CHIEF COMPLAINT: hematemesis

PRESENT ILLNESS: 69 year old who present with hematemesis and abdominal pain.
The patient initially woke up about this morning noticing blood
in his mouth. He said it was about a very small amount, less
than the bottom of a cup. Pt denies any vomiting, wretching or
melena. Because he was notified about his PCP 2 days prior that
he had a INR of 7.8 in the context of coumadin for atrial
fibriallation, he decided to come into the emergency room. In
the emergency room he started to experience sharp epigastric
abdominal pain that was gradually worsening. The pain was not
radiation and only improved with Dilaudid. He denies any similar
abdominal pain prior to this episode.
.
In the ED, the pt was found to have lateral STD and was given
Aspirin and Nitroglycerin initially without improvement. An NG
lavage found about 200cc of bright red blood in the stomach,
which subsequently cleared. He was given a GI cocktail,Protonix,
Morphine and Dilaudid for abdominal pain. A CT of the abdomen
did not show any poa[**Name (NI) 27529**] other then possible blood in his
stomach. Vit K was given for the reversal of his Coumadin. The
pt was hemodynamically stable throughout his hospital course.
.
ROS: He denies CP, lightheadedness, dizziness, mouthpain, easy
bleeding or easy bruising, dysuria, LLE. He reports chronic mild
SOB, which is uncahnged. He denies F/C/NS, weight loss. He also
denies changes in his diet or any intake of NSAIDS or large
amount of alcohol. Also, denies any liver problems in the past.

MEDICAL HISTORY: HTN
Smoking
Polycythemia [**1-19**] OSA?
OSA refractory to CPAP
hx iron deficiency anemia
CrI with bl CR 1.3-1.5 [**1-19**] HTN
CAD: last cath [**6-20**] documenting mild to mod diffuse CAD, but no
obstructing lesions, MI x 2; EF 50% most recently, 2+ MR, 2+ AR

MEDICATION ON ADMISSION: Calcitriol 0.5 [**Hospital1 **]
Fluoxetine 20 mg [**Hospital1 **]
Synthroid 150 mg qd
Coreg 3.125 mg [**Hospital1 **]
ASA 325 mg qd
Protonix 40 mg qd
Sucralfate 1 mg [**Hospital1 **]
Nfedipine 20 mg qd
Docusate 100 mg [**Hospital1 **]
Senna
Vitamin C [**Hospital1 **]
Calcium 600 mg tid
Ferrous gluconate 325 mg qd
Lipitor 80 mg qhs
Imdur 30 mg qhs
Doxazosin 2 mg
Coumadin 5d 5mg, 2d 2.5mg
Clonazepam 1 mg qhs
Uroxatral 10 mg qhs

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T96.1 BP 146/57 HR 56  R 20 94%4LNC
Gen: sleepy but awakens without difficulty, NAD
HEENT: NCAT, sclerae anicteric/noninjected, EOMI, P constricted
but ERRL, OP clear, no evidence of bleeding, uvula midline, dry
MM
Neck: JVP 8 cm, no LAD
CV: distant heart sounds, nl S1/S2, irregular 21/6 diastolic and
systolic non radiating murmur noted over precordium
Lungs: mild crackles in R base, no wheezes or rhonchi
Ab: soft, ND, NABS, no HSM by percussion, tenderness in
epigastrium, no rebound or guarding
Extrem: 2+ DP, no c/c/e
Skin: no rashes
Neuro: Oriented x3, moving all extremitites

FAMILY HISTORY: No h/o premature CAD, no family hx of Medullary thyorid CA

SOCIAL HISTORY: Lives in JP, divorced from wife [**Doctor First Name **], though she still is
involved w/ his care, Son [**Name (NI) 27524**] also suppportive, tobacco *40
pack year hx, stopped 1 month ago, rare EOTH, former engineer,
came to US from [**Country 532**] in'[**89**]
.
Other specified gastritis, with hemorrhage,Atrial fibrillation,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Malignant neoplasm of thyroid gland
Oth spf gastrt w hmrhg,Atrial fibrillation,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,Crnry athrscl natve vssl,Malign neopl thyroid
Admission Date:  [**2197-11-25**]              Discharge Date:   [**2197-11-28**]

Date of Birth:  [**2128-5-23**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
hematemesis

Major Surgical or Invasive Procedure:
Endoscopy


History of Present Illness:
69 year old who present with hematemesis and abdominal pain.
The patient initially woke up about this morning noticing blood
in his mouth. He said it was about a very small amount, less
than the bottom of a cup. Pt denies any vomiting, wretching or
melena. Because he was notified about his PCP 2 days prior that
he had a INR of 7.8 in the context of coumadin for atrial
fibriallation, he decided to come into the emergency room. In
the emergency room he started to experience sharp epigastric
abdominal pain that was gradually worsening. The pain was not
radiation and only improved with Dilaudid. He denies any similar
abdominal pain prior to this episode.
.
In the ED, the pt was found to have lateral STD and was given
Aspirin and Nitroglycerin initially without improvement. An NG
lavage found about 200cc of bright red blood in the stomach,
which subsequently cleared. He was given a GI cocktail,Protonix,
Morphine and Dilaudid for abdominal pain. A CT of the abdomen
did not show any poa[**Name (NI) 27529**] other then possible blood in his
stomach. Vit K was given for the reversal of his Coumadin. The
pt was hemodynamically stable throughout his hospital course.
.
ROS: He denies CP, lightheadedness, dizziness, mouthpain, easy
bleeding or easy bruising, dysuria, LLE. He reports chronic mild
SOB, which is uncahnged. He denies F/C/NS, weight loss. He also
denies changes in his diet or any intake of NSAIDS or large
amount of alcohol. Also, denies any liver problems in the past.


Past Medical History:
HTN
Smoking
Polycythemia [**1-19**] OSA?
OSA refractory to CPAP
hx iron deficiency anemia
CrI with bl CR 1.3-1.5 [**1-19**] HTN
CAD: last cath [**6-20**] documenting mild to mod diffuse CAD, but no
obstructing lesions, MI x 2; EF 50% most recently, 2+ MR, 2+ AR

Atrial fibrillation on coumadin
Medullary thyorid CA s/p thyroidectomy
Parathyroid adenoma s/p partial parathyroidectomy
TURP [**9-/2191**]
BPH
PUD s/p gastrectomy/Billroth II [**2172**]
[**Doctor First Name **] [**Doctor Last Name **] tear in [**2195**] p/w BRBPR
s/p CCY
ventral hernia
Raynaud's
hematuria with hx epidymitis
depression


Social History:
Lives in JP, divorced from wife [**Doctor First Name **], though she still is
involved w/ his care, Son [**Name (NI) 27524**] also suppportive, tobacco *40
pack year hx, stopped 1 month ago, rare EOTH, former engineer,
came to US from [**Country 532**] in'[**89**]
.

Family History:
No h/o premature CAD, no family hx of Medullary thyorid CA

Physical Exam:
Vitals: T96.1 BP 146/57 HR 56  R 20 94%4LNC
Gen: sleepy but awakens without difficulty, NAD
HEENT: NCAT, sclerae anicteric/noninjected, EOMI, P constricted
but ERRL, OP clear, no evidence of bleeding, uvula midline, dry
MM
Neck: JVP 8 cm, no LAD
CV: distant heart sounds, nl S1/S2, irregular 21/6 diastolic and
systolic non radiating murmur noted over precordium
Lungs: mild crackles in R base, no wheezes or rhonchi
Ab: soft, ND, NABS, no HSM by percussion, tenderness in
epigastrium, no rebound or guarding
Extrem: 2+ DP, no c/c/e
Skin: no rashes
Neuro: Oriented x3, moving all extremitites

Pertinent Results:
[**2197-11-25**] 09:14PM   CK(CPK)-110
[**2197-11-25**] 09:14PM   CK-MB-5 cTropnT-<0.01
[**2197-11-25**] 09:14PM   HCT-44.8
[**2197-11-25**] 09:14PM   PT-26.6* PTT-36.8* INR(PT)-2.7*
[**2197-11-25**] 02:04PM   TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2197-11-25**] 02:04PM   HGB-16.6 calcHCT-50
[**2197-11-25**] 10:20AM   GLUCOSE-95 UREA N-26* CREAT-1.3* SODIUM-139
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
[**2197-11-25**] 10:20AM   estGFR-Using this
[**2197-11-25**] 10:20AM   ALT(SGPT)-27 AST(SGOT)-25 CK(CPK)-122 ALK
PHOS-69 AMYLASE-73 TOT BILI-0.6
[**2197-11-25**] 10:20AM   CK-MB-6 cTropnT-<0.01
[**2197-11-25**] 10:20AM   WBC-6.4 RBC-5.31 HGB-16.4 HCT-47.7 MCV-90
MCH-30.9 MCHC-34.4 RDW-14.1
[**2197-11-25**] 10:20AM   NEUTS-69.2 LYMPHS-22.3 MONOS-4.1 EOS-3.0
BASOS-1.4
[**2197-11-25**] 10:20AM   PLT COUNT-163
[**2197-11-25**] 10:20AM   PLT COUNT-163
[**2197-11-25**] 10:20AM   PT-52.2* PTT-47.0* INR(PT)-6.2*
.


Brief Hospital Course:
69YO male with CAD, CM with EF 50%, CRI, hx BIllroth II for PUD,
polycythemia [**Doctor First Name **], Afib on coumadin who presents with UGIB in
the context of elevated INR with stable hematocrit and stable
vital signs. Brief hospital course by problem below:
.
GI bleed- EGD with multiple new and healed ulcers. Ulcers with
stigma of new bleeding. Pt was started on PPI [**Hospital1 **]. He was kept
NPO overnight. INR was reversed with 2U of FFP preprocedure and
1 additional unit post procedure. He was given Vit K 5mg 2x. Hct
was checked Q6h. pt dropped to as low as 42 and never required
blood transfusion. Hct has been stable for 8h on call out. Two
large bore ivs were maintained. H.pylori serology was sent and
empiric treatment was started. Given extend of ulceration and
history of PUD, NSAIDS use had to be suspected, however the
patient denies. Also, given hx of medullary thyroid cancer, and
prior hyperparathyroidism, possible MEN could be considered.
Medullary cancer would be associated with MEN II,
hyperparathyroidism with MEN I which presents which associated
Zollinger-[**Doctor Last Name 9480**] Syndrome. Gastrin levels were checked- given
gastrin level of 23, ZE unlikely. Pt had a stable Hct on
discharge and should follow up with Dr. [**Last Name (STitle) 3357**] on [**2197-12-5**].
.
Abdominal pain: likely etiology as above. No evidence of liver
disease or pancreatitis. No evidence of other intraabdominal
pathology on CT. No evidence of free air on CXR. Morphine iv prn
was given. Abdominal pain improved with treatment.
.
CV:new onset STD in V5, V6, concern for ischemia. Pt denies any
chest pain, suggesting against an acute coronary syndrome. Also,
hct > 40 therefore unlikely to be demand ischemia. SOB could be
CP-equivalent, however appears to be chronic. Aspirin was held
in the context of GIB. Antihypertensives in the context of GIB
were held initially, subsequently Carvedilol, Imdur, and
nifedipine were serially restarted. CE's trended-negative.
Statin started.
.
CHF: echo->EF 50% in [**2195**]. Antihypertensives in the context of
GIB were held initially, subsequently Carvedilol and Imdur were
restarted.
.
Afib: rate controlled with BB; held coumadin initially in the
context of GIB, restarted at low dose (2.5mg daily- to be
followed up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**]; holding BB initially,
subsequently restarted.
.
CRI- [**1-19**] long standing HTN. On baseline. Received dye load for
CT. IVF with sodium bicarbonate given for post-CT hydration.
Remained stable.
.
SOB: as above, might be ill-defined symptom of heart disease. No
evidence of fluid overload on CXR. Does not appear fluid
overloaded. Resolved to baseline at time of discharge.
.

Medications on Admission:
Calcitriol 0.5 [**Hospital1 **]
Fluoxetine 20 mg [**Hospital1 **]
Synthroid 150 mg qd
Coreg 3.125 mg [**Hospital1 **]
ASA 325 mg qd
Protonix 40 mg qd
Sucralfate 1 mg [**Hospital1 **]
Nfedipine 20 mg qd
Docusate 100 mg [**Hospital1 **]
Senna
Vitamin C [**Hospital1 **]
Calcium 600 mg tid
Ferrous gluconate 325 mg qd
Lipitor 80 mg qhs
Imdur 30 mg qhs
Doxazosin 2 mg
Coumadin 5d 5mg, 2d 2.5mg
Clonazepam 1 mg qhs
Uroxatral 10 mg qhs

Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
2. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 11 days.
Disp:*44 Capsule(s)* Refills:*0*
3. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 11 days.
Disp:*44 Tablet(s)* Refills:*0*
4. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
9. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*60 Capsule(s)* Refills:*2*
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
15. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Erosive gastritis
Secondary Diagnoses:
1. Afib
2. CAD
3. Hypertension
4. Medullary thyroid cancer


Discharge Condition:
Stable


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please remember to make your follow-up appointments below
.
Return to the ED if you have any of the following:
*fever>101
*blood in your stool
*dark stool
*feeling dizzy or lightheaded
*vomiting blood


Followup Instructions:
Please remember to make the follow-up appointments below
.
You have an appointment with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**] ([**Telephone/Fax (1) 4606**])
on [**2197-12-5**] at 9:30am. You will need to get your blood
checked on [**2197-11-30**] any time between 12pm-7pm. IT IS
VERY IMPORTANT TO MAKE THIS APPOINTMENT TO MAKE SURE YOUR BLOOD
THINNER IS WORKING PROPERLY. You will need to discuss with your
PCP about restarting medication for your prostate gland
including doxazosin and uroxatral.
.
These are your other appointments-
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2197-12-26**]
3:30
Provider: [**Name10 (NameIs) **] WEST,ROOM THREE GI ROOMS Date/Time:[**2198-2-9**] 1:30
Provider: [**Name10 (NameIs) **] PROCEDURES FELLOW Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2198-2-9**] 1:30



Completed by:[**2197-12-5**]
{'Other specified gastritis, with hemorrhage,Atrial fibrillation,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Malignant neoplasm of thyroid gland'}


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: hematemesis

PRESENT ILLNESS: 69 year old who present with hematemesis and abdominal pain.
The patient initially woke up about this morning noticing blood
in his mouth. He said it was about a very small amount, less
than the bottom of a cup. Pt denies any vomiting, wretching or
melena. Because he was notified about his PCP 2 days prior that
he had a INR of 7.8 in the context of coumadin for atrial
fibriallation, he decided to come into the emergency room. In
the emergency room he started to experience sharp epigastric
abdominal pain that was gradually worsening. The pain was not
radiation and only improved with Dilaudid. He denies any similar
abdominal pain prior to this episode.
.
In the ED, the pt was found to have lateral STD and was given
Aspirin and Nitroglycerin initially without improvement. An NG
lavage found about 200cc of bright red blood in the stomach,
which subsequently cleared. He was given a GI cocktail,Protonix,
Morphine and Dilaudid for abdominal pain. A CT of the abdomen
did not show any poa[**Name (NI) 27529**] other then possible blood in his
stomach. Vit K was given for the reversal of his Coumadin. The
pt was hemodynamically stable throughout his hospital course.
.
ROS: He denies CP, lightheadedness, dizziness, mouthpain, easy
bleeding or easy bruising, dysuria, LLE. He reports chronic mild
SOB, which is uncahnged. He denies F/C/NS, weight loss. He also
denies changes in his diet or any intake of NSAIDS or large
amount of alcohol. Also, denies any liver problems in the past.

MEDICAL HISTORY: HTN
Smoking
Polycythemia [**1-19**] OSA?
OSA refractory to CPAP
hx iron deficiency anemia
CrI with bl CR 1.3-1.5 [**1-19**] HTN
CAD: last cath [**6-20**] documenting mild to mod diffuse CAD, but no
obstructing lesions, MI x 2; EF 50% most recently, 2+ MR, 2+ AR

MEDICATION ON ADMISSION: Calcitriol 0.5 [**Hospital1 **]
Fluoxetine 20 mg [**Hospital1 **]
Synthroid 150 mg qd
Coreg 3.125 mg [**Hospital1 **]
ASA 325 mg qd
Protonix 40 mg qd
Sucralfate 1 mg [**Hospital1 **]
Nfedipine 20 mg qd
Docusate 100 mg [**Hospital1 **]
Senna
Vitamin C [**Hospital1 **]
Calcium 600 mg tid
Ferrous gluconate 325 mg qd
Lipitor 80 mg qhs
Imdur 30 mg qhs
Doxazosin 2 mg
Coumadin 5d 5mg, 2d 2.5mg
Clonazepam 1 mg qhs
Uroxatral 10 mg qhs

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T96.1 BP 146/57 HR 56  R 20 94%4LNC
Gen: sleepy but awakens without difficulty, NAD
HEENT: NCAT, sclerae anicteric/noninjected, EOMI, P constricted
but ERRL, OP clear, no evidence of bleeding, uvula midline, dry
MM
Neck: JVP 8 cm, no LAD
CV: distant heart sounds, nl S1/S2, irregular 21/6 diastolic and
systolic non radiating murmur noted over precordium
Lungs: mild crackles in R base, no wheezes or rhonchi
Ab: soft, ND, NABS, no HSM by percussion, tenderness in
epigastrium, no rebound or guarding
Extrem: 2+ DP, no c/c/e
Skin: no rashes
Neuro: Oriented x3, moving all extremitites

FAMILY HISTORY: No h/o premature CAD, no family hx of Medullary thyorid CA

SOCIAL HISTORY: Lives in JP, divorced from wife [**Doctor First Name **], though she still is
involved w/ his care, Son [**Name (NI) 27524**] also suppportive, tobacco *40
pack year hx, stopped 1 month ago, rare EOTH, former engineer,
came to US from [**Country 532**] in'[**89**]
. 

### Response:
{'Other specified gastritis, with hemorrhage,Atrial fibrillation,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Malignant neoplasm of thyroid gland'}
