CHIEF COMPLAINT: Hematochezia

PRESENT ILLNESS: [**Age over 90 **] y/o man admitted from rehab with BRBPR. Hct 31, baseline
32-33. Of note, was recently discharged [**2146-9-15**] after
admission for non-healing ulcer of right posterior heel
w/exposed achiles tendon. He underwent a right below knee
popliteal to dorsalis pedis artery bypass with reverse saphenous
vein [**2146-9-9**] followed by achilles tendon excision [**2146-9-13**].
Of note, he was discharged with Cipro, Linezolid and
Metronidazole to complete a 21 day course - exact reason is not
documented but presumed to be osteomyelitis in the right lateral
malleolus.
.
In ED - the patient was hemodynamically stable, was seen by GI
who recommended colonoscopy. Was found to have a
supratherapeutic INR @ 4.8 and was reversed with 2 Units FFP and
IV vitamin K. [**Year (4 digits) **] was contact[**Name (NI) **] who felt patient ok for
reversal. CT head negative

MEDICAL HISTORY: 1.Severe PVD: [**9-9**]: R BKPO-DP bypass w/ RSVG
2.10/2 Achilles tendon w/ abscess excision w/ VAC placement
3.Aortic Stenosis: Echo: [**12-19**]: moderate AS, aortic regurg,
mitral regurg, moderate pericardial effusion.
4.CAD: s/p cardiac cath: 90% distal LMCA, 80% LCX, Stent in
LMCA/LAD Cypher drug-eluting stent.
5.Carotid artery stenosis: Chronically occluded right internal
carotid artery. Left, with 40-59% carotid stenosis.
6. Hypercholesterolemia
7. Hypothyroidism
8. Chronic low back pain
9. AFib s/p ablation
[**48**]. s/p cholecystectomy
[**49**]. s/p bilateral carotid endartectomies
12. s/p left knee arthroscopy
13. s/p lumbar decompression '[**34**]
14. s/p left leg thrombectomy

MEDICATION ON ADMISSION: 1. Aspirin 81 mg PO Daily
2. Isosorbide Mononitrate 60 mg PO Daily
3. Furosemide 60 mg PO Daily
4. Levothyroxine 125 mcg PO Daily
5. Atorvastatin 80 mg PO Daily
6. Docusate Sodium 100 mg PO BID
7. Heparin (Porcine) 5,000 units TID
8. Pantoprazole 40 mg PO Q24H
9. Oxycodone-Acetaminophen 5-325 mg PO Q6H as needed
10. Warfarin 5 mg / 2.5 mg PO alternating days
11. Clopidogrel 75 mg PO Daily
12. Ciprofloxacin 500 mg PO Q12H
13. Ibuprofen 400 mg PO Q6H as needed for shoulder pain
14. Metronidazole 500 mg PO TID
15. Metoprolol Succinate 50 mg PO Daily
16. Linezolid 600 mg PO BID

ALLERGIES: Levaquin

PHYSICAL EXAM: Admission Physical Exam:
VS 98.0   85   123/55   18   100%RA
GEN: Well appearing - not oriented to date, but to person/place.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Previous 30 pack-year tobacco, quit 40 [**Year (2 digits) 1686**] ago. Occasional EtOH.
Currently at [**Hospital 169**] Center. Previously lived in the
basement of his daughter's house. Walks with a cane.
Dieulafoy lesion (hemorrhagic) of intestine,Pressure ulcer, ankle,Acute posthemorrhagic anemia,Delirium due to conditions classified elsewhere,Unspecified osteomyelitis, ankle and foot,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Peripheral vascular disease, unspecified,Retention of urine, unspecified,Atrial fibrillation,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Multiple involvement of mitral and aortic valves,Unspecified essential hypertension
Dieulafoy les, intestine,Pressure ulcer, ankle,Ac posthemorrhag anemia,Delirium d/t other cond,Osteomyelitis NOS-ankle,Long-term use anticoagul,Abnrml coagultion prfile,Adv eff anticoagulants,Periph vascular dis NOS,Retention urine NOS,Atrial fibrillation,Hypothyroidism NOS,Pure hypercholesterolem,Ocl crtd art wo infrct,Mitr/aortic mult involv,Hypertension NOS
Admission Date:  [**2146-10-12**]              Discharge Date:   [**2146-10-20**]


Service: MEDICINE

Allergies:
Levaquin

Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Hematochezia

Major Surgical or Invasive Procedure:
Mesenteric angiography
Flexible sigmoidoscopy

History of Present Illness:
[**Age over 90 **] y/o man admitted from rehab with BRBPR. Hct 31, baseline
32-33. Of note, was recently discharged [**2146-9-15**] after
admission for non-healing ulcer of right posterior heel
w/exposed achiles tendon. He underwent a right below knee
popliteal to dorsalis pedis artery bypass with reverse saphenous
vein [**2146-9-9**] followed by achilles tendon excision [**2146-9-13**].
Of note, he was discharged with Cipro, Linezolid and
Metronidazole to complete a 21 day course - exact reason is not
documented but presumed to be osteomyelitis in the right lateral
malleolus.
.
In ED - the patient was hemodynamically stable, was seen by GI
who recommended colonoscopy. Was found to have a
supratherapeutic INR @ 4.8 and was reversed with 2 Units FFP and
IV vitamin K. [**Year (4 digits) **] was contact[**Name (NI) **] who felt patient ok for
reversal. CT head negative

Past Medical History:
1.Severe PVD: [**9-9**]: R BKPO-DP bypass w/ RSVG
2.10/2 Achilles tendon w/ abscess excision w/ VAC placement
3.Aortic Stenosis: Echo: [**12-19**]: moderate AS, aortic regurg,
mitral regurg, moderate pericardial effusion.
4.CAD: s/p cardiac cath: 90% distal LMCA, 80% LCX, Stent in
LMCA/LAD Cypher drug-eluting stent.
5.Carotid artery stenosis: Chronically occluded right internal
carotid artery. Left, with 40-59% carotid stenosis.
6. Hypercholesterolemia
7. Hypothyroidism
8. Chronic low back pain
9. AFib s/p ablation
[**48**]. s/p cholecystectomy
[**49**]. s/p bilateral carotid endartectomies
12. s/p left knee arthroscopy
13. s/p lumbar decompression '[**34**]
14. s/p left leg thrombectomy

Social History:
Previous 30 pack-year tobacco, quit 40 [**Year (2 digits) 1686**] ago. Occasional EtOH.
Currently at [**Hospital 169**] Center. Previously lived in the
basement of his daughter's house. Walks with a cane.

Family History:
Non-contributory

Physical Exam:
Admission Physical Exam:
VS 98.0   85   123/55   18   100%RA
GEN: Well appearing - not oriented to date, but to person/place.

HEENT: EOMI, PERRL
NECK: no JVP appreciated
CV: RRR s1, soft s2, II/VI early peaking systolic murmur hear
best @ base
RESP: CTA b/l
ABD: soft, NT/ND, no masses
RECTAL: large clotty bright red blood on bedsheets when patient
turned.
EXT: well healed scar on right dorsum of foot, doplerable pulses
on right, palpable on left.

Pertinent Results:
Bleeding Scan: Positive bleeding scan, from rectum within the
first 5 minutes.
.
Femoral ultrasound: Normal [**Hospital 1106**] ultrasound in the right
groin. No hematoma.
.
Angio SMA,[**Female First Name (un) 899**],celic negative for bleeding.
.
Sigmoidoscopy: Bleeding rectal Dieulafoy lesion noted and
clipped.
.
[**2146-10-12**] 05:30PM BLOOD WBC-7.1 RBC-3.39* Hgb-10.2* Hct-30.2*
MCV-89 MCH-30.0 MCHC-33.7 RDW-17.8* Plt Ct-240
[**2146-10-12**] 05:30PM BLOOD Neuts-73.2* Lymphs-18.0 Monos-4.7 Eos-3.8
Baso-0.2
[**2146-10-12**] 05:30PM BLOOD PT-42.0* PTT-37.2* INR(PT)-4.8*
[**2146-10-18**] 05:07AM BLOOD PT-12.4 PTT-32.8 INR(PT)-1.1
[**2146-10-19**] 03:57PM BLOOD WBC-6.0 RBC-3.38* Hgb-10.5* Hct-30.5*
MCV-90 MCH-31.2 MCHC-34.6 RDW-16.8* Plt Ct-150
[**2146-10-12**] 05:30PM BLOOD Glucose-109* UreaN-24* Creat-1.3* Na-139
K-3.8 Cl-103 HCO3-26 AnGap-14
[**2146-10-19**] 05:50AM BLOOD Glucose-97 UreaN-9 Creat-1.0 Na-137 K-3.5
Cl-105 HCO3-26 AnGap-10
[**2146-10-12**] 10:42PM BLOOD ALT-12 AST-14 CK(CPK)-76 AlkPhos-68
Amylase-30 TotBili-0.6
[**2146-10-12**] 10:42PM BLOOD Lipase-41
[**2146-10-12**] 05:30PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2146-10-12**] 10:42PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2146-10-12**] 10:42PM BLOOD Albumin-2.9* Calcium-8.2* Phos-3.1 Mg-1.9
[**2146-10-19**] 05:50AM BLOOD Albumin-2.4* Calcium-7.9*
[**2146-10-13**] 04:28AM BLOOD TSH-14*
[**2146-10-14**] 01:33AM BLOOD T4-3.9* Free T4-0.69*
[**2146-10-15**] 04:00AM BLOOD CRP-28.6*
[**2146-10-13**] 07:37PM BLOOD Type-ART pH-7.33* Comment-GREEN TOP
[**2146-10-13**] 12:50PM BLOOD freeCa-1.02*
[**2146-10-18**] 03:38PM BLOOD freeCa-1.14

[**2146-10-19**] 03:57PM BLOOD WBC-6.0 RBC-3.38* Hgb-10.5* Hct-30.5*
MCV-90 MCH-31.2 MCHC-34.6 RDW-16.8* Plt Ct-150
[**2146-10-20**] 05:18AM BLOOD Glucose-88 UreaN-8 Creat-0.9 Na-134 K-3.5
Cl-105 HCO3-25 AnGap-8

Brief Hospital Course:
Patient is a [**Age over 90 **] year old man admitted from rehab with BRBPR,
supratherapeutic INR, confusion, now doing well after flexible
sigmoidoscopy, and colonoscopy, both with clipping of rectal
bleeding souce.
.
# Acute Blood Loss Anemia due to Rectal Bleeding:
Patient presented with BRBPR. Initially, a tagged red blood cell
scan showed bleeding from the rectum. However, subsequent
angiography was unable to localize and embolize the source of
bleed. A fexible sigmoidoscopy showed an actively bleeding
Dielafoys lesion which was successfully clipped. The patient
subsequently remained hemodynamically stable, with minimal
further RBC transfusions. Coumadin, aspirin, and Plavix were
initially held. Aspirin and Plavix were resumed prior to
discharge.
.
# Coagulopathy:
He was taking coumadin for a history of atrial fibrillation. He
presented with active GI bleeding in the context of a
supratherapeutic INR. He was reversed with vitamin K and FFP.
Coumadin, aspirin, and Plavix were initially held, though
aspirin and Plavix were resumed prior to discharge. Given his
recent large volume bleed, the risks of reinitiating coumadin
were felt to outweigh the benefits of stroke prevention.
.
# Atrial Fibrillation: Patient carries a history of atrial
fibrillation, status post ablation. He was noted to be in sinus
rhythm throughout his hospitalization. No details are available
as to what his history of "ablation" entailed. His coumadin was
stopped during this hospitalization, as described above.
.
# Delerium: Pt had sundowning at night and with aggitating
procedures that responded well to prn haldol. His mental status
improved with treatment of his medical illnesses and with his
daughter at bedside.
.
# Heel Ulcer: Patient was on cipro/Linezolid/Flagyl as
outpatient for 3 week course for suspected osteomyelitis, as
reported by [**Age over 90 1106**] surgery. ID was consulted. Given the
combination of non-elevated ESR/Sed rates and no sign of osteo
on f/u x-rays, the diagnosis of osteo was felt questionable. A 3
week course of Zosyn was initiated for treatment of pseudomonas
cultured from a wound swab.
.
# CAD: Patient had a DES placed in his LMCA in 1/[**2145**]. Although
antiplatelets were briefly held in the setting of active GI
bleed, they were restarted prior to his discharge. His
antihypertesnives and antianginals were also initially held in
the MICU. However, Imdur was restarted at 30 mg for elevated
blood pressures.
.
# Peripheral [**Year (4 digits) **] Disease: Seen by [**Year (4 digits) 1106**] in ED, and
enlisted help of podiatry.  [**Year (4 digits) **] surgery followed patient
and podiatry took care of the vac dressings changes.
.
# Hypothyroid: TSH in [**2146-4-12**] was 14 and currently on
levothyroxine.  TSH was 14 here with low T4 and free T4, so
increased levothyroxine dose to 150 mcg.
.
# Urinary retention: Patient had a foley placed [**9-9**] by urology
for tight phimosis, incontinence, and urinary retention.
Followed by urology as outpatinet. Voiding trial was to be
attempted as outpatient, unclear if this happened. Did not have
foley on arrival to ED, foley placed with pus expressed from
penis.  U/A positive for yeast on [**10-18**]. Voiding trial attempted
and failed. Flomax was initiated, and a foley replaced. A
voiding trial should be reattempted at rehab.
.
# ACCESS: 2 PIV, and a right IJ central line were placed. The IJ
was discontinued on [**2146-10-18**].
.
# PPx: The patient was placed on Heparin SQ for DVT prophylaxis
and continued on his PPI for GI prophylaxis.

Medications on Admission:
1. Aspirin 81 mg PO Daily
2. Isosorbide Mononitrate 60 mg PO Daily
3. Furosemide 60 mg PO Daily
4. Levothyroxine 125 mcg PO Daily
5. Atorvastatin 80 mg PO Daily
6. Docusate Sodium 100 mg PO BID
7. Heparin (Porcine) 5,000 units TID
8. Pantoprazole 40 mg PO Q24H
9. Oxycodone-Acetaminophen 5-325 mg PO Q6H as needed
10. Warfarin 5 mg / 2.5 mg PO alternating days
11. Clopidogrel 75 mg PO Daily
12. Ciprofloxacin 500 mg PO Q12H
13. Ibuprofen 400 mg PO Q6H as needed for shoulder pain
14. Metronidazole 500 mg PO TID
15. Metoprolol Succinate 50 mg PO Daily
16. Linezolid 600 mg PO BID

Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 3 weeks: Please
take until [**11-2**].
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital 169**] Center

Discharge Diagnosis:
Primary Diagnosis: Bleeding from a rectal Dieulafoy lesion
Secondary diagnoses: Right achilles tendon pressure ulcer
PVD s/p PO-DP bypass graft
aortic stenosis
hypercholesterolemia
hypothyroidism
hypertension


Discharge Condition:
Stable


Discharge Instructions:
You were admitted to the hospital for gastrointestinal bleeding.
You had a sigmoidoscopy that showed a Dieulefoy lesion that was
treated with a surgical clip. You recieved several units of
blood and platelets while you were in the hospital. Upon arrival
at the hospital, your INR (a measure of blood clotting) was
found to be high. You were taken off of the drug Coumadin and do
not need to take it again. The remainder of your home
medications have been continued.

You will also need to take three weeks of antibiotics for your
ankle wound, until [**11-3**].

You should also follow up with gastroenterology to schedule a
follow up colonoscopy.

If you experience any additional bleeding, changes in thinking
or behavior, experience shortness of breath, chest pain, or
lightheadedness, or other concerning symptoms please consult
your primary care physician or return to the emergency room.

Please follow up with the following doctors once [**Name5 (PTitle) **] are
discharged from the rehabilitation hospital.

Followup Instructions:
You will need to make followup appointments with the following
providers once you are discharged from rehab.

Gastroenterology: [**Telephone/Fax (1) 13246**]
[**First Name4 (NamePattern1) 21976**] [**Last Name (NamePattern1) 11679**] (primary care): [**Telephone/Fax (1) 26860**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiology): [**Telephone/Fax (1) 2394**]
Dermatology: ([**Telephone/Fax (1) 45763**]
.
You have the following appointments scheduled:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2146-11-10**] 1:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2146-11-10**] 2:00
{'Dieulafoy lesion (hemorrhagic) of intestine,Pressure ulcer, ankle,Acute posthemorrhagic anemia,Delirium due to conditions classified elsewhere,Unspecified osteomyelitis, ankle and foot,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Peripheral vascular disease, unspecified,Retention of urine, unspecified,Atrial fibrillation,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Multiple involvement of mitral and aortic valves,Unspecified essential hypertension'}


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: Hematochezia

PRESENT ILLNESS: [**Age over 90 **] y/o man admitted from rehab with BRBPR. Hct 31, baseline
32-33. Of note, was recently discharged [**2146-9-15**] after
admission for non-healing ulcer of right posterior heel
w/exposed achiles tendon. He underwent a right below knee
popliteal to dorsalis pedis artery bypass with reverse saphenous
vein [**2146-9-9**] followed by achilles tendon excision [**2146-9-13**].
Of note, he was discharged with Cipro, Linezolid and
Metronidazole to complete a 21 day course - exact reason is not
documented but presumed to be osteomyelitis in the right lateral
malleolus.
.
In ED - the patient was hemodynamically stable, was seen by GI
who recommended colonoscopy. Was found to have a
supratherapeutic INR @ 4.8 and was reversed with 2 Units FFP and
IV vitamin K. [**Year (4 digits) **] was contact[**Name (NI) **] who felt patient ok for
reversal. CT head negative

MEDICAL HISTORY: 1.Severe PVD: [**9-9**]: R BKPO-DP bypass w/ RSVG
2.10/2 Achilles tendon w/ abscess excision w/ VAC placement
3.Aortic Stenosis: Echo: [**12-19**]: moderate AS, aortic regurg,
mitral regurg, moderate pericardial effusion.
4.CAD: s/p cardiac cath: 90% distal LMCA, 80% LCX, Stent in
LMCA/LAD Cypher drug-eluting stent.
5.Carotid artery stenosis: Chronically occluded right internal
carotid artery. Left, with 40-59% carotid stenosis.
6. Hypercholesterolemia
7. Hypothyroidism
8. Chronic low back pain
9. AFib s/p ablation
[**48**]. s/p cholecystectomy
[**49**]. s/p bilateral carotid endartectomies
12. s/p left knee arthroscopy
13. s/p lumbar decompression '[**34**]
14. s/p left leg thrombectomy

MEDICATION ON ADMISSION: 1. Aspirin 81 mg PO Daily
2. Isosorbide Mononitrate 60 mg PO Daily
3. Furosemide 60 mg PO Daily
4. Levothyroxine 125 mcg PO Daily
5. Atorvastatin 80 mg PO Daily
6. Docusate Sodium 100 mg PO BID
7. Heparin (Porcine) 5,000 units TID
8. Pantoprazole 40 mg PO Q24H
9. Oxycodone-Acetaminophen 5-325 mg PO Q6H as needed
10. Warfarin 5 mg / 2.5 mg PO alternating days
11. Clopidogrel 75 mg PO Daily
12. Ciprofloxacin 500 mg PO Q12H
13. Ibuprofen 400 mg PO Q6H as needed for shoulder pain
14. Metronidazole 500 mg PO TID
15. Metoprolol Succinate 50 mg PO Daily
16. Linezolid 600 mg PO BID

ALLERGIES: Levaquin

PHYSICAL EXAM: Admission Physical Exam:
VS 98.0   85   123/55   18   100%RA
GEN: Well appearing - not oriented to date, but to person/place.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Previous 30 pack-year tobacco, quit 40 [**Year (2 digits) 1686**] ago. Occasional EtOH.
Currently at [**Hospital 169**] Center. Previously lived in the
basement of his daughter's house. Walks with a cane. 

### Response:
{'Dieulafoy lesion (hemorrhagic) of intestine,Pressure ulcer, ankle,Acute posthemorrhagic anemia,Delirium due to conditions classified elsewhere,Unspecified osteomyelitis, ankle and foot,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Peripheral vascular disease, unspecified,Retention of urine, unspecified,Atrial fibrillation,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Multiple involvement of mitral and aortic valves,Unspecified essential hypertension'}
