CHIEF COMPLAINT: Lightheadeness, Gastrointestinal bleed

PRESENT ILLNESS: Mr. [**Known lastname 14410**] is an 88 yo M with history of aortic aneursym status
post repair, MVR s/p porcine valve placement, atrial
fibrillation on coumadin, and diverticulosis who presented with
lightheadedness on [**2136-3-13**] and was found to have a GI bleed. He
admits to feeling weak one day prior and his wife reports he has
had increased fatigue throughout the week prior to presentation.
He notes he woke up early on morning of admission feeling very
dizzy and "woozy." His wife reports he has had bloody stools for
at least a week.  He also has had relatively severe nosebleeds
and had excessive bleeding from a cut on his hand over the past
week.  He denies any changes to his coumadin doses or other
changes in his medications recently.

MEDICAL HISTORY: -Coronary Artery Disease s/p 2 vessel CABG in [**5-11**] (LIMA to LAD,
SVG to PDA)
-Ascending Aortic Aneurysm s/p repair in [**2134**]
-Mitral Regurgitation s/p MVR with bioprosthetic valve in [**2134**]
-Atrial fibrillation
-Diabetes Mellitus
-Hypertension
-Benign Prostatic Hypertrophy
-Obesity
-Hiatal hernia
-S/p pacemaker in [**2129**]
-S/p left knee surgery
-Splenic hypodensity
-Anti-K antibiodies (requies [**Doctor Last Name **] antigen neg blood)

MEDICATION ON ADMISSION: Felodipine SR 10 mg daily
Finasteride 5 mg qam
Furosemide 20 mg daily
Insulin Asp Prt-Insulin Aspart [Novolog Mix 70-30] 5 units qam/8
units qpm
Lisinopril 2.5 mg daily
Metoprolol Tartrate 50 mg daily
Simvastatin 40 mg QHS
Terazosin 5 mg QHS
Aspirin 325 mg qam
Coumadin 5 mg 5 days, 10 mg 2 days
Benefiber

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T:97.1 BP: 119/47 P: 60 R: 16 O2: 99% on RA
General: Alert, oriented, no acute distress
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
Ext: large hematoma on L knee

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: He is a retired optometrist and a veteran of WWII.  He smoked
while he was in the Air Force and has not smoked since leaving
the army in the [**2067**]'s.  Extremely rare alcohol use.  He lives
at home with his wife.
Angiodysplasia of stomach and duodenum with hemorrhage,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Contusion of knee,Coronary atherosclerosis of unspecified type of vessel, native or graft,Diaphragmatic hernia without mention of obstruction or gangrene,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of venous thrombosis and embolism,Heart valve replaced by transplant,Cardiac pacemaker in situ,Aortocoronary bypass status,Anticoagulants causing adverse effects in therapeutic use,Unspecified fall
Angio stm/dudn w hmrhg,Acute kidney failure NOS,Ac posthemorrhag anemia,Urin tract infection NOS,Contusion of knee,Cor ath unsp vsl ntv/gft,Diaphragmatic hernia,DMII wo cmp nt st uncntr,Hypertension NOS,Hx-ven thrombosis/embols,Heart valve transplant,Status cardiac pacemaker,Aortocoronary bypass,Adv eff anticoagulants,Fall NOS
Admission Date:  [**2136-3-13**]              Discharge Date:   [**2136-3-17**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Lightheadeness, Gastrointestinal bleed

Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
Colonoscopy
Blood transfusions


History of Present Illness:
Mr. [**Known lastname 14410**] is an 88 yo M with history of aortic aneursym status
post repair, MVR s/p porcine valve placement, atrial
fibrillation on coumadin, and diverticulosis who presented with
lightheadedness on [**2136-3-13**] and was found to have a GI bleed. He
admits to feeling weak one day prior and his wife reports he has
had increased fatigue throughout the week prior to presentation.
He notes he woke up early on morning of admission feeling very
dizzy and "woozy." His wife reports he has had bloody stools for
at least a week.  He also has had relatively severe nosebleeds
and had excessive bleeding from a cut on his hand over the past
week.  He denies any changes to his coumadin doses or other
changes in his medications recently.

In the ED, initial vs were: T 97.3, P 78, BP 122/60, R 16, O2
sat 98% on RA. A foley was placed and per report approximately
200 cc of urine drained. He was found to have a 12 point Hct
drop from his prevoius value taken last summer and INR greater
than assay as well as acute renal failure. Patient was given 1 L
of NS, vitamin K 5 mg PO x1, protonix 40 mg IV x1 and 2 units of
PRBCs and 4 units of FFP were ordered. Additionally, patient got
up in the ED to urinate and fell. He was possibly unresponsive
mom[**Name (NI) 11711**]. CT head was negative. He did sustain bilateral knee
hematomas at the time.

He denies any recent changes in his coumadin dose and has been
on coumadin for about two years.  He reports taking some
supplements but mostly vitamins and melatonin. His last
colonoscopy was in [**11/2131**] and showed diverticulosis of the
sigmoid colon. EGD at that time showed a large hiatal hernia and
gastritis with normal biopsies.

In the MICU, the patient reports feeling well and denies ever
having chest pain, shortness of breath, abdominal pain, or
nausea and vomiting.  His greatest concern on transfer to the
floor is that his urine appeared quite bloody.

Review of Systems: The patient denied any fevers, chills, weight
loss, or recent illnesses.  No nausea, vomiting, abdominal pain,
or melena.  He denied any chest pain, shortness of breath, or
palpitations.  He did report some worsened urinary hesitancy and
feeling of being unable to void fully on the day prior to
presentation.


Past Medical History:
-Coronary Artery Disease s/p 2 vessel CABG in [**5-11**] (LIMA to LAD,
SVG to PDA)
-Ascending Aortic Aneurysm s/p repair in [**2134**]
-Mitral Regurgitation s/p MVR with bioprosthetic valve in [**2134**]
-Atrial fibrillation
-Diabetes Mellitus
-Hypertension
-Benign Prostatic Hypertrophy
-Obesity
-Hiatal hernia
-S/p pacemaker in [**2129**]
-S/p left knee surgery
-Splenic hypodensity
-Anti-K antibiodies (requies [**Doctor Last Name **] antigen neg blood)

Social History:
He is a retired optometrist and a veteran of WWII.  He smoked
while he was in the Air Force and has not smoked since leaving
the army in the [**2067**]'s.  Extremely rare alcohol use.  He lives
at home with his wife.


Family History:
Non-contributory

Physical Exam:
Vitals: T:97.1 BP: 119/47 P: 60 R: 16 O2: 99% on RA
General: Alert, oriented, no acute distress
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
Ext: large hematoma on L knee


Pertinent Results:
LABORATORY RESULTS
===================
On Presentation:
WBC-10.6# RBC-3.23*# Hgb-9.2*# Hct-28.1*# MCV-87 RDW-15.8* Plt
Ct-182
----Neuts-85.9* Lymphs-9.0* Monos-4.7 Eos-0.2 Baso-0.1
PT->150* PTT-68.5* INR(PT)->21.8*
Glucose-271* UreaN-40* Creat-2.6*# Na-137 K-4.8 Cl-101 HCO3-23
Calcium-9.1 Phos-4.6* Mg-2.9*

On Discharge:
WBC-6.7 RBC-3.76* Hgb-11.2* Hct-32.4* MCV-86 RDW-16.3* Plt
Ct-192
PT-18.7* PTT-29.0 INR(PT)-1.7*
Glucose-86 UreaN-14 Creat-0.9 Na-140 K-3.7 Cl-106 HCO3-25

Cardiac Enzymes:
CK 258 -- 256 -- 276
CK-MB: 4-- 4 -- 4
TropT 0.03 -- 0.02 -- 0.03

OTHER STUDIES
===============
CT head [**2136-3-13**]:
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Possible remote infarct in the left cerebellar hemisphere.
3. Diffuse pagetoid changes of the calvarium. Clinical
correlation
recommended.
4. Maxillary and ethmoid sinus disease, likely chronic in
nature. Clinical correlation recommended.

Chest Radiograph [**2136-3-13**]:
IMPRESSION: Interval improvement in lung aeration with band-like
atelectasis at the left lung base. Hiatal hernia. Mildly
prominent small bowel loops in the upper abdomen. Recommend
correlation with abdominal radiographs if there is need for
further evaluation.

ECG [**2136-3-14**]:
Regular ventricular pacing with probable underlying atrial
fibrillation.
Compared to the previous tracing pacing is now more consistent.


Brief Hospital Course:
88 year old man with significant cardiac history admitted with
significant coagulopathy, acute renal failure and a GI bleed.

1) Gastrointestinal bleed:  On presentation the patient had 12
point hematocrit drop from baseline and this was presumed to
have taken place over the previous week when he had been having
bleeding events.  He never evidenced any signs of hemodynamic
instability though his tachycardic response could be blunted by
his beta blockade.  At presentation he had guiac positive brown
stool but no hematochezia or melena.  His coagulopathy was
corrected and he was transfused.  Given overall he appeared
quite stable the decision was made to postpone endoscopy until
hematocrit was between 1.5 and 1.7.  Given the patient's history
of divericulosis this was considered the most likely cause of
bleeding and gastritis or upper source was considered much less
likely given he had not had melena.  Eventually, the patient
underwent upper and lower endoscopy of [**2136-3-16**], which showed no
active source of bleeding but erythema and congestion in the
lower part of the stomach with a small AVM.  Presumed source of
bleeding was this gastritis in the context in his initial severe
coagulopathy.  The patient was discharged on [**Hospital1 **] PPI therapy to
follow up with GI as an oupatient.  At the time of discharge his
hematocrit had been stable around 32 for >48 hours.

2) Coagulopathy: The etiology of the patient's coagulopathy is
unclear.  [**Name2 (NI) **] typically has had his INR checked monthly and
review of records by his [**Hospital3 **] reveals he has
been stable with INR's between 2 and 2.5 for a long time.  No
antibiotics, illnesses, or diet change.  On holding his coumadin
and reversal with vitamin K and FFP this quickly corrected.  He
was discharged on half of his usual coumadin dose with close
follow up in his [**Hospital3 **].  They will also inspect
his most recent set of coumadin pills to make sure he had not
received pills of a different dosage in error.  He was also
counseled to stop his supplements for the moment as these could
possibly interfere with his coumadin metabolism.  The patient
was also restarted on his aspirin prior to discharge.

3) Acute Kidney Injury: On presentation the patient's Cr was
increased at 2.6.  This quickly corrected with volume
resuscitation and transfusions, which suggests this was due to
pre-renal kidney injury due to his blood loss.  At the time of
discharge Cr was less than one.

4) Bilateral knee hematomas: These occurred after traumatic fall
in the ED.  He was seen by orthopedics who were confident that
this was superficial bleeding in the pre-patellar bursae with no
other major pathology.  This was observed and no further
management was instituted.

5) Coronary Artery Disease: The patient never had chest pain or
signs of active ischemia though he did have TWI that resolved in
the ED.  Three sets of cardiac enzymes remained stable
suggesting no demand infarction.  He was continued on his statin
and restarted on ACEi and beta blocker prior to discharge.

6) Aortic aneurysm s/p repair: Given lack of significant
abdominal pain and the patient's rapid improvement with volume
replacement no particular management for his history of aneurysm
repair was considered necessary.

7) Benign Prostatic Hypertrophy: The patient was continued on
his home finasteride and terazosin in the hospital.  Given
complaints of increased difficulty with urination he initially
had a foley catheter placed.  This was discontinued after he
left the ICU without difficulties with urination.  He did have
some hematuria while the catheter in place but this resolved
after removal and was thought most likely due to foley trauma in
the context of coagulopathy.

8) Diabetes Mellitus type 2: The patient was continued on his
home insulin regimen with some reduction in his standing doses
while NPO.  Reasonable control of his blood pressures was
obtained with this regimen.

9) Hypertension: The patient was nevery hypotensive.  Initially,
all of his home anti-hypertensives and diuretics were held.
Eventually his metoprolol, furosemide, and ACEi were restarted
but his calcium channel blocker continued to be held as he was
normotensive without it.

He received [**Hospital1 **] IV and then PO PPI for his GI bleed.  He had
pneumoboots for DVT prophylaxis.  He was full code.  Prior to
discharge he was tolerating a full diet.


Medications on Admission:
Felodipine SR 10 mg daily
Finasteride 5 mg qam
Furosemide 20 mg daily
Insulin Asp Prt-Insulin Aspart [Novolog Mix 70-30] 5 units qam/8
units qpm
Lisinopril 2.5 mg daily
Metoprolol Tartrate 50 mg daily
Simvastatin 40 mg QHS
Terazosin 5 mg QHS
Aspirin 325 mg qam
Coumadin 5 mg 5 days, 10 mg 2 days
Benefiber


Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: 5 in the
morning, 8 in the evening units Subcutaneous twice a day.
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please follow up with your primary care provider.  [**Name10 (NameIs) 2172**] dose may
need to be adjusted according to your blood work.
Disp:*30 Tablet(s)* Refills:*2*
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*3 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*3 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnoses:
GI Bleed
Supratherapeutic INR
Hiatal hernia
Arterio-venous malformations

Discharge Condition:
Vital signs stable, HCT 33, INR 1.6


Discharge Instructions:
You were admitted because you were bleeding from your GI tract.
This was most likely due to your blood being much too thin from
your coumadin.  The gastroenterologists looked and they only saw
some small foci of disordered vessels as a source of bleeding.
You seemed to stop bleeding once your blood was clotting
appropriately again but the gastroenterologists coagulated the
probable site of bleeding just in case.  It is unclear why your
blood was so much thinner than it has been.  It is possible you
got an incorrect prescription or somehow doses were confused.
You will need close monitoring of your coumadin over the next
weeks until your INR is stable once again.

Your medications have been changed.  You have been started on
OMEPRAZOLE, a medication to help stop further bleeding from the
AVM.  You should also stop taking the Warfarin you have and fill
a new prescription (you were given this).  You will start taking
2.5 mg/day and follow up with the [**Hospital 2786**] clinic at
[**Location (un) 620**] early next week.  Your FELODIPINE has been held as you
were not on this medication in the hospital and you had no high
blood pressure.  You should discuss with your regular doctor,
Dr. [**Last Name (STitle) 2204**], whether you need this medication.

We have stopped 1 of your hypertension (high blood pressure)
medications.  We have stopped your felodipine.  You should
continue with your metoprolol, lasix, and lisinopril.  Your
blood pressure has been fine while in the hospital.  Please
follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**] to see
if this medication needs to be re-added.

Please return to the hospital or call your doctor if you have
chest pain, shortness of breath, fevers or chills, or any other
concerning changes in your health.

Followup Instructions:
You have a follow up scheduled in [**Location (un) 620**] anticoagulation clinc
on Tuesday at 1:00 pm.  They would like you to bring the
coumadin pills you were taking prior to this in order to make
sure these were the appropriate dose.

You also have a follow up appointment with stomach and colon
specialist Dr. [**Last Name (STitle) 1940**] on [**2136-5-11**] at 3PM.  Please confirm this
with his clinic.  The clinic number is [**Telephone/Fax (1) 463**].

Please follow-up with Dr. [**Last Name (STitle) 2204**] next week.  His office number
is [**Telephone/Fax (1) 2205**].


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
{'Angiodysplasia of stomach and duodenum with hemorrhage,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Contusion of knee,Coronary atherosclerosis of unspecified type of vessel, native or graft,Diaphragmatic hernia without mention of obstruction or gangrene,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of venous thrombosis and embolism,Heart valve replaced by transplant,Cardiac pacemaker in situ,Aortocoronary bypass status,Anticoagulants causing adverse effects in therapeutic use,Unspecified fall'}


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: Lightheadeness, Gastrointestinal bleed

PRESENT ILLNESS: Mr. [**Known lastname 14410**] is an 88 yo M with history of aortic aneursym status
post repair, MVR s/p porcine valve placement, atrial
fibrillation on coumadin, and diverticulosis who presented with
lightheadedness on [**2136-3-13**] and was found to have a GI bleed. He
admits to feeling weak one day prior and his wife reports he has
had increased fatigue throughout the week prior to presentation.
He notes he woke up early on morning of admission feeling very
dizzy and "woozy." His wife reports he has had bloody stools for
at least a week.  He also has had relatively severe nosebleeds
and had excessive bleeding from a cut on his hand over the past
week.  He denies any changes to his coumadin doses or other
changes in his medications recently.

MEDICAL HISTORY: -Coronary Artery Disease s/p 2 vessel CABG in [**5-11**] (LIMA to LAD,
SVG to PDA)
-Ascending Aortic Aneurysm s/p repair in [**2134**]
-Mitral Regurgitation s/p MVR with bioprosthetic valve in [**2134**]
-Atrial fibrillation
-Diabetes Mellitus
-Hypertension
-Benign Prostatic Hypertrophy
-Obesity
-Hiatal hernia
-S/p pacemaker in [**2129**]
-S/p left knee surgery
-Splenic hypodensity
-Anti-K antibiodies (requies [**Doctor Last Name **] antigen neg blood)

MEDICATION ON ADMISSION: Felodipine SR 10 mg daily
Finasteride 5 mg qam
Furosemide 20 mg daily
Insulin Asp Prt-Insulin Aspart [Novolog Mix 70-30] 5 units qam/8
units qpm
Lisinopril 2.5 mg daily
Metoprolol Tartrate 50 mg daily
Simvastatin 40 mg QHS
Terazosin 5 mg QHS
Aspirin 325 mg qam
Coumadin 5 mg 5 days, 10 mg 2 days
Benefiber

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T:97.1 BP: 119/47 P: 60 R: 16 O2: 99% on RA
General: Alert, oriented, no acute distress
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
Ext: large hematoma on L knee

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: He is a retired optometrist and a veteran of WWII.  He smoked
while he was in the Air Force and has not smoked since leaving
the army in the [**2067**]'s.  Extremely rare alcohol use.  He lives
at home with his wife. 

### Response:
{'Angiodysplasia of stomach and duodenum with hemorrhage,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Contusion of knee,Coronary atherosclerosis of unspecified type of vessel, native or graft,Diaphragmatic hernia without mention of obstruction or gangrene,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of venous thrombosis and embolism,Heart valve replaced by transplant,Cardiac pacemaker in situ,Aortocoronary bypass status,Anticoagulants causing adverse effects in therapeutic use,Unspecified fall'}
