CHIEF COMPLAINT: GI Bleeding

PRESENT ILLNESS: 87 yo M with PMHx HTN, Afib, PVD, s/p PM for CHB and duodenal
AVM [**4-28**] who has had ongoing transfusion dependent GI bleeds
transferred from OSH for anemia and fatigue. His GI history
dates back to [**2-27**] where started having GI bleeds and underwent
a workup in Flordia. They had found mild gastric erosions on
EGD/[**Last Name (un) **] at that point. Subsequently he was admitted [**3-29**] to
[**Hospital3 **] hospital for syncope for which a PM was placed for CHB
and found to be anemic again. He was scoped at that admission
but there are is no documention but report of EGD/[**Last Name (un) **] - gastric
erosions - with ?avms in upper GI tract. Also per report he had
a capsule study which did not show evidence of bleeding. He was
admitted in [**4-28**] to [**Hospital1 18**] for anemia found to to have duodenal
AVM on endoscopy. Since then he has required 14 units of packed
RBCs and has had ongoing dark stools. At OSH today his hct was
found to be 20. He was given 2 units at OSH and a protonix gtt.
EKG showed paced rhythm but no STTW. Trop 0.28.

MEDICAL HISTORY: GI Bleed
Anemia from GI Bleed
AFib
Complete Heart Block s/p pacemaker
BPH
HTN
PVD
Right CEA
DJD

MEDICATION ON ADMISSION: Cardura 4mg po qHS
Digoxin 0.125 mg daily
Lasix 40mg PO daily
Fenestrate 5mg PO daily
colace 100mg po bid
hydralazine 50mg po tid
omeprazole 40mg po daily
ferrous sulfate 325mg po daily
toprol xl 75mg po daily

ALLERGIES: Ace Inhibitors / Norvasc

PHYSICAL EXAM: Tmax: 36.2 ??????C (97.2 ??????F)
Tcurrent: 36.2 ??????C (97.2 ??????F)
HR: 65 (65 - 76) bpm
BP: 135/51(70) {133/51(70) - 135/58(76)} mmHg
RR: 9 (8 - 14) insp/min
SpO2: 96%
Heart rhythm: V Paced
Height: 65 Inch

FAMILY HISTORY: Mother: had cancer (pt does not know the type)

SOCIAL HISTORY: Currently a resident of [**Hospital3 **] Pavilion ([**Hospital1 1501**] associated with
[**Hospital3 **] Hospital) - [**Telephone/Fax (1) 82406**].
Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Atrial fibrillation,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Cardiac pacemaker in situ
Chr stomach ulc w hem,Acute kidney failure NOS,Ac posthemorrhag anemia,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Atrial fibrillation,BPH w/o urinary obs/LUTS,Status cardiac pacemaker
Admission Date:  [**2192-9-20**]              Discharge Date:   [**2192-9-23**]


Service: MEDICINE

Allergies:
Ace Inhibitors / Norvasc

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
GI Bleeding

Major Surgical or Invasive Procedure:
Upper Endoscopy with biopsies pending

History of Present Illness:
87 yo M with PMHx HTN, Afib, PVD, s/p PM for CHB and duodenal
AVM [**4-28**] who has had ongoing transfusion dependent GI bleeds
transferred from OSH for anemia and fatigue. His GI history
dates back to [**2-27**] where started having GI bleeds and underwent
a workup in Flordia. They had found mild gastric erosions on
EGD/[**Last Name (un) **] at that point. Subsequently he was admitted [**3-29**] to
[**Hospital3 **] hospital for syncope for which a PM was placed for CHB
and found to be anemic again. He was scoped at that admission
but there are is no documention but report of EGD/[**Last Name (un) **] - gastric
erosions - with ?avms in upper GI tract. Also per report he had
a capsule study which did not show evidence of bleeding. He was
admitted in [**4-28**] to [**Hospital1 18**] for anemia found to to have duodenal
AVM on endoscopy. Since then he has required 14 units of packed
RBCs and has had ongoing dark stools. At OSH today his hct was
found to be 20. He was given 2 units at OSH and a protonix gtt.
EKG showed paced rhythm but no STTW. Trop 0.28.

.

In ED, 80 150/60 20 98 %RA. Per GI given history no need for
NGL. Hct 23.9. Cr up. Ordered for another unit of blood that he
had not recieved. Got 1/2-1L fluid. 3PIV, 1 20 and 2 18G.
Protonix gtt. 98.8 68 135/55 16 98% on RA. GI consulted and will
staff in am.

.

Currently, patient reports some abdominal cramps that he has had
after each meal. Reported fatigue but no lightheadness or LOC.
He denied nausea but reported dark tarry diarrhea. Denied CP,
SOB, cough, fever, chills. Has chronic lower extremity swelling
but denies orthopnea or PND.  No recent NSAID use.

.

ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.


Past Medical History:
GI Bleed
Anemia from GI Bleed
AFib
Complete Heart Block s/p pacemaker
BPH
HTN
PVD
Right CEA
DJD


Social History:
Currently a resident of [**Hospital3 **] Pavilion ([**Hospital1 1501**] associated with
[**Hospital3 **] Hospital) - [**Telephone/Fax (1) 82406**].

Tobacco: No
ETOH: Heavy drinker [**5-29**] scoth drinks per day, last drink was 6
wks back.


Family History:
Mother: had cancer (pt does not know the type)


Physical Exam:
Tmax: 36.2 ??????C (97.2 ??????F)
Tcurrent: 36.2 ??????C (97.2 ??????F)
HR: 65 (65 - 76) bpm
BP: 135/51(70) {133/51(70) - 135/58(76)} mmHg
RR: 9 (8 - 14) insp/min
SpO2: 96%
Heart rhythm: V Paced
Height: 65 Inch

General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
HEENT: pale conjunctiva
Chest: Regular HS, Lungs CTAB
Abd: soft, no tenderness elicited, no rebounding or guarding
Ext: [**1-24**]+ pitting edema b/l to knees
Skin:  Not assessed
Neurologic: Oriented and appropriate.

Pertinent Results:
EGD [**2192-9-20**]
Normal mucosa in the duodenum
Normal mucosa in the esophagus
Angioectasias in the stomach body
Ulcer in the stomach body (biopsy)
Otherwise normal EGD to third part of the duodenum

[**2192-9-20**] 03:55AM BLOOD WBC-4.8 RBC-2.73* Hgb-7.8* Hct-23.9*
MCV-88 MCH-28.8 MCHC-32.8 RDW-16.7* Plt Ct-294
[**2192-9-20**] 12:24PM BLOOD Hct-24.1*
[**2192-9-20**] 05:36PM BLOOD Hct-31.0*#
[**2192-9-20**] 11:34PM BLOOD Hct-27.3*
[**2192-9-21**] 04:39AM BLOOD WBC-5.0 RBC-3.22* Hgb-9.5* Hct-28.5*
MCV-89 MCH-29.6 MCHC-33.4 RDW-17.4* Plt Ct-268
[**2192-9-21**] 05:01PM BLOOD WBC-5.8 RBC-3.53* Hgb-10.2* Hct-31.3*
MCV-89 MCH-28.8 MCHC-32.5 RDW-17.2* Plt Ct-296
[**2192-9-22**] 01:15AM BLOOD Hct-28.7*
[**2192-9-22**] 05:10AM BLOOD WBC-5.5 RBC-3.35* Hgb-10.1* Hct-30.4*
MCV-91 MCH-30.1 MCHC-33.2 RDW-17.0* Plt Ct-280
[**2192-9-22**] 05:30PM BLOOD Hct-30.6*
[**2192-9-20**] 03:55AM BLOOD Neuts-71.6* Lymphs-19.2 Monos-7.0 Eos-1.9
Baso-0.4
[**2192-9-20**] 03:55AM BLOOD PT-12.0 PTT-24.1 INR(PT)-1.0
[**2192-9-22**] 05:10AM BLOOD PT-12.5 PTT-25.1 INR(PT)-1.1
[**2192-9-22**] 05:10AM BLOOD Plt Ct-280
[**2192-9-20**] 03:55AM BLOOD Glucose-110* UreaN-85* Creat-2.5*# Na-139
K-4.2 Cl-101 HCO3-26 AnGap-16
[**2192-9-20**] 05:36PM BLOOD Glucose-156* UreaN-67* Creat-2.1* Na-140
K-4.4 Cl-104 HCO3-24 AnGap-16
[**2192-9-21**] 04:39AM BLOOD Glucose-92 UreaN-56* Creat-1.8* Na-142
K-4.0 Cl-107 HCO3-27 AnGap-12
[**2192-9-22**] 05:10AM BLOOD Glucose-94 UreaN-37* Creat-1.4* Na-143
K-3.7 Cl-108 HCO3-29 AnGap-10
[**2192-9-20**] 03:55AM BLOOD CK(CPK)-29*
[**2192-9-20**] 12:24PM BLOOD CK(CPK)-16*
[**2192-9-20**] 03:55AM BLOOD CK-MB-NotDone cTropnT-0.13* proBNP-4085*
[**2192-9-20**] 12:24PM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2192-9-21**] 04:39AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.9
[**2192-9-22**] 05:10AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0

Chest x-ray ([**9-21**])-
1. Small bilateral pleural effusion and pulmonary vascular
congestion
compatible with mild fluid overload.
2. Asymmetrically enlarged and dense right hilus which could be
due to
vascular congestion, however oblique radiographs are recommended
for further
evaluation.
3. Severe atherosclerosis.

Chest x-ray (PA, lateral, obliques)- [**9-22**]-
Small bilateral pleural effusions and generalized pulmonary
vascular
engorgement persists. Heart is slightly larger. Multiple views
of both hila
show that their enlargement is probably due to dilated pulmonary
arteries.
Transvenous right atrial and right ventricular pacer leads are
in place.
Thoracic aorta is extremely heavily calcified, but not dilated.
No pneumonia

EKG- [**9-21**]- Sinus rhythm with marked first degree A-V block and
ventricular electronic
pacing. Compared to the previous tracing of [**2192-5-5**] the P-R
interval has
lengthened

Stomach biopsies- pending

Brief Hospital Course:
MICU COURSE:

The patient was transferred to [**Hospital1 18**] for further management of
his upper GI bleeding, and was admitted directly to the medical
intensive care unit. He had a prior enteroscopy with Dr. [**First Name (STitle) **]
[**Name (STitle) **] in [**Hospital1 18**] in [**2192-4-20**]. EGD in the MICU revealed
multiple linear 2-3cm ulcers were found along the gastric folds
in the stomach body. Blood clot suggested recent bleeding. The
folds around the ulcer was induated and edematous. This
appearance might be compatible with gastric lymphoma. Cold
forceps biopsies were performed for histology at the stomach
body.

He was transfused 2 units while at [**Hospital1 18**], but has remained
hemodynamiclly stable. He was treated with intravenous PPI.

He remained fully alert and oriented throughout his MICU stay.

FLOOR COURSE:

Patient transferred to the floor on the evening of [**2192-9-21**].  He
was stable and did well while in the MICU.  Upon transfer to the
floor, the patient had two non-bloody bowel movements.  His Hct
was closely monitored- trended from 31.3 to 28.7 overnight.  Up
to 30.4 upon discharge (was ~20 on admission).  He did not
require any transfusions while on the floor and tolerated oral
intake well.  His blood pressure medications were held and his
finesteride was restarted.  BP returned to SBP of 130s-140s.
Patient instructed to resume home blood pressure medications now
that bleed has resolved and he has no signs of hypovolemia on
exam or on vital signs.  Upon discharge, the patient was stable
and comfortable.

Medications on Admission:
Cardura 4mg po qHS
Digoxin 0.125 mg daily
Lasix 40mg PO daily
Fenestrate 5mg PO daily
colace 100mg po bid
hydralazine 50mg po tid
omeprazole 40mg po daily
ferrous sulfate 325mg po daily
toprol xl 75mg po daily

Discharge Medications:
1. 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*
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
4. Cardura 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a
day.
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
9. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
10. Outpatient Lab Work
Please check CBC, Chem-7 prior to [**2192-9-26**] and fax results to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 82407**] at [**Telephone/Fax (1) 82408**]
11. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
- Acute GI bleed resolved
- Multiple 2-3cm ulcers in the stomach body
- Acute renal failure; resolved
- Non-thrombotic troponin elevation
- Dense right hilus secondary to enlarged pulmonary artery.

Secondary:
- Atrial fibrillation
- Heart block, s/p pacemaker
- CKD Stage III
- Benign prostatic hypertrophy
- Hypertension
- Duodenal AVMs
- Peripheral vascular disease S/P iliac stent
- S/P right carotid endarterectomy
- S/P appendectomy
- Macular degeneration, blind in the right eye


Discharge Condition:
Good.  Vital signs stable.  No sign of active GI bleed.


Discharge Instructions:
You were transferred to [**Hospital1 18**] for GI bleed management.  When you
arrived here, you were fatigued with a low hematocrit (a measure
of your blood count).  You were transfused 3 total units of
blood and responded very well.  The GI team saw you and
performed an EGD.  They found stomach ulcer and believe that is
the cause of your bleed.  They took samples from the ulcer for
analysis- those results are still pending.  Your bleed has now
resolved and you have been hemodynamically stable.  Upon
discharge, you had no signs of active GI bleed.

Your blood pressure medications were held while you were in the
hospital.  Please resume all home medications at this time.
Please do not take any blood thinning medications (coumadin,
lovenox)

The following medication changes were made:
1.  Stop taking your omeprazole and start taking pantoprazole
40mg by mouth twice a day.

If you experience another GI bleed, fevers, chest pain,
shortness of breath, light-headedness, severe abdominal pain or
any other medically concerning symptoms, please contact your
primary care physician or go to the emergency department
immediately.

Followup Instructions:
Please follow-up with your primary care physician
([**Last Name (LF) **],[**First Name3 (LF) 2747**] S [**Telephone/Fax (1) 82409**]) next week.  Call Dr. [**Name (NI) 82410**] office on Monday [**9-24**] to make an appointment for
next week.

Please get your blood drawn by [**2192-9-26**] so your primary care
physician can have the results by the time you see her.

The GI doctors here [**Name5 (PTitle) **] [**Name5 (PTitle) 138**] you at [**Telephone/Fax (1) 82411**] to schedule a
follow-up appointment in the next week.



Completed by:[**2192-9-23**]
{'Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Atrial fibrillation,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Cardiac pacemaker in situ'}


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 Bleeding

PRESENT ILLNESS: 87 yo M with PMHx HTN, Afib, PVD, s/p PM for CHB and duodenal
AVM [**4-28**] who has had ongoing transfusion dependent GI bleeds
transferred from OSH for anemia and fatigue. His GI history
dates back to [**2-27**] where started having GI bleeds and underwent
a workup in Flordia. They had found mild gastric erosions on
EGD/[**Last Name (un) **] at that point. Subsequently he was admitted [**3-29**] to
[**Hospital3 **] hospital for syncope for which a PM was placed for CHB
and found to be anemic again. He was scoped at that admission
but there are is no documention but report of EGD/[**Last Name (un) **] - gastric
erosions - with ?avms in upper GI tract. Also per report he had
a capsule study which did not show evidence of bleeding. He was
admitted in [**4-28**] to [**Hospital1 18**] for anemia found to to have duodenal
AVM on endoscopy. Since then he has required 14 units of packed
RBCs and has had ongoing dark stools. At OSH today his hct was
found to be 20. He was given 2 units at OSH and a protonix gtt.
EKG showed paced rhythm but no STTW. Trop 0.28.

MEDICAL HISTORY: GI Bleed
Anemia from GI Bleed
AFib
Complete Heart Block s/p pacemaker
BPH
HTN
PVD
Right CEA
DJD

MEDICATION ON ADMISSION: Cardura 4mg po qHS
Digoxin 0.125 mg daily
Lasix 40mg PO daily
Fenestrate 5mg PO daily
colace 100mg po bid
hydralazine 50mg po tid
omeprazole 40mg po daily
ferrous sulfate 325mg po daily
toprol xl 75mg po daily

ALLERGIES: Ace Inhibitors / Norvasc

PHYSICAL EXAM: Tmax: 36.2 ??????C (97.2 ??????F)
Tcurrent: 36.2 ??????C (97.2 ??????F)
HR: 65 (65 - 76) bpm
BP: 135/51(70) {133/51(70) - 135/58(76)} mmHg
RR: 9 (8 - 14) insp/min
SpO2: 96%
Heart rhythm: V Paced
Height: 65 Inch

FAMILY HISTORY: Mother: had cancer (pt does not know the type)

SOCIAL HISTORY: Currently a resident of [**Hospital3 **] Pavilion ([**Hospital1 1501**] associated with
[**Hospital3 **] Hospital) - [**Telephone/Fax (1) 82406**]. 

### Response:
{'Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Atrial fibrillation,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Cardiac pacemaker in situ'}
