CHIEF COMPLAINT: Hematemesis

PRESENT ILLNESS: 80yoM with h/o CAD s/p 3v CABG [**2116**] who presented with
hematemesis, syncope, and guiaic positive stool. Patient was in
his usual state of health, until developing some mid-epigastric
pain. He said he began to feel dizzy and as his wife was calling
the ambulance he past out in the bathroom (did not hit his
head). In the ambulance on the way to [**Hospital3 46817**], the patient said he vomited bright red blood. Per
chart review, on arrival to OSH ED T 97.6 HR 88 BP 138/76 RR 18
99%RA. He again vomited bright red blood and passed a formed
guiaic positive stool. Hct was 32. TWI were noted on ECG in the
inferolateral leads. Cardiac enzymes were negative. He was
transfused one unit PRBC and stated on an octreotide gtt, and
transferred to [**Hospital1 18**] for further evaluation. In the [**Hospital1 18**] ED T
98.1 HR 85 BP 128/76 R 18 94%RA. NG lavage was positive for
bright red blood, and the NG tube left in place. He was
evaluated by GI who planned to perform EGD once second set of
cardiac enzymes were negative.
.
Briefly, the patient was admitted to the [**Hospital1 18**] ICU and had an
EGD that revealed a large ulcer just above GE junction in the
esophagus, he had a vessel cauterized. He was aggressively
hydrated, given PPI, transfused a total of 3 units (to maintain
his hct > 28), had some of his medications held (ASA, plavix,
labetalol and felodipine). His syncope was thought to be due to
his GIB, but he was ruled out for MI.
.
On transfer to floor, pt. denies cp, sob, dizziness, weakness,
palpitations, nausea, vomiting, abdominal pain. The patient says
he is feeling well and has no current complaint.

MEDICAL HISTORY: CAD s/p 3v CABG [**2116**] (LIMA to LAD, SVG to PDA, SVG to OM)
HTN
Hypercholesterolemia
Anemia
Carotid artery stenoses (U/S [**11/2120**] R ICA possible occlusion,
moderate stenosis R ECA, L ICA)

MEDICATION ON ADMISSION: Labetalol 200mg [**Hospital1 **]
Felodipine 5mg [**Hospital1 **]
Zantac 150mg daily
Lasix 40mg daily
Lipitor 60mg daily
Aspirin 81mg daily
Iron daily
Plavix 75mg daily
Advair 250/50 daily
[**Last Name (LF) 46819**], [**First Name11 (Name Pattern1) 504**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: BP: 139/61, HR: 87, RR 17, 97% RA
Gen: comfortable, NAD, in bed
HEENT: anicteric, MMM, OP clear, EOMI
Neck: supple, no LAD, no JVD, right carotid bruit
CV: RRR, no mrg
Resp: CTAB
Abd: +BS, soft, NT, ND, no masses, no HSM
Ext: no edema, 2+ DPs, pneumoboots in place
Neuro: A&Ox3, CN II-XII intact, strength 5/5 throughout,
sensation intact

FAMILY HISTORY: father d. of pneumonia
mother d. [**Age over 90 **]yrs
sister d. [**Age over 90 **]yrs

SOCIAL HISTORY: lives on [**Hospital3 4298**] with his wife; originally from
Poland, immigrated in [**2063**], retired painter
Tob: quit 4yrs ago, previously smoked 3ppd x 60yrs
EtOH: 3beers/week
Illicits: none
Ulcer of esophagus with bleeding,Hypovolemia,Mitral valve insufficiency and aortic valve insufficiency,Heart valve replaced by transplant,Rheumatic heart failure (congestive),Acute posthemorrhagic anemia,Asthma, unspecified type, unspecified,Aortocoronary bypass status,Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction,Pure hypercholesterolemia,Unspecified essential hypertension
Ulcer esophagus w bleed,Hypovolemia,Mitral/aortic val insuff,Heart valve transplant,Rheumatic heart failure,Ac posthemorrhag anemia,Asthma NOS,Aortocoronary bypass,Ocl mlt bi art wo infrct,Pure hypercholesterolem,Hypertension NOS
Admission Date:  [**2121-7-24**]              Discharge Date:   [**2121-7-29**]

Date of Birth:  [**2041-3-24**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
Hematemesis

Major Surgical or Invasive Procedure:
EGD


History of Present Illness:
 80yoM with h/o CAD s/p 3v CABG [**2116**] who presented with
hematemesis, syncope, and guiaic positive stool. Patient was in
his usual state of health, until developing some mid-epigastric
pain. He said he began to feel dizzy and as his wife was calling
the ambulance he past out in the bathroom (did not hit his
head). In the ambulance on the way to [**Hospital3 46817**], the patient said he vomited bright red blood. Per
chart review, on arrival to OSH ED T 97.6 HR 88 BP 138/76 RR 18
99%RA. He again vomited bright red blood and passed a formed
guiaic positive stool. Hct was 32. TWI were noted on ECG in the
inferolateral leads. Cardiac enzymes were negative. He was
transfused one unit PRBC and stated on an octreotide gtt, and
transferred to [**Hospital1 18**] for further evaluation. In the [**Hospital1 18**] ED T
98.1 HR 85 BP 128/76 R 18 94%RA. NG lavage was positive for
bright red blood, and the NG tube left in place. He was
evaluated by GI who planned to perform EGD once second set of
cardiac enzymes were negative.
.
Briefly, the patient was admitted to the [**Hospital1 18**] ICU and had an
EGD that revealed a large ulcer just above GE junction in the
esophagus, he had a vessel cauterized. He was aggressively
hydrated, given PPI, transfused a total of 3 units (to maintain
his hct > 28), had some of his medications held (ASA, plavix,
labetalol and felodipine). His syncope was thought to be due to
his GIB, but he was ruled out for MI.
.
On transfer to floor, pt. denies cp, sob, dizziness, weakness,
palpitations, nausea, vomiting, abdominal pain. The patient says
he is feeling well and has no current complaint.



Past Medical History:
CAD s/p 3v CABG [**2116**] (LIMA to LAD, SVG to PDA, SVG to OM)
HTN
Hypercholesterolemia
Anemia
Carotid artery stenoses (U/S [**11/2120**] R ICA possible occlusion,
moderate stenosis R ECA, L ICA)


Social History:
lives on [**Hospital3 4298**] with his wife; originally from
Poland, immigrated in [**2063**], retired painter
Tob: quit 4yrs ago, previously smoked 3ppd x 60yrs
EtOH: 3beers/week
Illicits: none


Family History:
father d. of pneumonia
mother d. [**Age over 90 **]yrs
sister d. [**Age over 90 **]yrs


Physical Exam:
BP: 139/61, HR: 87, RR 17, 97% RA
Gen: comfortable, NAD, in bed
HEENT: anicteric, MMM, OP clear, EOMI
Neck: supple, no LAD, no JVD, right carotid bruit
CV: RRR, no mrg
Resp: CTAB
Abd: +BS, soft, NT, ND, no masses, no HSM
Ext: no edema, 2+ DPs, pneumoboots in place
Neuro: A&Ox3, CN II-XII intact, strength 5/5 throughout,
sensation intact



Pertinent Results:
Labs on admission
[**2121-7-24**] 10:43PM   HCT-28.7*
[**2121-7-24**] 12:51PM   CK(CPK)-107
[**2121-7-24**] 12:51PM   CK-MB-6 cTropnT-<0.01
[**2121-7-24**] 09:45AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2121-7-24**] 08:41AM   GLUCOSE-133* UREA N-55* CREAT-1.3* SODIUM-143
POTASSIUM-5.5* CHLORIDE-113* TOTAL CO2-25 ANION GAP-11
[**2121-7-24**] 08:41AM   WBC-9.5 RBC-3.63* HGB-11.5* HCT-32.6* MCV-90
MCH-31.6 MCHC-35.1* RDW-15.1
.
Pertinent results:
CXR: IMPRESSION: No acute cardiopulmonary process
.
Head CT: IMPRESSION:
1. No acute intracranial hemorrhage.
2. Arachnoid cyst of the right middle cranial fossa measuring
4.5 cm in its greatest diameter.
.
Abd xray: IMPRESSION:
1. No free intraabdominal air.
2. Left pleural calcification.
3. Promient appearance of the bladder with surrounding lucency
may be technical. However, CT of the pelvis is suggested for
further evaluation
.
CT pelvis: IMPRESSION:
1. No evidence for bladder pathology.
2. Enlarged prostate and sigmoid diverticulosis.
.
EGD: EGD-large ulcer just above GE junction in the esophagus
.
EChO: Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal (LVEF
70%). Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated.
The number of aortic valve leaflets cannot be determined. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] There is no
pericardial effusion.


Brief Hospital Course:
This is an 80 yoM with h/o CAD presenting with hematemesis and
syncope, found to have a bleeding esophageal ulcer which
required cauterization.
.
1) Upper GI Bleed: Patient was admitted on aspirin and plavix,
and per EGD found to have an ulcer that had a vessel which was
cauterized.  He was followed by medicine and GI, and for
protection continued on a [**Hospital1 **] PPI (pantoprazole).  His
hematocrit was followed, and he was transfused red cells to
maintain his a hematocrit above 28.  At discharge his hematocrit
was stable, and his hemodynamics were stable as well.  Per GI,
he should have his ASA and plavix held for life, but with his
history of CAD restarting ASA 81mg can be considered at 1 week
post discharge, and restarting plavix not only for status post
CABG but for carotid stenosis, can be decided by his PCP, [**Last Name (NamePattern4) **]. [**Name (NI) 46818**] in [**Hospital3 4298**]. Hematocrit should be rechecked
soon after discharge.
.
2) Syncope: The patient's syncope on admission was attributed to
hypovolemia, secondary to his upper GI bleed. Other work-up was
pursued, and he did not exhibit signs of arrythmia on telemetry,
was ruled out for an MI, and his ECHO lacked significant
valvular pathology.  The patient has known carotid stenosis,
that should be further addressed as an outpatient.  On
discharge, the patient was stable and without symptoms of
pre-syncope.
.
3) Coronary artery disease: The patient has a known history of
CAD, and was ruled out for an MI.  He had no symptoms during his
course and was continued on atorvastatin, and labetolol.  As
above, because of his risk for bleed, his aspirin and Plavix,
were held. Risk/benefit needs to be considered with restarting
anti-platelet therapy.
.
4) Hypertension: As the patient presented with a GI bleed, his
anti-hypertensives were initially held.  Once he was
hemodynamically stable, his labetolol was titrated up to
pre-admission doses.  His felodipine and lasix were held, as he
was normotensive, and restarting these should be done as an
outpatient.
.
5) Hypercholesterolemia: Stable with atorvastatin.


Medications on Admission:
Labetalol 200mg [**Hospital1 **]
Felodipine 5mg [**Hospital1 **]
Zantac 150mg daily
Lasix 40mg daily
Lipitor 60mg daily
Aspirin 81mg daily
Iron daily
Plavix 75mg daily
Advair 250/50 daily
[**Last Name (LF) 46819**], [**First Name11 (Name Pattern1) 504**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **]


Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
2. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary
1. Upper GI bleed, secondary to an esophageal ulcer.
.
Secondary
2. Anemia
3. Hypertension


Discharge Condition:
stable, tolerating medications, ambulating


Discharge Instructions:
1. Please take all medications as prescribed. Please note that
we have stopped two of your medications, Aspirin 81mg and Plavix
75mg. We also have stopped your Lasix and Felodipine. These may
be restarted at the discretion of your Primary Care Physician.
2. Please see your doctor, Dr.[**Name (NI) 46820**] in [**Location (un) **], Wednesday,
[**2121-7-30**] at 10:30 AM for a follow-up after discharge from
the hospital.
3. Please return to the hospital for vomiting, unable to take
medications, uncontrolled fevers, black tarry stools or bright
red blood per rectum or breathing difficulties.

Followup Instructions:
1. You have an appointment with Dr.[**Name (NI) 46820**], your primary care
physician, [**Name10 (NameIs) **] Wednesday, [**2121-7-30**], at 10:30am.
([**Telephone/Fax (1) 36558**].
2. You had stool that was guaiac positive, while this may be
secondary to your upper GI bleed, you should discuss with your
doctor the need for a colonoscopy.
3. We held your aspirin and plavix, discuss with your doctor or
cardiologist the need to restart this given your significant
risk of bleeding.
4. We held your felodipine and your lasix as your blood pressure
was low, discuss restarting these with Dr.[**Name (NI) 46820**].
5. You have carotid bruits, discuss with Dr.[**Name (NI) 46820**] the need
for another study to confirm the degree of stenosis.
6. You are on pantoprazole (a proton pump inhibitor) for your
bleed, discuss with Dr.[**Name (NI) 46820**] the need for once versus twice a
day dosing, for longterm management of your ulcer.
7. You have been scheduled for a follow-up upper endoscopy on
Wednesday, [**2121-8-13**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**] and Dr. [**First Name (STitle) **]
[**Name (STitle) **] on the [**Hospital Ward Name 517**] at 1pm arrival time. Please call
([**Telephone/Fax (1) 2233**] with questions about this appointment.
8. You have been scheduled for a [**Hospital 702**] [**Hospital **]
Clinic Appointment to discuss the results of the upper endoscopy
on Wednesday, [**2121-8-20**] at 2pm with Dr. [**First Name (STitle) **] [**Name (STitle) **] in
the [**Hospital Ward Name 23**] Building, [**Location (un) **], [**Hospital Ward Name 516**].
{'Ulcer of esophagus with bleeding,Hypovolemia,Mitral valve insufficiency and aortic valve insufficiency,Heart valve replaced by transplant,Rheumatic heart failure (congestive),Acute posthemorrhagic anemia,Asthma, unspecified type, unspecified,Aortocoronary bypass status,Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction,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: Hematemesis

PRESENT ILLNESS: 80yoM with h/o CAD s/p 3v CABG [**2116**] who presented with
hematemesis, syncope, and guiaic positive stool. Patient was in
his usual state of health, until developing some mid-epigastric
pain. He said he began to feel dizzy and as his wife was calling
the ambulance he past out in the bathroom (did not hit his
head). In the ambulance on the way to [**Hospital3 46817**], the patient said he vomited bright red blood. Per
chart review, on arrival to OSH ED T 97.6 HR 88 BP 138/76 RR 18
99%RA. He again vomited bright red blood and passed a formed
guiaic positive stool. Hct was 32. TWI were noted on ECG in the
inferolateral leads. Cardiac enzymes were negative. He was
transfused one unit PRBC and stated on an octreotide gtt, and
transferred to [**Hospital1 18**] for further evaluation. In the [**Hospital1 18**] ED T
98.1 HR 85 BP 128/76 R 18 94%RA. NG lavage was positive for
bright red blood, and the NG tube left in place. He was
evaluated by GI who planned to perform EGD once second set of
cardiac enzymes were negative.
.
Briefly, the patient was admitted to the [**Hospital1 18**] ICU and had an
EGD that revealed a large ulcer just above GE junction in the
esophagus, he had a vessel cauterized. He was aggressively
hydrated, given PPI, transfused a total of 3 units (to maintain
his hct > 28), had some of his medications held (ASA, plavix,
labetalol and felodipine). His syncope was thought to be due to
his GIB, but he was ruled out for MI.
.
On transfer to floor, pt. denies cp, sob, dizziness, weakness,
palpitations, nausea, vomiting, abdominal pain. The patient says
he is feeling well and has no current complaint.

MEDICAL HISTORY: CAD s/p 3v CABG [**2116**] (LIMA to LAD, SVG to PDA, SVG to OM)
HTN
Hypercholesterolemia
Anemia
Carotid artery stenoses (U/S [**11/2120**] R ICA possible occlusion,
moderate stenosis R ECA, L ICA)

MEDICATION ON ADMISSION: Labetalol 200mg [**Hospital1 **]
Felodipine 5mg [**Hospital1 **]
Zantac 150mg daily
Lasix 40mg daily
Lipitor 60mg daily
Aspirin 81mg daily
Iron daily
Plavix 75mg daily
Advair 250/50 daily
[**Last Name (LF) 46819**], [**First Name11 (Name Pattern1) 504**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: BP: 139/61, HR: 87, RR 17, 97% RA
Gen: comfortable, NAD, in bed
HEENT: anicteric, MMM, OP clear, EOMI
Neck: supple, no LAD, no JVD, right carotid bruit
CV: RRR, no mrg
Resp: CTAB
Abd: +BS, soft, NT, ND, no masses, no HSM
Ext: no edema, 2+ DPs, pneumoboots in place
Neuro: A&Ox3, CN II-XII intact, strength 5/5 throughout,
sensation intact

FAMILY HISTORY: father d. of pneumonia
mother d. [**Age over 90 **]yrs
sister d. [**Age over 90 **]yrs

SOCIAL HISTORY: lives on [**Hospital3 4298**] with his wife; originally from
Poland, immigrated in [**2063**], retired painter
Tob: quit 4yrs ago, previously smoked 3ppd x 60yrs
EtOH: 3beers/week
Illicits: none 

### Response:
{'Ulcer of esophagus with bleeding,Hypovolemia,Mitral valve insufficiency and aortic valve insufficiency,Heart valve replaced by transplant,Rheumatic heart failure (congestive),Acute posthemorrhagic anemia,Asthma, unspecified type, unspecified,Aortocoronary bypass status,Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction,Pure hypercholesterolemia,Unspecified essential hypertension'}
