CHIEF COMPLAINT: Hematemesis and fevers

PRESENT ILLNESS: 67 yo M with history of COPD, CVA with residual left sided
weakness, history of aspiration, hypertension. Was admitted to
the MICU due to concerns for upper GI bleed, fevers, and
hypotension. Patient was at his [**Hospital3 **] facility when
discovered to have temp of 102 and was vomiting "blood and
coffee grounds". Patient reports multiple sick contacts in his
nursing home. Could not be more specific. He corraborates ED and
EMT story of coffee ground emesis; however, cannot further
elaborate. Denies current nausea or abdominal pain and denies
seeing blood in his stool.
.
Upon arrival to the ED, patient's vitals were T 100.8, BP
106/60, HR 70, RR 18, O2sat 91% RA. Received total of 2 L NS due
to blood pressures transiently to 90s systolic on several
occasions. Pressures were minimally fluid responsive and
systolics were never above 110. Had one rectal temp of 103 in
ED. Was given Vancomycin and Zosyn in ED due to question of
pneumonia. Blood cultures were sent prior to initiation of
anitbiotics. Had UA sent, which was positive by dipstick, no
culture was sent. Also received ondansetron and pantoprazole.
Stools were noted to be dark brown and guaiac positive. NG
lavage in the ED with small coffee ground specs, but otherwise
clear. Type and screen was sent, two 18G IVs were placed. GI was
made aware of the patient; however, did not officially consult
in the ED.
.
ROS:
(+)ve: coffee ground emesis, cough, fevers
(-)ve: chest pain, dyspnea, orthopnea, hematochezia, abdominal
pain, nausea, sputum production, constipation, diarrhea

MEDICAL HISTORY: COPD
HTN
CVA with residual left sided weakness
Dysphagia and aspiration pneumonitis
h/o ETOH abuse

MEDICATION ON ADMISSION: 1. Aspirin 325 mg daily
2. Multivitamin daily
3. Folic Acid 1 mg daily
5. Mirtazapine 45 mg at bedtime
6. Calcium Carbonate 500 mg chewable twice daily
7. Cholecalciferol 400 unit tab, two daily
8. Alendronate 70 mg PO every Tuesday
9. Docusate Sodium 100 mg twice daily
10. Simvastatin 10 mg daily
11. Psyllium one packet daily

ALLERGIES: Shellfish

PHYSICAL EXAM: VS: T 98.7, BP 99/40, HR 61, RR 18, O2sat 95% 2L NC
GEN: NAD
HEENT: PERRL, EOMI, oral mucosa moist
NECK: Supple, no LAD, JVP at ~8 cm
PULM: Inpiratory squeaks bilaterally anterior, decreased breath
sounds throughout
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS hyperactive, soft, non-tender, non-distended, no
organomegaly
EXT: No C/C/E
NEURO: Oriented to "hospital", date, year, current president
SKIN: stage I on sacrum - skin is erythematous, boggy, no area
of ulceration noted.

FAMILY HISTORY: Reviewed and non-contributory

SOCIAL HISTORY: Pt is a resident at [**Hospital3 2558**] nursing home. He is a former
heavy smoker, prior alcoholic who has been abstinent for 5 yrs.
Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Other vascular complications of medical care, not elsewhere classified,Hemorrhage of gastrointestinal tract, unspecified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Sepsis,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Pressure ulcer, buttock,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Diaphragmatic hernia without mention of obstruction or gangrene,Dysphagia, oropharyngeal phase,Retention of urine, unspecified
Septicemia NOS,Food/vomit pneumonitis,Urin tract infection NOS,Vasc comp med care NEC,Gastrointest hemorr NOS,Late ef-hemplga side NOS,Sepsis,Phlbts sprfc vn up extrm,Abn react-procedure NEC,Pressure ulcer, buttock,Chr airway obstruct NEC,Hypertension NOS,Diaphragmatic hernia,Dysphagia, oropharyngeal,Retention urine NOS
Admission Date:  [**2165-3-7**]              Discharge Date:   [**2165-3-12**]

Date of Birth:  [**2098-1-30**]             Sex:   M

Service: MEDICINE

Allergies:
Shellfish

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hematemesis and fevers

Major Surgical or Invasive Procedure:
none


History of Present Illness:
67 yo M with history of COPD, CVA with residual left sided
weakness, history of aspiration, hypertension. Was admitted to
the MICU due to concerns for upper GI bleed, fevers, and
hypotension. Patient was at his [**Hospital3 **] facility when
discovered to have temp of 102 and was vomiting "blood and
coffee grounds". Patient reports multiple sick contacts in his
nursing home. Could not be more specific. He corraborates ED and
EMT story of coffee ground emesis; however, cannot further
elaborate. Denies current nausea or abdominal pain and denies
seeing blood in his stool.
.
Upon arrival to the ED, patient's vitals were T 100.8, BP
106/60, HR 70, RR 18, O2sat 91% RA. Received total of 2 L NS due
to blood pressures transiently to 90s systolic on several
occasions. Pressures were minimally fluid responsive and
systolics were never above 110. Had one rectal temp of 103 in
ED. Was given Vancomycin and Zosyn in ED due to question of
pneumonia. Blood cultures were sent prior to initiation of
anitbiotics. Had UA sent, which was positive by dipstick, no
culture was sent. Also received ondansetron and pantoprazole.
Stools were noted to be dark brown and guaiac positive. NG
lavage in the ED with small coffee ground specs, but otherwise
clear. Type and screen was sent, two 18G IVs were placed. GI was
made aware of the patient; however, did not officially consult
in the ED.
.
ROS:
(+)ve: coffee ground emesis, cough, fevers
(-)ve: chest pain, dyspnea, orthopnea, hematochezia, abdominal
pain, nausea, sputum production, constipation, diarrhea


Past Medical History:
COPD
HTN
CVA with residual left sided weakness
Dysphagia and aspiration pneumonitis
h/o ETOH abuse

Social History:
Pt is a resident at [**Hospital3 2558**] nursing home. He is a former
heavy smoker, prior alcoholic who has been abstinent for 5 yrs.


Family History:
Reviewed and non-contributory

Physical Exam:
VS: T 98.7, BP 99/40, HR 61, RR 18, O2sat 95% 2L NC
GEN: NAD
HEENT: PERRL, EOMI, oral mucosa moist
NECK: Supple, no LAD, JVP at ~8 cm
PULM: Inpiratory squeaks bilaterally anterior, decreased breath
sounds throughout
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS hyperactive, soft, non-tender, non-distended, no
organomegaly
EXT: No C/C/E
NEURO: Oriented to "hospital", date, year, current president
SKIN: stage I on sacrum - skin is erythematous, boggy, no area
of ulceration noted.


Pertinent Results:
[**2165-3-7**] 07:51PM   HCT-30.5*
[**2165-3-7**] 12:37PM   LACTATE-1.3
[**2165-3-7**] 12:17PM   HCT-31.6*
[**2165-3-7**] 07:59AM   LACTATE-1.3
[**2165-3-7**] 05:00AM   GLUCOSE-87 UREA N-20 CREAT-0.8 SODIUM-135
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-19* ANION GAP-14
[**2165-3-7**] 05:00AM   CALCIUM-7.6* PHOSPHATE-3.5 MAGNESIUM-2.0
[**2165-3-7**] 05:00AM   WBC-10.1 RBC-3.70* HGB-10.5* HCT-32.8* MCV-89
MCH-28.4 MCHC-32.0 RDW-13.2
[**2165-3-7**] 05:00AM   NEUTS-76.5* LYMPHS-18.9 MONOS-4.2 EOS-0.2
BASOS-0.2
[**2165-3-7**] 05:00AM   PLT COUNT-246
[**2165-3-7**] 05:00AM   PT-14.1* PTT-28.2 INR(PT)-1.2*
[**2165-3-7**] 12:55AM URINE  HOURS-RANDOM
[**2165-3-7**] 12:55AM URINE  GR HOLD-HOLD
[**2165-3-7**] 12:30AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2165-3-7**] 12:30AM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM
[**2165-3-7**] 12:30AM URINE  RBC-[**5-1**]* WBC-[**10-11**]* BACTERIA-OCC
YEAST-NONE EPI-0
[**2165-3-6**] 10:28PM   LACTATE-1.0
[**2165-3-6**] 09:20PM   GLUCOSE-112* UREA N-31* CREAT-1.0 SODIUM-133
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-22 ANION GAP-14
[**2165-3-6**] 09:20PM   estGFR-Using this
[**2165-3-6**] 09:20PM   ALT(SGPT)-15 AST(SGOT)-18 CK(CPK)-27* ALK
PHOS-66 TOT BILI-0.3
[**2165-3-6**] 09:20PM   LIPASE-27
[**2165-3-6**] 09:20PM   cTropnT-<0.01
[**2165-3-6**] 09:20PM   CK-MB-NotDone
[**2165-3-6**] 09:20PM   ALBUMIN-3.4 CALCIUM-8.7 PHOSPHATE-3.5
MAGNESIUM-2.0
[**2165-3-6**] 09:20PM   ACETONE-NEGATIVE OSMOLAL-289
[**2165-3-6**] 09:20PM   WBC-13.4*# RBC-3.88* HGB-11.3* HCT-33.7*
MCV-87 MCH-29.2 MCHC-33.6 RDW-13.2
[**2165-3-6**] 09:20PM   NEUTS-86.7* LYMPHS-9.2* MONOS-4.0 EOS-0
BASOS-0.1
[**2165-3-6**] 09:20PM   PLT COUNT-285
[**2165-3-6**] 09:20PM   PT-13.9* PTT-24.8 INR(PT)-1.2*
[**2165-3-6**] 09:20PM   SED RATE-43*

Imaging:
CXR [**3-6**]:
IMPRESSION:
1. Limited evaluation with suggestion of new right mid lung
opacity.
Recommend dedicated PA and lateral radiographs for further
evaluation when
clinically feasible.
2. No pneumoperitoneum.
.
CT abd/pelvis [**3-6**]:
IMPRESSION:
1. Peribronchial cuffing with airspace opacification proximally
suggests a
pneumonitis that may be infectious or secondary to aspiration.
Age-
indeterminate given lack of prior.
2. Simple cyst in the left lower renal pole.
3. Small axial hiatal hernia.
4. Atherosclerosis of the SMA origin.
5. No intra-abdominal abscess. No diverticulitis.
6. Likely dilatation of the thoracic ascending aorta for which
further
imaging is needed.
.
Radiology Report CHEST (PA & LAT) Study Date of [**2165-3-9**] 1:31 PM

Impression:
Continue improvement with almost complete resolution of right
upper lobe
opacity. Opacities in the lower lobes medially are unchanged,
likely
atelectasis. There is no pneumothorax or enlarging pleural
effusions. If
any, there is a small left pleural effusion. Moderate
degenerative changes
are in the thoracic spine.
.
[**2165-3-12**] EGD:
Impression: Medium hiatal hernia
Slightly tortuous esophagus no rings or strictures.
No lesions, no old or fresh blood in stomach
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow-up with referring physician as needed
Observe in hospital setting
.


Brief Hospital Course:
Assessment and Plan
67 yo M with history of COPD, CVA with residual left sided
weakness, history of aspiration, hypertension. Was admitted to
the MICU due to concerns for upper GI bleed, fevers, and
hypotension.

# Fevers / Leukocytosis:
Pulmonary source thought initially to be most likely given that
patient had CXR opacity in RUL and new cough. Lactate at
presentation was 1.0. Patient thought to have had an aspiration
pneumonia as he already has a history of this. Legionella was
negative, levofloxacin which was initially started was then
discontinued once legionella negative. UA in the ED was positive
for bacteria, WBCs, and leuk est however UCx not sent before
antibiotics started. Patient treated with zosyn and vancomycin
for presumed UTI and PNA. Decreased to zosyn on floor. Patient
had 1x fever to 101 rectally while on floor on zosyn which
corresponded to R PIV site being red, warm, painful. After R arm
PIV pulled, he had no further fever, R arm no longer red - this
1x fever likely due to thrombophlebitis. Abx changed to PO cipro
on [**3-12**]. Foley d/c for infection risk.
.
# Hypotension:
Likely initially sepsis physiology given fever, elevated WBC.
Fluid responsive. Unlikely cardiac etiology. Patient with
unchanged EKG in the ED from baseline and no complaints of chest
pain. Cardiac enzymes were negative. Patient with several
episodes of asymptomatic hypotension at night with SBPs in high
80s which resolved w/waking patient, and were fluid responsive
(when fluids given). Patient not tachycardic during these
episodes.
.
# GI bleed:
Both coffee ground emesis and guaiac, but no grossly positive
stools point to upper GI bleed. HCT at presentation was 33.7 and
his baseline appears to be mid to upper 30s by review of medical
record. Patient with history of gastritis diagnosed on [**2160**] EGD.
Has recently been discontinued from ranitidine.  He was
restarted on protonix [**Hospital1 **] through his hospital course. Evaluated
for GI. EGD negative for gastritis, PUD. Should have outpatient
colonoscopy in future.
.
# Nutrition: As per S&S recommendations; Continue baseline diet
of nectar thick liquids and ground solids, pills crushed with
puree, swallow with chin tucked to chest, 1:1 supervision during
meals
.
# Sacral decub: a small area of erythema and boggy skin was
noted on the patient's sacrum upon presentation. We treated the
area with barrier cream and frequent turns while the patient was
here. This regimen will need to be continued when the patient is
at his [**Hospital1 1501**] to prevent further deterioration of the skin in this
area.
.
# Prophylaxis: Heparin subcutaneous
.
# Code status: FULL - d/w patient.

Medications on Admission:
1. Aspirin 325 mg daily
2. Multivitamin daily
3. Folic Acid 1 mg daily
5. Mirtazapine 45 mg at bedtime
6. Calcium Carbonate 500 mg chewable twice daily
7. Cholecalciferol 400 unit tab, two daily
8. Alendronate 70 mg PO every Tuesday
9. Docusate Sodium 100 mg twice daily
10. Simvastatin 10 mg daily
11. Psyllium one packet daily

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
urinary tract infection
superficial thrombophlebitis


Discharge Condition:
vital signs stable, tolerating PO.


Discharge Instructions:
You were admitted for fever and low blood pressure. We think
this was likely due to a urinary tract infection which we
treated with antibiotics and your fever improved. It is also
possible that you had a small amount of aspiration into your
lungs. Please be sure to adhere to the diet restrictions made by
our speach and swallow team when you return to your nursing
facility.
.
We removed your foley catheter because of your urinary tract
infection. Please try to avoid using a catheter in the future
because of the increased risk of infection that it provides.
.
While you were in the hospital you were noted to have a red area
on your sacrum which can signal the start of a pressure ulcer.
We treated it with barrier cream and frequent turning. Please be
sure to stay as active as possible and get out of bed as much as
you can. When you are in bed, you need to be sure to turn
frequently so that you do not further develop ulcers on your
back or bottom.
.
Please return to the ED if you develop any of the following
symptoms: high fever, shortness of breath, chest pain, diarrhea
or vomiting such that you cannot keep down food or your
medicines.

Followup Instructions:
Please have your nursing home help you to contact your primary
care provider, [**Name10 (NameIs) **] [**Last Name (STitle) 4321**], to determine when you will need to
follow up with her.
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Other vascular complications of medical care, not elsewhere classified,Hemorrhage of gastrointestinal tract, unspecified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Sepsis,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Pressure ulcer, buttock,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Diaphragmatic hernia without mention of obstruction or gangrene,Dysphagia, oropharyngeal phase,Retention of urine, unspecified'}


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: Hematemesis and fevers

PRESENT ILLNESS: 67 yo M with history of COPD, CVA with residual left sided
weakness, history of aspiration, hypertension. Was admitted to
the MICU due to concerns for upper GI bleed, fevers, and
hypotension. Patient was at his [**Hospital3 **] facility when
discovered to have temp of 102 and was vomiting "blood and
coffee grounds". Patient reports multiple sick contacts in his
nursing home. Could not be more specific. He corraborates ED and
EMT story of coffee ground emesis; however, cannot further
elaborate. Denies current nausea or abdominal pain and denies
seeing blood in his stool.
.
Upon arrival to the ED, patient's vitals were T 100.8, BP
106/60, HR 70, RR 18, O2sat 91% RA. Received total of 2 L NS due
to blood pressures transiently to 90s systolic on several
occasions. Pressures were minimally fluid responsive and
systolics were never above 110. Had one rectal temp of 103 in
ED. Was given Vancomycin and Zosyn in ED due to question of
pneumonia. Blood cultures were sent prior to initiation of
anitbiotics. Had UA sent, which was positive by dipstick, no
culture was sent. Also received ondansetron and pantoprazole.
Stools were noted to be dark brown and guaiac positive. NG
lavage in the ED with small coffee ground specs, but otherwise
clear. Type and screen was sent, two 18G IVs were placed. GI was
made aware of the patient; however, did not officially consult
in the ED.
.
ROS:
(+)ve: coffee ground emesis, cough, fevers
(-)ve: chest pain, dyspnea, orthopnea, hematochezia, abdominal
pain, nausea, sputum production, constipation, diarrhea

MEDICAL HISTORY: COPD
HTN
CVA with residual left sided weakness
Dysphagia and aspiration pneumonitis
h/o ETOH abuse

MEDICATION ON ADMISSION: 1. Aspirin 325 mg daily
2. Multivitamin daily
3. Folic Acid 1 mg daily
5. Mirtazapine 45 mg at bedtime
6. Calcium Carbonate 500 mg chewable twice daily
7. Cholecalciferol 400 unit tab, two daily
8. Alendronate 70 mg PO every Tuesday
9. Docusate Sodium 100 mg twice daily
10. Simvastatin 10 mg daily
11. Psyllium one packet daily

ALLERGIES: Shellfish

PHYSICAL EXAM: VS: T 98.7, BP 99/40, HR 61, RR 18, O2sat 95% 2L NC
GEN: NAD
HEENT: PERRL, EOMI, oral mucosa moist
NECK: Supple, no LAD, JVP at ~8 cm
PULM: Inpiratory squeaks bilaterally anterior, decreased breath
sounds throughout
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS hyperactive, soft, non-tender, non-distended, no
organomegaly
EXT: No C/C/E
NEURO: Oriented to "hospital", date, year, current president
SKIN: stage I on sacrum - skin is erythematous, boggy, no area
of ulceration noted.

FAMILY HISTORY: Reviewed and non-contributory

SOCIAL HISTORY: Pt is a resident at [**Hospital3 2558**] nursing home. He is a former
heavy smoker, prior alcoholic who has been abstinent for 5 yrs. 

### Response:
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Other vascular complications of medical care, not elsewhere classified,Hemorrhage of gastrointestinal tract, unspecified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Sepsis,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Pressure ulcer, buttock,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Diaphragmatic hernia without mention of obstruction or gangrene,Dysphagia, oropharyngeal phase,Retention of urine, unspecified'}
