CHIEF COMPLAINT: Bright red blood in bowel movement

PRESENT ILLNESS: This is an 83yo female with a past medical history of CAD/CVA,
DM2, hypertension, hypercholesterolemia, chronic pain on hospice
for pain control, with abd pain x 2 days, BRBPR x 1. Initially
constipated for 1 day, then took dulcolax and now with brbpr in
stool on the day of admission. She apparently fainted while
having bm, no fall, and then vomited x 1. Denied f/c/sob.
.
In ED, + BRBPR in vault, + TTP LLQ/RLQ. CT abd performed with
results suggestive of proctocolitis, differential including
ischemic bowel vs. less likely, infectious etiology. Surgery was
consulted for possible bowel ischemia, who recommended IVF, Hct
trending and possible OR if abdominal exams worsen.
.

MEDICAL HISTORY: - CAD: s/p CABG '[**15**] (reportedly had 2 vein grafts, but unclear
anatomy) and  cath at [**Name (NI) 336**] in [**3-22**] revealed severe triple vessel
disease, patent SVG to RCA, SVG to OM, SVG to D1, SVG to D2, SVG
to OM1.
- h/o multiple CVA's: residual L sided weakness. Severely
limited activity at home, with daughter providing help with all
[**Name (NI) 5669**].
- h/o seizures (last sz reportedly 1 yr ago, on keppra at home)

MEDICATION ON ADMISSION: Colace sodium 100 mg 1 cap(s) [**Hospital1 **]
Synthroid 75 mcg (0.075 mg) 1 tab(s) once a day
atenolol 25 mg 1 tab(s) once a day
aspirin 325 mg 1 tab(s) qd
roxanol 20 mg/mL .25 ml Q4H
benadryl 25 mg 1 tab(s) TID
Sarna 0.5%-0.5% as directed TID
Claritin 10 mg 1 tab(s) once a day
lactulose 10 g/15 mL 15 mL [**Hospital1 **]
Protonix 40 mg 1 tab(s) once a day
metformin 500 mg 1 tab(s) [**Hospital1 **]
Zetia 10 mg 1 tab(s) once a day
Aspirin Low Strength 81 mg 1 tab(s) once a day
Keppra 250 mg 2 tab(s) [**Hospital1 **]
simvastatin 40 mg 1 tab(s) once a day (at bedtime)
lisinopril 10 mg 1 tab(s) once a day
Morphine IR 15 mg 1 tab(s) q 12 hrs
morphine 5 mg sl q2hrs
.
Medications on transfer:
1. DiphenhydrAMINE 25 mg PO Q6H:PRN
2. Insulin SC  (per Insulin Flowsheet)
3. Levofloxacin 750 mg IV Q48H
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Levetiracetam 500 mg PO BID
6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
7. Morphine Sulfate 2-4 mg IV Q6H:PRN pain in abd, legs
8. Pantoprazole 40 mg IV Q24H
9. Simvastatin 40 mg PO DAILY
10. Vancomycin 1000 mg IV Q24H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
Vitals: Tm 99.0  P 64  BP 154/72  R [**12-7**]  100%ra  I/O- 1.6/1.5
General: Anxious appearing, but NAD
HEENT: AT/NC, PERRL, EOMI, anicteric. OP clear, MM dry.
Neck: no LAD. JVP at 5cm. Neck supple. EJ in place, c/d/i
Lungs: CTAB no w/r/r
Heart: RRR no m/r/g +S3
Abd: soft, ND, mild ttp LLQ, no rebound/guarding
Ext: no e/c/c. warm and well perfused. 2+ DP pulses.
Neuro: CN II-XII in tact bilaterally. Mild [**3-22**] LUE weakness, hip
flexors LLE [**3-22**], plantarflexion on L [**4-21**]. Right [**4-21**].

FAMILY HISTORY: Mother died of stomach CA. Brother and sister with "heart
problems."

SOCIAL HISTORY: Lives at home with elderly partner.  Daughter helps with most
ADL. No tobacco, EtOH or illicit drugs.  Retired professional
singer
Infectious colitis, enteritis, and gastroenteritis,Acute kidney failure, unspecified,Hyperpotassemia,Occlusion and stenosis of carotid artery with cerebral infarction,Mitral valve disorders,Atrial fibrillation,Unspecified acquired hypothyroidism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other chronic pulmonary heart diseases,Epilepsy, unspecified, without mention of intractable epilepsy,Aortocoronary bypass status,Pure hypercholesterolemia,Unspecified essential hypertension
Infectious enteritis NOS,Acute kidney failure NOS,Hyperpotassemia,Ocl crtd art w infrct,Mitral valve disorder,Atrial fibrillation,Hypothyroidism NOS,DMII wo cmp nt st uncntr,Chr pulmon heart dis NEC,Epilep NOS w/o intr epil,Aortocoronary bypass,Pure hypercholesterolem,Hypertension NOS
Admission Date:  [**2131-6-7**]              Discharge Date:   [**2131-6-15**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Bright red blood in bowel movement

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is an 83yo female with a past medical history of CAD/CVA,
DM2, hypertension, hypercholesterolemia, chronic pain on hospice
for pain control, with abd pain x 2 days, BRBPR x 1. Initially
constipated for 1 day, then took dulcolax and now with brbpr in
stool on the day of admission. She apparently fainted while
having bm, no fall, and then vomited x 1. Denied f/c/sob.
.
In ED, + BRBPR in vault, + TTP LLQ/RLQ. CT abd performed with
results suggestive of proctocolitis, differential including
ischemic bowel vs. less likely, infectious etiology. Surgery was
consulted for possible bowel ischemia, who recommended IVF, Hct
trending and possible OR if abdominal exams worsen.
.


Past Medical History:
- CAD: s/p CABG '[**15**] (reportedly had 2 vein grafts, but unclear
anatomy) and  cath at [**Name (NI) 336**] in [**3-22**] revealed severe triple vessel
disease, patent SVG to RCA, SVG to OM, SVG to D1, SVG to D2, SVG
to OM1.
- h/o multiple CVA's: residual L sided weakness. Severely
limited activity at home, with daughter providing help with all
[**Name (NI) 5669**].
- h/o seizures (last sz reportedly 1 yr ago, on keppra at home)

- DM2 x 20 yrs
- HTN
- hyperlipidemia
- hypothyroidism (on synthroid)
- arthritis
- spinal stenosis w/ chronic leg and hand pain


Social History:
Lives at home with elderly partner.  Daughter helps with most
ADL. No tobacco, EtOH or illicit drugs.  Retired professional
singer

Family History:
Mother died of stomach CA. Brother and sister with "heart
problems."

Physical Exam:
PHYSICAL EXAM:
Vitals: Tm 99.0  P 64  BP 154/72  R [**12-7**]  100%ra  I/O- 1.6/1.5
General: Anxious appearing, but NAD
HEENT: AT/NC, PERRL, EOMI, anicteric. OP clear, MM dry.
Neck: no LAD. JVP at 5cm. Neck supple. EJ in place, c/d/i
Lungs: CTAB no w/r/r
Heart: RRR no m/r/g +S3
Abd: soft, ND, mild ttp LLQ, no rebound/guarding
Ext: no e/c/c. warm and well perfused. 2+ DP pulses.
Neuro: CN II-XII in tact bilaterally. Mild [**3-22**] LUE weakness, hip
flexors LLE [**3-22**], plantarflexion on L [**4-21**]. Right [**4-21**].


Pertinent Results:
Pt. had a spike in WBC to 17.9 with a left shift on [**6-7**] which
subsequently decreased to 12.0 on discharge with resolution of L
shift.
.
Upon admission ([**6-6**]), BUN/Creat were elevated to 31/1.5 which
subsequently decreased with treatment to normal limits (9/0.7).
Potassium on [**6-6**] was 8.5 and decreased to normal limits by
discharge.
.
Troponin-T ranged from 0.17 to 0.10.
.
Stool studies showed WBCs, but was negative for all of the
following: C.dif, O+P, Salmonella and Shigella.
.
Urine cx showed no growth, blood cx: ******
.
EKG ([**6-13**])Atrial fibrillation, average ventricular response 116.
Since [**2131-6-11**] atrial fibrillation is now seen. The inferior T
wave inversions are
less prominent. The Q-T interval is shortened. Increased ST-T
wave abnormalities are noted
.
CXR: ([**6-6**])IMPRESSION:  No acute cardiopulmonary process.
.
CTA Head ([**6-12**]):
IMPRESSION:
1) Occlusion of the entire visualized superior left internal
carotid artery and left middle cerebral artery.  The left
anterior cerebral artery is supplied from the right via the
ACOM.  Obscuration of the left putamen
consistent with evolving left MCA infarction.  No evidence of
acute
intracranial hemorrhage or hemorrhagic transformation.  Findings
discussed
immediately with the neurology team, and an MRA with Gadolinium
of the neck was suggested to evaluate the more proximal carotid
system.
2) Short segment stenosis of the left posterior cerebral artery.

3) Scattered chronic small vessel ischemic disease in the white
matter and
chronic right thalamic lacune.
.
MRA/MRI Head/Neck ([**6-12**]):
IMPRESSION:
1) Evolving infarction involving the left putamen, caudate body,
corona
radiata, and medial aspect of the left temporal lobe.
2) Occlusion of the distal left cervical ICA, with two probable
areas of high-grade stenosis in the proximal left cervical ICA,
though the latter would be far better assessed with a gadolinium
enhanced study, and if the patient is able to tolerate such, a
repeat study with gadolinium is recommended.
.
Echocardiogram ([**6-14**]):Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and
cavity size are normal. There is moderate regional left
ventricular systolic dysfunction with basal inferior and
inferolateral hypokinesis. There is normal systolic function of
the remaining segments. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.

 .
IMPRESSION: Mild regional left ventricular systolic dysfunction.

Moderate-to-severe mitral regurgitation. Moderate pulmonary
hypertension.
 .
Compared with the prior study (images reviewed) of [**2130-12-12**],
mitral
regurgitation severity has increased and pulmonary pressures are
higher. The other findings are similar.
.
CT Abdomen/Pelvis:
IMPRESSION:
1.  Uniform, circumferential bowel wall thickening involving the
descending colon, sigmoid and rectum, concerning for an
inflammatory or infectious etiology. Rectal involvement make
ischemic etiology less likely.

2. Multiple hypodensities within the kidneys, too small to
characterize.


Brief Hospital Course:
The patient was initially admitted to the MICU for monitoring of
BRBPR. Her HCT fell from 42.8-- 34-- 29 over 20 hours (baseline
28-32). The patient was evaluated by GI and felt to have an
ischemic vs. infectious proctocolitis. She was given
levo/flagyl, IV ppi, 2L LR. Kayexelate was held as the patient
was having diarrhea and no peaked t's.  She remained stable
throughout her MICU course, she was given 1 unit of blood, she
remained afebrile with stable vitals and was transferred out to
the floor the following day.
.
On the floor her GI sx shortly resolved with levo/flagyl, and
her pain was adequately controlled. She had a run of atrial
fibrillation with RVR that responded to IV Diltizem and returned
to sinus. This recurred once again during her stay and again
converted to sinus after IV Dilt. and was maintained on po
metoprolol.
.
On the morning of [**6-12**] she was found to have a new right sided
facial droop and R sided hemiparesis as well as aphasia.  A
stroke alert was called, the patient was given aspirin and
underwent urgent CT/CTA of the head which showed a L sided
carotid occlusion and evolving area of infarction in the L
internal capsule.  There was no bleed.  MRI/MRA confirmed these
findings.  Due to the unclear time of onset of symptoms,
thrombolysis was not performed.  In addition, due to the
patient's history of bleeding and risk of hemorrhagic
transformation of the infarction, heparin was not given.
Coumadin was started on [**6-14**] due to discovery of paroxysmal Afib
to prevent future embolic events.
.
The patient remained stable throughout the remainder of the
hospital course.  Speech/swallow eval determined that she was in
fact globally aphasic, and recommended pureed foods and nectars.
 On the days of discharge she was afebrile, displaying normal
vital signs (sinus rhythm) and tolerating po with assistance.

Medications on Admission:
Colace sodium 100 mg 1 cap(s) [**Hospital1 **]
Synthroid 75 mcg (0.075 mg) 1 tab(s) once a day
atenolol 25 mg 1 tab(s) once a day
aspirin 325 mg 1 tab(s) qd
roxanol 20 mg/mL .25 ml Q4H
benadryl 25 mg 1 tab(s) TID
Sarna 0.5%-0.5% as directed TID
Claritin 10 mg 1 tab(s) once a day
lactulose 10 g/15 mL 15 mL [**Hospital1 **]
Protonix 40 mg 1 tab(s) once a day
metformin 500 mg 1 tab(s) [**Hospital1 **]
Zetia 10 mg 1 tab(s) once a day
Aspirin Low Strength 81 mg 1 tab(s) once a day
Keppra 250 mg 2 tab(s) [**Hospital1 **]
simvastatin 40 mg 1 tab(s) once a day (at bedtime)
lisinopril 10 mg 1 tab(s) once a day
Morphine IR 15 mg 1 tab(s) q 12 hrs
morphine 5 mg sl q2hrs
.
Medications on transfer:
1. DiphenhydrAMINE 25 mg PO Q6H:PRN
2. Insulin SC  (per Insulin Flowsheet)
3. Levofloxacin 750 mg IV Q48H
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Levetiracetam 500 mg PO BID
6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
7. Morphine Sulfate 2-4 mg IV Q6H:PRN pain in abd, legs
8. Pantoprazole 40 mg IV Q24H
9. Simvastatin 40 mg PO DAILY
10. Vancomycin 1000 mg IV Q24H


Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for prn pain.
4. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
5. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale
 Injection ASDIR (AS DIRECTED).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) infusion Intravenous Q8H (every 8 hours) for 7 days.
13. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: One (1)
infusion Intravenous once a day for 7 days.
15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea.
16. Morphine 2 mg/mL Syringe Sig: Two (2) mg Injection Q4H
(every 4 hours) as needed for pain legs/abd/chest.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
1. Infectious colitis
2. L-sided CVA (Stroke)
2. DMII
3. Chronic pain


Discharge Condition:
fair


Discharge Instructions:
You were admitted with an infection of your intestines and
placed on antibiotics.  While you were in the hospital you
suffered a stroke that resulted in weakness of the right side of
your face and body.
Continue full course of antibiotics and take all other
medications as prescribed.
If your condition worsens, such as severe abdominal pain,
vomiting, bloody diarrhea contact your physician.
[**Name10 (NameIs) **] if you have any new weakness, chest pain, difficulty
breathing or palpitations seek medical care.
Continue to keep all health care appointments.

Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**] in
one week of discharge from your rehab facility.
Follow-up with your physician for blood work to check INR and
adjust Coumadin dose as necessary
{'Infectious colitis, enteritis, and gastroenteritis,Acute kidney failure, unspecified,Hyperpotassemia,Occlusion and stenosis of carotid artery with cerebral infarction,Mitral valve disorders,Atrial fibrillation,Unspecified acquired hypothyroidism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other chronic pulmonary heart diseases,Epilepsy, unspecified, without mention of intractable epilepsy,Aortocoronary bypass status,Pure hypercholesterolemia,Unspecified essential hypertension'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Bright red blood in bowel movement

PRESENT ILLNESS: This is an 83yo female with a past medical history of CAD/CVA,
DM2, hypertension, hypercholesterolemia, chronic pain on hospice
for pain control, with abd pain x 2 days, BRBPR x 1. Initially
constipated for 1 day, then took dulcolax and now with brbpr in
stool on the day of admission. She apparently fainted while
having bm, no fall, and then vomited x 1. Denied f/c/sob.
.
In ED, + BRBPR in vault, + TTP LLQ/RLQ. CT abd performed with
results suggestive of proctocolitis, differential including
ischemic bowel vs. less likely, infectious etiology. Surgery was
consulted for possible bowel ischemia, who recommended IVF, Hct
trending and possible OR if abdominal exams worsen.
.

MEDICAL HISTORY: - CAD: s/p CABG '[**15**] (reportedly had 2 vein grafts, but unclear
anatomy) and  cath at [**Name (NI) 336**] in [**3-22**] revealed severe triple vessel
disease, patent SVG to RCA, SVG to OM, SVG to D1, SVG to D2, SVG
to OM1.
- h/o multiple CVA's: residual L sided weakness. Severely
limited activity at home, with daughter providing help with all
[**Name (NI) 5669**].
- h/o seizures (last sz reportedly 1 yr ago, on keppra at home)

MEDICATION ON ADMISSION: Colace sodium 100 mg 1 cap(s) [**Hospital1 **]
Synthroid 75 mcg (0.075 mg) 1 tab(s) once a day
atenolol 25 mg 1 tab(s) once a day
aspirin 325 mg 1 tab(s) qd
roxanol 20 mg/mL .25 ml Q4H
benadryl 25 mg 1 tab(s) TID
Sarna 0.5%-0.5% as directed TID
Claritin 10 mg 1 tab(s) once a day
lactulose 10 g/15 mL 15 mL [**Hospital1 **]
Protonix 40 mg 1 tab(s) once a day
metformin 500 mg 1 tab(s) [**Hospital1 **]
Zetia 10 mg 1 tab(s) once a day
Aspirin Low Strength 81 mg 1 tab(s) once a day
Keppra 250 mg 2 tab(s) [**Hospital1 **]
simvastatin 40 mg 1 tab(s) once a day (at bedtime)
lisinopril 10 mg 1 tab(s) once a day
Morphine IR 15 mg 1 tab(s) q 12 hrs
morphine 5 mg sl q2hrs
.
Medications on transfer:
1. DiphenhydrAMINE 25 mg PO Q6H:PRN
2. Insulin SC  (per Insulin Flowsheet)
3. Levofloxacin 750 mg IV Q48H
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Levetiracetam 500 mg PO BID
6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
7. Morphine Sulfate 2-4 mg IV Q6H:PRN pain in abd, legs
8. Pantoprazole 40 mg IV Q24H
9. Simvastatin 40 mg PO DAILY
10. Vancomycin 1000 mg IV Q24H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
Vitals: Tm 99.0  P 64  BP 154/72  R [**12-7**]  100%ra  I/O- 1.6/1.5
General: Anxious appearing, but NAD
HEENT: AT/NC, PERRL, EOMI, anicteric. OP clear, MM dry.
Neck: no LAD. JVP at 5cm. Neck supple. EJ in place, c/d/i
Lungs: CTAB no w/r/r
Heart: RRR no m/r/g +S3
Abd: soft, ND, mild ttp LLQ, no rebound/guarding
Ext: no e/c/c. warm and well perfused. 2+ DP pulses.
Neuro: CN II-XII in tact bilaterally. Mild [**3-22**] LUE weakness, hip
flexors LLE [**3-22**], plantarflexion on L [**4-21**]. Right [**4-21**].

FAMILY HISTORY: Mother died of stomach CA. Brother and sister with "heart
problems."

SOCIAL HISTORY: Lives at home with elderly partner.  Daughter helps with most
ADL. No tobacco, EtOH or illicit drugs.  Retired professional
singer 

### Response:
{'Infectious colitis, enteritis, and gastroenteritis,Acute kidney failure, unspecified,Hyperpotassemia,Occlusion and stenosis of carotid artery with cerebral infarction,Mitral valve disorders,Atrial fibrillation,Unspecified acquired hypothyroidism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other chronic pulmonary heart diseases,Epilepsy, unspecified, without mention of intractable epilepsy,Aortocoronary bypass status,Pure hypercholesterolemia,Unspecified essential hypertension'}
