CHIEF COMPLAINT: Melena intraoperatively complication from
plastic surgery.

PRESENT ILLNESS: The patient is an 81-year-old
female with diabetes mellitus Type 2 complicated by end-stage
renal disease on hemodialysis, history of retinopathy
(legally blind) hypertension, hypercholesterolemia, status
post cerebrovascular accident, peripheral vascular disease,
who is admitted to the [**Hospital1 69**]
Plastic Surgery service on [**2185-6-16**] for incision and drainage
of a left hand abscess.

MEDICAL HISTORY: 1.  Insulin dependent diabetes mellitus times 50 years,
complicated by end-stage renal disease on hemodialysis,
complicated by retinopathy, legally blind, complicated by
neuropathy.
2.  Hypertension.
3.  Hypercholesterolemia.
4.  Dementia.
5.  Status post cerebrovascular accident with left sided
residual weakness and right sided weakness.
6.  Hypothyroidism.
7.  Peripheral vascular disease.
8.  Status post total abdominal hysterectomy for fibroids.
9.  Status post right knee surgery.
10. Gout.
11. Scoliosis progressive.
12. Hip "fusion" with back pain requiring narcotics.

MEDICATION ON ADMISSION: 1.  Synthroid 150 mg p.o. q day.
2.  Neurontin 300 mg p.o. q day.
3.  Aspirin 81 mg q day.
4.  Norvasc 10 mg p.o. q day.
5.  Timolol eyedrops 0.5%
6.  Renagel
7.  Ultram.
8.  Colace.
9.  Lisinopril.

ALLERGIES: Codeine, question renal failure.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Other specified disorders of skin,Hemorrhage of gastrointestinal tract, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other complications due to renal dialysis device, implant, and graft,Drug-induced delirium,Unspecified acquired hypothyroidism,Peripheral vascular disease, unspecified,Other diseases of lung, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
Skin disorders NEC,Gastrointest hemorr NOS,Hyp kid NOS w cr kid V,Comp-ren dialys dev/grft,Drug-induced delirium,Hypothyroidism NOS,Periph vascular dis NOS,Other lung disease NEC,DMII renl nt st uncntrld
Admission Date:  [**2185-6-16**]       Discharge Date:  [**2185-6-27**]


Service:

CHIEF COMPLAINT:  Melena intraoperatively complication from
plastic surgery.

HISTORY OF PRESENT ILLNESS:  The patient is an 81-year-old
female with diabetes mellitus Type 2 complicated by end-stage
renal disease on hemodialysis, history of retinopathy
(legally blind) hypertension, hypercholesterolemia, status
post cerebrovascular accident, peripheral vascular disease,
who is admitted to the [**Hospital1 69**]
Plastic Surgery service on [**2185-6-16**] for incision and drainage
of a left hand abscess.

The patient initially admitted [**2185-5-28**] for left hand
abscess with gram positive bacteria and underwent incision
and drainage on [**2185-5-29**].  The patient was discharged on
Vancomycin.  The patient was seen in [**Hospital 3595**] Clinic on [**6-7**]
and had a 6 cm area of necrotic tissue over the dorsum of the
hand with edema more proximal to this area that was warm.
The patient was admitted to the [**Hospital1 188**] on [**2185-6-16**] and underwent a second incision and
drainage and Vac placement and started on Cefazolin
intravenous.

On admission the patient had a crit of 35 with baseline 35 to
40.  Following incision and drainage  the patient was given
Percocet for pain control, noted to have some tiny confusion
and the Percocet was discontinued and the patient was started
on Toradol, received 60 mg intramuscular on [**6-18**] mg
intramuscular on [**2185-6-19**], 30 mg on [**2185-6-20**].  On [**6-22**] the
patient was found to have decreased flow through the
Permacath at hemodialysis.  The patient was given TPA in both
ports.  At dialysis the patient complained of stomach pain
and hematocrit was drawn that showed it was 30 down from 35
on admission.  The patient was subsequently transferred to
the MICU on [**2185-6-23**].  The patient had initially gone to the
O.R. for a skin flap with a full thickness skin graft to the
left hand.  The patient received 15 mg intramuscular of
Toradol preop.  Following the procedure the patient passed
approximately 250 cc's of melanotic stool.  Crit at the time
was 23.5 at 11 AM and 20.3 at 3 PM.  The patient remained
hemodynamically stable with heart rates in 70's to 90's and
blood pressure of 100 to 160/40 to 60.  Anesthesia placed a
left IJ for central venous access and the patient received
approximately 700 cc's of intravenous fluids
intraoperatively.  In the Post Anesthesia Care Unit the
gastrointestinal team was consulted and
esophagogastroduodenoscopy performed which was normal
(bilious material in the stomach, no signs of bleeding).
Recommended colonoscopy following transfusion.  The labs were
drawn postoperatively showing platelets of 255, BUN 107 up
from 51 from [**2185-5-23**], an INR of 1.7 and a PTT of 55.1.  The
patient was subsequently given DDAVP.  At 7:15 PM the patient
passed approximately 200 cc's of melena and was subsequently
transferred to the medical Intensive Care Unit.

PAST MEDICAL HISTORY:
1.  Insulin dependent diabetes mellitus times 50 years,
complicated by end-stage renal disease on hemodialysis,
complicated by retinopathy, legally blind, complicated by
neuropathy.
2.  Hypertension.
3.  Hypercholesterolemia.
4.  Dementia.
5.  Status post cerebrovascular accident with left sided
residual weakness and right sided weakness.
6.  Hypothyroidism.
7.  Peripheral vascular disease.
8.  Status post total abdominal hysterectomy for fibroids.
9.  Status post right knee surgery.
10. Gout.
11. Scoliosis progressive.
12. Hip "fusion" with back pain requiring narcotics.

The patient has no known coronary artery disease.

MEDICATIONS ON ADMISSION:
1.  Synthroid 150 mg p.o. q day.
2.  Neurontin 300 mg p.o. q day.
3.  Aspirin 81 mg q day.
4.  Norvasc 10 mg p.o. q day.
5.  Timolol eyedrops 0.5%
6.  Renagel
7.  Ultram.
8.  Colace.
9.  Lisinopril.

ALLERGIES: Codeine, question renal failure.

PHYSICAL EXAMINATION:  Temperature 97.7, heart rate 84, blood
pressure 125/37, respiratory rate 14, sating 95% on three
liters.  General:  Awake but drowsy, answers questions
appropriately, well nourished in no apparent distress.  The
patient having periods of apnea greater than 20 seconds.
Head, eyes, ears, nose and throat anicteric sclera,
oropharynx benign.  Cardiovascular:  Regular rate and rhythm.
No murmurs, rubs or gallops.  Lungs:  Clear to auscultation
bilaterally.  Abdomen is soft, nontender, nondistended,
positive bowel sounds.  Extremities:  No edema, nonfunctional
arteriovenous fistula in the right upper extremity and left
upper extremity.

LABORATORY:  On [**2185-6-22**] white count 14.8, hematocrit 20.3,
potassium 5.1, BUN 107, creatinine 7.3, CPK 34, Troponin
0.11.

Electrocardiogram is normal sinus rhythm at 75 beats per
minute, normal axis and intervals, no acute ST changes, no
changes when compared to previous Echocardiogram.

Chest x-ray for left IG placement.  Heart normal size.  No
pneumothorax.  Right upper lobe opacity stable compared to
previous chest x-ray.  Recommend follow-up CT scan.

Microbiology:  Wound cultures left hand from [**6-16**] no growth.

HOSPITAL COURSE:
1.  Gastrointestinal bleed:   During the hospital course
hematocrit declined 35 to 30 to 24 on day of transfer.  The
patient went for skin graft of the left hand.  After the
procedure the patient passed 250 cc's of melena as before
though remained hemodynamically stable with a repeat crit of
20.  Underwent an esophagogastroduodenoscopy which was
negative with transfer to the TCU for monitoring.  The
patient was typed and crossed, matched for four units with a
goal crit of 30.  Protonix was started 40 mg intravenous q
day for gastrointestinal prophylaxis and aspirin and
non-steroidal anti-inflammatory drugs were held off.  The
recommendation was to move further with a colonoscopy for
further evaluation of the gastrointestinal bleed however, in
the MICU there was a long discussion with the patient's two
health care proxies and they felt that the patient did not
want to have invasive procedures done including colonoscopy
and angiography, said that the patient often declined medical
care and would not wish to have invasive procedures done now.
 They were given information regarding the procedure,
benefits and risks including the possibility of finding a
source of bleeding that is relatively easily treatable.  They
said they would like her to have more done but do not want to
go against the relatives wishes, they hope that with time she
will be able to wake up more and more and to make the final
decision for herself.  They understand she could have a life
threatening bleed in the meantime and she could expire.
Given the patient's multiple comorbidities and the quality of
life and her wishes the decision was to withdrawal invasive
procedures appears reasonable.  If she did re-bleed she would
be transfused with packed red blood cells only and provide
supportive care.  This was discussed with the MICU team and
the decision was to transfer the patient to the Medicine
service on the floor and the patient was transferred on
[**2185-6-26**].

After the family meeting and made DNR/DNI no colonoscopy was
to be done to diagnose the source of gastrointestinal bleed.
On the Medicine Team her crit remained stable and she
continued to refuse colonoscopy and a type cell scan with
angio.  Serial crits were followed.  Her hematocrit was
stabilizing at 26.9.

2.  Coagulations, heme.  There was an initial increase of her
INR of unclear reasons throughout to be done due to it being
drawn from the Heparin site and the patient was status post
Vitamin K reversal and now had stable INR at 1.3.  On the
floor she was continued to follow and no obvious pathology
was found.

3.  End-stage renal disease.  The patient continued to have
hemodialysis during hospital stay.  She was continued on
Nephrocaps with the Renal Team following and repletion of K
and subsequent following of her creatinine which was 8.0 at
discharge.

4.  Elevation of Troponin T.  Likely thought to be due to
decreased renal clearance as per the Renal Team.  The patient
did not have any acute electrocardiogram changes and no chest
pain and there is consideration of repeating the Troponin T
after hemodialysis to follow.  Otherwise there was no
significant medical changes that needed to occur.

5.  Endo.  The patient with hypothyroid and diabetes
mellitus.  Levothyroxine was continued in the house as is
regular insulin sliding scale.  Fingersticks were monitored
closely.

6.  Plastic surgery and hand.  The patient's arm was kept
elevated, dressing changes were done q day.  Ancef 1 gram
intravenous q 48 hours was continued.

7.  Pain.  The patient was maintained on Hydrocodone and
Acetaminophen 1 tab p.o. q 6 hours while in house.

8.  FEN.  The patient was unable to take p.o's and
intravenous meds were continued.

9.  Hypertension.  Elevation of her blood pressure given the
stable hematocrit, after transfer to the floor the patient
was restarted on her anti-hypertensive meds and titrated as
needed Amlodipine and Captopril.

10.  Prophylaxis.  The patient was given a proton pump
inhibitor for gastrointestinal, pneumo boots were in place.

11.  Access.  The patient has a left IJ in position placed on
[**2185-6-23**].

12.  Code:  DNR/DNI.

13.  Disposition:  On the day of discharge [**2185-6-27**] the
patient refused transfusion of packed red blood cells after a
crit of 26.0 from 29.1 was noted.  The patient also refused
all meds and requested desire to go home alone with health
care proxies.  The attending was [**Name (NI) 653**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and plan was for patient to be discharged on current
inpatient meds with hemodialysis three times a week at her
current location with follow-up with Plastic Surgery and
continued antibiotics changed from Ancef to Keflex p.o. with
follow-up with the PCP.

14.  Pulmonary nodule seen on a recent chest x-ray and will
be required to follow-up with CT scan as an outpatient.

CONDITION ON DISCHARGE:  Fair.  Patient requested to go home.

DISCHARGE STATUS:  Poor.  Patient refusing blood transfusion
and all in house medications.  Requesting desire to go home
and leave along with [**Hospital 228**] health care proxies.

DISCHARGE DIAGNOSIS:
1.  Gastrointestinal bleed (melena)
2.  Escharotomy.
3.  Left hand abscess status post full thickness skin
    graft from the abdomen to the left hand and
    VAC placement on left hand dorsum.

FOLLOW-UP PLANS:  The patient to follow-up with Plastic
Surgery provider, [**Name10 (NameIs) 648**] has been made for 7/25/0 after
the regular dialysis [**Name10 (NameIs) 648**].

Primary care provider with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to be followed
with an [**Last Name (NamePattern1) 648**] within two weeks, call [**Telephone/Fax (1) 16315**].

Continue to go to weekly dialysis appointments as you have
done prior to this admission.

DISCHARGE MEDICATIONS:
1.  Levothyroxine 150 mcg q day.
2.  Folic Acid.
3.  Vitamin B Complex 1 mg capsule q day.
4.  Calcium carbonate 1000 mg three times a day with meals.
5.  Lisinopril 5 mg q day.
6.  Cephalexin 250 mg q 12 hours.
7.  Amlodipine 5 mg one tab q day.
8.  Pantoprazole 40 mg q day.








                            [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, MPH[**MD Number(3) 96753**]

Dictated By:[**Last Name (NamePattern1) 11210**]
MEDQUIST36

D:  [**2185-8-1**]  15:55
T:  [**2185-8-1**]  16:02
JOB#:  [**Job Number 96754**]
{'Other specified disorders of skin,Hemorrhage of gastrointestinal tract, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other complications due to renal dialysis device, implant, and graft,Drug-induced delirium,Unspecified acquired hypothyroidism,Peripheral vascular disease, unspecified,Other diseases of lung, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled'}


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: Melena intraoperatively complication from
plastic surgery.

PRESENT ILLNESS: The patient is an 81-year-old
female with diabetes mellitus Type 2 complicated by end-stage
renal disease on hemodialysis, history of retinopathy
(legally blind) hypertension, hypercholesterolemia, status
post cerebrovascular accident, peripheral vascular disease,
who is admitted to the [**Hospital1 69**]
Plastic Surgery service on [**2185-6-16**] for incision and drainage
of a left hand abscess.

MEDICAL HISTORY: 1.  Insulin dependent diabetes mellitus times 50 years,
complicated by end-stage renal disease on hemodialysis,
complicated by retinopathy, legally blind, complicated by
neuropathy.
2.  Hypertension.
3.  Hypercholesterolemia.
4.  Dementia.
5.  Status post cerebrovascular accident with left sided
residual weakness and right sided weakness.
6.  Hypothyroidism.
7.  Peripheral vascular disease.
8.  Status post total abdominal hysterectomy for fibroids.
9.  Status post right knee surgery.
10. Gout.
11. Scoliosis progressive.
12. Hip "fusion" with back pain requiring narcotics.

MEDICATION ON ADMISSION: 1.  Synthroid 150 mg p.o. q day.
2.  Neurontin 300 mg p.o. q day.
3.  Aspirin 81 mg q day.
4.  Norvasc 10 mg p.o. q day.
5.  Timolol eyedrops 0.5%
6.  Renagel
7.  Ultram.
8.  Colace.
9.  Lisinopril.

ALLERGIES: Codeine, question renal failure.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Other specified disorders of skin,Hemorrhage of gastrointestinal tract, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other complications due to renal dialysis device, implant, and graft,Drug-induced delirium,Unspecified acquired hypothyroidism,Peripheral vascular disease, unspecified,Other diseases of lung, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled'}
