CHIEF COMPLAINT: GI bleed

PRESENT ILLNESS: 62 yo M h/o CAD s/p CABG, AS s/p bioprosthetic AVR, DM2, AFib on
AC, ?PUD p/w dizziness and worsened DOE x 5-7 days.  The patient
states that at baseline he has 20-25 step DOE.  He also noted
"two-toned stool" which he described as normal appearing on one
side and dark black on the other side.  The patient states that
he first presented with similar symptoms two months ago to
[**Hospital 4199**] Hospital, at which time, per his report, an EGD was
performed and he was diagnosed with an ulcer.  He is not sure
what treatment was initiated other than "changing some meds
around."  After this presentation, his stools returned to [**Location 213**]
and his DOE and dizziness resolved until this acute
presentation.

MEDICAL HISTORY: - bicuspid aortic valve leading to stenosis s/p bioprosthetic
AVR in [**2200-8-2**]
- CAD with 3VD s/p CABG in [**2200-8-2**]
- AFib, on anticoagulation with warfarin
- DM2
- HTN
- HLP
- degenerative lumbar disc disease
- h/o umbilical hernia repair

MEDICATION ON ADMISSION: ASA 81
protonix 40 [**Hospital1 **]
pravastatin 80 hs
metformin 500 [**Hospital1 **]
thiamine 100 qday
folate 1 qday
MVI 1 tab qday
warfarin 6-12 mg qday
metoprolol succinate 100 qday
lasix 20 qday
amlodipine 10 qday
lisinopril 40 qday

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 97.8 BP: 135/65 P: 69 R: 19 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM slightly dry
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, [**3-7**] harsh early
systolic murmur heard best @ LUSB but radiates across precordium
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Sister had unknown heart murmur and died at age 10

SOCIAL HISTORY: 2 ppd x 45 yrs, quit [**2200-8-2**].  3 quarts of beer/day x 40 yrs,
last drink [**2200-11-2**].  No h/o IVDU.
Other specified gastritis, with hemorrhage,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Unspecified essential hypertension,Coronary atherosclerosis of unspecified type of vessel, native or graft,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Leukocytosis, unspecified,Heart valve replaced by transplant,Aortocoronary bypass status,Long-term (current) use of anticoagulants
Oth spf gastrt w hmrhg,Acute kidney failure NOS,Ac posthemorrhag anemia,Hypertension NOS,Cor ath unsp vsl ntv/gft,Atrial fibrillation,DMII wo cmp nt st uncntr,Hyperlipidemia NEC/NOS,Leukocytosis NOS,Heart valve transplant,Aortocoronary bypass,Long-term use anticoagul
Admission Date:  [**2201-4-2**]              Discharge Date:   [**2201-4-5**]

Date of Birth:  [**2138-8-20**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
GI bleed

Major Surgical or Invasive Procedure:
EGD with biopsies

History of Present Illness:
62 yo M h/o CAD s/p CABG, AS s/p bioprosthetic AVR, DM2, AFib on
AC, ?PUD p/w dizziness and worsened DOE x 5-7 days.  The patient
states that at baseline he has 20-25 step DOE.  He also noted
"two-toned stool" which he described as normal appearing on one
side and dark black on the other side.  The patient states that
he first presented with similar symptoms two months ago to
[**Hospital 4199**] Hospital, at which time, per his report, an EGD was
performed and he was diagnosed with an ulcer.  He is not sure
what treatment was initiated other than "changing some meds
around."  After this presentation, his stools returned to [**Location 213**]
and his DOE and dizziness resolved until this acute
presentation.

He went to his doctor's office, who referred him to an OSH ED.
At this time he was found to be tachycardic and have an INR of
2.9 and a Hct of 21 with guaiac positive, black stool.  He was
transferred to [**Hospital1 18**] ED for further evaluation.  Vitals were 63,
103/47, 21,  98% on RA, afebrile.  At this time, it was
confirmed with his surgeon at [**Hospital1 2025**] that a bioprosthetic valve was
used for his AVR.  He was then reversed with 2u FFP + 10 mg IV
Vit K.  Repeat Hct in ED was 21.  Attempted NG tube placement
twice for lavage but failed, causing a nosebleed that was halted
with Afrin.  Patient was admitted to ICU for further management.
.
Review of systems: Denies fevers, chills, chest pain, nausea,
vomiting, diarrhea, constipation, abdominal pain, hematuria, or
dysuria.

Past Medical History:
- bicuspid aortic valve leading to stenosis s/p bioprosthetic
AVR in [**2200-8-2**]
- CAD with 3VD s/p CABG in [**2200-8-2**]
- AFib, on anticoagulation with warfarin
- DM2
- HTN
- HLP
- degenerative lumbar disc disease
- h/o umbilical hernia repair

Social History:
2 ppd x 45 yrs, quit [**2200-8-2**].  3 quarts of beer/day x 40 yrs,
last drink [**2200-11-2**].  No h/o IVDU.

Family History:
Sister had unknown heart murmur and died at age 10

Physical Exam:
Vitals: T: 97.8 BP: 135/65 P: 69 R: 19 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM slightly dry
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, [**3-7**] harsh early
systolic murmur heard best @ LUSB but radiates across precordium
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
[**2201-4-2**] 07:30PM   WBC-7.2 RBC-3.15* HGB-6.0* HCT-21.2* MCV-67*
MCH-19.0* MCHC-28.3* RDW-17.6*
[**2201-4-2**] 07:30PM   NEUTS-64.0 LYMPHS-25.2 MONOS-8.1 EOS-2.5
BASOS-0.3
[**2201-4-2**] 07:30PM   HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL PENCIL-OCCASIONAL BITE-1+
[**2201-4-2**] 07:30PM   PLT COUNT-137*
[**2201-4-2**] 07:30PM   PT-23.2* PTT-27.7 INR(PT)-2.2*
[**2201-4-2**] 07:30PM   GLUCOSE-183* UREA N-23* CREAT-1.3* SODIUM-141
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-23 ANION GAP-15
.
CXR: No consolidation or edema is evident. There is evidence of
prior median sternotomy, vascular clips consistent with CABG,
and a prosthetic valve. There is mild aortic tortuosity. The
cardiac silhouette is top normal for size. No effusion or
pneumothorax is noted. The osseous structures reveal extensive
degenerative changes throughout the thoracic spine.

Discharge Labs: [**2201-4-5**] 08:20AM
WBC-7.9 RBC-3.97* Hgb-8.9* Hct-28.8* MCV-73* Plt Ct-139*
Glucose-263* UreaN-15 Creat-1.0 Na-138 K-4.0 Cl-104 HCO3-23
AnGap-15

Brief Hospital Course:
62 yo M h/o AVR, CAD s/p CABG, AFib on coumadin, recent h/o PUD
p/w GI bleed

# GI bleed: Likely UGIB given melenic stools and recent h/o PUD
as seen on EGD @ OSH (per patient).  Patient's anticoagulation
status made him more susceptible to recurrent GI bleeding.
Pantoprazole IV BID was started, he received 2 RBC units and H
pylori serologies were sent. He underwent EGD the following day,
which showed erosions in the stomach, but no ulcers. Colonoscopy
was recommended in 2 weeks. At discharge he was started on
triple therapy for H.pylori.

# Elevated Cr: Initially unclear if this represented ARF as
patient's baseline Cr was not known. Pre-renal failure could be
consistent with the patient's history of GI bleeding.
- Cr improved with fluid hydration and transfusions

#Leukocytosis: Elevated WBC count noted on [**2201-4-4**], which
resolved on [**2201-4-5**] with no intervention.

# Afib: Currently in NSR. Initially held rate controlling
medication as not needed, BP low-normal.  Holding Warfarin in
setting of GI bleed.  Patient's CHADS2 = 3 assuming he has CHF
(not clearly documented, but likely given medications of
metoprolol succinate, lasix, lisinopril, and ROS positive for
DOE at baseline). Warfarin not prescribed at discharge as risks
of recurrent GI bleed deemed to be very high; to be discussed
further by outpatient PCP and Cardiologist.

# CAD/AVR: Anticoagulation not needed as valve is bioprosthesis.
 CAD appears stable as patient chest-pain free. Patient's statin
was continued; beta-blocker and Lisinopril were re-started at
half-dose as patient's blood pressure was only mildly elevated.
Aspirin held in setting of recent GIB. Would re-start as an
outpatient. At the time of discharge, SBP=125.

# DM2: Metformin held; would re-start at discharge.

# HTN: Antihypertensives held initially in setting of active
bleeding and acute renal failure; adjustments as above.

PCP: [**Last Name (NamePattern4) **].[**Last Name (STitle) **] [**Telephone/Fax (1) 25050**] CHA [**Location (un) 3786**] Family Health Center

Medications on Admission:
ASA 81
protonix 40 [**Hospital1 **]
pravastatin 80 hs
metformin 500 [**Hospital1 **]
thiamine 100 qday
folate 1 qday
MVI 1 tab qday
warfarin 6-12 mg qday
metoprolol succinate 100 qday
lasix 20 qday
amlodipine 10 qday
lisinopril 40 qday

Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
10. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
11. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
GI Bleed
Acute Renal Failure
Hypertension
Coronary Artery Disease
Aortic Valve Replacement

Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent

Discharge Instructions:
You were admitted with anemia secondary to a GI bleed. You
received 3 units of packed red blood cells, and underwent an EGD
which showed inflammation in your stomach, but no ulcers.

Your Coumadin was held, as was your Aspirin, and should continue
to be held until you meet with your primary care doctor. You
were also started on treatment for an H.pylori infection,
including amoxicillin and clarithromycin, which you should take
for 10 days. Your Lisinopril was decreased from 40mg a day to
20mg a day, and your Metoprolol was decreased from 100mg a day
to 50mg a day. The rest of your medications were unchanged.


Followup Instructions:
Please follow-up with Dr.[**Last Name (STitle) **] in three to five days for a
blood pressure check and to adjust your blood pressure
medications. Please bring all of your medications with you so
that you can confirm you are taking everything correctly.
{'Other specified gastritis, with hemorrhage,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Unspecified essential hypertension,Coronary atherosclerosis of unspecified type of vessel, native or graft,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Leukocytosis, unspecified,Heart valve replaced by transplant,Aortocoronary bypass status,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: GI bleed

PRESENT ILLNESS: 62 yo M h/o CAD s/p CABG, AS s/p bioprosthetic AVR, DM2, AFib on
AC, ?PUD p/w dizziness and worsened DOE x 5-7 days.  The patient
states that at baseline he has 20-25 step DOE.  He also noted
"two-toned stool" which he described as normal appearing on one
side and dark black on the other side.  The patient states that
he first presented with similar symptoms two months ago to
[**Hospital 4199**] Hospital, at which time, per his report, an EGD was
performed and he was diagnosed with an ulcer.  He is not sure
what treatment was initiated other than "changing some meds
around."  After this presentation, his stools returned to [**Location 213**]
and his DOE and dizziness resolved until this acute
presentation.

MEDICAL HISTORY: - bicuspid aortic valve leading to stenosis s/p bioprosthetic
AVR in [**2200-8-2**]
- CAD with 3VD s/p CABG in [**2200-8-2**]
- AFib, on anticoagulation with warfarin
- DM2
- HTN
- HLP
- degenerative lumbar disc disease
- h/o umbilical hernia repair

MEDICATION ON ADMISSION: ASA 81
protonix 40 [**Hospital1 **]
pravastatin 80 hs
metformin 500 [**Hospital1 **]
thiamine 100 qday
folate 1 qday
MVI 1 tab qday
warfarin 6-12 mg qday
metoprolol succinate 100 qday
lasix 20 qday
amlodipine 10 qday
lisinopril 40 qday

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 97.8 BP: 135/65 P: 69 R: 19 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM slightly dry
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, [**3-7**] harsh early
systolic murmur heard best @ LUSB but radiates across precordium
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Sister had unknown heart murmur and died at age 10

SOCIAL HISTORY: 2 ppd x 45 yrs, quit [**2200-8-2**].  3 quarts of beer/day x 40 yrs,
last drink [**2200-11-2**].  No h/o IVDU. 

### Response:
{'Other specified gastritis, with hemorrhage,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Unspecified essential hypertension,Coronary atherosclerosis of unspecified type of vessel, native or graft,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Leukocytosis, unspecified,Heart valve replaced by transplant,Aortocoronary bypass status,Long-term (current) use of anticoagulants'}
