CHIEF COMPLAINT: GI bleeding

PRESENT ILLNESS: 48 year old female with a history of recurrent GI bleeds felt to
be secondary to NSAID induced ulceration who presents with
increased fatigue and shortness of breath, found to be anemic.

MEDICAL HISTORY: # Recurrent GI bleed [**2-14**] NSAIDs with no clear source identified
([**2120-11-12**], [**2118-12-13**])- diverticuli of sigmoid colon and
descending colon, schatzki's ring in distal esophagus on
EGD/colonoscopy in [**2118**]
# Asthma
# Seasonal allergies
# Occasional GERD with spicy foods
# Dysmenorrhea
.
PAST SURGICAL HISTORY
# s/p breast biopsy in her 20s
# s/p L knee synovectomy ([**2118**])

MEDICATION ON ADMISSION: Fluticasone-salmeterol 250/50 INH [**Hospital1 **]
Ipratropium 1 capsule INH QID
Lansoprazole (stopped one week PTA)
Iron

ALLERGIES: Nsaids

PHYSICAL EXAM: Admission exam:
Vitals: T: 100.4 BP: 124/78 P: 105 R: 16 O2: 100% RA
General: Young female, awake and alert in NAD
HEENT: EOMI, PERRL, 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, grade II/VI
holosytolic murmur best heard at base
Abdomen: +BS, soft, nontender, nondistended, no
hepatosplenomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema

FAMILY HISTORY: No FH of bleeding disorder, colon or GI malignancy or IBD.
Mother - died young of [**Name (NI) 4278**].
Father -  primary hyperparathyroidism, cardiomyopathy, DM, HTN
Grandparents lived to 90's.
Siblings- one recently diagnosed with RA, one recently diagnosed
with psoriatic arthritis

SOCIAL HISTORY: Married with two children (8 and 11 yo daughters). Lives in
[**Location 32131**], MA.  She teaches yoga to children and also works in a
bakery.
Tobacco: none
Alcohol: occasional red wine
Illicits: negative
Exercise: 4x/day - walking, biking and yoga
Neoplasm of uncertain behavior of connective and other soft tissue,Acute posthemorrhagic anemia,Hemorrhage of gastrointestinal tract, unspecified,Asthma, unspecified type, unspecified,Disorders of phosphorus metabolism,Esophageal reflux
Unc behav neo soft tissu,Ac posthemorrhag anemia,Gastrointest hemorr NOS,Asthma NOS,Dis phosphorus metabol,Esophageal reflux
Admission Date:  [**2120-12-31**]              Discharge Date:   [**2121-1-6**]

Date of Birth:  [**2072-11-9**]             Sex:   F

Service: SURGERY

Allergies:
Nsaids

Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
GI bleeding

Major Surgical or Invasive Procedure:
Exploratory laparotomy with small-bowel resection and primary
anastomosis.


History of Present Illness:
48 year old female with a history of recurrent GI bleeds felt to
be secondary to NSAID induced ulceration who presents with
increased fatigue and shortness of breath, found to be anemic.

Ms. [**Known lastname 32130**] was hospitalized in [**Month (only) **] for melena and acute
anemia with profound drop in hematocrit to 21 from unclear
baseline. Her presentation was in the setting of recent
prescription of meloxicam for lateral epicondylitis. An EGD
performed during that admission did not reveal a source of
bleeding, and a capsule study was attempted but terminated early
secondary to equipment malfunction. She also had a GI bleed in
[**2118**], thought to be secondary to NSAIDs.  EGD/[**Last Name (un) **] at that time
also did see a source of active bleeding, but noted a Schatzki
ring in distal esophagus and diverticuli in sigmoid colon.

Patient was discharged on protonix and iron supplementation.
She has not had any NSAIDs since discharge.  She drinks very
little alcohol, rarely has an espresso, and usually drinks black
tea.  She reports that one week prior to admission, she was
unable to get a refill of her lansoprazole as her pharmacy ran
out of it.  She also stopped her iron pills as she was concerned
to take them without the PPI.  She was able to get lansoprazole
again two days prior to admission.  She reports that on the
thursday prior to admission, she "wasn't feeling good",
reporting an upset stomach similar to discomfort with prior GI
bleeds.  She restarted her iron pills at this time.  She notes
that over the past two days she has become increasingly fatigued
and short of breath with activity.  She reports "feeling
anemic," as she has in the past when her hematocrit is low.  She
reports pain in the center of her stomach which is [**2-22**], "small
zaps" and like "champagne bubbles."  Pain is not associated with
nausea or vomiting, and she has had a normal appetite.  She
reports hunger today.  She has lost approximately 5lbs in the
last several months, mostly during her last hospitalization.
She has three bowel movements a day, which is her baseline.  She
notes dark/black stools since sunday, which are different than
her dark stools with iron.  She denies bright red blood per
rectum.

In the ED inital vitals were 99.4 100 123/70 14 97% RA. Physical
exam was significant for black guaiac positive stool. Her labs
were significant for Hct 18 (discharge Hct 31), WBC 11.3,
creatinine 0.6.  She refused an NG lavage. She was typed and
crossed for 4 units. Two 18 gauge PIVs were placed. She was
given 1L NS.  GI was notified of her admission. She was started
on a protonix gtt. Vitals on transfer were significant for BP
132/75 HR 90s.

On arrival to the ICU, vital signs were T 100.4, HR 105, BP
124/78, RR 16, 100% on RA.  Patient was comfortable, reporting
[**2-22**] central stomach pain, no lightheadedness, no chest pain or
shortness of breath.  First unit of pRBCs hanging on arrival.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, constipation. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.


Past Medical History:
# Recurrent GI bleed [**2-14**] NSAIDs with no clear source identified
([**2120-11-12**], [**2118-12-13**])- diverticuli of sigmoid colon and
descending colon, schatzki's ring in distal esophagus on
EGD/colonoscopy in [**2118**]
# Asthma
# Seasonal allergies
# Occasional GERD with spicy foods
# Dysmenorrhea
.
PAST SURGICAL HISTORY
# s/p breast biopsy in her 20s
# s/p L knee synovectomy ([**2118**])


Social History:
Married with two children (8 and 11 yo daughters). Lives in
[**Location 32131**], MA.  She teaches yoga to children and also works in a
bakery.
Tobacco: none
Alcohol: occasional red wine
Illicits: negative
Exercise: 4x/day - walking, biking and yoga


Family History:
No FH of bleeding disorder, colon or GI malignancy or IBD.
Mother - died young of [**Name (NI) 4278**].
Father -  primary hyperparathyroidism, cardiomyopathy, DM, HTN
Grandparents lived to 90's.
Siblings- one recently diagnosed with RA, one recently diagnosed
with psoriatic arthritis


Physical Exam:
Admission exam:
Vitals: T: 100.4 BP: 124/78 P: 105 R: 16 O2: 100% RA
General: Young female, awake and alert in NAD
HEENT: EOMI, PERRL, 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, grade II/VI
holosytolic murmur best heard at base
Abdomen: +BS, soft, nontender, nondistended, no
hepatosplenomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema

Discharge exam:
Vitals - T 98.6, HR 69, BP 124/72, R 16, O2 99%
General - no acute distress, alert oriented x 3
Cardiac - RRR, no MRG, nl S1S2
Lungs - CTA b/l, no respiratory distress
Abd - soft, no rebound/guarding, mild paraincisional tenderness,
mild distension
Wound - primary dressing in place over midline incision


Pertinent Results:
Admission Labs:
[**2120-12-31**] 12:15PM BLOOD WBC-11.3*# RBC-2.01*# Hgb-6.1*#
Hct-18.2*# MCV-90 MCH-30.5 MCHC-33.7 RDW-13.0 Plt Ct-249
[**2120-12-31**] 12:15PM BLOOD Neuts-82.3* Lymphs-14.1* Monos-3.2
Eos-0.2 Baso-0.2
[**2120-12-31**] 12:15PM BLOOD Glucose-103* UreaN-22* Creat-0.6 Na-135
K-3.7 Cl-105 HCO3-21* AnGap-13
[**2120-12-31**] 12:15PM BLOOD LD(LDH)-236 TotBili-0.1
[**2120-12-31**] 12:15PM BLOOD Hapto-101

[**2121-1-6**] 06:20AM BLOOD WBC-7.5 RBC-3.05* Hgb-9.2* Hct-27.6*
MCV-91 MCH-30.3 MCHC-33.4 RDW-14.8 Plt Ct-382
[**2121-1-4**] 05:10AM BLOOD WBC-13.8* RBC-2.97* Hgb-9.0* Hct-26.6*
MCV-90 MCH-30.4 MCHC-33.9 RDW-16.4* Plt Ct-305
[**2120-12-31**] 12:15PM BLOOD Neuts-82.3* Lymphs-14.1* Monos-3.2
Eos-0.2 Baso-0.2
[**2121-1-6**] 06:20AM BLOOD Plt Ct-382
[**2121-1-3**] 05:06AM BLOOD PT-11.3 PTT-24.9* INR(PT)-1.0
[**2120-12-31**] 12:15PM BLOOD Ret Aut-2.9
[**2121-1-6**] 06:20AM BLOOD Glucose-90 UreaN-9 Creat-0.6 Na-138 K-4.2
Cl-104 HCO3-29 AnGap-9
[**2121-1-5**] 05:10AM BLOOD Glucose-103* UreaN-8 Creat-0.6 Na-140
K-4.5 Cl-106 HCO3-31 AnGap-8
[**2121-1-4**] 05:10AM BLOOD Glucose-103* UreaN-8 Creat-0.7 Na-140
K-4.4 Cl-107 HCO3-28 AnGap-9
[**2120-12-31**] 12:15PM BLOOD LD(LDH)-236 TotBili-0.1
[**2121-1-5**] 05:10AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.1
[**2121-1-3**] 10:18AM BLOOD Calcium-7.5* Phos-2.7 Mg-1.9
[**2120-12-31**] 12:15PM BLOOD Hapto-101

CT Abd/Pelvis [**2121-1-2**]:
IMPRESSION:

1. Enhancing intraluminal and extraluminal bilobed mass within
the mid to
proximal jejunum, corresponding to the mass observed on
endoscopy. No masses are present in the duodenum. Numerous lymph
nodes within the mesentery, but none are pathologically
enlarged.
2. No active bleeding from this jejunal mass or elsewhere in the
GI tract.
3. Sigmoid diverticulosis without diverticulitis.
4. Free fluid in the deep pelvis may be due to a ruptured
hemorrhagic cyst in the right adnexa.
5. Endoscopy capsule in the cecum.
6. Small hiatal hernia.


Brief Hospital Course:
46 yo F with history of recurrent GI bleeds presenting with
fatigue and anemia.

# GIB, SB mass: Patient has not had any BRBPR,
hematochezia/coffee ground emesis, however, does report dark
black stools (while on iron), which were guaiac positive in the
ER.  High concern for GIB.  During last admission, no source was
located in the upper GI system, however capsule study was not
performed.  As recent EGD was negative and patient has no risk
factors for UGIB (no NSAID use, infrequent alcohol use), low
suspicion for esophageal or gastric source.  In addition,
colonoscopy in [**2118**] showed only diverticuli, which may be source
of bleed but unlikely as they were in sigmoid colon and patient
denies any obviously bloody stool.  Initially planned repeat
EGD, but patient preferred less invasive study given recent
negative EGD.  Therefore, a tagged RBC scan was performed, which
showed slow bleed in the distal jejunum/proximal ileum.  IR
[**Name (NI) 653**], but felt that given the slow rate of bleed,
angiography unlikely to be positive. Patient was initially on a
protonix drip which was changed to IV BID once the location of
the bleed was localized to the small bowel. The acute care
surgery service was consulted and she was found to have a
bilobed 4.4 x 2.4 cm mass in her jejunum. She was taken to the
OR on [**2121-1-3**] and had an ex-lap and small bowel resection. She
was transfused 2 uPRBCs pre-operatively for a Hct of 20.2. Her
post-op hematocrit was 27.5. Over the next few days, her Hct
remained stable. Her diet was slowly advanced as her bowel
function was able to tolerate. She had no further bleeds and was
able to be discharged home with appropriate follow-up
instructions and warning signs

# Anemia: Normocytic anemia, most likely due to acute/subacute
blood loss.  As below, source was identified.  Patient required
2UPRBCs at the time of admission and hematocrit responded
appropriately.  Hemolysis labs were negative and reticulocyte
count was appropriate.  GIB workup as below. Likely source of
bleeding to be the SB mass as described above. Post-operatively,
she had no bleeding and her hematocrits were stable until
discharge.

# Tachycardia: Sinus in nature on EKG.  Most likely due to
anemia.  Resolved with transfusions and fluid resuscitation.

# Leukocytosis: Likely related to stress reaction and
demargination from GIB. Resolved with time.

# Asthma: No shortness of breath or wheezing on admission.
Continued outpatient advair and atrovent.

Medications on Admission:
Fluticasone-salmeterol 250/50 INH [**Hospital1 **]
Ipratropium 1 capsule INH QID
Lansoprazole (stopped one week PTA)
Iron

Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. ipratropium bromide  Inhalation
4. Advair HFA  Inhalation


Discharge Disposition:
Home

Discharge Diagnosis:
Intestinal bleeding with identification of a 4-cm small bowel
mass at the level of the jejunum.


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
It was a pleasure taking care of you during your stay at [**Hospital1 **]. You were admitted to the
hospital due to GI bleeding. You were taken to the OR where a
mass was seen at the level of the jejunum (a part of your small
intestine). This mass and part of your small intestine was
removed. You were then observed over the next few days to
monitor your GI function and your pain. We feel comfortable
sending you home at this time. Please remember to take it easy
over the next few weeks as you are recovering from a major
operation and need time to recuperate.

General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication.  Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed.  You
may not drive or heavy machinery while taking narcotic analgesic
medications.  You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.  Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions.  Please also
follow-up with your primary care physician.

Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water.  Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.

WARNING SIGNS:
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*You are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons.  Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.


Followup Instructions:
Please call ([**Telephone/Fax (1) 6815**] upon discharge to schedule an
appointment in the acute care surgery clinic in 2 weeks, or with
any questions/concerns.  Clinic is located in the [**Hospital 2577**] Medical
Office Building, [**Location (un) **], [**Hospital1 18**].



Completed by:[**2121-1-6**]
{'Neoplasm of uncertain behavior of connective and other soft tissue,Acute posthemorrhagic anemia,Hemorrhage of gastrointestinal tract, unspecified,Asthma, unspecified type, unspecified,Disorders of phosphorus metabolism,Esophageal reflux'}


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 bleeding

PRESENT ILLNESS: 48 year old female with a history of recurrent GI bleeds felt to
be secondary to NSAID induced ulceration who presents with
increased fatigue and shortness of breath, found to be anemic.

MEDICAL HISTORY: # Recurrent GI bleed [**2-14**] NSAIDs with no clear source identified
([**2120-11-12**], [**2118-12-13**])- diverticuli of sigmoid colon and
descending colon, schatzki's ring in distal esophagus on
EGD/colonoscopy in [**2118**]
# Asthma
# Seasonal allergies
# Occasional GERD with spicy foods
# Dysmenorrhea
.
PAST SURGICAL HISTORY
# s/p breast biopsy in her 20s
# s/p L knee synovectomy ([**2118**])

MEDICATION ON ADMISSION: Fluticasone-salmeterol 250/50 INH [**Hospital1 **]
Ipratropium 1 capsule INH QID
Lansoprazole (stopped one week PTA)
Iron

ALLERGIES: Nsaids

PHYSICAL EXAM: Admission exam:
Vitals: T: 100.4 BP: 124/78 P: 105 R: 16 O2: 100% RA
General: Young female, awake and alert in NAD
HEENT: EOMI, PERRL, 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, grade II/VI
holosytolic murmur best heard at base
Abdomen: +BS, soft, nontender, nondistended, no
hepatosplenomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema

FAMILY HISTORY: No FH of bleeding disorder, colon or GI malignancy or IBD.
Mother - died young of [**Name (NI) 4278**].
Father -  primary hyperparathyroidism, cardiomyopathy, DM, HTN
Grandparents lived to 90's.
Siblings- one recently diagnosed with RA, one recently diagnosed
with psoriatic arthritis

SOCIAL HISTORY: Married with two children (8 and 11 yo daughters). Lives in
[**Location 32131**], MA.  She teaches yoga to children and also works in a
bakery.
Tobacco: none
Alcohol: occasional red wine
Illicits: negative
Exercise: 4x/day - walking, biking and yoga 

### Response:
{'Neoplasm of uncertain behavior of connective and other soft tissue,Acute posthemorrhagic anemia,Hemorrhage of gastrointestinal tract, unspecified,Asthma, unspecified type, unspecified,Disorders of phosphorus metabolism,Esophageal reflux'}
