CHIEF COMPLAINT: BRBPR

PRESENT ILLNESS: Patient is a 83yo woman who was transferred from [**Hospital1 **] with 3
days of BRBPR found in her diaper. She has a medical history of
breast cancer s/p mastectomy, radiation, tamoxifen who had LN
recurrance 2 years ago treated initially with chemo and then
with radiation. More recently (6 weeks ago) she had a cerebellar
ICH/CVA, coag negative bacteremia and presumed endocarditis (on
vanco via PICC line) and c. diff colitis (with WBC max of 42,000
on [**5-26**] requiring flagyl + po vanco and associated with LGIB)
and a left superficial thrombosis associate with her PICC.
.
She was first noted to have blood clots mixed with her stool on
[**6-9**] and which worsened over the next 3 days. She was transfused
2U pRBC on [**6-6**] and [**6-10**].
.
In the ED her vs were stable; 99.2, HR in 80-90's, systolics in
120's, O2sat 90's on RA. Her physical exam showed her to be
alert and would open eyes to command (unclear baseline), benign
abdomin, bright red blood in diaper, rectal not done. NG tube
was already in place from [**Hospital1 **] (but above the diaphragm).
Reportedly an aspiration showed gastric contents without blood.
Hct was 27.2 and plts 54. She was transfused plts. CXR showed NG
tube mal-placement.
.
Surgery was made aware. GI was consulted and plans to see
patient on floor.
.
Unable to obtain ROS. [**Name (NI) **] son/HCP reports that since her
strokes 6 weeks ago that she is slow to respond, difficult to
wake up, but will respond with opening her eyes/shaking her head
and speaking, although her speach is difficult to understand. He
reports that her memory of people's identity is good, but she is
not oriented to place or time

MEDICAL HISTORY: left proximal brachial thrombosis secondary to PICC line ([**5-30**])

MEDICATION ON ADMISSION: 1. Fluconazole
2. Furosemide
3. Iron supplement
4. Methylphenidate
5. Vanco 1g QD

ALLERGIES: Caffeine / Heparin Agents

PHYSICAL EXAM: PE:
VS: 99.2F HR 89 BP 154/81 100% RA
General: Elderly woman in NAD, alert, minimally responsive
HEENT: PERRL 2 to 2.5, OP with dry mucous membranes, dried
mucous, poor dentition.
Neck: attempted EJ site,
Chest: CTAB, right mastectomy scar, left porta cath removal site
with bleeding and yellow not foul smelling discharge with no
erythema/swelling.
Cardiac: distant, rrr no m/r/g
Abd: +BS, soft, no guarding, no rebound, diffusely tender
Ext: 2+ pulses, cool extremities
Skin: stage I on coccyx, no petchiae
Neuro: Alert, arousable, not oriented to place, date, age is
"too old", moving all 4 and responds to commands in right arm,
feet bilaterally, toes mute bilaterally.

FAMILY HISTORY: No history of strokes. Sister and mother with HTN.

SOCIAL HISTORY: Recent rehab resident, prior to CVA lived at home with cat.  Son
[**Name (NI) **] involved in care. No smoking. EtOH socially.
Hemorrhage of gastrointestinal tract, unspecified,Pneumonia, organism unspecified,Intracerebral hemorrhage,Secondary malignant neoplasm of bone and bone marrow,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Acute and subacute bacterial endocarditis,Bacteremia,Hypopotassemia,Personal history of irradiation, presenting hazards to health,Personal history of malignant neoplasm of breast,Anticoagulants causing adverse effects in therapeutic use,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Acute posthemorrhagic anemia
Gastrointest hemorr NOS,Pneumonia, organism NOS,Intracerebral hemorrhage,Secondary malig neo bone,Urin tract infection NOS,Int inf clstrdium dfcile,Ac/subac bact endocard,Bacteremia,Hypopotassemia,Hx of irradiation,Hx of breast malignancy,Adv eff anticoagulants,Other staphylococcus,Ac posthemorrhag anemia
Admission Date:  [**2111-6-11**]              Discharge Date:   [**2111-7-1**]


Service: MEDICINE

Allergies:
Caffeine / Heparin Agents

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
BRBPR

Major Surgical or Invasive Procedure:
PICC line placed and removed
?EGD

History of Present Illness:
Patient is a 83yo woman who was transferred from [**Hospital1 **] with 3
days of BRBPR found in her diaper. She has a medical history of
breast cancer s/p mastectomy, radiation, tamoxifen who had LN
recurrance 2 years ago treated initially with chemo and then
with radiation. More recently (6 weeks ago) she had a cerebellar
ICH/CVA, coag negative bacteremia and presumed endocarditis (on
vanco via PICC line) and c. diff colitis (with WBC max of 42,000
on [**5-26**] requiring flagyl + po vanco and associated with LGIB)
and a left superficial thrombosis associate with her PICC.
.
She was first noted to have blood clots mixed with her stool on
[**6-9**] and which worsened over the next 3 days. She was transfused
2U pRBC on [**6-6**] and [**6-10**].
.
In the ED her vs were stable; 99.2, HR in 80-90's, systolics in
120's, O2sat 90's on RA. Her physical exam showed her to be
alert and would open eyes to command (unclear baseline), benign
abdomin, bright red blood in diaper, rectal not done. NG tube
was already in place from [**Hospital1 **] (but above the diaphragm).
Reportedly an aspiration showed gastric contents without blood.
Hct was 27.2 and plts 54. She was transfused plts. CXR showed NG
tube mal-placement.
.
Surgery was made aware. GI was consulted and plans to see
patient on floor.
.
Unable to obtain ROS. [**Name (NI) **] son/HCP reports that since her
strokes 6 weeks ago that she is slow to respond, difficult to
wake up, but will respond with opening her eyes/shaking her head
and speaking, although her speach is difficult to understand. He
reports that her memory of people's identity is good, but she is
not oriented to place or time


Past Medical History:
left proximal brachial thrombosis secondary to PICC line ([**5-30**])

-Coagulase Neg Staph Bacteremia/Port removal in [**2111-5-23**] with
presumed endocarditis and planned 6wk abx treatment
-c.diff colitis tested positive [**5-23**] and started on flagyl with
addition of vanco. CT abd showed colitis of descending/sigmoid
colon
-? LGIB in past
-Breast CA s/p mastectomy and chemo. Right mastectomy 6 yrs
ago, followed by chemo and tamoxifen. She had recurrence in LNs
and
was treated with 16 months chemo ~1 yr ago. She was off for
several months, then got new LNs, so started XRT and got 37
treatments which finished in [**2111-3-8**]. She also gets frequent

PRBCs. Onc is Dr [**Last Name (STitle) 6099**] at N-W (part of Farber)
-h/o possible seizure in [**2108**] (MRI at that time with age related

change only by report)
-GERD
-Anemia
-? gall stones (h/o elevated LFTs)
- HIT Ab positivity


Social History:
Recent rehab resident, prior to CVA lived at home with cat.  Son
[**Name (NI) **] involved in care. No smoking. EtOH socially.


Family History:
No history of strokes. Sister and mother with HTN.

Physical Exam:
PE:
VS: 99.2F HR 89 BP 154/81 100% RA
General: Elderly woman in NAD, alert, minimally responsive
HEENT: PERRL 2 to 2.5, OP with dry mucous membranes, dried
mucous, poor dentition.
Neck: attempted EJ site,
Chest: CTAB, right mastectomy scar, left porta cath removal site
with bleeding and yellow not foul smelling discharge with no
erythema/swelling.
Cardiac: distant, rrr no m/r/g
Abd: +BS, soft, no guarding, no rebound, diffusely tender
Ext: 2+ pulses, cool extremities
Skin: stage I on coccyx, no petchiae
Neuro: Alert, arousable, not oriented to place, date, age is
"too old", moving all 4 and responds to commands in right arm,
feet bilaterally, toes mute bilaterally.


Pertinent Results:
[**2111-6-11**] 09:01PM   GLUCOSE-84 UREA N-53* CREAT-0.8 SODIUM-141
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-26 ANION GAP-10
[**2111-6-11**] 09:01PM   CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-2.3
[**2111-6-11**] 09:01PM   PT-14.2* PTT-32.2 INR(PT)-1.3*
[**2111-6-11**] 07:05PM   WBC-14.9* RBC-2.63* HGB-8.9* HCT-25.0* MCV-95
MCH-34.0* MCHC-35.7* RDW-22.7*
[**2111-6-11**] 07:05PM   PLT COUNT-122*#
[**2111-6-11**] 02:20PM URINE  HOURS-RANDOM
[**2111-6-11**] 02:20PM URINE  GR HOLD-HOLD
[**2111-6-11**] 02:20PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2111-6-11**] 02:20PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2111-6-11**] 02:20PM URINE  RBC-[**2-9**]* WBC-[**5-17**]* BACTERIA-MOD
YEAST-MANY EPI-0
[**2111-6-11**] 02:20PM URINE  GRANULAR-0-2
[**2111-6-11**] 01:50PM   GLUCOSE-96 UREA N-59* CREAT-0.8 SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-27 ANION GAP-11
[**2111-6-11**] 01:50PM   estGFR-Using this
[**2111-6-11**] 01:50PM   CK(CPK)-51
[**2111-6-11**] 01:50PM   cTropnT-0.19*
[**2111-6-11**] 01:50PM   CK-MB-NotDone
[**2111-6-11**] 01:50PM   WBC-12.4*# RBC-2.77* HGB-9.2* HCT-27.2*
MCV-98 MCH-33.2* MCHC-33.8 RDW-22.5*
[**2111-6-11**] 01:50PM   NEUTS-88* BANDS-0 LYMPHS-1* MONOS-7 EOS-0
BASOS-0 ATYPS-1* METAS-3* MYELOS-0
[**2111-6-11**] 01:50PM   PLT COUNT-54*#
[**2111-6-11**] 01:50PM   PT-13.4* PTT-33.6 INR(PT)-1.2*

Brief Hospital Course:
In the MICU, pt was found to be HIT positive and was taken off
all heparin products. She required numerous transfusions of
PRBCs but her VS never showed changes indicating HD compromise.
Rather, her transfusion requirements were similar to those she
experienced as an outpatient. Abd CT showed an enlarging splenic
infarct.
Her mental status slowly improved over the course of her MICU
course such that she was responsive and more alert upon call out
to the floor but still only A and O x1.1
_______________________________

#Lower GI Bleed - Patient was initially admitted for the
hospital for passing blood clots mixed with stool.  She
initially required multiple units of PRBCs.  EGD done while in
the unit was unrevealing for a source of bleeding.  Initially
colonoscopy was deferred because it was thought to be of limited
utility and benefit.  While on the floor, the patient's HCT was
initially stable.  She was continued on IV flagyl for her CDiff
colitis, which was thought to be a possible source of her
bleeding.  Her HCT started trending down and there was noted to
be a few clots and some blood mixed with the stool.  She was
again transfused 2 units PRBCs.  GI was again consulted and they
decided to perform a colonoscopy to attempt to identify a source
of continued bleeding.  Colonoscopy only showed multiple
diverticuli and internal hemorrhoids, both of which were thought
to be possible sources of her GI bleeding.
.
#Recent CVA and Intracranial hemorrhage - Before this admission,
the patient had a history of multiple embolic strokes as well as
an acute intracranial hemorrhage.  After initial discharge from
the MICU, there was a question of possible anticoagulation in
this patient because of concern for HIT.  A repeat MRI was
performed which showed an interval increase in embolic
phenomenom as well as a subacute on chronic hemorrhage.  Repeat
echo was performed to evaluate embolic strokes.  Again, no
vegitations were seen on the cardiac valves and no PFO was seen.
.
#Thrombocytopenia - There was an initial concern for HIT in this
patient.  Hematology was consulted to help with assessment for
the diagnosis and determination if anticoagulation is needed.
With regard to the diagnosis of HIT, it is unlikely that she has
this.  Her thrombocytopenia has been going throughout her
inpatient stay at both the [**Hospital1 18**] and [**Hospital1 **] hospitals.  In
addition, there are many confounding factors for this finding,
including consecutive infections and polypharmacy (vancomycin,
ciprofloxacin).  Furthermore, her optical density value is 0.45
and the cut-off for a positive test result is 0.40.
Publications support an optical density of 1.0 better for the
diagnosis of HIT.  For these
reasons, the heme service did not believe that she had HIT and
thus argatroban was not indicated.
.
#Coag Neg Staff Endocarditis - On past admission, the patient
had 4/4 bottles positive for coag neg staff.  TTE at the time
was negative for vegitations.  She is being treated with a 6
week course of Vancomycin.  Repeat Echo done on current
admission still did not show any vegitations.
.
#Breast Cancer - She is followed by Dr. [**Last Name (STitle) 6099**] at [**Hospital3 328**] NW.
 On this admission, a new area of destruction of cortex of the
medial portion of the left
ilium was seen on CT Abd.  There was a concern for possible
metastatic lesions from her breast cancer verses metastatic
lesions from another unknown primary source.  Options for
further work up were discussed with Dr. [**Last Name (STitle) 6099**].  These were
presented to the patient's son.  [**Name (NI) **] son relayed that his mother
would not want any further treatment including both chemo or
radiation.  Based on this desire, it was decided that no further
work up of this lesion was warrented as the patient would not
want treatment.
.
#FEN - The patient has been maintained on a NG feeding tube for
most of her hospital stay.  A swallow study completed showed
that she would be able to safely tolerate ground food and thin
liquids.  Tube feeds were stopped and the patient was encouraged
to eat.  It was very difficult for the patient to sucessfully
take in PO, either because of neurological dysfunction or a lack
of desire.  The option of PEG placement was discussed with the
family.
_____________
After discussion with the patients son who is her health care
proxy, it was decided to make the patient comfort care only.
All of her antibiotics and other medications not related to
comfort were discountinued.  She will be discharged with oral
morphine for comfort.  She is being discharged to a hospice
facility for further care.


Medications on Admission:
1. Fluconazole
2. Furosemide
3. Iron supplement
4. Methylphenidate
5. Vanco 1g QD


Discharge Medications:
1. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-5 mg PO Q2H
(every 2 hours) as needed for discomfort.
Disp:*QS 1MTH * Refills:*0*
3. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual Q4HR PRN () as needed for
secretions.
Disp:*QS 1MTH Tablet, Sublingual(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Last Name (un) 14710**] House (Hospice Home) - [**Location (un) 620**]

Discharge Diagnosis:
Lower GI Bleed
Intracranial hemorrhage
Endocarditis
CDiff Colitis
Pneumonia
Deep Vein Thrombosis


Discharge Condition:
Patient is comfort care only and will be discharged to hospice
for further care.


Discharge Instructions:
Patient was treated in house for multiple medical problems.
After discussion with son who is patients health care proxy, it
was decided to make her comfort care only.  She will be
discharged to hospice.

Followup Instructions:
Patient will be discharged to hospice care facility.



Completed by:[**2111-7-1**]
{'Hemorrhage of gastrointestinal tract, unspecified,Pneumonia, organism unspecified,Intracerebral hemorrhage,Secondary malignant neoplasm of bone and bone marrow,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Acute and subacute bacterial endocarditis,Bacteremia,Hypopotassemia,Personal history of irradiation, presenting hazards to health,Personal history of malignant neoplasm of breast,Anticoagulants causing adverse effects in therapeutic use,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Acute posthemorrhagic anemia'}


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: Patient is a 83yo woman who was transferred from [**Hospital1 **] with 3
days of BRBPR found in her diaper. She has a medical history of
breast cancer s/p mastectomy, radiation, tamoxifen who had LN
recurrance 2 years ago treated initially with chemo and then
with radiation. More recently (6 weeks ago) she had a cerebellar
ICH/CVA, coag negative bacteremia and presumed endocarditis (on
vanco via PICC line) and c. diff colitis (with WBC max of 42,000
on [**5-26**] requiring flagyl + po vanco and associated with LGIB)
and a left superficial thrombosis associate with her PICC.
.
She was first noted to have blood clots mixed with her stool on
[**6-9**] and which worsened over the next 3 days. She was transfused
2U pRBC on [**6-6**] and [**6-10**].
.
In the ED her vs were stable; 99.2, HR in 80-90's, systolics in
120's, O2sat 90's on RA. Her physical exam showed her to be
alert and would open eyes to command (unclear baseline), benign
abdomin, bright red blood in diaper, rectal not done. NG tube
was already in place from [**Hospital1 **] (but above the diaphragm).
Reportedly an aspiration showed gastric contents without blood.
Hct was 27.2 and plts 54. She was transfused plts. CXR showed NG
tube mal-placement.
.
Surgery was made aware. GI was consulted and plans to see
patient on floor.
.
Unable to obtain ROS. [**Name (NI) **] son/HCP reports that since her
strokes 6 weeks ago that she is slow to respond, difficult to
wake up, but will respond with opening her eyes/shaking her head
and speaking, although her speach is difficult to understand. He
reports that her memory of people's identity is good, but she is
not oriented to place or time

MEDICAL HISTORY: left proximal brachial thrombosis secondary to PICC line ([**5-30**])

MEDICATION ON ADMISSION: 1. Fluconazole
2. Furosemide
3. Iron supplement
4. Methylphenidate
5. Vanco 1g QD

ALLERGIES: Caffeine / Heparin Agents

PHYSICAL EXAM: PE:
VS: 99.2F HR 89 BP 154/81 100% RA
General: Elderly woman in NAD, alert, minimally responsive
HEENT: PERRL 2 to 2.5, OP with dry mucous membranes, dried
mucous, poor dentition.
Neck: attempted EJ site,
Chest: CTAB, right mastectomy scar, left porta cath removal site
with bleeding and yellow not foul smelling discharge with no
erythema/swelling.
Cardiac: distant, rrr no m/r/g
Abd: +BS, soft, no guarding, no rebound, diffusely tender
Ext: 2+ pulses, cool extremities
Skin: stage I on coccyx, no petchiae
Neuro: Alert, arousable, not oriented to place, date, age is
"too old", moving all 4 and responds to commands in right arm,
feet bilaterally, toes mute bilaterally.

FAMILY HISTORY: No history of strokes. Sister and mother with HTN.

SOCIAL HISTORY: Recent rehab resident, prior to CVA lived at home with cat.  Son
[**Name (NI) **] involved in care. No smoking. EtOH socially. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Pneumonia, organism unspecified,Intracerebral hemorrhage,Secondary malignant neoplasm of bone and bone marrow,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Acute and subacute bacterial endocarditis,Bacteremia,Hypopotassemia,Personal history of irradiation, presenting hazards to health,Personal history of malignant neoplasm of breast,Anticoagulants causing adverse effects in therapeutic use,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Acute posthemorrhagic anemia'}
