CHIEF COMPLAINT: Weakness.

PRESENT ILLNESS: Patient is an 82-year-old
gentleman with a history of coronary artery disease, status
post coronary artery bypass graft on [**2186-1-5**] admitted to
the Intensive Care Unit with an upper gastrointestinal bleed.
On the day of admission, the patient felt weak.  He denied
any chest pain, any shortness of breath, or any palpitations.
He fell to the floor.  He denies any head trauma or loss of
consciousness, and he was brought to the Emergency Department
by the family.

MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass
graft in [**2186-1-5**].
2. Upper gastrointestinal bleed in [**7-/2183**] with esophagitis
and ulcer in the stomach and duodenum and H. pylori positive.
3. Benign prostatic hypertrophy.
4. Prostate cancer treated with watchful waiting.
5. Status post nephrectomy for renal cancer 40 years ago.
6. Ejection fraction is 40-45% measured before coronary
artery bypass graft.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He was born in [**Country 532**].  He moved to the US
on [**2112**].  He is a retired rabbi.  Smoked tobacco in the Army
and quit many years ago.  He denies any alcohol use.
Acute duodenal ulcer with hemorrhage, without mention of obstruction,Unspecified pleural effusion,Disorder of bone and cartilage, unspecified,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Personal history of malignant neoplasm of prostate,Personal history of tobacco use,Iron deficiency anemia, unspecified
Ac duodenal ulcer w hem,Pleural effusion NOS,Bone & cartilage dis NOS,Crnry athrscl natve vssl,Aortocoronary bypass,Hx-prostatic malignancy,History of tobacco use,Iron defic anemia NOS
Admission Date:  [**2186-1-28**]       Discharge Date:  [**2186-2-3**]


Service:  ACOVE

CHIEF COMPLAINT:  Weakness.

HISTORY OF PRESENT ILLNESS:  Patient is an 82-year-old
gentleman with a history of coronary artery disease, status
post coronary artery bypass graft on [**2186-1-5**] admitted to
the Intensive Care Unit with an upper gastrointestinal bleed.
On the day of admission, the patient felt weak.  He denied
any chest pain, any shortness of breath, or any palpitations.
He fell to the floor.  He denies any head trauma or loss of
consciousness, and he was brought to the Emergency Department
by the family.

In the Emergency Department, guaiac was found to be positive,
and hematocrit was 23.8 from 31 on [**2186-1-20**].  Nasogastric
lavage was performed and had coffee-ground which did not
clear after 2 liters of normal saline.  Also in the Emergency
Department, the patient was initially transfused with 1 unit
of packed red blood cells, and he was administered
intravenous fluids.  He was then admitted to the Intensive
Care Unit for endoscopy and further care.

PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery bypass
graft in [**2186-1-5**].
2. Upper gastrointestinal bleed in [**7-/2183**] with esophagitis
and ulcer in the stomach and duodenum and H. pylori positive.
3. Benign prostatic hypertrophy.
4. Prostate cancer treated with watchful waiting.
5. Status post nephrectomy for renal cancer 40 years ago.
6. Ejection fraction is 40-45% measured before coronary
artery bypass graft.

MEDICATIONS:
1. Metoprolol 25 po bid.
2. Finasteride 5 mg po q day.
3. Atorvastatin 5 mg po q day.
4. Aspirin 325 mg po q day.
5. Hydrochlorothiazide 25 po q day.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  He was born in [**Country 532**].  He moved to the US
on [**2112**].  He is a retired rabbi.  Smoked tobacco in the Army
and quit many years ago.  He denies any alcohol use.

PHYSICAL EXAMINATION ON PRESENTATION:  Blood pressure was
112/46, pulse 87, oxygen saturation is 99% on room air.
General appearance:  Elderly man pale in no acute distress.
HEENT:  No jugular venous distention, dry mucous membranes.
Lungs with decreased breath sounds in the right.  Heart:
Regular rate with normal S1, S2, no murmurs, rubs, or gallops
and a well-healing sternotomy.  Abdomen is soft, nontender,
nondistended with decreased bowel sounds.  Extremities:  2+
dorsalis pedis pulses bilaterally, no edema.  Neurologic is
alert and oriented times three.

LABORATORIES ON ADMISSION:  White blood cells was 7.2,
hematocrit 23.8, then dropped to 20.3, MCV of 91.  Coags:
PTT 31, INR 1.2.  Chem-7 was unremarkable except for a
potassium of 5.4.

Chest x-ray showed bilateral pleural effusions, small on the
left side and large on the right side.

Electrocardiogram showed sinus rhythm at 68, right axis,
right bundle branch block, T-wave depression in leads II,
III, aVF, and V2-V6, biphasic similar to the
electrocardiogram performed on [**2186-1-11**].

BRIEF HOSPITAL COURSE:  Mr. [**Known lastname 22292**] is an 82-year-old
gentleman with a history of coronary artery disease status
post recent coronary artery bypass graft presented with an
upper gastrointestinal bleed.

Upper gastrointestinal bleed:  Mr. [**Known lastname 22292**] presented to the
Emergency Department with a hematocrit of 23.8 from 31.1 on
[**1-20**].  He was guaiac positive and nasogastric lavage showed
coffee-grounds which did not clear after 2 liters of normal
saline.  The patient was admitted to the Intensive Care Unit.
He was transfused 4 units of packed red blood cells.

An EGD was performed which showed ulcers in the posterior
bulb of the duodenum, one of which was actively bleeding and
was electrocauterized with successful hemostasis.  There was
also a single nonbleeding ulcer in the second part of the
duodenum which was not treated at this time.

His lowest blood pressure was 80/50.  He had no chest pain,
shortness of breath, or palpitations at this time.  His
hematocrit then increased to 28 and after that 31.8, and on
the second day dropped once again to 26.4.  An EGD was
repeated which showed a single nonbleeding ulcer.  The
patient was once again transfused 2 units of packed red blood
cells with his hematocrit increasing to 34.

The rest of his hospital course was unremarkable.  His
hematocrit continued to increase spontaneously.  The patient
was advanced on clear diet and then regular diet without any
problems.  [**Name (NI) **] was started on pantoprazole IV which was then
weaned to pantoprazole 40 mg po bid and discharged on
pantoprazole 40 mg po q day for eight weeks after which he
should be getting omeprazole 20 mg po q day for life.
Aspirin was held, and at the time of discharge, it is still
held.  The plan is for the patient to be started after two
weeks.  At this time, his discharge hematocrit was 36.6

2. Coronary artery disease:  The patient is status post
coronary artery bypass graft.  His lowest pressure during the
upper gastrointestinal bleed with 80/50 and never had any
chest pain, shortness of breath, or palpitations.  His
electrocardiogram had no changes indicating ischemia.
Metoprolol and aspirin were initially held because of the low
blood pressure and the risk of bleeding.  Metoprolol was
restarted and his blood pressure improved.  Myocardial
infarction was ruled out by enzymes.  Aspirin at the time of
discharge is still held, and as discussed above, should not
be restarted within the next two weeks.

3. Pulmonary effusion:  The patient was found to have
bilateral pleural effusions with the right larger than left.
The pleural effusion was tapped and was found to be an
exudate with many white blood cells, no organisms, and no
PMNs on Gram stain.  Cytology was negative for malignant
cells.  The pleural effusion had a large amount of
eosinophils for which PE was considered a possible etiology
because of the intermediate risk for PE for this patient who
had recent surgery, patient initially underwent a VQ scan
which was read as low probability.  However, low probability
VQ scan in the context of a moderate .................... 20%
chance of missing a pulmonary embolus.  It was therefore,
felt that the patient could benefit from a CT angiogram.

The patient initially received intravenous hydration because
of his history of nephrectomy and Mucomyst in order to
protect his single kidney as much as possible and then
underwent a CT angiogram.  The CT angiogram showed no
pulmonary embolus, but revealed a sclerotic bone lesion at
T12.

A Pulmonary consult was called, and the pulmonologist felt
that the pleural effusion even though had eosinophilia, was
most consistent most likely with post-CABG pleural effusion.
The patient was started on Lasix 20 mg po q day.

It was felt that otherwise felt that since he is
asymptomatic, he did not need any further treatment or
workup.  Plan is for the patient to get a chest x-ray to
monitor the progression and hopefully the resolution of
pleural effusion within one month, and in discussion with his
primary care physician, [**Name10 (NameIs) **] is to followup with Pulmonary
Clinic here at [**Hospital1 69**].

4. Sclerotic bone lesion:  A sclerotic bone lesion at T12 was
accidentally found on CT scan.  Patient and his family were
made aware of this finding and because of his history of
prostate cancer, at this time, they were recommended to
followup with his primary care physician.

DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed.
2. Duodenal ulcer.
3. Coronary artery disease.
4. Pleural effusions.
5. Sclerotic bone lesion.
6. Other diagnoses he presented with.

FOLLOW-UP PLAN:  Referred the patient to followup with his
primary care physician and the patient's primary care
physician's discretion with the Pulmonary Clinic here and
with a the [**Hospital **] Clinic also here.

DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg po q24h for eight weeks after which he
should be switched to omeprazole 20 mg po q day for life.
2. Furosemide 20 mg po q day.
3. Metoprolol 25 mg po bid.
4. Bupropion 75 mg po q day.
5. Atorvastatin 10 mg po q day.
6. Hydrochlorothiazide 25 po q day.
7. Finasteride 7 mg po q day.
8. Aspirin is to be held for the next two weeks after which
it could be restarted.

DISCHARGE STATUS:  To home with physical therapy as
recommended by the physical therapist, and will see the
patient in house.

DISCHARGE CONDITION:  Good.




                            [**Name6 (MD) 251**] [**Name8 (MD) **], M.D.  [**MD Number(1) 1197**]

Dictated By:[**Last Name (NamePattern1) 6071**]
MEDQUIST36

D:  [**2186-2-3**]  10:16
T:  [**2186-2-3**]  10:17
JOB#:  [**Job Number 22293**]
{'Acute duodenal ulcer with hemorrhage, without mention of obstruction,Unspecified pleural effusion,Disorder of bone and cartilage, unspecified,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Personal history of malignant neoplasm of prostate,Personal history of tobacco use,Iron deficiency anemia, unspecified'}


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: Weakness.

PRESENT ILLNESS: Patient is an 82-year-old
gentleman with a history of coronary artery disease, status
post coronary artery bypass graft on [**2186-1-5**] admitted to
the Intensive Care Unit with an upper gastrointestinal bleed.
On the day of admission, the patient felt weak.  He denied
any chest pain, any shortness of breath, or any palpitations.
He fell to the floor.  He denies any head trauma or loss of
consciousness, and he was brought to the Emergency Department
by the family.

MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass
graft in [**2186-1-5**].
2. Upper gastrointestinal bleed in [**7-/2183**] with esophagitis
and ulcer in the stomach and duodenum and H. pylori positive.
3. Benign prostatic hypertrophy.
4. Prostate cancer treated with watchful waiting.
5. Status post nephrectomy for renal cancer 40 years ago.
6. Ejection fraction is 40-45% measured before coronary
artery bypass graft.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He was born in [**Country 532**].  He moved to the US
on [**2112**].  He is a retired rabbi.  Smoked tobacco in the Army
and quit many years ago.  He denies any alcohol use. 

### Response:
{'Acute duodenal ulcer with hemorrhage, without mention of obstruction,Unspecified pleural effusion,Disorder of bone and cartilage, unspecified,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Personal history of malignant neoplasm of prostate,Personal history of tobacco use,Iron deficiency anemia, unspecified'}
