CHIEF COMPLAINT: Transferred from OSH w/ anemia and cardiac ischemia

PRESENT ILLNESS: 77 yo male w/ hx of a fib on coumadin, CABG (20 yrs ago), PVD -
s/p femoral bypass (? graft) and CEA x 2 who presetned to OSH on
evening of [**10-19**] after a fall. Per patient and daughter, patient
fell at home and landed on his face, however the patient cannot
recall the events surrounding the fall.

MEDICAL HISTORY: -CAD - s/p CABG in [**2097**] (for anatomy see outside records in
chart), per PCP free of angina symptoms since then
-A fib - dx in [**4-1**], on coumadin since then, INR on [**10-13**] was 2.5
-valvular heart disease - ECHO at [**Hospital1 2436**] in [**4-1**] w/ EF
50-555%, mild AS, mod AR, mod MR, mod TR - has been asymptomatic
-PVD - s/p r fem-[**Doctor Last Name **] bypass (? graft) years ago, had revision in
'[**14**]
-hypercholesterolemia

MEDICATION ON ADMISSION: atenolol
atorvastatin
coumadin

ALLERGIES: Zosyn

PHYSICAL EXAM: T 98.6, BP 114/62, HR 94, RR 18, sat 93% RA
HEENT: PERRL, EOMI, MMM, poor dentition
Lungs: LLL ronchi, decreased breath sounds at the R base
Cards: irregularly irregular, diastolic and systolic murmur,
unable to characterize
Abd: + bs, soft, mildly distended abdomen
Ext: 1+ lower ext edema bilat, pulses PT 1+ bilaterally.
Neuro: ambulates with assist, AOx1-2, interactive, follows
commands, speech appropriate, EOMI, PERRL, CN2-12 normal, normal
stregnth in all 4 extremities.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Retired in '[**97**] after his CABG. Lives with his daughter. [**Name (NI) **]
smoked since he was a teenager, formerly a moderate drink but no
etoh x several years.
Subendocardial infarction, initial episode of care,Acute duodenal ulcer with hemorrhage, without mention of obstruction,Pneumonitis due to inhalation of food or vomitus,Acute systolic heart failure,Acidosis,Acute respiratory failure,Cardiogenic shock,Closed fracture of malar and maxillary bones,Acute kidney failure with lesion of tubular necrosis,Paroxysmal ventricular tachycardia,Acute posthemorrhagic anemia,Mitral valve disorders,Diseases of tricuspid valve,Other and unspecified hyperlipidemia,Aortocoronary bypass status,Thrombocytopenia, unspecified,Unspecified fall,Long-term (current) use of anticoagulants,Peripheral vascular disease, unspecified,Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use
Subendo infarct, initial,Ac duodenal ulcer w hem,Food/vomit pneumonitis,Ac systolic hrt failure,Acidosis,Acute respiratry failure,Cardiogenic shock,Fx malar/maxillary-close,Ac kidny fail, tubr necr,Parox ventric tachycard,Ac posthemorrhag anemia,Mitral valve disorder,Tricuspid valve disease,Hyperlipidemia NEC/NOS,Aortocoronary bypass,Thrombocytopenia NOS,Fall NOS,Long-term use anticoagul,Periph vascular dis NOS,Drug dermatitis NOS,Adv eff penicillins
Admission Date:  [**2116-10-20**]              Discharge Date:   [**2116-11-3**]

Date of Birth:  [**2039-3-8**]             Sex:   M

Service: MEDICINE

Allergies:
Zosyn

Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Transferred from OSH w/ anemia and cardiac ischemia

Major Surgical or Invasive Procedure:
-Intubation
-EGD with cauterization
-reduction of nasal septum
-suturing of facial lacerations
-placement of radial a-line
-placement of left IJ trauma line
-intubation

History of Present Illness:
77 yo male w/ hx of a fib on coumadin, CABG (20 yrs ago), PVD -
s/p femoral bypass (? graft) and CEA x 2 who presetned to OSH on
evening of [**10-19**] after a fall. Per patient and daughter, patient
fell at home and landed on his face, however the patient cannot
recall the events surrounding the fall.

Patient's daugher reports that he had grown progressively
fatigued for several days PTA. On the day of his admission to
[**Hospital1 2436**] he was extremely fatigued and she noticed he was
dyspneic with minimal exertion. He had not been complaining of
shortness of breath of chest pain. No fevers/chills, abd pain,
vomiting, hematemesis, BRBPR, or melena. Cicumstances
surrounding fall are unclear; neither patient nor family able to
provide clear history. Of note, patient recently lost "some
weight" and six weks ago underwent a screening colonscopy to
look for malignancy. Daughter also reports that patient seemed
to have some trouble swallowing his food and was frequently
coughing/choking.

For several days prior to the fall patient had been complaining
of extreme fatigue and the daughter noted him to have
significant dyspnea on exertion. He had also been complianing of
back pain and had been taking vicodin sevreal days prior to
admission.

Presented to [**Hospital3 2783**] w/ a hct of 16, INR of 22-
given 2uPRBC and 1uFFP and 10 sc vit K x 1.  Had facial fx on
head CT w/o ICH.  Found to have a trop of 1.59 (n < 0.4).  Tx to
[**Hospital1 18**].  In [**Hospital1 **] ER found to be borderline hypotensive SBP 90-110,
and HR in 90s sating 100% on 4L and afebrile- showed ST dep
1-2mm in V4-V6 and STE of 1mm in V1/V2.  Found to have LLL
infiltrate and R sided pleural effusion.  Given levofloxacin.
Noted to have guiac + stools, no gross blood.  Admitted to ICU-
hypotensive to SBP of 70 but alert and answering questions
appropriately.  HR 91, hypothermic to 91F axillary.  Became
acutely unresponsive w/ labored breathing and HR in 20-30
(palpable) and SBP down to 50, patient rec'd atropine and
pressors.  Given 4 uPRBC, 2uFFP. Bedside echo showed EF of 30%
and anteroseptal WMA.  Pressors weaned.  EGD performed revealing
duodenal bulb ulcer w/ visible vessel for which bicap/epi was
applied, ? ischemic changes of gastric mucosa.  Normal
colonoscopy 6 weeks prior to admission so colonoscopy deferred.
Per ICU team- pt also had 15 beat run of NSVT w/o hemodyamic
compromise and "resolving delerium."

Past Medical History:
-CAD - s/p CABG in [**2097**] (for anatomy see outside records in
chart), per PCP free of angina symptoms since then
-A fib - dx in [**4-1**], on coumadin since then, INR on [**10-13**] was 2.5
-valvular heart disease - ECHO at [**Hospital1 2436**] in [**4-1**] w/ EF
50-555%, mild AS, mod AR, mod MR, mod TR - has been asymptomatic
-PVD - s/p r fem-[**Doctor Last Name **] bypass (? graft) years ago, had revision in
'[**14**]
-hypercholesterolemia

Social History:
Retired in '[**97**] after his CABG. Lives with his daughter. [**Name (NI) **]
smoked since he was a teenager, formerly a moderate drink but no
etoh x several years.

Family History:
Noncontributory

Physical Exam:
T 98.6, BP 114/62, HR 94, RR 18, sat 93% RA
HEENT: PERRL, EOMI, MMM, poor dentition
Lungs: LLL ronchi, decreased breath sounds at the R base
Cards: irregularly irregular, diastolic and systolic murmur,
unable to characterize
Abd: + bs, soft, mildly distended abdomen
Ext: 1+ lower ext edema bilat, pulses PT 1+ bilaterally.
Neuro: ambulates with assist, AOx1-2, interactive, follows
commands, speech appropriate, EOMI, PERRL, CN2-12 normal, normal
stregnth in all 4 extremities.

Pertinent Results:
EGD: ulcer w/ visible vessel in the proximal bulb.  Mottled
red/purple appearing mucosa in the stomach body/fundus
compatible with ischemic changes.

[**10-20**] head CT: Study is limited by motion.  No evidence of
intracranial hemorrhage identified. Multiple facial fractures,
as detailed above, however, incompletely visualized.
Encephalomalacia in the right frontal and right temporal regions
suggest prior hemorrhage, contusion or infarct.

[**2116-10-28**] repeat Head CT: No significant change since [**2116-10-20**] with
no intracranial hemorrhages.

ECHO [**10-20**]: EF 30%
Repeat Echo [**10-28**]: EF 45-50%. mildly dilated LV, intrinsic LV
systolic function likely depressed given the severity of
valvular regurg.  no effusion.  2+MR, 1+TR, 1+AR, mild AS..

admission labs [**10-20**]: hct 19, INR 3.6, WBC 19.1.
discharge labs [**11-3**]: BUN 17, Cr 0.7, WBC 11.7, hct 30.4, Plt
181, INR 1.3
C diff negative x 1

[**10-20**] TnT 0.27, peak [**10-27**] 1.36
[**10-20**] CK 334, peak [**10-21**] 847, [**10-30**] 47

u/a [**10-29**]: Lg blood, > 50 RBC, otherwise negative
Ucx negative
H. Pylori antibody +
[**10-27**] sputum: respiratory / OP flora
[**10-20**], [**10-23**] blood cx negative

CTA chest [**10-20**]
1.  No evidence of traumatic aortic injury or retroperitoneal
hematoma.
2.  Patchy opacity in the left lung base, likely aspiration,
with developing pneumonia.
3.  Moderate right-sided simple pleural effusion.
4.  Extensive paraseptal emphysema.
5.  Extensive atherosclerotic disease involving the coronary
arteries, aorta, and its major branches.
6.  Cystic structure associated with the left hip joint, which
could be a
synovial cyst or fluid within a bursa, other joint pathology
cannot be
excluded and an MRI could be of value


Brief Hospital Course:
GI bleed: in setting of INR 22 (on [**10-19**], although 6 days earlier
was reportedly 2.5).  Hct initially 16, found to have ulcer w/
visible vessel.  Given high risk of re-bleed patient was
monitored closely and responded to blood transfusions and
clinically improved. Hemodynamically stable for > 72 hours upon
discharge with a stable hct.  Patient will be discharged on a
regimen including flagyl/clarithromycin for H. pylori treatment.
 Also, he should be on a PPI [**Hospital1 **] x 2-3 weeks, this can then be
changed to daily.

NSTEMI: In the setting of severe anemia and hypovolemia the
patient had an elevated troponin, ST depressions in the
antero-lateral leads and a CK that peaked in the 800s.  His EF
dropped to 30% and recovered to 40-45% upon repeat Echo.  He was
started on an ACEi and was diuresed for mild volume overload.
He was started on lasix 20mg po daily upon discharge, this
should be titrated to a goal diuresis of net negative 500cc
daily, please titrate his diuretic based upon his volume status
and renal function.  He has cardiology follow up and a repeat
ECHO scheduled.  He would benefit from an outpatient stress
test, will defer to outpatient cardiology to plan this if
indicated.  Per GI patient should not restart coumadin or
aspirin.  If patient must restart ASA 81mg daily in the future
per cardiology would not restart until re-evaluated by GI and
ulcer has resolved on repeat endoscopy.

Leukocytosis: peaked at 18, normal diff, this trended downward
with no clear source of infection.  Cultures negative, C diff
negative x 1.

CHF: previously no documented history of CHF but in acute NSTEMI
EF was 30%, increased to 40-45% upon re-ECHO.  Has cardiology
follow up set and a repeat ECHO, continue ACEi and Lasix.

A-FIB: given absolute severity of illness due to
supratherapeutic INR (INR 22) would hold coumadin.  Unclear as
to why it was so high, possibly due to patient taking excessive
medication or to sensitivity to coumadin; however, these are
speculations at this time.

Medications on Admission:
atenolol
atorvastatin
coumadin

Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as
needed for constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: as directed  PO TID (3
times a day): 200mg po tid.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for Constipation.
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
take 40mg po bid until [**2116-11-26**] then tke 40mg po daily.
6. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 10 days.
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 10 days.
9. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).

11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary Diagnosis:
#. GI bleed secondary to duodenal Ulcer
#. Ischemic Gastritis
#. NSTEMI
#. Acute systolic CHF with depressed EF 45%
#. Delerium
.
Secondary:
#. Coronary Artery Disease - s/p CABG in [**2097**]
#. Afib
#. Moderate MR, Moderate TR
#. Peripheral Vascular Disease
#. Hyperlipidemia


Discharge Condition:
stable, sating well on RA, hemodynamically stable


Discharge Instructions:
1. Please take all medications as prescribed
.
2. Please keep all outpatient appointments.
.
3. Please follow the care of the Physicians at [**Hospital **] Rehab
.
4. Please return to the hospital for any symptoms of chest pain,
shortness of breath, fevers, chills, nausea/vomiting or any
other concerning symptoms.

Followup Instructions:
Friday [**11-13**] at 1:00 [**Initials (NamePattern5) **] [**Last Name (NamePattern5) 23**] building [**Location (un) 470**] on
the [**Hospital Ward Name 516**] of [**Hospital1 18**].
.
2. You will also need to follow up with cardiology on discharge.
You have an ECHOCARDIOGRAM on [**2116-12-21**] at 9:00 am. Please call
[**Telephone/Fax (1) 128**] with questions.
.
You have a caridiology follow-up appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 171**] on [**2116-12-21**] 11:20 in the [**Hospital Ward Name 23**] building on the [**Location (un) **]. The phone number is [**Telephone/Fax (1) 1989**]. Please cal with any
questions or scheduling concerns.
.
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25699**], after
discharge from the rehab facility. Please contact his office at
[**Telephone/Fax (1) 47432**]
{'Subendocardial infarction, initial episode of care,Acute duodenal ulcer with hemorrhage, without mention of obstruction,Pneumonitis due to inhalation of food or vomitus,Acute systolic heart failure,Acidosis,Acute respiratory failure,Cardiogenic shock,Closed fracture of malar and maxillary bones,Acute kidney failure with lesion of tubular necrosis,Paroxysmal ventricular tachycardia,Acute posthemorrhagic anemia,Mitral valve disorders,Diseases of tricuspid valve,Other and unspecified hyperlipidemia,Aortocoronary bypass status,Thrombocytopenia, unspecified,Unspecified fall,Long-term (current) use of anticoagulants,Peripheral vascular disease, unspecified,Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use'}


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: Transferred from OSH w/ anemia and cardiac ischemia

PRESENT ILLNESS: 77 yo male w/ hx of a fib on coumadin, CABG (20 yrs ago), PVD -
s/p femoral bypass (? graft) and CEA x 2 who presetned to OSH on
evening of [**10-19**] after a fall. Per patient and daughter, patient
fell at home and landed on his face, however the patient cannot
recall the events surrounding the fall.

MEDICAL HISTORY: -CAD - s/p CABG in [**2097**] (for anatomy see outside records in
chart), per PCP free of angina symptoms since then
-A fib - dx in [**4-1**], on coumadin since then, INR on [**10-13**] was 2.5
-valvular heart disease - ECHO at [**Hospital1 2436**] in [**4-1**] w/ EF
50-555%, mild AS, mod AR, mod MR, mod TR - has been asymptomatic
-PVD - s/p r fem-[**Doctor Last Name **] bypass (? graft) years ago, had revision in
'[**14**]
-hypercholesterolemia

MEDICATION ON ADMISSION: atenolol
atorvastatin
coumadin

ALLERGIES: Zosyn

PHYSICAL EXAM: T 98.6, BP 114/62, HR 94, RR 18, sat 93% RA
HEENT: PERRL, EOMI, MMM, poor dentition
Lungs: LLL ronchi, decreased breath sounds at the R base
Cards: irregularly irregular, diastolic and systolic murmur,
unable to characterize
Abd: + bs, soft, mildly distended abdomen
Ext: 1+ lower ext edema bilat, pulses PT 1+ bilaterally.
Neuro: ambulates with assist, AOx1-2, interactive, follows
commands, speech appropriate, EOMI, PERRL, CN2-12 normal, normal
stregnth in all 4 extremities.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Retired in '[**97**] after his CABG. Lives with his daughter. [**Name (NI) **]
smoked since he was a teenager, formerly a moderate drink but no
etoh x several years. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute duodenal ulcer with hemorrhage, without mention of obstruction,Pneumonitis due to inhalation of food or vomitus,Acute systolic heart failure,Acidosis,Acute respiratory failure,Cardiogenic shock,Closed fracture of malar and maxillary bones,Acute kidney failure with lesion of tubular necrosis,Paroxysmal ventricular tachycardia,Acute posthemorrhagic anemia,Mitral valve disorders,Diseases of tricuspid valve,Other and unspecified hyperlipidemia,Aortocoronary bypass status,Thrombocytopenia, unspecified,Unspecified fall,Long-term (current) use of anticoagulants,Peripheral vascular disease, unspecified,Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use'}
