CHIEF COMPLAINT: Dizziness, shortness of breath and chest "tightness".

PRESENT ILLNESS: The pt. is a 58 year-old female with a history significant for
CAD, anemia (secondary to iron deficiency and bone marrow
"block") and aortic valve replacement in [**2183-3-15**] who
presents with shortness of breath, dizziness, and chest
"tightness."  Five days prior to admission, the pt. went to
receive her weekly arenesp treatment when her HCT was noted to
be 25.3.  She was transfused 2 units PRBCs at that time.  Since
then, she has noted increasing dizziness, shortness of breath,
and chest tightness.  She does not report any BRBPR,
hematemesis, abdominal pain, nausea, vomiting, or fevers.  The
pt. collapsed in [**Hospital Ward Name 23**] building lobby and was brought to the
ED.  In the ED she was noted to have a hematocrit of 18 and
guiaic positive, black charcoal-consistency stool. She was
started on a protonix drip, given FFP and Vitamin K (to reverse
her coumadin-induced therapeutic INR), and normal saline.
Initially she had systolic blood pressure readings in the 90's
that responded to fluid.  The GI service was consulted and NG
lavage performed which revealed red blood specks in the lavage
fluid.  The GI service felt that the lavage fluid was not
grossly bloody.  Coumadin was discontinued and she was started
on a heparin drip (necessary as the pt. has a mechanical AVR)
and transferred to the intensive care unit.

MEDICAL HISTORY: 1. Severe aortic stenosis
2. History of endocarditis status post a dental visit.
3. Congestive heart failure - EF 60% on [**2-16**] cardiac
catheterization.
4. Bilateral lower extremity peripheral neuropathy.
5. Anemia (secondary to absent iron stores and inflammatory
block), treated with darbopoeitin and iron therapy.
6. Status post cholecystectomy.
7. Status post C-section x four.
8. Hypertension.
9. Hypercholesterolemia.
10. Non-insulin dependent-diabetes mellitus.
11. AVR w. St. [**Male First Name (un) 1525**]  mechanical valve
12. CAD - 3vessel CAD by cath [**2-16**] (no CABG or PTCA done)
13. Pulmonary HTN

MEDICATION ON ADMISSION: Lantus 13 units qhs
Glyburide 10mg po once daily
Coumadin 2mg po once daily
ASA 81mg po once daily
Metoprolol 25mg po bid
Procrit
Folate 1mg po once daily
Lipitor 20mg po once daily
Iron sulfate 325mg po once daily
Vitamin C 500mg po once daily
Lasix 20mg po bid

ALLERGIES: Feldene

PHYSICAL EXAM: Vitals: T: 99.7F BP: 130/87  P: 82-109  R: 18  SaO2: 98% on RA
General: pt. lying in bed and is difficult to arouse
HEENT: PERRL, EOMI, MMM
Neck: supple
Chest: lungs CTA bilaterally
Cardiac: tachycardic, regular rhythm, S1S2, II/VI murmur at
upper LSB with radiation to bilateral carotids.
Abdomen: soft, NT/ND, active bowel sounds, no HSM
Extremities: no c/c/e bilaterally
Neuro: Difficult to arouse, but once aroused is oriented in all
3 spheres.
Skin: no rashes noted.

FAMILY HISTORY: Mother is alive at 83 with anemia and congestive heart failure.
Father died at 77 of an myocardial infarction.

SOCIAL HISTORY: She is originally from [**Country 1684**], emigrated in [**2145**]. The patient
quit smoking tobacco in [**2172**].
She rarely drinks alcohol.  She is married and has four
children.  She does not nor has ever used illicit drugs.
Acute gastritis, with hemorrhage,Subendocardial infarction, initial episode of care,Mechanical complication due to heart valve prosthesis,Congestive heart failure, unspecified,Peripheral vascular complications, not elsewhere classified,Acute posthemorrhagic anemia,Long-term (current) use of anticoagulants,Benign paroxysmal positional vertigo
Acute gastritis w hmrhg,Subendo infarct, initial,Malfunc prosth hrt valve,CHF NOS,Surg comp-peri vasc syst,Ac posthemorrhag anemia,Long-term use anticoagul,Benign parxysmal vertigo
Admission Date:  [**2183-7-1**]              Discharge Date:   [**2183-8-8**]

Date of Birth:  [**2124-12-30**]             Sex:   F

Service: MED

Allergies:
Feldene

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Dizziness, shortness of breath and chest "tightness".

Major Surgical or Invasive Procedure:
EGD and colonoscopy on [**2183-7-10**].


History of Present Illness:
The pt. is a 58 year-old female with a history significant for
CAD, anemia (secondary to iron deficiency and bone marrow
"block") and aortic valve replacement in [**2183-3-15**] who
presents with shortness of breath, dizziness, and chest
"tightness."  Five days prior to admission, the pt. went to
receive her weekly arenesp treatment when her HCT was noted to
be 25.3.  She was transfused 2 units PRBCs at that time.  Since
then, she has noted increasing dizziness, shortness of breath,
and chest tightness.  She does not report any BRBPR,
hematemesis, abdominal pain, nausea, vomiting, or fevers.  The
pt. collapsed in [**Hospital Ward Name 23**] building lobby and was brought to the
ED.  In the ED she was noted to have a hematocrit of 18 and
guiaic positive, black charcoal-consistency stool. She was
started on a protonix drip, given FFP and Vitamin K (to reverse
her coumadin-induced therapeutic INR), and normal saline.
Initially she had systolic blood pressure readings in the 90's
that responded to fluid.  The GI service was consulted and NG
lavage performed which revealed red blood specks in the lavage
fluid.  The GI service felt that the lavage fluid was not
grossly bloody.  Coumadin was discontinued and she was started
on a heparin drip (necessary as the pt. has a mechanical AVR)
and transferred to the intensive care unit.

Past Medical History:
1. Severe aortic stenosis
2. History of endocarditis status post a dental visit.
3. Congestive heart failure - EF 60% on [**2-16**] cardiac
catheterization.
4. Bilateral lower extremity peripheral neuropathy.
5. Anemia (secondary to absent iron stores and inflammatory
block), treated with darbopoeitin and iron therapy.
6. Status post cholecystectomy.
7. Status post C-section x four.
8. Hypertension.
9. Hypercholesterolemia.
10. Non-insulin dependent-diabetes mellitus.
11. AVR w. St. [**Male First Name (un) 1525**]  mechanical valve
12. CAD - 3vessel CAD by cath [**2-16**] (no CABG or PTCA done)
13. Pulmonary HTN


Social History:
She is originally from [**Country 1684**], emigrated in [**2145**]. The patient
quit smoking tobacco in [**2172**].
She rarely drinks alcohol.  She is married and has four
children.  She does not nor has ever used illicit drugs.


Family History:
Mother is alive at 83 with anemia and congestive heart failure.
Father died at 77 of an myocardial infarction.


Physical Exam:
Vitals: T: 99.7F BP: 130/87  P: 82-109  R: 18  SaO2: 98% on RA
General: pt. lying in bed and is difficult to arouse
HEENT: PERRL, EOMI, MMM
Neck: supple
Chest: lungs CTA bilaterally
Cardiac: tachycardic, regular rhythm, S1S2, II/VI murmur at
upper LSB with radiation to bilateral carotids.
Abdomen: soft, NT/ND, active bowel sounds, no HSM
Extremities: no c/c/e bilaterally
Neuro: Difficult to arouse, but once aroused is oriented in all
3 spheres.
Skin: no rashes noted.


Pertinent Results:
[**2183-7-1**] 10:45PM URINE  HOURS-RANDOM
[**2183-7-1**] 10:45PM URINE  GR HOLD-HOLD
[**2183-7-1**] 09:33PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2183-7-1**] 09:33PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2183-7-1**] 06:24PM   GLUCOSE-106* UREA N-69* CREAT-1.3* SODIUM-135
POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-26 ANION GAP-13
[**2183-7-1**] 06:24PM   LD(LDH)-284* CK(CPK)-35 TOT BILI-0.5 DIR
BILI-0.1 INDIR BIL-0.4
[**2183-7-1**] 06:24PM   CK-MB-NotDone cTropnT-<0.01
[**2183-7-1**] 06:24PM   HAPTOGLOB-<20*
[**2183-7-1**] 06:24PM   WBC-8.5 RBC-2.24*# HGB-6.2*# HCT-18.3*#
MCV-82 MCH-27.5 MCHC-33.7 RDW-19.6*
[**2183-7-1**] 06:24PM   NEUTS-66.1 LYMPHS-26.6 MONOS-4.1 EOS-2.2
BASOS-1.0
[**2183-7-1**] 06:24PM   HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MICROCYT-2+
[**2183-7-1**] 06:24PM   PLT COUNT-241
[**2183-7-1**] 06:24PM   PT-18.9* PTT-32.7 INR(PT)-2.3

Brief Hospital Course:
* Anemia: The pt. suffers from chronic anemia and is followed by
Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**].  As per her records, her anemia seems to be
due to a combination of iron deficiency and bone marrow block.
On arrival to the ED, the pt's. hematocrit was 18 and the pt.
was noted to have guiaic positive stool and specks of blood in
the NG lavage fluid, indicating a likely gastrointestinal bleed
as the cause of her presentation.  An upper endoscopy and
colonoscopy were tentatively planned while the patient was in
the ICU, however, she happened to rule in for an MI on the basis
of cardiac enzymes.  Therefore, the procedure was tentatively
deferred pending cardiac evaulation in this patient with a
previous history of three-vessel coronary disease.
In the ED and ICU, she received a total of five units of PRBCs.
Her hematocrit responded appropriately and trended up from 18 to
21, 24, 29 and 31 over the course of the first and second
hospital day.
The pt. was noted to have a low haptoglobin and high LDH on
laboratory studies, suggesting a possible hemolytic component to
her anemia.  Unfortunately, a peripheral smear was not reviewed
until after the pt. had received transfusions and was therefore
unremarkable.  A Coombs test was performed and was negative. It
is likely given her St. [**Male First Name (un) 923**] mechanical valve that there is some
degree of blood cell shearing.  A hematology consult was
obtained.  They recommended laboratory assessment to rule out
paroxysmal nocturnal hemoglobinuria, including flow cytometry
and C55 and 59 antibodies.  This workup proved to be negative.
An EGD and colonoscopy were performed on [**2183-7-10**] which revealed
areas of nodularity and erythema in the stomach suggestive of
gastritis and a normal colonoscopy. No areas of active or recent
bleeding were noted. Biopsies were taken from the erythematous
areas in the stomach and duodenum and review by pathology
determined that they were normal specimens.
As the pt. did experience a drop in hematocrit (to 30-31) after
warfarin was restarted and was noted to have guiaic positive
stool, GI was reconsulted and a capsule endoscopy was performed
on [**2183-7-23**].  This revealed bright red blood in the proximal small
bowel.  A push enteroscopy was then scheduled once the pt's INR
normalized. During the interval when the bleeding was discovered
in the small bowel by capusle endoscopy and the push
enteroscopy, the pt. required frequent transfusions of packed
red blood cells for falling hematocrits (in the low 30's).  The
pt. had the push enteroscopy performed on [**2183-7-30**] which showed
locatlized granularity and erythema in the gastric fundus
compatible with gastritis but an otherwise normal EGD to the
jejunum.
As the pt. did experience a drop in her hematocrit while on
aspirin, plavix and coumadin, it was decided that the pt. should
not take aspirin and plavix secondary to their propensity to
cause gastrointestinal bleeding.  It is realized that she does
need to be on life-long coumadin therapy because of her
mechanical heart valve.  In addition, the pt. was maintained on
high dose protonix (80mg [**Hospital1 **]) as it was noted that she did have
significant gastritis on EGD despite therapy with protonix 40mg
[**Hospital1 **].
After the pt. had had stable hematocrit values and did not
require transfusion for three consecutive days after the push
enteroscopy, warfarin was re-started and she was discharged once
her INR was greater than 2.0.  She was asked to follow-up with
her primary care doctor after having a CBC, PT, PTT, INR drawn
three days after discharge.
The pt. has been scheduled for a follow-up appointment with her
hematologist, Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**] on [**2183-8-20**].

* Aortic Stenosis: An echocardiogram performed on [**2183-7-2**]
revealed an aortic paravalvular leak and normal EF with no wall
motion abnormalities.  A subsequent echocardiogram on [**2183-7-4**]
did not show the paravalvular leak and confirmed the previous
findings.  As the pt. was suspected to suffer from a
gastrointestinal hemorrhage on admission, coumadin was
discontinued.  However, due to the need for anticoagulation
given her mechanical valve, she was maintained on a heparin drip
during the hospitalization, and transitioned to warfarin prior
to discharge. Her INR was therapeutic upon discharge.

* CAD: As per OMR records, the pt. had a cardiac catheterization
in [**2-16**] which revealed three vessel disease in addition to
aortic stenosis.  She was to undergo CABG at the time of aortic
valve replacement.  However, CABG was not performed at this
time.  According to Dr. [**Last Name (STitle) 1290**], who performed the procedure,
the pt. suffered from significant disease in only one vessel and
this was a non-bypassable lesion.
On this admission, while in the ICU, the pt. was noted to rule
in for a myocardial infarction with positive cardiac enzymes.
She had no EKG changes at the time (NSTEMI).  For this reason,
emergent EGD and colonoscopy were delayed.  A cardiology consult
was requested to determine the need for catheterization in light
of the need for the gastrointestinal procedures.  They had
opined that the MI represented "demand ischemia" in the setting
of a hematocrit 18.  They initially recommended an
echocardiogram (results described above) and a P-MIBI which was
performed on [**2183-7-8**].  This demonstrated moderate reversible
anterior and lateral defects and there was concern for left main
coronary artery disease.
The pt. underwent cardiac catheteriztion on [**2183-7-14**].  This
revealed three vessel and left main coronary artery disease.
The decision was made not to intervene at that time.  It was
recommended that the pt. have close follow-up with her
cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], after discharge.

* Dizziness: The pt. reported new-onset dizziness on [**2183-7-8**].
It was associated with nausea and diaphoresis at first.  The
initial thought was to rule-out myocardial infarction. An
emergent EKG was performed which did not reveal any changes and
cardiac enzymes were sent and returned negative.  The nausea and
diaphoresis subsided over the course of an hour, but the
dizziness was persistent.  A neurology consultation was
obtained.  In the setting of a mechanical valve and
anticoagulation, an emergent head CT was ordered to rule out
intracranial hemorrhage.  This revealed a small area of
hyperintensity in the left globus pallidus which was read as
hemorrhage versus calcification.  As there was no previous head
CT to compare, the definitive diagnosis was not able to be made
at that time.  Neurologic exam did not reveal any signs of
brainstem dysfunction and the area in question on CT would not
necessarily account for the pt's. symptomatology.  A subsequent
CT scan was performed on [**2183-7-10**] which was unchanged from the
previous study, making hemorrhage very unlikely, and
calcifaction the likely cause of the lesion.
The neurology service ultimately felt that the patient suffered
from BPPV.  They recommended meclizine and valium which were
prescribed.  The pt. had the Epley maneuver performed by the ENT
service which did not improve the pt's symptoms and, in fact,
caused her to be dizzy and nauseous.
The pt. eventually complained less of this symptom and required
no meclizine or valium for relief.

*Hearing Loss: Upon examination by the neurology team, it was
noted that the pt. had a significant degree of hearing loss on
the left side.  An otolaryngology consult was subsequently
obtained.  They discovered that the pt. suffered from "severe to
profound sudden sensorineural hearing loss."  They recommended
an MRI of the internal auditory canal to rule out a
cerebellopontine angle mass (i.e. vestibular Schwannoma).  This
study was not completed, however, as the pt. refused secondary
to claustrophobia.  They also recommended audiometry.  The pt.
will undergo audiometry prior to her follow-up appointment with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] on [**2183-8-22**] at 9:30 am
([**Telephone/Fax (1) 7732**]).

*Hematuria: The pt. was noted to have gross blood in her urine
on [**2183-7-4**].  The urology service consulted and recommended urine
cytology which was sent. The cytology returned as atypical
squamous cells.
The urology team therefore recommended outpatient follow-up with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**] for possible cystoscopy.  An appointment was
made for the patient for [**2183-8-14**] at 10:45am with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**] at [**Hospital1 9384**] ([**Telephone/Fax (1) 6445**]).

*Hypertension: The pt. was noted to have poor blood pressure
control over the course of the first few hospital days.
Systolic blood pressures were consistently noted to be in the
170-190 range.  Captopril was added on [**2183-7-5**] and titrated up
on multiple subsequent occasions with effect.  Her blood
pressure was much better controlled for the remainder of the
hospital course with systolic blood pressure readings
consistently in the 120-130 range.  The pt. was converted from
captopril to lisinopril prior to discharge.

*Diabetes Mellitus: The pt. was maintained on a sliding scale of
insulin for the duration of the hospitalization.  Her
fingerstick glucose levels were noted to be within acceptable
ranges.  She was discharged on her usual regimen.

*Right femoral artery pseudoaneurysm: Eight days after cardiac
catheterization, the pt. complained of tenderness and swelling
at the puncture site over her right groin area.  An ultrasound
of the area was performed which revealed a 2cm by 2cm hematoma
and a 1.4cm pseudoaneurysm of the right femoral artery.  The
[**Date Range 1106**] surgery team was consulted for possible intervention.
They recommended follow-up with Dr. [**Last Name (STitle) **] in one month's
time.  She has been scheduled for an outpt. appointment with Dr.
[**Last Name (STitle) **] on [**2183-8-25**] at 10am at [**Last Name (NamePattern1) **], [**Hospital Unit Name **]
([**Telephone/Fax (1) 3121**]).

Medications on Admission:
Lantus 13 units qhs
Glyburide 10mg po once daily
Coumadin 2mg po once daily
ASA 81mg po once daily
Metoprolol 25mg po bid
Procrit
Folate 1mg po once daily
Lipitor 20mg po once daily
Iron sulfate 325mg po once daily
Vitamin C 500mg po once daily
Lasix 20mg po bid

Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
Two (2) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO QD (once a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Meclizine HCl 12.5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
CBC, PT, PTT, INR
Results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38612**], please.
8. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO QD (once a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
10. Lantus 100 unit/mL Solution Sig: Thirteen (13) units
Subcutaneous qpm.
11. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
12. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
13. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.

14. Percocet 2.5-325 mg Tablet Sig: One (1) Tablet PO every [**2-18**]
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Anemia, multifactorial with components of iron deficiency and
bone marrow block.
Coronary Artery Disease
Hematuria
Hypertension
Diabetes Mellitus, type 2
Benign paroxysmal positional vertigo
Left ear hearing loss of uncertain etiology
Right femoral artery pseudoaneurysm


Discharge Condition:
Stable.

Discharge Instructions:
Please continue to take all of your medications.  Please be sure
to attend all of your follow-up appointments.
If you experience any concerning symptoms such as chest pain,
shortness of breath, severe lightheadedness, bleeding from your
gums or rectum, or increasing blood in your urine, please call
your primary care doctor or go to the emergency department for
evaluation.

Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**], [**Hospital1 1426**] Urology, [**Hospital1 **]
([**Telephone/Fax (1) 6445**])
[**2183-8-14**] at 10:45 am

Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**], [**Hospital1 1426**] Otolaryngology (Ears, nose
and throat). [**Hospital1 **] ([**Telephone/Fax (1) 7732**])
[**2183-8-22**] at 9:30 am

Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38612**]
Monday [**2183-8-11**] at 1:30pm

Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Cardiology, please call Dr.[**Name (NI) 38613**] office to
make an appointment within the next 2 to 3 weeks at a time
convenient for you.

Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2183-8-25**] 10:00

Please call the gastroenterology clinic at [**Telephone/Fax (1) 1954**] to
schedule an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3815**] for a time
convenient for you. Please follow up with Dr. [**Last Name (STitle) 3815**] within the
next 2-3 weeks.

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Where: [**Hospital6 29**]
HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2183-8-20**] 11:00
{'Acute gastritis, with hemorrhage,Subendocardial infarction, initial episode of care,Mechanical complication due to heart valve prosthesis,Congestive heart failure, unspecified,Peripheral vascular complications, not elsewhere classified,Acute posthemorrhagic anemia,Long-term (current) use of anticoagulants,Benign paroxysmal positional vertigo'}


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: Dizziness, shortness of breath and chest "tightness".

PRESENT ILLNESS: The pt. is a 58 year-old female with a history significant for
CAD, anemia (secondary to iron deficiency and bone marrow
"block") and aortic valve replacement in [**2183-3-15**] who
presents with shortness of breath, dizziness, and chest
"tightness."  Five days prior to admission, the pt. went to
receive her weekly arenesp treatment when her HCT was noted to
be 25.3.  She was transfused 2 units PRBCs at that time.  Since
then, she has noted increasing dizziness, shortness of breath,
and chest tightness.  She does not report any BRBPR,
hematemesis, abdominal pain, nausea, vomiting, or fevers.  The
pt. collapsed in [**Hospital Ward Name 23**] building lobby and was brought to the
ED.  In the ED she was noted to have a hematocrit of 18 and
guiaic positive, black charcoal-consistency stool. She was
started on a protonix drip, given FFP and Vitamin K (to reverse
her coumadin-induced therapeutic INR), and normal saline.
Initially she had systolic blood pressure readings in the 90's
that responded to fluid.  The GI service was consulted and NG
lavage performed which revealed red blood specks in the lavage
fluid.  The GI service felt that the lavage fluid was not
grossly bloody.  Coumadin was discontinued and she was started
on a heparin drip (necessary as the pt. has a mechanical AVR)
and transferred to the intensive care unit.

MEDICAL HISTORY: 1. Severe aortic stenosis
2. History of endocarditis status post a dental visit.
3. Congestive heart failure - EF 60% on [**2-16**] cardiac
catheterization.
4. Bilateral lower extremity peripheral neuropathy.
5. Anemia (secondary to absent iron stores and inflammatory
block), treated with darbopoeitin and iron therapy.
6. Status post cholecystectomy.
7. Status post C-section x four.
8. Hypertension.
9. Hypercholesterolemia.
10. Non-insulin dependent-diabetes mellitus.
11. AVR w. St. [**Male First Name (un) 1525**]  mechanical valve
12. CAD - 3vessel CAD by cath [**2-16**] (no CABG or PTCA done)
13. Pulmonary HTN

MEDICATION ON ADMISSION: Lantus 13 units qhs
Glyburide 10mg po once daily
Coumadin 2mg po once daily
ASA 81mg po once daily
Metoprolol 25mg po bid
Procrit
Folate 1mg po once daily
Lipitor 20mg po once daily
Iron sulfate 325mg po once daily
Vitamin C 500mg po once daily
Lasix 20mg po bid

ALLERGIES: Feldene

PHYSICAL EXAM: Vitals: T: 99.7F BP: 130/87  P: 82-109  R: 18  SaO2: 98% on RA
General: pt. lying in bed and is difficult to arouse
HEENT: PERRL, EOMI, MMM
Neck: supple
Chest: lungs CTA bilaterally
Cardiac: tachycardic, regular rhythm, S1S2, II/VI murmur at
upper LSB with radiation to bilateral carotids.
Abdomen: soft, NT/ND, active bowel sounds, no HSM
Extremities: no c/c/e bilaterally
Neuro: Difficult to arouse, but once aroused is oriented in all
3 spheres.
Skin: no rashes noted.

FAMILY HISTORY: Mother is alive at 83 with anemia and congestive heart failure.
Father died at 77 of an myocardial infarction.

SOCIAL HISTORY: She is originally from [**Country 1684**], emigrated in [**2145**]. The patient
quit smoking tobacco in [**2172**].
She rarely drinks alcohol.  She is married and has four
children.  She does not nor has ever used illicit drugs. 

### Response:
{'Acute gastritis, with hemorrhage,Subendocardial infarction, initial episode of care,Mechanical complication due to heart valve prosthesis,Congestive heart failure, unspecified,Peripheral vascular complications, not elsewhere classified,Acute posthemorrhagic anemia,Long-term (current) use of anticoagulants,Benign paroxysmal positional vertigo'}
