CHIEF COMPLAINT: Melena

PRESENT ILLNESS: 31 year old previously healthy male was seen at the office of
his PCP today for complaint of melena (black stools),
lightheadedness and mild ?coffee ground emesis. Patient states
he woke up on Sunday at 3am and had an episode of dark brown
emesis; given that he had just had BBQ for dinner, he was unsure
of the significance. The following morning, he had a solid
black, foul smelling, formed but slightly soft bowel movement.
He did not have any abdominal cramping but did have some
discomfort, so he started taking Pepto Bismo. The patient
proceeded to have two more episodes of tarry black stools on
Tuesday morning prior to going to his PCP's office. Throughout
Tuesday, he felt light headed and short of breath with mild
chest pressure when exerting himself (ex: walking up stairs to
his apartment). Labs at his PCP's office showed hemoglobin 7.6
and hematocrit 22.6. Patient was advised to come to the ER for
further work-up and management. Of note, patient denies
significant alcohol, NSAID, coffee consumption; also denies
significant retching with episode of emesis on Sunday or
significant history of GERD.
.
In the ED, patient was tachycardic to 110 although abdominal
exam was benign; patient was complaining of exertional chest
pressure/shortness of breath but cardiac enzymes were negative
X1. On rectal exam, no bright red blood or tarry stools were
found in the rectal vault but patient was guaiac positive. NG
lavage was performed which yielded coffee ground emesis that
would not clear after 400cc, no bright red emesis was noted.
Patient was given 1L intravenous fluid boluses and transfused 2
units of pRBC, type and crossed for 4 units. Two 18 gauge
peripheral IVs were placed and intravenous PPI started. GI was
informed of the patient and plans to do EGD in the morning
unless the patient is still tachycardic. VS upon transfer: were
afebrile, heart rate 102, BP126/65, RR20, 100%RA.
.
Upon arrival to the ICU, patient was resting comfortably in bed.
He denies current light headedness, chest pressure or shortness
of breath.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, rhinorrhea or congestion. Denies coughor
wheezing. Denies chest pain, palpitations, or weakness. Denies
nausea, diarrhea, constipation, abdominal pain. Denies dysuria,
frequency, or urgency.

MEDICAL HISTORY: Bilateral ankle fractures

MEDICATION ON ADMISSION: Occasional Centrum, Advil ~1X/week (up to 4 tabs

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: T: Afebrile BP: 156/84 P: 109  R: 18  O2: 98% RA
General: Alert, oriented, no acute distress, well-nourished
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: Diabetes Mellitus, no history of Peptic Ulcer Disease or
malignancies
.

SOCIAL HISTORY: Social History: Third year law student at [**University/College 86617**]T - Denies
A - [**1-24**] drinks every other weekend
D - Denies illicit drug use
Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute posthemorrhagic anemia,Helicobacter pylori [H. pylori],Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Tachycardia, unspecified,Chest pain, unspecified,Hypovolemia
Chr stomach ulc w hem,Ac posthemorrhag anemia,Helicobacter pylori,Gstr/ddnts NOS w/o hmrhg,Tachycardia NOS,Chest pain NOS,Hypovolemia
Admission Date:  [**2109-1-2**]              Discharge Date:   [**2109-1-5**]

Date of Birth:  [**2077-9-11**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Melena

Major Surgical or Invasive Procedure:
Upper endoscopy


History of Present Illness:
31 year old previously healthy male was seen at the office of
his PCP today for complaint of melena (black stools),
lightheadedness and mild ?coffee ground emesis. Patient states
he woke up on Sunday at 3am and had an episode of dark brown
emesis; given that he had just had BBQ for dinner, he was unsure
of the significance. The following morning, he had a solid
black, foul smelling, formed but slightly soft bowel movement.
He did not have any abdominal cramping but did have some
discomfort, so he started taking Pepto Bismo. The patient
proceeded to have two more episodes of tarry black stools on
Tuesday morning prior to going to his PCP's office. Throughout
Tuesday, he felt light headed and short of breath with mild
chest pressure when exerting himself (ex: walking up stairs to
his apartment). Labs at his PCP's office showed hemoglobin 7.6
and hematocrit 22.6. Patient was advised to come to the ER for
further work-up and management. Of note, patient denies
significant alcohol, NSAID, coffee consumption; also denies
significant retching with episode of emesis on Sunday or
significant history of GERD.
.
In the ED, patient was tachycardic to 110 although abdominal
exam was benign; patient was complaining of exertional chest
pressure/shortness of breath but cardiac enzymes were negative
X1. On rectal exam, no bright red blood or tarry stools were
found in the rectal vault but patient was guaiac positive. NG
lavage was performed which yielded coffee ground emesis that
would not clear after 400cc, no bright red emesis was noted.
Patient was given 1L intravenous fluid boluses and transfused 2
units of pRBC, type and crossed for 4 units. Two 18 gauge
peripheral IVs were placed and intravenous PPI started. GI was
informed of the patient and plans to do EGD in the morning
unless the patient is still tachycardic. VS upon transfer: were
afebrile, heart rate 102, BP126/65, RR20, 100%RA.
.
Upon arrival to the ICU, patient was resting comfortably in bed.
He denies current light headedness, chest pressure or shortness
of breath.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, rhinorrhea or congestion. Denies coughor
wheezing. Denies chest pain, palpitations, or weakness. Denies
nausea, diarrhea, constipation, abdominal pain. Denies dysuria,
frequency, or urgency.

Past Medical History:
Bilateral ankle fractures

Social History:
Social History: Third year law student at [**University/College 86617**]T - Denies
A - [**1-24**] drinks every other weekend
D - Denies illicit drug use


Family History:
 Diabetes Mellitus, no history of Peptic Ulcer Disease or
malignancies
.


Physical Exam:
Vitals: T: Afebrile BP: 156/84 P: 109  R: 18  O2: 98% RA
General: Alert, oriented, no acute distress, well-nourished
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:
[**2109-1-1**] 10:05PM BLOOD WBC-11.4* RBC-2.21* Hgb-6.2* Hct-18.5*
MCV-84 MCH-27.6 MCHC-33.0 RDW-15.9* Plt Ct-235
[**2109-1-1**] 10:05PM BLOOD Neuts-76* Bands-0 Lymphs-17* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-4*
[**2109-1-1**] 10:05PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2109-1-1**] 10:05PM BLOOD PT-13.5* PTT-25.0 INR(PT)-1.2*
[**2109-1-1**] 10:05PM BLOOD Ret Man-4.7*
[**2109-1-1**] 10:05PM BLOOD Glucose-109* UreaN-24* Creat-1.0 Na-137
K-4.2 Cl-105 HCO3-26 AnGap-10
[**2109-1-1**] 10:05PM BLOOD ALT-22 AST-24 LD(LDH)-176 CK(CPK)-92
AlkPhos-28* TotBili-0.2
[**2109-1-1**] 10:05PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2109-1-1**] 10:05PM BLOOD Lipase-47
[**2109-1-1**] 10:05PM BLOOD Albumin-3.4* [**Year/Month/Day **]-135
[**2109-1-1**] 10:05PM BLOOD calTIBC-289 VitB12-262 Folate-13.1
Hapto-105 Ferritn-98 TRF-222
[**2109-1-1**] 10:24PM BLOOD Glucose-108* Na-138 K-3.9 Cl-104
calHCO3-25
[**2109-1-1**] 11:12PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.019
[**2109-1-1**] 11:12PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG

[**1-2**]    HELICOBACTER PYLORI ANTIBODY TEST (Final [**2109-1-4**]):
      POSITIVE BY EIA.
           (Reference Range-Negative).

[**1-1**] ECG: Sinus tachycardia. Slight ST-T wave changes are
non-specific and may be within normal limits. No previous
tracing available for comparison.

[**1-2**] EGD: Old hematin was seen in the stomach. There was a very
small ulcer noted in her antrum with small clot overlying it.
This was likely the source of GI bleeding. There were also
several small erosions noted in the antrum as well as gastritis.
Erythema in the duodenal bulb compatible with duodenitis
Otherwise normal EGD to third part of the duodenum

[**2109-1-5**] 02:13AM BLOOD WBC-6.7 RBC-3.66* Hgb-10.4* Hct-31.0*
MCV-85 MCH-28.3 MCHC-33.5 RDW-17.8* Plt Ct-211
[**2109-1-5**] 02:13AM BLOOD Glucose-92 UreaN-12 Creat-1.2 Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
[**2109-1-4**] 05:10AM BLOOD ALT-18 AST-20 AlkPhos-32* TotBili-1.2
[**2109-1-5**] 02:13AM BLOOD Calcium-8.9 Phos-4.8*# Mg-2.2
[**2109-1-1**] 10:05PM BLOOD calTIBC-289 VitB12-262 Folate-13.1
Hapto-105 Ferritn-98 TRF-222
[**2109-1-1**] 10:05PM BLOOD Albumin-3.4* [**Year/Month/Day **]-135
[**2109-1-2**] 09:25AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2109-1-1**] 10:05PM BLOOD Ret Man-4.7*
[**2109-1-3**] 09:47AM BLOOD Hgb A-PENDING Hgb S-PND Hgb C-PND

Brief Hospital Course:
# Melena - Patient presented with melena and Hct of 18. He
received IVF and blood transfusions support as was admitted to
the MICU. An emergent EGD was performed and this revealed an
antral ulcer, as above. The patient denied alcohol or recent
NSAID use. Adequate type and screen and IV access were
maintained. He was also started on IV PPI boluses/gtt.
Overnight, the patient's Hct had decreased to 22.6, and the GI
fellow was paged. Urgent EGD was not felt to be necessary, as
the patient's NG lavage was negative for gross hemorrhage. Once
the patient was stable and Hct was also stable he was started on
a clear diet and advanced to regular. IV PPI was changed to PO
after 3 days of therapy. H Pylori serology was sent and resulted
in a positive test. He was started on clarithromycin and
metronidazole (allergic to penicillin) and given a prescription
to finish a 2 week course of triple therapy. He received a total
of 6 PRBC transfusions.
.
# Anemia - The patient had an active GI bleed as above, but it
was unclear what his baseline hematocrit is. Hemoglobin
electropheresis was sent, but these are still pending and should
be followed up by his PCP. [**Name10 (NameIs) **] panel and hemolysis labs were
WNL and this was all felt to be secondary to GI bleed.
.
# Substernal chest pressure - Believed to be mild demand
ischemia in setting of GI bleed. EKG and cardiac enzymes within
normal limits. The patient was followed on telemetry.
.
# Leukocytosis - Mild, likely demargination in the setting of
recent GI bleeding, this resolved after treatement for acute
GIB.
.
# Code: The patient was full code for the duration of the
admission

Medications on Admission:
Occasional Centrum, Advil ~1X/week (up to 4 tabs

Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 13 days.
Disp:*26 Tablet(s)* Refills:*0*
2. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 13 days.
Disp:*52 Tablet(s)* Refills:*0*
3. 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*


Discharge Disposition:
Home

Discharge Diagnosis:
Upper GI ulcer bleed
H. pylori


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


Discharge Instructions:
You were admitted because you were having blood in your stool
and found to be severe anemia due to blood loss. We transfused a
total of 6 units of blood. We did an upper endoscopy and found
you had an ulcer that looked like it had recently bled. You were
started on medications to decrease the acid in your stomach. You
were also found to have a bacteria in you stomach called H.
Pylori that can cause ulcers. You were started on antibiotics
for this and should finish a 2 week course of these.

Medication changes:
START: Pantoprazole 40 mg twice a day
START: Metronidazole 500 mg twice a day for 13 days
START: Clarithromycing 500 mg twice a day for 13 days


Followup Instructions:
Appointment #1
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Internal Medicine-Primary Care
Date/ Time:
Location: [**Street Address(2) 75332**], [**Location (un) 86**] Ma
Phone number: [**Telephone/Fax (1) 644**]
Special instructions for patient: The office will call you with
an appointment for your hospitalization. If you do not here from
the office in 2 business days please call them. Thanks.

Appointment #2
MD: Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 26390**]
Specialty: Gastroenterology
Date/ Time: [**2109-1-10**] 12:40pm
Location: [**Location (un) 4363**], [**Location (un) 86**] MA
Phone number: [**Telephone/Fax (1) 2296**]
{'Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute posthemorrhagic anemia,Helicobacter pylori [H. pylori],Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Tachycardia, unspecified,Chest pain, unspecified,Hypovolemia'}


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: 31 year old previously healthy male was seen at the office of
his PCP today for complaint of melena (black stools),
lightheadedness and mild ?coffee ground emesis. Patient states
he woke up on Sunday at 3am and had an episode of dark brown
emesis; given that he had just had BBQ for dinner, he was unsure
of the significance. The following morning, he had a solid
black, foul smelling, formed but slightly soft bowel movement.
He did not have any abdominal cramping but did have some
discomfort, so he started taking Pepto Bismo. The patient
proceeded to have two more episodes of tarry black stools on
Tuesday morning prior to going to his PCP's office. Throughout
Tuesday, he felt light headed and short of breath with mild
chest pressure when exerting himself (ex: walking up stairs to
his apartment). Labs at his PCP's office showed hemoglobin 7.6
and hematocrit 22.6. Patient was advised to come to the ER for
further work-up and management. Of note, patient denies
significant alcohol, NSAID, coffee consumption; also denies
significant retching with episode of emesis on Sunday or
significant history of GERD.
.
In the ED, patient was tachycardic to 110 although abdominal
exam was benign; patient was complaining of exertional chest
pressure/shortness of breath but cardiac enzymes were negative
X1. On rectal exam, no bright red blood or tarry stools were
found in the rectal vault but patient was guaiac positive. NG
lavage was performed which yielded coffee ground emesis that
would not clear after 400cc, no bright red emesis was noted.
Patient was given 1L intravenous fluid boluses and transfused 2
units of pRBC, type and crossed for 4 units. Two 18 gauge
peripheral IVs were placed and intravenous PPI started. GI was
informed of the patient and plans to do EGD in the morning
unless the patient is still tachycardic. VS upon transfer: were
afebrile, heart rate 102, BP126/65, RR20, 100%RA.
.
Upon arrival to the ICU, patient was resting comfortably in bed.
He denies current light headedness, chest pressure or shortness
of breath.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, rhinorrhea or congestion. Denies coughor
wheezing. Denies chest pain, palpitations, or weakness. Denies
nausea, diarrhea, constipation, abdominal pain. Denies dysuria,
frequency, or urgency.

MEDICAL HISTORY: Bilateral ankle fractures

MEDICATION ON ADMISSION: Occasional Centrum, Advil ~1X/week (up to 4 tabs

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: T: Afebrile BP: 156/84 P: 109  R: 18  O2: 98% RA
General: Alert, oriented, no acute distress, well-nourished
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: Diabetes Mellitus, no history of Peptic Ulcer Disease or
malignancies
.

SOCIAL HISTORY: Social History: Third year law student at [**University/College 86617**]T - Denies
A - [**1-24**] drinks every other weekend
D - Denies illicit drug use 

### Response:
{'Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute posthemorrhagic anemia,Helicobacter pylori [H. pylori],Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Tachycardia, unspecified,Chest pain, unspecified,Hypovolemia'}
