CHIEF COMPLAINT: ?melena vs. bright red blood per rectum

PRESENT ILLNESS: 54yo M with PMHx of chronic RLE pain and lymphedema, pAfib,
morbid obesity s/p gastric bypass, HTN, and depression who
presents with complaints of BRBPR.

MEDICAL HISTORY: -Right hip fracture
-Hypertension
-Obesity
-Depression
-MVA - remote, with fracture right upper extremity, s/p ORIF
-Chronic right lower extremity lymphedema
-Atrial fibrillation: Previously on Coumadin. This was d/c'ed
during his last admission in [**2164-6-22**] for a large hematoma and
his low CHADS score in consultation with his cardiologist, Dr. [**Doctor Last Name 11723**].
-Gastric Bypass surgery in [**2152**] [**Doctor First Name 30929**] followed by Dr. [**Last Name (STitle) **]
currently. (Max weight 846lb, currently 450 lb).

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN skin
irritation
3. Gabapentin 800 mg PO TID
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY
7. Ferrous Sulfate 325 mg PO BID
8. Furosemide 40 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Cal-Citrate *NF* (calcium citrate-vitamin D2) 630-400
mg-unit Oral [**Hospital1 **]
11. Vitamin D 1000 UNIT PO DAILY
Cholecalciferol
12. Cyanocobalamin 1000 mcg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Miconazole Powder 2% 1 Appl TP QID:PRN rash
15. Aspirin 325 mg PO DAILY

ALLERGIES: Adhesive Tape / Ibuprofen / tramadol

PHYSICAL EXAM: ADMISSION EXAM:
VS: T99.1 BP 98/56 HR 105 RR 20 96% on RA
General: pleasant, NAD, morbidly obese
EENT: PERRL, EOMI, sclerae anicteric, neck supple, moist mucous
membranes, no ulcers / lesions / thrush
CV: RRR, normal S1, S2, no murmurs / rubs / gallops
Pul: clear to auscultation bilaterally w/o wheezes / rhonchi /
rales
BACK: no focal tenderness, no costovertebral angle tenderness
GI: normoactive bowel sounds, soft, obese. Large scar present.
No erythema over skin folds. No hepatosplenomegaly. Tenderness
to palpation inferior to umbilicus, and RLQ.
MSK: no joint swelling or erythema
Extremities: RLE is violaceous and chronically edematous.
Markedly tender to palpation over anterior leg just inferior to
knee. LLE is warm and well perfused.
LYMPH: no cervical, axillary, or inguinal lymphadenopathy
SKIN: no rashes, no jaundice
NEURO: awake, alert and oriented x3, CN 2-12 intact, [**4-27**]
strength bil, reflexes 1+ bilaterally, normal sensitivity
PSYCH: non-anxious, normal affect

FAMILY HISTORY: Lung CA in mother and father, both were smokers, and both died
of this, his mother at age 39. His sister has ovarian ca. His
father also had gout.

SOCIAL HISTORY: Non-smoker. Denies EtOH or drug use. Patient is on disability.
Lives by himself in an apartment in [**Location (un) 86**]; bed bound given his
obesity.
Diverticulosis of colon with hemorrhage,Body Mass Index 60.0-69.9, adult,Acute posthemorrhagic anemia,Cellulitis and abscess of leg, except foot,Hyposmolality and/or hyponatremia,Atrial fibrillation,Other lymphedema,Other chronic pain,Pain in limb,Bariatric surgery status,Unspecified essential hypertension,Fecal impaction,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Internal hemorrhoids without mention of complication,Morbid obesity,Retention of urine, unspecified,Urethral stricture, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Essential thrombocythemia
Dvrtclo colon w hmrhg,BMI 60.0-69.9, adult,Ac posthemorrhag anemia,Cellulitis of leg,Hyposmolality,Atrial fibrillation,Other lymphedema,Chronic pain NEC,Pain in limb,Bariatric surgery status,Hypertension NOS,Fecal impaction,Esophageal reflux,Obstructive sleep apnea,Int hemorrhoid w/o compl,Morbid obesity,Retention urine NOS,Urethral stricture NOS,Chr blood loss anemia,Essntial thrombocythemia
Admission Date:  [**2165-6-24**]              Discharge Date:   [**2165-7-11**]

Date of Birth:  [**2110-10-11**]             Sex:   M

Service: MEDICINE

Allergies:
Adhesive Tape / Ibuprofen / tramadol

Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
?melena vs. bright red blood per rectum

Major Surgical or Invasive Procedure:
Colonoscopy

History of Present Illness:
54yo M with PMHx of chronic RLE pain and lymphedema, pAfib,
morbid obesity s/p gastric bypass, HTN, and depression who
presents with complaints of BRBPR.

[**Name (NI) **] friend noticed dark blood vs. BRBPR (unclear which)
when she came to check up on him at home. Patient thinks that
this may have started around 10PM the night prior to
presentation. He has been 'oozing'. Becaucse he is bed-bound,
brought the patient to the ED for evaluation. Patient reports
some lightheadedness with sitting up. He has also noticed some
shortness of breath. He reports some nausea, but denies
vomiting. The patient reports that his last BM was on Friday,
which was reportedly normal per the patient. He denies any
recent antibiotic use. He denies changes to his diet reporting
that he has been eating more canned vegetables and occassionally
raw vegetables, which he states taht he washes. He reports
chills, but denies fevers. He also reports drinking botteled
water. He reports that his brother has a new puppy at home;
patient with a cat at home. Reports some abdominal pain with his
symptoms located near where his umbilicus was.

In the ED, the patient triggered on arrival for HR 180-200s with
Atrial fibrillation w/ RVR. He had 2 PIV 18 gauge IVs placed in
the ED. In, the ED, the patient received a total of 3L NS; his
HR responded to IVFs, so he was bolused again. Pressures stable
110-130s SPBs 70-80. HCT 32.2 down from 36. He was T&C for 2
units. Received no transfusions in the ED. Mentating well. GI
thought that his bleed liking from a lower source and were
planning for scope tomorrow. If HD unstable get CTA of abdomen-
needs to be done on thrid floor given the patient's body
habitus. Tried Foley placement, but this was unsucessful.

On arrival to the MICU, the patient is alert and interactive,
answering questions appropriately.

Past Medical History:
-Right hip fracture
-Hypertension
-Obesity
-Depression
-MVA - remote, with fracture right upper extremity, s/p ORIF
-Chronic right lower extremity lymphedema
-Atrial fibrillation: Previously on Coumadin. This was d/c'ed
during his last admission in [**2164-6-22**] for a large hematoma and
his low CHADS score in consultation with his cardiologist, Dr. [**Doctor Last Name 11723**].
-Gastric Bypass surgery in [**2152**] [**Doctor First Name 30929**] followed by Dr. [**Last Name (STitle) **]
currently. (Max weight 846lb, currently 450 lb).

Social History:
Non-smoker. Denies EtOH or drug use. Patient is on disability.
Lives by himself in an apartment in [**Location (un) 86**]; bed bound given his
obesity.


Family History:
Lung CA in mother and father, both were smokers, and both died
of this, his mother at age 39. His sister has ovarian ca. His
father also had gout.

Physical Exam:
ADMISSION EXAM:
VS: T99.1 BP 98/56 HR 105 RR 20 96% on RA
General: pleasant, NAD, morbidly obese
EENT: PERRL, EOMI, sclerae anicteric, neck supple, moist mucous
membranes, no ulcers / lesions / thrush
CV: RRR, normal S1, S2, no murmurs / rubs / gallops
Pul: clear to auscultation bilaterally w/o wheezes / rhonchi /
rales
BACK: no focal tenderness, no costovertebral angle tenderness
GI: normoactive bowel sounds, soft, obese. Large scar present.
No erythema over skin folds. No hepatosplenomegaly. Tenderness
to palpation inferior to umbilicus, and RLQ.
MSK: no joint swelling or erythema
Extremities: RLE is violaceous and chronically edematous.
Markedly tender to palpation over anterior leg just inferior to
knee. LLE is warm and well perfused.
LYMPH: no cervical, axillary, or inguinal lymphadenopathy
SKIN: no rashes, no jaundice
NEURO: awake, alert and oriented x3, CN 2-12 intact, [**4-27**]
strength bil, reflexes 1+ bilaterally, normal sensitivity
PSYCH: non-anxious, normal affect

Exam on Discharge:
98.2  80  100/60  18  97 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild tender to deep palpation in multiple areas.
GU: no foley
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Ext: RLE is red, chronically edematous. Markedly tender to
palpation over anterior leg just inferior to knee. Right lower
extremity with chronic lymphedema and chronic venous and skin
changes including mild warmth and erythema with tenderness to
touch. LLE is warm and well perfused.

Pertinent Results:
Admission labs:
[**2165-6-24**] 09:20PM BLOOD WBC-26.3*# RBC-3.60* Hgb-10.5* Hct-32.2*
MCV-89 MCH-29.1 MCHC-32.6 RDW-15.4 Plt Ct-189#
[**2165-6-24**] 09:20PM BLOOD Neuts-89.9* Lymphs-4.4* Monos-3.5 Eos-0.1
Baso-0.2
[**2165-6-25**] 04:12AM BLOOD PT-14.5* PTT-23.6* INR(PT)-1.4*
[**2165-6-24**] 09:20PM BLOOD Glucose-164* UreaN-33* Creat-1.1 Na-130*
K-4.2 Cl-95* HCO3-22 AnGap-17
[**2165-6-24**] 09:20PM BLOOD ALT-13 AST-23 CK(CPK)-45* AlkPhos-77
TotBili-0.4
[**2165-6-24**] 09:20PM BLOOD CK-MB-1
[**2165-6-24**] 09:20PM BLOOD cTropnT-<0.01
[**2165-6-25**] 04:12AM BLOOD CK-MB-1 cTropnT-<0.01
[**2165-6-24**] 09:20PM BLOOD Albumin-3.0* Calcium-8.5 Phos-2.1*#
Mg-2.2
[**2165-6-27**] 12:02AM BLOOD CRP-GREATER TH
[**2165-6-27**] 12:02AM BLOOD Vanco-15.0
[**2165-6-25**] 06:02PM BLOOD Lactate-1.5
[**2165-7-3**] 09:10AM BLOOD WBC-12.0* RBC-2.70* Hgb-7.6* Hct-24.5*
MCV-91 MCH-28.0 MCHC-30.9* RDW-15.9* Plt Ct-480*

Discharge:

[**2165-7-11**] 08:50AM BLOOD WBC-8.9 RBC-3.03* Hgb-8.5* Hct-27.3*
MCV-90 MCH-28.0 MCHC-31.1 RDW-15.9* Plt Ct-615*
[**2165-7-10**] 07:00AM BLOOD Glucose-87 UreaN-14 Creat-0.7 Na-134
K-5.0 Cl-95* HCO3-32 AnGap-12

[**6-27**] colonoscopy:
Grade 1 internal hemorrhoid without stigmata of recent bleeding.
Diverticulosis of the sigmoid colon of mild severity.
The terminal ileum was identified and no blood was seen arising
from the terminal ileum.
Old blood in the colon
Grade 1 external hemorrhoids
Otherwise normal colonoscopy to cecum and terminal ileum

CT Abdomen/Pelvis:
TECHNIQUE:  Non-contrast axial images were acquired from the
lung bases to the pelvic outlet.  Upon review of these images,
it was decided that the study was nondiagnostic due to poor
penetration from the patient's body habitus.  At that time,
radiation dose was increased and a single axial slice was
acquired. This too was deemed nondiagnostic and study was
aborted.
FINDINGS:  Lung bases are clear.  Heart size is normal without
pericardial
effusion.  Extremely limited evaluation of the abdomen and
pelvis.  Patient is status post anterior abdominal hernia
repair. No gross abnormalities evident within the liver or
spleen.  No large fluid collection evident. Air noted in the
bladder, possibly due to foley instrumentation, but due to study
limitations, unabel to assess for foley.  Correlate clinically.
No suspicious lytic or blastic lesions are identified.

IMPRESSION:  Nondiagnostic study despite repeated attempts with
increased
radiation dose.

[**6-27**] U/S:
1.  Complex fluid collection in the left flank, little changed
from [**2164**] and present since [**2161**], consistent with a chronic
organized hematoma or seroma.
2.  Stable longstanding fluid collection in anterior abdominal
wall
surrounding implanted mesh, likely chronic seroma.

[**6-28**] U/S: Suboptimal study due to patient's body habitus.  Mildly
distended gallbladder with multiple gallstones.  No son[**Name (NI) 493**]
evidence of acute cholecystitis.

MRI [**7-1**]
IMPRESSION:
1.  Extremely limited exam due to body habitus with
field-of-view excluding
known left flank fluid collection.  Anterior abdominal wall
fluid collection
without evidence of superimposed infectious process, likely
represents
postoperative seroma, unchanged compared to [**2165-4-25**].
2.  Cholelithiasis without cholecystitis.
3.  Status post gastric bypass surgery.

CT RLE [**7-3**]
IMPRESSION:
1.  Extensive circumferential right lower extremity subcutaneous
stranding and
edema centered about the right calf, compatible with known
cellulitis.  No
subcutaneous gas or drainable fluid collection.
2.  No evidence of arterial embolus in either lower extremity.

[**2165-7-9**]:
BILATERAL NONINVASIVE LOWER EXTREMITY VENOUS STUDY

CLINICAL INDICATION:  54-year-old male with chronic cellulitis,
lower
extremity pain, increased erythema.

This is a technically limited study due to body habitus, in
particular the
swollen legs, which limits the ability to compress venous
structures.
However, color flow and pulse Doppler waveform analysis shows
full patency of
the right and left venous system from the groin to the popliteal
fossa.  Right
and left common femoral waveforms are symmetric and normal
bilaterally.
Compressibility of veins was adequate given the physical
limitations of the
study.  The posterior tibial and peroneal veins could not be
identified;
however, due to the size of the swollen legs.

CONCLUSION:  Technically limited study with no evidence of DVT
in right or
left lower extremity.


Brief Hospital Course:
54yo M with PMHx of chronic RLE pain and lymphedema, pAfib,
morbid obesity s/p gastric bypass, HTN, and depression who
presents with complaints of melena vs. BRBPR also found to be in
atrial fibrillation.

# BRBPR: Bleeding acutely began prior to presentation.
Differential included bleeding internal hemorrhoids versus
bleeding diverticulum versus colitis versus hemorrhagic
infectious colitis. Repeat HCT in unit [**Unit Number **].7. He had no further
episodes of large volume BRBPR. He was prepped x 2 days for
colonoscopy given h/o poor prep and overall risk associated with
endoscopy given habitus. Colonoscopy showed no clear source of
bleeding, mild diverticulosis, grade 1 internal hemorrhoid,
removed fecolith from appendiceal orifice. CTA abdomen was
attempted initially to localize source of bleed, but scan
aborted after poor image quality with double dose radiation due
to habitus. Hematocrits remained stable and he was given PO
Vitamin K for elevated INR. Transfused 1 unit PRBC at admission,
none afterwards. Cipro/Flagyl initially started for concern for
infectious colitis, stopped on hospital day #2. After transfer
to the floor the patient's Hematocrit remained stable with no
more episodes of bleeding.

#abdominal pain: evaluated by surgery, who thought that pain may
be due to discomfort at point of tenderness on exam due to thin
skin near area of mesh, no signs on exam of infected mesh and no
new hernia on limited CT scan and MRI. MRI showed seromas which
may be inflammed and contributing to pain. Pt was seen by ID who
recommended no further intervention as patients fevers subsided
and white count trended down. Pt also states abdominal pain is
improved. Can follow up with GI and consider EGD as an
outpatient.

# Atrial fibrillation: Patient responsive to IVFs in the ED. In
the unit, the patient received IVF bolus as well as IV
metoprolol with good response initially. Further beta blockade
limited by hypotension so he was given digoxin. He was
eventually started on a diltiazem drip which was weaned to PO
metoprolol, with HR still well controlled with increased dose of
metoprolol. CHADS2 score of 1, had not been on coumadin as outpt
given to hx of pelvic hematoma, did not restart in context of
GIB. Once transferred back to the floor, the patient continued
to be be in afib w/ rvr >150. Pt was switched to po diltiazem
and metoprolol was discontinued. Pt's hr was less than 100
following switch and spontaneously coverted to sinus rhyhthm on
[**7-8**].

# Lower extremity edema/Cellulitis: Chronic in nature. Patient
has had LENIs in the past that were negative. He did have
significant pain in the RLE and attempted to minimize narcotics.
Following transfer to the floor, patient notes his leg pain
became acutely worse. On physical exam, it was noted to be more
erythemic and warm. The patient was started back on Vancomycin
on [**7-2**] with concern for MRSA cellulitis. The patient also had a
RLE CT scan to rule out nectrotizing fascitis with pain out of
proportion to physical exam findings. The CT showed no NF, but
did note cellulits. The patient was started on morphine and
oxycodone for pain control as patient appeared in tremendous
pain and said it was the worst he had ever experienced. He was
transitioned to Bactrim/Keflex on [**7-5**] to complete course. LENIS
on [**2165-7-9**] were done [**1-24**] persistent pain which were negative. It
it felt that his right lower extremity skin changes and pain are
chronic which date back many years, even to [**2153**]. He has had
multiple admissions for this reason and thus after this most
recent treatment for cellulitis, pain control with increased
gapapentin, tylenol was initiated. He is not to remain on
chronic narcotics give history of abuse. The opiates were meant
as short term solution. Infectious disease has seen this patient
throughout his admission and were never convinced he had
cellulitis. They felt his coag neg staph in the blood was a
contaminent and not related to his initial leukocytosis nor
right lower extremity skin.

#Thrombocytosis: Most likely reactive however platlet count
continued to increase despite normalization of WBC. Currently at
615 from high of 750 a baseline below 300. Patient is on aspirin
325 daily.

# HTN: Low SBPs in light of atrial fibrillation at admission.
Held metoprolol and lasix initially, restarted metoprolol then
converted to diltiazem.

#Access: Right IJ was attempted on floor unsuccessfully.
Patient then triggered for afib with RVR in 140s, BP 102/palp,
which was baseline for day. Transferred to MICU, where 2 PIVs
placed until PICC placement.

# GERD: Continued home omeprazole.
# OSA:  Previous diagnosis on home CPAP. Continued in house.

Transitions of Care:
-F/up with GI for further endoscopic evaluation
-Trend elevated platlet count as an outpatient.
-Full Code
-Consider starting LASIX to assist with lower extremity for
edema- this may help his pain.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN skin
irritation
3. Gabapentin 800 mg PO TID
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY
7. Ferrous Sulfate 325 mg PO BID
8. Furosemide 40 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Cal-Citrate *NF* (calcium citrate-vitamin D2) 630-400
mg-unit Oral [**Hospital1 **]
11. Vitamin D 1000 UNIT PO DAILY
Cholecalciferol
12. Cyanocobalamin 1000 mcg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Miconazole Powder 2% 1 Appl TP QID:PRN rash
15. Aspirin 325 mg PO DAILY


Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 1200 mg PO Q8H
5. Miconazole Powder 2% 1 Appl TP QID:PRN rash
6. Omeprazole 40 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Diltiazem 90 mg PO QID
hold for hr<60 or sbp<95
10. Heparin 5000 UNIT SC TID
11. OxycoDONE (Immediate Release)  10-20 mg PO Q4H:PRN pain
hold for rr<10, sedation
RX *oxycodone 10 mg [**12-24**] tablet(s) by mouth q4ht Disp #*30 Tablet
Refills:*0
12. Senna 1 TAB PO BID:PRN constipation
13. Cal-Citrate *NF* (calcium citrate-vitamin D2) 630-400
mg-unit Oral [**Hospital1 **]
14. Cyanocobalamin 1000 mcg PO DAILY
15. Ferrous Sulfate 325 mg PO BID
16. Multivitamins 1 TAB PO DAILY
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN skin
irritation
18. Vitamin D 1000 UNIT PO DAILY
Cholecalciferol


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]

Discharge Diagnosis:
Primary: GI bleed, cause uncertain, Atrial fibrillation
Seconary: Right lower leg lyphedema with cellulitis,


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


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

It was a pleasure taking care of you during your stay at [**Hospital1 18**].
You came in due to blood in your stool and black stool. We found
you to be anemic and transfused you with blood. You had a
colonoscopy but it did not locate any bleeding. Your bleeding
stopped on admission. The bleeding was most likely caused by a
diverticular bleed.

In addition, you were having heart palpitations and were found
to be in atrial fibrillation. We controlled your heart with
medications and you rhythm returned to [**Location 213**] rhythm on [**7-8**].

Your right leg also bothered you during this admission and the
pain became increasingly worse. You had a CT scan of the leg
which showed cellulitis with no infection of the fascia. We
treated your skin infection with IV and oral antibiotics and
controlled your pain.

Please continue to take your home medications as directed.

Followup Instructions:
Department: ORTHOPEDICS
When: WEDNESDAY [**2165-7-31**] at 9:55 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: WEDNESDAY [**2165-7-31**] at 10:15 AM
With: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: FRIDAY [**2165-8-9**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
We are working on a follow up appt in the Gastroenterology
Department in [**9-7**] days. You will be called at home with the
appointment.   If you have not heard or have questions, please
call [**Telephone/Fax (1) 105798**].

Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30375**]
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2010**]

Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2165-7-24**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage
{'Diverticulosis of colon with hemorrhage,Body Mass Index 60.0-69.9, adult,Acute posthemorrhagic anemia,Cellulitis and abscess of leg, except foot,Hyposmolality and/or hyponatremia,Atrial fibrillation,Other lymphedema,Other chronic pain,Pain in limb,Bariatric surgery status,Unspecified essential hypertension,Fecal impaction,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Internal hemorrhoids without mention of complication,Morbid obesity,Retention of urine, unspecified,Urethral stricture, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Essential thrombocythemia'}


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: ?melena vs. bright red blood per rectum

PRESENT ILLNESS: 54yo M with PMHx of chronic RLE pain and lymphedema, pAfib,
morbid obesity s/p gastric bypass, HTN, and depression who
presents with complaints of BRBPR.

MEDICAL HISTORY: -Right hip fracture
-Hypertension
-Obesity
-Depression
-MVA - remote, with fracture right upper extremity, s/p ORIF
-Chronic right lower extremity lymphedema
-Atrial fibrillation: Previously on Coumadin. This was d/c'ed
during his last admission in [**2164-6-22**] for a large hematoma and
his low CHADS score in consultation with his cardiologist, Dr. [**Doctor Last Name 11723**].
-Gastric Bypass surgery in [**2152**] [**Doctor First Name 30929**] followed by Dr. [**Last Name (STitle) **]
currently. (Max weight 846lb, currently 450 lb).

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN skin
irritation
3. Gabapentin 800 mg PO TID
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY
7. Ferrous Sulfate 325 mg PO BID
8. Furosemide 40 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Cal-Citrate *NF* (calcium citrate-vitamin D2) 630-400
mg-unit Oral [**Hospital1 **]
11. Vitamin D 1000 UNIT PO DAILY
Cholecalciferol
12. Cyanocobalamin 1000 mcg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Miconazole Powder 2% 1 Appl TP QID:PRN rash
15. Aspirin 325 mg PO DAILY

ALLERGIES: Adhesive Tape / Ibuprofen / tramadol

PHYSICAL EXAM: ADMISSION EXAM:
VS: T99.1 BP 98/56 HR 105 RR 20 96% on RA
General: pleasant, NAD, morbidly obese
EENT: PERRL, EOMI, sclerae anicteric, neck supple, moist mucous
membranes, no ulcers / lesions / thrush
CV: RRR, normal S1, S2, no murmurs / rubs / gallops
Pul: clear to auscultation bilaterally w/o wheezes / rhonchi /
rales
BACK: no focal tenderness, no costovertebral angle tenderness
GI: normoactive bowel sounds, soft, obese. Large scar present.
No erythema over skin folds. No hepatosplenomegaly. Tenderness
to palpation inferior to umbilicus, and RLQ.
MSK: no joint swelling or erythema
Extremities: RLE is violaceous and chronically edematous.
Markedly tender to palpation over anterior leg just inferior to
knee. LLE is warm and well perfused.
LYMPH: no cervical, axillary, or inguinal lymphadenopathy
SKIN: no rashes, no jaundice
NEURO: awake, alert and oriented x3, CN 2-12 intact, [**4-27**]
strength bil, reflexes 1+ bilaterally, normal sensitivity
PSYCH: non-anxious, normal affect

FAMILY HISTORY: Lung CA in mother and father, both were smokers, and both died
of this, his mother at age 39. His sister has ovarian ca. His
father also had gout.

SOCIAL HISTORY: Non-smoker. Denies EtOH or drug use. Patient is on disability.
Lives by himself in an apartment in [**Location (un) 86**]; bed bound given his
obesity. 

### Response:
{'Diverticulosis of colon with hemorrhage,Body Mass Index 60.0-69.9, adult,Acute posthemorrhagic anemia,Cellulitis and abscess of leg, except foot,Hyposmolality and/or hyponatremia,Atrial fibrillation,Other lymphedema,Other chronic pain,Pain in limb,Bariatric surgery status,Unspecified essential hypertension,Fecal impaction,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Internal hemorrhoids without mention of complication,Morbid obesity,Retention of urine, unspecified,Urethral stricture, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Essential thrombocythemia'}
