CHIEF COMPLAINT: GI bleed

PRESENT ILLNESS: 32 year old female with history of UGIB related to duodenal
ulcers in setting of NSAID use in [**2102**] who now presents with
non-bloody emesis, blood streaked stool and epigastric pain.
Patient had two episodes of non-bloody emesis over the last five
days- emesis looked dark though she could not see frank blood.
She noted a dark brown stool that was blood streaked two days
ago. Notably, no bowel movement since that time. She describes
epigastric pain and lower back pain since yesterday which is
also new and some generalized myalgias.
.
In the ED, initial vs were: T 98.2 P102 BP129/57 R18 O2 sat
100RA. Per ED resident rectal exam demonstrated bright red blood
on glove. Pt refused NG tube placement. Seen by GI who rec
urgent EGD in MICU. Prior to transfer to the MICU her vitals
were T 100 HR 100 BP 131/65 RR 14 O2sat 100 RA.
.
In the ICU, patient reporting mild epigastric pain but otherwise
is comfortable. She reports that since her GI bleed in [**2102**] she
has continued to use ibuprofen sporadically for headache.
Possibly as often as once per month, never exceeding 4 tablets
in one day.
.
Review of systems:
(+) Per HPI, +HA
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. No recent change in bowel or bladder habits. No
dysuria.

MEDICAL HISTORY: **GI Bleeds:
[**12-23**] ?AVM
[**3-26**] - duodenal ulcers, required 2 units PRBCs, likely NSAID
induced (presented with melena)
** Anal fissure
**Ovarian cysts s/p removal [**12/2102**]
**Mild Asthma
**Alpha 1 anti-trypsin carrier

MEDICATION ON ADMISSION: MVI
Ibuprofen PRN HA

ALLERGIES: Codeine

PHYSICAL EXAM: General: Well appearing, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild epigastric tenderness, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Nuero: AOx3

FAMILY HISTORY: No gastric cancer, colon cancer, PUD, GI and or liver  disorders

SOCIAL HISTORY: Lives with husband who is surgical resident at [**Hospital1 **]. No
tobacco, occ ETOH, no IVDU. Under a great deal of stress as
husband recently diagnosed with NHL.
Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Iron deficiency anemia secondary to blood loss (chronic)
Chr duoden ulcer w hem,Chr blood loss anemia
Admission Date:  [**2113-10-29**]              Discharge Date:   [**2113-10-30**]

Date of Birth:  [**2081-4-5**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine

Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
GI bleed

Major Surgical or Invasive Procedure:
Upper endoscopy


History of Present Illness:
32 year old female with history of UGIB related to duodenal
ulcers in setting of NSAID use in [**2102**] who now presents with
non-bloody emesis, blood streaked stool and epigastric pain.
Patient had two episodes of non-bloody emesis over the last five
days- emesis looked dark though she could not see frank blood.
She noted a dark brown stool that was blood streaked two days
ago. Notably, no bowel movement since that time. She describes
epigastric pain and lower back pain since yesterday which is
also new and some generalized myalgias.
.
In the ED, initial vs were: T 98.2 P102 BP129/57 R18 O2 sat
100RA. Per ED resident rectal exam demonstrated bright red blood
on glove. Pt refused NG tube placement. Seen by GI who rec
urgent EGD in MICU. Prior to transfer to the MICU her vitals
were T 100 HR 100 BP 131/65 RR 14 O2sat 100 RA.
.
In the ICU, patient reporting mild epigastric pain but otherwise
is comfortable. She reports that since her GI bleed in [**2102**] she
has continued to use ibuprofen sporadically for headache.
Possibly as often as once per month, never exceeding 4 tablets
in one day.
.
Review of systems:
(+) Per HPI, +HA
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. No recent change in bowel or bladder habits. No
dysuria.


Past Medical History:
**GI Bleeds:
[**12-23**] ?AVM
[**3-26**] - duodenal ulcers, required 2 units PRBCs, likely NSAID
induced (presented with melena)
** Anal fissure
**Ovarian cysts s/p removal [**12/2102**]
**Mild Asthma
**Alpha 1 anti-trypsin carrier


Social History:
Lives with husband who is surgical resident at [**Hospital1 **]. No
tobacco, occ ETOH, no IVDU. Under a great deal of stress as
husband recently diagnosed with NHL.

Family History:
No gastric cancer, colon cancer, PUD, GI and or liver  disorders



Physical Exam:
General: Well appearing, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild epigastric tenderness, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Nuero: AOx3


Pertinent Results:
[**2113-10-29**] 09:15AM   GLUCOSE-88 UREA N-11 CREAT-0.9 SODIUM-141
POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-26 ANION GAP-10
[**2113-10-29**] 09:15AM   ALT(SGPT)-11 AST(SGOT)-17 LD(LDH)-131 ALK
PHOS-53 TOT BILI-0.2
[**2113-10-29**] 09:15AM   LIPASE-22
[**2113-10-29**] 09:15AM   IRON-30
[**2113-10-29**] 09:15AM   calTIBC-316 FERRITIN-24 TRF-243
[**2113-10-29**] 09:15AM   WBC-6.0 RBC-3.54* HGB-10.0* HCT-29.4* MCV-83
MCH-28.2 MCHC-33.9 RDW-13.4
[**2113-10-29**] 09:15AM   NEUTS-71.9* LYMPHS-22.4 MONOS-3.5 EOS-1.7
BASOS-0.5
[**2113-10-29**] 09:15AM   PLT COUNT-306
[**2113-10-29**] 07:53PM   HCT-26.6*
[**2113-10-29**] 10:40PM   HCT-26.7*

Micro:
[**2113-10-30**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2113-10-30**] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY
TEST-PENDING
[**2113-10-29**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2113-10-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]


Brief Hospital Course:
32 year old female with a history of upper GI bleeds related to
?AVM and to duodenal ulcers presenting with non-bloody emesis,
epigastric pain, blood streaked stools and noted to be
tachycardic.
.
# Emesis/Epigastric Pain: Concerning for UGIB given history of
duodenal ulcer bleeding. Patient certainly at risk for ulcers or
gastritis or esophagitis given NSAID use. LFTs normal making
hepatitis, cholecystitis or cholangitis much less likely. Given
epigastric location of pain also considered pancreatitis, though
no known risk factors and lipase normal. Also considered
pregnancy, beta HCG normal. Certainly pain could be MSK from
vomiting. Emesis plus myalgias could imply viral illness.  EGD
showed single clean based 10mm duodenal ulcer with
self-resolving oozing when traversed. No active bleeding.
Anti-emetics were given PRN. She was kept on maintenance fluids
and Hct remained stable.

.
# Hematochezia: Most likely related to anal fissure or
hemorrhoids especially given patient reports she has been
straining with stools. Pt will f/u as outpt with GI for
possibility of outpt flex sig or [**Last Name (un) **].
.
# Anemia: Hct 29 on admission, certainly abnormal. No recent
hcts to compare to. Concern was initially for UGIB vs LGIB.
Unlikely hemolysis given nl bili.  EGD results were as above.
She was found to be iron deficient and was started on iron
supplementation with colace.

.
# Headache: Likely tension headache as pain is frontal. Pt
taking fioricet as outpt.  Would prefer tylenol for HAs  and she
was advised to avoid NSAIDs. Pt will follow-up with PCP, [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], tomorrow.


Medications on Admission:
MVI
Ibuprofen PRN HA


Discharge Medications:
1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
4. Multivitamin     Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary: Iron Deficiency Anemia
Secondary: History of duodenal ulcers, tension headaches


Discharge Condition:
stable


Discharge Instructions:
You were admitted to the hospital because of vomiting, abdominal
pain and blood in your stool. You had an upper endoscopy that
did not indicate any bleeding. Your red blood cell count
remained stabely on the lower side- this is called anemia. You
will need to continue to have this issue followed as an outpt.
.
We would suggest that you avoid using non-steroidal
anti-inflammatory medications such as ibuprofen or naproxen.
.
New Medications:
-Omeprazole 40mg twice a day
-Colace 100 mg twice a day as needed for constipation
-Ferrous Sulfate (iron) 325mg twice a day
.
If you experience any continued rectal bleeding,
lightheadedness, dizziness, chest pain, passing out or any other
concerning symptoms please contact your primary care provider or
come to the emergency department for evaluation.

No changes made to your medications

If you experience dizziness, short

Followup Instructions:
We have made the following appointment for you:
Gastroenterology: [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2113-11-7**] 2:00

This appointment was previously scheduled:
Provider: [**First Name8 (NamePattern2) 2878**] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 2879**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2113-10-31**] 12:00


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Iron deficiency anemia secondary to blood loss (chronic)'}


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: GI bleed

PRESENT ILLNESS: 32 year old female with history of UGIB related to duodenal
ulcers in setting of NSAID use in [**2102**] who now presents with
non-bloody emesis, blood streaked stool and epigastric pain.
Patient had two episodes of non-bloody emesis over the last five
days- emesis looked dark though she could not see frank blood.
She noted a dark brown stool that was blood streaked two days
ago. Notably, no bowel movement since that time. She describes
epigastric pain and lower back pain since yesterday which is
also new and some generalized myalgias.
.
In the ED, initial vs were: T 98.2 P102 BP129/57 R18 O2 sat
100RA. Per ED resident rectal exam demonstrated bright red blood
on glove. Pt refused NG tube placement. Seen by GI who rec
urgent EGD in MICU. Prior to transfer to the MICU her vitals
were T 100 HR 100 BP 131/65 RR 14 O2sat 100 RA.
.
In the ICU, patient reporting mild epigastric pain but otherwise
is comfortable. She reports that since her GI bleed in [**2102**] she
has continued to use ibuprofen sporadically for headache.
Possibly as often as once per month, never exceeding 4 tablets
in one day.
.
Review of systems:
(+) Per HPI, +HA
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. No recent change in bowel or bladder habits. No
dysuria.

MEDICAL HISTORY: **GI Bleeds:
[**12-23**] ?AVM
[**3-26**] - duodenal ulcers, required 2 units PRBCs, likely NSAID
induced (presented with melena)
** Anal fissure
**Ovarian cysts s/p removal [**12/2102**]
**Mild Asthma
**Alpha 1 anti-trypsin carrier

MEDICATION ON ADMISSION: MVI
Ibuprofen PRN HA

ALLERGIES: Codeine

PHYSICAL EXAM: General: Well appearing, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild epigastric tenderness, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Nuero: AOx3

FAMILY HISTORY: No gastric cancer, colon cancer, PUD, GI and or liver  disorders

SOCIAL HISTORY: Lives with husband who is surgical resident at [**Hospital1 **]. No
tobacco, occ ETOH, no IVDU. Under a great deal of stress as
husband recently diagnosed with NHL. 

### Response:
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Iron deficiency anemia secondary to blood loss (chronic)'}
