CHIEF COMPLAINT: Severe anemia

PRESENT ILLNESS: 39F with PMH notable for menorrhagia and severe anemia with Hct
11 in [**2173**] presents at PCP's behest with severe anemia (Hct
again of 11).  The pt presented for a new PCP appt today in the
setting of a syncopal episode in [**Month (only) 205**].  She recalls that she had
been feeling run down and as if she may be anemic again,
although admits that this sensation had been developing for
months.  She also complained of dyspnea on exertion, having to
get mentally prepared for the SOB experienced on walking to the
grocery store.  She noticed some mild tachycardia as well but
denies chest pain.  She had no GI symptoms, and specifically
denies abdominal pain, constipation, diarrhea, BRBPR, melena,
hematemesis and GERD sx.  She has had heavy menses in the past
but has not had a period in over a year.  Labs drawn today after
that appt revealed severe iron-deficiency anemia and the pt was
referred to the ED.
.
Review of the OMR suggests that the pt's anemia dates back to
[**2165**] when she was found to have a Hct of 24.  At that time, she
was advised to undergo GYN eval for menorrhagia but apparently
did not follow-up due to ungoing care issues with her
handicapped daughter.  She re-presented in [**2173-12-15**] after a
syncopal episode and was admitted as detailed above.  Her severe
anemia at that time was attributed to ? menstrual losses.  An
electropheresis is referred to by the d/c summary but only a
[**Year (4 digits) 14165**] prep was evident in the labs record.  She was prescribed
oral iron but she does not like the way this makes her feel,
beyond constipation, so she did not keep up with therapy.  Given
that she sees so many physicians with her daughter, she has been
loathe to follow-up on her own behalf.
.
On ROS, in addition to the GI ROS above, she denied LH or
dizziness, but she has been more fatigued.  She has migraines a
few times a month for which she takes ibuprofen, 1-2 tabs every
week or two.  She denies cough or hemoptysis.  She has had nl
appetite and has not lost weight.  She denies GU sx.  She hsa
not had chest pain but occasional senses tachycardia with
exertion.  She takes no meds, including the iron tablets that
she was supposed to be taking.
.
In the ED, the pt was noted to have guaiac + [**Known lastname **] stool.  NG
lavage was attempted but the pt vomited clear emesis.  1 unit of
prbcs was transfused and she arrived with the 2nd running.  She
was tachycardic and SOB, and was thus referred to the ICU for
resuscitation and monitoring.

MEDICAL HISTORY: Iron-deficiency anemia with past Hct of 12 in [**2173-12-15**]
G2, P2. Status post tubal ligation in1992.
Wisdom Tooth extraction
Pneumonia in [**2165-5-15**] with fever, cough and hemoptysis.
Idiopathic hirsutism
Obesity
Menorrhagia, no menses for 2 years

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: Obese, hirsute, very pleasant but pale and tired-appearing
female, NAD
HEENT: Anicteric sclerae, conjunctivae pale, MMM, tongue with
areas of hyperpigmentation
Neck: Supple, fleshy, no LAD, no thyromegaly or nodules,
darkened skin posteriorly
Heart: rr, [**1-20**] hsm heard loundest over tricuspid area, no g/r
Lungs: CTAB
Abd: Obese, s/nt/nd, no hsm
Rectal: + per ED
Ext: No c/c/e, nl tone, 2+ DPs
Neuro: Cn2-12 intact, MAEW

FAMILY HISTORY: Mother was anemic, died from ESRD [**1-16**] HTN and DM.  Father alive,
has hypertension.  Pt has 11 siblings - 1 sister died at age 55
from lung Ca (was smoker).  Family hx also positive for HTN, DM.
 cousin with [**Name2 (NI) 14165**] cell anemia, uncle with [**Name2 (NI) 14165**] trait.  No FH
IBD, celiac disease.

SOCIAL HISTORY: Lives in [**Location (un) 3844**] with her husband and 2
children, does not work outside the home.  Pt has 2 children, a
17 y/o son and a 15 y/o multi-handicapped daughter who is blind
and deaf.  A PCA helps her take care of her daughter.  [**Name (NI) **]
tobacco, social alcohol, no illicit drug use.  Pt drinks [**12-16**]
cups of coffee a week and takes no dietary supplements.  She
eats plenty of red meat and green vegetables.
Other specified anemias,Hemorrhage of gastrointestinal tract, unspecified,Iron deficiency anemia, unspecified,Diaphragmatic hernia without mention of obstruction or gangrene,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage
Anemia NEC,Gastrointest hemorr NOS,Iron defic anemia NOS,Diaphragmatic hernia,Gstr/ddnts NOS w/o hmrhg
Admission Date:  [**2177-8-13**]              Discharge Date:   [**2177-8-14**]

Date of Birth:  [**2138-1-15**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Severe anemia

Major Surgical or Invasive Procedure:
Blood transfusions (4units packed red blood cells)
.
EGD


History of Present Illness:
39F with PMH notable for menorrhagia and severe anemia with Hct
11 in [**2173**] presents at PCP's behest with severe anemia (Hct
again of 11).  The pt presented for a new PCP appt today in the
setting of a syncopal episode in [**Month (only) 205**].  She recalls that she had
been feeling run down and as if she may be anemic again,
although admits that this sensation had been developing for
months.  She also complained of dyspnea on exertion, having to
get mentally prepared for the SOB experienced on walking to the
grocery store.  She noticed some mild tachycardia as well but
denies chest pain.  She had no GI symptoms, and specifically
denies abdominal pain, constipation, diarrhea, BRBPR, melena,
hematemesis and GERD sx.  She has had heavy menses in the past
but has not had a period in over a year.  Labs drawn today after
that appt revealed severe iron-deficiency anemia and the pt was
referred to the ED.
.
Review of the OMR suggests that the pt's anemia dates back to
[**2165**] when she was found to have a Hct of 24.  At that time, she
was advised to undergo GYN eval for menorrhagia but apparently
did not follow-up due to ungoing care issues with her
handicapped daughter.  She re-presented in [**2173-12-15**] after a
syncopal episode and was admitted as detailed above.  Her severe
anemia at that time was attributed to ? menstrual losses.  An
electropheresis is referred to by the d/c summary but only a
[**Year (4 digits) 14165**] prep was evident in the labs record.  She was prescribed
oral iron but she does not like the way this makes her feel,
beyond constipation, so she did not keep up with therapy.  Given
that she sees so many physicians with her daughter, she has been
loathe to follow-up on her own behalf.
.
On ROS, in addition to the GI ROS above, she denied LH or
dizziness, but she has been more fatigued.  She has migraines a
few times a month for which she takes ibuprofen, 1-2 tabs every
week or two.  She denies cough or hemoptysis.  She has had nl
appetite and has not lost weight.  She denies GU sx.  She hsa
not had chest pain but occasional senses tachycardia with
exertion.  She takes no meds, including the iron tablets that
she was supposed to be taking.
.
In the ED, the pt was noted to have guaiac + [**Known lastname **] stool.  NG
lavage was attempted but the pt vomited clear emesis.  1 unit of
prbcs was transfused and she arrived with the 2nd running.  She
was tachycardic and SOB, and was thus referred to the ICU for
resuscitation and monitoring.


Past Medical History:
Iron-deficiency anemia with past Hct of 12 in [**2173-12-15**]
G2, P2. Status post tubal ligation in1992.
Wisdom Tooth extraction
Pneumonia in [**2165-5-15**] with fever, cough and hemoptysis.
Idiopathic hirsutism
Obesity
Menorrhagia, no menses for 2 years


Social History:
Lives in [**Location (un) 3844**] with her husband and 2
children, does not work outside the home.  Pt has 2 children, a
17 y/o son and a 15 y/o multi-handicapped daughter who is blind
and deaf.  A PCA helps her take care of her daughter.  [**Name (NI) **]
tobacco, social alcohol, no illicit drug use.  Pt drinks [**12-16**]
cups of coffee a week and takes no dietary supplements.  She
eats plenty of red meat and green vegetables.


Family History:
Mother was anemic, died from ESRD [**1-16**] HTN and DM.  Father alive,
has hypertension.  Pt has 11 siblings - 1 sister died at age 55
from lung Ca (was smoker).  Family hx also positive for HTN, DM.
 cousin with [**Name2 (NI) 14165**] cell anemia, uncle with [**Name2 (NI) 14165**] trait.  No FH
IBD, celiac disease.


Physical Exam:
Gen: Obese, hirsute, very pleasant but pale and tired-appearing
female, NAD
HEENT: Anicteric sclerae, conjunctivae pale, MMM, tongue with
areas of hyperpigmentation
Neck: Supple, fleshy, no LAD, no thyromegaly or nodules,
darkened skin posteriorly
Heart: rr, [**1-20**] hsm heard loundest over tricuspid area, no g/r
Lungs: CTAB
Abd: Obese, s/nt/nd, no hsm
Rectal: + per ED
Ext: No c/c/e, nl tone, 2+ DPs
Neuro: Cn2-12 intact, MAEW


Pertinent Results:
[**2177-8-13**] 04:11PM   WBC-11.8* RBC-1.85*# HGB-2.9*# HCT-11.8*#
MCV-64*# MCH-15.8*# MCHC-24.7*# RDW-20.2*
[**2177-8-13**] 04:11PM   calTIBC-480* FERRITIN-2.1* TRF-369*
[**2177-8-13**] 04:11PM   IRON-10*
[**2177-8-13**] 07:00PM   TSH-1.6
[**2177-8-13**] 07:00PM   HAPTOGLOB-202*
[**2177-8-13**] 07:00PM   LD(LDH)-337* TOT BILI-0.1 DIR BILI-0.0 INDIR
BIL-0.1
[**2177-8-13**] 07:00PM   GLUCOSE-114* UREA N-9 CREAT-1.0 SODIUM-141
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-20* ANION GAP-18
[**2177-8-13**] 07:12PM   HGB-3.1* calcHCT-9
.
EGD: Large hiatal hernia
Abnormal mucosa in the stomach (biopsy)
Normal mucosa in the duodenum (biopsy)
Normal mucosa in the esophagus
.
CXR: Mild cardiomegaly.
.
EKG: ST at 112, twi flattenign diffusely, no acute ST changes.
.
Bedside echo in ED: Grossly neg for pericardial effusion


Brief Hospital Course:
39F with PMH notable for iron-deficiency anemia p/w severe iron
deficency anemia.
.
1) Anemia:  Etiology is unclear, suspect a mixed picture given
likely chronic nature, insidious presentation and lab
parameters.  Etiology is some combination of loss, poor
production and/or destruction.
  In terms of losses, plan for GI w/u starting with EGD
performed on [**8-14**].  Pt will likely require colonoscopy when she
is more stable as an outpatient.  Given that she has not had a
menstrual period x 1 year, this may have been a factor but not
likely acutely involved.  Would consider endometrial u/s in the
future.  First, however, replaced losses with a total of 4 units
of pRBC's elevating the Hct from 11 to 21.
  In terms of production, retic count is elevated, but not at an
expected level given degree of anemia, although perhaps this is
due to severity of iron deficiency.  Would consider heme w/u if
no obvious etiology.  In addition, MCV is quite low, suggesting
possible hemoglobinopathy. Clear iron deficiency, pt with
adequate nutrition.
  Patient will be discharged on iron with a bowel regimen and
follow up this week in [**Company 191**] for further work up of chronic iron
deficiency anemia.


Medications on Admission:
None

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
2. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO three times a
day.


Discharge Disposition:
Home

Discharge Diagnosis:
Severe anemia
.
iron deficiency


Discharge Condition:
Good, stable


Discharge Instructions:
Please return to the hospital immediately if you experience
dizziness, fainting, chest pain or palpitations.
.
We have started you on iron, to be taken three times daily. It
is very important that you take this medication to maintain
appropriate blood levels.

Followup Instructions:
Please follow up with in [**Hospital3 **] on [**Location (un) **] of
the [**Hospital Ward Name 23**] Building with [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 21149**], MD at 10:30AM on
Tuesday, [**2177-8-19**]. [**Telephone/Fax (1) 44863**].
{'Other specified anemias,Hemorrhage of gastrointestinal tract, unspecified,Iron deficiency anemia, unspecified,Diaphragmatic hernia without mention of obstruction or gangrene,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage'}


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: Severe anemia

PRESENT ILLNESS: 39F with PMH notable for menorrhagia and severe anemia with Hct
11 in [**2173**] presents at PCP's behest with severe anemia (Hct
again of 11).  The pt presented for a new PCP appt today in the
setting of a syncopal episode in [**Month (only) 205**].  She recalls that she had
been feeling run down and as if she may be anemic again,
although admits that this sensation had been developing for
months.  She also complained of dyspnea on exertion, having to
get mentally prepared for the SOB experienced on walking to the
grocery store.  She noticed some mild tachycardia as well but
denies chest pain.  She had no GI symptoms, and specifically
denies abdominal pain, constipation, diarrhea, BRBPR, melena,
hematemesis and GERD sx.  She has had heavy menses in the past
but has not had a period in over a year.  Labs drawn today after
that appt revealed severe iron-deficiency anemia and the pt was
referred to the ED.
.
Review of the OMR suggests that the pt's anemia dates back to
[**2165**] when she was found to have a Hct of 24.  At that time, she
was advised to undergo GYN eval for menorrhagia but apparently
did not follow-up due to ungoing care issues with her
handicapped daughter.  She re-presented in [**2173-12-15**] after a
syncopal episode and was admitted as detailed above.  Her severe
anemia at that time was attributed to ? menstrual losses.  An
electropheresis is referred to by the d/c summary but only a
[**Year (4 digits) 14165**] prep was evident in the labs record.  She was prescribed
oral iron but she does not like the way this makes her feel,
beyond constipation, so she did not keep up with therapy.  Given
that she sees so many physicians with her daughter, she has been
loathe to follow-up on her own behalf.
.
On ROS, in addition to the GI ROS above, she denied LH or
dizziness, but she has been more fatigued.  She has migraines a
few times a month for which she takes ibuprofen, 1-2 tabs every
week or two.  She denies cough or hemoptysis.  She has had nl
appetite and has not lost weight.  She denies GU sx.  She hsa
not had chest pain but occasional senses tachycardia with
exertion.  She takes no meds, including the iron tablets that
she was supposed to be taking.
.
In the ED, the pt was noted to have guaiac + [**Known lastname **] stool.  NG
lavage was attempted but the pt vomited clear emesis.  1 unit of
prbcs was transfused and she arrived with the 2nd running.  She
was tachycardic and SOB, and was thus referred to the ICU for
resuscitation and monitoring.

MEDICAL HISTORY: Iron-deficiency anemia with past Hct of 12 in [**2173-12-15**]
G2, P2. Status post tubal ligation in1992.
Wisdom Tooth extraction
Pneumonia in [**2165-5-15**] with fever, cough and hemoptysis.
Idiopathic hirsutism
Obesity
Menorrhagia, no menses for 2 years

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: Obese, hirsute, very pleasant but pale and tired-appearing
female, NAD
HEENT: Anicteric sclerae, conjunctivae pale, MMM, tongue with
areas of hyperpigmentation
Neck: Supple, fleshy, no LAD, no thyromegaly or nodules,
darkened skin posteriorly
Heart: rr, [**1-20**] hsm heard loundest over tricuspid area, no g/r
Lungs: CTAB
Abd: Obese, s/nt/nd, no hsm
Rectal: + per ED
Ext: No c/c/e, nl tone, 2+ DPs
Neuro: Cn2-12 intact, MAEW

FAMILY HISTORY: Mother was anemic, died from ESRD [**1-16**] HTN and DM.  Father alive,
has hypertension.  Pt has 11 siblings - 1 sister died at age 55
from lung Ca (was smoker).  Family hx also positive for HTN, DM.
 cousin with [**Name2 (NI) 14165**] cell anemia, uncle with [**Name2 (NI) 14165**] trait.  No FH
IBD, celiac disease.

SOCIAL HISTORY: Lives in [**Location (un) 3844**] with her husband and 2
children, does not work outside the home.  Pt has 2 children, a
17 y/o son and a 15 y/o multi-handicapped daughter who is blind
and deaf.  A PCA helps her take care of her daughter.  [**Name (NI) **]
tobacco, social alcohol, no illicit drug use.  Pt drinks [**12-16**]
cups of coffee a week and takes no dietary supplements.  She
eats plenty of red meat and green vegetables. 

### Response:
{'Other specified anemias,Hemorrhage of gastrointestinal tract, unspecified,Iron deficiency anemia, unspecified,Diaphragmatic hernia without mention of obstruction or gangrene,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage'}
