CHIEF COMPLAINT: Anemia

PRESENT ILLNESS: 82 yo F with recent hip fx, multiple prior GI bleeds, h/o of st
jude valve and ESRD on HD, presents from rehab with incidental
finding of anemia at HD. Pt was noted to have Hct 19.4 at
dialysis, in setting of INR 4.4, for which she received 2U
pRBCs. Pt's Hct only bumpted to 20 and thus pt referred to ED
for evaluation. She was unaware of any change in her state of
health, denying lightheadedness, dizziness, chest pain,
palpitations, shortness of breath, nausea, vomiting or abdominal
pain. She described her stool as dark brown but denied red or
black ostomy output, hematuria, or any trauma.

MEDICAL HISTORY: 1. repeated Hx of gastrointestinal bleeding (most recent
[**Month (only) 116**]/09, found to have GE junction polyp, clipped, recommended
repeat in 6-8wks, not done)
2. Left hemicolectomy with transverse colostomy for GIB [**11-13**],
found to have severe diverticulosis, no particular source of
bleeding found
3. Diastolic CHF (EF 65-75%) on 2L O2
4. Status post tracheostomy placement after prolonged intubation

MEDICATION ON ADMISSION: 1. Docusate Sodium 100 mg twice daily
2. Nexium 40 mg PO once a day.
3. Senna 8.6 mg PO BID prn
4. Simvastatin 20 mg PO DAILY
5. Amiodarone 200 mg PO DAILY
6. Ambien 5 mg PO at bedtime prn.
7. Lactulose 10 gram/15 mL Solution Oral prn
8. Levothyroxine 88 mcg PO DAILY
9. Warfarin 3 mg Daily
10. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
11. Acetaminophen 1000 mg PO Q 8H as needed for fever/pain.
12. Sevelamer Carbonate 2400 mg PO TID W/MEALS
13. Aranesp (Polysorbate) Injection
14. Aspirin 81 mg PO once a day

ALLERGIES: Protamine / Lovenox

PHYSICAL EXAM: DISCHARGE VS: T 98.6  BP= 142/60  HR= 66 RR= 20 O2= 100% RA
Fingersticks: 144, 135, 137, 117
PHYSICAL EXAM

FAMILY HISTORY: She is an only child. Grandfather died of cancer but son is not

SOCIAL HISTORY: Lives at home with husband, and son [**Name (NI) **] who lives below her
in the same house. (on [**Location (un) 453**] of 2-family home) Other
children in the area and involved in her care.
Pt is a retired former manager.
Is a non-smoker, no alcohol use, no IVDU.
Blood in stool,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic diastolic heart failure,Accidental puncture or laceration during a procedure, not elsewhere classified,Iron deficiency anemia secondary to blood loss (chronic),Pure hypercholesterolemia,Anemia in chronic kidney disease,Diverticulosis of colon (without mention of hemorrhage),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Heart valve replaced by other means,Renal dialysis status,Colostomy status,Knee joint replacement,Long-term (current) use of anticoagulants,Accidental cut, puncture, perforation or hemorrhage during endoscopic examination
Blood in stool,End stage renal disease,Hyp kid NOS w cr kid V,Chr diastolic hrt fail,Accidental op laceration,Chr blood loss anemia,Pure hypercholesterolem,Anemia in chr kidney dis,Dvrtclo colon w/o hmrhg,DMII wo cmp nt st uncntr,Hypothyroidism NOS,Atrial fibrillation,Crnry athrscl natve vssl,Heart valve replac NEC,Renal dialysis status,Colostomy status,Joint replaced knee,Long-term use anticoagul,Acc cut/hem w scope exam
Admission Date:  [**2166-10-21**]              Discharge Date:   [**2166-10-27**]

Date of Birth:  [**2084-10-17**]             Sex:   F

Service: MEDICINE

Allergies:
Protamine / Lovenox

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Anemia

Major Surgical or Invasive Procedure:
[**10-22**]-Dialysis
[**10-23**]- EGD
[**10-23**]- Colonoscopy
[**10-24**]- Dialysis
[**10-27**]- Dialysis


History of Present Illness:
82 yo F with recent hip fx, multiple prior GI bleeds, h/o of st
jude valve and ESRD on HD, presents from rehab with incidental
finding of anemia at HD. Pt was noted to have Hct 19.4 at
dialysis, in setting of INR 4.4, for which she received 2U
pRBCs. Pt's Hct only bumpted to 20 and thus pt referred to ED
for evaluation. She was unaware of any change in her state of
health, denying lightheadedness, dizziness, chest pain,
palpitations, shortness of breath, nausea, vomiting or abdominal
pain. She described her stool as dark brown but denied red or
black ostomy output, hematuria, or any trauma.

In the ED: initial vitals were : T98.6 HR150(inaccurate)
BP120/42 RR18 O291%RA.  EKG normal sinus. NG lavage was
preformed and showed minimal coffee ground blood which cleared
quickly. Exam was otherwise normal and ROS negative as above.

Labs were significant for
CBC: Hct 22.6, Cr 5.5, CEs neg x 1, INR 3.3 without any vit K.
Pt given IV PPI drip, typed and crossed but not given blood
prior to transfer. Access was difficult as left arm off limits
due to fistula, right IJ clotted, were unable to get femoral
access and ultimatelly had AC and EJ 18G PIVs placed. Renal was
informed and plan for HD tomorrow after transfusion. Prior to
transfer pt's vitals were T98.2, HR78, BP129/46, RR12, O2100%.

Past Medical History:
1. repeated Hx of gastrointestinal bleeding (most recent
[**Month (only) 116**]/09, found to have GE junction polyp, clipped, recommended
repeat in 6-8wks, not done)
2. Left hemicolectomy with transverse colostomy for GIB [**11-13**],
found to have severe diverticulosis, no particular source of
bleeding found
3. Diastolic CHF (EF 65-75%) on 2L O2
4. Status post tracheostomy placement after prolonged intubation

in ICU (at time of colectomy) - removed
5. Severe AS s/p mechanical AVR, [**Hospital3 **], goal INR [**2-11**]
6. Hypertension
7. Elevated cholesterol
8. Diabetes type 2
9. End-stage renal disease on HD MWF (via LUE AVF revised on
[**11-16**])
10. Bilateral total knee replacment
11. Multiple skin lesions removed by general and plastic surgery

12. Hypothyroidism
13. Presumptive history of atrial fibrillation; on amiodarone

Social History:
Lives at home with husband, and son [**Name (NI) **] who lives below her
in the same house. (on [**Location (un) 453**] of 2-family home) Other
children in the area and involved in her care.
Pt is a retired former manager.
Is a non-smoker, no alcohol use, no IVDU.

Family History:
She is an only child. Grandfather died of cancer but son is not

sure of what type. Three sons with htn.


Physical Exam:
DISCHARGE VS: T 98.6  BP= 142/60  HR= 66 RR= 20 O2= 100% RA
Fingersticks: 144, 135, 137, 117
PHYSICAL EXAM

GENERAL: Pleasant, well-appearing elderly African American lady,
sitting up in bed in NAD.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, mechanical S2.
no JVD
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, Non-tender, Not distended, no palpable
hepatosplenomegaly. ostomy in LLQ with greenish brown liquidy
output
EXTREMITIES: Trace edema, no calf pain, 1+ DP/PT pulses B/L
SKIN: No rashes/lesions. Old ecchymosis on right upper arm, no
hematoma.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation and stength throughout. Normal coordination. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant

Pertinent Results:
[**10-22**] LEFT HIP SOFT TISSUE ULTRASOUND: Focused son[**Name (NI) 493**]
examination performed
over the soft tissues of the left hip reveals no discrete
hematoma.

IMPRESSIONS: No discrete hematoma seen in the soft tissues
overlying the left hip.

[**10-27**] HCT 29.3
[**10-26**] HCT 28.3
[**10-25**] HCT 27.2

[**10-23**] EGD- No abnormal findings to explain melena. [**Month (only) 116**] have to
evaluate for AVMs in SB with capsule study and if negative, a
Meckel's scan as well.
Endoscope induced traumatic [**Doctor First Name 329**] [**Doctor Last Name **] tears with minimal
bleeding noted in distal third of esophagus Normal stomach.
Normal duodenum

[**10-23**] COLONOSCOPY- A few diverticula with medium openings were
seen in the transverse colon and ascending colon. Diverticulosis
appeared to be of moderate severity. Diverticulosis of the
transverse colon and ascending colon Otherwise normal
colonoscopy to cecum
 No clear source of lower GI bleed noted. Recommend capsule
study to rule out AVMs and also a meckel's scan


Brief Hospital Course:
Ms. [**Known lastname **] 82 year-old lady with coronary artery disease,
mechanical aortic valve replacement, on coumadin, history of GI
bleeds, end-stage renal disease due to diabetes and
hypertension, on hemodialysis, who presented from rehab with
findings of anemia at hemodialysis and inappropriate hematocrit
response to blood transfusion.

1. GI BLEED- Ms. [**Known lastname **] was intially admitted to the ICU on
[**10-21**] due to her history of multiple GI bleeds; she was
transfused 2 units of blood. She was transferred to the general
medical service on [**10-22**] and was hemodynamically stable. She was
evaluated by gastroenterology prior to transfer, who recommended
stopping coumadin and bridging her with heparin gtt in order to
allow her INR to decrease to a level safe for
endoscopy/colonoscopy. She underwent endoscopy/colonoscopy on
[**10-23**] without complications. No active source of bleeding was
identified, although colonoscopy revealed several diverticulae.
She has a history of ateriovenous malformations which could be
related to Aortic Stenosis (essentially, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 30060**] syndrome) or
to end-stage kidney disease and hemodialysis. GI recommended
outpatient capsule endoscopy to better evaluate the small bowel,
which could be a potential source of bleed. She is scheduled for
capsule endoscopy on [**11-3**].

2. MECHANICAL AORTIC VALVE- Ms [**Known lastname 47133**] outpatient regimen of
3mg Coumadin daily was held until INR was 2.5 and bridged with
heparin so she would be appropriate for GI procedure on [**10-23**].
After procedure, her Coumadin was re-started without a need for
heparin bridging as INR was 2.1. She was discharged on her home
regimen of 3mg daily and will need close INR follow-up. INR was
2.1 on day of discharge.

3. END-STAGE RENAL DISEASE- Patient is on Monday, Weds, Friday
dialysis schedule and received dialysis on [**9-14**] and
[**10-27**]. Nephrocaps and sevalemer were continued. She received 2
units of blood at dialysis on [**10-24**] due to a HCT of 23.1. Her
HCT had been around 23-25 throughout the remainder of her
hospital course, and she was asymptomatic. She has outpatient
renal follow-up.

Medications on Admission:
1. Docusate Sodium 100 mg twice daily
2. Nexium 40 mg PO once a day.
3. Senna 8.6 mg PO BID prn
4. Simvastatin 20 mg PO DAILY
5. Amiodarone 200 mg PO DAILY
6. Ambien 5 mg PO at bedtime prn.
7. Lactulose 10 gram/15 mL Solution Oral prn
8. Levothyroxine 88 mcg PO DAILY
9. Warfarin 3 mg Daily
10. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
11. Acetaminophen 1000 mg PO Q 8H as needed for fever/pain.
12. Sevelamer Carbonate 2400 mg PO TID W/MEALS
13. Aranesp (Polysorbate) Injection
14. Aspirin 81 mg PO once a day

Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
8. 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:*0*
9. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
10. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Lactulose 10 gram/15 mL Solution Sig: One (1)  PO once a day
as needed for constipation.
12. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.

13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
14. Aranesp (Polysorbate)  Injection


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
PRIMARY: GI bleed
SECONDARY: coronary artery disease, mechanical aortic valve
replacement, end-stage renal disease, diabetes, hypertension


Discharge Condition:
stable, afebrile, HCT stable


Discharge Instructions:
It was a pleasure being invovled in your care, Ms. [**Known lastname **]. You
were admitted to the hospital with low blood counts and concern
for GI bleeding. You had an EGD (scope of your esophagus and
stomach) and colonoscopy which revealed no obvious source of
bleeding. The GI doctors recommend that [**Name5 (PTitle) **] have an outpatient
capsule endoscopy. This is essentially a big pill you swallow
that has a camera in it and it can see the parts of your bowel
that the EGD and Colonscope can't see. Please keep your capsule
endoscopy schedule as below.

Your medications have CHANGED as follows:
1. We ADDED pantoprazole 40mg by mouth TWICE per day instead of
your nexium 40mg once per day

2. We STOPPED your Aspirin. Please do not take aspirin anymore
as it can contribute to GI bleeding.

You can continue to take your coumadin for your valve as well as
the rest of your other medications as indicated.

Please call your physician [**Last Name (NamePattern4) **] 911 if you experience crushing
chest pain, intractable nausea or vomiting, fevers/chills,
difficulty breathing, or blood in your urine vomit or stool or
any other concerning medical symptom.

Followup Instructions:
1. DIALYSIS,SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2166-10-24**] 12:00
2. You are scheduled to have an outpatient CAPSULE ENDOSCOPY on
Monday [**11-3**] at 8am- please arrive by 730am to [**Hospital Ward Name 1950**] 4 (GI
rooms on the [**Hospital Ward Name 516**] of [**Hospital1 18**], [**Location (un) **])

You will need to call [**Location (un) 13544**] at [**Telephone/Fax (1) 13545**] to go over the
details of this test. (or if you  need to reschedule) She will
get you all the information you need prior to the study, so
please contact her before your scheduled time.

3. [**Last Name (LF) **],[**First Name3 (LF) **] AV CARE AV CARE [**Location (un) **] (NHB)
Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2166-12-8**] 8:00



Completed by:[**2166-10-27**]
{'Blood in stool,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic diastolic heart failure,Accidental puncture or laceration during a procedure, not elsewhere classified,Iron deficiency anemia secondary to blood loss (chronic),Pure hypercholesterolemia,Anemia in chronic kidney disease,Diverticulosis of colon (without mention of hemorrhage),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Heart valve replaced by other means,Renal dialysis status,Colostomy status,Knee joint replacement,Long-term (current) use of anticoagulants,Accidental cut, puncture, perforation or hemorrhage during endoscopic examination'}


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: Anemia

PRESENT ILLNESS: 82 yo F with recent hip fx, multiple prior GI bleeds, h/o of st
jude valve and ESRD on HD, presents from rehab with incidental
finding of anemia at HD. Pt was noted to have Hct 19.4 at
dialysis, in setting of INR 4.4, for which she received 2U
pRBCs. Pt's Hct only bumpted to 20 and thus pt referred to ED
for evaluation. She was unaware of any change in her state of
health, denying lightheadedness, dizziness, chest pain,
palpitations, shortness of breath, nausea, vomiting or abdominal
pain. She described her stool as dark brown but denied red or
black ostomy output, hematuria, or any trauma.

MEDICAL HISTORY: 1. repeated Hx of gastrointestinal bleeding (most recent
[**Month (only) 116**]/09, found to have GE junction polyp, clipped, recommended
repeat in 6-8wks, not done)
2. Left hemicolectomy with transverse colostomy for GIB [**11-13**],
found to have severe diverticulosis, no particular source of
bleeding found
3. Diastolic CHF (EF 65-75%) on 2L O2
4. Status post tracheostomy placement after prolonged intubation

MEDICATION ON ADMISSION: 1. Docusate Sodium 100 mg twice daily
2. Nexium 40 mg PO once a day.
3. Senna 8.6 mg PO BID prn
4. Simvastatin 20 mg PO DAILY
5. Amiodarone 200 mg PO DAILY
6. Ambien 5 mg PO at bedtime prn.
7. Lactulose 10 gram/15 mL Solution Oral prn
8. Levothyroxine 88 mcg PO DAILY
9. Warfarin 3 mg Daily
10. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
11. Acetaminophen 1000 mg PO Q 8H as needed for fever/pain.
12. Sevelamer Carbonate 2400 mg PO TID W/MEALS
13. Aranesp (Polysorbate) Injection
14. Aspirin 81 mg PO once a day

ALLERGIES: Protamine / Lovenox

PHYSICAL EXAM: DISCHARGE VS: T 98.6  BP= 142/60  HR= 66 RR= 20 O2= 100% RA
Fingersticks: 144, 135, 137, 117
PHYSICAL EXAM

FAMILY HISTORY: She is an only child. Grandfather died of cancer but son is not

SOCIAL HISTORY: Lives at home with husband, and son [**Name (NI) **] who lives below her
in the same house. (on [**Location (un) 453**] of 2-family home) Other
children in the area and involved in her care.
Pt is a retired former manager.
Is a non-smoker, no alcohol use, no IVDU. 

### Response:
{'Blood in stool,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic diastolic heart failure,Accidental puncture or laceration during a procedure, not elsewhere classified,Iron deficiency anemia secondary to blood loss (chronic),Pure hypercholesterolemia,Anemia in chronic kidney disease,Diverticulosis of colon (without mention of hemorrhage),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Heart valve replaced by other means,Renal dialysis status,Colostomy status,Knee joint replacement,Long-term (current) use of anticoagulants,Accidental cut, puncture, perforation or hemorrhage during endoscopic examination'}
