CHIEF COMPLAINT: brbpr

PRESENT ILLNESS: HPI: [**Age over 90 **] yo Russian speaking F with CAD, AFib, DM, HTN, CHF, CRI
(Baseline Cr=1.4), anemia, who presents from [**Hospital 100**] rehab with 2
episodes of blood in her stool this am. She was found to have a
supratherapeutic INR (5.9) at [**Hospital 100**] Rehab. She received one
dose of Vit K 5 mg po and was transferred to [**Hospital1 18**] for
evaluation. Per report patient denied lightheadedness,
dizziness, CP, SOB, N/V, belly pain. Initial vitals revealed SBP
in the mid 90's which increased to 110's without intervention,
HR remained in the 60's. NG lavage negative. Hct noted to be
28.0. As per Nursing Home staff pt has been off coumadin for 5
days secondary to elevated INR. She was started on coumadin
after her recent hip surgery. Her INR has been difficult to
control. She has not been on any other new medications recently.

MEDICAL HISTORY: PMH:
1. CAD
2. AF
3. CKD (Cr 1.5-1.7)
4. DM
5. h/o UTI
6. Osteoporosis
7. Glaucoma
8. Hyperlipidemia
9. HTN
10. Depression
11. Anemia

MEDICATION ON ADMISSION: Home Meds:
1. Amlodipine 10 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Isosorbide Mononitrate 30 mg Sustained Release PO DAILY
4. trazadone 25 mg qhs prn insomnia
5. Mirtazapine 15 mg PO HS
6. Metoprolol Tartrate 100 mg PO BID
7. Lisinopril 5 mg PO DAILY
8. Oxycodone 5 mg PO Q4-6H as needed for pain.
9. Tylenol 975 mg q 6hrs
10. Senna 2 tabs qhs
11. simvastatin 20 mg qhs
12. coumadin d/c'ed 5 days ago
.
All:  Naproxen

ALLERGIES: Naproxen

PHYSICAL EXAM: Physical Exam:
Tc 97.6    BP 107/66    HR 72    RR  16   Sat 97% RA
Gen:  well appearing elderly female, NAD
HENNT:  MMM, anicteric
Neck:  no LAD, JVD flat, no carotid bruits
CV:  RRR, nl S1S2,  III/VI systolic murmur heard best at apex
Lungs: soft bibasilar crackles
Abd:  soft, NT/ND, +BS, No HSM
Ext:  no edema, strong DP/PT pulses bilaterally, blood filled
flacid blisters on bilateral heals w/o surrounding erythema
Neuro:  Moving all extremeties
.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Nursing Home resident, lives a [**Hospital 100**] Rehab.
Contact is son [**Name (NI) 4186**] ([**Telephone/Fax (1) 107323**] and ([**Telephone/Fax (1) 107324**] (h)
Hemorrhage of gastrointestinal tract, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Ulcer of heel and midfoot,Atrial fibrillation,Chronic kidney disease, unspecified,Congestive heart failure, unspecified,Other specified disease of white blood cells,Coronary atherosclerosis of unspecified type of vessel, native or graft,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Osteoporosis, unspecified,Other and unspecified hyperlipidemia
Gastrointest hemorr NOS,Chr blood loss anemia,Ulcer of heel & midfoot,Atrial fibrillation,Chronic kidney dis NOS,CHF NOS,Wbc disease NEC,Cor ath unsp vsl ntv/gft,DMII wo cmp nt st uncntr,Hypertension NOS,Osteoporosis NOS,Hyperlipidemia NEC/NOS
Admission Date:  [**2172-10-3**]              Discharge Date:   [**2172-10-7**]


Service: MEDICINE

Allergies:
Naproxen

Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
brbpr

Major Surgical or Invasive Procedure:
None


History of Present Illness:
HPI: [**Age over 90 **] yo Russian speaking F with CAD, AFib, DM, HTN, CHF, CRI
(Baseline Cr=1.4), anemia, who presents from [**Hospital 100**] rehab with 2
episodes of blood in her stool this am. She was found to have a
supratherapeutic INR (5.9) at [**Hospital 100**] Rehab. She received one
dose of Vit K 5 mg po and was transferred to [**Hospital1 18**] for
evaluation. Per report patient denied lightheadedness,
dizziness, CP, SOB, N/V, belly pain. Initial vitals revealed SBP
in the mid 90's which increased to 110's without intervention,
HR remained in the 60's. NG lavage negative. Hct noted to be
28.0. As per Nursing Home staff pt has been off coumadin for 5
days secondary to elevated INR. She was started on coumadin
after her recent hip surgery. Her INR has been difficult to
control. She has not been on any other new medications recently.

.
In the [**Name (NI) **], pt received an additional 10 mg of SC Vitamin K and 2
units of FFP. She has two large bore IV's. She has not yet
received a blood transfusion.
.


Past Medical History:
PMH:
1. CAD
2. AF
3. CKD (Cr 1.5-1.7)
4. DM
5. h/o UTI
6. Osteoporosis
7. Glaucoma
8. Hyperlipidemia
9. HTN
10. Depression
11. Anemia

Social History:
Nursing Home resident, lives a [**Hospital 100**] Rehab.
Contact is son [**Name (NI) 4186**] ([**Telephone/Fax (1) 107323**] and ([**Telephone/Fax (1) 107324**] (h)


Family History:
Non-contributory

Physical Exam:
Physical Exam:
Tc 97.6    BP 107/66    HR 72    RR  16   Sat 97% RA
Gen:  well appearing elderly female, NAD
HENNT:  MMM, anicteric
Neck:  no LAD, JVD flat, no carotid bruits
CV:  RRR, nl S1S2,  III/VI systolic murmur heard best at apex
Lungs: soft bibasilar crackles
Abd:  soft, NT/ND, +BS, No HSM
Ext:  no edema, strong DP/PT pulses bilaterally, blood filled
flacid blisters on bilateral heals w/o surrounding erythema
Neuro:  Moving all extremeties
.


Pertinent Results:
[**2172-10-3**] 08:08PM   ALT(SGPT)-20 AST(SGOT)-27 LD(LDH)-256* ALK
PHOS-480* TOT BILI-0.7
[**2172-10-3**] 08:08PM   HAPTOGLOB-121
[**2172-10-3**] 08:08PM   HCT-19.6*#
[**2172-10-3**] 06:00PM URINE  BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2172-10-3**] 06:00PM URINE  RBC-[**1-25**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2172-10-3**] 02:22PM   GLUCOSE-134* UREA N-33* CREAT-1.3* SODIUM-140
POTASSIUM-5.4* CHLORIDE-113* TOTAL CO2-16* ANION GAP-16
[**2172-10-3**] 02:22PM   WBC-11.9* RBC-2.98* HGB-9.3* HCT-28.0* MCV-94
MCH-31.2 MCHC-33.2 RDW-15.9*
[**2172-10-3**] 02:22PM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL
[**2172-10-3**] 02:22PM   PT-32.3* PTT-47.7* INR(PT)-7.9

Studies:
CXR [**2172-10-3**]:  hlar fullness, retrocardiac opacity with blunting
of left costophrenic angle.
.
ECG: NSR, rate 64, nl intervals, nl axis, old Q's III, V1-V3, no
new ST-T changes.
.
ECHO [**2-25**]:
1. The left atrium is mildly dilated. The interatrial septum is
aneurysmal.
2. The left ventricular cavity size is normal. There is moderate
global left ventricular hypokinesis. Overall left ventricular
systolic function is moderately depressed.
3. The aortic valve leaflets (3) are mildly thickened. Trace
aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
5. There is mild pulmonary artery systolic hypertension.


Brief Hospital Course:
A/P: [**Age over 90 **] yo Russian speaking F with CAD, AFib on coumadin, DM,
HTN, CHF, CRI (Baseline Cr=1.4), anemia (baseline hct ~30), who
presents from [**Hospital 100**] rehab with episodes of blood in her stool.

.
#  GI bleed: The pt was admitted to the [**Hospital Unit Name 153**]. On admission the
patient had a negative NG lavage in setting of INR of 7.9.  Tthe
etiology was felt to be a LGIB in the setting of a
supratherapeutic INR.  The DDX included diverticulosis, AVM,
malignancy, hemorrhoids. On admission the pt received 15 mg of
Vit K. She was given 2 units of FFP in addition to those given
in the ED for a total of 4 Units and transfused 2 units of
PRBC's. Initially she received q 6 hour hct checks and an IV PPI
[**Hospital1 **]. Her [**Hospital1 **] and Coumdain were held. In the [**Hospital Unit Name 153**], the pt's hct
stabilized. GI was consulted but did not want to do any
intervention because they believed bleed was caused by
supratherapeutic INR. The pt was transfered to the floor as she
was hemodynamically stable, her hct is stable, and her INR
dropped from 7.9 on admit to 0.9. While on the floor the pt
initially reported feeling weak, but on the day of discharge
reported feeling well after 2 days of po.
.
#  Coagulopathy.  The pt presented with an INR of 7.9. The pt
had been off coumadin x5 days, but had been supratherapeutic and
difficult to control on past admission.  She had no new
medications. Her coagulopathy was likely related to malnutrition
and poor control on coumadin. She was given FFP and Vitamin K as
above. Her coumadin was held. Her INR returned as above to 0.9.
Per ortho, she was placed on lovenox 30 mg qd X 4 weeks for
better-controlled anti-coagulation.
.
# CV:
h/o CAD: The pt was placed on a BB and ACE-I, once her preussure
could tolerate them. She wa splaced back on her home statin and
[**Hospital Unit Name **], once her hct was stable.
pump: Pt has a known CHF (EF 30-35%). An ACE-I was added for
afterload reduction. rhythm: h/o PAFIB. The remained in sinus
with well controlled HR. She wa splaced on  anti-coag as above.

.
#  Recent Hip Fracture s/p reduction and fixation: The patient
was kept non wt bearing throughout her admission with PT
follow-up. She was placed on standing tylenol with prn oxycodone
for pain control. Eventually she was weaned off the tylenol with
the prns adequately controlling her pain. Ortho recommended
lovenox out-pt as above.
.
# HTN. Her BP remained well-currently during admission. She was
continued on her out-pt lopressor 25 mg po bid. Her out-pt
amlodipine was d/c'd and lisinopril was added given her known
poor pump fxn and DM.

# DM. Not treated at [**Hospital 100**] Rehab. Her Blood sugars remained
well controlled on this admission without treatment.
.
#  FEN.  The pt was initially made NPO. On discharge she was
tolerating a regular heart healthy/DM diet.
.
#  PPX.  anti-coag discussed above, PPI [**Hospital1 **] (switched to po once
on the floor), bowel regimen
.
#  Code:  DNR/DNI as per NH records
.
#  Communication: Son - [**Name (NI) 4186**] ([**Telephone/Fax (1) 107323**] /([**Telephone/Fax (1) 107324**] (h)

.
.


Medications on Admission:
Home Meds:
1. Amlodipine 10 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Isosorbide Mononitrate 30 mg Sustained Release PO DAILY
4. trazadone 25 mg qhs prn insomnia
5. Mirtazapine 15 mg PO HS
6. Metoprolol Tartrate 100 mg PO BID
7. Lisinopril 5 mg PO DAILY
8. Oxycodone 5 mg PO Q4-6H as needed for pain.
9. Tylenol 975 mg q 6hrs
10. Senna 2 tabs qhs
11. simvastatin 20 mg qhs
12. coumadin d/c'ed 5 days ago
.
All:  Naproxen


Discharge Medications:
1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*15 Tablet(s)* Refills:*0*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. 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*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1)  Subcutaneous
DAILY (Daily) for 4 weeks.
Disp:*qs qs* Refills:*0*


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary Diagnoses:
1.  GI Bleed
2.  Supratherapeutic INR
3.  Congestive Heart Failure

Secondary Diagnoses:
1.  CAD
2.  PAfib
3.  CKD
4.  Diet controlled DM
5.  s/p R hip ORIF
6.  Hypertension
7.  Osteoporosis
8.  Hyperlipidemia


Discharge Condition:
stable, no further episodes of GI bleeding


Discharge Instructions:
Please contact your primary care doctor or 911 should you
develop any abdominal pain, blood in your stools, abdominal
pain, difficulty breathing, chest pain, or any other complaints.

For DVT prophylaxis after her hip surgery, she should begin
taking Lovenox, 30 mg sq qd x 4 weeks.  She does not need
coumadin.

Mrs [**Known lastname 107322**] should have daily weights checked.  If her weight
increases more then 2 lbs, she should begin her outpatient Lasix
dose.

We have changed Ms. [**Known lastname 107327**] cardiac regimen as follows:
1.  We have stopped her Isosorbide and Amlodipine.
2.  We have increased her Lisinopril to 10 mg qd.
3.  Her Metoprolol has been decreased to 50 mg [**Hospital1 **].
4.  We strongly recommend titrating her Lisinopril and
Metoprolol as tolerated for her congestive heart failure.  If
she is still hypertensive on max dose Lisinopril (ie, 40 mg), we
would recommend adding back the amlodipine.
5.  She is a diabetic and has CAD, therefore her Aspirin dose
has been increased to full strength (ie, 325 mg).

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 2637**]





Name:  [**Known lastname 17535**],[**Known firstname 17536**]                  Unit No:   [**Numeric Identifier 17537**]

Admission Date:  [**2172-10-3**]              Discharge Date:   [**2172-10-7**]

Date of Birth:  [**2082-7-10**]             Sex:   F

Service: MEDICINE

Allergies:
Naproxen

Attending:[**First Name3 (LF) 4143**]
Addendum:
Wound care: The pt was noted to have a right heel ulcer. The
ulcer was cleaned and dressed by the wound care service. She
should continue to have daily cleanings and dressing changes on
an out-pt basis.

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 609**] for the Aged - LTC

                             [**Name6 (MD) **] [**Name8 (MD) 4144**] MD [**MD Number(2) 4145**]

Completed by:[**2172-10-7**]
{'Hemorrhage of gastrointestinal tract, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Ulcer of heel and midfoot,Atrial fibrillation,Chronic kidney disease, unspecified,Congestive heart failure, unspecified,Other specified disease of white blood cells,Coronary atherosclerosis of unspecified type of vessel, native or graft,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Osteoporosis, 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: brbpr

PRESENT ILLNESS: HPI: [**Age over 90 **] yo Russian speaking F with CAD, AFib, DM, HTN, CHF, CRI
(Baseline Cr=1.4), anemia, who presents from [**Hospital 100**] rehab with 2
episodes of blood in her stool this am. She was found to have a
supratherapeutic INR (5.9) at [**Hospital 100**] Rehab. She received one
dose of Vit K 5 mg po and was transferred to [**Hospital1 18**] for
evaluation. Per report patient denied lightheadedness,
dizziness, CP, SOB, N/V, belly pain. Initial vitals revealed SBP
in the mid 90's which increased to 110's without intervention,
HR remained in the 60's. NG lavage negative. Hct noted to be
28.0. As per Nursing Home staff pt has been off coumadin for 5
days secondary to elevated INR. She was started on coumadin
after her recent hip surgery. Her INR has been difficult to
control. She has not been on any other new medications recently.

MEDICAL HISTORY: PMH:
1. CAD
2. AF
3. CKD (Cr 1.5-1.7)
4. DM
5. h/o UTI
6. Osteoporosis
7. Glaucoma
8. Hyperlipidemia
9. HTN
10. Depression
11. Anemia

MEDICATION ON ADMISSION: Home Meds:
1. Amlodipine 10 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Isosorbide Mononitrate 30 mg Sustained Release PO DAILY
4. trazadone 25 mg qhs prn insomnia
5. Mirtazapine 15 mg PO HS
6. Metoprolol Tartrate 100 mg PO BID
7. Lisinopril 5 mg PO DAILY
8. Oxycodone 5 mg PO Q4-6H as needed for pain.
9. Tylenol 975 mg q 6hrs
10. Senna 2 tabs qhs
11. simvastatin 20 mg qhs
12. coumadin d/c'ed 5 days ago
.
All:  Naproxen

ALLERGIES: Naproxen

PHYSICAL EXAM: Physical Exam:
Tc 97.6    BP 107/66    HR 72    RR  16   Sat 97% RA
Gen:  well appearing elderly female, NAD
HENNT:  MMM, anicteric
Neck:  no LAD, JVD flat, no carotid bruits
CV:  RRR, nl S1S2,  III/VI systolic murmur heard best at apex
Lungs: soft bibasilar crackles
Abd:  soft, NT/ND, +BS, No HSM
Ext:  no edema, strong DP/PT pulses bilaterally, blood filled
flacid blisters on bilateral heals w/o surrounding erythema
Neuro:  Moving all extremeties
.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Nursing Home resident, lives a [**Hospital 100**] Rehab.
Contact is son [**Name (NI) 4186**] ([**Telephone/Fax (1) 107323**] and ([**Telephone/Fax (1) 107324**] (h) 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Ulcer of heel and midfoot,Atrial fibrillation,Chronic kidney disease, unspecified,Congestive heart failure, unspecified,Other specified disease of white blood cells,Coronary atherosclerosis of unspecified type of vessel, native or graft,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Osteoporosis, unspecified,Other and unspecified hyperlipidemia'}
