiodarone
- Diabetes Mellitus
- HTN
- PVD s/p multiple vascular surgeries


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Ms. [**Known lastname **],

It was a pleasure treating you during your hospitalization. You
were admitted to [**Hospital1 18**] with a GI bleed requiring MICU stay. In
the MICU you were stabilized with IVFs and you received 5 units
of Packed Red Blood Cells and 2 units of Fresh Frozen Plasma.
Your Coumadin was held and you received 2 doses of Vitamin K to
reverse the anticoagulation. Upper and lower endoscopies
revealed gastritis and diverticulosis. Your bleed stopped and
when hemodynamically stable you were transferred to the general
medicine floor. On the floor you were hemodynamically stable and
did not have anymore GIBs. You had an interventional radiology
guided PICC line placement and HD line change. Your Coumadin was
restarted, you were bridged with Heparin drip and you were
discharged with an INR of 2.0(goal 2.5-3.5). You were discharged
in stable condition without anymore GIBs.

Medication Changes:
- CONTINUE Coumadin at your 4mg QDaily home dose
- Please continue to take your medications as prescribed
- Heparin Drip per weight based protocol. Continue Heparin drip
until patient INR therapeutic 2.5-3.5

Discharge Instructions
- Please monitor INR daily until she is therapeutic
- Please provide patient with a home INR monitor so she can more
closely titrate Coumadin doses. She has had recurrent GIBs
requiring hospitalization for periods of supratherapeutic INR.

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **]
Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 608**]
*Your primary care physician will be following up with you at
your home within 3 days.
{'Diverticulosis of colon with hemorrhage,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic diastolic heart failure,Compression of vein,Other colostomy and enterostomy complication,Acute posthemorrhagic anemia,Hypotension, unspecified,Febrile nonhemolytic transfusion reaction,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Peripheral vascular disease, unspecified,Abnormal coagulation profile,Thrombocytopenia, unspecified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypocalcemia,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Acquired absence of intestine (large) (small),Renal dialysis status,Heart valve replaced by other means,Other dependence on machines, supplemental oxygen,Knee joint replacement,Other postprocedural status,Personal history of colonic polyps,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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

PRESENT ILLNESS: In brief, Ms. [**Known lastname **] is an 83-year-old female with multiple
medical problems including ESRD on HD (MWF), DM2, PVD, Afib,
severe AS s/p mAVR (St. [**Known lastname 923**]'s valve), recurrent GIB [**2-10**]
diverticulosis s/p colectomy and [**Doctor Last Name **] procedure in [**2162**] with
continued GIBs, recently d/c'd from [**Hospital1 18**] after bleeding from
ostomy, now transfered from [**Hospital 1263**] Hospital after presenting
from rehab with approx ~1L of frank blood from ileostomy. Pt
noticed blood in ileostomy bag morning of presentation and
dropped SBPs into 80s (baseline 110-130s). Pt denies ever having
any abdominal pain, no pain around ileostomy site. Denies any
increased ileostomy output. Denies lightheadedness, weakness,
abd pain, CP, nausea, vomiting, fevers or chills.
.
Of note, most recent prior admission, pt was bleeding from
ostomy and found to have supratherapeutic INR of 6.6. After this
admission, INR goal changed to 2.5-3.0.
.
In the ED, initial VS were 98.1 84 102/52 16 100%RA. Received
3.5L NS and started receiving 1st unit PRBC. In the ED, SBPs
responded to fluids. Labs: INR 4.1, hematocrit 26.8 (similar to
baseline), plt 159. Cr 5.3 (ESRD on HD MWF, was 5.6 on [**9-13**]). GI
and colorectal surgery were consulted in the ED. VS on transfer
were 78, 115/73, 20, 98%RA.
.
During her ICU stay, pt was given 2U FFP and received 5U PRBC
total. EGD that showed gastritis, and colonoscopy that showed
diverticulosis in transverse and ascending colon, without a
specific source identified. However, likely bleed [**2-10**]
diverticuli as per GI. She was initially on protonix drip and
was later switched to daily PPIs.
.
The patient was also found to be hypocalcemic and given calcium
gluconate. Day 2 MICU patient spiked temp 101-102 and she became
hypotensive and associated AMS with hypotension, BPs minimally
responsive to 2.5 L IVF. She was started on Levo for <24hours,
she has poor peripheral access, unable to get CVL so Levo
administered through tunneled cath. Zosyn/Vanc started for
possible line infection, cultures negative and she remained
hemodynamically stable off pressors so ABx stopped, she was
given ABx for 3 days. Fever likely associated with transfusions.
AMS Required pressors <24hours. Unclear infection source,
patient Cdiff negative, blood cx still pending.
.
Upon transfer to the medicine floor, VSS with no acute bleeding.

MEDICAL HISTORY: 1. history of repeated GI bleeds: past work up revealing various
potential sources along her GI tract including small bowl AVM's,
colonic polyps, ascending and transverse colon diverticulosis.
Had L hemicolectomy with transverse colostomy and [**Doctor Last Name 3379**]
pouch in [**10/2162**] with pathology examination revealing
diverticulosis as the source of bleed.
2. Diastolic CHF (EF 65-75%) on 2L O2 at home
3. Severe AS s/p mechanical [**Year (4 digits) 1291**] [**12-14**], [**Hospital3 9642**]
4. HLD
5. ESRD on HD (MWF)
6. Hypothyroidism
7. Atrial fibrillation on amiodarone and coumadin
8. PVD
9. Diabetes Mellitus
10. HTN
11. [**2168-1-27**]: Stenting of left superficial femoral
artery/above-knee popliteal artery transition
12. [**2168-1-28**]: Left Calf Ulcer Debridement
13. [**2168-2-26**]: Left lower extremity wound debridement
14. [**2168-3-8**]: Split thickness skin graft from right thigh to left
lower calf
15. [**2168-4-19**]: left lower extremity angioplasty
16. [**2168-4-27**]: Debridement of eschar and bone from the posterior
aspect of the left heel
17. Bilateral TKR
18. Open cholecystectomy
[**76**]. ORIF right periprosthetic femur fracture with RLE plate [**2164**]
20. Left upper arm radiocephalic AV fistula [**2164**] , Left upper
arm arteriovenous graft angioplasty , L upper arm AV graft [**2165**]

MEDICATION ON ADMISSION: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY
5. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous
ASDIR (AS DIRECTED): As per sliding scale.
6. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS
7. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
9. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM

ALLERGIES: Protamine

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: She is an only child. Grandfather died of cancer but son is not
sure of what type. Three sons with htn.  Pt. denies any other
history of CA, DM, or HTN in her parents.

SOCIAL HISTORY: Denies tobacco, drug or illicit drug use. Discharged [**9-13**] to
rehab. Lives at home with husband and 53 year old son who
prepares her medications. Has been in the hospital or at rehab
for last 5 mos, Other sons lives in [**Name (NI) 47**] and [**Name (NI) 4565**],
daughter lives in [**Name (NI) 669**]. Pt is a retired work supervisor at
Veteran's Hospital in JP. Retired about 10 years ago. 

### Response:
{'Diverticulosis of colon with hemorrhage,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic diastolic heart failure,Compression of vein,Other colostomy and enterostomy complication,Acute posthemorrhagic anemia,Hypotension, unspecified,Febrile nonhemolytic transfusion reaction,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Peripheral vascular disease, unspecified,Abnormal coagulation profile,Thrombocytopenia, unspecified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypocalcemia,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Acquired absence of intestine (large) (small),Renal dialysis status,Heart valve replaced by other means,Other dependence on machines, supplemental oxygen,Knee joint replacement,Other postprocedural status,Personal history of colonic polyps,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
