CHIEF COMPLAINT: GI bleed

PRESENT ILLNESS: 81M with localized pancreatic cancer diagnosed in [**2141**] s/p 3
cycles gemcitabine and cyberknife therapy, as well as past ERCP
with CBD stenting in [**2141**] and re-stenting in [**3-/2144**], IDDM,
recently discharged on [**3-31**] after IR embolization of pancreatic
pseudoaneurysm who presented to [**Hospital **] Hospital earlier today
after having 2 black stools last night and 2 this AM. He did not
notice any gross blood in the stool, has no abdominal pain,
nausea/vomiting, hematemesis. He measured his temp to 101 last
night which improved with Tylenol. No loss of appetite or weight
loss, no CP or SOB, no dizziness. He recalls having black stools
in the past but does not remember when. He reports that his INR
has been therapeutic for the past 3 weeks (was supratherapeutic
on previous admission in 5/[**2142**]). Over the past month he has had
intermittent diarrhea and constipation but no melena or blood.
.
He presented to [**Hospital **] Hospital this AM and had INR of 3.63,
Hct 31.4. He had a negative NG lavage. He was given 2 units FFP
with improvement in INR to 2.4 after 2 units FFP. [**Hospital **]
transferred to [**Hospital1 **] given concern from aneurysmal bleed.
.
In the ED at [**Hospital1 **] vitals were 129/58 62 16 100% RA, he was found
to have maroon guaiac + stool on rectal exam. HCT 28.6, INR 2.4,
Plat 127. He was started on protonix drip. Given reported fever
of [**Age over 90 **] yesterday and wrist pain s/p recent fall, ortho was
consulted to evaluate for septic joint. XR did not show wrist
fracture and ortho did not believe this was a septic joint. IR,
GI, gen [**Doctor First Name **] and ERCP were consulted and recommended holding
coumadin and planning for EGD in AM. He was written for 1U FFP
and 1U RBCs but these were not given in the ED.
.
On the floor, pt had no complaints - no N/V, no abdominal pain,
no ongoing bleeding or subsequent stools. He reported being
thirsty, no dizziness or any pain.

MEDICAL HISTORY: - Pancreatic CA - s/p plastic, and now metal stenting in duct.
s/p 3 cycles of Gemcitabine with stereotactic XRT.  Followed at
[**Hospital **] hospital
- A.Fib, on coumadin
- Colon CA, s/p resection in [**2137**]
- DM II - on insulin
- S/P portacath right chest
- Chronic L>R LE edema, on lasix
- BPH
- Gout
- HTN

MEDICATION ON ADMISSION: -Celexa 20 mg Tab 1 Tablet(s) by mouth daily
-Oxycodone (dose uncertain) prn wrist and stomach pain
-Levemir 100 unit/mL Sub-Q 6 units twice a day Morning and
Evening
-Vitamin D 2,000 unit Cap Capsule(s) by mouth once a day
-Allopurinol 100 mg Tab Tablet(s) by mouth once a day
-Lisinopril 5 mg Tab Tablet(s) by mouth once a day
-Imodium A-D 2 mg Tab (dose uncertain)
-Lasix 40 mg Tab Oral 1 Tablet(s) Twice Daily
-Fentanyl patch 50mcg q72h
-loperamide 2 mg QID prn diarrhea
-lipase-protease-amylase 12,000-38,000 -60,000 unit TID w/meals

ALLERGIES: Penicillins / Aspirin

PHYSICAL EXAM: On admission:
Vitals: T 98.5, BP 107/60, HR 62, RR 20, 95% RA
General: AOX3, in no distress
HEENT: Sclera anicteric, dry oral mucosa, poor dentition
Neck: supple, JVP not elevated, no cervical lymphadenopathy
Lungs: CTA bilaterally, no wheezes or rales
CV: nl S1/S2, RRR, no murmurs
Abdomen: soft, non-tender, non-distended, BS normoactive,
negative [**Doctor Last Name 515**] sign, no rebound/guarding
Ext: brace and wrap over R wrist, hands warm and well perfused,
R foot cooler to touch than L with 2+ distal pulses b/l, good
capillary refill

FAMILY HISTORY: No CA in family.  Not relevant to this hospitalization

SOCIAL HISTORY: Non-smoker. No ETOH abuse.  Retired engineer.  Independent in
all  ADLs/IADLs.
Blood in stool,Malignant neoplasm of head of pancreas,Acute posthemorrhagic anemia,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Atrial fibrillation,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Aneurysm of other visceral artery,Anticoagulants causing adverse effects in therapeutic use,Cyst of kidney, acquired,Personal history of malignant neoplasm of large intestine,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Benign essential hypertension,Sprain of wrist, unspecified site,Unspecified fall,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Diarrhea,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage
Blood in stool,Mal neo pancreas head,Ac posthemorrhag anemia,Mal neo lymph intra-abd,Atrial fibrillation,Long-term use anticoagul,Abnrml coagultion prfile,Visceral aneurysm NEC,Adv eff anticoagulants,Cyst of kidney, acquired,Hx of colonic malignancy,BPH w/o urinary obs/LUTS,Benign hypertension,Sprain of wrist NOS,Fall NOS,Duodenal ulcer NOS,Diarrhea,DMII wo cmp nt st uncntr,Gstr/ddnts NOS w/o hmrhg
Admission Date:  [**2144-4-17**]              Discharge Date:   [**2144-4-21**]

Date of Birth:  [**2063-2-19**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Aspirin

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
GI bleed


Major Surgical or Invasive Procedure:
Endoscopy

History of Present Illness:
81M with localized pancreatic cancer diagnosed in [**2141**] s/p 3
cycles gemcitabine and cyberknife therapy, as well as past ERCP
with CBD stenting in [**2141**] and re-stenting in [**3-/2144**], IDDM,
recently discharged on [**3-31**] after IR embolization of pancreatic
pseudoaneurysm who presented to [**Hospital **] Hospital earlier today
after having 2 black stools last night and 2 this AM. He did not
notice any gross blood in the stool, has no abdominal pain,
nausea/vomiting, hematemesis. He measured his temp to 101 last
night which improved with Tylenol. No loss of appetite or weight
loss, no CP or SOB, no dizziness. He recalls having black stools
in the past but does not remember when. He reports that his INR
has been therapeutic for the past 3 weeks (was supratherapeutic
on previous admission in 5/[**2142**]). Over the past month he has had
intermittent diarrhea and constipation but no melena or blood.
.
He presented to [**Hospital **] Hospital this AM and had INR of 3.63,
Hct 31.4. He had a negative NG lavage. He was given 2 units FFP
with improvement in INR to 2.4 after 2 units FFP. [**Hospital **]
transferred to [**Hospital1 **] given concern from aneurysmal bleed.
.
In the ED at [**Hospital1 **] vitals were 129/58 62 16 100% RA, he was found
to have maroon guaiac + stool on rectal exam. HCT 28.6, INR 2.4,
Plat 127. He was started on protonix drip. Given reported fever
of [**Age over 90 **] yesterday and wrist pain s/p recent fall, ortho was
consulted to evaluate for septic joint. XR did not show wrist
fracture and ortho did not believe this was a septic joint. IR,
GI, gen [**Doctor First Name **] and ERCP were consulted and recommended holding
coumadin and planning for EGD in AM. He was written for 1U FFP
and 1U RBCs but these were not given in the ED.
.
On the floor, pt had no complaints - no N/V, no abdominal pain,
no ongoing bleeding or subsequent stools. He reported being
thirsty, no dizziness or any pain.


Past Medical History:
- Pancreatic CA - s/p plastic, and now metal stenting in duct.
s/p 3 cycles of Gemcitabine with stereotactic XRT.  Followed at
[**Hospital **] hospital
- A.Fib, on coumadin
- Colon CA, s/p resection in [**2137**]
- DM II - on insulin
- S/P portacath right chest
- Chronic L>R LE edema, on lasix
- BPH
- Gout
- HTN


Social History:
Non-smoker. No ETOH abuse.  Retired engineer.  Independent in
all  ADLs/IADLs.


Family History:
No CA in family.  Not relevant to this hospitalization


Physical Exam:
On admission:
Vitals: T 98.5, BP 107/60, HR 62, RR 20, 95% RA
General: AOX3, in no distress
HEENT: Sclera anicteric, dry oral mucosa, poor dentition
Neck: supple, JVP not elevated, no cervical lymphadenopathy
Lungs: CTA bilaterally, no wheezes or rales
CV: nl S1/S2, RRR, no murmurs
Abdomen: soft, non-tender, non-distended, BS normoactive,
negative [**Doctor Last Name 515**] sign, no rebound/guarding
Ext: brace and wrap over R wrist, hands warm and well perfused,
R foot cooler to touch than L with 2+ distal pulses b/l, good
capillary refill


Pertinent Results:
ADMISSION LABS
--------------
[**2144-4-17**] 05:15PM BLOOD WBC-9.3# RBC-3.19* Hgb-9.9* Hct-28.6*
MCV-90 MCH-31.1 MCHC-34.8 RDW-14.6 Plt Ct-127*
[**2144-4-17**] 05:15PM BLOOD PT-25.1* PTT-29.0 INR(PT)-2.4*
[**2144-4-17**] 05:15PM BLOOD Glucose-93 UreaN-15 Creat-0.6 Na-139
K-3.8 Cl-101 HCO3-31 AnGap-11
[**2144-4-17**] 05:15PM BLOOD ALT-42* AST-48* AlkPhos-240* TotBili-2.6*
[**2144-4-17**] 05:15PM BLOOD Calcium-8.9 Phos-2.1* Mg-1.8 UricAcd-2.4*
.
DISCHARGE LABS
--------------
[**2144-4-21**] 01:11PM BLOOD WBC-4.1 RBC-3.44* Hgb-10.6* Hct-31.4*
MCV-91 MCH-30.7 MCHC-33.6 RDW-14.5 Plt Ct-219
[**2144-4-21**] 05:42AM BLOOD Glucose-163* UreaN-11 Creat-0.7 Na-140
K-3.7 Cl-100 HCO3-35* AnGap-9
[**2144-4-21**] 05:42AM BLOOD ALT-34 AST-43* LD(LDH)-142 AlkPhos-263*
TotBili-2.2*
[**2144-4-21**] 05:42AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.8
.
MICROBIOLOGY
------------
[**2144-4-17**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2144-4-17**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
.
[**2144-4-17**] 6:50 pm URINE     Site: NOT SPECIFIED

                            **FINAL REPORT [**2144-4-18**]**

   URINE CULTURE (Final [**2144-4-18**]):
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
      AND/OR GENITAL CONTAMINATION.
.
Time Taken Not Noted     Log-In Date/Time: [**2144-4-20**] 10:42 am
      SEROLOGY/BLOOD
      TAKEN FROM # 64979G,ADDED HELI @ 10:42 AM ON [**2144-4-20**]..

   HELICOBACTER PYLORI ANTIBODY TEST (Pending):
.
IMAGING
-------
CT SCAN ABDOMEN/PELVIS
1. In this patient with known pseudoaneurysm of the
gastroduodenal artery,
status post coiling, there is no evidence of revascularization
or active leak from the aneurysm. Mild interval decrease in the
size of the thrombosed aneurysm. The evaluation is slightly
limited due to streak artifact from the coil pack.
2. Variant hepatic arterial anatomy, as described above.
3. Simple left renal cortical cysts and concerning lesion in the
right
kidney at midpole. This may represent a complex cyst, however
enhancement is concerning for papillary renal cell carcinoma,
further evaluation with MRI is recommended.
4. Bilateral small pleural effusions.
5. Mild splenomegaly.
6. Stable aneurysm of the left common iliac artery measuring 3.2
cm, and
ectasia of the right common iliac artery.
.
Right wrist X-ray:
IMPRESSION:
No fracture or dislocation. Evaluation for effusion is limited
on the
radiograph.
.
Chest X-ray on admission:
IMPRESSION:
Small left pleural effusion but no acute cardiopulmonary process
otherwise
identified.


Brief Hospital Course:
81 year old male with localized pancreatic cancer diagnosed in
[**2141**] s/p 3 cycles gemcitabine and cyberknife therapy, as well as
past ERCP with CBD stenting in [**2142**] and re-stenting in [**3-/2144**],
diabetes mellitus, recently discharged on [**3-31**] after IR
embolization of pancreatic pseudoaneurysm who presents with
melena.
.
ACTIVE ISSUES
-------------
# Gastrointestinal bleed: patient had four episodes of melanotic
stool at home with guaiac positive stool on exam.  Hematocrit
was stable without transfusions. CTA of the abdomen had no
evidence of extravasation through coiled pseudoaneurysm. No
hematemesis and benign abdominal exam were noted, and stable
hematocrits and negative NG lavage suggested that upper GI
source was less likely, though small shallow ulcerations were
seen in the duodenum on ERCP in 5/[**2143**]. Patient does have
diverticulosis seen on CT in [**2141**] with prior remote episodes of
melenic stool. INR was supratherapeutic slightly on admission to
OSH and previously this month, though patient reports
therapeutic range for past few weeks. Source of bleed seems to
most likely be lower gastrointestinal and differential diagnosis
included diverticular, AV malformation, or less likely internal
hemorrhoids or colon cancer.  Last colonoscopy was in [**2141**] and
was reportedly normal per patient. He does have a documented
history of colon cancer s/p resection in [**2137**].  GI did a bedside
endoscopy, showing shallow non-bleeding ulcer, but no active
bleeding.  Patient did have a few bloody stools during his
admission, for which no intervention was undertaken.  He will
likely need an outpatient colosnoscopy. Hematocrits remained
stable and patient did not require any further transfusion.
Patient was initially put on a pantoprazole drip on admission
which was later switched to IV pantoprazole [**Hospital1 **] and then PO
pantoprazole [**Hospital1 **] for discharge.  He will get a CBC soon after
discharge to assure no active bleeding.
.
# Right wrist pain: Pt complained of right wrist pain s/p
mechanical fall 4 days prior to admission with no evidence of
fracture or dislocation on X-ray and low suspicion for a septic
joint. He was evaluated by orthopedics and hand service in the
ED who put a brace on his wrist.  Pain was controlled with
oxycodone, which he will continue as an outpatient.
.
INACTIVE ISSUES
---------------
# Pancreatic pseudoaneurysm: on last admission in [**3-/2144**] patient
was found to have a 1.9 mm pseudoaneurysm in the pancreas.  It
was suspected to be due to his pancreatic cancer vs radiation
treatments. He underwent successful embolization in [**3-/2144**] and
CTA abdomen on this admission demonstrated thrombosed aneurysm
decreased in size from last imaging, with no signs of
extravasation or leaking.  This was determined to be unlikely to
be related to his presenting gastrointestinal bleed.
.
# Biliary obstruction: CBD stent has been placed in [**2141**] with
recent admission in [**3-/2144**] for abdominal pain and worsening
obstructive jaundice, found to have mobilized stent in CBD which
was replaced.  No abdominal pain was present during
hospitalization and his liver function tests were improved from
last admission and remained stable, so restenosis is unlikely.
.
# Pancreatic cancer: diagnosed in [**2141**] s/p 3 cycles gemcitabine
and cyberknife therapy.  Patient follows at [**Hospital **] Hospital
with no treatments in past year though with complications of
pseudoaneurysm and CBD obstruction likely due to recurrence of
active disease, as seen on most recent PET scan.  There was no
evidence of extravasation within his pseudoaneurysm.  On CT in
[**3-/2144**], there was evidence of increasing peripancreatic,
gastrohepatic and periportal lymphadenopathy, likely
representing metastatic disease from pancreatic cancer.  He was
continued on pancreatic enzymes per his home regimen.
.
# Kidney mass: upon getting a CTA of the abdomen, it was noted
that there was a mass in the right kidney, for which radiology
reported that a carcinoma could not be ruled out.  It was
suggested that an MRI be obtained for further classification.
.
# Fever: Per patient he had a temperature of 101 at home,
improved with tylenol. There were no documented fevers since
admission, no leukocytosis, and no localized signs/symptoms of
infection though patient had intermittent diarrhea for past few
weeks with possible evidence of colitis on CT few weeks ago.
Clostridium difficile toxin was checked and was negative.  There
was no suggestion of cholecystitis, diverticulitis, pneumonia or
genitourinary infection.
.
# Atrial fibrillation: Patient had been on warfarin and digoxin
on admission. INR was supratherapeutic to 3.4 at the outside
hospital, improved to 2.6 s/p 2 units FFP.  INR was 2.4 on
admission to [**Hospital1 18**] with goal <1.5 prior to EGD as above.
Coumadin was held. INR was reversed with 2 units of FFP and 10
mg Vitamin K.  Discussion was held with patient and family
regarding risks and benefits of anticoagulation, and it was
decided to discontinue his warfarin.
.
# Diabetes mellitus type 2: patient is on levemir 6 units [**Hospital1 **] at
home.  His blood sugars were controlled with sliding scale
insulin during his stay.  He will continue his aforementioned
levemir dosing at home.
.
# Gout: no evidence of gouty flare in wrist joint.  Patient was
continued on his home dose of allopurinol daily
.
# Hypertension: Home lasix and lisinopril were initially held on
admission given GI bleed and that he was normotensive.  These
were restarted following his EGD and he will resume these
medications upon discharge.
.
TRANSITION OF CARE
------------------
# Follow-up: patient will need a CBC after discharge for
evaluation of anemia.  He will likely also need an outpatient
colonoscopy.  An MRI of the abdomen is also needed to further
classify the mass noted in the patient's right kidney.  Patient
has several blood cultures which remain pending at the time of
discharge.  His H. pylori antibody test also remains pending.
Patient will follow up with his PCP and oncologist upon
discharge, for which both appointments are scheduled.
.
# Code status: full code, confirmed with patient
.
# Communication: wife cell [**Telephone/Fax (1) 82625**]; home [**Telephone/Fax (1) 82626**]

Medications on Admission:
-Celexa 20 mg Tab 1 Tablet(s) by mouth daily
-Oxycodone (dose uncertain) prn wrist and stomach pain
-Levemir 100 unit/mL Sub-Q 6 units twice a day Morning and
Evening
-Vitamin D 2,000 unit Cap Capsule(s) by mouth once a day
-Allopurinol 100 mg Tab Tablet(s) by mouth once a day
-Lisinopril 5 mg Tab Tablet(s) by mouth once a day
-Imodium A-D 2 mg Tab (dose uncertain)
-Lasix 40 mg Tab Oral 1 Tablet(s) Twice Daily
-Fentanyl patch 50mcg q72h
-loperamide 2 mg QID prn diarrhea
-lipase-protease-amylase 12,000-38,000 -60,000 unit TID w/meals

-potassium chloride 40meq daily
-Warfarin -5mg daily, 7.5mg on WED
-digoxin 125 mcg daily


Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain.
3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Imodium A-D  Oral
7. loperamide 2 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for diarrhea.
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO TID w/ meals.
13. Levemir 100 unit/mL Solution Sig: Six (6) units Subcutaneous
twice a day.
14. Outpatient Lab Work
Please perform CBC on [**2144-4-23**]


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Gastrointestianal bleed
Right wrist sprain

Secondary:
Pancreatic cancer
Atrial fibrillation


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


Discharge Instructions:
Dear Mr. [**Known lastname 82627**],

It was a pleasure taking care of you in the hospital.  You were
admitted with bloody bowel movements.  An EGD was performed that
did not show any active bleeding.  Your bleeding may be due to
aberrant vessels in your pancreatic tumor.  You were started on
a medication called pantoprazole that you should continue to
take twice a day to miminize the risk of bleeding.  Your
coumadin was also stopped because it is a blood thinner and can
increase the risk of bleeding.  It would also likely be
worthwhile for you to get a colonoscopy due to your
gastrointestinal bleeding that you came to the hospital for.
Please follow up with your primary care provider concerning
this.

While you were in the hospital you also experienced some pain in
your right wrist which you had fallen on.  You were evaluated by
our orthopedics team and an x-ray did not show a fracture.  This
is likely a sprain and you were given a brace to keep your hand
in.

There was a mass noted on your kidney that was found on a CT
scan that was performed during your admission.  You should
follow up with you oncologist concerning this finding.

The following changes were made to your medications:
1) START pantoprazole 40mg twice a day
2) STOP coumadin

Followup Instructions:
Name: [**Last Name (un) 17747**],[**Last Name (un) 82622**]
Location: [**Location (un) **] FAMILY DOCTORS
[**Name5 (PTitle) **]: [**Street Address(2) 82623**], STE#202, [**Location (un) **],[**Numeric Identifier 41397**]
Phone: [**Telephone/Fax (1) 59840**]
Appointment: [**Telephone/Fax (1) 766**] [**2144-4-27**] 2:30pm

You are scheduled to follow up with your oncologist on Friday,
[**4-24**].

An MRI of the kidneys should be performed on discharge for ?
complex cyst seen in right mid-kidney, concerning for ?
papillary renal cell carcinoma
{'Blood in stool,Malignant neoplasm of head of pancreas,Acute posthemorrhagic anemia,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Atrial fibrillation,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Aneurysm of other visceral artery,Anticoagulants causing adverse effects in therapeutic use,Cyst of kidney, acquired,Personal history of malignant neoplasm of large intestine,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Benign essential hypertension,Sprain of wrist, unspecified site,Unspecified fall,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Diarrhea,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage'}


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: 81M with localized pancreatic cancer diagnosed in [**2141**] s/p 3
cycles gemcitabine and cyberknife therapy, as well as past ERCP
with CBD stenting in [**2141**] and re-stenting in [**3-/2144**], IDDM,
recently discharged on [**3-31**] after IR embolization of pancreatic
pseudoaneurysm who presented to [**Hospital **] Hospital earlier today
after having 2 black stools last night and 2 this AM. He did not
notice any gross blood in the stool, has no abdominal pain,
nausea/vomiting, hematemesis. He measured his temp to 101 last
night which improved with Tylenol. No loss of appetite or weight
loss, no CP or SOB, no dizziness. He recalls having black stools
in the past but does not remember when. He reports that his INR
has been therapeutic for the past 3 weeks (was supratherapeutic
on previous admission in 5/[**2142**]). Over the past month he has had
intermittent diarrhea and constipation but no melena or blood.
.
He presented to [**Hospital **] Hospital this AM and had INR of 3.63,
Hct 31.4. He had a negative NG lavage. He was given 2 units FFP
with improvement in INR to 2.4 after 2 units FFP. [**Hospital **]
transferred to [**Hospital1 **] given concern from aneurysmal bleed.
.
In the ED at [**Hospital1 **] vitals were 129/58 62 16 100% RA, he was found
to have maroon guaiac + stool on rectal exam. HCT 28.6, INR 2.4,
Plat 127. He was started on protonix drip. Given reported fever
of [**Age over 90 **] yesterday and wrist pain s/p recent fall, ortho was
consulted to evaluate for septic joint. XR did not show wrist
fracture and ortho did not believe this was a septic joint. IR,
GI, gen [**Doctor First Name **] and ERCP were consulted and recommended holding
coumadin and planning for EGD in AM. He was written for 1U FFP
and 1U RBCs but these were not given in the ED.
.
On the floor, pt had no complaints - no N/V, no abdominal pain,
no ongoing bleeding or subsequent stools. He reported being
thirsty, no dizziness or any pain.

MEDICAL HISTORY: - Pancreatic CA - s/p plastic, and now metal stenting in duct.
s/p 3 cycles of Gemcitabine with stereotactic XRT.  Followed at
[**Hospital **] hospital
- A.Fib, on coumadin
- Colon CA, s/p resection in [**2137**]
- DM II - on insulin
- S/P portacath right chest
- Chronic L>R LE edema, on lasix
- BPH
- Gout
- HTN

MEDICATION ON ADMISSION: -Celexa 20 mg Tab 1 Tablet(s) by mouth daily
-Oxycodone (dose uncertain) prn wrist and stomach pain
-Levemir 100 unit/mL Sub-Q 6 units twice a day Morning and
Evening
-Vitamin D 2,000 unit Cap Capsule(s) by mouth once a day
-Allopurinol 100 mg Tab Tablet(s) by mouth once a day
-Lisinopril 5 mg Tab Tablet(s) by mouth once a day
-Imodium A-D 2 mg Tab (dose uncertain)
-Lasix 40 mg Tab Oral 1 Tablet(s) Twice Daily
-Fentanyl patch 50mcg q72h
-loperamide 2 mg QID prn diarrhea
-lipase-protease-amylase 12,000-38,000 -60,000 unit TID w/meals

ALLERGIES: Penicillins / Aspirin

PHYSICAL EXAM: On admission:
Vitals: T 98.5, BP 107/60, HR 62, RR 20, 95% RA
General: AOX3, in no distress
HEENT: Sclera anicteric, dry oral mucosa, poor dentition
Neck: supple, JVP not elevated, no cervical lymphadenopathy
Lungs: CTA bilaterally, no wheezes or rales
CV: nl S1/S2, RRR, no murmurs
Abdomen: soft, non-tender, non-distended, BS normoactive,
negative [**Doctor Last Name 515**] sign, no rebound/guarding
Ext: brace and wrap over R wrist, hands warm and well perfused,
R foot cooler to touch than L with 2+ distal pulses b/l, good
capillary refill

FAMILY HISTORY: No CA in family.  Not relevant to this hospitalization

SOCIAL HISTORY: Non-smoker. No ETOH abuse.  Retired engineer.  Independent in
all  ADLs/IADLs. 

### Response:
{'Blood in stool,Malignant neoplasm of head of pancreas,Acute posthemorrhagic anemia,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Atrial fibrillation,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Aneurysm of other visceral artery,Anticoagulants causing adverse effects in therapeutic use,Cyst of kidney, acquired,Personal history of malignant neoplasm of large intestine,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Benign essential hypertension,Sprain of wrist, unspecified site,Unspecified fall,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Diarrhea,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage'}
