CHIEF COMPLAINT: Gastrointestinal bleed.

PRESENT ILLNESS: This is a 57-year-old male with
a past medical history significant for hypothyroidism,
tobacco abuse, with no known gastrointestinal history who
presents with a 6-day history of "blueberry-colored" stools.

MEDICAL HISTORY: 1.  Hypothyroidism.
2.  Tobacco abuse (one pack per day times 40 years).
3.  Rectal condyloma; status post partial excision (present
for the last 20 years).
4.  One episode of melena in [**2197-12-16**] which was
incompletely evaluated as the patient declined an
esophagogastroduodenoscopy at that time.  No chronic
nonsteroidal antiinflammatory drug use.

MEDICATION ON ADMISSION: 1.  Synthroid 0.125 mg p.o. once per day.
2.  Aspirin 81 mg p.o. once per day (stopped six days prior
to admission).

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: No family history of inflammatory bowel
disease or colon cancer.  Two cousins with a history of
ulcers.

SOCIAL HISTORY: He is a bakery owner.  He lives with his
wife and daughter.  [**Name (NI) **] smokes one pack per day times 40
years.  Occasional alcohol use.  No history of illicit drug
use.  No herbal medications.  No human immunodeficiency virus
risk factors; including no history of intravenous drug use,
no history of blood transfusions, and no history of
homosexual receptive anal intercourse.
Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Diverticulosis of colon (without mention of hemorrhage),Unspecified acquired hypothyroidism,Viral warts, unspecified,Other specified disorders of skin,Tobacco use disorder,Acute posthemorrhagic anemia
Chr duoden ulcer w hem,Gstr/ddnts NOS w/o hmrhg,Dvrtclo colon w/o hmrhg,Hypothyroidism NOS,Viral warts NOS,Skin disorders NEC,Tobacco use disorder,Ac posthemorrhag anemia
Admission Date:  [**2199-5-14**]     Discharge Date:  [**2199-5-16**]

Date of Birth:   [**2141-8-3**]     Sex:  M

Service:  Medicine, [**Location (un) **] Firm

CHIEF COMPLAINT:  Gastrointestinal bleed.

HISTORY OF PRESENT ILLNESS:  This is a 57-year-old male with
a past medical history significant for hypothyroidism,
tobacco abuse, with no known gastrointestinal history who
presents with a 6-day history of "blueberry-colored" stools.

He was in his usual state of health until the morning of
[**5-9**] (six days prior to admission) when he developed
dark-colored stools times one.  No frank blood was noted.
Later that day, he developed an episode of lightheadedness
with nausea and vomiting times one.  No hematemesis or
bilious vomitus at that time.

He was seen in the Emergency Department at [**Hospital6 **] and reported blood pressure, electrocardiogram,
chest x-ray, and blood tests were okay.  Therefore, he was
given meclizine for lightheadedness and was discharged to
home.

The following day (on [**2199-5-10**]), he had a similar
dark-colored stool times one and developed fatigue, but he
had no nausea or vomiting.  He stayed from work the next
three days and had several additional similarly colored stool
and episode of nausea, vomiting, lightheaded, and
diaphoresis.  He has not had any syncope of chest pain.  He
had mild dyspnea on exertion on the day prior to admission
(on [**2199-5-13**]).  He reports no diarrhea, abdominal pain,
dysphagia, sick contacts, new food, rashes, or arthralgias.

He saw his primary care physician on the day of admission who
noted him to have orthostatic changes with a heart rate of
112 supine and 140 while standing.  Therefore, he was sent to
the Emergency Department for further evaluation.

While in the Emergency Department, he was found to be
guaiac-positive and have a hematocrit of 15, white blood cell
count was 17, and blood urea nitrogen to creatinine ratio was
34 to 0.7.  A nasogastric lavage was performed which was
negative for blood or coffee grounds.  He was then admitted
to the Medical Intensive Care Unit for monitoring and further
evaluation.

PAST MEDICAL HISTORY:
1.  Hypothyroidism.
2.  Tobacco abuse (one pack per day times 40 years).
3.  Rectal condyloma; status post partial excision (present
for the last 20 years).
4.  One episode of melena in [**2197-12-16**] which was
incompletely evaluated as the patient declined an
esophagogastroduodenoscopy at that time.  No chronic
nonsteroidal antiinflammatory drug use.

MEDICATIONS ON ADMISSION:
1.  Synthroid 0.125 mg p.o. once per day.
2.  Aspirin 81 mg p.o. once per day (stopped six days prior
to admission).

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  He is a bakery owner.  He lives with his
wife and daughter.  [**Name (NI) **] smokes one pack per day times 40
years.  Occasional alcohol use.  No history of illicit drug
use.  No herbal medications.  No human immunodeficiency virus
risk factors; including no history of intravenous drug use,
no history of blood transfusions, and no history of
homosexual receptive anal intercourse.

FAMILY HISTORY:   No family history of inflammatory bowel
disease or colon cancer.  Two cousins with a history of
ulcers.

PHYSICAL EXAMINATION ON PRESENTATION:   On physical
examination vital signs revealed temperature was 98.8, blood
pressure was 106/57, heart rate was 93, respiratory rate was
18, and oxygen saturation was 100% on room air.  In general,
the patient was a pleasant and well-appearing male in no
apparent distress.  On head, eyes, ears, nose, and throat
examination his sclerae were anicteric.  Conjunctivae were
pale.  Pupils were equal, round, and reactive.  The
oropharynx was clear.  Mucous membranes were moist.  No
petechiae were noted.  The neck was supple.  There  was no
lymphadenopathy and no thyromegaly.  Heart was regular in
rate.  Normal first heart sounds and second heart sounds.  No
third heart sounds or fourth heart sounds.  No murmurs.  The
lungs were clear to auscultation bilaterally.   The abdomen
revealed normal active bowel sounds.  Soft, nontender, and
nondistended.  Possible round nontender rubbery mass at the
xiphoid process base which was nonpulsatile.  No
hepatosplenomegaly.  Extremity examination revealed
extremities were warm and well perfused without edema.  The
skin revealed no rash, jaundice, or petechiae.  Rectal
examination revealed heme-positive melanotic stool (per
Emergency Department report).  Multiple flat approximately
2-cm round papules in the gluteal folds and rectal area with
stuck-on appearance.  Multiple additional small polypoid skin
colored lesions perianally.  Some brown papules with pink
centers.

PERTINENT LABORATORY VALUES ON PRESENTATION:  Laboratory
values on admission revealed white blood cell count was 17.7
(with 73% neutrophils, 21% lymphocytes, and 3% monocytes),
hemoglobin was 5.2, hematocrit was 15.7, and platelets were
317.  Prothrombin time was 12, partial thromboplastin time
was 21.8, and INR was 1.   Sodium was 139, potassium was 4.1,
chloride was 105, bicarbonate was 22, blood urea nitrogen was
34, creatinine was 0.7, and blood glucose was 97.

PERTINENT RADIOLOGY/IMAGING:  A chest x-ray showed no
evidence of pneumonia or free air beneath the diaphragm.  No
evidence of congestive heart failure.  Degenerative changes
in the thoracic spine.

Electrocardiogram on [**2199-5-14**] revealed a normal sinus
rhythm.  Normal axis and intervals.  No abnormalities.

IMPRESSION:  This is a 57-year-old male with a past medical
history significant for hypothyroidism and tobacco use
presenting with symptoms of an upper gastrointestinal bleed.

HOSPITAL COURSE BY ISSUE/SYSTEM:

1.  GASTROINTESTINAL ISSUES:  On presentation, the patient
had a 6-day history of dark-colored stools found to be
guaiac-positive by Emergency Department examination.

He was found to have orthostatic changes, and given his low
hematocrit he was admitted to the Medical Intensive Care Unit
for further observation.

An esophagogastroduodenoscopy was performed on hospital day
two which showed prepyloric erosions and a small ulcer in the
duodenal bulb with a stigmata (red spot) of recent bleeding.
There was no visible vesicles or active bleeding noted.
Therefore, no further interventional was performed during the
procedure.  Of note, there were additional findings
consistent with gastritis and duodenitis.

Additionally, a colonoscopy was performed and was found to
have diverticulosis throughout the sigmoid colon without
evidence of bleeding.  Otherwise, the colonoscopy was within
normal limits.

He was started initially on Protonix 40 mg intravenously
twice per day and transitioned to 40 mg p.o. twice per day
once taking oral intake.  Although his smoking may have been
contributing to ulcer formation, a Helicobacter pylori
antibody was sent and was pending at the time of this
dictation.  He will be treated appropriately, per his primary
care physician, [**Name10 (NameIs) 4801**] this become positive.

2.  HEMATOLOGIC ISSUES:  On presentation to the Emergency
Department, the patient's hematocrit was significantly
decreased to 15 secondary to gastrointestinal bleeding.  He
was transfused 5 units of packed red blood cells with an
appropriate response in his hematocrit.  He was stable for
the next 48 hours with his hematocrit ranging between 26 and
29.  His coagulations were checked and found to be within
normal limits.

3.  DERMATOLOGIC ISSUES:  The patient had the presence of
rectal condyloma for at least the last 20 years with some of
them status post excision.

He has been resistant to have them further evaluated.  The
Dermatology team was consulted while hospitalized and felt
that the lesions were consistent with condyloma acuminata
versus Bowenoid papulosis which could increase his risk for
potential squamous cell carcinoma.

It was not clear the etiology of these lesions, as he does
not have any risk factors for anal condyloma.  He was to
follow up with Dr. [**Last Name (STitle) **] in Dermatology on [**2199-5-20**] for
a biopsy and a definitive diagnosis.

4.  INFECTIOUS DISEASE ISSUES:  Elevated white blood cell
count to 17 on admission which trended down after appropriate
treatment.  There were no signs of infection in either
gastrointestinal, genitourinary, or pulmonary sources.

It was likely that his increased white blood cell count
without bandemia was secondary to stress from
gastrointestinal bleed.

5.  CARDIOVASCULAR SYSTEM:   The patient's orthostatic
changes resolved with a blood transfusion and intravenous
fluids resuscitation.

6.  FLUIDS/ELECTROLYTES/NUTRITION ISSUES:  The patient's diet
was advanced after colonoscopy and esophagogastroduodenoscopy
to clears and then eventually to a soft mechanical diet just
prior to discharge.

CONDITION AT DISCHARGE:  Condition on discharge was stable
and improved.

DISCHARGE DIAGNOSES:
1.  Upper gastrointestinal bleed secondary to peptic ulcer
disease.
2.  Anemia secondary to acute blood loss; status post blood
transfusion of 5 units of packed red blood cells.
3.  Hypothyroidism.
4.  Rectal condyloma acuminata.
5.  Diverticulosis.

MEDICATIONS ON DISCHARGE:
1.  Protonix 40 mg p.o. twice per day.
2.  Synthroid 0.125 mg p.o. once per day
3.  Aspirin 81 mg p.o. once per day (to be held until
instructed to restart).

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient was to follow up with his primary care
physician (Dr. [**Last Name (STitle) 311**] within one week.
2.  The patient was to schedule a follow-up appointment with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**] in Gastroenterology within two weeks.
3.  The patient was to follow up with Dermatology (Dr.
[**Last Name (STitle) **], [**Location (un) 55**], on [**2199-5-19**] for a biopsy of
suspicious lesions.





                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D.  [**MD Number(1) 1212**]

Dictated By:[**Last Name (NamePattern1) 6240**]

MEDQUIST36

D:  [**2199-5-16**]  18:55
T:  [**2199-5-22**]  11:32
JOB#:  [**Job Number 49126**]
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Diverticulosis of colon (without mention of hemorrhage),Unspecified acquired hypothyroidism,Viral warts, unspecified,Other specified disorders of skin,Tobacco use disorder,Acute posthemorrhagic anemia'}


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: Gastrointestinal bleed.

PRESENT ILLNESS: This is a 57-year-old male with
a past medical history significant for hypothyroidism,
tobacco abuse, with no known gastrointestinal history who
presents with a 6-day history of "blueberry-colored" stools.

MEDICAL HISTORY: 1.  Hypothyroidism.
2.  Tobacco abuse (one pack per day times 40 years).
3.  Rectal condyloma; status post partial excision (present
for the last 20 years).
4.  One episode of melena in [**2197-12-16**] which was
incompletely evaluated as the patient declined an
esophagogastroduodenoscopy at that time.  No chronic
nonsteroidal antiinflammatory drug use.

MEDICATION ON ADMISSION: 1.  Synthroid 0.125 mg p.o. once per day.
2.  Aspirin 81 mg p.o. once per day (stopped six days prior
to admission).

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: No family history of inflammatory bowel
disease or colon cancer.  Two cousins with a history of
ulcers.

SOCIAL HISTORY: He is a bakery owner.  He lives with his
wife and daughter.  [**Name (NI) **] smokes one pack per day times 40
years.  Occasional alcohol use.  No history of illicit drug
use.  No herbal medications.  No human immunodeficiency virus
risk factors; including no history of intravenous drug use,
no history of blood transfusions, and no history of
homosexual receptive anal intercourse. 

### Response:
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Diverticulosis of colon (without mention of hemorrhage),Unspecified acquired hypothyroidism,Viral warts, unspecified,Other specified disorders of skin,Tobacco use disorder,Acute posthemorrhagic anemia'}
