CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 71 year-old
male with a history of end stage renal disease on
hemodialysis and a history of gastrointestinal bleed, recent
myocardial infarction and hypotension.  The patient went to
an outside hospital one week ago.  He had been in his usual
state of health, but had chest pain, twice went to the
Emergency Department, but left AMA.  On [**2112-2-10**] he noticed
bright red blood per rectum.  His INR was found to be
supratherapeutic at 3.8.  The patient went to the Emergency
Department with chest pain and received po and intravenous
vitamin K, fresh frozen platelets and INR dropped to 1.0.
Hematocrit at that time was found to drop from 37 to 27.  The
patient was given 2 units of packed red blood cells.  The
patient had vague intermittent chest pain throughout
admission to the outside hospital for which he received
morphine and sublingual nitroglycerin.  CKs were negative,
but troponin was .63 with an unknown baseline value.  The
patient was transferred to [**Hospital1 188**] for the catheterization.  Upon being admitted to the
[**Hospital Unit Name 196**] Service and sent for catheterization the patient was
found to have maroon stool preprocedure.  Systolic blood
pressure went from 105 down to 85.  He received 250 cc bolus
and blood pressure increased to 95.  The patient was sent for
the Medical Intensive Care Unit for further monitoring of
hypotension.

MEDICAL HISTORY: 1.  End stage renal disease on hemodialysis.  The patient's
sees Dr. [**Last Name (STitle) 44753**].  The patient is aneuric and has an AV
fistula ni the left forearm with a history of clot.
2.  Hypercalcemia secondary to end stage renal disease and
hyperparathyroidism with a PTH of 491 in [**2110-11-11**].
3.  Hypertension.
4.  Coronary artery disease with history of myocardial
infarction in the anteroseptal region unclear when.
5.  Obstructive sleep apnea.
6.  Cerebrovascular accident in [**2111-11-11**] and left
hemiplegia.
7.  History of atrial fibrillation and rapid ventricular rate
and primary AV delay in [**2110-11-11**].  The patient was in
normal sinus rhythm on Coumadin after discharge.
8.  Catheterization [**2110-11-11**] revealed one vessel
disease in left anterior descending coronary artery disease
approximately 50% stenosis of the left circumflex, impaired
ejection fraction at 40% and 1+ aortic regurgitation and 3+
mitral regurgitation.
9.  History of OB positive stool in [**2110-11-11**].
10.  Diabetes type 2 diagnosed in [**2110-11-11**] during
inpatient admission, but no medical treatment.
11.  Right middle lobe pneumonia, history of aspiration.
12.  History of left subclavian vein stenosis status post
stenting.

MEDICATION ON ADMISSION: 1.  Coumadin 3 mg h.s.
2.  Nephrocaps daily.
3.  Renagel daily.
4.  Prevacid 30 mg q day.
5.  Atenolol 50 mg q day.
6.  Amiodarone 200 mg q day.
7.  Isosorbide 20 mg t.i.d.

ALLERGIES: Intravenous contrast requiring steroid use.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He lives with his wife whose name is [**Name (NI) **]
who care for each other although the patient is not mobilized
well given his left hemiplegia.  The patient has a history of
alcohol use unclear when.  Tobacco use of cigars on a regular
basis.  No illicit substance use.
Hemorrhage of gastrointestinal tract, unspecified,Subendocardial infarction, initial episode of care,Bacteremia,Other complications due to renal dialysis device, implant, and graft,Atrial fibrillation,Iron deficiency anemia secondary to blood loss (chronic),Benign neoplasm of colon,Unspecified vascular insufficiency of intestine,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
Gastrointest hemorr NOS,Subendo infarct, initial,Bacteremia,Comp-ren dialys dev/grft,Atrial fibrillation,Chr blood loss anemia,Benign neoplasm lg bowel,Vasc insuff intest NOS,DMII renl nt st uncntrld
Admission Date:  [**2112-2-12**]     Discharge Date:  [**2112-2-25**]

Date of Birth:   [**2040-6-19**]     Sex:  M

Service:  [**Hospital1 212**]

HISTORY OF PRESENT ILLNESS:  The patient is a 71 year-old
male with a history of end stage renal disease on
hemodialysis and a history of gastrointestinal bleed, recent
myocardial infarction and hypotension.  The patient went to
an outside hospital one week ago.  He had been in his usual
state of health, but had chest pain, twice went to the
Emergency Department, but left AMA.  On [**2112-2-10**] he noticed
bright red blood per rectum.  His INR was found to be
supratherapeutic at 3.8.  The patient went to the Emergency
Department with chest pain and received po and intravenous
vitamin K, fresh frozen platelets and INR dropped to 1.0.
Hematocrit at that time was found to drop from 37 to 27.  The
patient was given 2 units of packed red blood cells.  The
patient had vague intermittent chest pain throughout
admission to the outside hospital for which he received
morphine and sublingual nitroglycerin.  CKs were negative,
but troponin was .63 with an unknown baseline value.  The
patient was transferred to [**Hospital1 188**] for the catheterization.  Upon being admitted to the
[**Hospital Unit Name 196**] Service and sent for catheterization the patient was
found to have maroon stool preprocedure.  Systolic blood
pressure went from 105 down to 85.  He received 250 cc bolus
and blood pressure increased to 95.  The patient was sent for
the Medical Intensive Care Unit for further monitoring of
hypotension.

PAST MEDICAL HISTORY:
1.  End stage renal disease on hemodialysis.  The patient's
sees Dr. [**Last Name (STitle) 44753**].  The patient is aneuric and has an AV
fistula ni the left forearm with a history of clot.
2.  Hypercalcemia secondary to end stage renal disease and
hyperparathyroidism with a PTH of 491 in [**2110-11-11**].
3.  Hypertension.
4.  Coronary artery disease with history of myocardial
infarction in the anteroseptal region unclear when.
5.  Obstructive sleep apnea.
6.  Cerebrovascular accident in [**2111-11-11**] and left
hemiplegia.
7.  History of atrial fibrillation and rapid ventricular rate
and primary AV delay in [**2110-11-11**].  The patient was in
normal sinus rhythm on Coumadin after discharge.
8.  Catheterization [**2110-11-11**] revealed one vessel
disease in left anterior descending coronary artery disease
approximately 50% stenosis of the left circumflex, impaired
ejection fraction at 40% and 1+ aortic regurgitation and 3+
mitral regurgitation.
9.  History of OB positive stool in [**2110-11-11**].
10.  Diabetes type 2 diagnosed in [**2110-11-11**] during
inpatient admission, but no medical treatment.
11.  Right middle lobe pneumonia, history of aspiration.
12.  History of left subclavian vein stenosis status post
stenting.

ALLERGIES:  Intravenous contrast requiring steroid use.

SOCIAL HISTORY:  He lives with his wife whose name is [**Name (NI) **]
who care for each other although the patient is not mobilized
well given his left hemiplegia.  The patient has a history of
alcohol use unclear when.  Tobacco use of cigars on a regular
basis.  No illicit substance use.

MEDICATIONS ON ADMISSION:
1.  Coumadin 3 mg h.s.
2.  Nephrocaps daily.
3.  Renagel daily.
4.  Prevacid 30 mg q day.
5.  Atenolol 50 mg q day.
6.  Amiodarone 200 mg q day.
7.  Isosorbide 20 mg t.i.d.

PHYSICAL EXAMINATION ON ADMISSION:  Vital signs afebrile.
Heart rate 74.  Blood pressure 90/54.  Respirations 18.  99%
saturation on 2 liters nasal cannula as well as on room air.
In general, he was a cranky thin man laying at 45 degrees.
HEENT he had moist mucous membranes.  No elevation in JVP or
JVD.  Cardiovascular regular rate, 3 out of 6 systolic
murmur. No rubs.  Question of an S3.  Radial and dorsalis
pedis pulses were 1+ bilaterally.  Lungs were clear to
auscultation throughout.  Abdomen was soft, nontender,
nondistended with positive bowel sounds.  Extremities were
cool with no edema.

PERTINENT LABORATORY STUDIES:  Anemia with a hematocrit of
30.7, white blood cell count of 13.6 with 95% neutrophilia.
Electrolytes significant for bicarb of 27, BUN 37, creatinine
6.3, and a potassium of 6.3.  Electrocardiogram revealed
normal sinus rhythm at 60 beats per minute with lateral T
wave inversions.  Electrocardiogram revealed no R wave
progression and no R wave despite changes in lead placement.
Notably electrocardiogram sent from outside hospital taken on
[**2-10**] three days prior revealed normal R wave and
normal R wave progression throughout all precordial leads.

IMPRESSION:  Our impression was that this is a 71 year-old
man with a gastrointestinal bleed and hypotension whose
treatment was complicated by end stage renal disease
requiring hemodialysis and the patient having a history of
congestive heart failure and systolic dysfunction and 3+
mitral regurgitation.  The patient's hypotension was presumed
stable and all antihypertensive medications were held.  He
received 1 liter intravenous fluid bolus and 1 unit of packed
red blood cells.  Blood pressure was increased in maps were
maintained 60 to 65.  Over the first night of admission the
patient had 10 out of 10 chest pain in the substernal area
with burning decreased with two sublingual nitroglycerin.  No
hypotension throughout event and no electrocardiogram changes
from his baseline.  The patient slept well that night without
event and used CPAP throughout the night.  The patient
persistent refused arterial blood gas and blood draws.  The
patient also had esophagogastroduodenoscopy to investigate
source of gastrointestinal bleeding.  Bile was seen in the
stomach and the esophagogastroduodenoscopy was normal to the
third part of the duodenum and colonoscopy was recommended.
The patient received additional bolus of intravenous fluids
with no change in saturations.  Blood pressure was stable and
the patient was transferred to the floor.  CKs were cycled
after initial event of chest pain and were positive with an
MB index of 12.3.  Cardiology consult was called and they
recommended medical management and catheterization when the
patient could tolerate anticoagulation.

The patient was transferred to the floor when he was
normotensive.  Hematocrits were followed carefully.  The
patient persistently refused drawing of blood despite the
presence of triple lumen catheter in his right groin.  The
patient was given GoLYTELY for colonoscopy prep and had
persistent maroon stool.  Hematocrit continued to drop.  The
plan of care was frequently complicated by patient's
inability to recall conversations with the team over the
course of his stay and he was repeatedly reoriented and
reminded of why he was there and assured that care was being
done in his best interest.  The patient received additional
one unit of packed red blood cells when hematocrit dropped
again to 30%.  The patient had second hemodialysis without
event.  Given the patient's change in mental status and
frequent memory impairment he had a head CT to rule out
subdural hemorrhage and there was no evidence of bleeding.
Colonoscopy on [**2-17**] revealed two ulcerations that were
thought to be the probable sources of his gastrointestinal
bleed.  The patient had a polypectomy and there was another
ulcer in the hepatic flexure consistent with ischemic colitis
after hypotension.  On [**Month (only) 404**] the patient spiked to 102
temperature.  Blood cultures were sent from his right femoral
groin line.  Fem line was discontinued and the tip culture
was sent and line was resighted to the left femoral vein with
interventional radiology's assistance.  The line placement
was extremely difficult given that he had multiple clots in
multiple regions including the subclavians bilaterally and
very narrow vessels in the femoral region bilaterally not
allowing for the normal J wire to be passed through.

After being febrile the patient had persistent rigors and was
found to have gram negative rods grow in his blood cultures.
The patient was covered with Vancomycin and Levofloxacin. The
following day the patient spiked again to 102.  Four out of
four blood cultures were found to be positive for gram
negative rods.  The patient was started on Cipro and Zosyn
for double pseudomonal coverage.  The following day the
patient was noted to be bleeding from his AV fistula site
that was oozing stopping with pressure dressings applied.
Antibiotics were changed to Levofloxacin po given
sensitivities found on the gram negative rods.  Fistula
stopped working.  On [**2-19**] repair was attempted with
fistulogram.  Tissue plasminogen activator injection was done
with no effect and fistula site persistently oozed.
Hematocrits were monitored carefully and were stable.  The
patient was sent to the Operating Room with Vascular Surgery
to have fistula repaired without difficulty.  Final
sensitivities of gram negative rods revealed Enterococcus
faecalis and Salmonella.  Salmonella was susceptible to
Levofloxacin.  Vancomycin was continued for faecalis to be
continued renally dosed for two weeks of treatment.

HOSPITAL COURSE:  Gastrointestinal bleeding and hypotension
secondary to ulcerations in the ulcerations in the colon due
to ischemic colitis secondary to hypotension as well as
polyp. Pathology of polyp on [**2112-2-17**] found in the descending
colon revealed adenoma with high grade dysplasia.  The
patient was instructed to follow up with gastrointestinal as
an outpatient for additional colonoscopies and management of
this potentially cancerous condition.

For non ST elevation myocardial infarction that occurred on
[**2112-2-13**] the patient was maintained on beta-blockers
by mouth and nitroglycerin prn for medical management to
follow up with cardiology a full two weeks after having his
polypectomy at which time it was presumed that
anticoagulation would be safe.

For end stage renal disease on hemodialysis the patient had a
left AV fistula that clotted and led to excessive bleeding
after tissue plasminogen activator use and then with repair
in vascular surgery. The fistula was highly functional at the
time of discharge and was used by dialysis on the day of
discharge without any problems.  The patient has
hypercalcemia due to hyperparathyroidism.  The patient was
followed throughout his stay by renal consult and had
hemodialysis three times weekly.  The patient was maintained
on Sevelamer and calcium acetate and aluminum hydroxide to
keep his calcium phosphate less then 70.  He was maintained
on Nephrocaps and a renal diet and lytes were monitored
carefully.

The patient had a history of atrial fibrillation.  He was in
normal sinus rhythm throughout his stay and was maintained on
Amiodarone and anticoagulation was held despite concerns for
subsequent cerebrovascular accidents.

For fever and bacteremia, this was presumed due to femoral
line.  The patient had gram negative rods four out of four
cultures that was Salmonella sensitive to Levaquin.  The
patient also had gram positive anaerobic rod in one bottle
that was Enterococcus faecalis managed on
Vancomycin for a two week course renally dosed.

Diabetes, the patient had no home treatment.  He was
maintained on a diabetic diet and glucose levels were less
then 200 throughout his stay.

Obstructive sleep apnea, the patient was maintained on BIPAP
each night.  He had no home oxygen requirement and had no
desaturations throughout his stay.

Dementia, this was presumed to be some baseline level of
dementia without any evidence for reversible causes present
as well as due to his history of cerebrovascular accident and
left hemiplegia.  The patient was managed with Olanzapine prn
and frequent reorientation.

Poor musculoskeletal strength and deconditioning, the patient
was unable to care for self or transfer.  He had physical
therapy and occupational therapy assistance.  The patient
refused to go to rehab.  The patient agreed to have home VNA
as condition for discharge with medical advice and he was set
up for physical therapy and occupational therapy at home and
he was able to transfer and ambulate with walker at the time
of discharge.

DISCHARGE DIAGNOSES:
1.  Bacteremia.
2.  Diabetes type 2 with nephropathy uncontrolled.
3.  Renal failure chronic.
4.  Coagulation disorder not otherwise specified.
5.  Obstructive sleep apnea.
6.  History of cerebrovascular accident.
7.  Left hemiparesis.
8.  Hypercalcemia.
9.  Subclavian stenosis.
10.  Anemia due to blood loss.
11.  Atrial fibrillation, paroxysmal.
12.  Myocardial infarction, non Q wave myocardial infarction.
13.  Gastrointestinal bleeding.
14.  Hypokalemia.
15.  Hyperkalemia.
16.  Hypomagnesemia.
17.  Bacteremia.
18.  Fistula clot.

MEDICATIONS ON DISCHARGE:
1.  Atenolol 25 mg po q.d.
2.  Lipitor 20 mg po q.d.
3.  Amiodarone 200 mg po q.d.
4.  Multivitamin po q.d.
5.  Nitroglycerin prn.
6.  Calcium acetate two tablets po t.i.d. with meals.
7.  Trazodone 25 mg h.s. prn.
8.  Sevelamer 1600 mg po t.i.d.
9.  Levofloxacin 250 mg po q 48 hours for a 14 day course.
10.  Tylenol prn.
11.  Lisinopril 2.5 mg po q.d.
12.  Aspirin 81 mg q.d.
13.  The patient was instructed to not take Coumadin until he
discussed it with his physician and discussed the benefits
and drawbacks of anticoagulation given his multiple
illnesses.
14.  Vancomycin 1 gram at hemodialysis for a total of a 14
day course.

The patient was instructed to see his primary care physician
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] on the day after admission.  The patient was
instructed to have an echocardiogram.  The patient was
instructed to see a cardiolgoist for a myocardial perfusion
study or catheterization to prevent additional myocardial
infarctions.  The patient was instructed to have a
colonoscopy on [**2112-8-12**] to evaluate for new polyps.  VNA
was instructed to check the patient's blood pressure, monitor
medication use and to help the patient ambulate with walker
and transfer.





                          [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 5712**]

Dictated By:[**Last Name (NamePattern1) 6374**]

MEDQUIST36

D:  [**2112-4-25**]  04:57
T:  [**2112-4-26**]  11:35
JOB#:  [**Job Number 44754**]
{'Hemorrhage of gastrointestinal tract, unspecified,Subendocardial infarction, initial episode of care,Bacteremia,Other complications due to renal dialysis device, implant, and graft,Atrial fibrillation,Iron deficiency anemia secondary to blood loss (chronic),Benign neoplasm of colon,Unspecified vascular insufficiency of intestine,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled'}


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 71 year-old
male with a history of end stage renal disease on
hemodialysis and a history of gastrointestinal bleed, recent
myocardial infarction and hypotension.  The patient went to
an outside hospital one week ago.  He had been in his usual
state of health, but had chest pain, twice went to the
Emergency Department, but left AMA.  On [**2112-2-10**] he noticed
bright red blood per rectum.  His INR was found to be
supratherapeutic at 3.8.  The patient went to the Emergency
Department with chest pain and received po and intravenous
vitamin K, fresh frozen platelets and INR dropped to 1.0.
Hematocrit at that time was found to drop from 37 to 27.  The
patient was given 2 units of packed red blood cells.  The
patient had vague intermittent chest pain throughout
admission to the outside hospital for which he received
morphine and sublingual nitroglycerin.  CKs were negative,
but troponin was .63 with an unknown baseline value.  The
patient was transferred to [**Hospital1 188**] for the catheterization.  Upon being admitted to the
[**Hospital Unit Name 196**] Service and sent for catheterization the patient was
found to have maroon stool preprocedure.  Systolic blood
pressure went from 105 down to 85.  He received 250 cc bolus
and blood pressure increased to 95.  The patient was sent for
the Medical Intensive Care Unit for further monitoring of
hypotension.

MEDICAL HISTORY: 1.  End stage renal disease on hemodialysis.  The patient's
sees Dr. [**Last Name (STitle) 44753**].  The patient is aneuric and has an AV
fistula ni the left forearm with a history of clot.
2.  Hypercalcemia secondary to end stage renal disease and
hyperparathyroidism with a PTH of 491 in [**2110-11-11**].
3.  Hypertension.
4.  Coronary artery disease with history of myocardial
infarction in the anteroseptal region unclear when.
5.  Obstructive sleep apnea.
6.  Cerebrovascular accident in [**2111-11-11**] and left
hemiplegia.
7.  History of atrial fibrillation and rapid ventricular rate
and primary AV delay in [**2110-11-11**].  The patient was in
normal sinus rhythm on Coumadin after discharge.
8.  Catheterization [**2110-11-11**] revealed one vessel
disease in left anterior descending coronary artery disease
approximately 50% stenosis of the left circumflex, impaired
ejection fraction at 40% and 1+ aortic regurgitation and 3+
mitral regurgitation.
9.  History of OB positive stool in [**2110-11-11**].
10.  Diabetes type 2 diagnosed in [**2110-11-11**] during
inpatient admission, but no medical treatment.
11.  Right middle lobe pneumonia, history of aspiration.
12.  History of left subclavian vein stenosis status post
stenting.

MEDICATION ON ADMISSION: 1.  Coumadin 3 mg h.s.
2.  Nephrocaps daily.
3.  Renagel daily.
4.  Prevacid 30 mg q day.
5.  Atenolol 50 mg q day.
6.  Amiodarone 200 mg q day.
7.  Isosorbide 20 mg t.i.d.

ALLERGIES: Intravenous contrast requiring steroid use.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He lives with his wife whose name is [**Name (NI) **]
who care for each other although the patient is not mobilized
well given his left hemiplegia.  The patient has a history of
alcohol use unclear when.  Tobacco use of cigars on a regular
basis.  No illicit substance use. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Subendocardial infarction, initial episode of care,Bacteremia,Other complications due to renal dialysis device, implant, and graft,Atrial fibrillation,Iron deficiency anemia secondary to blood loss (chronic),Benign neoplasm of colon,Unspecified vascular insufficiency of intestine,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled'}
