CHIEF COMPLAINT: GIB, hypotension

PRESENT ILLNESS: Mr. [**Known lastname 21160**] is an 87 [**Hospital 100**] Rehab resident with a history of
coronary disease, s/p MI [**2167**], type II diabetes on oral therapy,
dementia, atrial fibrillation on coumadin, s/p recent admission
for hip fracture, with preop cath, found to have 3VD disease,
and s/p TEE cardioversion for atrial tachycardia who now
presents with 2 episodes of BRBPR and melena, 2x times.
.
In ED, HCT was initally 27 but with IVF dropped quickly to 19.
NG lavage negative. He subsequently became tachycardic and
hypotensive despite 6U of PRBC, 2U Factor [**7-23**] and 2U of FFP
transfusions and was intubated and started on dopamine while
waiting for angiography.

MEDICAL HISTORY: CAD s/p MI [**2167**], cath [**9-/2169**] with 3VD
Afib on warfarin
Type II diabetes
Dementia
s/p recent r hip fx
Moderate Pulmonary HTN

MEDICATION ON ADMISSION: Meds at last discharge:
Acetaminophen 500 mg PO Q4-6H as needed.
Morphine 2 mg/mL Q4H as needed.
Metoprolol Tartrate 50 mg PO Q6H
Amiodarone 200 mg PO daily
Bisacodyl 5 mg PO DAILY
Pantoprazole 40 mg Tablet PO Q24H
Docusate Sodium 100 mg PO BID
Senna 8.6 mg
Aspirin 81 mg Tablet
Oxycodone 5 mg PO Q6-8H as needed.
Enalapril Maleate 2.5 mg PO once a day.
Glyburide 5 mg PO once a day.
Warfarin 1 mg PO once a day
Simvastatin 20mg QD
Wellbyutrin 100mg Qd
Ferrous Sulfate 325mg QD
Insulin sliding scale

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: 98.4    156/84   90
AC 0.6, 550, 14, PIP 25, PEEP 5
Gen: intubated/sedated
HEENT: NC/AT, PERRLA, ET and NG tube in place
COR: Tachy, regular rhythm, no mrg
PULM: diffuse crackles bilaterally
ABD: + bowel sounds, soft, nd, nt
Skin: cool extremities, mottled feet, ulcer on dorsum of R foot,
multiple scratches on feet, operative wound on R hip well
healing
EXT: 1+ pulsus, 2+ edema up to the groin, scrotal edema
Neuro: moving all extremities, responding to pain, not following
commands, PERRLA, reflexes 1+ b/l

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Former bank teller. Lives at [**Hospital 100**] Rehab. Denies ETOH, tobacco.
Has cousins only still living for family. Makes own medical
decisions.
Other shock without mention of trauma,Acute kidney failure, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Congestive heart failure, unspecified,Acute and chronic respiratory failure,Atrial fibrillation,Acute posthemorrhagic anemia,Ulcer of ankle,Chronic kidney disease, unspecified,Thrombocytopenia, unspecified,Pneumonitis due to inhalation of food or vomitus,Mixed acid-base balance disorder,Methicillin susceptible pneumonia due to Staphylococcus aureus,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction,Diverticulosis of colon (without mention of hemorrhage),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery
Shock w/o trauma NEC,Acute kidney failure NOS,Gastrointest hemorr NOS,CHF NOS,Acute & chronc resp fail,Atrial fibrillation,Ac posthemorrhag anemia,Ulcer of ankle,Chronic kidney dis NOS,Thrombocytopenia NOS,Food/vomit pneumonitis,Mixed acid-base bal dis,Meth sus pneum d/t Staph,SIRS-noninf w ac org dys,Dvrtclo colon w/o hmrhg,DMII wo cmp nt st uncntr,Long-term use anticoagul,Crnry athrscl natve vssl
Admission Date:  [**2169-10-2**]              Discharge Date:   [**2169-10-28**]


Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 297**]
Chief Complaint:
GIB, hypotension

Major Surgical or Invasive Procedure:
s/p intubation
s/p IR embolization
s/p electrical cardioversion

History of Present Illness:
Mr. [**Known lastname 21160**] is an 87 [**Hospital 100**] Rehab resident with a history of
coronary disease, s/p MI [**2167**], type II diabetes on oral therapy,
dementia, atrial fibrillation on coumadin, s/p recent admission
for hip fracture, with preop cath, found to have 3VD disease,
and s/p TEE cardioversion for atrial tachycardia who now
presents with 2 episodes of BRBPR and melena, 2x times.
.
In ED, HCT was initally 27 but with IVF dropped quickly to 19.
NG lavage negative. He subsequently became tachycardic and
hypotensive despite 6U of PRBC, 2U Factor [**7-23**] and 2U of FFP
transfusions and was intubated and started on dopamine while
waiting for angiography.


Past Medical History:
CAD s/p MI [**2167**], cath [**9-/2169**] with 3VD
Afib on warfarin
Type II diabetes
Dementia
s/p recent r hip fx
Moderate Pulmonary HTN


Social History:
Former bank teller. Lives at [**Hospital 100**] Rehab. Denies ETOH, tobacco.
Has cousins only still living for family. Makes own medical
decisions.


Family History:
Noncontributory

Physical Exam:
Vitals: 98.4    156/84   90
AC 0.6, 550, 14, PIP 25, PEEP 5
Gen: intubated/sedated
HEENT: NC/AT, PERRLA, ET and NG tube in place
COR: Tachy, regular rhythm, no mrg
PULM: diffuse crackles bilaterally
ABD: + bowel sounds, soft, nd, nt
Skin: cool extremities, mottled feet, ulcer on dorsum of R foot,
multiple scratches on feet, operative wound on R hip well
healing
EXT: 1+ pulsus, 2+ edema up to the groin, scrotal edema
Neuro: moving all extremities, responding to pain, not following
commands, PERRLA, reflexes 1+ b/l


Pertinent Results:
139  110  20  /110    AGap=9
4.6  25  1.2  \
ALT: 15 AP: 94 Tbili: 0.5 Alb:
AST: 15 LDH:  Dbili:  TProt:
[**Doctor First Name **]:  Lip: 93
.
           95
9.4 \ 6.6  / 261
    / 19.5 \
 N:85.8 L:6.9 M:5.5 E:1.4 Bas:0.3
Comments: Notified Dr. [**First Name (STitle) 2855**] [**2169-10-2**] @9.50am
Macrocy: 1+
PT: 34.5  PTT: 38.2  INR: 3.7
.
[**2169-10-2**]
09:00a
             94
11.8 \  9.5 / 323
     / 27.4 \
.
[**10-2**] GI bleed study: No active GI bleeding identified.
.
[**10-3**] colonoscopy: Diverticulosis of the colon
Normal mucosa in the colon

[**10-3**] endoscopy: Normal EGD to second part of the duodenum


Brief Hospital Course:
a/p: 87 yo man with afib on coumadin, CHF, DMII, now with
massive lower GIB.
.
# GIB: Bleeding source was felt to be from a lower GI source
given negative NG lavage with BRBPR,  neg bleeding scan and EGD.
 Colonoscopy c/w diverticular bleed, although no active bleeding
seen. Initially rec'd 6U PRBC w/ appropriate bump in HCT.
however, while in angio, patient rec'd add'l 4U PRBC.  HCT
therefore transfused beyond goal, to approx 45.  Also rec'd 3U
FFP.  Maintained on [**Hospital1 **] PPI.  On transfer HCT stable. During
pt's prolonged MICU course, he developed recurrent BRBPR. On
[**10-17**] he underwent a tagged RBC scan which revealed bleeding in
the mid-transverse colon.    Selective superior mesenteric
arteriography revealed active extravasation from a third-order
terminal branch of the right middle colic artery and he
underwent successful superselective embolization of the bleeding
vessel using two microcoils and four straight coils with
immediate cessation of bleeding. Pt continued to have guiac
positive stools, but no further intervention was needed.
.
# Shock: initially though likely due to GIB and volume loss.  Hx
of diastolic CHF (last EF > 60%) and known 3VD. CXR consistent
with worsening failure. However following volume resuscitation
patient could not be weaned from pressors.  Started on Vanco,
Levo, Flagyl which he was maintained on until [**10-6**] (cultures
neg, off pressers).  Mvo2 71% and TTE was w/o evidence of
systolic dysfxn.  Titrated off norepinephrine on [**10-5**].
Throughout the prolonged MICU course, pt was intermittently
hypotensive, in the setting of diuresis, requiring intermittent
pressors.
.
# Respiratory Failure: Pt had respiratory failure of
multifactorial etiology secondary to diastolic CHF (in the
setting of large blood transfusion and IVF), multi-lobar
pneumonia, and possible ARDS physiology. Pt was diuresed as his
blood pressure tolerated. Pt was briefly extubated initially -
then required re-intubation. At the end of the pt's MICU course,
he was extubated. After discussions with the pt's HCP, he was
made DNR/DNI. During the morning that the pt expired, he was
noted to be breathing comfortably. A few minutes later, pt's
monitor was not [**Location (un) 1131**] a pulse ox. While the nurse and medical
team was at the bedside, pt became bradycardic and asystolic. No
CPR was initiated given pt's code status. He passed away very
quickly.
.
# Atrial fibrilliation: Difficult to control in the recent past.
On Amiodarone and Metoprolol for rate/rhythm control. In SR in
MICU initially. Amiodarone and Metoprolol were re-started when
BP stable.  Coumadin was held due to massive GIB. During the
MICU course, pt went into Af/Aflutter. He was seen by the EP
service who cardioverted him, given the possibility that his AF
was contributing to hemodynamic instability. Pt was successfully
converted into SR.
.
# CAD: Known 3VD. Initially held Aspirin, but re-started
following stable hct x48h.  Metoprolol as above.
.
# DM II: Maintained intermittently on insulin gtt and RISS
.
# PPX: Maintained on PPI [**Hospital1 **] and heparin sc once stable.


Medications on Admission:
Meds at last discharge:
Acetaminophen 500 mg PO Q4-6H as needed.
Morphine 2 mg/mL Q4H as needed.
Metoprolol Tartrate 50 mg PO Q6H
Amiodarone 200 mg PO daily
Bisacodyl 5 mg PO DAILY
Pantoprazole 40 mg Tablet PO Q24H
Docusate Sodium 100 mg PO BID
Senna 8.6 mg
Aspirin 81 mg Tablet
Oxycodone 5 mg PO Q6-8H as needed.
Enalapril Maleate 2.5 mg PO once a day.
Glyburide 5 mg PO once a day.
Warfarin 1 mg PO once a day
Simvastatin 20mg QD
Wellbyutrin 100mg Qd
Ferrous Sulfate 325mg QD
Insulin sliding scale


Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
GIB - diverticular bleed
Diastolic CHF
Multi-lobar pneumonia
Respiratory failure
Atrial fibrillation/A flutter
DM
CAD
Hypotension

Discharge Condition:
Expired

Discharge Instructions:
None

Followup Instructions:
None
{'Other shock without mention of trauma,Acute kidney failure, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Congestive heart failure, unspecified,Acute and chronic respiratory failure,Atrial fibrillation,Acute posthemorrhagic anemia,Ulcer of ankle,Chronic kidney disease, unspecified,Thrombocytopenia, unspecified,Pneumonitis due to inhalation of food or vomitus,Mixed acid-base balance disorder,Methicillin susceptible pneumonia due to Staphylococcus aureus,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction,Diverticulosis of colon (without mention of hemorrhage),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery'}


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: GIB, hypotension

PRESENT ILLNESS: Mr. [**Known lastname 21160**] is an 87 [**Hospital 100**] Rehab resident with a history of
coronary disease, s/p MI [**2167**], type II diabetes on oral therapy,
dementia, atrial fibrillation on coumadin, s/p recent admission
for hip fracture, with preop cath, found to have 3VD disease,
and s/p TEE cardioversion for atrial tachycardia who now
presents with 2 episodes of BRBPR and melena, 2x times.
.
In ED, HCT was initally 27 but with IVF dropped quickly to 19.
NG lavage negative. He subsequently became tachycardic and
hypotensive despite 6U of PRBC, 2U Factor [**7-23**] and 2U of FFP
transfusions and was intubated and started on dopamine while
waiting for angiography.

MEDICAL HISTORY: CAD s/p MI [**2167**], cath [**9-/2169**] with 3VD
Afib on warfarin
Type II diabetes
Dementia
s/p recent r hip fx
Moderate Pulmonary HTN

MEDICATION ON ADMISSION: Meds at last discharge:
Acetaminophen 500 mg PO Q4-6H as needed.
Morphine 2 mg/mL Q4H as needed.
Metoprolol Tartrate 50 mg PO Q6H
Amiodarone 200 mg PO daily
Bisacodyl 5 mg PO DAILY
Pantoprazole 40 mg Tablet PO Q24H
Docusate Sodium 100 mg PO BID
Senna 8.6 mg
Aspirin 81 mg Tablet
Oxycodone 5 mg PO Q6-8H as needed.
Enalapril Maleate 2.5 mg PO once a day.
Glyburide 5 mg PO once a day.
Warfarin 1 mg PO once a day
Simvastatin 20mg QD
Wellbyutrin 100mg Qd
Ferrous Sulfate 325mg QD
Insulin sliding scale

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: 98.4    156/84   90
AC 0.6, 550, 14, PIP 25, PEEP 5
Gen: intubated/sedated
HEENT: NC/AT, PERRLA, ET and NG tube in place
COR: Tachy, regular rhythm, no mrg
PULM: diffuse crackles bilaterally
ABD: + bowel sounds, soft, nd, nt
Skin: cool extremities, mottled feet, ulcer on dorsum of R foot,
multiple scratches on feet, operative wound on R hip well
healing
EXT: 1+ pulsus, 2+ edema up to the groin, scrotal edema
Neuro: moving all extremities, responding to pain, not following
commands, PERRLA, reflexes 1+ b/l

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Former bank teller. Lives at [**Hospital 100**] Rehab. Denies ETOH, tobacco.
Has cousins only still living for family. Makes own medical
decisions. 

### Response:
{'Other shock without mention of trauma,Acute kidney failure, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Congestive heart failure, unspecified,Acute and chronic respiratory failure,Atrial fibrillation,Acute posthemorrhagic anemia,Ulcer of ankle,Chronic kidney disease, unspecified,Thrombocytopenia, unspecified,Pneumonitis due to inhalation of food or vomitus,Mixed acid-base balance disorder,Methicillin susceptible pneumonia due to Staphylococcus aureus,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction,Diverticulosis of colon (without mention of hemorrhage),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery'}
