CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 73 year old
male with a recent history of paroxysmal atrial fibrillation
and hypercholesterolemia who presented to the Emergency
Department with the chief complaint of syncope.  The patient
was discharged from [**Hospital1 69**] with
the diagnosis of pulmonary embolism about six months prior to
the current admission and was started on Warfarin.  One month
prior to this admission, the patient reports not feeling well
with worsening gastric distress.  A few weeks prior to
admission, he fell down on his back and started taking
ibuprofen 1000 mg once a day for pain and Vioxx in addition
to his aspirin and Coumadin regimen.

MEDICAL HISTORY: 1.  Hyperthyroid disease status post radioactive iodine
ablation, now hypothyroid on Levoxyl.
2.  History of pulmonary embolism, etiology unknown.  It was
thought to be induced by frequent flying to [**State 108**].  The
patient was started on Coumadin five months prior to this
admission.
3.  Hypercholesterolemia.  Well controlled on Lipitor.  Last
total cholesterol was 168 in [**2142-5-28**].
4.  Paroxysmal atrial fibrillation in the setting of
pulmonary embolism.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for mother who has hypertension
and stroke at the age of 70.

SOCIAL HISTORY: The patient quit smoking 20 years ago;
ethanol one glass of wine a day.  He is a retired elementary
school principal and now works in [**Last Name (un) **] management.
Hematemesis,Atrial fibrillation,Acute myocardial infarction of other anterior wall, initial episode of care,Pure hypercholesterolemia,Postsurgical hypothyroidism,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Hematemesis,Atrial fibrillation,AMI anterior wall, init,Pure hypercholesterolem,Postsurgical hypothyroid,Abn react-procedure NEC
Admission Date:  [**2142-8-26**]       Discharge Date:  [**2142-8-31**]

Date of Birth:   [**2068-12-5**]       Sex:  M

Service:  MICU-GREEN

HISTORY OF PRESENT ILLNESS:  The patient is a 73 year old
male with a recent history of paroxysmal atrial fibrillation
and hypercholesterolemia who presented to the Emergency
Department with the chief complaint of syncope.  The patient
was discharged from [**Hospital1 69**] with
the diagnosis of pulmonary embolism about six months prior to
the current admission and was started on Warfarin.  One month
prior to this admission, the patient reports not feeling well
with worsening gastric distress.  A few weeks prior to
admission, he fell down on his back and started taking
ibuprofen 1000 mg once a day for pain and Vioxx in addition
to his aspirin and Coumadin regimen.

The night prior to admission, he was found by his wife on the
bathroom floor in a pool of urine, unresponsive without any
body movements, post-ictal state.  EMS was activated,
however, the patient refused to go to the hospital.  A
similar episode happened at 2 a.m. the same night and at
07:45 on the day of admission, the patient lost consciousness
once again when he was trying to sit up.  He was then
transferred to [**Hospital1 69**].

The patient reports some nausea and epigastric pressure which
is post-prandial.  He denies any emesis, melena, diarrhea or
constipation.  He describes the room spinning with attempts
to sit upright.  No history of previous episodes was noted.
Denies incontinence.  He does have diaphoresis and weakness
with orthostatic changes.

In the Emergency Department, stool guaiac was trace positive.
Hematocrit was 24.8, with a baseline of 46.  Gastric lavage
was grossly positive for coffee ground material.  His INR was
found to be 4.4.  He was given Vitamin K 10 mg
subcutaneously, 2.5 liters of normal saline, two units of
packed red blood cells and two units of fresh frozen plasma
and transferred to the Medical Intensive Care Unit for
further management.

PAST MEDICAL HISTORY:
1.  Hyperthyroid disease status post radioactive iodine
ablation, now hypothyroid on Levoxyl.
2.  History of pulmonary embolism, etiology unknown.  It was
thought to be induced by frequent flying to [**State 108**].  The
patient was started on Coumadin five months prior to this
admission.
3.  Hypercholesterolemia.  Well controlled on Lipitor.  Last
total cholesterol was 168 in [**2142-5-28**].
4.  Paroxysmal atrial fibrillation in the setting of
pulmonary embolism.

PAST SURGICAL HISTORY:
1.  Only significant for a right inguinal hernia repair.

ALLERGIES:   Penicillin.

OUTPATIENT MEDICATIONS:
1.  Lipitor 10 mg three times a week.
2.  Aspirin 81.
3.  Propranolol 10 mg three times a day.
4.  Coumadin 6.25 mg once a day.
5.  Levoxyl 100 mEq q. day.
6.  Ambien p.r.n.
7.  Vitamins.
8.  Vioxx times three weeks.

SOCIAL HISTORY:  The patient quit smoking 20 years ago;
ethanol one glass of wine a day.  He is a retired elementary
school principal and now works in [**Last Name (un) **] management.

FAMILY HISTORY:  Significant for mother who has hypertension
and stroke at the age of 70.

PHYSICAL EXAMINATION:  Temperature was 100.3 F.; heart rate
was 115.  In general, in no acute distress.  Alert and
oriented times three.  HEENT:  Extraocular movements are
intact.  Pupils equally round and reactive to light and
accommodation bilaterally.  Oropharynx clear.  Mucosal
membranes are moist.  Cardiovascular:  Regular rate and
rhythm, normal S1, S2, no murmurs, rubs or gallops.
Pulmonary clear to auscultation anteriorly.  Abdomen soft,
mildly distended, nontender, positive bowel sounds.
Extremities with no edema, one to two pulses in all four
extremities.

LABORATORY:  Sodium 141, potassium 4.4, chloride 108,
bicarbonate 23, BUN 57, creatinine 0.7, glucose 115.  White
blood cell count 11.0, differential with 76 neutrophils, 2
monos, 21 lymphocytes, and no eosinophils.  Hematocrit 24.8,
platelets 223, INR 2.4, CK 234.

CT scan of the head showed no hemorrhage or edema.  EKG
showed normal sinus rhythm at 90 with normal intervals and ST
wave inversions and early R wave progression.

HOSPITAL COURSE:  The patient was transferred to Medical
Intensive Care Unit for further management for acute GI
bleed.
1.  Gastrointestinal bleed:  The patient continued to receive
blood transfusions on the floor and serial hematocrits with
serial INR checks were drawn.  As he was receiving his third
unit of packed red blood cells, the patient became
tachycardic and short of breath.  His temperature raised from
98.6 F., to 101.0 F.  He was shown to have rigors.  The
transfusion was stopped and the patient was given Tylenol 1
mg with epinephrine, 100 mg of hydrocortisone, 25 mg of
Benadryl and Demerol 15 as well as Pepcid.  He had emesis
times three of 75 cc of coffee ground material.  The patient
also desaturated to the low 80s and was started on a
non-rebreather mask.

His saturations improved quickly on 100% non-rebreather mask
within 15 to 20 minutes.  Shortly after his mental status
changed; he became disoriented and euphoric and continued to
be in this state for two more hours.  After that period of
time, his mental status gradually improved and he continued
to receive his blood transfusions requiring a total of ten
units of packed red blood cells and four units of fresh
frozen plasma to reach a hematocrit of 30.0, which remained
stable for the duration of his stay.

On admission, the patient was started on high dose proton
pump inhibitors for prophylaxis.  On Wednesday, [**8-29**],
an esophagogastroduodenoscopy was performed and was
significant for the following findings:  Medium hiatal
hernia, Barrett's esophagus, erosion of the gastroesophageal
junction, granularity, erythema and congestion of the antrum
in the pre-pyloric region compatible with gastritis.
Erosions in the antrum and pre-pyloric region, granularity,
erythema and congestion of the anterior bulb and posterior
bulb compatible with duodenitis.

It was recommended by Gastroenterology that the patient is to
stay off aspirin for at least four to six weeks at discharge
to prevent further bleeding.

2.  Cardiovascular:  During transfusion reaction episode, the
patient had an episode of tachycardia ranging from 134 to
158, for one to two hours.  EKG during this episode was taken
and showed sinus tachycardia; however, serial enzymes were
significant for CK peaking at 1075, MB peaking at 114 and MB
index peaking at 10.8, consistent with myocardial damage.
The day following this episode, EKG showed loss of R wave
progression in anterior leads and Q waves in leads III and
AVF consistent with anteroseptal myocardial infarction.

The patient's blood pressures remained stable during his
stay.  He had no episodes of arrhythmia on Telemetry.
Cardiology consultation was obtained.  The myocardial
infarction was attributed to demand ischemia secondary to
acute hematocrit drop exacerbated by tachycardia secondary to
blood transfusion reaction.  Further Cardiologic work-up was
suggested as an outpatient at four to six weeks post
discharge.  The patient was started on Lopressor, Lipitor and
Lisinopril.

3.  After ten units of packed red blood cells and four units
of fresh frozen plasma transfusions, the patient's hematocrit
remained stable at above 30.  His INR decreased to 1.3 at the
time of discharge.  He required no blood transfusions for
four days prior to discharge.

4.  History of pulmonary embolism likely secondary to
frequent flying.  The need for further anti-coagulation was
discussed with the patient's attending, Dr. [**Last Name (STitle) 2146**], and it
was decided not to continue anti-coagulation due to increased
risk of gastrointestinal bleeding.  The patient remained
symptom free during his stay in the hospital, saturating well
in room air.

5.  Endocrine:  The patient was restarted on Levothyroxine
soon after admission.  His hemoglobin A1C was sent and it was
pending at the time of discharge.

6.  Single mental status change times two hours during
episode of blood transfusion reaction.  Was most likely due
to multiple drugs administered during the episode including
Demerol.  After this episode, the patient's mental status
remained clear for the rest of the duration of his stay.

7.  Prophylaxis:  The patient was sent home on proton pump
inhibitors.  His Helicobacter pylori serology was sent and
was pending at the time of discharge.

CONDITION AT DISCHARGE:   Good.

DISPOSITION:   The patient was discharged to home on the
following medications.

DISCHARGE MEDICATIONS:
1.  Lisinopril 5 mg p.o. q. day.
2.  Metoprolol 37.5 mg p.o. twice a day.
3.  Lipitor 10 mg p.o. q. day.
4.  Pantoprazole 40 mg p.o. q. day.
5.  Levothyroxine 100 micrograms p.o. q. day.

DISCHARGE INSTRUCTIONS:
1.  The patient was to arrange his follow-up with his primary
care physician, [**First Name4 (NamePattern1) 4559**] [**Last Name (NamePattern1) 4560**].
2.  To follow-up with his Cardiologist, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]
within one to two weeks of discharge.


                            [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 4561**]

Dictated By:[**Name8 (MD) 4562**]
MEDQUIST36

D:  [**2142-8-30**]  15:15
T:  [**2142-8-30**]  16:10
JOB#:  [**Job Number 4564**]


Admission Date:  [**2142-8-26**]       Discharge Date:  [**2142-8-31**]

Date of Birth:   [**2068-12-5**]       Sex:  M

Service:  MICU-GREEN

HISTORY OF PRESENT ILLNESS:  The patient is a 73 year old
male with a recent history of paroxysmal atrial fibrillation
and hypercholesterolemia who presented to the Emergency
Department with the chief complaint of syncope.  The patient
was discharged from [**Hospital1 69**] with
the diagnosis of pulmonary embolism about six months prior to
the current admission and was started on Warfarin.  One month
prior to this admission, the patient reports not feeling well
with worsening gastric distress.  A few weeks prior to
admission, he fell down on his back and started taking
ibuprofen 1000 mg once a day for pain and Vioxx in addition
to his aspirin and Coumadin regimen.

The night prior to admission, he was found by his wife on the
bathroom floor in a pool of urine, unresponsive without any
body movements, post-ictal state.  EMS was activated,
however, the patient refused to go to the hospital.  A
similar episode happened at 2 a.m. the same night and at
07:45 on the day of admission, the patient lost consciousness
once again when he was trying to sit up.  He was then
transferred to [**Hospital1 69**].

The patient reports some nausea and epigastric pressure which
is post-prandial.  He denies any emesis, melena, diarrhea or
constipation.  He describes the room spinning with attempts
to sit upright.  No history of previous episodes was noted.
Denies incontinence.  He does have diaphoresis and weakness
with orthostatic changes.

In the Emergency Department, stool guaiac was trace positive.
Hematocrit was 24.8, with a baseline of 46.  Gastric lavage
was grossly positive for coffee ground material.  His INR was
found to be 4.4.  He was given Vitamin K 10 mg
subcutaneously, 2.5 liters of normal saline, two units of
packed red blood cells and two units of fresh frozen plasma
and transferred to the Medical Intensive Care Unit for
further management.

PAST MEDICAL HISTORY:
1.  Hyperthyroid disease status post radioactive iodine
ablation, now hypothyroid on Levoxyl.
2.  History of pulmonary embolism, etiology unknown.  It was
thought to be induced by frequent flying to [**State 108**].  The
patient was started on Coumadin five months prior to this
admission.
3.  Hypercholesterolemia.  Well controlled on Lipitor.  Last
total cholesterol was 168 in [**2142-5-28**].
4.  Paroxysmal atrial fibrillation in the setting of
pulmonary embolism.

PAST SURGICAL HISTORY:
1.  Only significant for a right inguinal hernia repair.

ALLERGIES:   Penicillin.

OUTPATIENT MEDICATIONS:
1.  Lipitor 10 mg three times a week.
2.  Aspirin 81.
3.  Propranolol 10 mg three times a day.
4.  Coumadin 6.25 mg once a day.
5.  Levoxyl 100 mEq q. day.
6.  Ambien p.r.n.
7.  Vitamins.
8.  Vioxx times three weeks.

SOCIAL HISTORY:  The patient quit smoking 20 years ago;
ethanol one glass of wine a day.  He is a retired elementary
school principal and now works in [**Last Name (un) **] management.

FAMILY HISTORY:  Significant for mother who has hypertension
and stroke at the age of 70.

PHYSICAL EXAMINATION:  Temperature was 100.3 F.; heart rate
was 115.  In general, in no acute distress.  Alert and
oriented times three.  HEENT:  Extraocular movements are
intact.  Pupils equally round and reactive to light and
accommodation bilaterally.  Oropharynx clear.  Mucosal
membranes are moist.  Cardiovascular:  Regular rate and
rhythm, normal S1, S2, no murmurs, rubs or gallops.
Pulmonary clear to auscultation anteriorly.  Abdomen soft,
mildly distended, nontender, positive bowel sounds.
Extremities with no edema, one to two pulses in all four
extremities.

LABORATORY:  Sodium 141, potassium 4.4, chloride 108,
bicarbonate 23, BUN 57, creatinine 0.7, glucose 115.  White
blood cell count 11.0, differential with 76 neutrophils, 2
monos, 21 lymphocytes, and no eosinophils.  Hematocrit 24.8,
platelets 223, INR 2.4, CK 234.

CT scan of the head showed no hemorrhage or edema.  EKG
showed normal sinus rhythm at 90 with normal intervals and ST
wave inversions and early R wave progression.

HOSPITAL COURSE:  The patient was transferred to Medical
Intensive Care Unit for further management for acute GI
bleed.
1.  Gastrointestinal bleed:  The patient continued to receive
blood transfusions on the floor and serial hematocrits with
serial INR checks were drawn.  As he was receiving his third
unit of packed red blood cells, the patient became
tachycardic and short of breath.  His temperature raised from
98.6 F., to 101.0 F.  He was shown to have rigors.  The
transfusion was stopped and the patient was given Tylenol 1
mg with epinephrine, 100 mg of hydrocortisone, 25 mg of
Benadryl and Demerol 15 as well as Pepcid.  He had emesis
times three of 75 cc of coffee ground material.  The patient
also desaturated to the low 80s and was started on a
non-rebreather mask.

His saturations improved quickly on 100% non-rebreather mask
within 15 to 20 minutes.  Shortly after his mental status
changed; he became disoriented and euphoric and continued to
be in this state for two more hours.  After that period of
time, his mental status gradually improved and he continued
to receive his blood transfusions requiring a total of ten
units of packed red blood cells and four units of fresh
frozen plasma to reach a hematocrit of 30.0, which remained
stable for the duration of his stay.

On admission, the patient was started on high dose proton
pump inhibitors for prophylaxis.  On Wednesday, [**8-29**],
an esophagogastroduodenoscopy was performed and was
significant for the following findings:  Medium hiatal
hernia, Barrett's esophagus, erosion of the gastroesophageal
junction, granularity, erythema and congestion of the antrum
in the pre-pyloric region compatible with gastritis.
Erosions in the antrum and pre-pyloric region, granularity,
erythema and congestion of the anterior bulb and posterior
bulb compatible with duodenitis.

It was recommended by Gastroenterology that the patient is to
stay off aspirin for at least four to six weeks at discharge
to prevent further bleeding.

2.  Cardiovascular:  During transfusion reaction episode, the
patient had an episode of tachycardia ranging from 134 to
158, for one to two hours.  EKG during this episode was taken
and showed sinus tachycardia; however, serial enzymes were
significant for CK peaking at 1075, MB peaking at 114 and MB
index peaking at 10.8, consistent with myocardial damage.
The day following this episode, EKG showed loss of R wave
progression in anterior leads and Q waves in leads III and
AVF consistent with anteroseptal myocardial infarction.

The patient's blood pressures remained stable during his
stay.  He had no episodes of arrhythmia on Telemetry.
Cardiology consultation was obtained.  The myocardial
infarction was attributed to demand ischemia secondary to
acute hematocrit drop exacerbated by tachycardia secondary to
blood transfusion reaction.  Further Cardiologic work-up was
suggested as an outpatient at four to six weeks post
discharge.  The patient was started on Lopressor, Lipitor and
Lisinopril.

3.  After ten units of packed red blood cells and four units
of fresh frozen plasma transfusions, the patient's hematocrit
remained stable at above 30.  His INR decreased to 1.3 at the
time of discharge.  He required no blood transfusions for
four days prior to discharge.

4.  History of pulmonary embolism likely secondary to
frequent flying.  The need for further anti-coagulation was
discussed with the patient's attending, Dr. [**Last Name (STitle) 2146**], and it
was decided not to continue anti-coagulation due to increased
risk of gastrointestinal bleeding.  The patient remained
symptom free during his stay in the hospital, saturating well
in room air.

5.  Endocrine:  The patient was restarted on Levothyroxine
soon after admission.  His hemoglobin A1C was sent and it was
pending at the time of discharge.

6.  Single mental status change times two hours during
episode of blood transfusion reaction.  Was most likely due
to multiple drugs administered during the episode including
Demerol.  After this episode, the patient's mental status
remained clear for the rest of the duration of his stay.

7.  Prophylaxis:  The patient was sent home on proton pump
inhibitors.  His Helicobacter pylori serology was sent and
was pending at the time of discharge.

CONDITION AT DISCHARGE:   Good.

DISPOSITION:   The patient was discharged to home on the
following medications.

DISCHARGE MEDICATIONS:
1.  Lisinopril 5 mg p.o. q. day.
2.  Metoprolol 37.5 mg p.o. twice a day.
3.  Lipitor 10 mg p.o. q. day.
4.  Pantoprazole 40 mg p.o. q. day.
5.  Levothyroxine 100 micrograms p.o. q. day.

DISCHARGE INSTRUCTIONS:
1.  The patient was to arrange his follow-up with his primary
care physician, [**First Name4 (NamePattern1) 4559**] [**Last Name (NamePattern1) 4560**].
2.  To follow-up with his Cardiologist, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]
within one to two weeks of discharge.


                            [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 4561**]

Dictated By:[**Name8 (MD) 4562**]
MEDQUIST36

D:  [**2142-8-30**]  15:15
T:  [**2142-8-30**]  16:10
JOB#:  [**Job Number 4563**]
{'Hematemesis,Atrial fibrillation,Acute myocardial infarction of other anterior wall, initial episode of care,Pure hypercholesterolemia,Postsurgical hypothyroidism,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: 

PRESENT ILLNESS: The patient is a 73 year old
male with a recent history of paroxysmal atrial fibrillation
and hypercholesterolemia who presented to the Emergency
Department with the chief complaint of syncope.  The patient
was discharged from [**Hospital1 69**] with
the diagnosis of pulmonary embolism about six months prior to
the current admission and was started on Warfarin.  One month
prior to this admission, the patient reports not feeling well
with worsening gastric distress.  A few weeks prior to
admission, he fell down on his back and started taking
ibuprofen 1000 mg once a day for pain and Vioxx in addition
to his aspirin and Coumadin regimen.

MEDICAL HISTORY: 1.  Hyperthyroid disease status post radioactive iodine
ablation, now hypothyroid on Levoxyl.
2.  History of pulmonary embolism, etiology unknown.  It was
thought to be induced by frequent flying to [**State 108**].  The
patient was started on Coumadin five months prior to this
admission.
3.  Hypercholesterolemia.  Well controlled on Lipitor.  Last
total cholesterol was 168 in [**2142-5-28**].
4.  Paroxysmal atrial fibrillation in the setting of
pulmonary embolism.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for mother who has hypertension
and stroke at the age of 70.

SOCIAL HISTORY: The patient quit smoking 20 years ago;
ethanol one glass of wine a day.  He is a retired elementary
school principal and now works in [**Last Name (un) **] management. 

### Response:
{'Hematemesis,Atrial fibrillation,Acute myocardial infarction of other anterior wall, initial episode of care,Pure hypercholesterolemia,Postsurgical hypothyroidism,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
