CHIEF COMPLAINT: Bright red [**First Name3 (LF) **] per rectum

PRESENT ILLNESS: 85 year old female h/o afib with RVR on pradaxa with BRBPR x
several weeks with increased amount of [**Month/Day/Year **] this week. Patient
reports the increased bleeding was also associated with
suprapubic pain accompanied by dysuria and some fevers, chills,
nausea and vomiting. Patient previously diagnosed with UTI and
has been taking Nitrofurantoin with improvement of her symptoms.
Patient additionally noted chest pain prior to presentation to
ED. The chest pain resolved without intervention and she is
currently chest pain free. Initially an EKG showed afib without
any acute changes. SBP 100, not lightheaded or dizzy.

MEDICAL HISTORY: Diabetes
Dyslipidemia
Hypertension
Atrial fibrillation
Hypothyroidism
Osteoarthritis, s/p bilateral knee replacements in [**2182**]
Depression
Asthma, diagnosed in [**2184**]
C-sections in past

MEDICATION ON ADMISSION: 1. Isosorbide Mononitrate 30 mg PO QDAILY
2. Furosemide 40 mg PO DAILY
3. GlyBURIDE 2.5 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Valsartan 160 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Pravastatin 40 mg PO DAILY
8. Allopurinol 100 mg PO BID
9. Oxybutynin 5 mg PO BID
10. Dabigatran Etexilate 150 mg PO BID
11. Colchicine 0.6 mg PO PRN arthritis
12. Diltiazem Extended-Release 240 mg PO DAILY

ALLERGIES: Lisinopril / Metformin

PHYSICAL EXAM: Physical Exam upon presentation:
Vitals: 97.4 111 127/78 17 100% RA
GEN: A&O to self, appropriate, resting comfortably, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregular, rate controlled, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, minimally tender, no rebound or
guarding, normoactive bowel sounds, no palpable masses
DRE: normal tone, guiac positive, no gross [**Year (4 digits) **]
Ext: No LE edema, LE warm and well perfused.  R femoral sheath
intact.

FAMILY HISTORY: Family history of CVA/CAD.

SOCIAL HISTORY: Husband died many years ago. Patient lives with her
granddaughter who is her proxy. Smoked 36 years x 1 ppd, quit in
[**2181**], remote social ETOH.
Unspecified vascular insufficiency of intestine,Other specified peritonitis,Acute respiratory failure following trauma and surgery,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Other acute and subacute forms of ischemic heart disease, other,Cardiac complications, not elsewhere classified,Congestive heart failure, unspecified,Peritoneal adhesions (postoperative) (postinfection),Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Unspecified acquired hypothyroidism,Diverticulosis of colon (without mention of hemorrhage),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypotension, unspecified,Chronic kidney disease, unspecified,Gout, unspecified,Mild cognitive impairment, so stated,Asthma, unspecified type, unspecified,Thrombocytopenia, unspecified,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Other specified disorders of intestine,Personal history, urinary (tract) infection,Personal history of tobacco use,Knee joint replacement
Vasc insuff intest NOS,Peritonitis NEC,Ac resp flr fol trma/srg,Ac posthemorrhag anemia,Urin tract infection NOS,Acute kidney failure NOS,Ac ischemic hrt dis NEC,Surg compl-heart,CHF NOS,Peritoneal adhesions,Atrial fibrillation,Hy kid NOS w cr kid I-IV,Hypothyroidism NOS,Dvrtclo colon w/o hmrhg,DMII wo cmp nt st uncntr,Hypotension NOS,Chronic kidney dis NOS,Gout NOS,Mild cognitive impairemt,Asthma NOS,Thrombocytopenia NOS,Hyperlipidemia NEC/NOS,Depressive disorder NEC,Intestinal disorders NEC,Personal history UTI,History of tobacco use,Joint replaced knee
Admission Date:  [**2194-8-18**]              Discharge Date:   [**2194-8-27**]

Date of Birth:  [**2108-10-18**]             Sex:   F

Service: SURGERY

Allergies:
Lisinopril / Metformin

Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Bright red [**First Name3 (LF) **] per rectum

Major Surgical or Invasive Procedure:
[**2194-8-19**] SMA arteriogram, selective ileocolic arteriogram
exploratory laparotomy with extended right colectomy.
[**2194-8-20**] end ileostomy


History of Present Illness:
85 year old female h/o afib with RVR on pradaxa with BRBPR x
several weeks with increased amount of [**Month/Day/Year **] this week. Patient
reports the increased bleeding was also associated with
suprapubic pain accompanied by dysuria and some fevers, chills,
nausea and vomiting. Patient previously diagnosed with UTI and
has been taking Nitrofurantoin with improvement of her symptoms.
Patient additionally noted chest pain prior to presentation to
ED. The chest pain resolved without intervention and she is
currently chest pain free. Initially an EKG showed afib without
any acute changes. SBP 100, not lightheaded or dizzy.

In ED patient noted to be mildly tachycardic, with increasing
heart rate after volume resuscitation with 2L NS. Patient
underwent CTA of the abdomen which showed active venous

Past Medical History:
Diabetes
Dyslipidemia
Hypertension
Atrial fibrillation
Hypothyroidism
Osteoarthritis, s/p bilateral knee replacements in [**2182**]
Depression
Asthma, diagnosed in [**2184**]
C-sections in past

Social History:
Husband died many years ago. Patient lives with her
granddaughter who is her proxy. Smoked 36 years x 1 ppd, quit in
[**2181**], remote social ETOH.


Family History:
Family history of CVA/CAD.

Physical Exam:
Physical Exam upon presentation:
Vitals: 97.4 111 127/78 17 100% RA
GEN: A&O to self, appropriate, resting comfortably, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregular, rate controlled, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, minimally tender, no rebound or
guarding, normoactive bowel sounds, no palpable masses
DRE: normal tone, guiac positive, no gross [**Year (4 digits) **]
Ext: No LE edema, LE warm and well perfused.  R femoral sheath
intact.

Physical Exam upon discharge:
VS:97.6, 95, 125/58, 20, 99/RA
GEN: Arousable to voice, NAD.
HEENT:HEENT: No scleral icterus, mucus membranes moist
CV: Irregular, rate controlled. No M/R/G.
PULM: Faint expiratory wheezes bilaterally. No rales/rhonchi.
ABD: Soft, nondistended, nontender. Ileostomy + fecal output.
EXT: + 1 pitting edema all four extremities. No Cyanosis,
clubbing. WWP.

Pertinent Results:
[**2194-8-18**] 08:10PM [**Month/Day/Year 3143**] WBC-8.0 RBC-2.76*# Hgb-8.7*# Hct-26.9*#
MCV-97# MCH-31.4 MCHC-32.3 RDW-15.2 Plt Ct-204
[**2194-8-19**] 01:17AM [**Month/Day/Year 3143**] WBC-7.8 RBC-2.32* Hgb-7.2* Hct-22.1*
MCV-96 MCH-31.1 MCHC-32.5 RDW-15.5 Plt Ct-164
[**2194-8-19**] 06:03AM [**Month/Day/Year 3143**] WBC-10.5 RBC-2.97*# Hgb-8.6* Hct-26.3*
MCV-89# MCH-29.0 MCHC-32.8 RDW-16.7* Plt Ct-124*
[**2194-8-19**] 11:00AM [**Month/Day/Year 3143**] Hct-29.0*
[**2194-8-19**] 03:01PM [**Month/Day/Year 3143**] WBC-8.9 RBC-3.06* Hgb-9.1* Hct-26.4*
MCV-90 MCH-29.8 MCHC-33.2 RDW-16.5* Plt Ct-124*
[**2194-8-19**] 07:18PM [**Month/Day/Year 3143**] Hct-28.5*
[**2194-8-20**] 01:53AM [**Month/Day/Year 3143**] WBC-5.4 RBC-2.96* Hgb-9.1* Hct-26.4*
MCV-89 MCH-30.8 MCHC-34.5 RDW-15.1 Plt Ct-71*
[**2194-8-20**] 05:26AM [**Month/Day/Year 3143**] WBC-12.7*# RBC-3.57* Hgb-11.3* Hct-31.3*
MCV-88 MCH-31.5 MCHC-35.9* RDW-15.3 Plt Ct-92*
[**2194-8-20**] 09:25AM [**Month/Day/Year 3143**] Hct-30.3*
[**2194-8-20**] 01:38PM [**Month/Day/Year 3143**] Hct-26.7*
[**2194-8-20**] 03:24PM [**Month/Day/Year 3143**] Hgb-9.9* Hct-29.0*
[**2194-8-21**] 12:50AM [**Month/Day/Year 3143**] WBC-13.0* RBC-2.63*# Hgb-7.8* Hct-23.4*
MCV-89 MCH-29.8 MCHC-33.6 RDW-16.0* Plt Ct-104*
[**2194-8-21**] 04:02AM [**Month/Day/Year 3143**] Hct-26.9*
[**2194-8-21**] 09:31AM [**Month/Day/Year 3143**] Hct-25.5*
[**2194-8-21**] 01:05PM [**Month/Day/Year 3143**] Hgb-8.3* Hct-23.6*
[**2194-8-21**] 05:05PM [**Month/Day/Year 3143**] Hct-22.0*
[**2194-8-21**] 09:44PM [**Month/Day/Year 3143**] Hct-27.1*
[**2194-8-22**] 02:47AM [**Month/Day/Year 3143**] WBC-8.0 RBC-2.99* Hgb-9.1* Hct-26.4*
MCV-88 MCH-30.4 MCHC-34.5 RDW-16.0* Plt Ct-105*
[**2194-8-22**] 07:22AM [**Month/Day/Year 3143**] Hct-19.8*
[**2194-8-22**] 09:30AM [**Month/Day/Year 3143**] Hct-25.5*#
[**2194-8-22**] 04:00PM [**Month/Day/Year 3143**] WBC-5.8 RBC-2.97* Hgb-9.1* Hct-26.2*
MCV-88 MCH-30.5 MCHC-34.5 RDW-16.5* Plt Ct-113*

[**2194-8-18**] 08:10PM [**Month/Day/Year 3143**] PT-19.8* PTT-33.9 INR(PT)-1.9*
[**2194-8-19**] 01:17AM [**Month/Day/Year 3143**] PT-18.7* PTT-47.9* INR(PT)-1.8*
[**2194-8-19**] 03:27PM [**Month/Day/Year 3143**] PT-15.6* PTT-38.1* INR(PT)-1.5*
[**2194-8-19**] 09:50PM [**Month/Day/Year 3143**] PT-17.9* PTT-43.0* INR(PT)-1.7*
[**2194-8-20**] 01:53AM [**Month/Day/Year 3143**] PT-18.2* PTT-43.2* INR(PT)-1.7*
[**2194-8-21**] 12:50AM [**Month/Day/Year 3143**] PT-20.4* PTT-46.7* INR(PT)-1.9*
[**2194-8-22**] 02:47AM [**Month/Day/Year 3143**] PT-18.0* PTT-53.8* INR(PT)-1.7*
[**2194-8-22**] 04:00PM [**Month/Day/Year 3143**] PT-15.6* PTT-46.8* INR(PT)-1.5*

[**2194-8-18**] 08:10PM [**Month/Day/Year 3143**] Glucose-154* UreaN-42* Creat-1.8* Na-139
K-4.1 Cl-104 HCO3-18* AnGap-21*
[**2194-8-19**] 01:17AM [**Month/Day/Year 3143**] Glucose-121* UreaN-39* Creat-1.5* Na-141
K-3.6 Cl-110* HCO3-19* AnGap-16
[**2194-8-19**] 06:03AM [**Month/Day/Year 3143**] Glucose-165* UreaN-38* Creat-1.2* Na-143
K-3.3 Cl-113* HCO3-19* AnGap-14
[**2194-8-20**] 01:53AM [**Month/Day/Year 3143**] Glucose-168* UreaN-34* Creat-1.1 Na-146*
K-3.5 Cl-120* HCO3-17* AnGap-13
[**2194-8-21**] 12:50AM [**Month/Day/Year 3143**] Glucose-218* UreaN-36* Creat-1.4* Na-145
K-4.9 Cl-118* HCO3-14* AnGap-18
[**2194-8-21**] 09:31AM [**Month/Day/Year 3143**] Glucose-166* UreaN-34* Creat-1.3* Na-144
K-4.0 Cl-115* HCO3-19* AnGap-14
[**2194-8-22**] 02:47AM [**Month/Day/Year 3143**] Glucose-118* UreaN-28* Creat-0.7 Na-144
K-3.7 Cl-116* HCO3-19* AnGap-13
[**2194-8-22**] 04:00PM [**Month/Day/Year 3143**] Glucose-114* UreaN-23* Creat-1.1 Na-144
K-3.3 Cl-115* HCO3-20* AnGap-12

[**2194-8-19**] 07:43PM [**Month/Day/Year 3143**] Lactate-1.2
[**2194-8-19**] 09:56PM [**Month/Day/Year 3143**] Glucose-124* Lactate-2.4* Na-141 K-3.7
Cl-119*
[**2194-8-19**] 11:37PM [**Month/Day/Year 3143**] Glucose-247* Lactate-2.0 Na-142 K-4.1
Cl-115*
[**2194-8-20**] 01:01AM [**Month/Day/Year 3143**] Glucose-189* Lactate-2.1* Na-140 K-3.8
Cl-119*
[**2194-8-20**] 02:02AM [**Month/Day/Year 3143**] Glucose-153* Lactate-2.7* Na-139 K-3.5
Cl-120*
[**2194-8-20**] 10:02PM [**Month/Day/Year 3143**] Lactate-3.5* K-4.1
[**2194-8-21**] 12:56AM [**Month/Day/Year 3143**] Lactate-5.0* K-4.7
[**2194-8-21**] 04:09AM [**Month/Day/Year 3143**] Lactate-3.0* K-4.2
[**2194-8-21**] 09:39AM [**Month/Day/Year 3143**] Lactate-2.1*
[**2194-8-21**] 01:19PM [**Month/Day/Year 3143**] Lactate-1.8
[**2194-8-21**] 05:16PM [**Month/Day/Year 3143**] Lactate-1.7
[**2194-8-21**] 08:49PM [**Month/Day/Year 3143**] Lactate-1.6
[**2194-8-22**] 02:56AM [**Month/Day/Year 3143**] Lactate-1.0

[**2194-8-27**] 05:46AM [**Month/Day/Year 3143**] WBC-8.0 RBC-2.68* Hgb-8.2* Hct-25.6*
MCV-96 MCH-30.8 MCHC-32.2 RDW-16.9* Plt Ct-249
[**2194-8-26**] 05:54AM [**Month/Day/Year 3143**] WBC-8.2 RBC-2.76* Hgb-8.7* Hct-25.9*
MCV-94 MCH-31.4 MCHC-33.5 RDW-16.8* Plt Ct-230
[**2194-8-27**] 05:46AM [**Month/Day/Year 3143**] Glucose-185* UreaN-17 Creat-0.9 Na-141
K-3.5 Cl-108 HCO3-27 AnGap-10
[**2194-8-26**] 06:21PM [**Month/Day/Year 3143**] Glucose-211* UreaN-16 Creat-0.9 Na-144
K-3.8 Cl-110* HCO3-26 AnGap-12
[**2194-8-27**] 05:46AM [**Month/Day/Year 3143**] Calcium-7.7* Phos-2.3* Mg-1.8
[**2194-8-26**] 06:21PM [**Month/Day/Year 3143**] Calcium-8.5 Phos-2.1* Mg-2.0

[**2194-8-18**] Mesenteric CTA abdomen/pelvis

ABDOMEN:  Focal area of scarring in the right middle lobe base
is similar to prior exam (3A:3). The liver shows no intrahepatic
biliary dilatation.  A 4-mm focus of arterial enhancement in the
left lobe of the liver persists during the venous phase, likely
making this a small hemangioma as opposed to more aggressive
lesion with washout features; its appearance is similar to prior
chest CTA (3B:206). The gallbladder is distended, but shows no
stones or wall edema.  The CBD is prominent in diameter,
measuring up to 11 mm in diameter and tapering to 5 mm more
distally. The spleen is normal in size.  The pancreas and
adrenal glands show no masses.
The kidneys enhance with and excrete contrast symmetrically
without evidence of hydronephrosis.  A small hypodensity in
right upper pole is too small to characterize and likely
represents a simple cyst and measures 6 mm in diameter (3B:211).
 In the mid pole of the left kidney is an area of cortical
thinning, likely representing scarring from either prior
infection or infarct (3B:222). Incidental note is made of a
fat-containing ventral wall hernia (3B:279). The small and large
bowel show no evidence of obstruction or wall edema.  The right
colon contains liquid stool with peripheral aerosolized
contents.  No pneumatosis or portal venous gas is present.  A
focal blush of intraluminal contrast is present within the right
colon during the venous phase (3B:253). There is no free air,
free fluid, or lymphadenopathy.

PELVIS:  The bladder is decompressed around a Foley balloon.
The uterus
demonstrates calcified fibroids.  The rectum is unremarkable.
There is no
free fluid or lymphadenopathy.  A lipoma is incidentally noted
anterior to the right hip, measuring 5 x 3 cm in the axial plane
(3B:339). Sigmoid diverticulosis is present without
diverticulitis.

CTA/CTV:  The aorta is of a normal caliber along its course.
The origins of the celiac and SMA are narrowed but patent.  The
renal arteries demonstrate calcified atherosclerotic disease at
their origins, but are also patent.  The [**Female First Name (un) 899**] is open.  The iliac
and femoral arterial branches are also patent. In the venous
phase, the portal vein, splenic vein, and SMV are all patent.
Again is noted a blush within the lumen of the right colon on
this phase.

IMPRESSION:
1.  Focal blush of intraluminal contrast in the right colon
during the venous phase concerning for active hemorrhage
2.  No evidence of pneumatosis or portal venous gas or bowel
wall edema.
3.  Sigmoid diverticulosis without evidence of diverticulitis.
4.  Prominent CBD raises the question of a stenotic sphincter of
Oddi -
correlate with LFT's.

[**8-19**] SMA arteriogram,  Selective ileocolic arteriogram

Using a combined palpatory and fluoroscopic guidance and
following
administration of local anesthetic, the right common femoral
artery was
accessed with a 19-guage single wall puncture needle.  [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**]
wire was
easily advanced into the lower order and the needle exchanged
for a 5 French [**Last Name (un) 2493**]-Tip vascular sheath.  A Cobra catheter was
then advanced over the [**Last Name (un) 7648**] wire and the SMA selectively
calculated.  An initial nonselective SMA DSA run in 2
projections demonstrated a normal anatomy of the SMA branches,
specifically with no evidence of active extravasation in the
area of the cecum (area of hemorrhage on previous CTA). The same
procedure for a selective DSA run with a microcatheter inserted
into
the ileocolic artery. Wires and catheters were withdrawn.  Given
an INR of 1.8 and Pradaxa use, the sheath was left in place to
be withdrawn after successful correction of coagulopathy.

IMPRESSION:
Normal appearance of SMA branches, specifically without evidence
of active
extravasation in the area of the cecum (site of extravasation on
prior CTA). Given an INR of 1.8 and Pradaxa use, the sheath is
left in place and should be continuously flushed until removed
in the setting of corrected coagulopathy.

[**2194-8-21**] Echocardiogram

There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF 65%). The right ventricular cavity is dilated with
depressed free wall contractility. There is abnormal septal
motion/position. The ascending aorta is mildly dilated. There
are focal calcifications in the aortic arch. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion. There
is an anterior space which most likely represents a prominent
fat pad.

Compared with the findings of the prior study (images reviewed)
of [**2191-5-6**], the heart rate is increased, the left ventricle
is smaller (underfilled), with persistent right ventricular
dysfunction.

[**2194-8-20**] OR pathology R colon - pending


Brief Hospital Course:
Ms. [**Known lastname 3647**] was initially admitted to the MICU service with
BRBPR in the setting of chronic atrial fibrillation on pradaxa.
CTA positive for blush in right colon, mesenteric angiogram
negative for active extravasation. On [**8-19**], hospital day 2, GI
was planning to perform a colonoscopy to evaluate for a possible
source of the bleed. The patient was unable to tolerate the prep
and was becoming increasingly tachycardic with a worsening
abdominal exam. She continued to pass maroon stools and received
4 units of [**Month/Day (4) **] that day. In the evening, she became more
diffusely tender with concern for peritonitis and was taken to
the OR for exploratory laparotomy, found to have ischemic areas
throughout the transverse and right colon, as well as an
abnormal cecal appendage. There was a significant amount of
[**Month/Day (4) **] throughout the ascending and transverse colon. She
underwent an extended right colectomy, end ileostomy. She
received 3 more units of [**Month/Day (4) **] and 2 units of FFP during the
case. She was transferred to the SICU intubated and sedated.

On [**8-20**], the patient had periods of atrial fibrillation with RVR
to 130's alternating with sinus tachycardia 120-130. A diltiazem
gtt was started and an a-line was placed. Her BP did not
tolerate the drip and it was stopped as she remained mostly in
sinus. She continued to pass old [**Month/Day (1) **] per rectum and her urine
dropped to 15/hour. She was given a 1L bolus. IR removed her
right groin sheath at the bedside. Her hematocrit was ranging
between 26 and 30 on serial checks and no transfusion was given.

On [**8-21**], she continued to be tachycardic, in and out of afib, and
her hematocrit drifted to 23. She was transfused 1 unit of [**Month/Day (4) **]
and bumped to 26.9. She was given albumin 500cc 5% x 3 and 1L of
LR for ongoing tachycardia. Hematocrit down again throughout the
day to 22.4 and was given a second unit of [**Month/Day (4) **], up to 27.1.
Her diltizem drip was restarted for better rate control and a
right IJ CVL was placed to assess CVP which was found to be >20.
Heparin prophylaxis was restarted. Ileostomy teaching was
initiated by the Wound/Ostomy nurse.

On [**8-22**], Ms. [**Known lastname 3647**] was extubated without difficulty and weaned
to room air, lasix 10 x 1 given. She was having scant ostomy
output at this point, tube feeds were started on [**8-23**] and
advanced to goal, tolerated well, low residuals. On [**8-23**], the
ostomy output started to pick up. Diltiazem was transitioned to
enteral via NG route and heart rates remained in atrial
fibrillation, 70-90 range.

On [**8-24**], the patient was transferred to the surgical floor in
stable condition.

0n [**8-25**], the patient was experiencing inspiratory wheezes, lasix
20mg IV was given. She had a Speech and Swallow evaluation,
however she was too sleepy to be able to have a thorough
evaluation, and they recommended keeping patient NPO for the
time being. Her nasogastric tube remained in place for tube
feeds, which were being transfused at goal. Her hematocrit
remained stable at 25.

On [**8-26**], the patient's foley was discontinued and she voided
large quantity of urine. Her mental status improved and she was
more alert. She became tachycardic to the 130s and complained of
chest pain. An EKG revealed she was in atrial fibrillation. She
was given IV Lopressor and an adult dose aspirin. An ABG was
drawn which showed hypoxia, so the patient also received 40mg IV
lasix to improve her pulmonary function. A CXR also revealed a
presentation consistent with congestive heart failure. A foley
catheter was replaced for urine output monitoring. Patient's
chest pain resolved; troponins and CKMBs were drawn and were
negative. Physical therapy evaluated patient and they
recommended a rehab facility.

On [**8-27**], the patient passed her speech and swallow evaluation
and was advanced to a puree diet and nectar thickened fluids.
She was able to tolerate PO medications. Her nasogastric tube
was discontinued.  She was restarted on her all her home
medications, including Pradaxa. She was still exhibiting signs
of fluid overload and received 40mg IV lasix x 2. Foley remained
in place for urine output monitoring. Vitals remained stable,
and patients heart rate was controlled with Metoprolol.



Medications on Admission:
1. Isosorbide Mononitrate 30 mg PO QDAILY
2. Furosemide 40 mg PO DAILY
3. GlyBURIDE 2.5 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Valsartan 160 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Pravastatin 40 mg PO DAILY
8. Allopurinol 100 mg PO BID
9. Oxybutynin 5 mg PO BID
10. Dabigatran Etexilate 150 mg PO BID
11. Colchicine 0.6 mg PO PRN arthritis
12. Diltiazem Extended-Release 240 mg PO DAILY


Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Pravastatin 40 mg PO DAILY
4. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
5. Pantoprazole 40 mg PO Q24H
6. Allopurinol 100 mg PO BID
7. Colchicine 0.6 mg PO PRN arthritis
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
9. Gabapentin 300 mg PO Q12H
10. Diltiazem Extended-Release 240 mg PO DAILY
11. GlyBURIDE 2.5 mg PO DAILY
12. Isosorbide Mononitrate 30 mg PO QDAILY
13. Metoprolol Succinate XL 100 mg PO DAILY
14. Oxybutynin 5 mg PO BID
15. Valsartan 160 mg PO DAILY
16. Ipratropium Bromide Neb 1 NEB IH Q6H
17. Insulin SC
      Sliding Scale

Fingerstick q 6
Insulin SC Sliding Scale using REG Insulin
18. Dabigatran Etexilate 75 mg PO BID


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Lower Gastrointestinal bleed
Atrial fibrillation
Acute [**Hospital6 **] Loss Anemia
Acute on chronic pulmonary edema


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You came to the hospital with rectal bleeding. You lost a
significant amount of [**Last Name (LF) **], [**First Name3 (LF) **] you were taken to the OR for an
exploratory lapartomy in order to find the source of your
bleeding, and underwent a Right colectomy and ileostomy
placement. You had a nasogastric tube which was used to give you
tube feedings, but before you were discharged we were able to
start a puree diet. Pathology results are still pending of your
colon.
Please follow up in [**Hospital 2536**] clinic at the appointment sdcheduled for
you below. Your staples will be removed at this appointment.
ACTIVITY:

Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Hospital 5059**] at your next visit.
Don't lift more than 20-25 lbs for 4-6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.

HOW YOU [**Month (only) **] FEEL:

You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time.  If they do not, tell your [**Month (only) 5059**].

YOUR INCISION:
Your incision may be slightly red around the staples. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.

YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].


PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain

MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].

DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red [**Name2 (NI) **] or foul smelling discharge coming from the
wound
- an increase in drainage from the wound.

Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 249**]
[**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 1, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2010**]
Date/Time:[**2194-10-20**] 10:50

Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2194-9-18**] at 1 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2194-8-28**]
{'Unspecified vascular insufficiency of intestine,Other specified peritonitis,Acute respiratory failure following trauma and surgery,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Other acute and subacute forms of ischemic heart disease, other,Cardiac complications, not elsewhere classified,Congestive heart failure, unspecified,Peritoneal adhesions (postoperative) (postinfection),Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Unspecified acquired hypothyroidism,Diverticulosis of colon (without mention of hemorrhage),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypotension, unspecified,Chronic kidney disease, unspecified,Gout, unspecified,Mild cognitive impairment, so stated,Asthma, unspecified type, unspecified,Thrombocytopenia, unspecified,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Other specified disorders of intestine,Personal history, urinary (tract) infection,Personal history of tobacco use,Knee joint replacement'}


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 [**First Name3 (LF) **] per rectum

PRESENT ILLNESS: 85 year old female h/o afib with RVR on pradaxa with BRBPR x
several weeks with increased amount of [**Month/Day/Year **] this week. Patient
reports the increased bleeding was also associated with
suprapubic pain accompanied by dysuria and some fevers, chills,
nausea and vomiting. Patient previously diagnosed with UTI and
has been taking Nitrofurantoin with improvement of her symptoms.
Patient additionally noted chest pain prior to presentation to
ED. The chest pain resolved without intervention and she is
currently chest pain free. Initially an EKG showed afib without
any acute changes. SBP 100, not lightheaded or dizzy.

MEDICAL HISTORY: Diabetes
Dyslipidemia
Hypertension
Atrial fibrillation
Hypothyroidism
Osteoarthritis, s/p bilateral knee replacements in [**2182**]
Depression
Asthma, diagnosed in [**2184**]
C-sections in past

MEDICATION ON ADMISSION: 1. Isosorbide Mononitrate 30 mg PO QDAILY
2. Furosemide 40 mg PO DAILY
3. GlyBURIDE 2.5 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Valsartan 160 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Pravastatin 40 mg PO DAILY
8. Allopurinol 100 mg PO BID
9. Oxybutynin 5 mg PO BID
10. Dabigatran Etexilate 150 mg PO BID
11. Colchicine 0.6 mg PO PRN arthritis
12. Diltiazem Extended-Release 240 mg PO DAILY

ALLERGIES: Lisinopril / Metformin

PHYSICAL EXAM: Physical Exam upon presentation:
Vitals: 97.4 111 127/78 17 100% RA
GEN: A&O to self, appropriate, resting comfortably, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: Irregular, rate controlled, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, minimally tender, no rebound or
guarding, normoactive bowel sounds, no palpable masses
DRE: normal tone, guiac positive, no gross [**Year (4 digits) **]
Ext: No LE edema, LE warm and well perfused.  R femoral sheath
intact.

FAMILY HISTORY: Family history of CVA/CAD.

SOCIAL HISTORY: Husband died many years ago. Patient lives with her
granddaughter who is her proxy. Smoked 36 years x 1 ppd, quit in
[**2181**], remote social ETOH. 

### Response:
{'Unspecified vascular insufficiency of intestine,Other specified peritonitis,Acute respiratory failure following trauma and surgery,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Other acute and subacute forms of ischemic heart disease, other,Cardiac complications, not elsewhere classified,Congestive heart failure, unspecified,Peritoneal adhesions (postoperative) (postinfection),Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Unspecified acquired hypothyroidism,Diverticulosis of colon (without mention of hemorrhage),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypotension, unspecified,Chronic kidney disease, unspecified,Gout, unspecified,Mild cognitive impairment, so stated,Asthma, unspecified type, unspecified,Thrombocytopenia, unspecified,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Other specified disorders of intestine,Personal history, urinary (tract) infection,Personal history of tobacco use,Knee joint replacement'}
