CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 33 year old
homosexual male with medical history significant for asthma,
chronic headaches and internal and external hemorrhoids
status post banding times five, with most recent banding in
[**2158-3-4**].  He presented with two weeks of worsening
bright red blood per rectum, fatigue and three episodes of
syncope.

MEDICAL HISTORY: 1.  Internal and external hemorrhoids:  The patient reports
having had hemorrhoids since his teen years, prevalent among
his family members.  [**Name (NI) **] is status post banding times five,
with most recent banding in [**2158-3-4**] by Dr. [**Last Name (STitle) 3314**].
Last colonoscopy in [**2154**].  He indicates that bleeding has
become more frequent for the last two weeks.
2.  Rectal Prolapse:  Intermittently reduced by the patient t
home.
3.  Chronic headaches.
4.  Status post trauma to the head in [**2158-4-4**]:  This
occurred at work at [**University/College **] [**Location (un) **], when a speaker on
stage hit his head.  CT scan of the head and cervical spine
films, and MRI of cervical spine were all negative.
5.  Asthma:  Controlled on Albuterol.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Pertinent for hemorrhoids, pancreatic and
breast cancer.  No history of colon cancer.  History of
thalassemia [**Doctor First Name **] in his mother.

SOCIAL HISTORY: The patient reports an eleven pack year
smoking history; he is still a smoker.  He denies any alcohol
or illicit drug use.  He identifies himself as a homosexual
male, reports being active in receptive anal intercourse.
Reports intermittent condom use.  Works as a costume
technician.  Lives in [**Location **].  He is single with no
children.
External hemorrhoids with other complication,Iron deficiency anemia secondary to blood loss (chronic),Hemorrhage of gastrointestinal tract, unspecified,Rectal prolapse,Syncope and collapse,Tachycardia, unspecified,Asthma, unspecified type, unspecified,Headache,Late effect of intracranial injury without mention of skull fracture
Ext hemrrhoid w comp NEC,Chr blood loss anemia,Gastrointest hemorr NOS,Rectal prolapse,Syncope and collapse,Tachycardia NOS,Asthma NOS,Headache,Lt eff intracranial inj
Admission Date:  [**2158-7-24**]     Discharge Date:  [**2158-7-27**]

Date of Birth:   [**2124-11-7**]     Sex:  M

Service:  [**Hospital1 **]-MED

HISTORY OF PRESENT ILLNESS:   The patient is a 33 year old
homosexual male with medical history significant for asthma,
chronic headaches and internal and external hemorrhoids
status post banding times five, with most recent banding in
[**2158-3-4**].  He presented with two weeks of worsening
bright red blood per rectum, fatigue and three episodes of
syncope.

The patient reports that he has had chronic internal and
external hemorrhoids since his teenage years and the rest of
his immediate family members also suffer from them.  He has
had rectal bleeding for years, and he believes anxiety,
stress, caffeine and hot weather exacerbates the bleeding, as
well as large bowel movements; however, in the past two
weeks, he has experienced increased bright and dark red blood
per rectum, approximately three times a day.  At times, the
bright red blood per rectum is mixed with stool, and at other
times it is just blood.  However, he denies any history of
melena or dark, tarry stools and reports no hematemesis.

On [**2158-7-8**], the patient states that he felt warm,
lightheaded, developed a headache, and subsequently had a
syncopal episode with a fall down a flight of stairs.  He did
not suffer any lasting acute trauma from this event.

His second syncopal event occurred on [**2158-7-20**], when he
experienced "hot flashes" and headaches, and later awoke on
the bathroom floor.

Most recently, on [**2158-7-24**], his date of admission, he woke
up in the a.m. with a headache, nausea, which resulted in a
green-yellow vomitus and had a syncopal event.  The patient
then presented to the [**Hospital1 69**]
Emergency Department for evaluation and treatment.

In the Emergency Department, the patient was evaluated for
his multiple syncopal episodes.  He also complained of rectal
discomfort with bowel movements, crampy lower abdominal pain
radiating to the rest of the abdomen, sometimes relieved with
bowel movements.  The patient noted that he had had
constipation a few days ago but had been experiencing
diarrhea recently.

His vital signs in the Emergency Department were as follows:
Temperature 97.2 F.; heart rate 91; blood pressure 121/75;
respiratory rate 16; oxygen saturation 100% on room air. This
patient appeared pale, but resting comfortably and in no
acute distress.  A nasogastric lavage was negative for blood.
External hemorrhoids were noted on physical examination and
he was guaiac positive.  The rest of his physical exam was
unremarkable.

Moreover, an EKG demonstrated sinus tachycardia at the rate
of 122, with ST depressions noted in leads II, III, AVF, and
V4 through V6.  The complete blood cell count came back with
a white blood cell count of 18.5, platelet count 310, and
hematocrit of 12.2.

Therefore, the patient was transfused two units of packed red
blood cells, and admitted to the Medical Intensive Care Unit
for close management and treatment.

PAST MEDICAL HISTORY:
1.  Internal and external hemorrhoids:  The patient reports
having had hemorrhoids since his teen years, prevalent among
his family members.  [**Name (NI) **] is status post banding times five,
with most recent banding in [**2158-3-4**] by Dr. [**Last Name (STitle) 3314**].
Last colonoscopy in [**2154**].  He indicates that bleeding has
become more frequent for the last two weeks.
2.  Rectal Prolapse:  Intermittently reduced by the patient t
home.
3.  Chronic headaches.
4.  Status post trauma to the head in [**2158-4-4**]:  This
occurred at work at [**University/College **] [**Location (un) **], when a speaker on
stage hit his head.  CT scan of the head and cervical spine
films, and MRI of cervical spine were all negative.
5.  Asthma:  Controlled on Albuterol.

ALLERGIES:   No known drug allergies.

MEDICATIONS PRIOR TO ADMISSION:
1.  Albuterol.
2.  Flovent.
3.  Advil.

SOCIAL HISTORY:   The patient reports an eleven pack year
smoking history; he is still a smoker.  He denies any alcohol
or illicit drug use.  He identifies himself as a homosexual
male, reports being active in receptive anal intercourse.
Reports intermittent condom use.  Works as a costume
technician.  Lives in [**Location **].  He is single with no
children.

FAMILY HISTORY:  Pertinent for hemorrhoids, pancreatic and
breast cancer.  No history of colon cancer.  History of
thalassemia [**Doctor First Name **] in his mother.

PHYSICAL EXAMINATION:  Upon admission, vital signs were
temperature of 98.6 F.; blood pressure 120/66; heart rate 74;
respiratory rate 20; oxygen saturation 98% on room air.
General appearance:  Resting comfortably in bed in no acute
distress.  Appears stated age, thin, pale, pleasant.  HEENT:
Normocephalic, atraumatic.  Sclerae anicteric, noninjected.
No lesions noted in oropharynx.  Pupils are equal, round, and
reactive to light and accommodation.  Extraocular movements
intact.  No rhinorrhea noted.  Neck:  Soft, trachea midline;
jugular veins flat.  No thyromegaly.  No lymphadenopathy.
Chest clear to auscultation bilaterally.  Heart regular,
audible but distant S1 and S2 heart sounds.  No murmurs, rubs
or gallops noted.  Abdomen:  Soft, nondistended, positive
bowel sounds.  Mild mid-epigastric tenderness.  No
hepatosplenomegaly.  Back with no costovertebral angle
tenderness bilaterally.  Rectal examination with prominent
external hemorrhoids noted.  The rest of the examination is
deferred.  Pulses:  Two plus radial pulses and palpable two
plus pedal pulses bilaterally.  Extremities with no
peripheral edema.  Neurological:  Alert and oriented times
three; cranial nerves II through XII intact.  Dermatologic:
No lesions appreciated.

LABORATORY AND PERTINENT STUDIES:  Complete blood cell count
on transfer to the General Medicine Floor demonstrated a CBC
with white blood cell count of 9.5, hematocrit 29.5, platelet
count 197.  Serum chemistry showed a sodium of 141, potassium
4.0, chloride 110, bicarbonate 25, BUN 8, creatinine 0.7,
glucose 85.

Calcium 9.1, phosphorus 3.9, magnesium 2.0.  Urinalysis was
negative.

Esophagogastroduodenoscopy on [**2158-7-25**], was normal
esophagus, normal stomach, normal duodenum; no signs of
gastrointestinal bleed.

Colonoscopy on [**2158-7-25**]: Normal colon; no sign of lower GI
bleed.

Abdominal ultrasound on [**2158-7-27**], with normal abdominal
ultrasound.

Small bowel follow through on [**2158-7-28**]:  Normal small bowel
follow through.

Head CT scan with contrast on [**2158-7-26**], with no evidence of
chronic subdural hematoma or intracranial mass effect.  There
is a small mucous retention cyst or poly in the sphenoid
sinus and a few opacified ethmoid air cells; otherwise
normal.

SUMMARY OF HOSPITAL COURSE:
1.  GASTROINTESTINAL BLEED:  The patient was admitted
directly to the Medical Intensive Care Unit on [**2158-7-24**],
for an acute gastrointestinal bleed and symptomatic anemia
requiring two units of packed red blood cells in the
Emergency Department.

In the Medical Intensive Care Unit course, the patient
received a total of four units of packed red blood cells and
was started on pantoprazole 40 mg intravenously q. 24 hours.
The patient continued to have bright red blood per rectum and
the Gastrointestinal Consultation Service was notified.  On
[**2158-7-25**], an esophagogastroduodenoscopy and colonoscopy
were performed.

The esophagogastroduodenoscopy was normal and demonstrated no
cause of upper gastrointestinal bleed.  The colonoscopy
revealed a normal appearing colon with the stigmata of recent
bleeding and his internal and external hemorrhoids.

Following these studies, Mr. [**Known lastname **] was stabilized and
transferred to the floor for further evaluation and
management on [**2158-7-25**].  Overnight, however, his hematocrit
dropped from 29.5 to 25.6, and he received another unit of
blood in the early morning of [**2158-7-26**].  His hematocrit
subsequently rose back to the level of 30.5.

Subsequently, the patient received a small bowel follow
through which was unremarkable and revealed no source of
bleeding in the small bowel.

Given these studies, the most likely bleeding source was
thought to be his internal and external hemorrhoids.  Of
note, the patient reports that he can hold the blood in,
suggesting accumulation of blood from the internal
hemorrhoids.

The patient was informed of the importance of reducing trauma
to his rectum and advised of the risks involved in receptive
anal intercourse.  Moreover, Dr. [**Last Name (STitle) 3314**] from Surgery was
consulted and at the time of this dictation, the patient was
being evaluated for possible inpatient versus outpatient
hemorrhoidectomy.  The further results of his surgical
decision making and hospital course will be dictated in a
separate addendum to this report.

2.  CHRONIC HEADACHES:  The patient reports more acute
headaches status post trauma to this head in [**2158-4-4**].
Previous headaches had been more diffuse and dull, but
recently the headache has been more focal to the occipital
region, with a sharp quality, rating a ten out of ten on the
pain scale.

He received a head CT scan with contrast which was normal,
and was evaluated by the Neurology consultation service.
They indicated that a head MRI would not be necessary as this
appeared to be an acute on chronic headache with a component
due to post-concussive syndrome.  There also seems to be an
underlying anxiety and depression, which have exacerbated the
headache.

They recommended outpatient follow-up with a psychiatrist.
Additionally, the patient was started on Sertraline 50 mg
p.o. q. day.

At this time of this dictation, arrangements were being made
to link the patient to an outpatient psychiatrist or
outpatient program.

3.  ASTHMA:  The patient's asthma was well controlled on
inhaled steroids and albuterol throughout the hospital
course.

4.  SYNCOPE:  The multiple syncopal episodes were thought to
be most likely secondary to hypovolemia and anemia.  Once the
patient's hematocrit and volume status was under control,
there were no other incidences of syncope.

5.  ABDOMINAL PAIN:  The patient complained of right upper
quadrant abdominal pain, with positive [**Doctor Last Name 515**] sign;
however, there were no fevers or leukocytosis noted.  Given
the patient's acute gastrointestinal bleed, a right upper
quadrant ultrasound was performed which was normal.  His pain
was controlled alternately with Tylenol 325 to 650 mg p.o. q.
day and Ultram.


The rest of the hospital course including condition on
discharge, discharge status, discharge diagnosis and
discharge medications with follow-up plans will be dictated
as an addendum to his dictation summary by a second
physician.


                          [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D.  [**MD Number(1) 314**]

Dictated By:[**Last Name (NamePattern1) 41068**]

MEDQUIST36

D:  [**2158-7-27**]  17:01
T:  [**2158-8-9**]  21:31
JOB#:  [**Job Number 41790**]

cc:[**Last Name (NamePattern4) **]

Admission Date:  [**2158-7-24**]     Discharge Date:  [**2158-8-3**]

Date of Birth:   [**2124-11-7**]     Sex:  M

Service:  MICU WEST

The date of transfer to the Floor is [**2158-7-25**].

HISTORY OF PRESENT ILLNESS:   This is a 33 year old male with
a history of hemorrhoids since his teens requiring multiple
bandings, who presents with rectal bleeding, syncope, and
vomiting with a hematocrit of 12.2 in the Emergency
Department.  This patient reports waking up and having a
bowel movement with bright red to dark blood mixed in the
stool, loose stools times two days, feeling lightheaded and
nauseous and then subsequently passing out and awakening in a
puddle of vomit.  His friends convinced him to come to the
[**Hospital1 69**].

He reports having blood per rectum for many many years, but
it has been increasing in frequency over the past couple of
weeks.  He has been having loose stools as well for the past
couple of days, so with every bowel movement he has bleeding
and then even at times he will have bleeding from his rectum
without bowel movements.  He reports cramps in his abdomen
which are relieved after bowel movements.  Symptoms of reflux
disease.  No melena, no hematemesis.

In addition, he reports feeling short of breath, tired, weak,
headachy, having a lack of energy.  Additionally this patient
reports using advil and Tylenol alternating between the two,
of using up to 400 mg of Advil every four hours for the past
several months for his headaches.

No sick contacts, no travel, no contaminated food.

In the Emergency Department, he was lavaged through an
nasogastric tube with air and then with 50 cc of normal
saline and it was a negative lavage.

PAST MEDICAL HISTORY:
1.  Significant for hemorrhoids since his teens.
2.  He reports a flexible sigmoidoscopy in [**2154**] that was
normal.
3.  He has had five bandings of hemorrhoids since [**2154**].
4.  He also reports a history of asthma for which he takes
albuterol and Flovent.

MEDICATIONS:
1.  Albuterol and Flovent.
2.  Motrin 400 mg alternating with Tylenol q. four hours for
headaches for the past several months.
3.  Multivitamins.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:   No alcohol and no drugs.  Smokes one pack a
day times ten years.  He is single.  He is a costume
technician and lives in [**Location **].

FAMILY HISTORY:   Significant for his mother with beta
thalassemia, hemorrhoids and a sister with hemorrhoids as
well.  No history of colon cancer or inflammatory bowel
disease in his family.

CODE STATUS:  Full.

PHYSICAL EXAMINATION:   On physical examination, vital signs
were temperature of 97.2 F.; blood pressure 121/75; heart
rate 100; respiratory rate 19; O2 saturation 100% on two
liters nasal cannula.  In general, this is a pale man,
resting in bed, conversing appropriately.  No stigmata of
liver disease.  HEENT:  Normocephalic, atraumatic.  Pupils
are equal, round and reactive to light.  Clear oropharynx.
Positive angular chilosis.  No cervical lymphadenopathy.
Pale conjunctivae.  Cardiovascular is regular rate,
tachycardia, flow murmur II/VI systolic ejection murmur in
the right sternal border.  Chest clear to auscultation
bilaterally.  Abdomen is soft and nontender.  Bowel sounds
present.  Mid epigastric pain with deep palpation.  Smooth
liver edge.  His extremities were warm, no clubbing or edema.
Capillary refill about three seconds.  On rectal examination,
there is no stool in the vault to guaiac but no external
fissures, no external hemorrhoids.

LABORATORY:  White blood cell count 18.5, hematocrit 12.2,
with an MCV of 62, platelets 310.  Coagulation studies were
within normal limits.  Liver function tests within normal
limits.  Electrolytes were sodium 139, potassium 4.1,
chloride 107, bicarbonate 23, BUN 16, creatinine 0.6, and
glucose 111 with an anion gap of 9.0.  Troponin was less than
0.01.

Iron studies with iron 7.0, ferritin 1.4, TRS 415, calculated
TIBC 540.

HOSPITAL COURSE WHILE IN THE MEDICAL INTENSIVE CARE UNIT:
The patient was transfused four units of packed red blood
cells with a subsequent bump in his hematocrit to 21.7.  He
was then transfused another two units of packed red blood
cells for a hematocrit of 29.6.  He also received GoLYTELY
for a colonoscopy the next day.

The colonoscopy showed external hemorrhoids with stigmata of
recent bleeding.  The impression of the colonoscopy was mixed
hemorrhoids, otherwise normal colonoscopy to the cecum.

Recommendations were follow-up with surgeon for banding;
follow-up with referring physician as needed.  In addition,
the patient received an esophagogastroduodenoscopy which
showed a normal esophagus, normal stomach, normal duodenum
with impression of normal esophagogastroduodenoscopy to the
third part of the duodenum.

Both the colonoscopy and esophagogastroduodenoscopy were
performed on [**7-25**].

Subsequently, the patient was found to be hemodynamically
stable with a hematocrit of 29.6 with a normal EGD and
hemorrhoids found on colonoscopy and resolution of symptoms.
Thus, the patient was transferred to the floor for further
observation and also a small bowel follow through was to be
done on the floor to rule out small bowel causes of bleeding.
On the day of transfer on [**7-25**], the patient was
complaining of headache present since [**Month (only) 547**] since injury on
the job to his head.

He was seen in the Emergency Department right after the
injury and no bleeding was found on the CT scan of the head.
Please see the full report on CCC.  The patient also had an
MRI of the spine and was essentially normal but please see
the full report in the computer.

The patient was seen and examined by me, the intern, and the
patient reports constant headache since [**Month (only) 547**], pain 10 out of
10, on the scale of 10, decreasing to about a 6 out of 10
when he takes Tylenol or Motrin.  This is primarily a
posterior headache, posterior in his head.  The patient
reports seeing black spots but no other photophobia or
worsening was found.

The patient reports some slight weakness and some sensory
changes in his arms, primarily left more than right, however,
on neurological examination strength was five out of five
throughout upper extremities and lower extremities.
Sensation was intact to both touch and pinprick and cold.
Reflexes were two plus throughout biceps, brachioradialis,
patellar, Achilles bilaterally.  Cerebellar examination was
normal finger-to-nose, normal heel-to-shin, no dictyokinesis
bilaterally.

Recommend outpatient follow-up with his primary care
physician for these chronic headaches.

CONDITION ON TRANSFER TO THE FLOOR:  Good.

TRANSFER DIAGNOSES:
1.  Lower gastrointestinal bleed secondary to hemorrhoids.

TRANSFER MEDICATIONS:
1.  Continuation of Albuterol and Flovent per his primary
care physician.

DISCHARGE INSTRUCTIONS:
1.  He is to follow-up with his primary care physician for
evaluation of chronic headache.
2.  He is to follow-up with his surgeon, Dr. [**Last Name (STitle) 3314**], phone
number [**Telephone/Fax (1) 41791**], for further surgical management of his
hemorrhoids.


                          [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D.  [**MD Number(1) 5587**]

Dictated By:[**Last Name (NamePattern1) 9789**]

MEDQUIST36

D:  [**2158-7-26**]  15:54
T:  [**2158-8-3**]  22:53
JOB#:  [**Job Number 41792**]

cc:[**Last Name (NamePattern1) 41793**]

Admission Date:  [**2158-7-24**]     Discharge Date:  [**2158-8-3**]

Date of Birth:   [**2124-11-7**]     Sex:  M

Service:  Medicine, [**Hospital1 139**] Firm

HISTORY OF PRESENT ILLNESS:  The patient is a 33-year-old
homosexual male with a history of internal and external
hemorrhoids with associated bright red blood per rectum which
he had intermittently and attributed to hemorrhoids for some
time, but over the last two weeks he has had increasing
bright and dark red blood per rectum for about three times
per day; sometimes pure blood and sometimes in stool. No
melena, and no hematemesis.  He also complains of some rectal
discomfort when having bowel movements and some crampy lower
abdominal pain radiating to the rest of the abdomen and
sometimes relieved with bowel movements.

He notes that he was constipated a few days ago, but now
having more loose stools and diarrhea.  He has also had three
syncopal events over the last three days.  The last one
occurred in the morning on the day of admission, and he had
some yellow-green emesis.  No fevers, chills, or night
sweats.  No changes in his weight.  No travel history.  No
unusual food intake.

He came into to the Emergency Department where his hematocrit
was noted to be 12%.  His heart rate was 122, and his blood
pressure was 121/75.  He had an nasogastric lavage which was
negative in the Emergency Room.

PHYSICAL EXAMINATION ON PRESENTATION:  On examination,
temperature was 97.2 degrees Fahrenheit, heart rate was 122,
blood pressure was 121/75, respiratory rate was 16, and
oxygen saturation was 100% on room air.  In general, he was a
pale-appearing white male sitting in bed, in no acute
distress.  Head, eyes, ears, nose, and throat examination
revealed sclerae were white.   The mucous membranes were
moist.  Neck examination revealed no adenopathy.
Cardiovascular examination revealed a regular rhythm,
tachycardic.  A soft 1/6 systolic murmur at the left sternal
border.  Chest was clear to auscultation bilaterally.  The
abdomen was soft, nontender, and nondistended.  Normal active
bowel sounds.  Extremities were without edema.  Rectal
examination revealed no masses or hemorrhoids palpated.  No
stool for guaiac.  Neurologic examination revealed alert and
oriented times three.

PERTINENT LABORATORY VALUES ON PRESENTATION:  Laboratories
revealed white blood cell count was 18.5, hematocrit was
12.2%, and platelets were 310.  RDW was 17.1.  Mean cell
volume was 62.  Differential with 84% neutrophils, 10%
lymphocytes, and 5% monocytes.  Prothrombin time was 13.1,
INR was 1.1, and partial thromboplastin time was 19.8.
Sodium was 139, potassium was 4.1, chloride was 107,
bicarbonate was 23, blood urea nitrogen was 16, and
creatinine was 0.8.

HOSPITAL COURSE BY ISSUE/SYSTEM:

1.  GASTROINTESTINAL ISSUES:  The patient with a history of
internal and external hemorrhoids who presented with
recurrent bright red blood per rectum and syncopal episodes.
Noted to have a hematocrit on admission of 12.2.  His
hematocrit on [**2157-5-15**] was 41%  He was transfused to keep
his hematocrit at greater than 24% and received a total of 6
units of packed red blood cells.

He had an esophagogastroduodenoscopy and colonoscopy which
was only significant for internal hemorrhoids with a stigmata
of recent bleeding.

His hematocrit after 6 units of packed red blood cells bumped
appropriately from 12.2% to 30%.  He remained hemodynamically
stable but was admitted initially to the Medical Intensive
Care Unit for a severely decreased hematocrit on admission.
He left the Medical Intensive Care Unit on the same day (on
[**7-24**]) and received an additional one unit of packed red
blood cells after leaving the Intensive Care Unit.

He has had multiple banding procedures in the past, and
engaged in anal intercourse, but denies putting any foreign
bodies in the anal canal.

After being transferred from the Medical Intensive Care Unit
to the floor on [**7-24**], his hematocrit remained in the low
20s to 30s and remained stable on the floor.

2.  NEUROLOGIC ISSUES:  The patient complained of pulsating
posterior headaches since [**Month (only) 547**] of this year after hitting
his head.  Neurology was consulted and suggested the patient
had a post-tussive headache or migraine headache.  He was
started on Imitrex which subsequently relieved his headache
and Zoloft for depression.

3.  URINARY RETENTION ISSUES:  After having an internal
hemorrhoidectomy on [**8-2**], the patient had some urinary
retention and was noted to have a residual of 800 cc after
anesthesia.  He had a Foley catheter in for 24 hours after
surgery, and after pulling the Foley catheter the patient
voided on his own prior to going home.

4.  PAIN ISSUES:  The patient had some rectal pain after
surgery which was controlled postoperatively on Percocet.
The patient was sent home on Percocet for control of pain.

CONDITION AT DISCHARGE:  Condition on discharge was stable.

CODE STATUS:  The patient is a full code.

DISCHARGE DIAGNOSES:
1.  Lower gastrointestinal bleed secondary to internal
hemorrhoids.
2.  Status post internal hemorrhoidectomy.

MEDICATIONS ON DISCHARGE:
 1.  Dibucaine one application topically as needed (for
rectal pain).
 2.  Zoloft 50 mg by mouth once per day.
 3.  Imitrex 25 mg by mouth q.2h. as needed (for headaches);
may be repeated every two hours up to a total of 100 mg; do
not exceed 200 mg to 300 mg per day.
 4.  Colace 100 mg by mouth twice per day.
 5.  Iron 325 mg by mouth once per day.
 6.  Ambien 5 mg by mouth q.h.s. (for insomnia).
 7.  Nicotine patch 21-mg transdermally once per day.
 8.  Percocet 5/325 one to two tablets by mouth q.4-6h. as
needed (for pain).
 9.  Flovent 110-mcg inhaler 2 puffs inhaled twice per day.
10.  [**Last Name (un) **] baths three times per day.
11.  Metamucil one tablespoon with a glass of water twice per
day.

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient was to follow up with Dr. [**Last Name (STitle) 3314**] in two
weeks.
2.  The patient was also to follow up with his primary care
physician (Dr. [**Last Name (STitle) 2539**] in two to four weeks.
3.  The patient was instructed to call if he noted a marked
increase in bleeding, or dizziness upon standing, or
shortness of breath.






                          [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D.  [**MD Number(1) 314**]

Dictated By:[**Last Name (NamePattern1) 5819**]

MEDQUIST36

D:  [**2158-8-3**]  16:53
T:  [**2158-8-12**]  04:57
JOB#:  [**Job Number 41794**]
{'External hemorrhoids with other complication,Iron deficiency anemia secondary to blood loss (chronic),Hemorrhage of gastrointestinal tract, unspecified,Rectal prolapse,Syncope and collapse,Tachycardia, unspecified,Asthma, unspecified type, unspecified,Headache,Late effect of intracranial injury without mention of skull fracture'}


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: 

PRESENT ILLNESS: The patient is a 33 year old
homosexual male with medical history significant for asthma,
chronic headaches and internal and external hemorrhoids
status post banding times five, with most recent banding in
[**2158-3-4**].  He presented with two weeks of worsening
bright red blood per rectum, fatigue and three episodes of
syncope.

MEDICAL HISTORY: 1.  Internal and external hemorrhoids:  The patient reports
having had hemorrhoids since his teen years, prevalent among
his family members.  [**Name (NI) **] is status post banding times five,
with most recent banding in [**2158-3-4**] by Dr. [**Last Name (STitle) 3314**].
Last colonoscopy in [**2154**].  He indicates that bleeding has
become more frequent for the last two weeks.
2.  Rectal Prolapse:  Intermittently reduced by the patient t
home.
3.  Chronic headaches.
4.  Status post trauma to the head in [**2158-4-4**]:  This
occurred at work at [**University/College **] [**Location (un) **], when a speaker on
stage hit his head.  CT scan of the head and cervical spine
films, and MRI of cervical spine were all negative.
5.  Asthma:  Controlled on Albuterol.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Pertinent for hemorrhoids, pancreatic and
breast cancer.  No history of colon cancer.  History of
thalassemia [**Doctor First Name **] in his mother.

SOCIAL HISTORY: The patient reports an eleven pack year
smoking history; he is still a smoker.  He denies any alcohol
or illicit drug use.  He identifies himself as a homosexual
male, reports being active in receptive anal intercourse.
Reports intermittent condom use.  Works as a costume
technician.  Lives in [**Location **].  He is single with no
children. 

### Response:
{'External hemorrhoids with other complication,Iron deficiency anemia secondary to blood loss (chronic),Hemorrhage of gastrointestinal tract, unspecified,Rectal prolapse,Syncope and collapse,Tachycardia, unspecified,Asthma, unspecified type, unspecified,Headache,Late effect of intracranial injury without mention of skull fracture'}
