CHIEF COMPLAINT: melena

PRESENT ILLNESS: This is a 55 y/o F with a PMHx of MS, CAD s/p MI/LAD stent in
[**10/2174**], FVL def and Prot S deficiency on coumadin, presented to
an OSH with N/V/coffee ground emesis x1 week, and melena x 3
days.  She states that she has been feeling progressively weaker
over the past 2 weeks, and developed nausea with coffee ground
emesis intermittantly over the past week.  She also states that
she had black, tarry stools for the past 3 days.  She does not
know how many BMs she is having per day; last melenic stool was
9am this morning.  She was taken to an OSH for further w/u this
AM.
.
At the OSH, her HR was in the 130s with BP in the 80s; initial
hct 31 --> 24.6, intial INR 10.  Pt received 10mg IM Vit K, PPI,
2u FFP, and 1u pRBC.  An NG tube at the OSH showed coffee ground
emesis, and she was placed on Protonix gtt and taken to their GI
suite where an an EGD performed that saw copious blood in
stomach on EGD, ? duodenal angioma, ? duodenal bleeding,
although no definitive source found.  At that time, due to her
coagulopathy, no intervention was performed.  Pt was transferred
to to [**Hospital1 18**] post-EGD where she received a 2nd unit of pRBC en
route.
.
In our ED, T98.1, HR 130s, BP130/70 - received 2L NS.  Hct here
26.6, INR 2.7.  She was admitted to the [**Hospital Unit Name 153**] for monitoring and
transfused an additional pRBC with goal hct >28 given h/o CAD;
no active ischemia at this time.  Pt had 2 large bore IV's in
place at all times and was placed on IV PPI [**Hospital1 **].  Her ASA,
Plavix and coumadin were held.  GI was consulted and on HD#2 due
to ongoing melena, with an INR of 5.8, she was transfused 3u FFP
prior to having an additional EGD which was unremarkable for any
ulcer or bleeding diathesis.  Her hct remained stable over the
next day, with no further episodes of melena.  Her diet was
advanced as tolerated.  Currently she is s/p 6UPRBCs in total
with a stable HCt for >48 hours.

MEDICAL HISTORY: h/o GIB likely from duodenal AVMs as seen on prior capsule
endoscopy
Multiple Sclerosis
IBS with frequent constipation
CAD (MI in [**2174**]), s/p LAD stent [**10/2174**]
+Factor V Leiden (requiring coumadin)
Protein S deficiency
h/o DVT/PE
PTSD
L knee arthroscopy
Degenerative disc disease treated with steroid injections
Asthma
Chronic pelvic pain d/t post-herpetic neuralgia

MEDICATION ON ADMISSION: Protonix 40mg
Plavix 75mg QHS
ASA 325
Toprol 25mg
Topamax 75 tid
Nortryptiline 100 qhs
Trazadone 300mg qhs
Valtrex 1gm qD
Ultram 100mg TID
Lipitor 80
Vicodin [**Hospital1 **]
Soma 350 TID
Coumadin (5 SMTWF, 6 ThSa)
Miralax
Albuterol prn
Advair prn
Boniva
Lidoderm patch

ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Tetracycline / Darvon

PHYSICAL EXAM: On admission:
VS: T98.4  HR85  BP124/65  RR16  o2sat: 100% RA
GEN: Thin woman, in NAD.
HEENT: Anicteric sclera. PERRL.
NECK: No elevated JVP.
CV: Regular, nml s1,s2. No murmurs.
RESP: CTAB. No c/w/r.
ABD: Soft, ND. +BS.  Mild epigastric pain
EXT: No edema bilat.
NEURO: AAOx3.  Moves all ext
RECTAL: No masses.  Melenic stool in the vault, grossly guiaic
positive.

FAMILY HISTORY: breast and lung ca

SOCIAL HISTORY: Lives alone, not currently working, on disability. [**1-22**] ppd
tobacco since age 17, past heavy ETOH use, quit 15 years ago.
Blood in stool,Multiple sclerosis,Congenital deficiency of other clotting factors,Primary hypercoagulable state,Herpes zoster with other nervous system complications,Iron deficiency anemia secondary to blood loss (chronic),Percutaneous transluminal coronary angioplasty status,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Tobacco use disorder,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage
Blood in stool,Multiple sclerosis,Cong def clot factor NEC,Prim hypercoagulable st,H zoster nerv syst NEC,Chr blood loss anemia,Status-post ptca,Hx-ven thrombosis/embols,Long-term use anticoagul,Tobacco use disorder,Gstr/ddnts NOS w/o hmrhg
Admission Date:  [**2176-6-25**]              Discharge Date:   [**2176-7-2**]

Date of Birth:  [**2121-6-21**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamides) / Tetracycline / Darvon

Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
melena

Major Surgical or Invasive Procedure:
EGD

History of Present Illness:
This is a 55 y/o F with a PMHx of MS, CAD s/p MI/LAD stent in
[**10/2174**], FVL def and Prot S deficiency on coumadin, presented to
an OSH with N/V/coffee ground emesis x1 week, and melena x 3
days.  She states that she has been feeling progressively weaker
over the past 2 weeks, and developed nausea with coffee ground
emesis intermittantly over the past week.  She also states that
she had black, tarry stools for the past 3 days.  She does not
know how many BMs she is having per day; last melenic stool was
9am this morning.  She was taken to an OSH for further w/u this
AM.
.
At the OSH, her HR was in the 130s with BP in the 80s; initial
hct 31 --> 24.6, intial INR 10.  Pt received 10mg IM Vit K, PPI,
2u FFP, and 1u pRBC.  An NG tube at the OSH showed coffee ground
emesis, and she was placed on Protonix gtt and taken to their GI
suite where an an EGD performed that saw copious blood in
stomach on EGD, ? duodenal angioma, ? duodenal bleeding,
although no definitive source found.  At that time, due to her
coagulopathy, no intervention was performed.  Pt was transferred
to to [**Hospital1 18**] post-EGD where she received a 2nd unit of pRBC en
route.
.
In our ED, T98.1, HR 130s, BP130/70 - received 2L NS.  Hct here
26.6, INR 2.7.  She was admitted to the [**Hospital Unit Name 153**] for monitoring and
transfused an additional pRBC with goal hct >28 given h/o CAD;
no active ischemia at this time.  Pt had 2 large bore IV's in
place at all times and was placed on IV PPI [**Hospital1 **].  Her ASA,
Plavix and coumadin were held.  GI was consulted and on HD#2 due
to ongoing melena, with an INR of 5.8, she was transfused 3u FFP
prior to having an additional EGD which was unremarkable for any
ulcer or bleeding diathesis.  Her hct remained stable over the
next day, with no further episodes of melena.  Her diet was
advanced as tolerated.  Currently she is s/p 6UPRBCs in total
with a stable HCt for >48 hours.


Past Medical History:
h/o GIB likely from duodenal AVMs as seen on prior capsule
endoscopy
Multiple Sclerosis
IBS with frequent constipation
CAD (MI in [**2174**]), s/p LAD stent [**10/2174**]
+Factor V Leiden (requiring coumadin)
Protein S deficiency
h/o DVT/PE
PTSD
L knee arthroscopy
Degenerative disc disease treated with steroid injections
Asthma
Chronic pelvic pain d/t post-herpetic neuralgia

Social History:
Lives alone, not currently working, on disability. [**1-22**] ppd
tobacco since age 17, past heavy ETOH use, quit 15 years ago.

Family History:
breast and lung ca

Physical Exam:
On admission:
VS: T98.4  HR85  BP124/65  RR16  o2sat: 100% RA
GEN: Thin woman, in NAD.
HEENT: Anicteric sclera. PERRL.
NECK: No elevated JVP.
CV: Regular, nml s1,s2. No murmurs.
RESP: CTAB. No c/w/r.
ABD: Soft, ND. +BS.  Mild epigastric pain
EXT: No edema bilat.
NEURO: AAOx3.  Moves all ext
RECTAL: No masses.  Melenic stool in the vault, grossly guiaic
positive.

Transfer to floor:
VS:


Pertinent Results:
EKG: NSR, 95.  Nml axis, nml intervals. LAA. <1mm depression in
V4-V6, no prior to compare.  No Q waves.


Brief Hospital Course:
Impression: 55 y/o F with a PMHx of MS, CAD s/p MI/LAD stent in
[**10/2174**], FVL def and Prot S deficiency on coumadin, presented to
an OSH with melena and found to have an INR of 10.
.
Plan:
# Melena/Coffee ground emesis
Pt with melena and 14 point drop in hct in the context of an INR
of 10.  Likely UGI source given melena and coagulopathy and
previous h/o duodenal AVMs seen on prior capsule endoscopy at
OSH.  Pt is s/p FFP, Vit K at OSH, INR 2.7 at time of admission.
 She was admitted to the [**Hospital Unit Name 153**] for monitoring and transfused an
additional pRBC with goal hct >28 given h/o CAD; no active
ischemia at this time.  Pt had 2 large bore IV's in place at all
times and was placed on IV PPI [**Hospital1 **].  Her ASA, Plavix and
coumadin were held.  GI was consulted and on HD#2 due to ongoing
melena, with an INR of 5.8, she was transfused 3u FFP prior to
having an additional EGD which was unremarkable for any ulcer or
bleeding diathesis.  Her hct remained stable over the next day,
with no further episodes of melena.  Her diet was advanced
as tolerated. HCT remained stable and she had no episodes of
melena or hemetemesis while inpatient.  She was maintained on
PPI [**Hospital1 **].
.
# Coagulopathy
Pt with a reported INR of 10 at OSH, unclear etiology, but
likely due to decreased PO intake over the past 2 weeks with
poor follow up of INR levels.   She received Vit K at the OSH,
and received 1mg Vit K IV as well as 3u FFP as above.  Her INR
decreased to 1.8.   Her OSH hematologist was contact[**Name (NI) **] regarding
to restarting her anticoagulation in the setting of her GIB,
given her hypercoagulable state of +factor V leiden and protein
S deficiency.  Coumadin was resumed [**2176-6-28**] at 2mg/day, without
lovenox bridge intitially.  However, INR continued to fall from
1.8 and her coumadin was increased slowly to 5 mg PO QD and
lovenox bridge was started on [**2176-7-1**].  Her INR will NEED TO BE
FOLLOWED CLOSELY as an outpatient, with goal [**2-23**].  We would
recommend holding the coumadin at 5mg and allowing the INR to
increase slowly so as not to overshoot and precipitate a GI
bleed.  Plan to continue lovenox until INR therapeutic.
.
# hx of CAD s/p LAD stent (last ECHO nromal w. EF 55%.  EKG only
showed <1mm of ST depressions laterally; 2 sets of CE's were
negative.  Pt remained completely asymptomatic.  Her hct was
transfused as needed to maintain hct >28.  Her ASA, plavix were
held, and her cardiologist was contact[**Name (NI) **] due to the fact that
patient had been on Plavix >18 months post-stent placement.  Her
cardiologist (Dr. [**First Name (STitle) **] [**Name (STitle) 121**], formerly at [**Last Name (un) 4068**]) agreed that
Plavix was no longer needed, and to continue ASA once tolerating
in regards to her GIB.  Her bblocker was initially held and then
restarted once her SBP was stable.  ASA restarted on discharge.

.
# Factor V Leiden & Protein S deficiencies
Pt with a hypercoagulable state, currently on coumadin and
Plavix for anticoagulation. Anticoagulation was initially held
in the setting of active GI bleed.  After discussion with her
cardiologist, Plavix was discontniued indefinitely.  Since she
has a stent she does require a full dose aspirin which was
re-started immediately before discharge, and after consultation
with the hematology service, coumadin  was restarted at a lower
dose than previous.  Given the amount of vitamin K she recived
at the OSH, it is likely that it will be quite some time before
patient is therapeutic and her INR should be watched very
closely as an outpatient to allow for the appropriate dose
adjustments.
.
# Chronic Pain: Patient has very complex pain issues and attends
an outpatient pain management clinic.  Continued topamax,
ultram, lidoderm patch, vicodin prn.  Nortriptiline was stopped
and trazadone was increased to 500mg PO QHS and ambien continued
at night.
.
# Mild asthma - cont albuterol
.
# Ativan PRN - Started on klonopin during this admission.  She
was on 0.5 TID, and dose was increased to 1mg [**Hospital1 **].  Consider
increasing this to 1mg TID as needed.
.
# PPx - On lovenox, PPI [**Hospital1 **]
.

Medications on Admission:
Protonix 40mg
Plavix 75mg QHS
ASA 325
Toprol 25mg
Topamax 75 tid
Nortryptiline 100 qhs
Trazadone 300mg qhs
Valtrex 1gm qD
Ultram 100mg TID
Lipitor 80
Vicodin [**Hospital1 **]
Soma 350 TID
Coumadin (5 SMTWF, 6 ThSa)
Miralax
Albuterol prn
Advair prn
Boniva
Lidoderm patch

Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. Topiramate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
4. Trazodone 100 mg Tablet Sig: Five (5) Tablet PO HS (at
bedtime).
5. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Carisoprodol 350 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO twice a day.
9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic  PRN (as needed).
11. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
12. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

13. Erythromycin 5 mg/g Ointment Sig: One (1)  Ophthalmic  QID
(4 times a day).
14. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral [**Hospital1 **] (2
times a day) as needed.
15. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed.
18. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
20. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1)  Subcutaneous
twice a day.
21. Valtrex 1 g Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Primary:
Gastrointestinal Bleed
Elevated INR
.
Secondary
h/o GIB likely from duodenal AVMs as seen on prior capsule
endoscopy
Multiple Sclerosis
IBS with frequent constipation
CAD (MI in [**2174**]), s/p LAD stent [**10/2174**]
+Factor V Leiden (requiring coumadin)
Protein S deficiency
h/o DVT/PE
PTSD
L knee arthroscopy
Degenerative disc disease treated with steroid injections
Asthma
Chronic pelvic pain d/t post-herpetic neuralgia


Discharge Condition:
Good. Patient able to sit in chair and ambulate.  Hct stable
without evidence of ongoing bleeding.


Discharge Instructions:
Please take all of your medications as prescribed.
Please call your PCP or return to the ED if you have shortness
of breath, chest pain, fevers, chills, nausea, vomiting, bright
red blood per rectum, melena, or other symptoms that are of
concern to you.

Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17103**], at [**Telephone/Fax (1) 3658**] to
schedule a follow up appointment 1-2 weeks after you are
discharged from the rehabilitation facility.
.
Please schedule a follow up appointment with your neurologist,
Dr. [**Last Name (STitle) **], at your earliest convenience.  She has been e-mailed
and is aware of your recent admission.
{'Blood in stool,Multiple sclerosis,Congenital deficiency of other clotting factors,Primary hypercoagulable state,Herpes zoster with other nervous system complications,Iron deficiency anemia secondary to blood loss (chronic),Percutaneous transluminal coronary angioplasty status,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Tobacco use disorder,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage'}


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

PRESENT ILLNESS: This is a 55 y/o F with a PMHx of MS, CAD s/p MI/LAD stent in
[**10/2174**], FVL def and Prot S deficiency on coumadin, presented to
an OSH with N/V/coffee ground emesis x1 week, and melena x 3
days.  She states that she has been feeling progressively weaker
over the past 2 weeks, and developed nausea with coffee ground
emesis intermittantly over the past week.  She also states that
she had black, tarry stools for the past 3 days.  She does not
know how many BMs she is having per day; last melenic stool was
9am this morning.  She was taken to an OSH for further w/u this
AM.
.
At the OSH, her HR was in the 130s with BP in the 80s; initial
hct 31 --> 24.6, intial INR 10.  Pt received 10mg IM Vit K, PPI,
2u FFP, and 1u pRBC.  An NG tube at the OSH showed coffee ground
emesis, and she was placed on Protonix gtt and taken to their GI
suite where an an EGD performed that saw copious blood in
stomach on EGD, ? duodenal angioma, ? duodenal bleeding,
although no definitive source found.  At that time, due to her
coagulopathy, no intervention was performed.  Pt was transferred
to to [**Hospital1 18**] post-EGD where she received a 2nd unit of pRBC en
route.
.
In our ED, T98.1, HR 130s, BP130/70 - received 2L NS.  Hct here
26.6, INR 2.7.  She was admitted to the [**Hospital Unit Name 153**] for monitoring and
transfused an additional pRBC with goal hct >28 given h/o CAD;
no active ischemia at this time.  Pt had 2 large bore IV's in
place at all times and was placed on IV PPI [**Hospital1 **].  Her ASA,
Plavix and coumadin were held.  GI was consulted and on HD#2 due
to ongoing melena, with an INR of 5.8, she was transfused 3u FFP
prior to having an additional EGD which was unremarkable for any
ulcer or bleeding diathesis.  Her hct remained stable over the
next day, with no further episodes of melena.  Her diet was
advanced as tolerated.  Currently she is s/p 6UPRBCs in total
with a stable HCt for >48 hours.

MEDICAL HISTORY: h/o GIB likely from duodenal AVMs as seen on prior capsule
endoscopy
Multiple Sclerosis
IBS with frequent constipation
CAD (MI in [**2174**]), s/p LAD stent [**10/2174**]
+Factor V Leiden (requiring coumadin)
Protein S deficiency
h/o DVT/PE
PTSD
L knee arthroscopy
Degenerative disc disease treated with steroid injections
Asthma
Chronic pelvic pain d/t post-herpetic neuralgia

MEDICATION ON ADMISSION: Protonix 40mg
Plavix 75mg QHS
ASA 325
Toprol 25mg
Topamax 75 tid
Nortryptiline 100 qhs
Trazadone 300mg qhs
Valtrex 1gm qD
Ultram 100mg TID
Lipitor 80
Vicodin [**Hospital1 **]
Soma 350 TID
Coumadin (5 SMTWF, 6 ThSa)
Miralax
Albuterol prn
Advair prn
Boniva
Lidoderm patch

ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Tetracycline / Darvon

PHYSICAL EXAM: On admission:
VS: T98.4  HR85  BP124/65  RR16  o2sat: 100% RA
GEN: Thin woman, in NAD.
HEENT: Anicteric sclera. PERRL.
NECK: No elevated JVP.
CV: Regular, nml s1,s2. No murmurs.
RESP: CTAB. No c/w/r.
ABD: Soft, ND. +BS.  Mild epigastric pain
EXT: No edema bilat.
NEURO: AAOx3.  Moves all ext
RECTAL: No masses.  Melenic stool in the vault, grossly guiaic
positive.

FAMILY HISTORY: breast and lung ca

SOCIAL HISTORY: Lives alone, not currently working, on disability. [**1-22**] ppd
tobacco since age 17, past heavy ETOH use, quit 15 years ago. 

### Response:
{'Blood in stool,Multiple sclerosis,Congenital deficiency of other clotting factors,Primary hypercoagulable state,Herpes zoster with other nervous system complications,Iron deficiency anemia secondary to blood loss (chronic),Percutaneous transluminal coronary angioplasty status,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Tobacco use disorder,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage'}
