CHIEF COMPLAINT: BRBPR

PRESENT ILLNESS: Mr. [**Known lastname 97375**] is a 74 year old male with Hypertension, history of
diverticular bleed, who presents after 8 bright red bloody bowel
movements.  After approximately 8 bloody bowel movements, he
began feeling lightheaded, slid off the toilet and passed out.
His wife called 911 to take him to the hospital.
.
Upon arrival to the ED, BP 70s-90s/palp HR 70, RR 16, 100% on
RA, T 95.6.  He was given 3L NS and his [**Known lastname **] pressure improved.
 He was crossed for 6 units of [**Known lastname **], but did not receive any
[**Known lastname **].  He was seen by GI who recommended tagged RBC scan with
plans to possibly scope in a few days after prepping.
.

MEDICAL HISTORY: Past medical history:
1.  Hypertension.
2.  Arthritis.
3.  Left foot neuropathy.
4.  Back pain.
5.  Varicose veins.
6.  Prostate cancer.
7.  Psoriasis.
8.  Colonic polyps.
9.  Diverticulosis with history of diverticulitis.
.
Past surgical history is significant for:
1.  Laparoscopic cholecystectomy, [**2119**].
2.  Lumbar laminectomy, [**2125**].
3.  Vein stripping.
4.  Retropubic radical prostatectomy for prostate cancer.

MEDICATION ON ADMISSION: HCTZ 12.5 daily
Omeprazole 20mg daily
Enalapril 20mg daily
Tramadol 50mg [**Hospital1 **]
Neurontin 600mg tid
Aspirin 81 daily
naprocen prn
benandryl prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: MICU Admission Note:

FAMILY HISTORY: Father with unknown incurable cancer.

SOCIAL HISTORY: He has quit smoking three years ago, does not drink or use
drugs.  He is a salesman trading in stocks and bonds.
Diverticulosis of colon with hemorrhage,Acute kidney failure, unspecified,Bacteremia,Cellulitis and abscess of upper arm and forearm,Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Mononeuritis of lower limb, unspecified,Unspecified essential hypertension,Personal history of malignant neoplasm of prostate,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Dvrtclo colon w hmrhg,Acute kidney failure NOS,Bacteremia,Cellulitis of arm,React-oth vasc dev/graft,Mth sus Stph aur els/NOS,Mononeuritis leg NOS,Hypertension NOS,Hx-prostatic malignancy,Abn react-procedure NEC
Admission Date:  [**2127-8-31**]              Discharge Date:   [**2127-9-5**]

Date of Birth:  [**2053-4-13**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
BRBPR

Major Surgical or Invasive Procedure:
embolization of left colic artery
Intubation and mechanical ventillation
PICC Line Placement [**2127-9-5**]

History of Present Illness:
Mr. [**Known lastname 97375**] is a 74 year old male with Hypertension, history of
diverticular bleed, who presents after 8 bright red bloody bowel
movements.  After approximately 8 bloody bowel movements, he
began feeling lightheaded, slid off the toilet and passed out.
His wife called 911 to take him to the hospital.
.
Upon arrival to the ED, BP 70s-90s/palp HR 70, RR 16, 100% on
RA, T 95.6.  He was given 3L NS and his [**Known lastname **] pressure improved.
 He was crossed for 6 units of [**Known lastname **], but did not receive any
[**Known lastname **].  He was seen by GI who recommended tagged RBC scan with
plans to possibly scope in a few days after prepping.
.


Past Medical History:
Past medical history:
1.  Hypertension.
2.  Arthritis.
3.  Left foot neuropathy.
4.  Back pain.
5.  Varicose veins.
6.  Prostate cancer.
7.  Psoriasis.
8.  Colonic polyps.
9.  Diverticulosis with history of diverticulitis.
.
Past surgical history is significant for:
1.  Laparoscopic cholecystectomy, [**2119**].
2.  Lumbar laminectomy, [**2125**].
3.  Vein stripping.
4.  Retropubic radical prostatectomy for prostate cancer.

Social History:
He has quit smoking three years ago, does not drink or use
drugs.  He is a salesman trading in stocks and bonds.

Family History:
Father with unknown incurable cancer.

Physical Exam:
MICU Admission Note:

Gen: NAD, lying in stretcher, comfortable
HEENT: dry mucous membranes, sclera anicteric
CV: bradycardic, no m/r/g
Pulm: CTA b/l
Abd: soft, NT, ND, bowel sounds present
Ext: right greater than left 2+ pitting edema
Neuro: AxOx3, appropriate, moving all extremities

Physical Exam on Day of Discharge ([**2127-9-5**])
VS: 98.3 HR 70 BP 140/60 RR 16 97% RA
Gen: NAD, lying in stretcher, comfortable
HEENT: dry mucous membranes, sclera anicteric
CV: RRR, no m/r/g
Pulm: CTA b/l
Abd: soft, NT, ND, bowel sounds present
Ext: Area over bilateral antecubital are improving, although
left antecub has small area with small amount of exudate,
slightly indurated. Right greater than left lower extremity 2+
pitting edema, stable over last few days
Neuro: AxOx3, appropriate, no focal defecits


Pertinent Results:
Admission Labs:
.
143 | 110 | 30 /
--------------- 154
3.8 | 24  | 1.3 \
.
.. \ 11.2 /
10.7 ----- 257
.. / 36.1 \
.
Diff: 79.3%N, 16.1%L, 3.6%M, 0.9%E, 0.1%B
.
PT 14
PTT 23.9
INR 1.2
.
[**2127-8-31**].  Tagged RBC scan.
IMPRESSION: Brisk GI bleeding at the junction of the descending
and sigmoid colons.
.
[**2127-9-1**]. Mesenteric embolization. Unable to embolize the bleeding
vessel.
.
[**2127-9-1**].  Mesenteric embolization.  Successful embolization of
the left colic artery.

[**2127-9-4**]:
ECHO:
IMPRESSION: no obvious vegetations seen; however, best excluded
by transesophageal echocardiography.

US Left Antecubital Fossa:
IMPRESSION: Occlusive thrombus in the cephalic vein without
proximal
migration. No abscess in the antecubital fossa.

[**2127-9-5**]:  Hct was stable over last several days, Hgb/Hct remained
stable, WBC trended down and bck to normal.

[**2127-9-5**] 05:20AM [**Month/Day/Year 3143**] WBC-7.7 RBC-3.62* Hgb-10.0* Hct-30.2*
MCV-83 MCH-27.5 MCHC-33.0 RDW-13.6 Plt Ct-189


Brief Hospital Course:
Mr. [**Known lastname 97375**] is a 74 year old male with HTN, diverticosis with a
history of a diverticular bleed admitted for the MICU with GI
bleeding secondary to diverticular bleed.
.
Diverticular bleed.  Mr. [**Known lastname 97375**] presented with several bloody
bowel movements and then ultimately became lightheaded and
syncopized at home.  He was found to have a systolic [**Known lastname **]
pressure in the 70s upon arrival to the ED. He was given IVFs
and his [**Known lastname **] pressure stabilized.  He went directly to tagged
RBC scan which was positive for sigmoid colonic bleeding.  He
went to angio directly but they were unable to embolize the
bleed.  Six hours later, he began to re-bleed so was taken back
to IR for embolization.  He required intubation for sedation,
but they were able to succesffuly embolize the left colic
artery. In total, he required 4 units of PRBCs during his MICU
stay. After being transferred to the floor, he remained stable
and his Hct was stable around 30.  He had occasional [**Known lastname **]
surrounding his stools, but his hematocrit was unchanged.
.
Hypertension.  As above, patient was hypotensive on presentation
likely secondary to hypovolemia in setting of GI bleeding.  His
antihypertensives were held during his MICU course and on day of
discharge, pt's SBP was between 140-160/70s.  We felt
comfortable sending him home and restarting his HTN meds
(Enalapril and HCTZ)
.
Acute renal failure.  Patient was in acute renal failure on
arrival, likely secondary to hypovolemia from bleeding.  This
resolved with IV fluids.
.
Pain.  Patient takes aspirin, naprocen, tramadol, and neurontin
for pain at home.  NSAIDS and aspirin were held due to his bleed
and his renal failure.
.
Bacteremia:  Pt. spiked a temperature upon DC from the MICU to
101F on [**2127-9-2**].  He was cultured, started on vancomycin and
[**Date Range **] cultures grew coag + staph aureus (MSSA) from specimens
taken from his A-Line and a venipuncture.  The likely source of
infection was 2 IV sites (b/l antecubital fossa) that became red
and indurated.  ID was consulted and it was decided that pt.
would go home on IV Nafcillin q4 hours through a PICC line.  He
was given teaching and VNS services.
.
Thrombus in Left Cephalic:  Pt. developed thrombus at the site
of a prior IV in left antecubital fossa described via ultrasound
as occluding the left cephalic vein.  I spoke with radiology and
they did not see an overlying abscess.  Due to the patient's GI
bleeding and the fact that this was an iatrogenic thrombus (at
IV site), anticoagulation was not initiated.

CODE:  FULL, confirmed with patient.

PROPH: pneumoboots d/t GIB

Medications on Admission:
HCTZ 12.5 daily
Omeprazole 20mg daily
Enalapril 20mg daily
Tramadol 50mg [**Hospital1 **]
Neurontin 600mg tid
Aspirin 81 daily
naprocen prn
benandryl prn

Discharge Medications:
1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
3. Nafcillin 2 gram Piggyback Sig: Two (2) gram Intravenous
every four (4) hours: first day [**2127-9-5**] and to continue for 6
weeks unless advised differently by infectious disease clinic.
Disp:*180 Piggyback* Refills:*0*
4. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO once a
day.


Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
Primary Diagnosis:
1.  GI Bleed
2.  Staph Aureus Bacteremia
3.  Thrombus in left cephalic vein.


Discharge Condition:
Good, stable, pt. feels well and wants to go home


Discharge Instructions:
You were admitted to the hospital on [**2127-8-31**] for intestinal
bleeding.  Your [**Date Range **] pressure was low and you continued to
bleed. You were admitted to the medical ICU and underwent a
procedure done to place a coil in the vessel bleeding.  This was
effective.  Before leaving the medical ICU, you had a fever and
developed infection at your IV sites that spread to your [**Date Range **]
stream.  You are being discharged home with IV antibiotics.

Due to your intestinal bleeding we stopped your aspirin.  You
should avoid taking any non-steroidal antiinflammatories, such
as Motrin, Naprosyn or Advil as they can also cause bleeding.
You can otherwise start back on your home medications.  You will
be getting 2g of Nafcillin through an infusion pump every four
hours.

If you should develop fever, worsening pain especially in your
back or abdomen, any chest pain or shortness of breath,
worsening bleeding in you bowel movements or you have any
concerns you should call your doctor immediately or return to
the emergency department for further management.

Followup Instructions:
You have several appointments for follow up:

You need to have a TEE (transesophageal echo) on Monday, [**2127-9-8**]
at 8:30 am to evaluate your heart.  Please see attached sheet
with details.

Your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**] is unable to see you in the office within the
next 1-2 weeks, but his colleague, Dr. [**Last Name (STitle) 4922**] is available to
see you on [**2127-9-15**] at 1:15 pm.  You can call the office
([**Telephone/Fax (1) 2205**]) to chage the appointment if needed, but you
should be seen to repeat your Hematocrit within the next [**1-31**]
weeks.

You need to follow up in the Infectious Disease Clinic with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**9-22**] at 9am in the [**Hospital Unit Name **] on the
[**Hospital Ward Name 517**].  Call ([**Telephone/Fax (1) 4170**] with any questions.

You have follow up with GI as well:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2127-10-21**] 9:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 3921**] (ST-3) GI ROOMS Date/Time:[**2127-10-21**] 9:00


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
{'Diverticulosis of colon with hemorrhage,Acute kidney failure, unspecified,Bacteremia,Cellulitis and abscess of upper arm and forearm,Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Mononeuritis of lower limb, unspecified,Unspecified essential hypertension,Personal history of malignant neoplasm of prostate,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: BRBPR

PRESENT ILLNESS: Mr. [**Known lastname 97375**] is a 74 year old male with Hypertension, history of
diverticular bleed, who presents after 8 bright red bloody bowel
movements.  After approximately 8 bloody bowel movements, he
began feeling lightheaded, slid off the toilet and passed out.
His wife called 911 to take him to the hospital.
.
Upon arrival to the ED, BP 70s-90s/palp HR 70, RR 16, 100% on
RA, T 95.6.  He was given 3L NS and his [**Known lastname **] pressure improved.
 He was crossed for 6 units of [**Known lastname **], but did not receive any
[**Known lastname **].  He was seen by GI who recommended tagged RBC scan with
plans to possibly scope in a few days after prepping.
.

MEDICAL HISTORY: Past medical history:
1.  Hypertension.
2.  Arthritis.
3.  Left foot neuropathy.
4.  Back pain.
5.  Varicose veins.
6.  Prostate cancer.
7.  Psoriasis.
8.  Colonic polyps.
9.  Diverticulosis with history of diverticulitis.
.
Past surgical history is significant for:
1.  Laparoscopic cholecystectomy, [**2119**].
2.  Lumbar laminectomy, [**2125**].
3.  Vein stripping.
4.  Retropubic radical prostatectomy for prostate cancer.

MEDICATION ON ADMISSION: HCTZ 12.5 daily
Omeprazole 20mg daily
Enalapril 20mg daily
Tramadol 50mg [**Hospital1 **]
Neurontin 600mg tid
Aspirin 81 daily
naprocen prn
benandryl prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: MICU Admission Note:

FAMILY HISTORY: Father with unknown incurable cancer.

SOCIAL HISTORY: He has quit smoking three years ago, does not drink or use
drugs.  He is a salesman trading in stocks and bonds. 

### Response:
{'Diverticulosis of colon with hemorrhage,Acute kidney failure, unspecified,Bacteremia,Cellulitis and abscess of upper arm and forearm,Infection and inflammatory reaction due to other vascular device, implant, and graft,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Mononeuritis of lower limb, unspecified,Unspecified essential hypertension,Personal history of malignant neoplasm of prostate,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
