CHIEF COMPLAINT: upper GI bleed, NSTEMI

PRESENT ILLNESS: [**Age over 90 **]M first noticed dark black stools associated with progressive
SOB and fatigue 3 months ago.  On [**4-6**], he presented to [**Hospital1 882**]
and was noted to be newly anemic (Hct 26, reported baseline 37).
 He was transfused 4 units with stabilization of Hct at 30.  EGD
demonstrated a non-bleeding duodenal ulcer with overlying clot;
no biopsy or H. pylori stain was performed.  Given no active
bleeding, he was managed with daily PPI.  Both aspirin and
coumadin were discontinued.  His beta-blocker was also
discontinued due to asymptomatic bradycardia (HR 50s).  He was
discharged home on [**2199-4-9**].

MEDICAL HISTORY: HTN, hypercholesterolemia, atrial fibrillation, h/o bleeding
duodenal ulcer, CAD, colon ca s/p colectomy (20 years ago), h/o
pleural effusion, s/p back surgery

MEDICATION ON ADMISSION: Lasix 20', lisinorpil 15', omeprazole 20', Zocor 40', Coumadin
1' (on hold since discharge from [**Hospital1 882**] [**2199-4-9**])

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
97.2  75  140/65  18  98%RA
Gen: well nourished, NAD
HEENT: NC, PERRL
Lymph: cervical WNL
CVS: irregular rhythm, distant S2
Pulm: CTA b/l, symmetric expansion
Abd: soft, NT, ND, +BS, formed black stool prior to exam
Ext: no cyanosis/clubbing, no muscle wasting
Skin: warm
Neuro: attentive, follows simple commands, responds to verbal
stimuli, oriented

FAMILY HISTORY: NC

SOCIAL HISTORY: Retired [**Location (un) 86**] policeman.  Daughter lives upstairs.  Non-smoker.
 Rare EtOH (1-2 drinks/week).
Hemorrhage of gastrointestinal tract, unspecified,Subendocardial infarction, initial episode of care,Acute posthemorrhagic anemia,Arterial embolism and thrombosis of lower extremity,Urinary tract infection, site not specified,Accidental puncture or laceration during a procedure, not elsewhere classified,Dissection of iliac artery,Primary pulmonary hypertension,Atrial fibrillation,Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction,Benign neoplasm of colon,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Pure hypercholesterolemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Acquired absence of intestine (large) (small),Personal history of malignant neoplasm of large intestine,Personal history of peptic ulcer disease,Long-term (current) use of anticoagulants
Gastrointest hemorr NOS,Subendo infarct, initial,Ac posthemorrhag anemia,Lower extremity embolism,Urin tract infection NOS,Accidental op laceration,Dissection iliac artery,Prim pulm hypertension,Atrial fibrillation,Acute duodenal ulcer NOS,Benign neoplasm lg bowel,Acc cut/hem in surgery,Pure hypercholesterolem,Hypertension NOS,Crnry athrscl natve vssl,Mitral valve disorder,Acquire absnce intestine,Hx of colonic malignancy,Prsnl hst peptic ulcr ds,Long-term use anticoagul
Admission Date:  [**2199-4-26**]              Discharge Date:   [**2199-5-11**]


Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
upper GI bleed, NSTEMI

Major Surgical or Invasive Procedure:
[**2199-4-26**] EGD
[**2199-4-28**] open L femoral & iliac embolectomy
[**2199-4-30**] small bowel enteroscopy
[**2199-5-3**] ultrasound-guided imaging for [**Month/Day/Year 1106**] access,
contralateral second order arteriography from a brachial
approach, abdominal aortogram with pelvis followed by a left
iliac stent
[**2199-5-6**] colonoscopy

History of Present Illness:
[**Age over 90 **]M first noticed dark black stools associated with progressive
SOB and fatigue 3 months ago.  On [**4-6**], he presented to [**Hospital1 882**]
and was noted to be newly anemic (Hct 26, reported baseline 37).
 He was transfused 4 units with stabilization of Hct at 30.  EGD
demonstrated a non-bleeding duodenal ulcer with overlying clot;
no biopsy or H. pylori stain was performed.  Given no active
bleeding, he was managed with daily PPI.  Both aspirin and
coumadin were discontinued.  His beta-blocker was also
discontinued due to asymptomatic bradycardia (HR 50s).  He was
discharged home on [**2199-4-9**].

He felt well initially following discharge, but continued to
have dark black stools and developed slowly progressive fatigue,
malaise, and dizziness. Three prior to admission, he had dyspnea
and substernal chest pressure associated with walking across the
room and relieved by rest. Denies nausea, vomiting, or
diaphoresis.  He presented to [**Hospital1 882**], where he was found to
have Hct 24, CK 119, troponin 25.  ECG was unchanged from prior.
 He was transfused 1U PRBC and transferred to [**Hospital1 18**] for further
management.

On arrival to [**Hospital1 18**], he was afebrile and hemodynamically stable.
 Stool was guiaic positive with Hct 26.  NG lavage was negative.
 He was transfused 1U PRBC.  Troponin was 1.23 and CK 107 with
MB 11 (MB index 10). ECG demonstrated afib, q V1-2, unchanged
from prior.  He was admitted to the MICU.

Past Medical History:
HTN, hypercholesterolemia, atrial fibrillation, h/o bleeding
duodenal ulcer, CAD, colon ca s/p colectomy (20 years ago), h/o
pleural effusion, s/p back surgery

Social History:
Retired [**Location (un) 86**] policeman.  Daughter lives upstairs.  Non-smoker.
 Rare EtOH (1-2 drinks/week).

Family History:
NC

Physical Exam:
On admission:
97.2  75  140/65  18  98%RA
Gen: well nourished, NAD
HEENT: NC, PERRL
Lymph: cervical WNL
CVS: irregular rhythm, distant S2
Pulm: CTA b/l, symmetric expansion
Abd: soft, NT, ND, +BS, formed black stool prior to exam
Ext: no cyanosis/clubbing, no muscle wasting
Skin: warm
Neuro: attentive, follows simple commands, responds to verbal
stimuli, oriented

On discharge:
____________________________
Gen: NAD, A&O
CVS: RRR
Pulm: CTA b/l
Abd: soft, NT, ND, +BS
Ext: no cyanosis/clubbing, 2+ edema b/l LE, L DP & PT palpable,
R DP & PT [**Name (NI) **], b/l feet warm, incisions healing well
c/d/i

Pertinent Results:
On admission:
[**2199-4-25**] 09:59PM BLOOD WBC-6.3 RBC-2.83* Hgb-8.6* Hct-26.0*
MCV-92 MCH-30.5 MCHC-33.2 RDW-15.6* Plt Ct-304
[**2199-4-25**] 09:59PM BLOOD Neuts-76.5* Lymphs-16.6* Monos-5.2
Eos-1.3 Baso-0.4
[**2199-4-25**] 09:59PM BLOOD PT-12.6 PTT-23.1 INR(PT)-1.1
[**2199-4-25**] 09:59PM BLOOD Glucose-108* UreaN-51* Creat-1.6* Na-141
K-4.8 Cl-107 HCO3-20* AnGap-19
[**2199-4-25**] 09:59PM BLOOD ALT-32 AST-67* LD(LDH)-442* CK(CPK)-107
AlkPhos-83 TotBili-0.6
[**2199-4-25**] 09:59PM BLOOD Lipase-39
[**2199-4-25**] 09:59PM BLOOD CK-MB-11* MB Indx-10.3*
[**2199-4-25**] 09:59PM BLOOD TotProt-6.5 Albumin-4.1 Globuln-2.4
Calcium-9.2

Troponin
[**2199-4-25**] 09:59PM BLOOD cTropnT-1.23*
[**2199-4-26**] 05:21AM BLOOD CK-MB-8 cTropnT-1.23*
[**2199-4-28**] 01:43PM BLOOD CK-MB-6 cTropnT-1.26*
[**2199-4-28**] 07:20PM BLOOD CK-MB-13* MB Indx-3.9 cTropnT-1.05*
[**2199-4-29**] 04:45AM BLOOD CK-MB-8 cTropnT-1.08*
[**2199-4-29**] 09:50PM BLOOD CK-MB-6 cTropnT-0.85*
[**2199-4-30**] 05:15AM BLOOD CK-MB-5 cTropnT-0.87*
[**2199-5-1**] 04:26AM BLOOD CK-MB-3 cTropnT-0.56*

CK
[**2199-4-28**] 01:43PM BLOOD CK(CPK)-255*
[**2199-4-28**] 07:20PM BLOOD CK(CPK)-331*
[**2199-4-29**] 04:45AM BLOOD CK(CPK)-950*
[**2199-4-29**] 09:50PM BLOOD CK(CPK)-514*
[**2199-4-30**] 05:15AM BLOOD CK(CPK)-362*
[**2199-5-1**] 04:26AM BLOOD CK(CPK)-129

[**2199-4-26**] HELICOBACTER PYLORI ANTIBODY TEST (Final [**2199-4-29**]):
NEGATIVE BY EIA.

[**2199-4-26**] ECHOCARDIOGRAM
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-20mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size. There is mild global left ventricular
hypokinesis (LVEF = 40-45 %). The estimated cardiac index is
borderline low (2.0-2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate to severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild global hypokinesis and boderline low cardiac index.
Moderate mitral regurgitation. Moderate to severe tricuspid
regurgitation. Moderate to severe pulmonary hypertension.

[**2199-4-28**] URINE CULTURE (Final [**2199-4-30**]): ESCHERICHIA COLI.
>100,000 ORGANISMS/ML.
SENSITIVITIES: MIC expressed in MCG/ML
AMPICILLIN------------     8 S
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

[**2199-5-1**] CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS
CHEST: There is a moderate-sized right and a small left pleural
effusion, with associated compressive atelectasis. No focal
airspace opacification or suspicious nodule is seen. There are
non-pathologically enlarged mediastinal lymph nodes. Heart is at
the upper limits of normal in size.
ABDOMEN: Liver, spleen, pancreas, and adrenal glands are
unremarkable. Gallbladder is present. There is no biliary
dilatation. No lymphadenopathy or abnormal mass. Right kidney
contains numerous cysts and several subcentimeter hypodensities
which are too small to completely characterize but likely cysts.
There is no hydronephrosis or nephrolithiasis. The left kidney
has some surrounding nonspecific perinephric stranding, and an
ill-defined area of decreased attenuation at the lower pole,
which may represent a small infarct or focal pyelonephritis. The
remainder of the cortex is thin but enhances normally. There is
no hydronephrosis or delayed excretion when compared to the
contralateral kidney. No surrounding nodes.
PELVIS: The bowel loops are unremarkable. There are coarse
calcifications within the prostate. Foley catheter balloon is
within a nondistended bladder.
There is diffuse bony demineralization and degenerative changes
of the thoracolumbar spine with slight anterolisthesis of L2 on
3 and slight retrolisthesis of L4 on 5, as well as L5 on S1.
There is near complete disc space obliteration at L4-5 and
L5-S1. SI joints are fused superiorly. Notable degenerative
changes of the glenohumeral joint with small loose body seen in
the right glenohumeral joint.
CT ANGIOGRAPHY: Thoracic aorta maintains normal course and
caliber with conventional arterial arch anatomy. There is a
small amount of calcified atherosclerotic plaque at the arch and
within the descending thoracic aorta. No large vegetations are
seen on the aortic valve, although echocardiography would be
much more sensitive modality. Great vessels are widely patent.
Below the diaphragm, there is both soft and hard atherosclerotic
plaques with a small penetrating aortic ulcer posteriorly at or
just beyond the level of the celiac axis. Celiac axis and SMA
are patent. Just beyond the SMA origin, there is a focal
narrowing due to large area of mural thrombus. Beyond this mural
thrombus, a replaced right hepatic artery originates. Renal
arteries maintain patency. [**Female First Name (un) 899**] is contrast opacified. There is
no aneurysmal dilatation of the abdominal aorta.
At the aortic bifurcation, there is a moderate amount of mural
thrombus with a focal linear filling defect in the left common
iliac (3, 173). Distal to this, there is significant narrowing
of that vessel with large amount of thrombus. The ipsilateral
hypogastric artery is thrombosed, although the distal
hypogastric does opacify, likely through collateral vessels. The
left external iliac does opacify thoroughly, as does the femoral
and proximal SFA/profunda. There are post-procedural changes
around the left SFA with edema and fluid/gas within the
subcutaneous soft tissues.
The right internal and external iliac arteries are patent, as
are the right common, profunda, and superficial femoral
arteries. There is mild atherosclerotic plaque involving these
vessels.
There is a small right hydrocele.
IMPRESSION:
1. No aneurysmal dilatation seen as a source for thrombus. There
is dissection and mural thrombus involving the proximal left
common iliac artery with significant narrowing, as well as
thrombosis of that ipsilateral internal iliac artery. Findings
discussed with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. This may be the source of
recently removed thrombus in the left iliac artery.
2. Marked narrowing of the SMA beyond the origin due to soft
plaque, good opacification of the distal vessels, however.
3. Ill-defined area of decreased enhancement at the lower pole
of the left kidney which is suspicious for focal pyelonephritis
or infarct.
4. Bilateral pleural effusions, right greater than left.

ECHOCARDIOGRAM [**2199-5-2**]
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Regional left ventricular wall motion is normal. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is mildly dilated The mitral valve leaflets
are mildly thickened. The tricuspid valve leaflets are mildly
thickened.
Compared with the prior study (images reviewed) of [**2199-4-26**],
left ventricular function has improved. No LV thrombus
identified.

VENOUS DUP EXT UNI (MAP/DVT) LEFT  [**2199-5-6**] 10:51 AM
FINDINGS: Duplex evaluation was performed in the left lower
extremity veins as well as the left groin arterial vessels. In
the left groin, the common femoral artery and vein as well as
the superficial femoral artery and vein were visualized noted to
be widely patent with triphasic arterial waveforms. No evidence
of pseudoaneurysm or arteriovenous fistula. Analysis of the
venous structures reveals normal compression and augmentation of
the common femoral, superficial femoral, popliteal, posterior
tibial, and peroneal veins. There is normal phasicity of the
common femoral veins bilaterally.
IMPRESSION: No evidence of left lower extremity deep vein
thrombosis. No evidence of left groin pseudoaneurysm or
arteriovenous fistula.

On discharge:
[**2199-5-8**] 06:35AM BLOOD WBC-4.9 RBC-3.00* Hgb-9.1* Hct-26.6*
MCV-89 MCH-30.3 MCHC-34.2 RDW-14.8 Plt Ct-252
[**2199-5-7**] 05:35AM BLOOD Glucose-404* UreaN-13 Creat-1.2 Na-136
K-4.3 Cl-106 HCO3-23 AnGap-11
[**2199-5-7**] 05:35AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.7

Brief Hospital Course:
Patient was admitted to [**Hospital 30166**] transferred to the [**Hospital Ward Name 516**]
Hospitalist Service on HD 1, transferred to [**Hospital Ward Name **] Surgery on
HD 3, and discharged home with services on HD 16.

CVS: Cardiology was consulted.  His NSTEMI was attributed to
demand ischemia [**2-9**] anemia.  Recommendations were to transfuse
to Hct >30, trend cardiac enzymes, and obtain an echo to
evaluate wall motion.  Anticoagulation was held given his GI
bleed.  Beta blocker and ACE inhibitor were held in the setting
of recent hypotension.  Statin was continued.  On HD 1, his echo
demonstrated mild symmetric LVH with mild global hypokinesis
(LVEF 40-45%), borderline low CI (2-2.5), moderate MR, moderate
to severe TR, and moderate to severe pulm HTN.  Cardiac enzymes
trended down.  He was placed on heparin gtt on HD 3 given acute
LLE embolus, which was continued postoperatively.  Metoprolol
and ASA were started as recommended by Cardiology.  Echo was
repeated on HD 7, and demonstrated improved LVEF (>55%), normal
LV size & wall motion, and no masses/thrombi.

GI: Intravenous PPI was started on a [**Hospital1 **] schedule.  He underwent
upper endoscopy on HD 1, which was normal to the 3rd portion of
the duodenum.  H. pylori was sent, which was negative.  On HD 5,
he underwent small bowel enteroscopy, which was normal to the
jejunum.  Colonoscopy performed on POD 8/PPD 3 demonstrated
several benign appearing sessile polyps.  These were not
biopsied in the setting of GIB.  No source of bleeding was
identified.  On POD 9/PPD 4, patient underwent capsule
endoscopy.  It had not been read by the time of discharge.  The
patient's PCP will follow up on the results and determine
whether or not it is appropriate to restart Coumadin.

Renal: His Cr was 1.6; as his baseline was unknown, it was
unclear whether this was acute or chronic in nature.  Lasix and
lisinopril were held on admission. Cr improved with fluid
resuscitation.  On HD 3, he was started on Cipro for E.coli UTI.
 Lisinopril was restarted on HD 4 as per postoperative
Cardiology consult.  Cr was 1.2 on discharge.

[**Hospital1 **]: On HD 3, patient developed L leg pain.  [**Hospital1 **]
Surgery was consulted.  His foot was noted to be cool with
decreased cap refill, and no [**Hospital1 **] signals below the
popliteal.  Heparin gtt was started.  He went emergently to the
OR for L femoral and iliac embolectomy.  Postoperatively, he was
admitted to the VICU.  Heparin gtt was restarted, held for
significant oozing from the L groin overnight on POD 0, and
restarted on POD 1.  On POD 3, his Foley was d/c'd.  He was
started on Keflex for L groin cellulitis.  He underwent CTA
demonstrating dissection and mural thrombus in the proximal L
CIA and IIA.  On POD 5, he underwent angiography with placement
of L iliac stent.  Postoperatively, heparin gtt was not
restarted [**2-9**] to bleeding from the L groin incision.  It was
restarted on POD 7/PPD 2 with goal PTT 40-60.  On POD 8/PPD 3,
patient was noted to have significant LLE edema.  Ultrasound was
negative for DVT and pseudoaneurysm.  It was felt to be [**2-9**]
reperfusion.  ACE bandages were applied.  Heparin gtt was held
for colonoscopy and restarted afterwards.  He remained on
heparin gtt until discharge, when he was started on Lovenox.  He
will follow up with his PCP regarding Coumadin after his capsule
endoscopy results are finalized.

At the time of discharge, patient was afebrile with stable vital
signs, had palpable L pedal pulses, was tolerating regular diet,
and was cleared by PT for d/c home with home PT & RN services
(which he had prior to his hospital stay).

Medications on Admission:
Lasix 20', lisinorpil 15', omeprazole 20', Zocor 40', Coumadin
1' (on hold since discharge from [**Hospital1 882**] [**2199-4-9**])

Discharge Disposition:
Home With Service

Facility:
[**Location (un) **] vna

Discharge Diagnosis:
Primary:
PVD, acute ischemia of L lower extremity, GI bleed
.
Secondary:
CAD s/p NSTEMI, Afib, h/o bleeding duodenal ulcer,
hypercholesterolemia, HTN, colon ca s/p
colectomy/ostomy/reversal, s/p back surgery


Discharge Condition:
Afebrile, vital signs stable, L pedal pulses palpable,
tolerating regular diet, ambulating, pain well controlled on PO
medication.


Discharge Instructions:
Division of [**Location (un) **] and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions

Medications:
??????	Take Aspirin 325mg (enteric coated) once daily
??????	If instructed, take Plavix (Clopidogrel) 75mg once daily
??????	Continue all other medications you were taking before surgery,
unless otherwise directed
??????	You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort

What to expect when you go home:
It is normal to have slight swelling of the legs:
??????	Elevate your leg above the level of your heart (use [**2-10**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
??????	Avoid prolonged periods of standing or sitting without your
legs elevated
??????	It is normal to feel tired and have a decreased appetite, your
appetite will return with time
??????	Drink plenty of fluids and eat small frequent meals
??????	It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
??????	To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication

What activities you can and cannot do:
??????	When you go home, you may walk and go up and down stairs
??????	You may shower (let the soapy water run over groin incision,
rinse and pat dry)
??????	Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
??????	No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
??????	After 1 week, you may resume sexual activity
??????	After 1 week, gradually increase your activities and distance
walked as you can tolerate
??????	No driving until you are no longer taking pain medications
??????	Call and schedule an appointment to be seen in [**3-12**] weeks for
post procedure check and ultrasound

What to report to office:
??????	Numbness, coldness or pain in lower extremities
??????	Temperature greater than 101.5F for 24 hours
??????	New or increased drainage from incision or white, yellow or
green drainage from incisions
??????	Bleeding from groin puncture site

SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
??????	Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.


Followup Instructions:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2199-5-30**]
10:45
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2199-5-30**]
11:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2199-5-30**] 11:30



Completed by:[**2199-5-20**]
{'Hemorrhage of gastrointestinal tract, unspecified,Subendocardial infarction, initial episode of care,Acute posthemorrhagic anemia,Arterial embolism and thrombosis of lower extremity,Urinary tract infection, site not specified,Accidental puncture or laceration during a procedure, not elsewhere classified,Dissection of iliac artery,Primary pulmonary hypertension,Atrial fibrillation,Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction,Benign neoplasm of colon,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Pure hypercholesterolemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Acquired absence of intestine (large) (small),Personal history of malignant neoplasm of large intestine,Personal history of peptic ulcer disease,Long-term (current) use of anticoagulants'}


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: upper GI bleed, NSTEMI

PRESENT ILLNESS: [**Age over 90 **]M first noticed dark black stools associated with progressive
SOB and fatigue 3 months ago.  On [**4-6**], he presented to [**Hospital1 882**]
and was noted to be newly anemic (Hct 26, reported baseline 37).
 He was transfused 4 units with stabilization of Hct at 30.  EGD
demonstrated a non-bleeding duodenal ulcer with overlying clot;
no biopsy or H. pylori stain was performed.  Given no active
bleeding, he was managed with daily PPI.  Both aspirin and
coumadin were discontinued.  His beta-blocker was also
discontinued due to asymptomatic bradycardia (HR 50s).  He was
discharged home on [**2199-4-9**].

MEDICAL HISTORY: HTN, hypercholesterolemia, atrial fibrillation, h/o bleeding
duodenal ulcer, CAD, colon ca s/p colectomy (20 years ago), h/o
pleural effusion, s/p back surgery

MEDICATION ON ADMISSION: Lasix 20', lisinorpil 15', omeprazole 20', Zocor 40', Coumadin
1' (on hold since discharge from [**Hospital1 882**] [**2199-4-9**])

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
97.2  75  140/65  18  98%RA
Gen: well nourished, NAD
HEENT: NC, PERRL
Lymph: cervical WNL
CVS: irregular rhythm, distant S2
Pulm: CTA b/l, symmetric expansion
Abd: soft, NT, ND, +BS, formed black stool prior to exam
Ext: no cyanosis/clubbing, no muscle wasting
Skin: warm
Neuro: attentive, follows simple commands, responds to verbal
stimuli, oriented

FAMILY HISTORY: NC

SOCIAL HISTORY: Retired [**Location (un) 86**] policeman.  Daughter lives upstairs.  Non-smoker.
 Rare EtOH (1-2 drinks/week). 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Subendocardial infarction, initial episode of care,Acute posthemorrhagic anemia,Arterial embolism and thrombosis of lower extremity,Urinary tract infection, site not specified,Accidental puncture or laceration during a procedure, not elsewhere classified,Dissection of iliac artery,Primary pulmonary hypertension,Atrial fibrillation,Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction,Benign neoplasm of colon,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Pure hypercholesterolemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Acquired absence of intestine (large) (small),Personal history of malignant neoplasm of large intestine,Personal history of peptic ulcer disease,Long-term (current) use of anticoagulants'}
