CHIEF COMPLAINT: OSH transfer for UGIB

PRESENT ILLNESS: [**Age over 90 **] yo M with a history of Afib on coumadin, CKD, and dCHF who
presents with 2 days of weakness and shortness of breath
complained of bloody stools x2 on [**5-6**] and abdominal cramping.
He was admitted to OSH on [**5-7**], with a HCT of 15.5. He had
guaiac positive black stools. He was given 5mg Vitamin K an INR
of 4.0 and started on a protonix gtt. He was transferred to OSH
ICU.
In ICU she had 500cc brown emesis. NGT placed and put out 2300cc
fluid. She received 5 units RBCs and 3u FFP. Repeat HCT after
transfusions was 17.5 with INR of 2.5.
.
BPs were 80s/40, so he was started on Levophed today at 3:30pm.
Vitals prior to transfer were BP 111/45 HR 109. He continues to
have melenotic stools. His 6th unit of PRBCs was hanging on
transfer.

MEDICAL HISTORY: CKD stage 3
HTN
CHF -diastolic
Hypothyroidism
Paroxysmal Afib
BPH
Gout
Venous stasis
L hip fracture 1 year ago

MEDICATION ON ADMISSION: Amlodipine 2.5mg po daily
Lasix 120mg po qd
Lasix 80mg po qhs
Hydralazine 50mg po bid
Synthroid 25mg po daily
Warfarin 5mg po daily
Allopurinol 300mg po daily  Amlodipine 2.5mg po daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:
Vitals: T: BP:127/68 P: 106 R: 18 O2: 98% on RA
General: Alert, NG tube in place, breathing comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: NC

SOCIAL HISTORY: He is the sole caregiver of his wife who has dementia.
- Tobacco: None
- Alcohol: None
Malignant neoplasm of pylorus,Acute respiratory failure,Chronic diastolic heart failure,Blood in stool,Acute posthemorrhagic anemia,Hyperosmolality and/or hypernatremia,Cellulitis and abscess of upper arm and forearm,Acquired hypertrophic pyloric stenosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Atrial fibrillation,Hypotension, unspecified,Gout, unspecified,Unspecified acquired hypothyroidism,Venous (peripheral) insufficiency, unspecified,Long-term (current) use of anticoagulants,Phlebitis and thrombophlebitis of superficial veins of upper extremities
Malignant neo pylorus,Acute respiratry failure,Chr diastolic hrt fail,Blood in stool,Ac posthemorrhag anemia,Hyperosmolality,Cellulitis of arm,Acq pyloric stenosis,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Atrial fibrillation,Hypotension NOS,Gout NOS,Hypothyroidism NOS,Venous insufficiency NOS,Long-term use anticoagul,Phlbts sprfc vn up extrm
Admission Date:  [**2153-5-8**]              Discharge Date:   [**2153-5-15**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
OSH transfer for UGIB

Major Surgical or Invasive Procedure:
EGD [**2153-5-8**]

History of Present Illness:
[**Age over 90 **] yo M with a history of Afib on coumadin, CKD, and dCHF who
presents with 2 days of weakness and shortness of breath
complained of bloody stools x2 on [**5-6**] and abdominal cramping.
He was admitted to OSH on [**5-7**], with a HCT of 15.5. He had
guaiac positive black stools. He was given 5mg Vitamin K an INR
of 4.0 and started on a protonix gtt. He was transferred to OSH
ICU.
In ICU she had 500cc brown emesis. NGT placed and put out 2300cc
fluid. She received 5 units RBCs and 3u FFP. Repeat HCT after
transfusions was 17.5 with INR of 2.5.
.
BPs were 80s/40, so he was started on Levophed today at 3:30pm.
Vitals prior to transfer were BP 111/45 HR 109. He continues to
have melenotic stools. His 6th unit of PRBCs was hanging on
transfer.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
CKD stage 3
HTN
CHF -diastolic
Hypothyroidism
Paroxysmal Afib
BPH
Gout
Venous stasis
L hip fracture 1 year ago


Social History:
He is the sole caregiver of his wife who has dementia.
- Tobacco: None
- Alcohol: None


Family History:
NC

Physical Exam:
Admission Exam:
Vitals: T: BP:127/68 P: 106 R: 18 O2: 98% on RA
General: Alert, NG tube in place, breathing comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema


Pertinent Results:
Admission Labs:
[**2153-5-8**] 08:14AM   PT-19.4* PTT-33.0 INR(PT)-1.8*
[**2153-5-8**] 08:14AM   PLT COUNT-193
[**2153-5-8**] 08:14AM   WBC-14.1* RBC-2.37* HGB-7.3* HCT-20.1* MCV-85
MCH-30.6 MCHC-36.1* RDW-17.7*
[**2153-5-8**] 08:14AM   CALCIUM-7.3* PHOSPHATE-3.6 MAGNESIUM-2.5
[**2153-5-8**] 08:14AM   CK-MB-4 cTropnT-0.06*
[**2153-5-8**] 08:14AM   ALT(SGPT)-14 AST(SGOT)-18 LD(LDH)-160
CK(CPK)-79 ALK PHOS-46 TOT BILI-1.6*
[**2153-5-8**] 08:14AM   GLUCOSE-146* UREA N-108* CREAT-2.4*
SODIUM-151* POTASSIUM-4.0 CHLORIDE-113* TOTAL CO2-27 ANION
GAP-15
[**2153-5-8**] 10:51AM   freeCa-0.98*
[**2153-5-8**] 10:51AM   LACTATE-4.3*
[**2153-5-8**] 10:51AM   TYPE-ART PH-7.36
[**2153-5-8**] 10:54AM   PLT COUNT-144*
[**2153-5-8**] 10:54AM   WBC-12.5* RBC-2.32* HGB-7.1* HCT-19.5* MCV-84
MCH-30.7 MCHC-36.6* RDW-17.5*
[**2153-5-8**] 10:58AM   freeCa-0.96*
[**2153-5-8**] 10:58AM   O2 SAT-97
[**2153-5-8**] 10:58AM   LACTATE-3.0*
[**2153-5-8**] 10:58AM   TYPE-ART TEMP-36.6 RATES-16/0 TIDAL VOL-500
PEEP-5 O2-60 PO2-240* PCO2-36 PH-7.50* TOTAL CO2-29 BASE XS-5
INTUBATED-INTUBATED VENT-CONTROLLED
.
Discharge Labs:
146 110  35
------------< 107
3.4  27  1.8
.
6.0 > 9.2/27.4 < 199
.
INR 1.2
.
Studies:
CXR [**2153-5-8**]:
The tip of the endotracheal tube terminates 6.6 cm above the
level of the carina. The nasogastric tube tip is in the stomach.
The lungs are clear. There is no vascular congestion or pleural
effusions.  The cardiac silhouette is moderately enlarged.
Tortuosity of the aorta is noted. The remainder of the
mediastinal and hilar contours are normal. There is no
pneumothorax. IMPRESSION:  1) Standard position of support
devices. 2) Moderate cardiomegaly and tortuosity of the aorta.
3. No pneumonia or pulmonary edema.
.
CT TORSO, NONCONTRAST [**2153-5-8**]:
1. Lobulated mass extending from the pylorus, into the first
portion of the duodenum; however, it is unclear whether this
mass originates from the pylorus, or the duodenum. No
obstruction to oral contrast transit.
2. Numerous regional lymph nodes, none of which necessarily meet
CT criteria for enlargement, but the number of these nodes is
concerning for local metastatic disease. Slight stranding of the
adjacent mesenteric fat. No signs, however, of distant
metastatic foci, although solid organs, such as the liver, are
limited in evaluation.
3. Cardiomegaly, coronary artery disease, and aortic
atherosclerosis.
.
TRANSTHORACIC ECHOCARDIOGRAM [**2153-5-9**]:
The left atrium is normal in size. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: poor technical quality study. Left ventricular
function is probably normal, a focal wall motion abnormality
cannot be fully excluded. At least moderate tricuspid
regurgitation with moderate pulmonary artery systolic
hypertension.
.
EGD [**2153-5-8**]:
Contents: Coffee ground heme was seen in the fundus and stomach
body. Food was found in the stomach body and fundus.  Protruding
Lesions A large fungating mass of malignant appearance with
friability and stigmata of recent bleeding was found at the
pylorus. The scope traversed the lesion easily. Cold forceps
biopsies were performed for histology at the pyloric mass.
Duodenum: Normal duodenum. Impression: Blood in the fundus and
stomach body Food in the stomach body and fundus Mass in the
pylorus (biopsy) Otherwise normal EGD to third part of the
duodenum
Recommendations: Mass with stigmata of recent bleeding. No blood
or bleeding post-pylorus. F/u bx results. Cont supportive care w
blood and INR reversal. Suggest CT scan and surgical consult.
.
PYLORIC MASS BIOPSY [**2153-5-8**]:
Adenocarcinoma, at least intramucosal, arising in a background
of low and high grade dysplasia.  Note: No submucosal tissue is
present.  [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6311**] stain is negative for H. pylori.


Brief Hospital Course:
HOSPITAL COURSE
Mr. [**Known lastname 5730**] is a pleasant [**Age over 90 **]yo male with a history of paroxysmal
atrial fibrillation on coumadin, hypertension, diastolic heart
failure, who was transferred from OSH with a large volume GI
bleed, attributed to a bleeding pyloric mass identified as
adenocarcinoma.  THe patient was discharged with general surgery
and oncology follow-up to discuss further treatment plan.
.
ACTIVE ISSUES:
# UPPER GI BLEED/PYLORIC ADENOCARCINOMA:  He initially presented
to OSH with weakness and fatigue and was found to have a
hematocrit of 15.5.  He had further hematemesis in their ICU and
had a minimal hematocrit response to 5 units PRBC. He was
hypotensive on pressors and transferred to [**Hospital1 18**], where he
maintained his hemodynamic stability and pressors were weaned.
He was intubated for airway support prior to EGD. His admission
hematocrit was 20.1.  He received 4 units PRBC with an
appropriate rise.  He was continued on IV PPI infusion and did
not require pressors.  GI team performed upper endoscopy which
revealed a large fungating pyloric mass with stigmata of recent
bleeding, and retained food products in the stomach suggesting
possible gastric outlet obstruction. Biopsies were taken but no
hemostatic procedure was done.  Surgery was consulted.  CT torso
without contrast showed this pyloric mass with possibly enlarged
lymph nodes nearby, but no widespread metastatic disease. As his
hematocrit remained stable, no emergent surgery was performed
overnight on HD1.  He was extubated on HD2.  Discussion with his
family yielded a DNR code status change.  Biopsy result returned
as adenocarcinoma.  After discussing diagnosis with patient,
family, and surgery team, will stay current course of supportive
therapy.  If he bleeds again, he will require surgery or
interventional radiology itnervention. His hematocrit was stable
for the duration of his hospitalization. Plan for follow-up with
oncology and general surgery for discussion of management.
.
# HYPOTENSION: He was hypotension on admission secondary to
acute blood loss but was aggressively resuscitated with fluids
and blood products. Required several fluid boluses on HD2 for
borderline low blood pressures to 90s systolic, though HCT was
stable. His hydralazine and amlodine were discontinued.  Lasix
was down titrated.
.
# RIGHT ARM SWELLING: Etiology unclear.  Upper extremity
ultrasound revealed a non-occlusive thrombus in the right
cephalic vein which did not extend to the axillary vein and no
evidence of deep vein thrombosis.  Appearance likely to be
thrombophlebitis superinfection.  Mr. [**Name14 (STitle) 77163**] was started on a 10
day course of kephlex with significant improvement in edema at
the time of discharge.
.
INACTIVE ISSUES
# DIASTOLIC HEART FAILURE:  Outpatient cardiologist echo showing
EF=50% with evidecne of diastolic dysfunction.  He became
progressively edematous by HD3 due to fluid/blood resuscitation.
 Wound care was consulted to help manage lower extremity edema
which was treated with aquafor ointment and kerlex wraps.  His
peripheral edema was improving at the time of discharge. No
ulcers on exam. His lasix had been held on admission and was
restarted at a lower dose than home dose.
.
# ATRIAL FIBRILLATION: Has paroxysmal atrial fibrillation.
Coumadin was held.  He was started on low dose metoprolol
tartrate 12.5 [**Hospital1 **] on [**2153-5-10**] due to RVR to 120s and
hypertension. Metoprolol succinate on discharge.
.
# HYPERTENSION:  Developed BP to 160s-180s on HD3, felt to be
related to fluid overload.
.
# HYPOTHYROIDISM: Continue synthroid
.
# CKD:  Creatinine stabilized.
.
TRANSITIONAL ISSUES
# Follow-Up: General Surgery, Hematology Oncology, Primary Care
# Disposition: Home with nursing care was suggested for
managment of significant medication changes and peripheral
edema.  Mr. [**Known lastname 5730**] and his family strongly objected to home
nursing; they agreed to arrange their own services if needed.
# Code Status: Do not rescussitate, but do intubate

Medications on Admission:
Amlodipine 2.5mg po daily
Lasix 120mg po qd
Lasix 80mg po qhs
Hydralazine 50mg po bid
Synthroid 25mg po daily
Warfarin 5mg po daily
Allopurinol 300mg po daily  Amlodipine 2.5mg po daily


Discharge Medications:
1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.

3. Lasix 20 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 6 days.
Disp:*12 Capsule(s)* Refills:*0*
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Aquaphor     Ointment Sig: One (1)  Topical three times a
day.
Disp:*1 tube* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Upper GI bleed
Gastric Adenocarcinoma


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted for management of large volume
gastrointestinal bleeding in our intensive care unit. You were
transfused packed red blood cells.  An upper endoscopy
demonstrated a large mass in your stomach.  Biopsy revealed a
gastric cancer. Your coumadin was stopped in the setting of your
bleed and your bleeding ultimately stopped. You will have close
follow-up with oncology and surgery for ongoing management.
.
You were started on antibiotic therapy for a skin infection on
your right arm that continued to improve throughout your
hospital stay.  Please continue this medication for six more
days.
.
Your blood pressure was noted to be low, and your heart rate was
higher than normal, therefore multiple changes were made to your
medication list.  It will be important for your to follow-up
with all of your physicians to discuss these changes.
.
The following changes were made to your medication list.
1. STOP coumadin
2. STOP aspirin
3. STOP amlodipine
4. STOP hydalazine
5. DECREASE lasix to 60mg twice daily
6. START pantoprazole 40mg twice a day
7. START metoprolol succinate 25mg daily
8. START cephalexin for six more days
.
Your family opted to provide home services for further managment
of your care.

Followup Instructions:
Name: NP [**First Name8 (NamePattern2) 16001**] [**Last Name (NamePattern1) 25236**] (works with Dr [**Last Name (STitle) 71168**]
Location: [**Location (un) 20590**] FAMILY PRACTICE
Address: [**Street Address(2) 20589**]., LUNENBERG,[**Numeric Identifier 20591**]
Phone: [**Telephone/Fax (1) 20587**]
Appt:  [**5-22**] at 11:30am
.
Name: [**Last Name (LF) **], [**Name8 (MD) 333**] MD
Dept: Surgery/Critical Care Medicine
Address: [**Hospital Unit Name 58920**], [**Location (un) 86**], MA
Phone: [**Telephone/Fax (1) 2981**]
Appt:  We are working on an appt for you within the next few
weeks.  Dr [**Last Name (STitle) 77164**] office will call you at home with an appt.
 If you dont hear from them by Thursday, please call the office
directly to book.
.
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2153-5-25**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
{'Malignant neoplasm of pylorus,Acute respiratory failure,Chronic diastolic heart failure,Blood in stool,Acute posthemorrhagic anemia,Hyperosmolality and/or hypernatremia,Cellulitis and abscess of upper arm and forearm,Acquired hypertrophic pyloric stenosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Atrial fibrillation,Hypotension, unspecified,Gout, unspecified,Unspecified acquired hypothyroidism,Venous (peripheral) insufficiency, unspecified,Long-term (current) use of anticoagulants,Phlebitis and thrombophlebitis of superficial veins of upper extremities'}


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: OSH transfer for UGIB

PRESENT ILLNESS: [**Age over 90 **] yo M with a history of Afib on coumadin, CKD, and dCHF who
presents with 2 days of weakness and shortness of breath
complained of bloody stools x2 on [**5-6**] and abdominal cramping.
He was admitted to OSH on [**5-7**], with a HCT of 15.5. He had
guaiac positive black stools. He was given 5mg Vitamin K an INR
of 4.0 and started on a protonix gtt. He was transferred to OSH
ICU.
In ICU she had 500cc brown emesis. NGT placed and put out 2300cc
fluid. She received 5 units RBCs and 3u FFP. Repeat HCT after
transfusions was 17.5 with INR of 2.5.
.
BPs were 80s/40, so he was started on Levophed today at 3:30pm.
Vitals prior to transfer were BP 111/45 HR 109. He continues to
have melenotic stools. His 6th unit of PRBCs was hanging on
transfer.

MEDICAL HISTORY: CKD stage 3
HTN
CHF -diastolic
Hypothyroidism
Paroxysmal Afib
BPH
Gout
Venous stasis
L hip fracture 1 year ago

MEDICATION ON ADMISSION: Amlodipine 2.5mg po daily
Lasix 120mg po qd
Lasix 80mg po qhs
Hydralazine 50mg po bid
Synthroid 25mg po daily
Warfarin 5mg po daily
Allopurinol 300mg po daily  Amlodipine 2.5mg po daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:
Vitals: T: BP:127/68 P: 106 R: 18 O2: 98% on RA
General: Alert, NG tube in place, breathing comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: NC

SOCIAL HISTORY: He is the sole caregiver of his wife who has dementia.
- Tobacco: None
- Alcohol: None 

### Response:
{'Malignant neoplasm of pylorus,Acute respiratory failure,Chronic diastolic heart failure,Blood in stool,Acute posthemorrhagic anemia,Hyperosmolality and/or hypernatremia,Cellulitis and abscess of upper arm and forearm,Acquired hypertrophic pyloric stenosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Atrial fibrillation,Hypotension, unspecified,Gout, unspecified,Unspecified acquired hypothyroidism,Venous (peripheral) insufficiency, unspecified,Long-term (current) use of anticoagulants,Phlebitis and thrombophlebitis of superficial veins of upper extremities'}
