CHIEF COMPLAINT: melena

PRESENT ILLNESS: 53 y/oF with mechanical aortic valve on anticoagulation (lovenox
and coumadin) who presents with melena in the setting of
colonoscopy with polypectomy x 2 on [**7-2**]. Patient underwent
uncomplicated colonoscopy with polypectomy on the proximal
ascending colon x 2 on [**7-2**] (done at [**University/College **] Vangard). Given
mechanical aortic valve, she started therapeutic lovenox bridge
following the procedure and resumed coumadin at 10mg daily on
[**7-3**]. Starting yesterday evening, patient had 6-7 episodes of
foul smelling loose dark tarry stools mixed with minimal amounts
of BRB. Bowel movements were accompanied by a minimal amout of
lower abdominal cramping and tenesmus. She denies any associated
chest pain, SOB, lightheadedness, fatigue or other symptoms.
Last dose of lovenox at 7am this morning.
.
In ED VS were 98.9 95 138/92 16 100% RA. On exam, no abd TTP,
rectal with large amount dark red gross blood on glove. Labs
notable for INR of 1.4 and Hct of 35.5 from an unknown baseline.
18 guage PIVs x 2 placed and she was given 1L IVF. GI saw the
patient with plan to perform colonoscopy in the am. Vitals on
transfer: 98.6po 76 126/99 16 99%RA.
.
On floor, Pt was given Moviprep for colonoscopy in tomorrow. She
went to the bathroom and had a very large bloody BM with clots.
On her way back to bed she felt lightheaded and as she was
getting to bed she LOC. At the time her tele showed that she was
brady to 20s, and SBP dropped to 70s from 130s prior to this.
She quickly regained conscious. She was given 2 L of IV fluids
and 1 unit of PRBCs. GI was called and she was transferred to
the ICU for further evaluation.

MEDICAL HISTORY: aortic arch repair [**2136**]
aortic valve repair [**2136**]
hx of GI bleed following colonoscopy [**2141**]

MEDICATION ON ADMISSION: -lovenox 60mg SC BID
-toprol 25mg daily
-lasix 20mg QOD (taken Saturday)
-coumadin 5mg QOD, 7.5mg M/W/F

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin:
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.

FAMILY HISTORY: -sister with breast cancer

SOCIAL HISTORY: -Lives in [**Location 38**] MA
-Manages an office
-Denies tobacco
-Denies ETOH
Hemorrhage complicating a procedure,Blood in stool,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Long-term (current) use of anticoagulants,Heart valve replaced by other means,Right bundle branch block,Unspecified essential hypertension
Hemorrhage complic proc,Blood in stool,Abn react-procedure NEC,Long-term use anticoagul,Heart valve replac NEC,Rt bundle branch block,Hypertension NOS
Admission Date:  [**2144-7-5**]              Discharge Date:   [**2144-7-9**]

Date of Birth:  [**2091-4-3**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Doctor First Name 3290**]
Chief Complaint:
melena

Major Surgical or Invasive Procedure:
Colonoscopy
Blood Transfusion (3 units)


History of Present Illness:
53 y/oF with mechanical aortic valve on anticoagulation (lovenox
and coumadin) who presents with melena in the setting of
colonoscopy with polypectomy x 2 on [**7-2**]. Patient underwent
uncomplicated colonoscopy with polypectomy on the proximal
ascending colon x 2 on [**7-2**] (done at [**University/College **] Vangard). Given
mechanical aortic valve, she started therapeutic lovenox bridge
following the procedure and resumed coumadin at 10mg daily on
[**7-3**]. Starting yesterday evening, patient had 6-7 episodes of
foul smelling loose dark tarry stools mixed with minimal amounts
of BRB. Bowel movements were accompanied by a minimal amout of
lower abdominal cramping and tenesmus. She denies any associated
chest pain, SOB, lightheadedness, fatigue or other symptoms.
Last dose of lovenox at 7am this morning.
.
In ED VS were 98.9 95 138/92 16 100% RA. On exam, no abd TTP,
rectal with large amount dark red gross blood on glove. Labs
notable for INR of 1.4 and Hct of 35.5 from an unknown baseline.
18 guage PIVs x 2 placed and she was given 1L IVF. GI saw the
patient with plan to perform colonoscopy in the am. Vitals on
transfer: 98.6po 76 126/99 16 99%RA.
.
On floor, Pt was given Moviprep for colonoscopy in tomorrow. She
went to the bathroom and had a very large bloody BM with clots.
On her way back to bed she felt lightheaded and as she was
getting to bed she LOC. At the time her tele showed that she was
brady to 20s, and SBP dropped to 70s from 130s prior to this.
She quickly regained conscious. She was given 2 L of IV fluids
and 1 unit of PRBCs. GI was called and she was transferred to
the ICU for further evaluation.


Past Medical History:
aortic arch repair [**2136**]
aortic valve repair [**2136**]
hx of GI bleed following colonoscopy [**2141**]


Social History:
-Lives in [**Location 38**] MA
-Manages an office
-Denies tobacco
-Denies ETOH


Family History:
-sister with breast cancer

Physical Exam:
Admission Physical Exam:
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin:
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.

DISCHARGE EXAM:
O: 96.8/98.0, 118/72, 66, 14, 99% RA
PE:GA: AOx3, NAD
HEENT:  PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. [**1-12**] sys murmur over entire precordium.
Pulm: CTAB no crackles or wheezes.  heart sounds audible
throughout lung exam.
Abd: soft, NT, ND, +BS. no g/rt
Extremities: wwp, no edema. DPs, PTs 2+.
Neuro/Psych: CNs II-XII intact.


Pertinent Results:
Admission Labs:
[**2144-7-5**] 12:05PM BLOOD WBC-5.6 RBC-3.93* Hgb-12.1 Hct-35.2*
MCV-90 MCH-30.9 MCHC-34.5 RDW-13.1 Plt Ct-167
[**2144-7-5**] 12:05PM BLOOD Neuts-65.5 Lymphs-24.9 Monos-4.8 Eos-3.6
Baso-1.1
[**2144-7-5**] 12:05PM BLOOD PT-14.9* PTT-35.7* INR(PT)-1.3*
[**2144-7-5**] 12:05PM BLOOD Glucose-100 UreaN-23* Creat-0.8 Na-141
K-5.3* Cl-107 HCO3-23 AnGap-16
[**2144-7-5**] 09:20PM BLOOD Calcium-8.0* Phos-3.9 Mg-1.9

Other Notable Labs:
[**2144-7-5**] 09:20PM BLOOD WBC-10.1# RBC-4.33 Hgb-13.5 Hct-39.0
MCV-90 MCH-31.3 MCHC-34.7 RDW-14.3 Plt Ct-142*
[**2144-7-6**] 11:03AM BLOOD Hct-34.3*
[**2144-7-7**] 05:18AM BLOOD WBC-6.5 RBC-3.96* Hgb-12.1 Hct-34.3*
MCV-87 MCH-30.6 MCHC-35.3* RDW-14.0 Plt Ct-121*

Imaging:
FINDINGS: Dependent atelectasis are seen in the visualized
portion of the
lung bases, no nodules, consolidations, or effusions are
present.
The liver enhances homogeneously with no evidence of focal
lesions. The main portal vein is patent. The gallbladder and
spleen are normal. The spleen has a heterogeneous appearance
consistent with arterial imaging. The adrenal gland demonstrate
fullness bilaterally (3:31). The kidneys enhance and  excrete
contrast symmetrically. Naked calices are seen in the upper pole
of the right kidney (3:43) consistent with cortical atrophy from
prior ischemic or inflammatory insult. There is no pathologic
mesenteric or retroperitoneal adenopathy. No ascites is present.
The stomach, small and large bowel are of normal caliber. Trace
hyperdense material is seen in the lumen of the ascending colon
(3:77, 3:81).
There is no evidence of intraluminal active extravasation.
PELVIS WITH CONTRAST: The remainder of the bowel is of normal
caliber and
appearance. The bladder and uterus are unremarkable.
BONE WINDOWS: There are no concerning lytic or sclerotic
lesions.
IMPRESSION:
1. No extravasation into the GI tract; high-density material in
the ascending colon represents clotted blood. A preliminary
report "no evidence of intraluminal active extravasation or
other acute intra-abdominal abnormality" was discussed with Dr
[**Last Name (STitle) 17157**] at 10:50 p.m. on [**2144-7-5**] by Dr. [**Last Name (STitle) **].

Colonoscopy Report:
Normal mucosa in the colon
Large clot was found in the proximal ascending colon near the
cecum. Clot was adherant to the folds. It was removed with clip.
Three clips were then applied to the area where the clot had
been adhered too. No further bleeding from the area was noted.
This was likely the site of the polypectomy and likely the site
where the patient had been bleeding from.
Blood in the colon
(endoclip)
Otherwise normal colonoscopy to cecum

DISCHARGE LABS:
(could not obtain labs on day of discharge [**1-8**] poor access)
[**2144-7-8**] 08:20AM BLOOD WBC-6.1 RBC-4.15* Hgb-12.8 Hct-36.6
MCV-88 MCH-30.9 MCHC-35.0 RDW-14.1 Plt Ct-114*
[**2144-7-8**] 08:20AM BLOOD PT-18.1* PTT-28.3 INR(PT)-1.6*
[**2144-7-8**] 08:20AM BLOOD Glucose-143* UreaN-14 Creat-0.7 Na-145
K-3.7 Cl-108 HCO3-29 AnGap-12
[**2144-7-8**] 08:20AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.9

Brief Hospital Course:
53 y/oF with mechanical aortic valve on anticoagulation present
with melena in the setting of colonoscopy with polypectomy x 2
on [**7-2**] admitted with GI bleed.

# GI BLEED: Patient was s/p polypectomy on [**7-2**]. After starting
lovenox patient developed melena and came to [**Hospital1 18**].  She was
begun on a bowel prep for repeat colonscopy, after which she she
had an episode of large BM w/ dark blood and clots, followed by
a vagal episode w/ transient bradycardia and hypotension. She
was given 2 L of fluids in the floor and 1 unit of PRBCs and
transferred to the MICU, where she received another 2 units of
blood and 2L IVF.  Her metoprolol was held during this time.
She underwent a colonoscopy which showed bleeding at the
polypectomy site and 3 clips were placed and epi injected at the
site.  Pt stabilized and was transferred back to the floor where
her Hct remained stable.  She initially described a small amount
of black material in her stool the morning after transfer but
subsequently did not note any further blood in her stool.

# MECHANICAL AV VALVE: Patient has a mechanical AV (St. Jude's
valve) and is typically on anticoagulation, which was stopped
for her initial colonscopy.  She was bridging her coumadin with
lovenox when she developed bleeding at her polypectomy site and
was admitted.  Lovenox and coumadin were again held because of
her bleeding.  After her colonoscopy and subsequent transfer to
the general medicine floor, she was restarted on coumadin with a
heparin drip, which was later transitioned to lovenox for
discharge.  She did not notice any further blood in her stool
and was discharged on lovenox and her usual home coumadin
regimen with plans to follow up at her usual coumadin clinic for
an INR check the day after discharge.  Her metoprolol was also
restarted on [**2144-7-8**] because pt had a 10 beat run of Vtach for
which she felt palpitations.  She had not had any other
palpitations or new symptoms at the time of discharge and felt
well.

# ROMI: pt found to have TWI on V1-V3 in the setting of RBBB and
<1 ST depressions on lat leads. She denied chest pain, but had
nausea and felt unwell. Although her nausea was most likely due
to movi-prep intake, she was ruled out for MI with CE, which
were neg times two, and repeat EKG which also showed RBBB and
was unchanged.

Medications on Admission:
-lovenox 60mg SC BID
-toprol 25mg daily
-lasix 20mg QOD (taken Saturday)
-coumadin 5mg QOD, 7.5mg M/W/F

Discharge Medications:
1. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO [**Doctor First Name **], TU, TH, SA.

2. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO M, W, F.
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
4. enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg
Subcutaneous [**Hospital1 **] (2 times a day).
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
GI bleed secondary to polypectomy

Secondary Diagnosis:
Mechanical heart valve


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Ms. [**Known lastname 70847**],

You came to [**Hospital1 **] because you were experiencing
bleeding in your GI tract.  You were admitted to the ICU and
your blood counts were low so you received 3 units of blood.
You had a colonoscopy which showed bleeding from the site of
your polypectomy, so clips were put in to stop the bleeding.
Your blood counts remained stable after that and you were
transferred to the general medicine floor, where you were
restarted on your lovenox and coumadin.  You should get your INR
checked tomorrow.

No changes were made to your medications.  Please continue
lovenox 60mg subcutaneously twice a day as well as your usual
coumadin dosing and follow up at your usual coumadin clinic for
INR checks.

Followup Instructions:
Follow up with your Primary Care Doctor in 1 week.

Please have your INR checked tomorrow and adjust your lovenox
and coumadin as directed.
{'Hemorrhage complicating a procedure,Blood in stool,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Long-term (current) use of anticoagulants,Heart valve replaced by other means,Right bundle branch block,Unspecified essential hypertension'}


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: melena

PRESENT ILLNESS: 53 y/oF with mechanical aortic valve on anticoagulation (lovenox
and coumadin) who presents with melena in the setting of
colonoscopy with polypectomy x 2 on [**7-2**]. Patient underwent
uncomplicated colonoscopy with polypectomy on the proximal
ascending colon x 2 on [**7-2**] (done at [**University/College **] Vangard). Given
mechanical aortic valve, she started therapeutic lovenox bridge
following the procedure and resumed coumadin at 10mg daily on
[**7-3**]. Starting yesterday evening, patient had 6-7 episodes of
foul smelling loose dark tarry stools mixed with minimal amounts
of BRB. Bowel movements were accompanied by a minimal amout of
lower abdominal cramping and tenesmus. She denies any associated
chest pain, SOB, lightheadedness, fatigue or other symptoms.
Last dose of lovenox at 7am this morning.
.
In ED VS were 98.9 95 138/92 16 100% RA. On exam, no abd TTP,
rectal with large amount dark red gross blood on glove. Labs
notable for INR of 1.4 and Hct of 35.5 from an unknown baseline.
18 guage PIVs x 2 placed and she was given 1L IVF. GI saw the
patient with plan to perform colonoscopy in the am. Vitals on
transfer: 98.6po 76 126/99 16 99%RA.
.
On floor, Pt was given Moviprep for colonoscopy in tomorrow. She
went to the bathroom and had a very large bloody BM with clots.
On her way back to bed she felt lightheaded and as she was
getting to bed she LOC. At the time her tele showed that she was
brady to 20s, and SBP dropped to 70s from 130s prior to this.
She quickly regained conscious. She was given 2 L of IV fluids
and 1 unit of PRBCs. GI was called and she was transferred to
the ICU for further evaluation.

MEDICAL HISTORY: aortic arch repair [**2136**]
aortic valve repair [**2136**]
hx of GI bleed following colonoscopy [**2141**]

MEDICATION ON ADMISSION: -lovenox 60mg SC BID
-toprol 25mg daily
-lasix 20mg QOD (taken Saturday)
-coumadin 5mg QOD, 7.5mg M/W/F

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin:
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.

FAMILY HISTORY: -sister with breast cancer

SOCIAL HISTORY: -Lives in [**Location 38**] MA
-Manages an office
-Denies tobacco
-Denies ETOH 

### Response:
{'Hemorrhage complicating a procedure,Blood in stool,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Long-term (current) use of anticoagulants,Heart valve replaced by other means,Right bundle branch block,Unspecified essential hypertension'}
