CHIEF COMPLAINT: ?GI bleed

PRESENT ILLNESS: Ms. [**Known lastname 4541**] is a 76 year-old female with past medical history of
myelodysplastic syndrome (finished her third cycle of
5-Azacitidine four days prior to admission), status post recent
MI who was transferred from an OSH status post one episode of
brown emesis. The patient states she had not been feeling well
four days prior to admission. She went for her chemotherapy with
Vadasa and was found to have low hematocrit and
thrombocytopenia. She states that over the past few days she has
had diffuse abdominal pain with "gas pains" through her abdomen
and pain in her upper back. The morning of admission she awoke
with the need to vomit. She had one episode of brown emesis, but
did not note streaks of blood or coffee ground emesis. She
denies diarrhea and states she has been constipated over the
past few days. She has occasionally noted small amounts of
bright red blood on her toilet paper, but none in the toilet.
The day or admission she states that she initially had
constipation and then one large loose brown bowel movement. She
denies melena, fevers, chills.
.
She presented to an OSH for the emesis and abdominal pain. At
the OSH she recieved one unit of platelets for a platelet count
of 10. Hematocrit was 26. She was transferred to [**Hospital1 18**] for
further evaluation and management.
.
In the ER she received 1 L NS, anzemet and 2 mg of morphine IV.
Her temperature was noted to be 100.6. She was ordered for 2
units PRBCs and receieved 1 gm tylenol. She was found to have
guaiac positive brown stool on exam.
.
Upon arrival to the [**Hospital Unit Name 153**] her vital signs were stable. She was
still receiving her first unit of PRBCs.
.
In the ICU the patient was initially hemodynamically stable. Her
SBPs trended down to the upper 80s and she was transfused an
additional unit of PRBCs for possible bleed (hematocrit was
around 29 at that time and had risen appropriately). She was
also transfused platelets to keep her platelet count >50. She
was started on cipro/flagyl to cover for posisble diverticulitis
seen on CT abdomen. She was started on stress-dose steroids and
pressures improved over the next day. She was also noted to be
slightly hypoxic with O2 saturations 92% off O2. Her CXR was
clear and it did not appear she had an infection. The relative
hypoxia was believed to be secondary to some component of volume
overload.
.
ROS: Denies fevers, chills, dysuria, hematuria, SOB, dizziness.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
1. Myelodysplastic syndrome in transformation to AML, with 11%
blasts on peripheral smear [**4-30**], undergoing 5-azocytadine
treatment with no blasts seen for three months
2. Coronary artery disease status post Cypher stent to LAD [**11-30**]
off Plavix shortly thereafter with oncology input; recent MI
[**7-31**] treated medically secondary to thrombocytopenia. Restarted
on ASA at that time. Stress MIBI [**9-6**] showed moderate
inferolateral reversible defect.
4. Hypertension
5. Hypercholesterolemia
6. Left total hip replacement
7. Partial hysterectomy
8. Left nephrectomy 20 years ago secondary to nephrolithiasis
9. Detached retina

MEDICATION ON ADMISSION: ASA 325 mg
Lipitor 80 mg
Lisinopril 10 mg
Toprol XL 100 mg
Predlo 10 mg qd
Furosemide 20 mg-patient stopped taking for urinary frequency

ALLERGIES: Sulfa (Sulfonamides) / Shellfish

PHYSICAL EXAM: VITAL SIGNS: 100.0  130/42  98  24  95% on RA
GENERAL: Lying in bed, breathing comfortably, in NAD
HEENT: Left pupil minimally reactive, right pupil reactive, MMM

FAMILY HISTORY: Mother with uterine cancer. Father with history of hypertension,
died of stroke. Sister with "[**Name2 (NI) 500**] cancer." Sister died at 59 of
heart disease. Brother with myocardial infarction at age 63, son
in 40s.

SOCIAL HISTORY: She is a widow and lives alone in [**Hospital1 1806**], Mass. She does have a
20 pack-year smoking history but quit 7 years ago. She denies
alcohol use. She has two children.
Anemia of other chronic disease,Unspecified gastritis and gastroduodenitis, with hemorrhage,Diverticulitis of colon (without mention of hemorrhage),Acute kidney failure, unspecified,Thrombocytopenia, unspecified,Myelodysplastic syndrome, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Acute myocardial infarction of other inferior wall, subsequent episode of care,Unspecified essential hypertension,Pure hypercholesterolemia,Hip joint replacement,Family history of ischemic heart disease
Anemia-other chronic dis,Gstr/ddnts NOS w hmrhg,Dvrtcli colon w/o hmrhg,Acute kidney failure NOS,Thrombocytopenia NOS,Myelodysplastic synd NOS,Crnry athrscl natve vssl,Status-post ptca,AMI inferior wall,subseq,Hypertension NOS,Pure hypercholesterolem,Joint replaced hip,Fam hx-ischem heart dis
Admission Date:  [**2115-9-23**]              Discharge Date:   [**2115-9-27**]

Date of Birth:  [**2039-4-9**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides) / Shellfish

Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
?GI bleed

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Ms. [**Known lastname 4541**] is a 76 year-old female with past medical history of
myelodysplastic syndrome (finished her third cycle of
5-Azacitidine four days prior to admission), status post recent
MI who was transferred from an OSH status post one episode of
brown emesis. The patient states she had not been feeling well
four days prior to admission. She went for her chemotherapy with
Vadasa and was found to have low hematocrit and
thrombocytopenia. She states that over the past few days she has
had diffuse abdominal pain with "gas pains" through her abdomen
and pain in her upper back. The morning of admission she awoke
with the need to vomit. She had one episode of brown emesis, but
did not note streaks of blood or coffee ground emesis. She
denies diarrhea and states she has been constipated over the
past few days. She has occasionally noted small amounts of
bright red blood on her toilet paper, but none in the toilet.
The day or admission she states that she initially had
constipation and then one large loose brown bowel movement. She
denies melena, fevers, chills.
.
She presented to an OSH for the emesis and abdominal pain. At
the OSH she recieved one unit of platelets for a platelet count
of 10. Hematocrit was 26. She was transferred to [**Hospital1 18**] for
further evaluation and management.
.
In the ER she received 1 L NS, anzemet and 2 mg of morphine IV.
Her temperature was noted to be 100.6. She was ordered for 2
units PRBCs and receieved 1 gm tylenol. She was found to have
guaiac positive brown stool on exam.
.
Upon arrival to the [**Hospital Unit Name 153**] her vital signs were stable. She was
still receiving her first unit of PRBCs.
.
In the ICU the patient was initially hemodynamically stable. Her
SBPs trended down to the upper 80s and she was transfused an
additional unit of PRBCs for possible bleed (hematocrit was
around 29 at that time and had risen appropriately). She was
also transfused platelets to keep her platelet count >50. She
was started on cipro/flagyl to cover for posisble diverticulitis
seen on CT abdomen. She was started on stress-dose steroids and
pressures improved over the next day. She was also noted to be
slightly hypoxic with O2 saturations 92% off O2. Her CXR was
clear and it did not appear she had an infection. The relative
hypoxia was believed to be secondary to some component of volume
overload.
.
ROS: Denies fevers, chills, dysuria, hematuria, SOB, dizziness.

(+) abdominal pain
(+) fatigue
(+) occasional headache

Past Medical History:
PAST MEDICAL HISTORY:
1. Myelodysplastic syndrome in transformation to AML, with 11%
blasts on peripheral smear [**4-30**], undergoing 5-azocytadine
treatment with no blasts seen for three months
2. Coronary artery disease status post Cypher stent to LAD [**11-30**]
off Plavix shortly thereafter with oncology input; recent MI
[**7-31**] treated medically secondary to thrombocytopenia. Restarted
on ASA at that time. Stress MIBI [**9-6**] showed moderate
inferolateral reversible defect.
4. Hypertension
5. Hypercholesterolemia
6. Left total hip replacement
7. Partial hysterectomy
8. Left nephrectomy 20 years ago secondary to nephrolithiasis
9. Detached retina

Social History:
She is a widow and lives alone in [**Hospital1 1806**], Mass. She does have a
20 pack-year smoking history but quit 7 years ago. She denies
alcohol use. She has two children.


Family History:
Mother with uterine cancer. Father with history of hypertension,
died of stroke. Sister with "[**Name2 (NI) 500**] cancer." Sister died at 59 of
heart disease. Brother with myocardial infarction at age 63, son
in 40s.

Physical Exam:
VITAL SIGNS: 100.0  130/42  98  24  95% on RA
GENERAL: Lying in bed, breathing comfortably, in NAD
HEENT: Left pupil minimally reactive, right pupil reactive, MMM

NECK: No carotid bruits, JVP not well visualized
HEART: Regular rate and rhythm, 2/6 SEM
LUNGS: Clear to auscultation bilaterally
ABDOMEN: Hypoactive BS, soft, nondistended, + tenderness in
epigastric region, RLQ and LLQ, no rebound/guarding
EXTREMITIES: No c/c/e
NEUROLOGIC: Alert and oriented times three, MAEW
SKIN: Multiple areas of ecchymosis, petechiae

Pertinent Results:
Labwork on admission:
[**2115-9-23**] 04:35PM   WBC-34.4*# RBC-2.78*# HGB-8.4*# HCT-23.3*#
MCV-84 MCH-30.2 MCHC-36.0* RDW-16.8*
[**2115-9-23**] 04:35PM   PLT SMR-LOW PLT COUNT-82*
[**2115-9-23**] 04:35PM   NEUTS-64 BANDS-4 LYMPHS-14* MONOS-12* EOS-0
BASOS-1 ATYPS-0 METAS-4* MYELOS-1*
[**2115-9-23**] 04:35PM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2115-9-23**] 04:35PM   GLUCOSE-114* UREA N-41* CREAT-1.2* SODIUM-135
POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-24 ANION GAP-15
[**2115-9-23**] 04:35PM   ALT(SGPT)-38 AST(SGOT)-24 LD(LDH)-548*
CK(CPK)-33 ALK PHOS-79 AMYLASE-27 TOT BILI-1.1
[**2115-9-23**] 04:35PM   LIPASE-36
[**2115-9-23**] 04:35PM   CK-MB-NotDone cTropnT-0.02*
.
[**2115-9-25**] 04:02AM BLOOD Cortsol-6.2
[**2115-9-25**] 04:28AM BLOOD Cortsol-24.2*
[**2115-9-25**] 04:55AM BLOOD Cortsol-30.5*
.
Labwork on discharge:
[**2115-9-27**] 12:10AM BLOOD WBC-11.8* RBC-3.72* Hgb-10.9* Hct-30.9*
MCV-83 MCH-29.4 MCHC-35.4* RDW-16.5* Plt Ct-37*
[**2115-9-27**] 12:10AM BLOOD Neuts-41* Bands-0 Lymphs-19 Monos-27*
Eos-1 Baso-0 Atyps-1* Metas-6* Myelos-4* Promyel-1* NRBC-2*
[**2115-9-27**] 12:10AM BLOOD Glucose-169* UreaN-40* Creat-1.0 Na-135
K-4.3 Cl-102 HCO3-23 AnGap-14
.
CT ABDOMEN/PELVIS W/O CONTRAST  [**2115-9-23**]
IMPRESSION:
1. Inflammatory stranding adjacent to the ascending colon in the
setting of pancolonic diverticulosis. These findings are highly
suspicious for ascending colonic diverticulitis.
2. No evidence of retroperitoneal or other intraabdominal
hemorrhage.
3. Extensive atherosclerotic disease.
4. Status post left nephrectomy.
5. Cholelithiasis without evidence of cholecystitis.
6. Severe degenerative disease throughout the lumbar spine.
7. Anemia.
8. Adrenal hyperplasia.
.
ECG Study Date of [**2115-9-23**]
Sinus rhythm
Atrial premature complex
Nonspecific inferolateral ST-T wave abnormalities
Since previous tracing of 9=18-06, T wave changes slightly less
prominent
.
CHEST (PORTABLE AP)  [**2115-9-24**]
IMPRESSION: AP chest compared to [**2115-8-10**]:
Lung volumes are now normal. Lungs are clear. There is no
pleural effusion. Mild cardiomegaly is stable, and pulmonary
vasculature is mildly engorged. There is no free
subdiaphragmatic gas.
Tip of the right subclavian infusion port projects over the
upper SVC. Previous transvenous pacemaker has been removed.
.
CHEST (PORTABLE AP)  [**2115-9-25**]
IMPRESSION: AP chest compared to [**9-24**]:
Borderline cardiomegaly unchanged. Lungs clear. Mediastinal
fullness and leftward tracheal deviation suggest an enlarged
right thyroid lobe. No pneumothorax or pleural effusion.
Tip of the left subclavian line projects over the mid SVC.

Brief Hospital Course:
76 year-old female with MDS on chemotherapy with several days of
increasing lethargy, small amounts of BRBPR, and one episode of
brown emesis transferred from OSH with worsening anemia and
thrombocytopenia.
.
1. Anemia/question of gastrointestinal bleed. Her anemia is
likely secondary to recent chemotherapy and her underlying
disease with some component of gastrointestinal losses. The
patient was admitted with abdominal pain and one episode of
brown emesis. She complained of occasional small amounts of
bright red blood per rectum over the course of the week.
Possible sources for bleed are hemorrhoids in the setting of
thrombocytopenia (the patient has a history of hemorrhoids),
gastritis secondary to steroids, polyps, AVMs, or diverticula.
She had no episodes of overt GI bleeding during hospitalization
although she was guaiac positive on admission. The patient was
seen by gastroenterology, who did not wish to perform an
endoscopy given that the patient was not actively bleeding, was
thrombocytopenic, and was hemodynamically stable.
Gastroenterology believed the presumed upper GI bleeding to be
secondary to steroid gastritis versus lower GI bleeding from
diverticula. The patient was continued on a PPI. The patient's
aspirin was initially held; she was given one dose of aspirin in
the ICU when it was clear she was not bleeding. The patient's
oncologist did not want the patient to continue on aspirin with
her history of MDS and thrombocytopenia and the patient was
instructed not to restart aspirin.
.
2. Abdominal pain. The patient complained of diffuse lower
abdominal pain on admission. CT abdomen showed evidence of
diverticulitis as above. No evidence for ischemia. Lactate
remained elevated and was believed secondary to the patient's
underlying hematologic malignancy. The patient was treated with
ciprofloxacin and flagyl for a fourteen-day course. The patient
was febrile to 100.6 on admission but otherwise remained
afebrile. The patient's abdominal pain was resolved on
discharge.
.
3. Myelodysplastic syndrome. The patient was followed by her
primary oncologist throughout hospitalization. The patient
completed chemotherapy as above. WBC was elevated at 34 on admit
with evidence of atypical cells on smear. The patient received
two units packed red blood cells on admission. The patient was
transfused one unit packed red blood cells and one bag of
platelets prior to discharge. The patient requires HLA typed
transfusions.
.
4. History of recent myocardial infarction. The patient has a
recent history of inferior myocardial infarction. She was
asymptomatic throughout hospitalization. Cardiac enzymes were
slightly elevated on admission, likely secondary to demand. The
patient was continued on her statin, BB, and ACEI. ASA was held
as above.
.
5. Hypertension. The patient was continued on lisinopril and
half of her home dose of Toprol XL with good effect. The patient
was discharged home on half of her home Toprol XL.
.
6. Acute renal failure. The patient's creatinine was elevated on
admission; 1.2 from baseline 0.8-1.0. The patient's creatinine
improved after receiving blood transfusions and IV fluids.
Consistent with pre-renal etiology.
.
7. Elevated lactate. The patient's lactate remained elevated on
admission. The patient was not septic. The elevated lactate was
likely secondary to the patient's underlying hematologic
malignancy.
.
Code: DNR/DNI

Medications on Admission:
ASA 325 mg
Lipitor 80 mg
Lisinopril 10 mg
Toprol XL 100 mg
Predlo 10 mg qd
Furosemide 20 mg-patient stopped taking for urinary frequency

Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 21 doses.
Disp:*21 Tablet(s)* Refills:*0*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 31 doses.
Disp:*31 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Packet Sig: One (1)  PO once a day.
Disp:*30 Packets* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
1. Anemia, likely secondary to MDS versus GI source
2. Diverticulitis, on course of antibiotics, tolerating po
.
Secondary:
1. Myelodysplastic syndrome in transformation to AML, with 11%
blasts on peripheral smear [**4-30**], status post 5-azocytadine
treatment
2. Coronary artery disease status post Cypher stent to LAD [**11-30**]
off Plavix shortly thereafter with oncology input; recent MI
[**7-31**] treated medically secondary to thrombocytopenia. Restarted
on ASA at that time. Stress MIBI [**9-6**] showed moderate
inferolateral reversible defect.
4. Hypertension
5. Hypercholesterolemia
6. Left total hip replacement
7. Partial hysterectomy
8. Detached retina


Discharge Condition:
Afebrile, vital signs stable. Hematocrit and platelet count
stable.


Discharge Instructions:
Please contact a physician if you experience fevers, chills,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, black stools or blood in your stools, or any other
concerning symptoms.
.
Please take your medications as prescribed.
- You should take levofloxacin and flagyl (antibiotics) for
diverticulitis. Take one dose of each tonight and then as
direceted for ten more days.
- You should take lasix 20 mg once daily and one potassium
packet once daily later in the day for potassium repletion.
- Your dose of toprol XL was decreased to 50 mg once daily.
- You should continue prednisone 10 mg once daily.
- You should not take aspirin.
.
Please keep your follow-up appointments as below.

Followup Instructions:
Please go to [**Hospital3 7571**]Hospital on Monday morning for
follow-up. You should receive a Procrit shot at that time.
{'Anemia of other chronic disease,Unspecified gastritis and gastroduodenitis, with hemorrhage,Diverticulitis of colon (without mention of hemorrhage),Acute kidney failure, unspecified,Thrombocytopenia, unspecified,Myelodysplastic syndrome, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Acute myocardial infarction of other inferior wall, subsequent episode of care,Unspecified essential hypertension,Pure hypercholesterolemia,Hip joint replacement,Family history of ischemic heart disease'}


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: ?GI bleed

PRESENT ILLNESS: Ms. [**Known lastname 4541**] is a 76 year-old female with past medical history of
myelodysplastic syndrome (finished her third cycle of
5-Azacitidine four days prior to admission), status post recent
MI who was transferred from an OSH status post one episode of
brown emesis. The patient states she had not been feeling well
four days prior to admission. She went for her chemotherapy with
Vadasa and was found to have low hematocrit and
thrombocytopenia. She states that over the past few days she has
had diffuse abdominal pain with "gas pains" through her abdomen
and pain in her upper back. The morning of admission she awoke
with the need to vomit. She had one episode of brown emesis, but
did not note streaks of blood or coffee ground emesis. She
denies diarrhea and states she has been constipated over the
past few days. She has occasionally noted small amounts of
bright red blood on her toilet paper, but none in the toilet.
The day or admission she states that she initially had
constipation and then one large loose brown bowel movement. She
denies melena, fevers, chills.
.
She presented to an OSH for the emesis and abdominal pain. At
the OSH she recieved one unit of platelets for a platelet count
of 10. Hematocrit was 26. She was transferred to [**Hospital1 18**] for
further evaluation and management.
.
In the ER she received 1 L NS, anzemet and 2 mg of morphine IV.
Her temperature was noted to be 100.6. She was ordered for 2
units PRBCs and receieved 1 gm tylenol. She was found to have
guaiac positive brown stool on exam.
.
Upon arrival to the [**Hospital Unit Name 153**] her vital signs were stable. She was
still receiving her first unit of PRBCs.
.
In the ICU the patient was initially hemodynamically stable. Her
SBPs trended down to the upper 80s and she was transfused an
additional unit of PRBCs for possible bleed (hematocrit was
around 29 at that time and had risen appropriately). She was
also transfused platelets to keep her platelet count >50. She
was started on cipro/flagyl to cover for posisble diverticulitis
seen on CT abdomen. She was started on stress-dose steroids and
pressures improved over the next day. She was also noted to be
slightly hypoxic with O2 saturations 92% off O2. Her CXR was
clear and it did not appear she had an infection. The relative
hypoxia was believed to be secondary to some component of volume
overload.
.
ROS: Denies fevers, chills, dysuria, hematuria, SOB, dizziness.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
1. Myelodysplastic syndrome in transformation to AML, with 11%
blasts on peripheral smear [**4-30**], undergoing 5-azocytadine
treatment with no blasts seen for three months
2. Coronary artery disease status post Cypher stent to LAD [**11-30**]
off Plavix shortly thereafter with oncology input; recent MI
[**7-31**] treated medically secondary to thrombocytopenia. Restarted
on ASA at that time. Stress MIBI [**9-6**] showed moderate
inferolateral reversible defect.
4. Hypertension
5. Hypercholesterolemia
6. Left total hip replacement
7. Partial hysterectomy
8. Left nephrectomy 20 years ago secondary to nephrolithiasis
9. Detached retina

MEDICATION ON ADMISSION: ASA 325 mg
Lipitor 80 mg
Lisinopril 10 mg
Toprol XL 100 mg
Predlo 10 mg qd
Furosemide 20 mg-patient stopped taking for urinary frequency

ALLERGIES: Sulfa (Sulfonamides) / Shellfish

PHYSICAL EXAM: VITAL SIGNS: 100.0  130/42  98  24  95% on RA
GENERAL: Lying in bed, breathing comfortably, in NAD
HEENT: Left pupil minimally reactive, right pupil reactive, MMM

FAMILY HISTORY: Mother with uterine cancer. Father with history of hypertension,
died of stroke. Sister with "[**Name2 (NI) 500**] cancer." Sister died at 59 of
heart disease. Brother with myocardial infarction at age 63, son
in 40s.

SOCIAL HISTORY: She is a widow and lives alone in [**Hospital1 1806**], Mass. She does have a
20 pack-year smoking history but quit 7 years ago. She denies
alcohol use. She has two children. 

### Response:
{'Anemia of other chronic disease,Unspecified gastritis and gastroduodenitis, with hemorrhage,Diverticulitis of colon (without mention of hemorrhage),Acute kidney failure, unspecified,Thrombocytopenia, unspecified,Myelodysplastic syndrome, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Acute myocardial infarction of other inferior wall, subsequent episode of care,Unspecified essential hypertension,Pure hypercholesterolemia,Hip joint replacement,Family history of ischemic heart disease'}
