CHIEF COMPLAINT: BRBPR

PRESENT ILLNESS: 83 yo male with 4 days of BRBPR. The history is obtained mostly
through the niece who is living together with the patient and is
translating. The patient reportedly had about 7 episodes of
diarrhea (unknown amounts) per day since Wednesday. The diarrhea
was watery and bloody. It was bright red blood. The patient went
to dialysis today without mentioning the ongoing BRBPR to his
dialysis team and was dialysed as usual receiving Heparin. He
then after dialysis noticed worsening BRBPR and decided to come
to the ED. The patient is asymptomatic without any
lightheadedness or dizziness. He was also complaining of some
abdominal pain last night, and during the days prior but this
has since improved. The abdominal pain was of crampy character
and mild and it occurred intermittently. It is located in the
LLQ and not radiating. The patient denies hematemesis, nausea or
vomiting.
.
ED course: VS 97.5 77  119/54  18  96% on RA
Pt was found to be hemodynamically stable with a hct drop from
37 five days ago to 23. GI was consulted who did not think a GI
lavage was necessary. A CTA was performed given the possibility
for an aorto-enteric fistula s/p AAA repair in [**2178**]. No
aorto-enteric fistula was found, but diverticulosis without
diverticulitis as well as a moderate right inguinal hernia,
containing loops of non-incarcerated small bowel was found.
Vascular was contact[**Name (NI) **] initially for probablity of aorto-enteric
fistula, but thought that this was very unlikely. On the CT an
incidental finding of a large pleural effusion on the L side was
made which was present on prior studies. GI was contact[**Name (NI) **] and
reportedly is planning to do a non-urgent colonoscopy on Monday,
unless the patient's clinical status changes and more BRBPR is
present. Renal was also notified. 2 U of PRBC were ordered but
were not hung by the time the patient was transferred to the
ICU.
.
ROS: negative for CP, SOB, constipation, f/c/ns, weight loss.
The patient does not produce any urine. Reportedly he has normal
appetite but at times is choking after taking in food.

MEDICAL HISTORY: 1. ESRD likely d/t HTN
2. HTN
3. AAA repair c/b LLE compartment syndrome
4. BPH

MEDICATION ON ADMISSION: Renagel 2400mg tid w/ meals
Renal caps 1 capsule qday
Norvasc 5mg qday
Zyprexa 20mg qday
Benzotropine 0.5-1 qday,
Lorazepam 2mg qam of HD
Docusate prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 97.4  BP 122/61 HR 94 RR 20  O2Sat 97 3L
Gen: NAD
HEENT: NC/AT, PERRLA 2>3, dry mm
NECK: no LAD, no JVD, no carotid bruit
COR: mild S1 normal S2, regular rhythm, mild endsystolic murmur
over apex, no r/g
PULM: CTA over R lung field, decreased breath sounds over Left
field about 1/2 up without egophony, no wheezing or rhonchi
ABD: + bowel sounds, soft, mild distended, nt
Skin: warm extremities, no rash, dry skin
EXT: 1+ DP, no edema/c/c,
Neuro: moving all extremities, strength testing limited by
committment, following commands, PERRLA, answering questions
appropriately

FAMILY HISTORY: no bowel problems, no [**Name2 (NI) 499**] cancer

SOCIAL HISTORY: Smoking: no; EthOH: no; drug abuse: no. Cantonese speaking.
Lives with his niece. Ambulatory at baselines with walked.
Independent in washing himself. Food and medications are getting
prepared for him. Not married, no children.
Hemorrhage of gastrointestinal tract, unspecified,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified protein-calorie malnutrition,Hyperosmolality and/or hypernatremia,Unspecified pleural effusion,Other and unspecified coagulation defects,Iron deficiency anemia secondary to blood loss (chronic),Other persistent mental disorders due to conditions classified elsewhere,Atrial fibrillation,Depressive disorder, not elsewhere classified
Gastrointest hemorr NOS,End stage renal disease,Hyp kid NOS w cr kid V,Protein-cal malnutr NOS,Hyperosmolality,Pleural effusion NOS,Coagulat defect NEC/NOS,Chr blood loss anemia,Mental disor NEC oth dis,Atrial fibrillation,Depressive disorder NEC
Admission Date:  [**2182-2-16**]              Discharge Date:   [**2182-3-6**]

Date of Birth:  [**2098-12-4**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
BRBPR

Major Surgical or Invasive Procedure:
colonoscopy
EGD
interventional radiology embolization procedure
placement of PICC line


History of Present Illness:
83 yo male with 4 days of BRBPR. The history is obtained mostly
through the niece who is living together with the patient and is
translating. The patient reportedly had about 7 episodes of
diarrhea (unknown amounts) per day since Wednesday. The diarrhea
was watery and bloody. It was bright red blood. The patient went
to dialysis today without mentioning the ongoing BRBPR to his
dialysis team and was dialysed as usual receiving Heparin. He
then after dialysis noticed worsening BRBPR and decided to come
to the ED. The patient is asymptomatic without any
lightheadedness or dizziness. He was also complaining of some
abdominal pain last night, and during the days prior but this
has since improved. The abdominal pain was of crampy character
and mild and it occurred intermittently. It is located in the
LLQ and not radiating. The patient denies hematemesis, nausea or
vomiting.
.
ED course: VS 97.5 77  119/54  18  96% on RA
Pt was found to be hemodynamically stable with a hct drop from
37 five days ago to 23. GI was consulted who did not think a GI
lavage was necessary. A CTA was performed given the possibility
for an aorto-enteric fistula s/p AAA repair in [**2178**]. No
aorto-enteric fistula was found, but diverticulosis without
diverticulitis as well as a moderate right inguinal hernia,
containing loops of non-incarcerated small bowel was found.
Vascular was contact[**Name (NI) **] initially for probablity of aorto-enteric
fistula, but thought that this was very unlikely. On the CT an
incidental finding of a large pleural effusion on the L side was
made which was present on prior studies. GI was contact[**Name (NI) **] and
reportedly is planning to do a non-urgent colonoscopy on Monday,
unless the patient's clinical status changes and more BRBPR is
present. Renal was also notified. 2 U of PRBC were ordered but
were not hung by the time the patient was transferred to the
ICU.
.
ROS: negative for CP, SOB, constipation, f/c/ns, weight loss.
The patient does not produce any urine. Reportedly he has normal
appetite but at times is choking after taking in food.

Past Medical History:
1. ESRD likely d/t HTN
2. HTN
3. AAA repair c/b LLE compartment syndrome
4. BPH

** NOTE: Problem list had contained Liver disease - ?Hep B,
however HepB surface antigen negative in [**2180**]/? NASH - no
evidence supporting this diagnosis. Pt was evaluated in the past
for ascites, but liver ultrasound other wise normal with patent
vasculature. No evidence in our records supporting the diagnosis
of portal HTN and esophageal varices as mentioned on prior dc
summaries.


Social History:
Smoking: no; EthOH: no; drug abuse: no. Cantonese speaking.
Lives with his niece. Ambulatory at baselines with walked.
Independent in washing himself. Food and medications are getting
prepared for him. Not married, no children.

Family History:
no bowel problems, no [**Name2 (NI) 499**] cancer

Physical Exam:
VS T 97.4  BP 122/61 HR 94 RR 20  O2Sat 97 3L
Gen: NAD
HEENT: NC/AT, PERRLA 2>3, dry mm
NECK: no LAD, no JVD, no carotid bruit
COR: mild S1 normal S2, regular rhythm, mild endsystolic murmur
over apex, no r/g
PULM: CTA over R lung field, decreased breath sounds over Left
field about 1/2 up without egophony, no wheezing or rhonchi
ABD: + bowel sounds, soft, mild distended, nt
Skin: warm extremities, no rash, dry skin
EXT: 1+ DP, no edema/c/c,
Neuro: moving all extremities, strength testing limited by
committment, following commands, PERRLA, answering questions
appropriately


Pertinent Results:
EKG: HR 80, left axis, RBBB, left anterior fasicle block,
irrgeular rate, AVB 1st degree, mildly prolonged QT 480. No ST
or TW changes.
.
CT ABDOMEN/PELVIS
.
IMPRESSION:
1.  No evidence of aortoenteric fistula.
2.  Diverticulosis, without evidence of diverticulitis.
3.  Large left pleural effusion, and associated compressive
telectasis.  This is incompletely evaluated on this CT of the
abdomen and pelvis only.
4.  Moderate right inguinal hernia, containing loops of small
bowel, and fluid, with no evidence of incarceration.
5.  Dilated, 12 mm appendix, containing dense material which
appears most consistent with residual contrast from prior
radiological procedure, as dense material is also seen within
several diverticula throughout the [**Name2 (NI) 499**].  No secondary signs of
appendicitis are seen, and clinical context for appendicitis
seems unlikely.
6.  Moderate atherosclerotic calcification of the abdominal
aorta, and branches, without focal dilatation or aneurysm.
.
RADIOLOGY  Final Report
-59 DISTINCT PROCEDURAL SERVICE  [**2182-2-18**] 6:32 PM

IMPRESSION:
1. SMA arteriogram demonstrates an inferior mesenteric artery
with occluded origin and supplied via the middle colic branches
into the left colic artery and superior rectal arteries. No
areas of extravasation of contrast demonstrated at the level of
the splenic flexure, sigmoid and rectum.
2. Active extravasation of contrast at the level of the hepatic
flexure supplied by a branch of the middle colic artery,
successfully embolized with 3 cc of Gelfoam slurry.
.
RADIOLOGY  Final Report
CHEST (PORTABLE AP)  [**2182-2-19**] 3:21 AM

IMPRESSION:
1. Slight decrease in the moderate-to-large left pleural
effusion.
2. Decreased, mild pulmonary edema.
3. Skinfold should not be mistaken for left pneumothorax.
.
   RADIOLOGY  Final Report
GI BLEEDING STUDY  [**2182-2-21**]

IMPRESSION:
No GI bleeding identified.
.
   RADIOLOGY  Final Report
CHEST (PORTABLE AP)  [**2182-2-27**] 8:22 AM

COMPARISON: [**2182-2-19**].

As compared to the previous examination, the extent of the
left-sided pleural effusion is minimally decreased. However, the
effusion is also distributed in a different manner given
different patient position. As compared to the previous
examination of [**2182-2-19**], there still is atelectasis of the
left lower lobe and a small right-sided pleural effusion. The
signs of fluid overload have slightly decreased. The visible
parts of the cardiac silhouette are unchanged in size. There are
no parenchymal opacities that have occurred in the meantime.
.
   RADIOLOGY  Final Report
VIDEO OROPHARYNGEAL SWALLOW  [**2182-2-28**] 2:06 PM

VIDEO OROPHARYNGEAL SWALLOW: Study done in conjunction with
speech and swallow division. A teaspoon of honey consistency
barium was administered to the patient under constant video
fluoroscopy. The oral phase was discoordinated with no bolus
propulsion. The pharyngeal phase showed mild delay in swallow
initiation. Laryngeal elevationa nd valve closre were moderately
reduced with severely reduced pharyngeal constrictions. A large
amount of residue was noted in the valleculae and pyriform
sinuses. The pateint aspirated a modereate amount of honey,
which was followed by prolonged coughing and and small amount of
emesis.

IMPRESSION: Aspiration of honey consistency barium.
.

Brief Hospital Course:
LGIB: Pt was hemodynamically stable on admission to th ICU.  NG
lavage was deferred in ED.  Pt was transfused for goal Hct>30.
Serial hematocrits were trended.  Larger bore IVs were placed.
IV PPI [**Hospital1 **] was started.  GI was consulted.  EGD demonstrated
duodenitis, but no active bleeding.  Colonoscopy showed fresh
and clotted blood throughout [**Hospital1 499**] and 10 cm into terminal
ileum.  No active bleeding source was identified.  GI
recommended tagged RBC scan, which was positive.  He was taken
to IR where active extravasation of contrast was seen at the
level of the hepatic flexure supplied by a branch of the middle
colic artery.  This was successfully embolized with 3 cc of
Gelfoam slurry.  Surgery input was obtained for worry of
ischemia after embolization.  Serial lactates remained stable.
Abdominal exam remained reassuring.  After embolization, serial
Hcts were followed, and he remained hemodynamically stable.  PPI
changed to daily as no UGIB.  Pt. transferred to the floor and
3days post embolization had BRBPR --> repeat bleeding scan
negative and hct stable.  Pt. had two additional episodes of
~30cc of black liquid stool during the week post embolization.
At present the pt. has had no further evidence of bleeding and
his hematocrit has been stable.

New Atrial Fibrillation: Episode while in ICU.  HR in 80-120's.
No history of Afib.  Monitored on telemetry.  Not anticoagulated
secondary to recent GI bleed.  Pt. with episodes of tachy-brady
syndrome [**2182-2-21**] - tachy to 130s and brady to 30s.  Cardiology
was contact[**Name (NI) **] - evaluated pt. tele strips and EKGs and it was
felt that his brady episodes occured as the pt. was attempting
to convert back into sinus rhythm.  No intervention needed.  Pt.
remained HD stable.

ESRD: Renal followed pt throughout hospitalization.
Tues/Thurs/Sat hemodialysis while in hospital.

Coagulopathy: INR increasing initially while in hospital and in
context of NPO. Vitamin K x 1 given.  INR has now trended down.
No further intervention needed.

Hypertension: Held antihypertensives in context of GIB.  As pt.
not taking POs at present have given prn doses of hydralazine
for SBP>160.

Large pleural effusions: Chronic. Family denied workup in the
past. No respiratory compromise.

Depression/Dementia: Required frequent reorientation.  The
patient has been continued on his Zyprexa at 5mg po daily.

? Extrapyramidal disease: patient on Benztropine. No mention in
chart of Parkinsonism or extrapyramidal disease. Pt reports that
it was started for tremor in the context of Zyprexa. Held
Benztropine while in ICU.  Have not restarted these medications.
 Using Zyprexa sublingual prn.

DELIRIUM: Waxing and [**Doctor Last Name 688**] mental status throughout his
admission, initially with agitation requiring chemical and
physical safety restraint.  Was noticed to continually pull at
invasive devices, including pulling out his PICC line.  Delirium
slowly improved as sedating medications were weaned.

FEN: Speech and Swallow evaluation completed, and pt failed.
Kept NPO initially. However, after several discussions with
family, the pt was allowed to take po per their request. The
family stated that the patient was eating at his usual baseline
prior to hospitalization, and has never had any documented
episodes of aspiration or aspiration pna. The pt's diet is
pureed solids and honey-thickened liquids, and he should be
assisted with po intake to minimize aspiration risk.

GOALS OF CARE:  Multiple meetings were held with the patient's
niece and nephew.  They were in agreement that invasive feeding
tube placement was not consistent with what their uncle would
want.  Despite multiple speech and swallow evaluations
demonstrating aspiration of oral intake, feeding was attempted
as the patient was able to vocalize that he wanted to eat.  He
was able to tolerate pureed solid and thickened liquids, under
supervision, without respiratory compromise or gross aspiration.
 Plan was thus to continue oral feeding, with aspiration
precautions, as tolerated.

Code: DNR/DNI, as discussed in detail with the patient's family.

Communication:
[**Name (NI) **] [**Name (NI) 12444**] (Niece and decision maker) [**Telephone/Fax (1) 12445**]
[**Name (NI) **] [**Name (NI) **] (Nephew and decision maker) [**Telephone/Fax (1) 12446**]

Medications on Admission:
Renagel 2400mg tid w/ meals
Renal caps 1 capsule qday
Norvasc 5mg qday
Zyprexa 20mg qday
Benzotropine 0.5-1 qday,
Lorazepam 2mg qam of HD
Docusate prn

Discharge Medications:
1. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for fever or pain.
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Health Center

Discharge Diagnosis:
lower gastrointestinal bleed
chronic aspiration

Secondary:
- ESRD likely d/t HTN, on dialysis T/T/Sa
- HTN
- AAA repair in [**2178**] c/b LLE compartment syndrome
- Dementia/delirium
- BPH
- Liver disease

Discharge Condition:
stable

Discharge Instructions:
You were admitted to the hospital and treated for your complaint
of blood per rectum.  You were seen by the gastroenterology team
as well as the inverventional radiologists.  You underwent a
colonscopy and an embolization to control the bleeding from your
[**Year (4 digits) 499**].  You were seen by the nephrology team while here and
underwent your normal course of hemodialysis.  The speech and
swallow team were very involved in your care and evaluating your
ability to swallow.  Many family meetings were held regarding
your care plan.  You are now stable and ready for discharge to a
long term care facility.

You will need to take all medications as instructed.

You will need to keep all follow-up appointments as indicated.

Call your primary care doctor or return to the ED if T>100.5,
chills, nausea, vomiting, chest pain, shortness of breath, blood
per rectum, change in mental status, or any other concern.

Followup Instructions:
You should follow-up with your primary care doctor in the next
1-2 weeks. Please call to arrange an appointment

                             [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
{'Hemorrhage of gastrointestinal tract, unspecified,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified protein-calorie malnutrition,Hyperosmolality and/or hypernatremia,Unspecified pleural effusion,Other and unspecified coagulation defects,Iron deficiency anemia secondary to blood loss (chronic),Other persistent mental disorders due to conditions classified elsewhere,Atrial fibrillation,Depressive disorder, not elsewhere classified'}


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: BRBPR

PRESENT ILLNESS: 83 yo male with 4 days of BRBPR. The history is obtained mostly
through the niece who is living together with the patient and is
translating. The patient reportedly had about 7 episodes of
diarrhea (unknown amounts) per day since Wednesday. The diarrhea
was watery and bloody. It was bright red blood. The patient went
to dialysis today without mentioning the ongoing BRBPR to his
dialysis team and was dialysed as usual receiving Heparin. He
then after dialysis noticed worsening BRBPR and decided to come
to the ED. The patient is asymptomatic without any
lightheadedness or dizziness. He was also complaining of some
abdominal pain last night, and during the days prior but this
has since improved. The abdominal pain was of crampy character
and mild and it occurred intermittently. It is located in the
LLQ and not radiating. The patient denies hematemesis, nausea or
vomiting.
.
ED course: VS 97.5 77  119/54  18  96% on RA
Pt was found to be hemodynamically stable with a hct drop from
37 five days ago to 23. GI was consulted who did not think a GI
lavage was necessary. A CTA was performed given the possibility
for an aorto-enteric fistula s/p AAA repair in [**2178**]. No
aorto-enteric fistula was found, but diverticulosis without
diverticulitis as well as a moderate right inguinal hernia,
containing loops of non-incarcerated small bowel was found.
Vascular was contact[**Name (NI) **] initially for probablity of aorto-enteric
fistula, but thought that this was very unlikely. On the CT an
incidental finding of a large pleural effusion on the L side was
made which was present on prior studies. GI was contact[**Name (NI) **] and
reportedly is planning to do a non-urgent colonoscopy on Monday,
unless the patient's clinical status changes and more BRBPR is
present. Renal was also notified. 2 U of PRBC were ordered but
were not hung by the time the patient was transferred to the
ICU.
.
ROS: negative for CP, SOB, constipation, f/c/ns, weight loss.
The patient does not produce any urine. Reportedly he has normal
appetite but at times is choking after taking in food.

MEDICAL HISTORY: 1. ESRD likely d/t HTN
2. HTN
3. AAA repair c/b LLE compartment syndrome
4. BPH

MEDICATION ON ADMISSION: Renagel 2400mg tid w/ meals
Renal caps 1 capsule qday
Norvasc 5mg qday
Zyprexa 20mg qday
Benzotropine 0.5-1 qday,
Lorazepam 2mg qam of HD
Docusate prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 97.4  BP 122/61 HR 94 RR 20  O2Sat 97 3L
Gen: NAD
HEENT: NC/AT, PERRLA 2>3, dry mm
NECK: no LAD, no JVD, no carotid bruit
COR: mild S1 normal S2, regular rhythm, mild endsystolic murmur
over apex, no r/g
PULM: CTA over R lung field, decreased breath sounds over Left
field about 1/2 up without egophony, no wheezing or rhonchi
ABD: + bowel sounds, soft, mild distended, nt
Skin: warm extremities, no rash, dry skin
EXT: 1+ DP, no edema/c/c,
Neuro: moving all extremities, strength testing limited by
committment, following commands, PERRLA, answering questions
appropriately

FAMILY HISTORY: no bowel problems, no [**Name2 (NI) 499**] cancer

SOCIAL HISTORY: Smoking: no; EthOH: no; drug abuse: no. Cantonese speaking.
Lives with his niece. Ambulatory at baselines with walked.
Independent in washing himself. Food and medications are getting
prepared for him. Not married, no children. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified protein-calorie malnutrition,Hyperosmolality and/or hypernatremia,Unspecified pleural effusion,Other and unspecified coagulation defects,Iron deficiency anemia secondary to blood loss (chronic),Other persistent mental disorders due to conditions classified elsewhere,Atrial fibrillation,Depressive disorder, not elsewhere classified'}
