CHIEF COMPLAINT: Coffee-ground emesis

PRESENT ILLNESS: 93-year old female from NH (DNR/I) with history of stroke,
dementia, dvt on coumading, schizophrenia, DM, presents with
coffee-ground emesis.
.
Pt developed coffee-ground emesis one day PTA at [**Hospital1 100**]-Rehab.
No previous h/o GIB. SBP was in the 100s but dropped to 80s,
responsive to IVFs. Pt was sent to the ED. VS were HR 108, BP
106/67, then 86/45 which came back up to 136/64 after 1L NS. Pt
was guaiac positive. NG lavage was attempted several times,
including by GI but was unsuccessful. 2 large-bore IVs were
placed. Hct was 18 from baseline of 30 to 34 (on Aranesp).
Patient also on coumadin for h/o DVT. INR was 2.3 and pt
received Vitamin K 5mg sc x1. FFP was ordered in the ED but not
yet administered. One unit of pRBC were started prior to
transfer to ICU.
.
ROS could not be obtained given her dementia. HPI was obtained
from daughter who is HCP. Confirmed DNR/I. No central lines.

MEDICAL HISTORY: dementia with paranoid psychosis
depression/anxiety
DM Type II
CRI, Cr baseline 1.3
CVA in [**2099**] per family, only speech impairment that resolved
OP with compression fx (T11,12, L4)
diverticulitits
BCC of nose
Breast Ca: excision/XRT '[**00**]
esophagitis
OA
anemia Hct baseline 30, has been on aranesp
hypernatremia
constipation
LLE DVT [**2115-4-22**], on coumadin
R hip fracture [**4-/2115**]

MEDICATION ON ADMISSION: (per NH sheet):
Morphine 4mg q4h prn
Ativan 0.25mg q6h prn
Tylenol 650mg q6h prn
Iron 325 mg daily
Zyprexa 5mg daily
Compazine 25mg q12h prn
Warfarin (per schedule - not included)
Trazodone 50mg qHS
Senna
Erythromycin ointment
Pioglitazone 30mg daily
Lidoderm patch
Protonix 40mg [**Hospital1 **]

ALLERGIES: Risperidone / Rofecoxib / Ciprofloxacin

PHYSICAL EXAM: VS: Temp: 96.7 BP: 138/55  HR: 107 RR: 27  O2sat 100%RA
GEN: demented, comfortably lying in bed, NAD
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions
NECK: no cervical lymphadenopathy, no jvd, no carotid bruits
RESP: CTA b/l, no wheezes, rhales or rhonchi
CV: RR, S1 and S2 wnl, [**4-9**] decrescendo murmur at USB w/o
radiation
ABD: nd, +b/s, soft, nt, no masses
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: demented, moving all extremities, responds to simple
commands

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: No ETOH. No tobacco. Lives at [**Hospital6 459**].
Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Unspecified schizophrenia, unspecified,Chronic kidney disease, unspecified,Aortic valve disorders,Hyposmolality and/or hyponatremia,Procedure not carried out for other reasons,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other persistent mental disorders due to conditions classified elsewhere,Disorder of bone and cartilage, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Long-term (current) use of anticoagulants
Gastrointest hemorr NOS,Ac posthemorrhag anemia,Urin tract infection NOS,Schizophrenia NOS-unspec,Chronic kidney dis NOS,Aortic valve disorder,Hyposmolality,No proc for reasons NEC,DMII renl nt st uncntrld,Mental disor NEC oth dis,Bone & cartilage dis NOS,Osteoarthros NOS-unspec,Long-term use anticoagul
Admission Date:  [**2115-9-12**]              Discharge Date:   [**2115-9-16**]


Service: MEDICINE

Allergies:
Risperidone / Rofecoxib / Ciprofloxacin

Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Coffee-ground emesis

Major Surgical or Invasive Procedure:
EGD

History of Present Illness:
93-year old female from NH (DNR/I) with history of stroke,
dementia, dvt on coumading, schizophrenia, DM, presents with
coffee-ground emesis.
.
Pt developed coffee-ground emesis one day PTA at [**Hospital1 100**]-Rehab.
No previous h/o GIB. SBP was in the 100s but dropped to 80s,
responsive to IVFs. Pt was sent to the ED. VS were HR 108, BP
106/67, then 86/45 which came back up to 136/64 after 1L NS. Pt
was guaiac positive. NG lavage was attempted several times,
including by GI but was unsuccessful. 2 large-bore IVs were
placed. Hct was 18 from baseline of 30 to 34 (on Aranesp).
Patient also on coumadin for h/o DVT. INR was 2.3 and pt
received Vitamin K 5mg sc x1. FFP was ordered in the ED but not
yet administered. One unit of pRBC were started prior to
transfer to ICU.
.
ROS could not be obtained given her dementia. HPI was obtained
from daughter who is HCP. Confirmed DNR/I. No central lines.

Past Medical History:
dementia with paranoid psychosis
depression/anxiety
DM Type II
CRI, Cr baseline 1.3
CVA in [**2099**] per family, only speech impairment that resolved
OP with compression fx (T11,12, L4)
diverticulitits
BCC of nose
Breast Ca: excision/XRT '[**00**]
esophagitis
OA
anemia Hct baseline 30, has been on aranesp
hypernatremia
constipation
LLE DVT [**2115-4-22**], on coumadin
R hip fracture [**4-/2115**]

Social History:
No ETOH. No tobacco. Lives at [**Hospital6 459**].

Family History:
non-contributory

Physical Exam:
VS: Temp: 96.7 BP: 138/55  HR: 107 RR: 27  O2sat 100%RA
GEN: demented, comfortably lying in bed, NAD
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions
NECK: no cervical lymphadenopathy, no jvd, no carotid bruits
RESP: CTA b/l, no wheezes, rhales or rhonchi
CV: RR, S1 and S2 wnl, [**4-9**] decrescendo murmur at USB w/o
radiation
ABD: nd, +b/s, soft, nt, no masses
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: demented, moving all extremities, responds to simple
commands

Pertinent Results:
Labs in the ED:
128  92  70
===========380
4.9  24  1.3
.
Ca: 8.5 Mg: 2.7 P: 3.3
.
WBC 9.2, Hct 18.3, Plt 373
.
[**2115-9-13**] 12:41a
Urine Chemistry:
UreaN:1115
Creat:59
Na:<10
Osmolal:604

Source: Catheter
Color Yellow  Appear Clear  SpecGr 1.018  pH   5.0  Urobil Neg
Bili Neg  Leuk Mod  Bld Lge  Nitr Neg  Prot Tr  Glu 250  Ket Neg
RBC 57  WBC 143  Bact Many  Yeast None  Epi 1
.
Imaging:
CXR [**2115-9-12**]:  IMPRESSION:  No definite volume overload.  No
consolidation seen. Marked low lung volumes with baseline
cardiomegaly.
.
[**2115-9-13**] EGD: unable to scope past pharynx secondary to pt's
mental status and intolerability; further EGD deferred as pt is
hemodynamically stable with medical management
.
[**2115-9-13**] TTE: IMPRESSION: Mild aortic valve stenosis. Mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function. Left ventricular
diastolic dysfunction with elevated LVEDP. Mild aortic
regurgitation.
.


Brief Hospital Course:
A/P:  This 93-year old female from NH (DNR/I) with history of
stroke, dementia, schizophrenia, DM, presents coffee-ground
emesis.

# Upper GI bleed: The patient presented with coffee-ground
emesis and mild tachycardia and hypotension to the ED. Patient
was on coumadin with therapeutic INR upon presentation. Given
her age and comorbities at high risk for bleeding, it was felt
that coffee-ground emesis was consistent with upper GIB. Sources
were most likely felt to be gastritis/PUD but also esophagitis
possible given prior history. The patient was kept NPO
(including po meds) and given IVFs through large bore peripheral
IVs. She was started on an IV PPI [**Hospital1 **]. Hct increased from 18 to
20 to 22.6 to 26.9 with 3 units PRBC. GI evaluated her in the ED
with plan to scope on HD2 since she remained hemodynamically
stable overnight. The patient was also given 2u FFP(see below)
prior to attempted scope. EGD by GI was not successfull after
several attempts given the patient's anatomy and intolerability
due to mental status. After discussion with the patient's
daughter, it was decided that further EGD attempts would be
deferred as the patient was hemodynamically stable.
-the patient was evaluated in the ICU, remained hemodynamically
stable without evidence of further bleed and was transferred to
a general medical floor.
-her po medicines were restarted, her hematocrit remained stable
(31) for >48 hours after tranfer from the ICU.

# DVT -placed on coumadin [**4-10**] for lower extremity DVT per
records. coumadin therapeutic at time of admission, though
patient admitted with life-threatening gi bleed. She has
completed nearly 6 months of therapy, and in the setting of a
life-threatening GI bleed that was unamenable to endoscopy
(barring intubation which is against her DNR/I order) due to her
dementia, I would favor discontinuing coumadin at this time as
the benefit of preventing recurrent DVT seems to be outweighed
by recent risk of life-threatening bleed.  I discussed this with
her daughter (HCP) and she was in agreement with withholding
coumadin at this time, realizing she may be at risk for
recurrent dvt or pulmonary embolism.

# Elevated INR: Patient was on coumadin for h/o DVT. Coumadin
was held upon presentation. The patient received Vitamin K and 2
units of FFP in the setting of active GI bleed and planned
endoscopy.

# UTI: the patient was started on Bactrim on [**9-13**] for evidence
of UTI on admission UA; urine cultures returned pan-sensitive
e.coli. plan for 7 day course of treatment.

# Arotic Stenosis -noted on physical exam, likely accentuated by
volume depletion.  Echo revealed mild AS and preserved systolic
function.

# Chronic anemia: Likely due to diabetic nephropathy. Baseline
around 30-34 on Aranesp. On iron supplementation. No iron
studies in our system, but not pursued during this
hospitalization.
.
# Hyponatremia: Hypovolemic Hyponatremia in the setting of GI
bleed. resolved with volume resusitation
.
# DM II controlled with complications: Insulin sliding scale
while hospitalzed. may resume actos outpatient regimen upon
transfer back to [**Hospital **] rehab.


Medications on Admission:
(per NH sheet):
Morphine 4mg q4h prn
Ativan 0.25mg q6h prn
Tylenol 650mg q6h prn
Iron 325 mg daily
Zyprexa 5mg daily
Compazine 25mg q12h prn
Warfarin (per schedule - not included)
Trazodone 50mg qHS
Senna
Erythromycin ointment
Pioglitazone 30mg daily
Lidoderm patch
Protonix 40mg [**Hospital1 **]

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - LTC

Discharge Diagnosis:
upper gastrointestinal bleed


Discharge Condition:
stable


Discharge Instructions:
complete antibiotics as prescribed
we are not restarting coumadin
all other orders as prior to admit, or per facility

Followup Instructions:
as per facility


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]

Completed by:[**2115-11-13**]
{'Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Unspecified schizophrenia, unspecified,Chronic kidney disease, unspecified,Aortic valve disorders,Hyposmolality and/or hyponatremia,Procedure not carried out for other reasons,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other persistent mental disorders due to conditions classified elsewhere,Disorder of bone and cartilage, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Long-term (current) use of anticoagulants'}


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: Coffee-ground emesis

PRESENT ILLNESS: 93-year old female from NH (DNR/I) with history of stroke,
dementia, dvt on coumading, schizophrenia, DM, presents with
coffee-ground emesis.
.
Pt developed coffee-ground emesis one day PTA at [**Hospital1 100**]-Rehab.
No previous h/o GIB. SBP was in the 100s but dropped to 80s,
responsive to IVFs. Pt was sent to the ED. VS were HR 108, BP
106/67, then 86/45 which came back up to 136/64 after 1L NS. Pt
was guaiac positive. NG lavage was attempted several times,
including by GI but was unsuccessful. 2 large-bore IVs were
placed. Hct was 18 from baseline of 30 to 34 (on Aranesp).
Patient also on coumadin for h/o DVT. INR was 2.3 and pt
received Vitamin K 5mg sc x1. FFP was ordered in the ED but not
yet administered. One unit of pRBC were started prior to
transfer to ICU.
.
ROS could not be obtained given her dementia. HPI was obtained
from daughter who is HCP. Confirmed DNR/I. No central lines.

MEDICAL HISTORY: dementia with paranoid psychosis
depression/anxiety
DM Type II
CRI, Cr baseline 1.3
CVA in [**2099**] per family, only speech impairment that resolved
OP with compression fx (T11,12, L4)
diverticulitits
BCC of nose
Breast Ca: excision/XRT '[**00**]
esophagitis
OA
anemia Hct baseline 30, has been on aranesp
hypernatremia
constipation
LLE DVT [**2115-4-22**], on coumadin
R hip fracture [**4-/2115**]

MEDICATION ON ADMISSION: (per NH sheet):
Morphine 4mg q4h prn
Ativan 0.25mg q6h prn
Tylenol 650mg q6h prn
Iron 325 mg daily
Zyprexa 5mg daily
Compazine 25mg q12h prn
Warfarin (per schedule - not included)
Trazodone 50mg qHS
Senna
Erythromycin ointment
Pioglitazone 30mg daily
Lidoderm patch
Protonix 40mg [**Hospital1 **]

ALLERGIES: Risperidone / Rofecoxib / Ciprofloxacin

PHYSICAL EXAM: VS: Temp: 96.7 BP: 138/55  HR: 107 RR: 27  O2sat 100%RA
GEN: demented, comfortably lying in bed, NAD
HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions
NECK: no cervical lymphadenopathy, no jvd, no carotid bruits
RESP: CTA b/l, no wheezes, rhales or rhonchi
CV: RR, S1 and S2 wnl, [**4-9**] decrescendo murmur at USB w/o
radiation
ABD: nd, +b/s, soft, nt, no masses
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: demented, moving all extremities, responds to simple
commands

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: No ETOH. No tobacco. Lives at [**Hospital6 459**]. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Unspecified schizophrenia, unspecified,Chronic kidney disease, unspecified,Aortic valve disorders,Hyposmolality and/or hyponatremia,Procedure not carried out for other reasons,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Other persistent mental disorders due to conditions classified elsewhere,Disorder of bone and cartilage, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Long-term (current) use of anticoagulants'}
