CHIEF COMPLAINT: GI bleed

PRESENT ILLNESS: 77 y/o woman with Afib not on coumadin, dCHF, HTN,
hyperlipidemia, COPD, IBS, CKD, and myeloproliferative disorder
transferred from OSH for management of recurrent GI bleeding s/p
hemorrhoidectomy requiring multiple hospitalizations and
transfusions. The patient has had about 1.5 years of
intermittent GI bleeding, with painless BRBPR, maroon stools,
and clots, which worsened over past 4-5 months. Per report, she
has also had intermittent hematochezia. Colonoscopy on [**6-10**] at
OSH showed diverticulosis and hemorrhoids, which were believed
to be the source of the bleeding. She had large amounts of
rectal bleeding s/p hemorrhoidectomy on [**7-9**] and was transferred
to ICU of OSH from [**Date range (1) 9463**], where she received 7 units PRBC and
3 units FFP and Vit K. Last Hct was 30.7. Post-op, she was
started on flagyl x 5 days and levoquin for Klebsiella UTI. She
is s/p upper and lower endoscopy suggestive of duodenitis and
mild gastritis, colonoscopy, and a tagged RBC scan without clear
source (stomach or transverse colon). A second colonoscopy was
attempted but patient was unable to tolerate prep.

MEDICAL HISTORY: CAD s/p RCA stent [**2-/2136**]
HTN
Hyperlipidemia
Afib off coumadin x 2 years due to bleeding
Chronic kidney disease
CHF with diastolic dysfunction but normal EF
GERD
pericardial effusion
pulmonary hypertension - right heart cath in [**2136**]
s/p TIA
depression
angina
pneumonia/bronchitis
gout
Anemia
Arthritis
Irritable Bowel Syndrome
Chronic Kidney Disease
OSA
Myeloproliferative disorder with leukocytosis
s/p TAH//BSO - reports R ovary explosion
s/p CCY and appendectomry
bilateral cataract surgery

MEDICATION ON ADMISSION: Lasix 40 mg x 2 qAM
Lasix 40 mg x 1 at 4 pm
Toprol xL 75 mg
Prozac 40 mg
Colchicine 0.6mg
Allopurinol 100 mg x 2
Protonix 40 mg
Mag Oxide 400 mg TID
Folic acid 1 mg
Aspirin 325 mg
Hydrea 500 mg MWF
Vitamin D 400 mg
Metolazone 2.5 mg Mon
Lipitor 80 mg QHS
Metamucil 4 capsules QHS
Lidoderm Patch q 12 hrs on/q12 hrs off prn pain
Lidocaine Viscous 2% 4x per day prn pain
Anusol [**Hospital1 **] prn
Xanax 0.25 mg [**Hospital1 **] prn anxiety
Trazodone 50 mg QHS prn anxiety
Vicodin 5mg/500 1-2 tabs q8hrs prn pain
Nitrostat 0.4 mg 1 tab q 5 min prn angina
nystatin ointment 100,000 U 15 gm [**Hospital1 **] prn
Home O2 2-3L

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Codeine / Diazepam /
Benzodiazepines / Iodine

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
General: Lying comfortably on 4 pillows, no acute distress
HEENT: Sclear anicteric. HD trauma line in right IJ, no
Skin: Pale, bruising on arms, no petechiae
Heart: nl S1 and S2, irregular rhythm, flow murmur
Lungs: Bibasilar crackles, R>L
Abdomen: Soft, nontender, nondistended, hypertympanic around
umbilicus, transverse surgical scar, no rebound, no guarding
Rectum: Incision visible with sutures, dilated anal sphincter,
no draining fistulas, ~ 4 cm hematoma lateral to sphincter,
confluent patch of perirectal erythema, yellow stool
Ext: warm and well perfused, no edema
Neuro: AOx3, no focal deficits
.
DISCHARGE PHYSICAL EXAM:
VS Tm 99.7  119/56 87 22 97% 3L
Gen: pt resting quietly, tearful when talking about rehab.
HEENT: moist mucous membranes
Neck: supple, no thyromegaly
CV: irregularly irregular, systolic flow murmur
LUNGS: crackles bilaterally at bases.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: 2+ peripheral pulses.
SKIN: large hematoma in right groin with surrounding ecchymosis,
tender to palpation, diffuse erythema of inner thighs and sacrum

FAMILY HISTORY: Father had colitis. Granddaughter with ulcerative colitis

SOCIAL HISTORY: Widowed and lives alone in [**Hospital3 4634**] in [**Location (un) 5110**], MA.
Unable to walk up stairs without SOB. 6 children and 17
grandchildren. Tobacco: [**1-8**] cig/day x 30 years EtOH: social
Illicits: none
Hemorrhage complicating a procedure,Acute respiratory failure,Acute on chronic diastolic heart failure,Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Other lymphatic and hematopoietic tissues,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Primary pulmonary hypertension,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Gout, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status
Hemorrhage complic proc,Acute respiratry failure,Ac on chr diast hrt fail,Ac posthemorrhag anemia,Acute kidney failure NOS,Lymph/hematpoitc tis NEC,Urin tract infection NOS,Protein-cal malnutr NOS,Prim pulm hypertension,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Atrial fibrillation,Chr airway obstruct NEC,Esophageal reflux,Obstructive sleep apnea,Gout NOS,Crnry athrscl natve vssl,Status-post ptca
Admission Date:  [**2139-7-16**]              Discharge Date:   [**2139-7-25**]

Date of Birth:  [**2061-10-28**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Diazepam /
Benzodiazepines / Iodine

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
GI bleed

Major Surgical or Invasive Procedure:
IR coiling of superior rectal artery
PICC placement

History of Present Illness:
77 y/o woman with Afib not on coumadin, dCHF, HTN,
hyperlipidemia, COPD, IBS, CKD, and myeloproliferative disorder
transferred from OSH for management of recurrent GI bleeding s/p
hemorrhoidectomy requiring multiple hospitalizations and
transfusions. The patient has had about 1.5 years of
intermittent GI bleeding, with painless BRBPR, maroon stools,
and clots, which worsened over past 4-5 months. Per report, she
has also had intermittent hematochezia. Colonoscopy on [**6-10**] at
OSH showed diverticulosis and hemorrhoids, which were believed
to be the source of the bleeding. She had large amounts of
rectal bleeding s/p hemorrhoidectomy on [**7-9**] and was transferred
to ICU of OSH from [**Date range (1) 9463**], where she received 7 units PRBC and
3 units FFP and Vit K. Last Hct was 30.7. Post-op, she was
started on flagyl x 5 days and levoquin for Klebsiella UTI. She
is s/p upper and lower endoscopy suggestive of duodenitis and
mild gastritis, colonoscopy, and a tagged RBC scan without clear
source (stomach or transverse colon). A second colonoscopy was
attempted but patient was unable to tolerate prep.

A hemodialysis trauma line was placed in the right IJ. Hct was
30.7. Her Cr was 1.5, INR 1.68, and WBC 21 (chronically elevated
WBC in 18) at OSH.

She was transferred to MICU for angiography to help localize
source of persistent GI bleed with the plan of returning to
outside hospital for non-emergent surgery if source cannot be
embolized.

Upon arrival to the floor, initial vs were T 96.3 F, HR 106 BP
127/57, RR 16, 95% on 3L NC.

Patient reports she has been incontinent of stool since
procedure.
She was guaiac positive without frank blood per rectum and was
given additional fluid given elevated Cr 1.5 in preparation for
angiography. She denied feeling lightheaded since this morning.
She has SOB, orthopnea, chronic hot flashes, night sweats, and
130 lb weight loss over past year. She denies fever or chills.
She has history of constipation and diarrhea. ROS otherwise
negative.

Review of systems:
(+) Per HPI
(-) Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.

Past Medical History:
CAD s/p RCA stent [**2-/2136**]
HTN
Hyperlipidemia
Afib off coumadin x 2 years due to bleeding
Chronic kidney disease
CHF with diastolic dysfunction but normal EF
GERD
pericardial effusion
pulmonary hypertension - right heart cath in [**2136**]
s/p TIA
depression
angina
pneumonia/bronchitis
gout
Anemia
Arthritis
Irritable Bowel Syndrome
Chronic Kidney Disease
OSA
Myeloproliferative disorder with leukocytosis
s/p TAH//BSO - reports R ovary explosion
s/p CCY and appendectomry
bilateral cataract surgery

Social History:
Widowed and lives alone in [**Hospital3 4634**] in [**Location (un) 5110**], MA.
Unable to walk up stairs without SOB. 6 children and 17
grandchildren. Tobacco: [**1-8**] cig/day x 30 years EtOH: social
Illicits: none


Family History:
Father had colitis. Granddaughter with ulcerative colitis

Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Lying comfortably on 4 pillows, no acute distress
HEENT: Sclear anicteric. HD trauma line in right IJ, no
Skin: Pale, bruising on arms, no petechiae
Heart: nl S1 and S2, irregular rhythm, flow murmur
Lungs: Bibasilar crackles, R>L
Abdomen: Soft, nontender, nondistended, hypertympanic around
umbilicus, transverse surgical scar, no rebound, no guarding
Rectum: Incision visible with sutures, dilated anal sphincter,
no draining fistulas, ~ 4 cm hematoma lateral to sphincter,
confluent patch of perirectal erythema, yellow stool
Ext: warm and well perfused, no edema
Neuro: AOx3, no focal deficits
.
DISCHARGE PHYSICAL EXAM:
VS Tm 99.7  119/56 87 22 97% 3L
Gen: pt resting quietly, tearful when talking about rehab.
HEENT: moist mucous membranes
Neck: supple, no thyromegaly
CV: irregularly irregular, systolic flow murmur
LUNGS: crackles bilaterally at bases.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: 2+ peripheral pulses.
SKIN: large hematoma in right groin with surrounding ecchymosis,
tender to palpation, diffuse erythema of inner thighs and sacrum


Pertinent Results:
Admission Labs:
[**2139-7-16**] 05:02PM   GLUCOSE-78 UREA N-34* CREAT-1.5* SODIUM-141
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-32 ANION GAP-14
[**2139-7-16**] 05:02PM   CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-2.0
[**2139-7-16**] 05:02PM   WBC-19.7* RBC-3.50* HGB-10.8* HCT-32.6*
MCV-93 MCH-30.8 MCHC-33.0 RDW-22.2*
[**2139-7-16**] 05:02PM   PT-16.5* PTT-29.3 INR(PT)-1.5*
[**2139-7-16**] 05:02PM   CK-MB-1 cTropnT-<0.01
[**2139-7-16**] 11:29PM   CK-MB-1 cTropnT-<0.01
.
DISCHARGE LABS
[**2139-7-25**] 05:44AM BLOOD WBC-14.9* RBC-3.26* Hgb-10.3* Hct-28.7*
MCV-88 MCH-31.5 MCHC-35.9* RDW-19.6* Plt Ct-188
[**2139-7-25**] 05:44AM BLOOD Glucose-89 UreaN-48* Creat-1.0 Na-138
K-4.2 Cl-100 HCO3-34* AnGap-8
[**2139-7-25**] 05:44AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.8
.
Imaging:
[**7-16**] CXR: Moderate cardiomegaly is less pronounced, and although
there is mild vascular engorgement in the upper lungs,
mediastinal veins are not dilated. Therefore, the
mild-to-moderate generalized pulmonary edema could be due to
transfusion reaction rather than the hemodynamic effect of blood
product administration. Dual-channel right supraclavicular line
ends in the upper right atrium. No pneumothorax. Pleural
effusions are minimal if any.
.
[**7-16**] CTA: IMPRESSION:
1. Non-contrast CT scan performed due to contrast allergy.
Significant
residual barium within the bowel is noted which limits
evaluation for GI
bleeding.
2. Splenomegaly measuring 15.5 cm.
3. Diverticulosis of descending colon and sigmoid colon without
evidence of acute diverticulitis.
4. Multiple compression fractures noted of T9, L1, L3 and L5
which are age
indeterminate.
5. Small bilateral pleural effusions greater on the right than
the left.
6. Severe four-chamber cardiac enlargement.
.
[**7-21**] Tagged RBC scan:
IMPRESSION: Moderate hemorrhage into the sigmoid colon beginning
15 minutes into the study.
.
[**7-21**] Angio:
FINDINGS:
1. [**Female First Name (un) 899**] gram demonstrated normal anatomy with opacification of
left colic,
sigmoidal, and superior rectal arterial branches.
2. Sigmoidal and superior rectal arteriograms demonstrated
contrast
extravasation in the region of distal rectum, associated with
some early
filling veins.
3. Following embolization of a superior rectal artery, there was
no contrast extravasation.
.
[**7-22**] KUB:
FINDINGS: There continues to be borderline dilatation of the
transverse
colon. This might be consistent with mild ileus. A small amount
of residual barium is still observed in the cecum or ascending
colon. No evidence of calcifications or free air.


Brief Hospital Course:
77 y/o woman with Afib not on coumadin due to various bleeding
disorders, dCHF, HTN, hyperlipidemia, COPD, and
myeloproliferative disorder transferred from OSH for management
of several months of recurrent GI bleeding s/p hemorrhoidectomy,
massive transfusion protocol, and IR coiling of superior rectal
artery.
.
ACTIVE ISSUES:
# GI Bleed: The patient was transferred from an outside hospital
with GI bleed requiring 7 units PRBCs.  Work-up at OSH included
upper and lower endoscopy, colonoscopy, and tagged RBC scan
unable to localize bleeding (either stomach or transverse
colon).  On admission, the patient had intermittent episodes of
bright red blood per rectum.  However, her hematocrit remained
stable.  She underwent a non-contrast CT that was limited by
residual barium in her intestines from a past study prior to
hospital transfer.  Given the length of time barium remained in
her colon, gastroenterolgy felt that her bleeding was not from
either an upper GI or an intestinal source.  She was then seen
by colorectal who felt that her bleeding was related to her
recent hemorrhoidectomy.  The patient was transferred to the
medical floor.  On the medical floor, the patient began to
experience massive GIB with BRBPR and clots.  She was
transferred back to the MICU, where she was transfused 12 units
pRBC, 4 units FFP, 3 units platelets.  She underwent iodine
desensitization and tagged RBC scan that showed bleeding
localized to the sigmoid colon.  She then went to angio, and
underwent coiling of her right superior rectal artery with
resolution of her bleeding.  The patient did have a small right
hematoma as a result of the angiogram.  However, she had no
bruits and pulses remained intact.  Her diet was advanced and
she tolerated it well.  Pt continued to have loose stools
throughout her hospitalization.  She was ruled out for C. diff
and it was thought that her loose stools were secondary to
absent rectal tone from her hemorrhoidectomy.
.
#Hemorrhoids s/p hemorrhoidectomy: The patient was admitted with
a healing wounds s/p hemorrhoidectomy surrounded by diffuse
erythema from stool incontinence.  She was seen by wound care
and given [**Last Name (un) **] baths as tolerated.  She was also followed by
colorectal surgery who did not feel any additional intervention
was necessary.  Pt is at high infection risk given that she does
have an open wound with stool incontinence and she will need
close monitoring by wound care with frequent repositioning in
bed. We kept her foley in place given her open rectal wound.
Wound care recommendations are included in this summary.
.
# acute on chronic diastolic CHF: Last Echo in [**2136**] showed
EF>55%, moderate RV dilation signs of RV overload, and moderate
pericardial effusion. The patient was admitted with crackles on
exam, and CXR with cardiomegaly and evidence of pulmonary edema.
Lasix was initially held on admission due to concern for
potential hypotension from GI bleed.  She was intermittently
diuresed as needed for fluid overload throughout admission.
Following angio coil and cessation of bleeding, the patient was
started on standing lasix dose.  She remained euvolemic and was
discharged to rehab on lasix with metolazone PRN.
.
#Acute on Chronic Kidney Disease: Patient had elevated
creatinine on admission with urine lytes consistent with
intrinsic renal or post-renal etiology.  Home lasix and
metolazone were held on admission.  Renal function slowly
improved on admission.  With cessation of bleeding, renal
function improved to baseline.
.
#Afib not on coumadin: Patient has CHADS score of 5 but not
candidate for coumadin in context of history of bleeding
disorder and current GI bleeding. INR 1.5 on admission.  The
patient's lopressor was held on admission out of concern for
hemodynamic instability.  However, once she stablized, she was
restarted on lopressor with dose increased to 37.5mg daily for
improved rate control.
.
#C.diff: Stools were concerning for C. diff on admission. The
patient was empirically covered with Flagyl while at OSH.  A C.
diff toxin assay was sent on admission to MICU.  Empiric flagyl
therapy was stopped following return of negative C. diff assay.
Loose stools are attributed to absent rectal tone and fecal
incontinence
.
#UTI: Patient has history of Klebsiella UTI. Patient completed 3
of planned 7 day course of at OSH.  7 day course of Levaquin was
completed while in the MICU.  Pt continued to complain of
dysuria, though UA was not concerning.  Dysuria was likely
secondary to foley.
.
INACTIVE ISSUES:
.
#Myeloproliferative disorder: Chronic leukocytosis for
approximately 11 years.
The patient remained on home hydroxyurea and folic acid with
baseline WBC around 18.
.
#COPD - Patient was continued on home 2L O2.  She did not have
increasing oxygen requirements throughout admission.
.
#Pulmonary Hypertension: Right heart cath in [**2136**] consistent
with both cardiogenic and pulmonary contributions with elevated
wedge pressure and even greater elevated PA diastolic pressure
per report.  Monitored during admission.
.
# Gout: Chronic.  Allopurinol and cholchicine held on admission.
.
TRANSITIONAL ISSUES:
.
# Code: Full (discussed with patient)
.
# Pt will need follow up with colorectal surgeon at [**Hospital1 **] who
performed her surgery.  Per the patient, the appointment is
already scheduled and her daughter has the information regarding
time and place.
.
# Pt is at high risk for infection given her open rectal wound.
She will need multiple dressing changes daily to keep the area
clean and dry.  She will likely need to keep the foley in place
for a period of time to aid in healing.
.
# Pt has had long hospital course and is severely deconditioned.
 She will need frequent PT to return to baseline.
.
# Pt lasix dose was increased while hospitalized.  She will need
monitoring of her Cr and may require adjustment of her lasix
dose
.
# Pt sent with PICC line, please remove if persistently stable
and no further need for IV access (assess in 3 days time).

Medications on Admission:
Lasix 40 mg x 2 qAM
Lasix 40 mg x 1 at 4 pm
Toprol xL 75 mg
Prozac 40 mg
Colchicine 0.6mg
Allopurinol 100 mg x 2
Protonix 40 mg
Mag Oxide 400 mg TID
Folic acid 1 mg
Aspirin 325 mg
Hydrea 500 mg MWF
Vitamin D 400 mg
Metolazone 2.5 mg Mon
Lipitor 80 mg QHS
Metamucil 4 capsules QHS
Lidoderm Patch q 12 hrs on/q12 hrs off prn pain
Lidocaine Viscous 2% 4x per day prn pain
Anusol [**Hospital1 **] prn
Xanax 0.25 mg [**Hospital1 **] prn anxiety
Trazodone 50 mg QHS prn anxiety
Vicodin 5mg/500 1-2 tabs q8hrs prn pain
Nitrostat 0.4 mg 1 tab q 5 min prn angina
nystatin ointment 100,000 U 15 gm [**Hospital1 **] prn
Home O2 2-3L

Discharge Medications:
1. Wound Care
Pressure relief per pressure ulcer guidelines
 Support surface: Atmos Air
 Turn and reposition every 1-2 hours and prn off back

 If OOB, limit sit time to one hour at a time and sit on a
pressure relief cushion.

 Gentle cleansing of perianal tissue with warm water and
disposable washcloths. (Pt is allergic to Aloe so do not use the
Foam cleanser).
 Pat the tissue dry.
 Apply a thin layer of Antifungal Critic Aid Clear Moisture
Barrier Ointment daily and prn or every 3rd cleansing.
 Lay a Xeroform gauze on either side of the anus to protect the
open tissue when she is stooling
 Lay a large Sofsorb sponge under her anal area and change daily
or prn.

2. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. nystatin-triamcinolone 100,000-0.1 unit/gram-% Ointment Sig:
One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for
infection.
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 3X/WEEK
(MO,WE,FR).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
16. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
17. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
18. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.

19. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day
as needed for pain.
20. MagOx 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
21. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
22. Metamucil 0.52 g Capsule Sig: Four (4) Capsule PO at
bedtime.
23. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a week
as needed for weight gain > 2 lbs or signs of fluid overload.
24. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual q5 min as needed for chest pain.
25. Outpatient Lab Work
Check Chem 7 every 3 days to assess renal function. If renal
injury, consider reducing total daily dose of lasix.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Arterial Hemorrhage from hemorrhoidal artery
Malnutrition
Rectal incontinence


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.


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

You were transferred to the [**Hospital1 18**] for ongoing evaluation of your
bleeding. After carefully monitoring you for sometime and
co-ordinating with a multidisciplinary team, you ultimately
received a radiological procedure that fixed the bleeding
artery. Your major problems thereafter were the malnutrition
from your prolonged illness and the wound care required to keep
your skin intact around the rectum

We did make some changes to your medicines.
We continued but reduced the dose of your aspirin to 81mg
We increased the dose of your lasix to 80 mg twice daily
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Please have the rehab schedule an appointment with your PCP on
discharge



Completed by:[**2139-7-26**]
{'Hemorrhage complicating a procedure,Acute respiratory failure,Acute on chronic diastolic heart failure,Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Other lymphatic and hematopoietic tissues,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Primary pulmonary hypertension,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Gout, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status'}


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: 77 y/o woman with Afib not on coumadin, dCHF, HTN,
hyperlipidemia, COPD, IBS, CKD, and myeloproliferative disorder
transferred from OSH for management of recurrent GI bleeding s/p
hemorrhoidectomy requiring multiple hospitalizations and
transfusions. The patient has had about 1.5 years of
intermittent GI bleeding, with painless BRBPR, maroon stools,
and clots, which worsened over past 4-5 months. Per report, she
has also had intermittent hematochezia. Colonoscopy on [**6-10**] at
OSH showed diverticulosis and hemorrhoids, which were believed
to be the source of the bleeding. She had large amounts of
rectal bleeding s/p hemorrhoidectomy on [**7-9**] and was transferred
to ICU of OSH from [**Date range (1) 9463**], where she received 7 units PRBC and
3 units FFP and Vit K. Last Hct was 30.7. Post-op, she was
started on flagyl x 5 days and levoquin for Klebsiella UTI. She
is s/p upper and lower endoscopy suggestive of duodenitis and
mild gastritis, colonoscopy, and a tagged RBC scan without clear
source (stomach or transverse colon). A second colonoscopy was
attempted but patient was unable to tolerate prep.

MEDICAL HISTORY: CAD s/p RCA stent [**2-/2136**]
HTN
Hyperlipidemia
Afib off coumadin x 2 years due to bleeding
Chronic kidney disease
CHF with diastolic dysfunction but normal EF
GERD
pericardial effusion
pulmonary hypertension - right heart cath in [**2136**]
s/p TIA
depression
angina
pneumonia/bronchitis
gout
Anemia
Arthritis
Irritable Bowel Syndrome
Chronic Kidney Disease
OSA
Myeloproliferative disorder with leukocytosis
s/p TAH//BSO - reports R ovary explosion
s/p CCY and appendectomry
bilateral cataract surgery

MEDICATION ON ADMISSION: Lasix 40 mg x 2 qAM
Lasix 40 mg x 1 at 4 pm
Toprol xL 75 mg
Prozac 40 mg
Colchicine 0.6mg
Allopurinol 100 mg x 2
Protonix 40 mg
Mag Oxide 400 mg TID
Folic acid 1 mg
Aspirin 325 mg
Hydrea 500 mg MWF
Vitamin D 400 mg
Metolazone 2.5 mg Mon
Lipitor 80 mg QHS
Metamucil 4 capsules QHS
Lidoderm Patch q 12 hrs on/q12 hrs off prn pain
Lidocaine Viscous 2% 4x per day prn pain
Anusol [**Hospital1 **] prn
Xanax 0.25 mg [**Hospital1 **] prn anxiety
Trazodone 50 mg QHS prn anxiety
Vicodin 5mg/500 1-2 tabs q8hrs prn pain
Nitrostat 0.4 mg 1 tab q 5 min prn angina
nystatin ointment 100,000 U 15 gm [**Hospital1 **] prn
Home O2 2-3L

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Codeine / Diazepam /
Benzodiazepines / Iodine

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
General: Lying comfortably on 4 pillows, no acute distress
HEENT: Sclear anicteric. HD trauma line in right IJ, no
Skin: Pale, bruising on arms, no petechiae
Heart: nl S1 and S2, irregular rhythm, flow murmur
Lungs: Bibasilar crackles, R>L
Abdomen: Soft, nontender, nondistended, hypertympanic around
umbilicus, transverse surgical scar, no rebound, no guarding
Rectum: Incision visible with sutures, dilated anal sphincter,
no draining fistulas, ~ 4 cm hematoma lateral to sphincter,
confluent patch of perirectal erythema, yellow stool
Ext: warm and well perfused, no edema
Neuro: AOx3, no focal deficits
.
DISCHARGE PHYSICAL EXAM:
VS Tm 99.7  119/56 87 22 97% 3L
Gen: pt resting quietly, tearful when talking about rehab.
HEENT: moist mucous membranes
Neck: supple, no thyromegaly
CV: irregularly irregular, systolic flow murmur
LUNGS: crackles bilaterally at bases.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: 2+ peripheral pulses.
SKIN: large hematoma in right groin with surrounding ecchymosis,
tender to palpation, diffuse erythema of inner thighs and sacrum

FAMILY HISTORY: Father had colitis. Granddaughter with ulcerative colitis

SOCIAL HISTORY: Widowed and lives alone in [**Hospital3 4634**] in [**Location (un) 5110**], MA.
Unable to walk up stairs without SOB. 6 children and 17
grandchildren. Tobacco: [**1-8**] cig/day x 30 years EtOH: social
Illicits: none 

### Response:
{'Hemorrhage complicating a procedure,Acute respiratory failure,Acute on chronic diastolic heart failure,Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Other lymphatic and hematopoietic tissues,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Primary pulmonary hypertension,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Gout, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status'}
