CHIEF COMPLAINT: Anemia

PRESENT ILLNESS: 81 yo woman with hx of CAD, Afib, CKD here after few weeks of
progressive fatigue and anemia over which time she noted dark
black stools which she attributed to her iron supplementation,
she has been off iron for a few weeks and was started on IV iron
and eopgen shots per her nephrologist as anemia thought to be
secondary to her renal insufficiency.  They were unable to
transfuse her with a Hct of 23 b/c of difficult anitbody match
and very trying other methods to support her anemia.  She has
had chronic anemia initially was on B12 shots, but increasing
difficulty recently.  She was transfused many yrs ago and also
after her right BKA.
.
She was seen at [**Hospital3 7569**] and noted to have an INR 10.1
and Hct 14.9, was given 2uFFP, Vitamin K and sent over because
of difficult to transfuse anemia and Gi evaluation.
.
NGL here was clear with 400cc per ED and stool was dark brown
with guiaic positive.
.
Currently getting 1uPRBC and 2u FFP and overall still feels
tired but has her chronic arthritis pain.  She denies any CP,
SOB or palpitations.  She admits to DOE at 10-15 feet, some
nausea, but no vomiting, no abd pain or other complaints.

MEDICAL HISTORY: Paroxysmal Atrial fibrillation on coumadin
CAD
CHF normal EF, diastolic dysfunction
Anemia-- chronic of unknonw etiology
Rheumatic fever at age 7, no known valvular disease
Diabetic diet controlled, very sensitive to insulin
Right elbow surgery.
Right hip total joint arthroplasty with sciatic injury and
neuropathy s/p stasis ulcers and gangrene resulted in right
right BKA
Bilateral mastectomy for breast cancer; the first 23years ago,
the second 15 years ago.
Status post cataract surgery in both eyes.
Bladder cancer, status post surgery with recurrent bladder
polyps, has placed local chemo [**Doctor Last Name 360**] placed by her chemo
Status post foot surgery in [**2117**]
Hypertension times 35 years
Diabetes mellitus, diet controlled times three to four years
Gout
Chronic renal insufficiency with a baseline of mid 2's
Hx of DVT

MEDICATION ON ADMISSION: atenolol 50 mg p.o. [**Hospital1 **]
glucosamine
chondroitin
allopurinol 100mg qd
coumadin 2.5 M-F/1.25 S/S
lasix 40mg qd
norvasc 10mg qd
prevacid 30mg qd
tapazole 5mg qd
oscal

ALLERGIES: Codeine / Adhesive

PHYSICAL EXAM: VS: T 98.0  BP 133/45  P 64  R18  Sat 99%Ra and 100%2L
GEN aao, nad
HEENT PERRL, MMM, +pallor conjunctiva, neck supple with minimal
JVD
CHEST CTAB no wheezes, crackles.
CV RRR no murmurs, distant heart sounds.
ABD soft, Nt/ND, +BS, guaiac +, brown stool.
EXT right BKA, left LE with trace LE edema, 1+Dp pulses
NEURO a&ox3, cn ii-xii intact; motor, sensory, coordination, and
language grossly intact.

FAMILY HISTORY: Her mother died at 68 of a heart attack. Her father died at 57
of stomach cancer.

SOCIAL HISTORY: She is a retired office worker. Lives with her husband, son and
daughter in law [**Name (NI) 2048**] [**Name (NI) 30075**] her HCP [**Telephone/Fax (1) 30076**]. She does not
smoke, nor does she drink.
Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Atrial fibrillation,Chronic kidney disease, unspecified,Chronic diastolic heart failure,Unspecified essential hypertension,Personal history of malignant neoplasm of bladder,Personal history of malignant neoplasm of breast,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of anticoagulants,Below knee amputation status
Gastrointest hemorr NOS,Ac posthemorrhag anemia,Atrial fibrillation,Chronic kidney dis NOS,Chr diastolic hrt fail,Hypertension NOS,Hx of bladder malignancy,Hx of breast malignancy,DMII wo cmp nt st uncntr,Long-term use anticoagul,Status amput below knee
Admission Date:  [**2125-1-19**]              Discharge Date:   [**2125-1-21**]


Service: MEDICINE

Allergies:
Codeine / Adhesive

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Anemia

Major Surgical or Invasive Procedure:
Blood transfusion.


History of Present Illness:
81 yo woman with hx of CAD, Afib, CKD here after few weeks of
progressive fatigue and anemia over which time she noted dark
black stools which she attributed to her iron supplementation,
she has been off iron for a few weeks and was started on IV iron
and eopgen shots per her nephrologist as anemia thought to be
secondary to her renal insufficiency.  They were unable to
transfuse her with a Hct of 23 b/c of difficult anitbody match
and very trying other methods to support her anemia.  She has
had chronic anemia initially was on B12 shots, but increasing
difficulty recently.  She was transfused many yrs ago and also
after her right BKA.
.
She was seen at [**Hospital3 7569**] and noted to have an INR 10.1
and Hct 14.9, was given 2uFFP, Vitamin K and sent over because
of difficult to transfuse anemia and Gi evaluation.
.
NGL here was clear with 400cc per ED and stool was dark brown
with guiaic positive.
.
Currently getting 1uPRBC and 2u FFP and overall still feels
tired but has her chronic arthritis pain.  She denies any CP,
SOB or palpitations.  She admits to DOE at 10-15 feet, some
nausea, but no vomiting, no abd pain or other complaints.

Past Medical History:
Paroxysmal Atrial fibrillation on coumadin
CAD
CHF normal EF, diastolic dysfunction
Anemia-- chronic of unknonw etiology
Rheumatic fever at age 7, no known valvular disease
Diabetic diet controlled, very sensitive to insulin
Right elbow surgery.
Right hip total joint arthroplasty with sciatic injury and
neuropathy s/p stasis ulcers and gangrene resulted in right
right BKA
Bilateral mastectomy for breast cancer; the first 23years ago,
the second 15 years ago.
Status post cataract surgery in both eyes.
Bladder cancer, status post surgery with recurrent bladder
polyps, has placed local chemo [**Doctor Last Name 360**] placed by her chemo
Status post foot surgery in [**2117**]
Hypertension times 35 years
Diabetes mellitus, diet controlled times three to four years
Gout
Chronic renal insufficiency with a baseline of mid 2's
Hx of DVT


Social History:
She is a retired office worker. Lives with her husband, son and
daughter in law [**Name (NI) 2048**] [**Name (NI) 30075**] her HCP [**Telephone/Fax (1) 30076**]. She does not
smoke, nor does she drink.


Family History:
Her mother died at 68 of a heart attack. Her father died at 57
of stomach cancer.


Physical Exam:
VS: T 98.0  BP 133/45  P 64  R18  Sat 99%Ra and 100%2L
GEN aao, nad
HEENT PERRL, MMM, +pallor conjunctiva, neck supple with minimal
JVD
CHEST CTAB no wheezes, crackles.
CV RRR no murmurs, distant heart sounds.
ABD soft, Nt/ND, +BS, guaiac +, brown stool.
EXT right BKA, left LE with trace LE edema, 1+Dp pulses
NEURO a&ox3, cn ii-xii intact; motor, sensory, coordination, and
language grossly intact.

Pertinent Results:
[**2125-1-20**] 11:33PM BLOOD WBC-18.8*# RBC-3.28*# Hgb-10.4*#
Hct-28.0*# MCV-85 MCH-31.7 MCHC-37.2* RDW-20.7* Plt Ct-328
[**2125-1-19**] 07:00AM BLOOD WBC-10.8 RBC-1.37*# Hgb-3.9*# Hct-13.1*#
MCV-95# MCH-28.2 MCHC-29.6* RDW-23.6* Plt Ct-418
[**2125-1-19**] 07:00AM BLOOD Neuts-81.4* Lymphs-12.5* Monos-3.3
Eos-2.3 Baso-0.5
[**2125-1-19**] 07:00AM BLOOD PT-18.8* PTT-39.9* INR(PT)-2.5
[**2125-1-19**] 07:00AM BLOOD Plt Ct-418
[**2125-1-19**] 07:00AM BLOOD Ret Aut-7.5*
[**2125-1-19**] 07:00AM BLOOD Glucose-124* UreaN-70* Creat-2.7* Na-143
K-4.3 Cl-108 HCO3-22 AnGap-17
[**2125-1-20**] 11:33PM BLOOD Glucose-122* UreaN-66* Creat-2.6* Na-140
K-4.0 Cl-105 HCO3-23 AnGap-16
[**2125-1-19**] 07:00AM BLOOD ALT-11 AST-12 LD(LDH)-164 CK(CPK)-46
AlkPhos-62 Amylase-78 TotBili-0.1
[**2125-1-19**] 07:00AM BLOOD CK-MB-2 cTropnT-<0.01
[**2125-1-20**] 11:33PM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8
[**2125-1-19**] 07:00AM BLOOD calTIBC-265 VitB12-385 Folate-7.6
Hapto-230* Ferritn-220* TRF-204
[**2125-1-19**] 07:00AM BLOOD TSH-4.1
[**2125-1-19**] 09:48PM BLOOD Free T4-1.1
.
ECG: Sinus rhythm. First degree atrio-ventricular conduction
delay. Left bundle-branch block with secondary repolarization
abnormalities.


Brief Hospital Course:
A/P: 81 yo woman with CAD, Afib, CHF, CKD admitted with
worsening anemia in setting of supratherapeutic INR. Was seen at
OSH but had difficult antibodies for RBC transfusion,
transferred to [**Hospital1 18**] for further management.
.
Anemia: Likely acute blood loss superimprosed on chronic
underproduction from chronic kidney dx or even possibly from her
history of local chemotherapy for bladder cancer treatment.  Hct
increased from 13 on admission to 28 with 4 units pRBCs.
Patient had melanotic stools x1, otherwise was asymptomatic.
Was diuresed with IV lasix with transfusions, and her BB/CCB
were held on admission, so as not to mask reflex tachycardia in
the setting of acute blood loss.  At the time of discharge, she
was hemodynamically stable and her home doses of BB and CCB were
restarted.
.
GI bleed: Pt. was transfused to support anemia, and
anticoagulation was reversed with Vit. K and FFP.  Pt. will have
a colonoscopy/EGD as outpatient to be arranged this week.
Aspirin and coumadin will be held until after GI studies are
completed.  Pt. has h/o labile INR and was supratherapeutic (INR
2.5) on admission, so will have to be cautious when
anticoagulation is restarted.  Encouraged Pt. to have frequent
INR checks.

Medications on Admission:
atenolol 50 mg p.o. [**Hospital1 **]
glucosamine
chondroitin
allopurinol 100mg qd
coumadin 2.5 M-F/1.25 S/S
lasix 40mg qd
norvasc 10mg qd
prevacid 30mg qd
tapazole 5mg qd
oscal


Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Glucosamine / Chondroitin
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.

5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).



Discharge Disposition:
Home

Discharge Diagnosis:
Anemia, GI Bleed


Discharge Condition:
Fair, stable.


Discharge Instructions:
Continue to monitor your symptoms. Return to the emergency room
immediately for bloody or black stools, chest pains, shortness
of breath, increased lightheadedness, or any other symptom which
concerns you.
.
For today ([**1-21**]) only, if you are feeling short of breath,
please take an extra lasix (furosemide) pill.
.
Please arrange for colonoscopy as soon as possible.
.
Please arrange to see a PCP after your colonoscopy so that your
coumadin can be restarted.  Do not take coumadin or aspirin
until this appointment.
.
Please continue to take all your other meds as you have been
doing.

Followup Instructions:
Follow up with gastroenterology on Tuesday for a colonoscopy as
scheduled.
.
PCP: [**Name10 (NameIs) 30077**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 16827**]



Completed by:[**2125-1-21**]
{'Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Atrial fibrillation,Chronic kidney disease, unspecified,Chronic diastolic heart failure,Unspecified essential hypertension,Personal history of malignant neoplasm of bladder,Personal history of malignant neoplasm of breast,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of anticoagulants,Below knee amputation status'}


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: Anemia

PRESENT ILLNESS: 81 yo woman with hx of CAD, Afib, CKD here after few weeks of
progressive fatigue and anemia over which time she noted dark
black stools which she attributed to her iron supplementation,
she has been off iron for a few weeks and was started on IV iron
and eopgen shots per her nephrologist as anemia thought to be
secondary to her renal insufficiency.  They were unable to
transfuse her with a Hct of 23 b/c of difficult anitbody match
and very trying other methods to support her anemia.  She has
had chronic anemia initially was on B12 shots, but increasing
difficulty recently.  She was transfused many yrs ago and also
after her right BKA.
.
She was seen at [**Hospital3 7569**] and noted to have an INR 10.1
and Hct 14.9, was given 2uFFP, Vitamin K and sent over because
of difficult to transfuse anemia and Gi evaluation.
.
NGL here was clear with 400cc per ED and stool was dark brown
with guiaic positive.
.
Currently getting 1uPRBC and 2u FFP and overall still feels
tired but has her chronic arthritis pain.  She denies any CP,
SOB or palpitations.  She admits to DOE at 10-15 feet, some
nausea, but no vomiting, no abd pain or other complaints.

MEDICAL HISTORY: Paroxysmal Atrial fibrillation on coumadin
CAD
CHF normal EF, diastolic dysfunction
Anemia-- chronic of unknonw etiology
Rheumatic fever at age 7, no known valvular disease
Diabetic diet controlled, very sensitive to insulin
Right elbow surgery.
Right hip total joint arthroplasty with sciatic injury and
neuropathy s/p stasis ulcers and gangrene resulted in right
right BKA
Bilateral mastectomy for breast cancer; the first 23years ago,
the second 15 years ago.
Status post cataract surgery in both eyes.
Bladder cancer, status post surgery with recurrent bladder
polyps, has placed local chemo [**Doctor Last Name 360**] placed by her chemo
Status post foot surgery in [**2117**]
Hypertension times 35 years
Diabetes mellitus, diet controlled times three to four years
Gout
Chronic renal insufficiency with a baseline of mid 2's
Hx of DVT

MEDICATION ON ADMISSION: atenolol 50 mg p.o. [**Hospital1 **]
glucosamine
chondroitin
allopurinol 100mg qd
coumadin 2.5 M-F/1.25 S/S
lasix 40mg qd
norvasc 10mg qd
prevacid 30mg qd
tapazole 5mg qd
oscal

ALLERGIES: Codeine / Adhesive

PHYSICAL EXAM: VS: T 98.0  BP 133/45  P 64  R18  Sat 99%Ra and 100%2L
GEN aao, nad
HEENT PERRL, MMM, +pallor conjunctiva, neck supple with minimal
JVD
CHEST CTAB no wheezes, crackles.
CV RRR no murmurs, distant heart sounds.
ABD soft, Nt/ND, +BS, guaiac +, brown stool.
EXT right BKA, left LE with trace LE edema, 1+Dp pulses
NEURO a&ox3, cn ii-xii intact; motor, sensory, coordination, and
language grossly intact.

FAMILY HISTORY: Her mother died at 68 of a heart attack. Her father died at 57
of stomach cancer.

SOCIAL HISTORY: She is a retired office worker. Lives with her husband, son and
daughter in law [**Name (NI) 2048**] [**Name (NI) 30075**] her HCP [**Telephone/Fax (1) 30076**]. She does not
smoke, nor does she drink. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Atrial fibrillation,Chronic kidney disease, unspecified,Chronic diastolic heart failure,Unspecified essential hypertension,Personal history of malignant neoplasm of bladder,Personal history of malignant neoplasm of breast,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of anticoagulants,Below knee amputation status'}
