CHIEF COMPLAINT: elevated INR, BRBPR

PRESENT ILLNESS: This is an 82 year-old man with a history of recurrent GI
bleeding-requiring admissions in [**Month (only) 359**] and [**Month (only) **] of
[**2203**]-obscure/overt with last EGD [**10-6**]-gastritis, duodenitis
with erosions but no frank ulcers, [**Last Name (un) **] [**10-6**]-diverticulosis,
atrial fibrillation on coumadin, chf-preserved EF with 3+MR,
who presents with 1 week of guiaic positive stools from NH in
setting of recent diagnosis of c. diff colitis and
supratherapeutic INR. He noticed bright red blood on his sheets
on day of admission. He complains of rectal pain and lower
abdominal pain and thirst. He denies nausea, vomiting, chest
pain, SOB, dysuria (but has foley chronically), PND. He also
notes weight loss and decreased appetite and weakness. It
appears he is not very active at the NH.
.
Nursing home providers noted intermittent blood on sheets,
guiaic positivity, relative hypotension, weakness over past
week.  Crit has been stable, hct 35 on [**2203-1-4**] (bl mid to high
30's), INR supratherapeutic to 9 on [**1-4**] and diagnosed with c.
diff--treatment (flagyl )started [**1-2**], his third time with c diff
over past year.  Vitamin K subcu 10 given [**1-4**].
.
In terms of his history of GIB, he is followed by GI--last seen
[**2203-12-28**] by Dr. [**First Name (STitle) 2643**].  Plan for bleeding was outpatient capsule
endoscopy.  EGD and [**Last Name (un) **] as above.  PRBC scan with 10/06 admit
was negative and CT abdomen was unremarkable.

MEDICAL HISTORY: 1. HTN
2. Valvular HD (mainly 3+MR)
3. AFib on coumadin
4. Hyperlipidemia
5. Prostate CA s/p XRT - no recent followup
6. AAA s/p repair [**2187**]
7. UGIB [**2188**] from duodenal polyps
8. SBO s/p LOA [**2200**]
9. Anxiety
10. Diverticulosis w/ diverticulitis
11. C. diff colitis x3 in past year, currently on flagyl for
active infection

MEDICATION ON ADMISSION: folic Acid 1mg daily
citalopram 20 mg daily
lisinopril 2.5 mg QD
Toprol 25 mg QD
Lasix 20 po daily
aspirin 81 mg QD
Art tears
Coumadin 0.5 daily
flagyl x 4 days
keppra 1000 [**Hospital1 **]
sucralfate 1000 mg TID
MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:  Temp: 93.4  BP: 102 /65  HR: 79  RR: 18 O2sat 98%2L

FAMILY HISTORY: unknown, non-contributory.

SOCIAL HISTORY: Tobacco: 30 pack year smoking history, quit 20y ago.
Alcohol: Denies alcohol use.
Widowed x 13 years, lives alone, son lives in the area, no
services at home.
has been at nursing home since [**Month (only) **]. Son lives close by
([**First Name5 (NamePattern1) **] [**Known lastname 46031**]), other son [**Name (NI) **] [**Name (NI) 46031**] is HCP.
Intestinal infection due to Clostridium difficile,Chronic systolic heart failure,Atrial fibrillation,Acute posthemorrhagic anemia,Mitral valve disorders,Pressure ulcer, lower back,Long-term (current) use of anticoagulants,Candidiasis of other urogenital sites,Epilepsy, unspecified, without mention of intractable epilepsy,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of prostate
Int inf clstrdium dfcile,Chr systolic hrt failure,Atrial fibrillation,Ac posthemorrhag anemia,Mitral valve disorder,Pressure ulcer, low back,Long-term use anticoagul,Candidias urogenital NEC,Epilep NOS w/o intr epil,Hyperlipidemia NEC/NOS,Hx-prostatic malignancy
Admission Date:  [**2204-1-5**]              Discharge Date:   [**2204-1-16**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
elevated INR, BRBPR

Major Surgical or Invasive Procedure:
none


History of Present Illness:
This is an 82 year-old man with a history of recurrent GI
bleeding-requiring admissions in [**Month (only) 359**] and [**Month (only) **] of
[**2203**]-obscure/overt with last EGD [**10-6**]-gastritis, duodenitis
with erosions but no frank ulcers, [**Last Name (un) **] [**10-6**]-diverticulosis,
atrial fibrillation on coumadin, chf-preserved EF with 3+MR,
who presents with 1 week of guiaic positive stools from NH in
setting of recent diagnosis of c. diff colitis and
supratherapeutic INR. He noticed bright red blood on his sheets
on day of admission. He complains of rectal pain and lower
abdominal pain and thirst. He denies nausea, vomiting, chest
pain, SOB, dysuria (but has foley chronically), PND. He also
notes weight loss and decreased appetite and weakness. It
appears he is not very active at the NH.
.
Nursing home providers noted intermittent blood on sheets,
guiaic positivity, relative hypotension, weakness over past
week.  Crit has been stable, hct 35 on [**2203-1-4**] (bl mid to high
30's), INR supratherapeutic to 9 on [**1-4**] and diagnosed with c.
diff--treatment (flagyl )started [**1-2**], his third time with c diff
over past year.  Vitamin K subcu 10 given [**1-4**].
.
In terms of his history of GIB, he is followed by GI--last seen
[**2203-12-28**] by Dr. [**First Name (STitle) 2643**].  Plan for bleeding was outpatient capsule
endoscopy.  EGD and [**Last Name (un) **] as above.  PRBC scan with 10/06 admit
was negative and CT abdomen was unremarkable.


Past Medical History:
1. HTN
2. Valvular HD (mainly 3+MR)
3. AFib on coumadin
4. Hyperlipidemia
5. Prostate CA s/p XRT - no recent followup
6. AAA s/p repair [**2187**]
7. UGIB [**2188**] from duodenal polyps
8. SBO s/p LOA [**2200**]
9. Anxiety
10. Diverticulosis w/ diverticulitis
11. C. diff colitis x3 in past year, currently on flagyl for
active infection

Social History:
Tobacco: 30 pack year smoking history, quit 20y ago.
Alcohol: Denies alcohol use.
Widowed x 13 years, lives alone, son lives in the area, no
services at home.
has been at nursing home since [**Month (only) **]. Son lives close by
([**First Name5 (NamePattern1) **] [**Known lastname 46031**]), other son [**Name (NI) **] [**Name (NI) 46031**] is HCP.


Family History:
unknown, non-contributory.

Physical Exam:
VS:  Temp: 93.4  BP: 102 /65  HR: 79  RR: 18 O2sat 98%2L

general: pleasant, comfortable, NAD
HEENT: PERLLA, EOMI, anicteric, OP dry with possible white
plaques, no supraclavicular or cervical lymphadenopathy, jvd at
8cm, no thyromegaly
lungs: CTA b/l with good air movement throughout
heart: RR, S1 and S2 wnl, + murmurs at apex and RSB
abdomen: nd, +b/s, soft, tender in prepubic area, +midline scar,
erythematous buttocks, brown stool with a few small dark red
clots, small decub with duoderm
extremities: no edema, cool feet, 1+ pedal pulses
skin/nails: no rashes
neuro: AAOx3.


Pertinent Results:
[**2204-1-5**] 05:57PM   GLUCOSE-114* UREA N-24* CREAT-0.8 SODIUM-143
POTASSIUM-3.2* CHLORIDE-109* TOTAL CO2-26 ANION GAP-11
[**2204-1-5**] 05:57PM   CK(CPK)-15*
[**2204-1-5**] 05:57PM   CK-MB-2 cTropnT-0.06*
[**2204-1-5**] 05:57PM   WBC-6.2 RBC-3.60* HGB-10.0* HCT-31.5* MCV-87
MCH-27.8 MCHC-31.8 RDW-18.0*
[**2204-1-5**] 05:57PM   PLT COUNT-253
[**2204-1-5**] 05:57PM   PT-21.6* PTT-40.4* INR(PT)-2.1*
[**2204-1-5**] 05:19PM URINE  COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
[**2204-1-5**] 05:19PM URINE  BLOOD-LGE NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2204-1-5**] 05:19PM URINE  RBC-141* WBC-32* BACTERIA-NONE
YEAST-MANY EPI-<1
[**2204-1-5**] 05:19PM URINE  HYALINE-2*
[**2204-1-5**] 01:11PM   WBC-7.0 RBC-3.61* HGB-9.8*# HCT-32.0* MCV-89
MCH-27.1 MCHC-30.6* RDW-17.4*
[**2204-1-5**] 01:11PM   PLT COUNT-278
[**2204-1-5**] 09:30AM   TYPE-ART RATES-/18 O2 FLOW-3 PO2-117*
PCO2-33* PH-7.40 TOTAL CO2-21 BASE XS--2 INTUBATED-NOT INTUBA
[**2204-1-5**] 09:07AM   TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF
[**2204-1-5**] 09:07AM   K+-5.0
[**2204-1-5**] 09:07AM   HGB-13.3* calcHCT-40
[**2204-1-5**] 09:00AM   GLUCOSE-104 UREA N-27* CREAT-1.0 SODIUM-138
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-25 ANION GAP-11
[**2204-1-5**] 09:00AM   estGFR-Using this
[**2204-1-5**] 09:00AM   CK(CPK)-18*
[**2204-1-5**] 09:00AM   CK-MB-NotDone
[**2204-1-5**] 09:00AM   CALCIUM-9.8 PHOSPHATE-3.2 MAGNESIUM-2.2
[**2204-1-5**] 09:00AM   WBC-9.4 RBC-4.67 HGB-13.0* HCT-41.4 MCV-89
MCH-27.9 MCHC-31.5 RDW-17.6*
[**2204-1-5**] 09:00AM   NEUTS-75.3* LYMPHS-20.1 MONOS-2.5 EOS-2.0
BASOS-0.2
[**2204-1-5**] 09:00AM   HYPOCHROM-3+ ANISOCYT-1+ MICROCYT-1+
[**2204-1-5**] 09:00AM   PLT COUNT-300
[**2204-1-5**] 09:00AM   PT-45.4* PTT-49.1* INR(PT)-5.2*

CXR: Massive LA enlargement with possible present pulmonary
hypertension, could be due to mitral valve regurgitation


Brief Hospital Course:
1) C. diff colitis: Pt with copious diarrhea despite PO vanco.
Added IV Flagyl at the recommendation of ID. Abd CT [**1-8**] with
wall thickening and adjacent inflammatory stranding of the
sigmoid colon and rectum. Diarrhea improved now transitioned to
both po vanco and flagyl for a 2 week course.
.
2) GI bleed: The patient has a history of GI bleeding dating
back to [**10-6**] when he was admitted with BRBPR - EGD w/
gastritis/duodenitis with erosions, colonoscopy w/
diverticulosis, tagged RBC scan negative, and abd CT (-).
Readmitted [**11-6**] w/ rectal bleeding, resolved spontaneously.
Current episode likely due to C. diff + coumadin; per
cardiologist ([**Doctor Last Name **]) needs to be anti-coagulated, but aiming
lower INR goal 1.5-2. HCT now stable. Follow up for colonoscopy
with Dr. [**Last Name (STitle) **] in [**2-5**] weeks.
.
3) Systolic CHF: Hypoxic, 96% 3L, CXR with bilateral effusions
and pulmonary edema. Had been Diuresing with lasix 20 mg IV BID,
now changed to lasix 40 mg PO daily, titrating up lisinopril.
Follow up with his cardiologist Dr. [**Last Name (STitle) **] in [**2-5**] weeks.
.
4) AF/severe MR: goal INR 1.5-2 as above; cont. lopressor
.
5) Acute blood loss anemia: secondaty to GIB; HCT now stable w/o
evidence of active bleeding. Vit B12/folate high; given h/o abnl
SPEP, recheking SPEP and UPEP.
.
6) Candidal UTI: continue diflucan per ID (day [**4-7**]). Per ID not
treating VRE (10-100k) given they think it is a colonizer.
Repeat UA after Foley removed positive, but will have UCx
followed up from [**Hospital1 1501**] as he is currently on treatement for cadida
UTI. Would not treat unless patient symptomatic or UCx has
higher counts of VRE or growing out a new organism.
.
6) seizure disorder: Continued on Keppra
.
7) Decubitus ulcer: wound care evaluation recieved, to continue
sacral dresing changes
.
8) CAD: continue beta-blocker; no ASA given GIB
.
10) Dispo: to [**Hospital1 1501**]

Medications on Admission:
folic Acid 1mg daily
citalopram 20 mg daily
lisinopril 2.5 mg QD
Toprol 25 mg QD
Lasix 20 po daily
aspirin 81 mg QD
Art tears
Coumadin 0.5 daily
flagyl x 4 days
keppra 1000 [**Hospital1 **]
sucralfate 1000 mg TID
MVI


Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
11. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 weeks.
Disp:*56 Capsule(s)* Refills:*0*
12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Please make sure you have your INR checked in the next 1-2 days
to have your coumadin dose adjusted for a goal INR 1.5-2.
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
17. Outpatient Lab Work
Please have your INR checked either [**1-17**] or [**1-18**] to have your
coumadin dose adjusted for a goal INBR 1.5-2.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] - [**Location (un) **]

Discharge Diagnosis:
C. Diff Colitis
Systolic CHF
Atrial Fibrillation


Discharge Condition:
stable


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 cc. Please take your medications as
listed below. Please make sure your urine culture result is
followed up in the next week at your [**Hospital1 1501**] to make sure you do not
have a new bacteria growing in your urine. Please also make sure
you follow up with your PCP and your cardiologist.

Followup Instructions:
1. Please call to reschedule your follow up colonoscopy in the
next 2-4 weeks. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**]


2. Please make sure you follow up with your PCP in the next [**2-5**]
weeks.

3. Please also make sure you follow up with your cardiologist in
the next 2-4 weeks.

4. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 1690**]
Date/Time:[**2204-4-4**] 2:30
{'Intestinal infection due to Clostridium difficile,Chronic systolic heart failure,Atrial fibrillation,Acute posthemorrhagic anemia,Mitral valve disorders,Pressure ulcer, lower back,Long-term (current) use of anticoagulants,Candidiasis of other urogenital sites,Epilepsy, unspecified, without mention of intractable epilepsy,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of prostate'}


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: elevated INR, BRBPR

PRESENT ILLNESS: This is an 82 year-old man with a history of recurrent GI
bleeding-requiring admissions in [**Month (only) 359**] and [**Month (only) **] of
[**2203**]-obscure/overt with last EGD [**10-6**]-gastritis, duodenitis
with erosions but no frank ulcers, [**Last Name (un) **] [**10-6**]-diverticulosis,
atrial fibrillation on coumadin, chf-preserved EF with 3+MR,
who presents with 1 week of guiaic positive stools from NH in
setting of recent diagnosis of c. diff colitis and
supratherapeutic INR. He noticed bright red blood on his sheets
on day of admission. He complains of rectal pain and lower
abdominal pain and thirst. He denies nausea, vomiting, chest
pain, SOB, dysuria (but has foley chronically), PND. He also
notes weight loss and decreased appetite and weakness. It
appears he is not very active at the NH.
.
Nursing home providers noted intermittent blood on sheets,
guiaic positivity, relative hypotension, weakness over past
week.  Crit has been stable, hct 35 on [**2203-1-4**] (bl mid to high
30's), INR supratherapeutic to 9 on [**1-4**] and diagnosed with c.
diff--treatment (flagyl )started [**1-2**], his third time with c diff
over past year.  Vitamin K subcu 10 given [**1-4**].
.
In terms of his history of GIB, he is followed by GI--last seen
[**2203-12-28**] by Dr. [**First Name (STitle) 2643**].  Plan for bleeding was outpatient capsule
endoscopy.  EGD and [**Last Name (un) **] as above.  PRBC scan with 10/06 admit
was negative and CT abdomen was unremarkable.

MEDICAL HISTORY: 1. HTN
2. Valvular HD (mainly 3+MR)
3. AFib on coumadin
4. Hyperlipidemia
5. Prostate CA s/p XRT - no recent followup
6. AAA s/p repair [**2187**]
7. UGIB [**2188**] from duodenal polyps
8. SBO s/p LOA [**2200**]
9. Anxiety
10. Diverticulosis w/ diverticulitis
11. C. diff colitis x3 in past year, currently on flagyl for
active infection

MEDICATION ON ADMISSION: folic Acid 1mg daily
citalopram 20 mg daily
lisinopril 2.5 mg QD
Toprol 25 mg QD
Lasix 20 po daily
aspirin 81 mg QD
Art tears
Coumadin 0.5 daily
flagyl x 4 days
keppra 1000 [**Hospital1 **]
sucralfate 1000 mg TID
MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:  Temp: 93.4  BP: 102 /65  HR: 79  RR: 18 O2sat 98%2L

FAMILY HISTORY: unknown, non-contributory.

SOCIAL HISTORY: Tobacco: 30 pack year smoking history, quit 20y ago.
Alcohol: Denies alcohol use.
Widowed x 13 years, lives alone, son lives in the area, no
services at home.
has been at nursing home since [**Month (only) **]. Son lives close by
([**First Name5 (NamePattern1) **] [**Known lastname 46031**]), other son [**Name (NI) **] [**Name (NI) 46031**] is HCP. 

### Response:
{'Intestinal infection due to Clostridium difficile,Chronic systolic heart failure,Atrial fibrillation,Acute posthemorrhagic anemia,Mitral valve disorders,Pressure ulcer, lower back,Long-term (current) use of anticoagulants,Candidiasis of other urogenital sites,Epilepsy, unspecified, without mention of intractable epilepsy,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of prostate'}
