CHIEF COMPLAINT: GI Bleed

PRESENT ILLNESS: Briefly, Mr. [**Known lastname 82748**] was recently on our servce with a MICU
transfer for lower GIB thought to be due to Crohn's flare in
setting of anticoagulation.  Pt has been maintained on
mesalamine and prednisone  Has a recent submassive PE last month
with thrombolytics and placement of IVF filter.  Was admitted
with Hct stable; coumadin reversed with IV vit K on admission by
ED.  Restarted heparin though pt quickly rebled.
.
Has been in ICU ~36 hours.  Recieved total of 1 unit on transfer
to ICU; nothing since.  Had tagged RBC initially that showed
diffuse bleeding ("findings consistent with intermittent active
bleeding likely within sigmoid colon").  Then had sigmoidoscopy
on [**2195-8-28**] which showed friable colon, diffuse bleeding c/w
Crohn's; biopsies were taken. Hct has stabilized around 26-28.
Hemodynamically stable and transferred back to our service.

MEDICAL HISTORY: Type 2 Diabetes
Obestiy
Crohn's disease, with history of GI bleed
Hypertension
Diverticulitis s/p Partial Colectomy x 2
s/p Multiple Herniorraphy's
Arthritis

MEDICATION ON ADMISSION: 1. Mesalamine 250 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
2. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units

ALLERGIES: Azithromycin / Metformin

PHYSICAL EXAM: General: obese, NAD
HEENT: poor dentition, neck supple
Lungs: CTA b/l, no c/q/r
Cardio: RR, soft heart sounds
Abd: obese, + BS, soft, non tender, multiple surgical scars
Ext: trace [**Location (un) **]

FAMILY HISTORY: No family history of blood clots, malignancy, or sudden cardiac
death. No family history of Crohn's disease. His mother passed
away from pneumonia, but also had hypertension.

SOCIAL HISTORY: After discharge in [**2195-7-25**]. Pt had altercation with wife
leading to restraining order. Patient is not married but lives
with significant other (female) and lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**].
He only drinks alcohol 2x year currently, but reports heavy
alcohol use that stopped approximately 20 years ago. He denies
tobacco use. He reports using cocaine with cessation
approximately 25 years ago. He is a former mechanic.
Regional enteritis of small intestine with large intestine,Acute posthemorrhagic anemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Benign essential hypertension,Depressive disorder, not elsewhere classified,Arthropathy, unspecified, site unspecified,Personal history of venous thrombosis and embolism,Anticoagulants causing adverse effects in therapeutic use
Reg enterit sm/lg intest,Ac posthemorrhag anemia,DMII wo cmp nt st uncntr,Obesity NOS,Benign hypertension,Depressive disorder NEC,Arthropathy NOS-unspec,Hx-ven thrombosis/embols,Adv eff anticoagulants
Admission Date:  [**2195-8-25**]              Discharge Date:   [**2195-9-3**]

Date of Birth:  [**2139-1-6**]             Sex:   M

Service: MEDICINE

Allergies:
Azithromycin / Metformin

Attending:[**Doctor First Name 2080**]
Chief Complaint:
GI Bleed

Major Surgical or Invasive Procedure:
Colonoscopy


History of Present Illness:
Briefly, Mr. [**Known lastname 82748**] was recently on our servce with a MICU
transfer for lower GIB thought to be due to Crohn's flare in
setting of anticoagulation.  Pt has been maintained on
mesalamine and prednisone  Has a recent submassive PE last month
with thrombolytics and placement of IVF filter.  Was admitted
with Hct stable; coumadin reversed with IV vit K on admission by
ED.  Restarted heparin though pt quickly rebled.
.
Has been in ICU ~36 hours.  Recieved total of 1 unit on transfer
to ICU; nothing since.  Had tagged RBC initially that showed
diffuse bleeding ("findings consistent with intermittent active
bleeding likely within sigmoid colon").  Then had sigmoidoscopy
on [**2195-8-28**] which showed friable colon, diffuse bleeding c/w
Crohn's; biopsies were taken. Hct has stabilized around 26-28.
Hemodynamically stable and transferred back to our service.

Past Medical History:
Type 2 Diabetes
Obestiy
Crohn's disease, with history of GI bleed
Hypertension
Diverticulitis s/p Partial Colectomy x 2
s/p Multiple Herniorraphy's
Arthritis


Social History:
After discharge in [**2195-7-25**]. Pt had altercation with wife
leading to restraining order. Patient is not married but lives
with significant other (female) and lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**].
He only drinks alcohol 2x year currently, but reports heavy
alcohol use that stopped approximately 20 years ago. He denies
tobacco use. He reports using cocaine with cessation
approximately 25 years ago. He is a former mechanic.

Family History:
No family history of blood clots, malignancy, or sudden cardiac
death. No family history of Crohn's disease. His mother passed
away from pneumonia, but also had hypertension.

Physical Exam:
General: obese, NAD
HEENT: poor dentition, neck supple
Lungs: CTA b/l, no c/q/r
Cardio: RR, soft heart sounds
Abd: obese, + BS, soft, non tender, multiple surgical scars
Ext: trace [**Location (un) **]

Pertinent Results:
Admission Labs:
[**8-25**]: WBC-11.1* RBC-3.88* Hgb-10.2* Hct-32.0* MCV-82 MCH-26.4*
MCHC-32.1 RDW-14.1 Plt Ct-313
[**8-28**]: WBC-7.0 RBC-3.22* Hgb-8.8* Hct-26.8* MCV-83 MCH-27.3
MCHC-32.9 RDW-13.7 Plt Ct-279
[**8-31**]: WBC-6.4 RBC-3.08* Hgb-8.4* Hct-25.6* MCV-83 MCH-27.2
MCHC-32.7 RDW-14.4 Plt Ct-284
[**9-3**]: WBC-8.3 RBC-3.34* Hgb-9.5* Hct-28.1* MCV-84 MCH-28.4
MCHC-33.8 RDW-14.5 Plt Ct-350
[**8-26**]: ESR-43*
[**8-25**]: Glucose-80 UreaN-20 Creat-1.0 Na-140 K-3.6 Cl-106 HCO3-22
AnGap-16
[**9-2**]: Glucose-177* UreaN-17 Creat-1.1 Na-141 K-3.7 Cl-103
HCO3-29 AnGap-13
[**8-26**]: CRP-77.2*
.
Studies:
CT Abd (9/1)1. Thickening of the transverse colon, and mild
thickening of the terminalv ileum, most likely related to the
patient's known Crohn's disease, although infection is an
additional possibility.
 2. Large right spigelian hernia, with some ascending colon
outside of the
field of view. Small ventral hernia containing a small bowel
loop, without
evidence of obstruction. 3. No evidence of abscess or abnormal
fluid collection.4. Right basilar airspace opacity most likely
infectious, or less likely, the sequelae of prior pulmonary
embolus.
.
CXR ([**8-26**]):  No focal consolidation identified. However, please
note, given
the size and position of the opacities noted on abdominal CT,
the chest x-ray may be relatively insensitive. Continued
surveillance recommended.
.
Bleeding Study ([**8-27**]):  Findings consistent with intermittent
active bleeding likely within sigmoid colon.
.
GI Biopsy: Colon, biopsy: - Chronic active colitis.No dysplasia
or granulomas identified.
.
Colonoscopy report attached.

Brief Hospital Course:
Assessment and Plan: This is a 56 yo male h/o Crohn's,
diverticulosis s/p hemicolectomy, with recent hospitalization
for bilateral PE discharged on warfarin anticoagulation who was
readmitted for lower GI bleeding.  Stable HCT off all
anticoagulation.
.
# GI Bleeding secondary to Crohn's flare/Acute Blood Loss
Anemia: Pt was admitted to the hospital after he noticed a small
amount of blood in his bowel movements. Pt was recently admitted
with a gi bleed and during admission developed pulmonary emboli
necessitating intubation in the intensive care unit. He was
discharged on coumadin. During admission pts hematocrit was
initially stable and bleeding controlled. Mesalamine was
increased to 2grams twice daily and prednisone 40mg was
continued. Pt was given another trial on anticoagulation and
heparin was started with the hopes of bridging to coumadin.
Overnight the patient developed multiple bloody bowel movements.
Pt remained hemodynamically stable however had a significant
drop in hematocrit necessitating one unit of packed red blood
cells and transfer to the ICU. In the ICU the patient remained
stable. Labeled red blood cell scan showed bleeding in the
sigmoid colon. Colonoscopy was consistent with severe Crohn's
disease. After 36 hours he returned to the general medicine
floor where patient continued to be stable with guaiac negative
stools. At this time it was decided patient is not a candidate
for anticoagulation until his Crohn's Flare is stabilized. After
patient's Crohns Disease is better managed pt may then be a
candidate for anticoagulation. Pt will follow up with he DR.
[**Last Name (STitle) **] (GI) in [**Hospital1 1562**] for further therapy.
.
# Bilateral Pulmonary Emboli/s/p IVC filter: On admission
anticoagulation was reversed given GI bleed. After stablized
anticoagulation was restarted with Heparin, however as noted
above pt had further bleeding. It was determined the patient has
failed anticoagulation give his repeat bleeding. If his Crohn's
is better managed anticoaguation should be reconsidered. During
his stay patient was hemodynamically stable, sating 98% on room
air. Pt had IVC filter placed during previous admission.
.
# Type 2 Diabetes, poorly controlled, no complications: Pt was
continued on lantus with sliding scale insulin.
.
# Depression: Pt reports major social issues after discharge
from hospital. Was evaluated on [**Hospital3 4298**] and started on
Citalopram and Ativan PRN anxiety. During stay patient tearful
in regards to restraining order against him by his girlfriend.
Psychiatry  and social work saw patient. No active suicidal
ideation per patient. Psych recommended increasing citalopram
to 30mg monitoring for mania given patients hx of aggression.
Also monitor closely for seretonin syndrome given patient is on
Citalopram and Tramadol.

Medications on Admission:
1. Mesalamine 250 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
2. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units

Subcutaneous at bedtime: please continue to take your humalog
sliding scale as prior to hospitalization.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).


5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for pain.
7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at

4 PM: Please follow up with your PCP as scheduled to check your
INR, with goal INR of [**1-27**].
Disp:*30 Tablet(s)* Refills:*2*
8. Citalopram 20 mg daily
9. Lorazepam 1mg Q 8hours.

Discharge Medications:
1. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day:
Dr. [**Last Name (STitle) **] will adjust this dose at your next appt. Do not stop
medicine without tappering. .
Disp:*60 Tablet(s)* Refills:*0*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety: Do not take this medication with
alcohol. Do not operate vehicles or heavy machinery when taking
this medication. . Tablet(s)
7. Mesalamine 500 mg Capsule, Sustained Release Sig: Four (4)
Capsule, Sustained Release PO twice a day.
Disp:*240 Capsule, Sustained Release(s)* Refills:*2*
8. Lantus Insulin
25 Units each evening.
9. Insulin Sliding Scale
Please see attached sheet or refer to sliding scale provided by
Dr. [**Last Name (STitle) **].
10. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnoses:
Crohn's Flair with GIB
Secondary Diagnoses:
Recent pulmonary embolism
IVF filter

Discharge Condition:
stable. afebrile. On room air. Ambulating without difficulty.


Discharge Instructions:
You were admitted to the hospital after you developed bleeding
from your gastrointestinal tract. This bleeding occurred in the
setting of anticoagulation (blood thinning). You were
anticoagulated after your previous hospitalization when you
developed pulmonary emboli. During this hospitalization your
bleeding was initially controlled and medications to treat your
Crohn's disease were increased. After bleeding was controlled we
attempted to thin your blood again but you developed another
gastrointestinal bleed. Throughout this time your hematocrit
remained relatively stable. At this time we think your Crohn's
disease must be better under control before anticoagulation can
be restarted. You should follow up closely with your
[**Last Name (STitle) **].

The following changes were made to your medicine regimen.
(1) Change Mesalamine 2grams twice daily
(2) Continue taking Prednisone 40mg Daily, Dr. [**Last Name (STitle) 36863**] will decide
how long to continue you on this dose of Prednisone.
(3) Stop taking Warfarin until advised by your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) **].

Please return to the hospital or contact your physician if you
notice bright red blood in your stools, you have dark black
tarry stools, you develop chest pain, shortness of breath,
nausea, vomiting, or fever.

Followup Instructions:
Please follow up with your PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 29822**], on
Wednesday [**9-9**], at 12:00.
- Follow up in regards to your recent hospitalization and
bleeding.
- Follow up in regards to your diabetes management.
- Follow up in regards to anticoagulation for your blood clot.

FU with your [**Month (only) **], Dr. [**Last Name (STitle) **],([**Telephone/Fax (1) 82749**], on
Monday [**9-21**] arriving 3:45.
-Follow up in regards to your recent hospitalization and Crohn's
Disease management.
{'Regional enteritis of small intestine with large intestine,Acute posthemorrhagic anemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Benign essential hypertension,Depressive disorder, not elsewhere classified,Arthropathy, unspecified, site unspecified,Personal history of venous thrombosis and embolism,Anticoagulants causing adverse effects in therapeutic use'}


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: GI Bleed

PRESENT ILLNESS: Briefly, Mr. [**Known lastname 82748**] was recently on our servce with a MICU
transfer for lower GIB thought to be due to Crohn's flare in
setting of anticoagulation.  Pt has been maintained on
mesalamine and prednisone  Has a recent submassive PE last month
with thrombolytics and placement of IVF filter.  Was admitted
with Hct stable; coumadin reversed with IV vit K on admission by
ED.  Restarted heparin though pt quickly rebled.
.
Has been in ICU ~36 hours.  Recieved total of 1 unit on transfer
to ICU; nothing since.  Had tagged RBC initially that showed
diffuse bleeding ("findings consistent with intermittent active
bleeding likely within sigmoid colon").  Then had sigmoidoscopy
on [**2195-8-28**] which showed friable colon, diffuse bleeding c/w
Crohn's; biopsies were taken. Hct has stabilized around 26-28.
Hemodynamically stable and transferred back to our service.

MEDICAL HISTORY: Type 2 Diabetes
Obestiy
Crohn's disease, with history of GI bleed
Hypertension
Diverticulitis s/p Partial Colectomy x 2
s/p Multiple Herniorraphy's
Arthritis

MEDICATION ON ADMISSION: 1. Mesalamine 250 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
2. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units

ALLERGIES: Azithromycin / Metformin

PHYSICAL EXAM: General: obese, NAD
HEENT: poor dentition, neck supple
Lungs: CTA b/l, no c/q/r
Cardio: RR, soft heart sounds
Abd: obese, + BS, soft, non tender, multiple surgical scars
Ext: trace [**Location (un) **]

FAMILY HISTORY: No family history of blood clots, malignancy, or sudden cardiac
death. No family history of Crohn's disease. His mother passed
away from pneumonia, but also had hypertension.

SOCIAL HISTORY: After discharge in [**2195-7-25**]. Pt had altercation with wife
leading to restraining order. Patient is not married but lives
with significant other (female) and lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**].
He only drinks alcohol 2x year currently, but reports heavy
alcohol use that stopped approximately 20 years ago. He denies
tobacco use. He reports using cocaine with cessation
approximately 25 years ago. He is a former mechanic. 

### Response:
{'Regional enteritis of small intestine with large intestine,Acute posthemorrhagic anemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Benign essential hypertension,Depressive disorder, not elsewhere classified,Arthropathy, unspecified, site unspecified,Personal history of venous thrombosis and embolism,Anticoagulants causing adverse effects in therapeutic use'}
