CHIEF COMPLAINT: SOB

PRESENT ILLNESS: 56 yo [**Male First Name (un) 4746**] male with Crohn's disease, diverticulosis s/p
hemicolectomy times 2, type 2 diabetes, and obesity who
initially presented to OSH for shortness of breath of one week
duration and found to have bilateraly submassive PEs and
intubated for respiratory failure.
.
Transferred to [**Hospital1 18**] on [**2195-7-29**]. Echo showed RB strain. Received
TPA for thrombolysis and heparin gtt was started. Vital signs
were stable and was extubated on [**2195-7-30**]. After the heparin gtt
was initiated, pt developed maroon stools mixed with BRBPR,
thought likely secondary to underlying crohn's disease. Hcts
were measured closely and fell from 40 on admission to 30
following heparin initiation. GI was consulted and pt underwent
upper endoscopy which showed no active source of bleeding.
Steroids were increased from 20mg daily to 40mg daily and pt was
continued on pentasa.
.
Called out to the floor on [**2195-8-2**] with stable vital signs, but
hct dropped from 30->26 requiring transfusion of 2 units prbcs.
With bowel prep for colonoscopy planned for the next day, it was
decided to readmit patient to ICU for better monitoring of Hcts
and vital signs. Patient was never hemodynamically unstable. In
total, he has needed 4 units of PRBCs.
.
In the ICU, patient underwent colonoscopy, showing diffuse
crohn's disease consistent with a flare but no intervention was
warranted. IVC filter was placed on [**2195-8-4**], should the patient
require emergent cessation of anticoagulation secondary to large
GI bleed. Hcts  and vitals signs stable during this admission.
Bridge to coumadin has been initiated.
.
Upon reaching the floor, patient reports that he is feeling
good. Denies lightheadedness, weakness, shortness of breath,
chest pain, acute change in abdominal pain.

MEDICAL HISTORY: Type 2 Diabetes
Obestiy
Crohn's disease, with history of GI bleed
Hypertension
Diverticulitis s/p Partial Colectomy x 2
s/p Multiple Herniorraphy's
Arthritis

MEDICATION ON ADMISSION: Medications at Home: (as per initial note)
Lisinopril 10 mg daily
Humalog ISS
Lantus 30 qhs
NPH 30 qam
Tramadol 50 mg PO daily
Pentasa 500 mg [**Hospital1 **]
.
Medications on Transfer:
Pantoprazole 40 mg PO Q24H
Warfarin 5 mg PO DAILY
Hydrocortisone Acetate Ointment 1% 1 Appl PR DAILY
Heparin IV Sliding Scale
Insulin SC (per Insulin Flowsheet)
Mesalamine 500 mg PO BID
PredniSONE 40 mg PO DAILY
Cepacol (Menthol) 1 LOZ PO PRN
Morphine Sulfate 1-2 mg IV Q4H:PRN pain
Acetaminophen 325-650 mg PO Q6H:PRN
Docusate Sodium (Liquid) 100 mg PO BID
Senna 1 TAB PO BID:PRN
Bisacodyl 10 mg PO/PR DAILY:PRN

ALLERGIES: Azithromycin / Metformin

PHYSICAL EXAM: Physical exam: ([**2195-8-5**])
VS: T: 97.3 (97.5-98.6), HR 61 (61-76) BP 139/80
(133-139/80-90), 97% RA, RR: 18
Gen: NAD, comfortable.
HEENT: PERRLA, EOMI, MMM, oropharynx clear
CV: distant heart sounds, RRR with nl S1, S2. No m/r/g.
Pulm: CTA B with no w/r/r.
Abd: obese, midline scar and lateral scars on left and right
with herniations visible. Nontender, positive bowel sounds in
all 4 quadrants. Right femoral site has dressing from IVC
placement - c/d/i.
Ext: ecchymosis noted on the arms bilaterally, no pedal edema,
no calf tenderness, no palpable cord.
Neuro: A+OX3, 5/5 strength in all 4 extremities

FAMILY HISTORY: No family history of blood clots, malignancy, or sudden cardiac
death. No family history of Crohn's disease. His mother passed
away from pneumonia, but also had hypertension.

SOCIAL HISTORY: Patient is not married but lives with significant other (female)
and lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**]. He only drinks alcohol 2x year
currently, but reports heavy alcohol use that stopped
approximately 20 years ago. He denies tobacco use. He reports
using cocaine with cessation approximately 25 years ago. He is a
former mechanic.
Other pulmonary embolism and infarction,Acute respiratory failure,Acute kidney failure, unspecified,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Blood in stool,Acute posthemorrhagic anemia,Regional enteritis of large intestine,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Chronic kidney disease, Stage I,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diverticulosis of colon (without mention of hemorrhage),Leukocytosis, unspecified,Hyperpotassemia,Abnormal coagulation profile,Anxiety state, unspecified,Arthropathy, unspecified, site unspecified,Fibrinolysis-affecting drugs causing adverse effects in therapeutic use,Adrenal cortical steroids causing adverse effects in therapeutic use
Pulm embol/infarct NEC,Acute respiratry failure,Acute kidney failure NOS,Ac DVT/emb distl low ext,Blood in stool,Ac posthemorrhag anemia,Reg enteritis, lg intest,DMII wo cmp nt st uncntr,Obesity NOS,Chro kidney dis stage I,Hy kid NOS w cr kid I-IV,Dvrtclo colon w/o hmrhg,Leukocytosis NOS,Hyperpotassemia,Abnrml coagultion prfile,Anxiety state NOS,Arthropathy NOS-unspec,Adv eff fibrinolysis agt,Adv eff corticosteroids
Admission Date:  [**2195-7-29**]              Discharge Date:   [**2195-8-17**]

Date of Birth:  [**2139-1-6**]             Sex:   M

Service: MEDICINE

Allergies:
Azithromycin / Metformin

Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
CVL placement
Midline access placement
Intubation
Thrombolysis of submassive PE
EGD and Colonoscopy
IVC filter placement


History of Present Illness:
56 yo [**Male First Name (un) 4746**] male with Crohn's disease, diverticulosis s/p
hemicolectomy times 2, type 2 diabetes, and obesity who
initially presented to OSH for shortness of breath of one week
duration and found to have bilateraly submassive PEs and
intubated for respiratory failure.
.
Transferred to [**Hospital1 18**] on [**2195-7-29**]. Echo showed RB strain. Received
TPA for thrombolysis and heparin gtt was started. Vital signs
were stable and was extubated on [**2195-7-30**]. After the heparin gtt
was initiated, pt developed maroon stools mixed with BRBPR,
thought likely secondary to underlying crohn's disease. Hcts
were measured closely and fell from 40 on admission to 30
following heparin initiation. GI was consulted and pt underwent
upper endoscopy which showed no active source of bleeding.
Steroids were increased from 20mg daily to 40mg daily and pt was
continued on pentasa.
.
Called out to the floor on [**2195-8-2**] with stable vital signs, but
hct dropped from 30->26 requiring transfusion of 2 units prbcs.
With bowel prep for colonoscopy planned for the next day, it was
decided to readmit patient to ICU for better monitoring of Hcts
and vital signs. Patient was never hemodynamically unstable. In
total, he has needed 4 units of PRBCs.
.
In the ICU, patient underwent colonoscopy, showing diffuse
crohn's disease consistent with a flare but no intervention was
warranted. IVC filter was placed on [**2195-8-4**], should the patient
require emergent cessation of anticoagulation secondary to large
GI bleed. Hcts  and vitals signs stable during this admission.
Bridge to coumadin has been initiated.
.
Upon reaching the floor, patient reports that he is feeling
good. Denies lightheadedness, weakness, shortness of breath,
chest pain, acute change in abdominal pain.


Past Medical History:
Type 2 Diabetes
Obestiy
Crohn's disease, with history of GI bleed
Hypertension
Diverticulitis s/p Partial Colectomy x 2
s/p Multiple Herniorraphy's
Arthritis


Social History:
Patient is not married but lives with significant other (female)
and lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**]. He only drinks alcohol 2x year
currently, but reports heavy alcohol use that stopped
approximately 20 years ago. He denies tobacco use. He reports
using cocaine with cessation approximately 25 years ago. He is a
former mechanic.

Family History:
No family history of blood clots, malignancy, or sudden cardiac
death. No family history of Crohn's disease. His mother passed
away from pneumonia, but also had hypertension.

Physical Exam:
Physical exam: ([**2195-8-5**])
VS: T: 97.3 (97.5-98.6), HR 61 (61-76) BP 139/80
(133-139/80-90), 97% RA, RR: 18
Gen: NAD, comfortable.
HEENT: PERRLA, EOMI, MMM, oropharynx clear
CV: distant heart sounds, RRR with nl S1, S2. No m/r/g.
Pulm: CTA B with no w/r/r.
Abd: obese, midline scar and lateral scars on left and right
with herniations visible. Nontender, positive bowel sounds in
all 4 quadrants. Right femoral site has dressing from IVC
placement - c/d/i.
Ext: ecchymosis noted on the arms bilaterally, no pedal edema,
no calf tenderness, no palpable cord.
Neuro: A+OX3, 5/5 strength in all 4 extremities


Pertinent Results:
Selected Labs:
[**2195-7-29**] 02:15PM BLOOD WBC-16.7* RBC-4.72 Hgb-13.2* Hct-40.8
MCV-86 MCH-27.9 MCHC-32.3 RDW-15.1 Plt Ct-338
[**2195-7-30**] 03:04AM BLOOD WBC-17.1* RBC-4.31* Hgb-11.7* Hct-37.3*
MCV-87 MCH-27.2 MCHC-31.4 RDW-14.3 Plt Ct-267
[**2195-7-31**] 03:14AM BLOOD WBC-10.8 RBC-3.67* Hgb-10.2* Hct-30.5*
MCV-83 MCH-28.0 MCHC-33.6 RDW-15.1 Plt Ct-240
[**2195-8-1**] 03:02AM BLOOD WBC-8.2 RBC-3.29* Hgb-9.1* Hct-27.6*
MCV-84 MCH-27.8 MCHC-33.1 RDW-15.0 Plt Ct-261
[**2195-8-2**] 08:09AM BLOOD WBC-7.2 RBC-3.21* Hgb-9.0* Hct-26.6*
MCV-83 MCH-28.0 MCHC-33.7 RDW-14.9 Plt Ct-273
[**2195-8-3**] 04:05AM BLOOD WBC-9.5 RBC-3.68* Hgb-10.0* Hct-30.3*
MCV-82 MCH-27.1 MCHC-32.9 RDW-15.0 Plt Ct-309
[**2195-8-4**] 04:52AM BLOOD WBC-9.0 RBC-3.62* Hgb-10.2* Hct-30.1*
MCV-83 MCH-28.1 MCHC-33.7 RDW-14.6 Plt Ct-317
[**2195-8-5**] 06:04AM BLOOD WBC-10.5 RBC-3.70* Hgb-10.1* Hct-30.9*
MCV-84 MCH-27.3 MCHC-32.7 RDW-14.6 Plt Ct-362
[**2195-8-13**] 07:10AM BLOOD WBC-14.1* RBC-4.27* Hgb-11.4* Hct-36.0*
MCV-84 MCH-26.6* MCHC-31.5 RDW-15.3 Plt Ct-441*
[**2195-8-14**] 07:00AM BLOOD WBC-14.1* RBC-4.17* Hgb-11.3* Hct-35.0*
MCV-84 MCH-27.1 MCHC-32.3 RDW-15.4 Plt Ct-411
[**2195-8-15**] 07:22AM BLOOD WBC-13.9* RBC-4.34* Hgb-11.5* Hct-37.1*
MCV-86 MCH-26.6* MCHC-31.1 RDW-14.5 Plt Ct-416
[**2195-8-16**] 06:47AM BLOOD WBC-13.6* RBC-4.29* Hgb-11.5* Hct-36.0*
MCV-84
.
[**2195-7-29**] 02:15PM BLOOD Glucose-265* UreaN-22* Creat-1.4* Na-139
K-5.6* Cl-106 HCO3-23 AnGap-16
[**2195-8-16**] 06:47AM BLOOD Glucose-145* UreaN-23* Creat-1.2 Na-135
K-4.1 Cl-100 HCO3-24 AnGap-15
.
[**2195-7-29**] 02:15PM BLOOD PT-12.8 PTT-27.8 INR(PT)-1.1
[**2195-8-7**] 06:39AM BLOOD PT-13.6* PTT-82.7* INR(PT)-1.2*
[**2195-8-8**] 05:27AM BLOOD PT-15.9* PTT-66.9* INR(PT)-1.4*
[**2195-8-9**] 05:22AM BLOOD PT-17.2* PTT-62.5* INR(PT)-1.5*
[**2195-8-10**] 05:55AM BLOOD PT-17.3* PTT-78.4* INR(PT)-1.6*
[**2195-8-10**] 05:09PM BLOOD PT-16.7* PTT-45.0* INR(PT)-1.5*
[**2195-8-11**] 02:51AM BLOOD PT-17.3* PTT-101.6* INR(PT)-1.6*
[**2195-8-11**] 09:10AM BLOOD PT-18.3* PTT-66.3* INR(PT)-1.7*
[**2195-8-11**] 04:32PM BLOOD PT-17.6* PTT-49.1* INR(PT)-1.6*
[**2195-8-12**] 06:38AM BLOOD PT-17.0* PTT-58.4* INR(PT)-1.5*
[**2195-8-12**] 10:00AM BLOOD PT-16.7* PTT-52.5* INR(PT)-1.5*
[**2195-8-15**] 01:25AM BLOOD PT-24.4* PTT-58.3* INR(PT)-2.3*
[**2195-8-14**] 04:25PM BLOOD PT-23.9* PTT-43.7* INR(PT)-2.3*
[**2195-8-14**] 07:00AM BLOOD Plt Ct-411
[**2195-8-14**] 07:00AM BLOOD PT-23.4* PTT-83.9* INR(PT)-2.2*
[**2195-8-13**] 07:10AM BLOOD PT-20.0* PTT-77.1* INR(PT)-1.8*
[**2195-8-13**] 01:40AM BLOOD PT-18.4* PTT-71.9* INR(PT)-1.7*
[**2195-8-14**] 07:00AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.1
[**2195-8-13**] 07:10AM BLOOD Calcium-9.6 Phos-4.8* Mg-2.1
[**2195-8-12**] 06:38AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.1
[**2195-8-16**] 06:47AM BLOOD PT-30.5* PTT-87.6* INR(PT)-3.0*
[**2195-8-15**] 04:55PM BLOOD PT-27.4* PTT-61.2* INR(PT)-2.7*
.
[**2195-7-29**] 02:15PM BLOOD Calcium-8.6 Phos-6.1* Mg-2.0
[**2195-8-12**] 06:38AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.1
.
Upon reaching the floor on [**2195-8-5**] until discharge, patient's
hematocrit remained between 30.4 and 37.3.
.
ECG ([**2195-7-29**]): Tracing 1.  Sinus tachycardia. Non-specific
intraventricular conduction delay.  Non-specific ST-T wave
changes. No previous tracing available for comparison.
.
TTE ([**2195-7-29**]): IMPRESSION: RV strain c/w acute pulmonary
embolism.
.
CTA Chest, Abdomen, Pelvis ([**2195-7-29**]): IMPRESSION: 1. Extensive
bilateral pulmonary emboli involving the bilateral main
pulmonary arteries with extension through to the lobar,
segmental, lower lobe subsegmental branches bilaterally, as
above. Associated findings of right heart strain. 2. No evidence
of acute aortic injury. 3. Bilateral dependent
atelectasis/aspiration. 4. Small left-sided ventral abdominal
hernia containing non-obstructed loop of small bowel. Suggestion
of right-sided spigelian hernia, incompletely assessed as right
lateral aspect of the abdomen fully included.
.
ECG ([**2195-7-30**]): Tracing 2.  Sinus tachycardia. Non-specific T wave
changes. Low QRS voltage in the limb leads. Compared to the
previous tracing of [**2195-7-29**] the QRS voltage has decreased in the
limb leads. ST segment depression is less pronounced and the
ventricular rate is slower.
.
ECG ([**2195-7-31**]): Tracing 3.  Sinus rhythm. T wave inversions in
leads V1-V3. Cannot exclude ischemia.  Low QRS voltage in the
limb leads. Compared to the previous tracing of [**2195-7-31**] artifact
is present. T wave inversions are less pronounced in lead V3 and
the T waves are more upright and normal appearing in leads
V4-V5.
.
CXR ([**2195-7-30**]): The ET tube tip is 4.5 cm above the carina. The
right internal jugular line tip is at the level of mid low SVC.
There is no change in the cardiomediastinal contour with the
mediastinal widening being due to extensive mediastinal
lipomatosis. Bibasilar atelectasis have developed in the
interim, new, but note is made that the lung bases cannot be
entirely evaluated since they were not entirely included in the
field of view. No evidence of pulmonary edema. No pneumothorax.
.
Bilateral Lower Extremity Vein Ultrasound ([**2195-7-31**]):  IMPRESSION:
1. Non-occlusive thrombosis of the right popliteal (deep) vein.
Non- visualization of right posterior tibial veins, can not
exclude thrombosis
within these veins. 2. No evidence of deep venous thrombosis in
the left lower extremity.
.
ECG ([**2195-8-5**]): Sinus tachycardia. Possible left atrial
abnormality. There is one ventricular premature contraction.
Non-specific inferior ST-T wave changes. Compared to the
previous tracing of [**2195-8-5**] there is no significant change.

Brief Hospital Course:
56 yo [**Male First Name (un) 4746**] with DMII, HTN, crohn's disease on steroids,
diverticulosis s/p colectomy X 2, who was admitted to the MICU
on [**7-29**] for respiratory failure requiring intubation secondary to
submassive PE.
.
# Pulmonary Embolism.  Patient presented to [**Hospital1 18**] and found to
have submassive clot burden on CTA with significant hypoxia
(PAO2 only 130 in spite of 100% oxygen).  He required intubation
for respiratory failure and also had evidence of right heart
strain from bedside echo.  He was lysed with TPA and extubated
afteward.  He was begun on heparin gtt.  Shortly after the
initiation of heparin, pt developed maroon stools with BRBPR and
required transfusion of 4 u PRBC.  Hematocrits were measured
closely and fell from 40 on admission to 30 following heparin
initiation.  GI was consulted and pt underwent upper endoscopy
which showed no active source of bleeding.  Steroids were
increased from 20mg daily to 40mg daily and pt was continued on
pentasa.  Patient was called out to the floor on [**2195-8-2**], but
given persistence of maroon stools with BRBPR, patient returned
to the MICU the following morning for bowel prep for anticipated
colonoscopy with close monitoring of vitals and hematocrit.  He
underwent colonoscopy and was found to have evidence of active
Crohns disease, though no active bleeding was identified.  His
hematocrit stabilized but because he had a clot in his lower
extremities in combination with concerns regarding his ability
to tolerate anticoauglation in the short term, an IVC filter was
placed on [**2195-8-4**].  Patient was called out to floor on [**2195-8-5**]
with a stable hematocrit greater than 30.  Vital signs remained
stable without any requirement for supplemental oxygen.
.
On the floor, heparin gtt was continued with bridge to
therapeutic INR with Coumadin.  Hematocrits were monitored
closely and remained stable.  The option to be discharged home
on lovenox therapy was presented to the patient on several
occasions but given the gravity of his presentation and his
underlying anxiety, pt preferred to remain hospitalized until
his INR was therapeutic.  Patient never developed hypoxia and
never complained of shortness of breath on the floor.  Patient's
INR slowly elevated over the course of this admission, reaching
therapeutic INR (2.2) on [**2195-8-14**].  In order to reach this INR,
coumadin doses were increased as tolerated, with daily doses
between 5-15 mg daily depending on the INR.  On [**2195-8-10**], patient
reported that central line was accidentally removed during
showering, and occlusive dressing was placed.  Patient was given
midline access and was without anticoagulation for approximately
3-4 hours.  Patient was bridged for 48 hours upon reaching
therapeutic INR.  The duration of his anticoagulation therapy
remains unclear, but patient has been instructed to follow up
with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], for further guidance.
 He will likely need anticoagulation for at least 3 months, with
repeat LENIs to determine if clot burden is still present.  If
clots are present, he will need to continue anticoagulation.  If
clots are absent, stopping of anticoagulation may be considered.
 However, if his underlying crohn's disease is the etiology of
his increased susceptibility to hypercoagulability, patient may
require life-long anticoagulation with coordinated care between
his PCP and gastroenterologist.  In regards to patient's IVC
filter, it was not removed during this admission due to
persistent clot burden and the necessity to continue heparin
gtt.  He will follow up with interventional radiology at [**Hospital1 18**]
and will have it removed within the next year, as per IR.
.
# acute blood blood loss anemia:  Likely secondary to underlying
crohn's disease with flare in the setting of anticoagulation.
Patient developed maroon stools with BRBPR in response to
initiation of heparin gtt, with concurrent drop in hematocrit
from 40 on admission to 26 on [**2195-8-2**].  Patient was transfused
with 4 units PRBC in the MICU.  EGD showed no acute bleeding but
colonoscopy showed diffuse crohn's disease.  Hematocrit was
measured frequently, stabilized around 30 on [**2195-8-3**] and
remained at or above this level throughout this admission.  On
[**2195-8-15**], Hct was noted to be 37.2.  Active type and screen was
maintained.  Patient continued to have BRBPR/maroon stools until
[**2195-8-9**], which may have been due to the passing of clots.  All
other vital signs remained stable and patient did not experience
any signs of hypotension or anemia.
.
# Crohns.  Diagnosed in [**5-2**] but patient reported chronic
symptoms for many years.  Prior to admission, patient was on
20mg PO prednisone taper for prior crohn's flare.  As above,
following administration of tpa lysis and heparin gtt for PE,
patient developed BRBPR and maroon stools.  In the MICU, an EGD
showed no upper GI bleeding and a colonoscopy showed an active
crohn's flare with no intervenable bleeding areas.  GI followed
patient during this admission and increased PO steroid dose to
40mg PO in the MICU.  He was continued on mesalamine 500mg PO
BID.  On [**2195-8-9**], patient reported that his stools were brown,
formed, without blood.  On [**2195-8-10**], GI was re-consulted and his
prednisone was tapered down.  He will be discharged on 30mg PO
daily with a goal taper of 5mg per week.  Remained
hemodynamically stable and asx.  Patient will follow up with his
gastroenterologist, Dr. [**Last Name (STitle) **], for further management as an
outpatient.
.
# Type 2 Diabetes:  With the administration of increased
steroids, it was suspected that blood sugars would run higher.
It was difficult to control dinner and evening sugars, which
spiked in the 300's.  During this admission, patient was
continued on HISS with long acting glargine.  The scale was
continually uptitrated with goals of containing sugars under
300.  Patient will be discharged on his home insulin regimen,
which he reports was effective in controlling his sugars.  The
tapering of steroids will help with better sugar control.
.
# HTN. Patient's outpatient medication for hypertension included
lisinopril.  In the MICU and in the setting of his lower GI
bleeding, this medication was held.  After several days of
continued stabilized of the hematocrits and vital signs,
lisinopril was restarted.  Blood pressures remained stable
following re-initiation of this medication.
.
# Acute Renal failure.  Patient was noted to have a creatinine
of 1.4 on presentation.  Likely secondary to decreased volume
status in the setting of lower GI bleeding.  Creatinine improved
in response to fluids and remained stable over the course of
this admission.
.
# Disposition:  There were several obstacles to the discharge of
this patient.  Patient is from [**Hospital3 4298**] and
transportation was an initial problem.  [**Name (NI) **] was originally
agreeable to discharge on lovenox therapy, provided that his
significant other could pick him up from the hospital.  Primary
team and social work contact[**Name (NI) **] pt's significant other, who
reported that she was not ready to have patient back home.  She
initially reported that the weekend traffic at [**Hospital3 4298**]
was too overwhelming for her to travel.  Upon further
conversation, she revealed that in the last year, patient had
become increasingly angry and had become more threatening
(though not physically).  Patient believed that he was not
medically stable, was anxious, and demanded to stay on heparin
gtt until he was therapeutic.  Denied several offers to leave on
lovenox therapy.
.
Patient if FULL code.  HCP is long-time girlfriend, [**Name (NI) **]
[**Name (NI) **] ([**Telephone/Fax (1) 82747**].

Medications on Admission:
Medications at Home: (as per initial note)
Lisinopril 10 mg daily
Humalog ISS
Lantus 30 qhs
NPH 30 qam
Tramadol 50 mg PO daily
Pentasa 500 mg [**Hospital1 **]
.
Medications on Transfer:
Pantoprazole 40 mg PO Q24H
Warfarin 5 mg PO DAILY
Hydrocortisone Acetate Ointment 1% 1 Appl PR DAILY
Heparin IV Sliding Scale
Insulin SC (per Insulin Flowsheet)
Mesalamine 500 mg PO BID
PredniSONE 40 mg PO DAILY
Cepacol (Menthol) 1 LOZ PO PRN
Morphine Sulfate 1-2 mg IV Q4H:PRN pain
Acetaminophen 325-650 mg PO Q6H:PRN
Docusate Sodium (Liquid) 100 mg PO BID
Senna 1 TAB PO BID:PRN
Bisacodyl 10 mg PO/PR DAILY:PRN


Discharge Medications:
1. Mesalamine 250 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
2. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime: please continue to take your humalog
sliding scale as prior to hospitalization.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for pain.
7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: Please follow up with your PCP as scheduled to check your
INR, with goal INR of [**1-27**].
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Submassive Pulmonary Embolus
Acute Blood loss anemia from lower GI bleed
Crohns Disease
Type 2 Diabetes
Hypertension
Arthritis


Discharge Condition:
Stable, hematocrit 30-33, stools brown and formed.


Discharge Instructions:
You initially went to an outside hospital with difficulty
breathing. After getting transferred to [**Hospital1 18**], we found that you
had a large blood clot in your lung.  We treated your with
medication to dissolve your clot and this caused you to have
lower GI bleeding.  We then put a filter in your IVC, put you on
blood thinners, and your bleeding has improved.  Your vital
signs and hematocrit continue to remain stable.  You were given
coumadin to thin your blood and now your INR levels are
therapeutic.  Your stools are no longer bloody or maroon in
color.
.
We made the following changes to your medications:
-ADDED Coumadin 7.5mg by mouth daily.  Your dose of this
medication may vary.  Your primary care doctor, Dr. [**Last Name (STitle) **], [**First Name3 (LF) **]
tell you whether to increase or decrease this medication to keep
your INR between 2 and 3
-ADDED Prednisone 30mg by mouth daily.  You should continue to
take this medication until you follow up with your GI doctor.
-ADDED Pantoprozole 40mg by mouth daily.  You can speak with
your GI doctor about when to stop this medication.
.
Please follow up with your GI doctor and your PCP as below.  You
will need to have your blood levels monitored closely over the
next few weeks.
.
If you have any abdominal pain, fevers, chills, increase in your
bloody bowel movements, please contact your primary care
physician or visit the emergency room.

Followup Instructions:
GI doctor: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. Thursday [**8-20**] at 4pm.
[**Telephone/Fax (1) 82746**].  Please talk to your doctor about starting Bactrim
for prophylaxis if you will require long term steroids.  Please
follow up with him regarding the tapering of your steroid doses.
.
Primary Care Doctor:  Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], check INR Wednesday [**8-19**] at 12:00pm.  [**Telephone/Fax (1) 29822**].  Please go to the clinic on
Wednesday morning to have your labs drawn.  The clinic will call
you in the afternoon and tell you if you need to adjust your
coumadin dose.  Your primary care physician will order you a
repeat ultrasound at 3 months after discharge to see if you
still have a blood clot in your leg.  If this ultrasound is
negative, you may consider stopping anticoagulation and schedule
to remove your IVC filter.  You can call the interventional
radiology department at [**Hospital1 18**] to remove your IVC filter within 1
year.  Phone: [**Telephone/Fax (1) 8243**]
.
You may ask your primary care physician to set you up with a
hematologist to determine if you are at risk for any future
clots.
{'Other pulmonary embolism and infarction,Acute respiratory failure,Acute kidney failure, unspecified,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Blood in stool,Acute posthemorrhagic anemia,Regional enteritis of large intestine,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Chronic kidney disease, Stage I,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diverticulosis of colon (without mention of hemorrhage),Leukocytosis, unspecified,Hyperpotassemia,Abnormal coagulation profile,Anxiety state, unspecified,Arthropathy, unspecified, site unspecified,Fibrinolysis-affecting drugs causing adverse effects in therapeutic use,Adrenal cortical steroids causing adverse effects in therapeutic use'}


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: SOB

PRESENT ILLNESS: 56 yo [**Male First Name (un) 4746**] male with Crohn's disease, diverticulosis s/p
hemicolectomy times 2, type 2 diabetes, and obesity who
initially presented to OSH for shortness of breath of one week
duration and found to have bilateraly submassive PEs and
intubated for respiratory failure.
.
Transferred to [**Hospital1 18**] on [**2195-7-29**]. Echo showed RB strain. Received
TPA for thrombolysis and heparin gtt was started. Vital signs
were stable and was extubated on [**2195-7-30**]. After the heparin gtt
was initiated, pt developed maroon stools mixed with BRBPR,
thought likely secondary to underlying crohn's disease. Hcts
were measured closely and fell from 40 on admission to 30
following heparin initiation. GI was consulted and pt underwent
upper endoscopy which showed no active source of bleeding.
Steroids were increased from 20mg daily to 40mg daily and pt was
continued on pentasa.
.
Called out to the floor on [**2195-8-2**] with stable vital signs, but
hct dropped from 30->26 requiring transfusion of 2 units prbcs.
With bowel prep for colonoscopy planned for the next day, it was
decided to readmit patient to ICU for better monitoring of Hcts
and vital signs. Patient was never hemodynamically unstable. In
total, he has needed 4 units of PRBCs.
.
In the ICU, patient underwent colonoscopy, showing diffuse
crohn's disease consistent with a flare but no intervention was
warranted. IVC filter was placed on [**2195-8-4**], should the patient
require emergent cessation of anticoagulation secondary to large
GI bleed. Hcts  and vitals signs stable during this admission.
Bridge to coumadin has been initiated.
.
Upon reaching the floor, patient reports that he is feeling
good. Denies lightheadedness, weakness, shortness of breath,
chest pain, acute change in abdominal pain.

MEDICAL HISTORY: Type 2 Diabetes
Obestiy
Crohn's disease, with history of GI bleed
Hypertension
Diverticulitis s/p Partial Colectomy x 2
s/p Multiple Herniorraphy's
Arthritis

MEDICATION ON ADMISSION: Medications at Home: (as per initial note)
Lisinopril 10 mg daily
Humalog ISS
Lantus 30 qhs
NPH 30 qam
Tramadol 50 mg PO daily
Pentasa 500 mg [**Hospital1 **]
.
Medications on Transfer:
Pantoprazole 40 mg PO Q24H
Warfarin 5 mg PO DAILY
Hydrocortisone Acetate Ointment 1% 1 Appl PR DAILY
Heparin IV Sliding Scale
Insulin SC (per Insulin Flowsheet)
Mesalamine 500 mg PO BID
PredniSONE 40 mg PO DAILY
Cepacol (Menthol) 1 LOZ PO PRN
Morphine Sulfate 1-2 mg IV Q4H:PRN pain
Acetaminophen 325-650 mg PO Q6H:PRN
Docusate Sodium (Liquid) 100 mg PO BID
Senna 1 TAB PO BID:PRN
Bisacodyl 10 mg PO/PR DAILY:PRN

ALLERGIES: Azithromycin / Metformin

PHYSICAL EXAM: Physical exam: ([**2195-8-5**])
VS: T: 97.3 (97.5-98.6), HR 61 (61-76) BP 139/80
(133-139/80-90), 97% RA, RR: 18
Gen: NAD, comfortable.
HEENT: PERRLA, EOMI, MMM, oropharynx clear
CV: distant heart sounds, RRR with nl S1, S2. No m/r/g.
Pulm: CTA B with no w/r/r.
Abd: obese, midline scar and lateral scars on left and right
with herniations visible. Nontender, positive bowel sounds in
all 4 quadrants. Right femoral site has dressing from IVC
placement - c/d/i.
Ext: ecchymosis noted on the arms bilaterally, no pedal edema,
no calf tenderness, no palpable cord.
Neuro: A+OX3, 5/5 strength in all 4 extremities

FAMILY HISTORY: No family history of blood clots, malignancy, or sudden cardiac
death. No family history of Crohn's disease. His mother passed
away from pneumonia, but also had hypertension.

SOCIAL HISTORY: Patient is not married but lives with significant other (female)
and lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**]. He only drinks alcohol 2x year
currently, but reports heavy alcohol use that stopped
approximately 20 years ago. He denies tobacco use. He reports
using cocaine with cessation approximately 25 years ago. He is a
former mechanic. 

### Response:
{'Other pulmonary embolism and infarction,Acute respiratory failure,Acute kidney failure, unspecified,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Blood in stool,Acute posthemorrhagic anemia,Regional enteritis of large intestine,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Chronic kidney disease, Stage I,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diverticulosis of colon (without mention of hemorrhage),Leukocytosis, unspecified,Hyperpotassemia,Abnormal coagulation profile,Anxiety state, unspecified,Arthropathy, unspecified, site unspecified,Fibrinolysis-affecting drugs causing adverse effects in therapeutic use,Adrenal cortical steroids causing adverse effects in therapeutic use'}
