CHIEF COMPLAINT: Bright red blood per rectum

PRESENT ILLNESS: 73 yo M with ESRD on HD, severe PVD s/p multiple interventions,
PUD/GERD, past RA thrombus on coumadin, who presents from
routine HD with BRBPR. The patient states that he otherwise felt
well today when he had a large bloody BM during HD. He denies
dizzyness, lightheadedness, CP, abd pain, n/v when this
occurred. He states that prior to this he had been having
regular brown BMs frequently which he attributed to C. diff. He
denies any black or tarry stool at that time, or pain with bowel
movements. His vital signs were reportedly stable at that time,
but he was referred to [**Hospital6 19155**] for further
evaluation.
.
At the OSH, initial VS HR 64, BP 140/68. Orthostatics were
157/67->147/68, HR 53->76. He was noted to have another episode
of BRBPR with clots. Initial labs with Hct 38.9 9lats Hct 40 per
record), INR 15.4 (last INR 2.7 on [**9-30**]). IV access was attempted
multiple times by surgery, including LIJ, LSC line
unsuccessfully. Ultrasound showed narrowing/stenosis. RIJ could
not be performed given tunneled R HD line. Groin line unable to
be performed given extensive PVD and surgical history. A 20
guage PIV was obtained and patient was transferred to [**Hospital1 18**].
Out OSH, INR found to be 15.4.  No record that patient received
FFP or Vitamin K.
.
On arrival, pt had additional moderate sized BRBPR with clot. He
otherwise feels well and denies any complaints except for
fatigue. He denies f/c, HA, lightheadedness, CP, SOB, n/v, abd
pain, rectal pain, swelling, rash.  His vitals were BP 156/64,
HR 52, RR 20, 98% on RA. His INR was found to be 9.0, so he was
given 10 mg of Vit K and 2 units of FFP.   After discussion with
the GI fellow, decision was made to further monitor patient in
the ICU.

MEDICAL HISTORY: ESRD on HD
PVD (see below)
GERD/PUD [**3-1**] ASA -> EGD [**10-4**] with ulceration of posterior wall
? MDS
Hyperlipidemia
HTN
h/o C.diff
DM2
Prostate ca s/p XRT
RCC s/p Nephrectomy
RA thrombus in [**5-5**]
Blood dyscrasian, on hydrea
h/o dialysis catheter thrombosis
.
PSH (taken from vascular notes):
11/12 L CFA thromboendarterectomy w/ patch profunda plasty,
L EIA stenting
[**2103-10-30**]- Redo right interposition tube graft between
external iliac artery and profunda femoral artery with 8 mm
Dacron tube graft, Reopening of previous incision on right
groin,
release of contained hematoma and repair of leak at the
distal anastomosis between Dacron tube graft and profunda
femoral artery on the right
[**2103-10-16**]- diagnostic angio, Right common iliac plaque seen on
prior angiograms, Occlusion of the Dacron graft distal to the
take-off of the right internal iliac artery. There is
reconstitution of the right profunda femoral artery. Complete
occlusion of the superficial femoral artery and popliteal artery

MEDICATION ON ADMISSION: Plavix 75 mg daily
Atenolol 25 mg daily
Folic Acid 1 mg daily
Nifedipine 30mg daily
Omeprazole 30 mg daily
Renvela 1600mg TID
Lipitor 10 mg daily
Nephrocap 1 cap daily
Percocet 1 tab TID prn
Coumadin 5mg daily  --has not refilled since [**7-6**]
Hydrea 500mg daily -- has not refilled since [**8-5**]
Lisinopril 20mg daily  --has not refilled since [**8-5**]
Amitriptyline 25mg daily  --has not refilled since [**8-4**]

ALLERGIES: Aspirin

PHYSICAL EXAM: VS: BP 156/65, HR 56, RR 18, 99% on RA
Gen: awake, alert, talkative, NAD
HEENT: EOMI, anicteric sclera, MM moist, OP clear
Neck: supple, central line attempts dressed, R tunneled HD line
intact
Lung: CTAB no wheezes or crackles
Heart: RRR nl S1 S2 no m/r/g
Abd: thin, soft, NT/ND +BS, no rebound or guarding, no masses
Back: no CVA tenderness
Rectal: normal rectal tone, no stool in vault though exam
limited by patient cooperation, dried red blood externally, no
obvious bleeding in external structures
Ext: no pitting edema, warm
Skin: no rash

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Lives alone and semi-independent with wheelchair. Smokes 1ppd
x50 yrs. Denies EtOH use
Ulcer of anus and rectum,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Mechanical complication of other vascular device, implant, and graft,Acute posthemorrhagic anemia,Methicillin susceptible Staphylococcus aureus septicemia,Sepsis,Late effect of radiation,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Esophageal reflux,Long-term (current) use of anticoagulants,Essential thrombocythemia,Personal history of malignant neoplasm of kidney,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of prostate
Rectal & anal ulcer,End stage renal disease,Hyp kid NOS w cr kid V,Malfunc vasc device/graf,Ac posthemorrhag anemia,Meth susc Staph aur sept,Sepsis,Late effect of radiation,Abnrml coagultion prfile,Adv eff anticoagulants,Esophageal reflux,Long-term use anticoagul,Essntial thrombocythemia,Hx of kidney malignancy,DMII wo cmp uncntrld,Hyperlipidemia NEC/NOS,Hx-prostatic malignancy
Admission Date:  [**2104-10-6**]              Discharge Date:   [**2104-10-16**]

Date of Birth:  [**2030-11-2**]             Sex:   M

Service: MEDICINE

Allergies:
Aspirin

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Bright red blood per rectum

Major Surgical or Invasive Procedure:
Blood transfusions
Fresh frozen plasma transfusions

History of Present Illness:
73 yo M with ESRD on HD, severe PVD s/p multiple interventions,
PUD/GERD, past RA thrombus on coumadin, who presents from
routine HD with BRBPR. The patient states that he otherwise felt
well today when he had a large bloody BM during HD. He denies
dizzyness, lightheadedness, CP, abd pain, n/v when this
occurred. He states that prior to this he had been having
regular brown BMs frequently which he attributed to C. diff. He
denies any black or tarry stool at that time, or pain with bowel
movements. His vital signs were reportedly stable at that time,
but he was referred to [**Hospital6 19155**] for further
evaluation.
.
At the OSH, initial VS HR 64, BP 140/68. Orthostatics were
157/67->147/68, HR 53->76. He was noted to have another episode
of BRBPR with clots. Initial labs with Hct 38.9 9lats Hct 40 per
record), INR 15.4 (last INR 2.7 on [**9-30**]). IV access was attempted
multiple times by surgery, including LIJ, LSC line
unsuccessfully. Ultrasound showed narrowing/stenosis. RIJ could
not be performed given tunneled R HD line. Groin line unable to
be performed given extensive PVD and surgical history. A 20
guage PIV was obtained and patient was transferred to [**Hospital1 18**].
Out OSH, INR found to be 15.4.  No record that patient received
FFP or Vitamin K.
.
On arrival, pt had additional moderate sized BRBPR with clot. He
otherwise feels well and denies any complaints except for
fatigue. He denies f/c, HA, lightheadedness, CP, SOB, n/v, abd
pain, rectal pain, swelling, rash.  His vitals were BP 156/64,
HR 52, RR 20, 98% on RA. His INR was found to be 9.0, so he was
given 10 mg of Vit K and 2 units of FFP.   After discussion with
the GI fellow, decision was made to further monitor patient in
the ICU.


Past Medical History:
ESRD on HD
PVD (see below)
GERD/PUD [**3-1**] ASA -> EGD [**10-4**] with ulceration of posterior wall
? MDS
Hyperlipidemia
HTN
h/o C.diff
DM2
Prostate ca s/p XRT
RCC s/p Nephrectomy
RA thrombus in [**5-5**]
Blood dyscrasian, on hydrea
h/o dialysis catheter thrombosis
.
PSH (taken from vascular notes):
11/12 L CFA thromboendarterectomy w/ patch profunda plasty,
L EIA stenting
[**2103-10-30**]- Redo right interposition tube graft between
external iliac artery and profunda femoral artery with 8 mm
Dacron tube graft, Reopening of previous incision on right
groin,
release of contained hematoma and repair of leak at the
distal anastomosis between Dacron tube graft and profunda
femoral artery on the right
[**2103-10-16**]- diagnostic angio, Right common iliac plaque seen on
prior angiograms, Occlusion of the Dacron graft distal to the
take-off of the right internal iliac artery. There is
reconstitution of the right profunda femoral artery. Complete
occlusion of the superficial femoral artery and popliteal artery

with only a small 1 cm opening in that popliteal vessel.
Reconstitution of the posterior tibial artery which continues
down to the foot with a short 1 cm occlusion in the mid leg.
There is no DP artery in the foot. There is a large posterior
tibial artery with collaterals in the foot.
[**2103-8-20**]- L jump graft. From the in-situ bypass from above the
knee to below the knee to a posterior tibialis.
[**2103-7-27**]- percutaneous balloon angioplasty of a left external
iliac in-stent restenosis, percutaneous balloon angioplasty of
the distal external iliac and proximal common femoral arteries,

percutaneous balloon angioplasty of distal femoral to
posterior tibialis in situ bypass graft and distal
anastomoses, stent placement within the distal bypass graft
[**2103-4-30**]- Resection of common femoral artery aneurysm with
8 mm Dacron graft from the external iliac artery to the
profunda artery
[**2103-4-12**]- Left femoral endarterectomy with Dacron patch
angioplasty, left in situ femoral to posterior tibialis
bypass graft
[**2103-4-11**]- left external iliac artery stent, left external
iliac artery percutaneous angioplasty
R nephrectomy (hydronephrosis), tunneled dialysis cath

Social History:
Lives alone and semi-independent with wheelchair. Smokes 1ppd
x50 yrs. Denies EtOH use

Family History:
noncontributory

Physical Exam:
VS: BP 156/65, HR 56, RR 18, 99% on RA
Gen: awake, alert, talkative, NAD
HEENT: EOMI, anicteric sclera, MM moist, OP clear
Neck: supple, central line attempts dressed, R tunneled HD line
intact
Lung: CTAB no wheezes or crackles
Heart: RRR nl S1 S2 no m/r/g
Abd: thin, soft, NT/ND +BS, no rebound or guarding, no masses
Back: no CVA tenderness
Rectal: normal rectal tone, no stool in vault though exam
limited by patient cooperation, dried red blood externally, no
obvious bleeding in external structures
Ext: no pitting edema, warm
Skin: no rash

Pertinent Results:
ADMIT LABS:
139 | 103 | 41 /
--------------- 84
5.0 | 23 | 5.9 \
.
..
.. \ 12.1 /
6.5 ------ 487
.. / 37.5 \
.
PT 72.5
PTT 48.9
INR 9.0
.
IMAGING:
[**2102-10-24**]. EGD.
1cm duodenal ulcer with clot
.
Echo.  [**5-5**]
Left ventricular cavity size and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. A mass is seen in the right atrium measuring 3.0 x
1.4 cm. The mass appears to be attached to the eustachian valve
or may be a prominent eustachian valve . No vegitation is seen
in the tricuspid, aortic or mitral valves. The pulmonic valve
was not adequately visualized. Mild (grade I) diastolic
dysfunction. No atrial septal defect is seen by 2D or color
Doppler. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. Trivial
mitral regurgitation is seen. There is no pericardial effusion.

.
Stress test.  [**2103-7-31**].
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.

Brief Hospital Course:
STUDIES:
ABD U/S:
1. Patent hepatic vasculature.
2. Increased echogenicity of the portal triads, a nonspecific
finding. While
this finding may be seen in acute hepatitis as well as other
entities, it can
be considered a normal variant as well. Please correlate
clinically. The
liver contour is not nodular and there are no signs of portal
hypertension to
suggest cirrhosis.

PICC LINE CULTURE: Negative
HD CATHETER CULTURE: Positive for staph

.
#. GI bleed.  No brisk bleeding while in ICU, one episode of
BRBPR afternoon of [**10-7**]. INR now down to 2.0-2.7, Hct has
remained stable on transfer. Patient is prepped for colonoscopy
but will not be done prior to transfer given supratherapeutic
INR. Tagged RBC scan showed delayed bleeding in LLQ, no
indication for emergent angio, especially given PVD. Underwent
golytely prep prior to transfer to floor. Ddx includes bleeding
in sigmoid/rectum as pt s/p radiation for prostate cancer vs
diverticulum vs AVM. Pt also with h/o duodenal ulcer but sxs and
imaging more c/s with lower GIB. GI, vascular [**Doctor First Name **], and general
surgery have been following patient. Patient was not emergently
taken to angio or colonoscopy/flex sig. Had bleeding study that
showed bleeding from rectum. Plavix and coumadin held.
Colonoscopy later showed two non-bleeding rectal ulcers and
radiation proctitis. Pathology showed normal mucosa with no
evidence of IBD. Patient's diet was advanced and his hct
remained stable. He experienced no further episodes of
melena/BRBPR. His hct on dc was 38.6 and stable.
.
#.  Anticoagulation.  Patient noted to have a RA thrombus in
[**5-5**].  As outpatient, was anticoagulated with coumadin.  Found
to have supratherapeutic INR to 9 on admission which has been
reversed to 2-2.7 with PO vitamin K and FFP. Started on heparin
drip when INR <2. After procedures was bridged back to coumadin.
However after TTE was negative for right atrial thrombus the
heparin drip was turned off and coumadin was d/cd as the patient
no longer had a reason to be anticoagulated and was at high risk
of further bleeding from the GI tract.
.
#.  ESRD on HD. Continued on home HD schedule (MWF). Continued
on nephrocaps, renvela. HD catheter replaced over wire on
[**2104-10-10**] and subsequently found to be leaking a few days later so
was changed over a wire. The catheter tip subsequently grew
staph on culture. He was treated with IV vanco per HD protocol.
.
#.  HTN. Antihypertensives (nifedepine, atenolol, lisinopril)
held in context of GIB. Then restarted slowly.
.
#. Bacteremia: Patient had fever and blood cultures showed coag
negative staph sensitive to Vancomycin in [**5-2**] bottles. Started
on Vanco for a course of 14 days. Source was presumed to be the
HD line. The PICC line was pulled and cultured with no growth.
The HD line was changed over a wire and culture results showed
staph on the tip. As the patient has such difficult access this
was felt to be the best approach. He may need a replacement HD
catheter placed eventually if he has persistent bacteremia
although subsequent blood cultures taken here since the catheter
was changed show no growth to date.
.
#PVD: Held plavix in setting of GIB. Vascular surgeons thought
no change to foot. In setting of bacteremia had foot XR that
showed no evidence of osetomyelitis and vascular surgery felt
the foot had not changed in appearance. He was restarted on his
plavix as Dr. [**Last Name (STitle) 1391**] felt it was necessary to keep his stents
patent.
.
#.  H/o C. Diff.  Per patient, currently on Flagyl for C. diff.
In our system, had positive cdiff in 1/[**2104**]. Patient's PCP was
called and had not placed patient on long course of flagyl.
CDiff cultures X 3 were negative. Flagyl was d/cd.
.
#.  Hyperlipidemia. continued on pravastatin
.
#.  Possible Blood Dyscrasia/thrombocytosis.  Patient on hydrea
as outpatient which was continued as an inpatient.  He will
follow up with his hematologist as an outpatient for further
management.
.
#. Diabetes. Maintained on insulin sliding scale
.
#.Chronic foot pain. continued on amytriptyline and percocet.
.
#. Atrial tachycardia: Patient had several episodes of acute
tachycardia felt to be sinus tach vs atrial tachycardia usually
associated with volume depletion after HD. His electrolytes were
kept wnl and the dose of his beta blocker was increased with
good effect. The patient remained asymptomatic with stable blood
pressures and mentation throughout all episodes of the
tachycardia. His beta blocker was up-titrated and he was sent
home on toprol XL 50mg daily.


Medications on Admission:
Plavix 75 mg daily
Atenolol 25 mg daily
Folic Acid 1 mg daily
Nifedipine 30mg daily
Omeprazole 30 mg daily
Renvela 1600mg TID
Lipitor 10 mg daily
Nephrocap 1 cap daily
Percocet 1 tab TID prn
Coumadin 5mg daily  --has not refilled since [**7-6**]
Hydrea 500mg daily -- has not refilled since [**8-5**]
Lisinopril 20mg daily  --has not refilled since [**8-5**]
Amitriptyline 25mg daily  --has not refilled since [**8-4**]

Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours as needed.
Disp:*20 Tablet(s)* Refills:*0*
5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Renvela 800 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Disp:*180 Tablet(s)* Refills:*2*
9. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Amitriptyline 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime).
11. Vancomycin 1000 mg IV HD PROTOCOL
please give after HD every other day
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **]Hospice

Discharge Diagnosis:
Lower GI bleed from rectal ulcers and radiation proctitis.
Atrial tachycardia.
Coagulase negative bactermia from HD catheter line

Discharge Condition:
The patient was normotensive, not tachycardic, afebrile, and
with a stable hematocrit for >24hours before discharge.

Discharge Instructions:
You were admitted to the hospital with bleeding from your
rectum. This bleeding likely happened because your blood was too
thin. Your plavix and coumadin were not given to you and you
were given clotting factors and vitamin K to help your blood
thicken. You then had a colonoscopy that showed the bleeding was
from two ulcers in your rectum and possibly from injury to your
rectum caused by radiation. You had an ultrasound of you heart
to look for the clot in your heart. We did not see the clot in
your heart so we have stopped your coumadin. You no longer need
to take it.
 While you were here you were continued on your hemodialysis
treatments every other day. Your dialysis catheter needed to be
exchanged and this was done.
 You had a fever from an infection in your blood that came from
your dialysis catheter. You have been given antibiotics for this
infection and should continue these antibiotics for four weeks.
Your hemodialysis doctor will give you these medicines when you
go for your dialysis treatments.

MEDICATION CHANGES:
CHANGE: Omeprazole 30mg by mouth daily to omeprazole 40mg by
mouth daily
STOP: Coumadin
STOP: Atenolol
STOP: Nifedipine
STOP: Lisinopril
START: Toprol XL 50mg by mouth daily
START: Vancomycin each time you go to dialysis they will dose
this for you and you should continue this for 4 weeks.

You should call your doctor or come to the emergency room if you
experience light-headedness, dizziness, chest pain, shortness of
breath, worsening foot pain, fevers, blood in your stool or
black tarry stools, or any other concerning symptoms.


Followup Instructions:
Please followup with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 19154**] next wednesday [**2104-10-22**]
at 10:45am.

Please continue your hemodialysis treatments at your regular
clinic on Mondays, Wednesdays, and Fridays once you are
discharged from the hospital. Your nephrologist should check
your vancomycin level on [**2104-10-17**] when you go to HD.

Please follow up with your hematologist/oncologist, Dr. [**Last Name (STitle) 1492**],
Thursday [**10-30**] at 3:00pm. Fax [**Telephone/Fax (1) 72156**]



Completed by:[**2104-10-16**]
{'Ulcer of anus and rectum,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Mechanical complication of other vascular device, implant, and graft,Acute posthemorrhagic anemia,Methicillin susceptible Staphylococcus aureus septicemia,Sepsis,Late effect of radiation,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Esophageal reflux,Long-term (current) use of anticoagulants,Essential thrombocythemia,Personal history of malignant neoplasm of kidney,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of prostate'}


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: Bright red blood per rectum

PRESENT ILLNESS: 73 yo M with ESRD on HD, severe PVD s/p multiple interventions,
PUD/GERD, past RA thrombus on coumadin, who presents from
routine HD with BRBPR. The patient states that he otherwise felt
well today when he had a large bloody BM during HD. He denies
dizzyness, lightheadedness, CP, abd pain, n/v when this
occurred. He states that prior to this he had been having
regular brown BMs frequently which he attributed to C. diff. He
denies any black or tarry stool at that time, or pain with bowel
movements. His vital signs were reportedly stable at that time,
but he was referred to [**Hospital6 19155**] for further
evaluation.
.
At the OSH, initial VS HR 64, BP 140/68. Orthostatics were
157/67->147/68, HR 53->76. He was noted to have another episode
of BRBPR with clots. Initial labs with Hct 38.9 9lats Hct 40 per
record), INR 15.4 (last INR 2.7 on [**9-30**]). IV access was attempted
multiple times by surgery, including LIJ, LSC line
unsuccessfully. Ultrasound showed narrowing/stenosis. RIJ could
not be performed given tunneled R HD line. Groin line unable to
be performed given extensive PVD and surgical history. A 20
guage PIV was obtained and patient was transferred to [**Hospital1 18**].
Out OSH, INR found to be 15.4.  No record that patient received
FFP or Vitamin K.
.
On arrival, pt had additional moderate sized BRBPR with clot. He
otherwise feels well and denies any complaints except for
fatigue. He denies f/c, HA, lightheadedness, CP, SOB, n/v, abd
pain, rectal pain, swelling, rash.  His vitals were BP 156/64,
HR 52, RR 20, 98% on RA. His INR was found to be 9.0, so he was
given 10 mg of Vit K and 2 units of FFP.   After discussion with
the GI fellow, decision was made to further monitor patient in
the ICU.

MEDICAL HISTORY: ESRD on HD
PVD (see below)
GERD/PUD [**3-1**] ASA -> EGD [**10-4**] with ulceration of posterior wall
? MDS
Hyperlipidemia
HTN
h/o C.diff
DM2
Prostate ca s/p XRT
RCC s/p Nephrectomy
RA thrombus in [**5-5**]
Blood dyscrasian, on hydrea
h/o dialysis catheter thrombosis
.
PSH (taken from vascular notes):
11/12 L CFA thromboendarterectomy w/ patch profunda plasty,
L EIA stenting
[**2103-10-30**]- Redo right interposition tube graft between
external iliac artery and profunda femoral artery with 8 mm
Dacron tube graft, Reopening of previous incision on right
groin,
release of contained hematoma and repair of leak at the
distal anastomosis between Dacron tube graft and profunda
femoral artery on the right
[**2103-10-16**]- diagnostic angio, Right common iliac plaque seen on
prior angiograms, Occlusion of the Dacron graft distal to the
take-off of the right internal iliac artery. There is
reconstitution of the right profunda femoral artery. Complete
occlusion of the superficial femoral artery and popliteal artery

MEDICATION ON ADMISSION: Plavix 75 mg daily
Atenolol 25 mg daily
Folic Acid 1 mg daily
Nifedipine 30mg daily
Omeprazole 30 mg daily
Renvela 1600mg TID
Lipitor 10 mg daily
Nephrocap 1 cap daily
Percocet 1 tab TID prn
Coumadin 5mg daily  --has not refilled since [**7-6**]
Hydrea 500mg daily -- has not refilled since [**8-5**]
Lisinopril 20mg daily  --has not refilled since [**8-5**]
Amitriptyline 25mg daily  --has not refilled since [**8-4**]

ALLERGIES: Aspirin

PHYSICAL EXAM: VS: BP 156/65, HR 56, RR 18, 99% on RA
Gen: awake, alert, talkative, NAD
HEENT: EOMI, anicteric sclera, MM moist, OP clear
Neck: supple, central line attempts dressed, R tunneled HD line
intact
Lung: CTAB no wheezes or crackles
Heart: RRR nl S1 S2 no m/r/g
Abd: thin, soft, NT/ND +BS, no rebound or guarding, no masses
Back: no CVA tenderness
Rectal: normal rectal tone, no stool in vault though exam
limited by patient cooperation, dried red blood externally, no
obvious bleeding in external structures
Ext: no pitting edema, warm
Skin: no rash

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Lives alone and semi-independent with wheelchair. Smokes 1ppd
x50 yrs. Denies EtOH use 

### Response:
{'Ulcer of anus and rectum,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Mechanical complication of other vascular device, implant, and graft,Acute posthemorrhagic anemia,Methicillin susceptible Staphylococcus aureus septicemia,Sepsis,Late effect of radiation,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Esophageal reflux,Long-term (current) use of anticoagulants,Essential thrombocythemia,Personal history of malignant neoplasm of kidney,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of prostate'}
