CHIEF COMPLAINT: bright red blood per rectum

PRESENT ILLNESS: 71 yr old male with h/o CAD, s/p MI in [**2145-8-6**] with 2 LAD
stents placed at that time, on coumadin for low EF and LV
akinesis, bipolar disorder, on lithium, who presented with chest
pain and melena for evaluation. Patient reports dark stool with
intermittent brigh red blood per rectum with fall in hematocrit
from 31 on [**8-22**] to 22 on the day of admission. Patient had one
hour of chest discomfort with associated shortness of breath at
rest the night prior to admission. The patient called  his
primary physician who referred the patient to the ED. Patient
was found to be in acute renal failure, lithium of 2.0 later
developed T-wave inversions. Also, found to have elevated INR
and was stool guaiac positive.

MEDICAL HISTORY: bipolar disorder, stable on lithium
congestive heart failure with EF 15% and akinetic wall
coronary artery disease
s/p myocardial infarction and stenting in 8/04chronic renal
insufficiency

MEDICATION ON ADMISSION: coumadin
atorvastatin
aspirin
plavix
lipitor
lithium
HCTZ
Protonix
Lisinopril 5 mg po qd
Toprol XL 50 mg po qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Examination on admission:
Vitals: 98.9, 127/51, 73, RR 26, O2 97% on RA, ABG on RA
7.43/27/69
General: alert and oriented, pleasant and cooperative
HEENT: MMM, sclera mildly icteric
CV: RRR, no murmurs
Pulm: mild crackles throughout
Abd: obese, + bowel sounds, soft, nontender, nondistended
Ext: WWP, trace pitting edema throughout, DP 1+ bilaterally,
pneumoboots in place
Skin: no lesions

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Lives alone and worked in real estate. Former smoker and EtOH
abuse, now stable with AA.
Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Cardiogenic shock,Pneumonia due to other gram-negative bacteria,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute respiratory failure,Atrial fibrillation
Subendo infarct, initial,CHF NOS,Cardiogenic shock,Pneumo oth grm-neg bact,Gastrointest hemorr NOS,Acute kidney failure NOS,Hyp kid NOS w cr kid V,Acute respiratry failure,Atrial fibrillation
Admission Date:  [**2146-9-13**]              Discharge Date:   [**2146-9-28**]

Date of Birth:  [**2075-4-5**]             Sex:   M

Service: MED

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 18988**]
Chief Complaint:
bright red blood per rectum

Major Surgical or Invasive Procedure:
1. Intubation and mechanical ventilation
2. Mid-line placement for IV antibiotics


History of Present Illness:
71 yr old male with h/o CAD, s/p MI in [**2145-8-6**] with 2 LAD
stents placed at that time, on coumadin for low EF and LV
akinesis, bipolar disorder, on lithium, who presented with chest
pain and melena for evaluation. Patient reports dark stool with
intermittent brigh red blood per rectum with fall in hematocrit
from 31 on [**8-22**] to 22 on the day of admission. Patient had one
hour of chest discomfort with associated shortness of breath at
rest the night prior to admission. The patient called  his
primary physician who referred the patient to the ED. Patient
was found to be in acute renal failure, lithium of 2.0 later
developed T-wave inversions. Also, found to have elevated INR
and was stool guaiac positive.

ROS: no HAs, no LH, no dizziness, no CP/palpitations, no SOB,
no N/V, no vision changes.

Past Medical History:
bipolar disorder, stable on lithium
congestive heart failure with EF 15% and akinetic wall
coronary artery disease
s/p myocardial infarction and stenting in 8/04chronic renal
insufficiency

Social History:
Lives alone and worked in real estate. Former smoker and EtOH
abuse, now stable with AA.

Family History:
noncontributory

Physical Exam:
Examination on admission:
Vitals: 98.9, 127/51, 73, RR 26, O2 97% on RA, ABG on RA
7.43/27/69
General: alert and oriented, pleasant and cooperative
HEENT: MMM, sclera mildly icteric
CV: RRR, no murmurs
Pulm: mild crackles throughout
Abd: obese, + bowel sounds, soft, nontender, nondistended
Ext: WWP, trace pitting edema throughout, DP 1+ bilaterally,
pneumoboots in place
Skin: no lesions

Pertinent Results:
Labs on admission:

[**2146-9-13**] 08:51PM   HCT-25.4*
[**2146-9-13**] 11:15AM   CK(CPK)-46
[**2146-9-13**] 11:15AM   CK-MB-NotDone cTropnT-0.12*
[**2146-9-13**] 11:15AM   LITHIUM-2.0*#
[**2146-9-13**] 11:15AM   PT-49.4* PTT-56.6* INR(PT)-15.4
[**2146-9-13**] 02:55PM BLOOD WBC-14.4* RBC-2.48* Hgb-7.6* Hct-21.6*
MCV-87 MCH-30.5 MCHC-35.0 RDW-14.6 Plt Ct-285
[**2146-9-13**] 11:15AM BLOOD Glucose-112* UreaN-72* Creat-3.0* Na-137
K-5.7* Cl-110* HCO3-16* AnGap-17
[**2146-9-17**] 06:26AM BLOOD CK-MB-4 cTropnT-1.37*
[**2146-9-14**] 08:10PM BLOOD CK-MB-37* MB Indx-8.5* cTropnT-1.75*
[**2146-9-21**] 03:09AM BLOOD Albumin-2.7* Calcium-10.5* Phos-3.0
Mg-2.7*
[**2146-9-13**] 11:15AM BLOOD T4-7.3 Free T4-1.3
[**2146-9-13**] 11:15AM BLOOD TSH-3.2

Cardiac Echo: The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated with severe regional
dysfunction - with severe hypokinesis of the basal inferolateral
and basal
inferior walls, and near akinesis of the distal half of the
septum, distal
half of the anterior wall, and distal inferior wall. The apex is
mildly
aneurysmal and akinetic. No masses or thrombi are seen in the
left ventricle.
Right ventricular chamber size and free wall motion are normal.
The aortic
valve leaflets are mildly thickened. Trace aortic regurgitation
is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is a
trivial/physiologic pericardial effusion.

Compared with the prior study (tape reviewed) of [**2146-8-17**],
moderate pulmonary
artery systolic hypertension is now identified. Overall and
regional left
ventricular systolic function is similar.

[**2146-9-19**] 7:53 am SPUTUM
   GRAM STAIN (Final [**2146-9-19**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2146-9-21**]):
      OROPHARYNGEAL FLORA ABSENT.
      SERRATIA MARCESCENS.    MODERATE GROWTH.

                      SENSITIVITIES: MIC expressed in MCG/ML

_________________________________________________________
                             SERRATIA MARCESCENS
                             |
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
GENTAMICIN------------   <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------     2 S
TRIMETHOPRIM/SULFA----   <=1 S

Labs on discharge:

[**2146-9-28**] 06:15AM BLOOD WBC-9.6 RBC-4.25* Hgb-12.4* Hct-39.9*#
MCV-94 MCH-29.3 MCHC-31.2 RDW-14.7 Plt Ct-653*
[**2146-9-28**] 06:15AM BLOOD Glucose-106* UreaN-29* Creat-2.1* Na-142
K-4.6 Cl-112* HCO3-20* AnGap-15
[**2146-9-28**] 06:15AM BLOOD ALT-137* AST-42* AlkPhos-148* TotBili-0.6
[**2146-9-28**] 06:15AM BLOOD Calcium-10.0 Phos-3.6 Mg-2.2
[**2146-9-27**] 06:10AM BLOOD Triglyc-184* HDL-18 CHOL/HD-6.3
LDLcalc-59
[**2146-9-26**] 06:10AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2146-9-26**] 06:10AM BLOOD HCV Ab-NEGATIVE

Brief Hospital Course:
1. Gastrointestinal bleed: Mr. [**Known lastname **] presented to this
facility with an INR of 15.4 and reporting melena since his
stenting and bright red blood per rectum for the past few days
prior to admission. He denied hematemesis. He was thought to be
coagulopathic due to his unmonitored use of plavix, aspirin, and
coumadin for his left ventricular wall motion abnormalities. His
INR improved with administration of vitamin K and 4 units of
fresh frozen plasma. He also received 4 units of packed red
blood cells for his hematocrit of 21. An EGD revealed gastritis
but no acute bleed. His coumadin, aspirin, plavix, beta blocker,
and ACE inhibitor were discontinued. Placed on a twice daily
PPI, he stabilized quickly and once his coagulopathy resolved,
he required only one additional transfusion of packed red blood
cells. He was found to be negative for h. pylori. His plavix and
aspirin were restarted once his hematocrit had been stable for 2
days.

2. Coronary artery disease: Mr. [**Known lastname **] is status post anterior
ST elevation myocardial infarction with stenting x 2 in [**Month (only) 216**]
of [**2146**] following a motor vehicle accident. He had been doing
well until a few days ago when he noticed the onset of
intermittent chest pain, mostly at rest. At times it was
accompanied by dyspnea and might last up to 30 minutes. He also
had some paroxysmal nocturnal dyspnea in the last few days. The
night before admission he experienced chest pain that woke him
from sleep and was accompanied by dyspnea and light headedness.
He denied nausea, emesis, diaphoresis, or dizzyness. These
symptoms resolved within 30 minutes. The morning of admission,
he called his primary care physician who advised him to come to
the Emergency Department for evaluation. At admission, he was on
aspirin, plavix, an ACE inhibitor, and a beta blocker. With the
exception of the ACE inhibitor, these were continued in their
short acting forms during this admission. The ACE inhibitor was
held until his kidney function normalized. It was restarted on
the day of discharge and the patient's blood pressures have
tolerated it well. He will be continued on his current
medication. If his renal function deteriorates, consider
discontinuing ACE inhibitor.

2. Congestive heart failure: Mr. [**Known lastname **] has a history of CHF
with EF of 20% with RV apical akinesis and an apical left
ventricular aneurysm. For this reason, he had been placed on
coumadin during his previous hospitalization. In addition to
aggressive diuresis to avoid volume overload, he received at
least 8 units of blood products for his GIB and to prevent
further myocardial ischemia. Although his ins and outs were
negative, Mr. [**Known lastname **] soon developed respiratory failure. On
the evening of admission, he suddenly became dyspneic,
tachypneic, and diaphoretic. He was emergently intubated for
flash pulmonary edema and upon introducing the endotracheal
tube, large quantities of foamy red secretions emerged. The
patient was restarted on coumadin, however, given his past
medical history, he may not be a candidate for coumadin therapy.
Dr. [**Last Name (STitle) 1683**] will discuss with Dr. [**Last Name (STitle) 5715**], the patient's
psychiatrist, whether the patient is reliable to remain on
Coumadin. Please verify with Dr. [**Last Name (STitle) 1683**] whether to send the
patient home on Coumadin prior to discharge form rehabilitation
hospital.

3. Cardiogenic Shock: Shortly after his intubation, Mr.
[**Known lastname **]' systolic blood pressures fell to the 70s. A pulmonary
artery catheter was placed and norepinephrine, dopamine, and
dobutamine drips were started. These pressors were titrated to
maintain a mean arterial pressure greater than 65. His pulmonary
artery catheter revealed pressures consistent with volume
overload and cardiogenic shock (CVP 18, RA 15, RV 58/20, PA
58/27/40, PCWP 24). The patient's cardiac markers were cycled
and were consistent with new ischemia, although a later
transthoracic echo was unchanged. He was transfused
intermittently to maintain a hematocrit greater than 30.

4. Atrial fibrillation/SVT: One day after placement of the PA
catheter, the patient developed hypotension with a narrow
complex tachycardia, which did not break with carotid massage.
The dobutamine, dopamine, and norepinephrine were turned off.
Neosynephrine was started and a liter of normal saline was
bolused with improvement in the BP to the 90's and 100's. When
adenosine did not break the rhythm, which appeared to be atrial
fibrillation, amiodarone was loaded. Concomittently, electrical
cardioversion with 100 then 200 joules was initiated, whereupon
sinus rhythm was recovered. In the following days, the
neosynephrine was weaned, the amiodarone was continued, and the
patient remained in sinus rhythm with a brief episode of
atrioventricular node reentrent tachycardia. Once off pressors,
beta blockade was initiated to rate control the patient. It was
thought that these arrhythmias occured in the setting of
cardiogenic shock and the irritating effect of the catheter on
the myocardium. Given these considerations, no AV node ablation
or long term amiodarone was indicated.

5. Respiratory Failure: Mr. [**Known lastname **] developed flash pulmonary
edema in the setting of receiving several units of blood and
fresh frozen plasma. He was emergently intubated and sedated. He
remained on the ventilator until his cardiogenic shock was
resolved and then was weaned. He did well until he became
febrile and developed the onset of increasing secretions and
oxygen desaturations. His endotracheal secretions grew out
serratia and he responded well to piperacillin/ tazobactam. Once
the patient produced fewere secretions and his ventilator
requirements decreased, he was successfully extubated.

6. Acute Renal Failure: Mr. [**Known lastname **]' baseline creatinine is 1.5
but when he presented, it was 3.1. His failure was though to be
secondary to prerenal hypoperfusion due to the GI bleed, the
myocardial ischemia, and the CHF. His ACE inhibitor had been
started during his previous hospitalization in [**Month (only) 216**] and likely
contributed to the increase in the creatinine. Both his ACE
inhibitor and the lithium were held until his renal failure
resolved. Once his cardiogenic shock resolved and perfusion to
his kidneys improved, Mr. [**Known lastname **]' creatinine trended down. In
the interim, he developed hypercalcemia which was though to
represent the action of lithium usually blunting the calcium
sensing receptors on the parathyroid gland. It was believed that
this would resolve once his lithium was restarted. He also
briefly became hypernatremic, which was thought to be due to
increased insensible losses during his febrile state
(ventilatory associated pneumonia) vs RTA and resolved with free
water boluses and administration of IV D5W. The patient's sodium
has been stable in the last few days prior to discharge.

7. Bipolar disorder: Mr. [**Known lastname **] has a history of bipolar
disorder and has been followed at this facility by Dr. [**Last Name (STitle) 5715**].
According to the patient and his brother, he had been stable on
lithium for about 4 years. In the interest of preserving his
renal function, his lithium was discontinued and other
medications were initiated. However, he developed severe
depression and was placed back on lithium. When he presented to
this facility, his lithium level was 2, much higher than his
usual tight control of 0.5 - 1.0. This increase was thought to
be secondary to his acute renal failure. Dr. [**Last Name (STitle) 5715**] was
contact[**Name (NI) **] and the decision was made to restart lithium with
close monitoring. The patient will need close monitoring for his
lithium level and follow up with Dr. [**Last Name (STitle) 5715**]. Dr. [**Last Name (STitle) 5715**] will be
notified of the [**Hospital 228**] rehabilitation facility.

8. Thrombocytosis - the patients platelet count has been
trending up. The etiology of this is not entirely clear. The
patient does not look actively infected to explain acute phase
reactant effect. Please monitor platelet counts closely.

Medications on Admission:
coumadin
atorvastatin
aspirin
plavix
lipitor
lithium
HCTZ
Protonix
Lisinopril 5 mg po qd
Toprol XL 50 mg po qd

Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).

3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day) as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q4H (every 4 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
9. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Patient may benefit from higher INR. Please adjust
level to goal INR [**2-8**]. Please monitor closely as patient has
history of supratherapeutic INR and GI bleed during recent
admission. .
10. Lithium Carbonate 150 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)): Please check lithium levels every [**4-11**]
days or as directed by Dr. [**Last Name (STitle) 5715**]. Please monitor closely and
keep lithium level <1.
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
13. Piperacillin-Tazobactam 2-0.25 g Recon Soln Sig: One (1)
Recon Soln Intravenous  Q6H (every 6 hours) as needed for GNR in
sputum for 4 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
cardiogenic shock
atrial fibrillation
acute renal failure
gastrointestinal bleed, gastritis
bipolar disorder
congestive heart failure with EF of 15%
coronary artery disease s/p MI and stenting
ventilator associated pneumonia
hypernatremia
hypercalcemia
transient atrioventricular node reentrent tachycardia


Discharge Condition:
Improved.

Discharge Instructions:
Please administer all medications as prescribed.
Please ensure that the patient has follow up after discharge
form the hospital.

Followup Instructions:
1. Psychiatry - please reschedule if the patient is still at
rehabilitation hospital
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8698**], MD Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX) HMFP Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2146-10-12**] 2:40

2. PRIMARY CARE PHYSICIAN  Please call ([**Telephone/Fax (1) 29642**] to
schedule a follow up appointment with Dr. [**Last Name (STitle) 1683**]  in [**1-7**] weeks
after discharge from rehabilitation hospital.

3. CARDIOLOGY Please call ([**Telephone/Fax (1) 12468**] to schedule a follow up
appointment with Dr. [**Last Name (STitle) 73**] in [**1-7**] weeks after discharge from
rehabilitation hospital.



Completed by:[**2146-9-28**]
{'Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Cardiogenic shock,Pneumonia due to other gram-negative bacteria,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute respiratory failure,Atrial fibrillation'}


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: bright red blood per rectum

PRESENT ILLNESS: 71 yr old male with h/o CAD, s/p MI in [**2145-8-6**] with 2 LAD
stents placed at that time, on coumadin for low EF and LV
akinesis, bipolar disorder, on lithium, who presented with chest
pain and melena for evaluation. Patient reports dark stool with
intermittent brigh red blood per rectum with fall in hematocrit
from 31 on [**8-22**] to 22 on the day of admission. Patient had one
hour of chest discomfort with associated shortness of breath at
rest the night prior to admission. The patient called  his
primary physician who referred the patient to the ED. Patient
was found to be in acute renal failure, lithium of 2.0 later
developed T-wave inversions. Also, found to have elevated INR
and was stool guaiac positive.

MEDICAL HISTORY: bipolar disorder, stable on lithium
congestive heart failure with EF 15% and akinetic wall
coronary artery disease
s/p myocardial infarction and stenting in 8/04chronic renal
insufficiency

MEDICATION ON ADMISSION: coumadin
atorvastatin
aspirin
plavix
lipitor
lithium
HCTZ
Protonix
Lisinopril 5 mg po qd
Toprol XL 50 mg po qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Examination on admission:
Vitals: 98.9, 127/51, 73, RR 26, O2 97% on RA, ABG on RA
7.43/27/69
General: alert and oriented, pleasant and cooperative
HEENT: MMM, sclera mildly icteric
CV: RRR, no murmurs
Pulm: mild crackles throughout
Abd: obese, + bowel sounds, soft, nontender, nondistended
Ext: WWP, trace pitting edema throughout, DP 1+ bilaterally,
pneumoboots in place
Skin: no lesions

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Lives alone and worked in real estate. Former smoker and EtOH
abuse, now stable with AA. 

### Response:
{'Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Cardiogenic shock,Pneumonia due to other gram-negative bacteria,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute respiratory failure,Atrial fibrillation'}
