CHIEF COMPLAINT: Melena

PRESENT ILLNESS: Ms. [**Known lastname 57309**] is a [**Age over 90 **] yo Russian speaking only female with PMH
of CHF, Afib on coumadin, HTN and dementia, presenting from
[**Hospital 100**] Rehab with a one day h/o melena. Per her son, pt was more
lethargic than her baseline on the day prior to admission and
melena was noted at her longterm care facility. Baseline Hct
approximately 37 on last admission. HCT from 25.8 two days ago
and was noted to be 14.7 upon presentation to the ED. She has no
prior h/o GIB, but is anticoagulated for PMH of atrial
fibrillation with RVR. Admission INR 11.2.
.
In the ED was given 2 units of FFP and 2 units of PRBCs as well
as 2LNS Vitamin K and started on a PPI gtt.  Initially her BP
was in 70s systolic, after fluids and blood, her BP increased to
100s. No further stools.

MEDICAL HISTORY: CAD
CHF  EF 25% per son
AFib on Coumadin
HTN
CRI
Cholelithiasis
Depression
Dementia (severity unclear)
Cataracts
Glaucoma
Hyperlipidemia

MEDICATION ON ADMISSION: Aspirin 81mg daily
Trazadone 25mg at bedtime
Digoxin 0.125mg every other day
Allopurinol 100mg every other day
Trusopot eye drop
Imdur 60mg daily
Coumadin as directed
Tylenol prn
Milk of magnesia prn
Vitamin B12 50mcg daily
Sorbitol 15ml daily
Lasix 20mg daily
Aranesp 25 mcg weekly
Coreg 25mg [**Hospital1 **]
Hydralazine 10mg tid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: AFebrile  BP 80s/40s, HR 70s
GEN: Cachectic pale woman lying in bed moaning
HEENT: Pale conjunctiva, dry MM, anicteric
CVS: Irreg irreg with regular rate, nl s1s2
LUNGS: CTA b/l (but poor inspiratory effort)
ABD: Soft, NT, ND, NABS
Rectal: Melena, guiac +

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives at [**Hospital6 459**]. No toxic habits.
Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Abnormal coagulation profile,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other persistent mental disorders due to conditions classified elsewhere,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia
Gastrointest hemorr NOS,Acute kidney failure NOS,Chr diastolic hrt fail,Hyperosmolality,Abnrml coagultion prfile,Atrial fibrillation,Long-term use anticoagul,Hy kid NOS w cr kid I-IV,Mental disor NEC oth dis,Chronic kidney dis NOS,Hyperlipidemia NEC/NOS
Admission Date:  [**2135-1-1**]              Discharge Date:   [**2135-1-3**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Melena

Major Surgical or Invasive Procedure:
transfusion of pRBCs

History of Present Illness:
Ms. [**Known lastname 57309**] is a [**Age over 90 **] yo Russian speaking only female with PMH
of CHF, Afib on coumadin, HTN and dementia, presenting from
[**Hospital 100**] Rehab with a one day h/o melena. Per her son, pt was more
lethargic than her baseline on the day prior to admission and
melena was noted at her longterm care facility. Baseline Hct
approximately 37 on last admission. HCT from 25.8 two days ago
and was noted to be 14.7 upon presentation to the ED. She has no
prior h/o GIB, but is anticoagulated for PMH of atrial
fibrillation with RVR. Admission INR 11.2.
.
In the ED was given 2 units of FFP and 2 units of PRBCs as well
as 2LNS Vitamin K and started on a PPI gtt.  Initially her BP
was in 70s systolic, after fluids and blood, her BP increased to
100s. No further stools.

Past Medical History:
CAD
CHF  EF 25% per son
AFib on Coumadin
HTN
CRI
Cholelithiasis
Depression
Dementia (severity unclear)
Cataracts
Glaucoma
Hyperlipidemia

Social History:
Lives at [**Hospital6 459**]. No toxic habits.


Family History:
non-contributory

Physical Exam:
AFebrile  BP 80s/40s, HR 70s
GEN: Cachectic pale woman lying in bed moaning
HEENT: Pale conjunctiva, dry MM, anicteric
CVS: Irreg irreg with regular rate, nl s1s2
LUNGS: CTA b/l (but poor inspiratory effort)
ABD: Soft, NT, ND, NABS
Rectal: Melena, guiac +


Pertinent Results:
[**2135-1-1**] 04:20PM   WBC-3.9* RBC-1.51*# HGB-4.7*# HCT-14.7*#
MCV-98 MCH-31.5 MCHC-32.3 RDW-18.6*
[**2135-1-1**] 04:20PM   NEUTS-72.5* LYMPHS-24.2 MONOS-2.9 EOS-0.2
BASOS-0.1
[**2135-1-1**] 04:20PM   PLT COUNT-183
.
[**2135-1-1**] 04:20PM   PT-87.0* PTT-50.4* INR(PT)-11.2*
[**2135-1-1**] 11:16PM   HCT-23.7*#
[**2135-1-1**] 11:18PM   PT-30.1* INR(PT)-3.1*
.
[**2135-1-1**] 04:20PM   CK-MB-NotDone cTropnT-0.22*
[**2135-1-1**] 04:20PM   CK(CPK)-68
[**2135-1-1**] 11:16PM   CK-MB-8 cTropnT-0.27*

Brief Hospital Course:
This is a [**Age over 90 **] yo woman who presented with melena and an 11 point
Hct drop, anticoagulated with INR = 11.2 on admission.  Hospital
course outlined by problem below:

# Melena- Likely GI Bleed in setting of INR of 11.2.  GI
consulted and evaluated patient.  She recieved 3 units pRBCs
with Hct 34.7 from 14.4 in ED.  Coagulopathy reversed with 2
units FFP and Vit K.  She was admitted to the ICU for close
monitoring.  Two large bore peripheral IVs were maintained for
access.  She was given a IV PPI.  Serial Hcts were followed and
remained stable.  All anti-coagulation was held - including ASA
and coumadin.  Anti-hypertensives were also held given unstable
blood volume.  Twice daily Hct should be checked tomorrow, as
well as daily Hct for the following 2 days to ensure stablility.
.
# CAD- EKG in ED showed diffuse ST depressions.  This resolved
with improvement in her Hct.
.
# Hypernatremia - This was likely due to volume depletion.
Lasix was held.  She received free water intravenously with
improvement in her Na.  A repeat Na should be checked tomorrow,
and periodically.
.
# AFib on Coumadin- She was continued on digoxin 0.125 mg every
other day for rate controll; coumadin was held.  She should not
resume coumadin therapy without discussion with her family re
risks and benefits.
.
# HTN - At baseline treated with Imdur, Lasix, Coreg and
Hydralazine.  These were held pending stabilization of her Hct.

.
# ARF on CRI: Her renal function improved with IV hydration.
Her lasix should be held for now; renal function should be
reassessed in [**1-9**] days.
.
# Diet: She was given IV fluid hydration.  She was made NPO
pending stabilization of her Hct.  She may resume her diet per
prior.

Code Status: DNR/DNI - confirmed with son, [**Name (NI) 57310**] [**Name (NI) 57311**]
[**Telephone/Fax (1) 57312**]


Medications on Admission:
Aspirin 81mg daily
Trazadone 25mg at bedtime
Digoxin 0.125mg every other day
Allopurinol 100mg every other day
Trusopot eye drop
Imdur 60mg daily
Coumadin as directed
Tylenol prn
Milk of magnesia prn
Vitamin B12 50mcg daily
Sorbitol 15ml daily
Lasix 20mg daily
Aranesp 25 mcg weekly
Coreg 25mg [**Hospital1 **]
Hydralazine 10mg tid

Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
4. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for hr <60, sbp <100.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
11. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
12. Aranesp SureClick -Polysorbate 25 mcg/0.42 mL Pen Injector
Sig: One (1) injection Subcutaneous once a week.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Primary:
coumadin induced coagulopathy
melena
hypernatremia
.
Secondary
CAD
CHF EF 25%
AFib on Coumadin
HTN
CRI
Cholelithiasis
Depression
Dementia (severity unclear)
Cataracts
Glaucoma
Hyperlipidemia


Discharge Condition:
Hct 33.8 at 2pm on Monday.
Discussed discharge plan by telephone with NP [**First Name5 (NamePattern1) 1894**] [**Last Name (NamePattern1) 57313**]
and Dr. [**Last Name (STitle) **].


Discharge Instructions:
You were hospitalized for blood in your stool; we found that the
level of coumadin in your blood was too high, which caused you
to bleed. We reversed this level and your bleeding stopped on
its own. we transfused you with blood products to keep you blood
counts high.  You were also given free water for dehydration.
.
We think it is most useful for you to not restart the coumadin,
as it give you a risk of bleeding again. Please also do not take
your aspirin until instructed to do so by your doctor.
.
We are also holding most of your antihypertensives for now since
you had some low blood pressures while here. Your primary doctor
will tell you when to resume these.
.
Please take all medicines as prescribed and keep all your
followup appointments. If you experience any furhter blood in
your stools, or if you are lightheaded or dizzy, please notify
your doctor or go to the ED.

Followup Instructions:
Please follow-up with Nurse [**First Name4 (NamePattern1) 1894**] [**Last Name (NamePattern1) 57313**]


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Abnormal coagulation profile,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other persistent mental disorders due to conditions classified elsewhere,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia'}


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: Ms. [**Known lastname 57309**] is a [**Age over 90 **] yo Russian speaking only female with PMH
of CHF, Afib on coumadin, HTN and dementia, presenting from
[**Hospital 100**] Rehab with a one day h/o melena. Per her son, pt was more
lethargic than her baseline on the day prior to admission and
melena was noted at her longterm care facility. Baseline Hct
approximately 37 on last admission. HCT from 25.8 two days ago
and was noted to be 14.7 upon presentation to the ED. She has no
prior h/o GIB, but is anticoagulated for PMH of atrial
fibrillation with RVR. Admission INR 11.2.
.
In the ED was given 2 units of FFP and 2 units of PRBCs as well
as 2LNS Vitamin K and started on a PPI gtt.  Initially her BP
was in 70s systolic, after fluids and blood, her BP increased to
100s. No further stools.

MEDICAL HISTORY: CAD
CHF  EF 25% per son
AFib on Coumadin
HTN
CRI
Cholelithiasis
Depression
Dementia (severity unclear)
Cataracts
Glaucoma
Hyperlipidemia

MEDICATION ON ADMISSION: Aspirin 81mg daily
Trazadone 25mg at bedtime
Digoxin 0.125mg every other day
Allopurinol 100mg every other day
Trusopot eye drop
Imdur 60mg daily
Coumadin as directed
Tylenol prn
Milk of magnesia prn
Vitamin B12 50mcg daily
Sorbitol 15ml daily
Lasix 20mg daily
Aranesp 25 mcg weekly
Coreg 25mg [**Hospital1 **]
Hydralazine 10mg tid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: AFebrile  BP 80s/40s, HR 70s
GEN: Cachectic pale woman lying in bed moaning
HEENT: Pale conjunctiva, dry MM, anicteric
CVS: Irreg irreg with regular rate, nl s1s2
LUNGS: CTA b/l (but poor inspiratory effort)
ABD: Soft, NT, ND, NABS
Rectal: Melena, guiac +

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives at [**Hospital6 459**]. No toxic habits. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Abnormal coagulation profile,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other persistent mental disorders due to conditions classified elsewhere,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia'}
