CHIEF COMPLAINT: Rectal bleeding

PRESENT ILLNESS: Ms. [**Known lastname 2392**] is a 71yo female with PMH significant for ESRD on
HD, respiratory failure, who presents from HD with BRBPR.
Patient was at HD earlier this morning and was noted to have
400cc BRBPR. She was also hypotensive and HD was stopped. Her
blood pressure was 118/80 before her BP dropped. It is unclear
what her BP or how much fluid was removed at this time. Per NH
records, she had quaiac positive BM last night. While in
transport to the ED, she sounded extremely congested per EMS
reports.
In the ED, initial vitals were T 97.1 BP 80/70 AR 80 RR 24 O2
sat 70% on 50% flowmask. She was placed on 95% high flow mask
and her oxygen saturation increased to 99%. She was noted to
have thick, creamy looking secretions. Given improvement in her
O2 sat, the FIO2 was decreased to 0.50. She received Protonix
80mg IV and 1L NS bolus. She was then transferred to the MICU
for further management.

MEDICAL HISTORY: 1)ESRD on HD of unclear etiology.
2)Respiratory failure s/p trach in [**2-11**], vent dependent until
[**1-11**] when she was successfully weaned
3)COPD
4)Chronic pleural effusions
5)Recurrent aspiration PNA
6)PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of
toes bilaterally and autoamputating
7)HTN
8)Hypothyroidism
9)h/o GI bleeding
10)CHF no previous echo here, so unclear [**Name2 (NI) **]
11)h/o Cholesterol emboli syndrome
12)Paroxysmal AF
13)Anemia
14)s/p multiple embolic CVA
[**95**])Dementia
16)Adenocarcinoma of the colon s/p resection in [**2186**]
17)hx of C.diff colitis
18)Sepsis [**3-8**] to PNA d/c'd from MICU [**2188-6-25**]

MEDICATION ON ADMISSION: Combivent 2 puffs Q6H
Aluminum hydroxide suspension
Aspirin 81mg PO daily
Chlorhexidine gluconate 5cc [**Hospital1 **]
Cyanocobalamin 1000 micrograms Q month
Docusate sodium liquid 100cc [**Hospital1 **]
Flovent [**Hospital1 **]
Folic acid 1mg PO daily
Heparin SQ [**Hospital1 **]
Levothyroxine 200micrograms PO daily
Lidocaine patich
Nystatin 5cc PO daily
Omeprazole 20mg PO BID
Oxycodone 2.5mg Q M,W,F at HD
Acetaminophen 650mg PO Q4H PRN

ALLERGIES: Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines

PHYSICAL EXAM: Tcurrent: 35.4  (95.8 ) HR: 84 () bpm  BP: 133/67 RR: 20 ()
SpO2: 89

FAMILY HISTORY: Her parents lived until old age. One brother died of an MI in
his 60s. Another brother with schizophrenia. Son with
hypothyroidism.

SOCIAL HISTORY: # Personal: Lives at [**Hospital 100**] Rehab MACU. Divorced. Three adult
children. [**Doctor Last Name **] id her HCP and is very involved
# Tobacco: Former smoker. 3 packs per day x 13 years.
# Alcohol: Occasional past use.
Diverticulosis of colon with hemorrhage,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified hemorrhoids with other complication,Other persistent mental disorders due to conditions classified elsewhere,Personal history of malignant neoplasm of large intestine,Foreign body in larynx,Foreign body accidentally entering other orifice,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Atrial fibrillation,Hypotension, unspecified,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Anemia, unspecified,Disorders of phosphorus metabolism,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Dvrtclo colon w hmrhg,End stage renal disease,Hyp kid NOS w cr kid V,Hemrrhoid NOS w comp NEC,Mental disor NEC oth dis,Hx of colonic malignancy,Foreign body in larynx,FB entering oth orifice,Chr airway obstruct NEC,CHF NOS,Atrial fibrillation,Hypotension NOS,Hypertension NOS,Hypothyroidism NOS,Anemia NOS,Dis phosphorus metabol,Hx TIA/stroke w/o resid
Admission Date:  [**2188-9-10**]              Discharge Date:   [**2188-9-12**]

Date of Birth:  [**2116-10-30**]             Sex:   F

Service: MEDICINE

Allergies:
Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Rectal bleeding

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Ms. [**Known lastname 2392**] is a 71yo female with PMH significant for ESRD on
HD, respiratory failure, who presents from HD with BRBPR.
Patient was at HD earlier this morning and was noted to have
400cc BRBPR. She was also hypotensive and HD was stopped. Her
blood pressure was 118/80 before her BP dropped. It is unclear
what her BP or how much fluid was removed at this time. Per NH
records, she had quaiac positive BM last night. While in
transport to the ED, she sounded extremely congested per EMS
reports.
In the ED, initial vitals were T 97.1 BP 80/70 AR 80 RR 24 O2
sat 70% on 50% flowmask. She was placed on 95% high flow mask
and her oxygen saturation increased to 99%. She was noted to
have thick, creamy looking secretions. Given improvement in her
O2 sat, the FIO2 was decreased to 0.50. She received Protonix
80mg IV and 1L NS bolus. She was then transferred to the MICU
for further management.

Past Medical History:
1)ESRD on HD of unclear etiology.
2)Respiratory failure s/p trach in [**2-11**], vent dependent until
[**1-11**] when she was successfully weaned
3)COPD
4)Chronic pleural effusions
5)Recurrent aspiration PNA
6)PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of
toes bilaterally and autoamputating
7)HTN
8)Hypothyroidism
9)h/o GI bleeding
10)CHF no previous echo here, so unclear [**Name2 (NI) **]
11)h/o Cholesterol emboli syndrome
12)Paroxysmal AF
13)Anemia
14)s/p multiple embolic CVA
[**95**])Dementia
16)Adenocarcinoma of the colon s/p resection in [**2186**]
17)hx of C.diff colitis
18)Sepsis [**3-8**] to PNA d/c'd from MICU [**2188-6-25**]

Social History:
# Personal: Lives at [**Hospital 100**] Rehab MACU. Divorced. Three adult
children. [**Doctor Last Name **] id her HCP and is very involved
# Tobacco: Former smoker. 3 packs per day x 13 years.
# Alcohol: Occasional past use.


Family History:
Her parents lived until old age. One brother died of an MI in
his 60s. Another brother with schizophrenia. Son with
hypothyroidism.

Physical Exam:
Tcurrent: 35.4  (95.8 ) HR: 84 () bpm  BP: 133/67 RR: 20 ()
SpO2: 89

General Appearance: Anxious, responds to verbal commands
Eyes / Conjunctiva: PERRL, Anicteric sclera
Lymphatic: Cervical WNL
Cardiovascular: RRR, distant heart sounds, no m,r,g
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Diminished), (Left
DP pulse: Diminished)
Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: ),
CTA anteriorly, scattered crackles anteriorly and posteriorly
Abdomen: Soft, NT/ND, +BS; PEG tube in place
Extremities: Right: Absent, Left: Absent, Clubbing, Gangrenous
toes with evidence of auto-amputation
Skin:  Not assessed, No rashes
Neurologic: Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed


Pertinent Results:
==================
  ADMISSION LABS
==================

[**2188-9-10**] 10:15AM BLOOD WBC-10.9 RBC-3.30* Hgb-11.9* Hct-35.5*
MCV-108* MCH-36.1* MCHC-33.6 RDW-17.2* Plt Ct-304
[**2188-9-10**] 10:15AM BLOOD Neuts-74.5* Bands-0 Lymphs-12.6*
Monos-5.2 Eos-7.3* Baso-0.5
[**2188-9-10**] 11:13AM BLOOD PT-18.9* PTT-150* INR(PT)-1.7*
[**2188-9-10**] 10:15AM BLOOD Glucose-125* UreaN-53* Creat-3.0*# Na-142
K-5.4* Cl-97 HCO3-27 AnGap-23*
[**2188-9-10**] 10:15AM BLOOD cTropnT-0.58*
[**2188-9-10**] 04:05PM BLOOD Lactate-1.9
[**2188-9-10**] 10:24AM BLOOD Hgb-13.0 calcHCT-39

==============
  RADIOLOGY
==============

CHEST X-RAY ([**2188-9-10**])
FINDINGS: There is a tracheostomy tube that terminates in the
standard
position. The cardiomediastinal silhouette is stable. There is a
left basal effusion with atelectasis in the left lower lobe. The
right lung does not show any focal consolidations. The tip of
the central venous line is projected over the right atrium.

CONCLUSION:
Left basal effusion with atelectasis in the left lower lobe,
though focal
consolidation cannot be excluded and followup is advised.


Brief Hospital Course:
Ms. [**Known lastname 2392**] is a 71yo female with PMH significant for ESRD on
HD, anemia, respiratory failure s/p tracheostomy who is being
transferred to the MICU for LGIB.

1)LGIB: Patient presented with approximately 400cc of BRBPR at
HD. Per her PMH, she has a history of GI bleeding. Differential
diagnosis for LGIB includes hemmoroids, diverticuliosis,
angiodysplasia, colitis (infectious, ischemia, IBD, and
neoplasm. No report of fevers, chills, or diarrhea to suggest an
infectious colitis or IBD.  Most likely diverticulitis vs.
hemorrhoids. Per OMR, she has not had a colonoscopy here. Her
baseline Hct is between 25-30 but her Hct on admission today of
35.5. Her INR and PTT are elevated today.  She is on Aspirin as
an outpatient but is not on any anti-coagulation (in light of
history of atrial fibrillation).

Patients hematocrit remained stable and she did not require any
transfusions. GI consult was obtained and given spontaneous
resolution of bleeding and low expectation for intervation,
colonoscopy was not pursued.

Aspirin was held given on clear indication for therapy was
found, defer further management to PCP.

Heparin prophylaxis dose was adjusted (reduced) from normal
amount, to 2500 SC BID.

2)Hypotension:  Patient was noted to be hypotensive with SBPs in
80??????s, possibly lower at dialysis. Unclear how much fluid was
removed at dialysis. She also had 400cc of BRBPR which may be
accounting for her transient hypotension.  She received 1L NS in
the ED and her BP quickly stabilized and remained at baseline.
No fevers or chills to suggest an underlying infectious process.
 Lactate was elevated to 3.9 but quickly returned to [**Location 213**]. Her
hypotension also resolved upon tranfer to the MICU.

3)Respiratory: Patient has history of respiratory failure s/p
tracheostomy and was successfully weaned in [**1-11**]. Patient was
acutely hypoxic with O2 saturation between 50-70%. She was also
noted to have increased secretions; she likely mucous plugged
given acute desaturation. Her Upon transfer to the MICU, her
respiratory status stabilized.  She is currently on 50%
trachmask.  No evidence of a pneumonia on cxray. Patient had a
single, transient episode of desaturation wich resolved with
suctioning. She has remained with good oxygen saturation the the
trach mask per her baseline. We continued inhaler regimen as per
rehab.

4)Coagulopathy: Patient presented with elevated INR and PTT. She
is not on any anti-coagulation or blood thinners as outpatient.
These labs may have been draw via a line that was flushed with
heparin. This may also be due to heparin SQ she has been
receiving at home. Her labs were repeated and they normalized.
As above, SC heparin for prophylaxis was re-started at a reduced
dose.

5)ESRD on HD: Patient underwent dialysis prior to being
discharged to rehab.

6)COPD: Continue Atrovent and Albuterol

7)Anemia: Baseline Hct between 25-30. Hct on admission was 35,
which is slightly elevated from baseline.  Her Hct remained
stable at 30 during her stay in the MICU. She also receives
Epogen at HD.

8)Hypothyroidism: Patient was continued on Levoxyl.

Medications on Admission:
Combivent 2 puffs Q6H
Aluminum hydroxide suspension
Aspirin 81mg PO daily
Chlorhexidine gluconate 5cc [**Hospital1 **]
Cyanocobalamin 1000 micrograms Q month
Docusate sodium liquid 100cc [**Hospital1 **]
Flovent [**Hospital1 **]
Folic acid 1mg PO daily
Heparin SQ [**Hospital1 **]
Levothyroxine 200micrograms PO daily
Lidocaine patich
Nystatin 5cc PO daily
Omeprazole 20mg PO BID
Oxycodone 2.5mg Q M,W,F at HD
Acetaminophen 650mg PO Q4H PRN


Discharge Medications:
1. Levothyroxine 100 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).

3. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1)  PO BID (2
times a day).
5. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]:
Two (2) Adhesive Patch, Medicated Topical Q24H (every 24 hours).

8. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 2500 (2500)
units Injection [**Hospital1 **] (2 times a day).
9. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Aluminum Hydroxide Gel 600 mg/5 mL Suspension [**Hospital1 **]: Thirty
(30) ML PO Q8H (every 8 hours).
11. Diphenhydramine HCl 25 mg Capsule [**Hospital1 **]: One (1) Capsule PO
Q6H (every 6 hours) as needed.
12. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1)  Inhalation
Q6H (every 6 hours).


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
PRIMARY:
HEMATOCHEZIA


Discharge Condition:
Hemodynamically stable, without bleeding


Discharge Instructions:
You were admitted to the hospital due to bleeding from your
gastrointestinal track during dialysis. We closely monitored you
and you did not need any blood transfusions. You did not require
a colonoscopy at this time.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

If you experience any further bleeding, or have any chest pain,
further desaturations or any other symptom that concerns you,
please seek medical attention.

Followup Instructions:
Please follow up with your rehab physician on arrival to MACU
{'Diverticulosis of colon with hemorrhage,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified hemorrhoids with other complication,Other persistent mental disorders due to conditions classified elsewhere,Personal history of malignant neoplasm of large intestine,Foreign body in larynx,Foreign body accidentally entering other orifice,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Atrial fibrillation,Hypotension, unspecified,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Anemia, unspecified,Disorders of phosphorus metabolism,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}


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: Rectal bleeding

PRESENT ILLNESS: Ms. [**Known lastname 2392**] is a 71yo female with PMH significant for ESRD on
HD, respiratory failure, who presents from HD with BRBPR.
Patient was at HD earlier this morning and was noted to have
400cc BRBPR. She was also hypotensive and HD was stopped. Her
blood pressure was 118/80 before her BP dropped. It is unclear
what her BP or how much fluid was removed at this time. Per NH
records, she had quaiac positive BM last night. While in
transport to the ED, she sounded extremely congested per EMS
reports.
In the ED, initial vitals were T 97.1 BP 80/70 AR 80 RR 24 O2
sat 70% on 50% flowmask. She was placed on 95% high flow mask
and her oxygen saturation increased to 99%. She was noted to
have thick, creamy looking secretions. Given improvement in her
O2 sat, the FIO2 was decreased to 0.50. She received Protonix
80mg IV and 1L NS bolus. She was then transferred to the MICU
for further management.

MEDICAL HISTORY: 1)ESRD on HD of unclear etiology.
2)Respiratory failure s/p trach in [**2-11**], vent dependent until
[**1-11**] when she was successfully weaned
3)COPD
4)Chronic pleural effusions
5)Recurrent aspiration PNA
6)PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of
toes bilaterally and autoamputating
7)HTN
8)Hypothyroidism
9)h/o GI bleeding
10)CHF no previous echo here, so unclear [**Name2 (NI) **]
11)h/o Cholesterol emboli syndrome
12)Paroxysmal AF
13)Anemia
14)s/p multiple embolic CVA
[**95**])Dementia
16)Adenocarcinoma of the colon s/p resection in [**2186**]
17)hx of C.diff colitis
18)Sepsis [**3-8**] to PNA d/c'd from MICU [**2188-6-25**]

MEDICATION ON ADMISSION: Combivent 2 puffs Q6H
Aluminum hydroxide suspension
Aspirin 81mg PO daily
Chlorhexidine gluconate 5cc [**Hospital1 **]
Cyanocobalamin 1000 micrograms Q month
Docusate sodium liquid 100cc [**Hospital1 **]
Flovent [**Hospital1 **]
Folic acid 1mg PO daily
Heparin SQ [**Hospital1 **]
Levothyroxine 200micrograms PO daily
Lidocaine patich
Nystatin 5cc PO daily
Omeprazole 20mg PO BID
Oxycodone 2.5mg Q M,W,F at HD
Acetaminophen 650mg PO Q4H PRN

ALLERGIES: Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines

PHYSICAL EXAM: Tcurrent: 35.4  (95.8 ) HR: 84 () bpm  BP: 133/67 RR: 20 ()
SpO2: 89

FAMILY HISTORY: Her parents lived until old age. One brother died of an MI in
his 60s. Another brother with schizophrenia. Son with
hypothyroidism.

SOCIAL HISTORY: # Personal: Lives at [**Hospital 100**] Rehab MACU. Divorced. Three adult
children. [**Doctor Last Name **] id her HCP and is very involved
# Tobacco: Former smoker. 3 packs per day x 13 years.
# Alcohol: Occasional past use. 

### Response:
{'Diverticulosis of colon with hemorrhage,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Unspecified hemorrhoids with other complication,Other persistent mental disorders due to conditions classified elsewhere,Personal history of malignant neoplasm of large intestine,Foreign body in larynx,Foreign body accidentally entering other orifice,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Atrial fibrillation,Hypotension, unspecified,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Anemia, unspecified,Disorders of phosphorus metabolism,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}
