CHIEF COMPLAINT: Lower GI Bleed

PRESENT ILLNESS: This is a 67 y/o female s/p OLT on [**2172-5-1**] for autoimmune
hepatitis, c/b by anterior abdominal wall necrosis, readmitted
on
[**2172-7-15**] for fevers and poor PO intake. On the previous
admission,
the patient had a klebsiella UTI, which was treated with
ciprofloxacin. In addition, she was found to have a right calf
DVT, in which coumadin was started. The patient was in her usual
state of health from [**7-21**] until 2 days ago, when she began to
have
dark, tarry stools. She had approximately [**3-24**] BM/day for the
past
2 days. She also complains of nausea and persistent poor PO
intake (which is her baseline and she has a Dobbhoff tube in
place for TF). Her hct last week was 31, now it is 25. Her INR
is
4.4. She received 10mg IV Vit K in the ED. The patient denies
headache, chest pain, SOB, chills/fever, and dysuria. However,
the patient does state dizziness on ambulating and persistent
right calf pain.

MEDICAL HISTORY: HLD
Autoimmune hepatitis/cirrhosis, diagnoed 14 yrs ago with bx in
[**Male First Name (un) 1056**], complicated by varices
RA
DM2 with neuropathy
HTN, incl hypertensive nephropathy
B12 deficiency
Vitamin D Deficiency
Chronic pain syndrome - "colonic pain" per pt records
Colon polyps (hyperplastic and tubular adenoma)
Diverticulitis
Depression
PAD
s/p chole
s/p appy
s/p TAH/USO
Bladder prolapse repair
[**2172-5-1**] Liver transplant
[**2172-5-12**] ERCP, sphincterotomy, stent placement

MEDICATION ON ADMISSION: mycophenolate sodium 360 mg [**Hospital1 **], Tacrolimus 1mg [**Hospital1 **],
Ursodiol 300 mg TID, valganciclovir 450 mg TID, Vitamin D 800U
daily, amlodipine 10mg daily, ascorbic acid 500 mg [**Hospital1 **],
clonidine
0.1 mg daily, esomeprazole 40mg [**Hospital1 **], fluconazole 200 mg daily,
gabapentin 300mg [**Hospital1 **], regular insulin SS, metoprolol 37.5 mg
TID,
MVI daily, olanzapine 2.5 mg qHS, prednisone 2.5 mg daily,
sertraline 25 mg daily, Bactrim SS daily, Insulin glargine 12U
qHS, levothyroxine 25 mcg daily, ambien 5mg prn, loperamide 4mg
TID prn, ondansetron 4mg TID prn, Dilaudid prn

ALLERGIES: No Known Drug Allergies / Lactose

PHYSICAL EXAM: T 97.7 HR 86  BP 108/42  RR 18  98% RA
GEN: NAD, AAOx3, no jaundice
HEENT: no scleral icterus, appears dry
CHEST: CTA B/L
HEART: RRR, S1, S2
ABD: soft, NT, Chevron incision with packing, no
rebound/guarding
Wound: opened Chevron incision with packing, good granulation
tissue, areas of exudate at the base of the wound, no drainage.
EXT: warm, no edema, R calf tender to palpation

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: originally from [**Male First Name (un) 1056**]; has lived her with family for last
3 years. No etoh, illicits or tobacoo.
Blood in stool,Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity,Acute kidney failure, unspecified,Liver replaced by transplant,Unspecified protein-calorie malnutrition,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Urinary tract infection, site not specified,Polyneuropathy in diabetes,Abnormal coagulation profile,Other and unspecified hyperlipidemia,Rheumatoid arthritis,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other B-complex deficiencies,Depressive disorder, not elsewhere classified,Other chronic pain,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other specified disorders of skin,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Infection with drug-resistant microorganisms, unspecified, with multiple drug resistance,Postprocedural fever,Diarrhea
Blood in stool,Ch DVT/embl prox low ext,Acute kidney failure NOS,Liver transplant status,Protein-cal malnutr NOS,Pseudomonas infect NOS,Urin tract infection NOS,Neuropathy in diabetes,Abnrml coagultion prfile,Hyperlipidemia NEC/NOS,Rheumatoid arthritis,DMII neuro nt st uncntrl,Long-term use of insulin,B-complex defic NEC,Depressive disorder NEC,Chronic pain NEC,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Skin disorders NEC,Abn react-org transplant,Infc mcrg drgrst mult,Postprocedural fever,Diarrhea
Admission Date:  [**2172-7-27**]              Discharge Date:   [**2172-8-5**]

Date of Birth:  [**2105-3-24**]             Sex:   F

Service: SURGERY

Allergies:
No Known Drug Allergies / Lactose

Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Lower GI Bleed

Major Surgical or Invasive Procedure:
[**2172-7-31**]: IVC Filter placement

History of Present Illness:
 This is a 67 y/o female s/p OLT on [**2172-5-1**] for autoimmune
hepatitis, c/b by anterior abdominal wall necrosis, readmitted
on
[**2172-7-15**] for fevers and poor PO intake. On the previous
admission,
the patient had a klebsiella UTI, which was treated with
ciprofloxacin. In addition, she was found to have a right calf
DVT, in which coumadin was started. The patient was in her usual
state of health from [**7-21**] until 2 days ago, when she began to
have
dark, tarry stools. She had approximately [**3-24**] BM/day for the
past
2 days. She also complains of nausea and persistent poor PO
intake (which is her baseline and she has a Dobbhoff tube in
place for TF). Her hct last week was 31, now it is 25. Her INR
is
4.4. She received 10mg IV Vit K in the ED. The patient denies
headache, chest pain, SOB, chills/fever, and dysuria. However,
the patient does state dizziness on ambulating and persistent
right calf pain.


Past Medical History:
HLD
Autoimmune hepatitis/cirrhosis, diagnoed 14 yrs ago with bx in
[**Male First Name (un) 1056**], complicated by varices
RA
DM2 with neuropathy
HTN, incl hypertensive nephropathy
B12 deficiency
Vitamin D Deficiency
Chronic pain syndrome - "colonic pain" per pt records
Colon polyps (hyperplastic and tubular adenoma)
Diverticulitis
Depression
PAD
s/p chole
s/p appy
s/p TAH/USO
Bladder prolapse repair
[**2172-5-1**] Liver transplant
[**2172-5-12**] ERCP, sphincterotomy, stent placement


Social History:
originally from [**Male First Name (un) 1056**]; has lived her with family for last
3 years. No etoh, illicits or tobacoo.


Family History:
non-contributory

Physical Exam:
T 97.7 HR 86  BP 108/42  RR 18  98% RA
GEN: NAD, AAOx3, no jaundice
HEENT: no scleral icterus, appears dry
CHEST: CTA B/L
HEART: RRR, S1, S2
ABD: soft, NT, Chevron incision with packing, no
rebound/guarding
Wound: opened Chevron incision with packing, good granulation
tissue, areas of exudate at the base of the wound, no drainage.
EXT: warm, no edema, R calf tender to palpation


Pertinent Results:
On Admission: [**2172-7-27**]
WBC-10.5 RBC-2.88* Hgb-8.7* Hct-24.9* MCV-87 MCH-30.4 MCHC-35.0
RDW-16.4* Plt Ct-268
PT-42.8* PTT-39.9* INR(PT)-4.4*
Glucose-184* UreaN-58* Creat-1.6* Na-134 K-4.8 Cl-96 HCO3-24
AnGap-19
ALT-15 AST-24 LD(LDH)-438* AlkPhos-113* TotBili-0.2
Albumin-3.3* Calcium-9.0 Phos-4.4 Mg-2.1 Iron-26*
TSH-7.4*
calTIBC-243 Ferritn-2504* TRF-187*
tacroFK-6.5
At Discharge: [**2172-8-4**]
WBC-5.1 RBC-3.36* Hgb-10.2* Hct-28.1* MCV-84 MCH-30.4 MCHC-36.3*
RDW-16.1* Plt Ct-182
PT-15.0* INR(PT)-1.3*
Glucose-201* UreaN-32* Creat-0.8 Na-139 K-3.2* Cl-106 HCO3-21*
AnGap-15
ALT-10 AST-19 AlkPhos-137* TotBili-0.3
Calcium-8.8 Phos-3.2 Mg-1.6
tacroFK-10.3

Brief Hospital Course:
67 y/o female admitted with melena and large number of stools
over last two days. Patient was initially admitted to the SICU
where she received 3 units of packed RBCs for a hct of 22.4. The
hct bumped appropriately and she did not require any more
transfusions.
Additionally the patient was noted to have an INR of 4.4 on
admission. She had received coumadin prior to her discharge 5
days prior. INR had been checked and lovenox d/c'd however the
INR became supertherapeutic. She was given 2 units FFP and
Vitamin K.
Fluconazole has been d/c'd.
Urine culture was obtained as she had been sent out on PO Cipro
with the last discharge. The new culture showed that the
Pseudomonas was now resistant to Cipro and she was started on IV
Cefepime. Another urien culture was obtained on [**8-1**] and the
Cefepime has now become resistant, and she was switched to IV
Ceftazadime. This will require long infusion times of 3 hours
each s the medication is Intermediate in sensitivity. Flagyl was
started empirically although C diffs have been negative.
Patient noted to have elevated creatinine upon admission. This
resolved with hydration, blood products and treatment of her UTI
nd she was back to better than baseline by day of discharge.
A PICC line has been placed for antibiotic infusion through
[**2172-8-10**].
On [**2172-7-31**], Dr [**Last Name (STitle) 1391**] took the patient to the OR for placement
of an IVC filter as it has been determined that anticoagulation
is not a safe option for this patient given recent GI bleeding.
The ultrasound done on admission on her legs showed
"Non-occlusive thrombus seen involving the distal right common
femoral vein and proximal right superficial femoral vein, right
posterior tibial veins, and left posterior tibial veins." The
right common femoral vein thrombus is new, the others were
existing prior and why the anticoagulation had been started. The
procedure was without complication.
The abdominal wound is healing. Initially the dressings were
changed [**Hospital1 **] as NS wet to dry dressings. There is good
granulation tissue and only a small amount of necrotic appearing
tissue at the apex. On Monday [**8-3**] a wound VAC was placed to the
wound to continue closure.
Tube feeds have been maintained via a post pyloric feeding tube.
Immunosuppression has been monitored throughout the admission.
Daily prograf levels have been done due to the fluconazole being
d/c'd. In addition she has been started on imuran 75 mg daily
due to her pre-op diagnosis of autoimmune hepatitis, and she
will stay on 5 mg prednisone with no further taper.
The patient has been very slow to be out of bed, with poor oral
intake. She stated to several caregivers that she feels
depressed, and concerned about how long she has been in the
hospital. Will benefit from more social work intervention.


Medications on Admission:
mycophenolate sodium 360 mg [**Hospital1 **], Tacrolimus 1mg [**Hospital1 **],
Ursodiol 300 mg TID, valganciclovir 450 mg TID, Vitamin D 800U
daily, amlodipine 10mg daily, ascorbic acid 500 mg [**Hospital1 **],
clonidine
0.1 mg daily, esomeprazole 40mg [**Hospital1 **], fluconazole 200 mg daily,
gabapentin 300mg [**Hospital1 **], regular insulin SS, metoprolol 37.5 mg
TID,
MVI daily, olanzapine 2.5 mg qHS, prednisone 2.5 mg daily,
sertraline 25 mg daily, Bactrim SS daily, Insulin glargine 12U
qHS, levothyroxine 25 mcg daily, ambien 5mg prn, loperamide 4mg
TID prn, ondansetron 4mg TID prn, Dilaudid prn


Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: per sliding
scale  Injection ASDIR (AS DIRECTED).
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. levothyroxine 50 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
11. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
12. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
14. azathioprine 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).

15. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Do not taper.
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Lower
back.
18. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: [**12-22**] Tablet, Chewables PO BID (2 times a day) as needed for
heartburn.
19. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
20. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
TID (3 times a day): Take 2 hours separately from
immunosuppression.
21. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for Empiric Cdiff: Through [**8-10**] unless
otherwise directed.
22. ceftazidime 2 gram Recon Soln Sig: Two (2) grams Injection
Q8H (every 8 hours) for 6 days: Please infuse dose over 3 hours
to maximize exposure (Intermediate sensitivity, all others
resistant)  .
23. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Lower GI bleed
Supertherapeutic INR on Coumadin
Acute on chronic kidney failure (resolved)
UTI
Slow Abdominal wound healing
Malnutrition
Depression
Bilateral lower extremity DVT's s/p IVC filter placement


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, increased number of bowel movements,
dark or tarry stools, bright red blood per rectum, difficulties
with the tube feeds, dislodgement of feeding tube, increased
abdominal pain.
Please continue the VAC at 125 mm Hg continuous and change 3
times weekly per your facility protocol
Continue tube feeds (see nutrtion order)
Continue IV Ceftazadime via PICC line through [**2172-8-10**]. It is
mportant that the IV infusion be done over 3 hours to maximize
exposure as this medication is intermediate in sensitivity.

Plesae do not alter medications with consulting the transplant
clinic
Please courier labs to [**Hospital1 18**] with requisition every Monday and
Thursday

Followup Instructions:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**2172-8-12**]: 3:20 PM. Tel [**Telephone/Fax (1) 673**], [**Last Name (NamePattern1) 10357**], LMOB 7, [**Location (un) 86**], MA


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

Completed by:[**2172-8-5**]
{'Blood in stool,Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity,Acute kidney failure, unspecified,Liver replaced by transplant,Unspecified protein-calorie malnutrition,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Urinary tract infection, site not specified,Polyneuropathy in diabetes,Abnormal coagulation profile,Other and unspecified hyperlipidemia,Rheumatoid arthritis,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other B-complex deficiencies,Depressive disorder, not elsewhere classified,Other chronic pain,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other specified disorders of skin,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Infection with drug-resistant microorganisms, unspecified, with multiple drug resistance,Postprocedural fever,Diarrhea'}


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: Lower GI Bleed

PRESENT ILLNESS: This is a 67 y/o female s/p OLT on [**2172-5-1**] for autoimmune
hepatitis, c/b by anterior abdominal wall necrosis, readmitted
on
[**2172-7-15**] for fevers and poor PO intake. On the previous
admission,
the patient had a klebsiella UTI, which was treated with
ciprofloxacin. In addition, she was found to have a right calf
DVT, in which coumadin was started. The patient was in her usual
state of health from [**7-21**] until 2 days ago, when she began to
have
dark, tarry stools. She had approximately [**3-24**] BM/day for the
past
2 days. She also complains of nausea and persistent poor PO
intake (which is her baseline and she has a Dobbhoff tube in
place for TF). Her hct last week was 31, now it is 25. Her INR
is
4.4. She received 10mg IV Vit K in the ED. The patient denies
headache, chest pain, SOB, chills/fever, and dysuria. However,
the patient does state dizziness on ambulating and persistent
right calf pain.

MEDICAL HISTORY: HLD
Autoimmune hepatitis/cirrhosis, diagnoed 14 yrs ago with bx in
[**Male First Name (un) 1056**], complicated by varices
RA
DM2 with neuropathy
HTN, incl hypertensive nephropathy
B12 deficiency
Vitamin D Deficiency
Chronic pain syndrome - "colonic pain" per pt records
Colon polyps (hyperplastic and tubular adenoma)
Diverticulitis
Depression
PAD
s/p chole
s/p appy
s/p TAH/USO
Bladder prolapse repair
[**2172-5-1**] Liver transplant
[**2172-5-12**] ERCP, sphincterotomy, stent placement

MEDICATION ON ADMISSION: mycophenolate sodium 360 mg [**Hospital1 **], Tacrolimus 1mg [**Hospital1 **],
Ursodiol 300 mg TID, valganciclovir 450 mg TID, Vitamin D 800U
daily, amlodipine 10mg daily, ascorbic acid 500 mg [**Hospital1 **],
clonidine
0.1 mg daily, esomeprazole 40mg [**Hospital1 **], fluconazole 200 mg daily,
gabapentin 300mg [**Hospital1 **], regular insulin SS, metoprolol 37.5 mg
TID,
MVI daily, olanzapine 2.5 mg qHS, prednisone 2.5 mg daily,
sertraline 25 mg daily, Bactrim SS daily, Insulin glargine 12U
qHS, levothyroxine 25 mcg daily, ambien 5mg prn, loperamide 4mg
TID prn, ondansetron 4mg TID prn, Dilaudid prn

ALLERGIES: No Known Drug Allergies / Lactose

PHYSICAL EXAM: T 97.7 HR 86  BP 108/42  RR 18  98% RA
GEN: NAD, AAOx3, no jaundice
HEENT: no scleral icterus, appears dry
CHEST: CTA B/L
HEART: RRR, S1, S2
ABD: soft, NT, Chevron incision with packing, no
rebound/guarding
Wound: opened Chevron incision with packing, good granulation
tissue, areas of exudate at the base of the wound, no drainage.
EXT: warm, no edema, R calf tender to palpation

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: originally from [**Male First Name (un) 1056**]; has lived her with family for last
3 years. No etoh, illicits or tobacoo. 

### Response:
{'Blood in stool,Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity,Acute kidney failure, unspecified,Liver replaced by transplant,Unspecified protein-calorie malnutrition,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Urinary tract infection, site not specified,Polyneuropathy in diabetes,Abnormal coagulation profile,Other and unspecified hyperlipidemia,Rheumatoid arthritis,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other B-complex deficiencies,Depressive disorder, not elsewhere classified,Other chronic pain,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other specified disorders of skin,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Infection with drug-resistant microorganisms, unspecified, with multiple drug resistance,Postprocedural fever,Diarrhea'}
