CHIEF COMPLAINT: Bright red blood per rectum

PRESENT ILLNESS: Ms. [**Known lastname 59441**] is a [**Age over 90 **] y/o F with a h/o CAD s/p CABGx3 in [**2140**]
that was complicated by post-op occlusion of her LIMA requiring
2 stents and AICD/Pacer placed for recurrent VT, h/o prior lower
GI bleed on coumadin (during CABG), HTN and HL who presented
from home with BRBPR.  Last night before she went to bed and
felt fine, got up in the night to go to the bathroom and she had
a bloody/tarry bowel movement and had some blood on her
underwear and in the toilet bowl.  She then pressed her life
line and was brought in by ambulance to the [**Hospital1 18**] ER, this
morning she is complaining of feeling tired and fatigued.  She
has never had a colonoscopy.
.
In the ED, initial vs were: 97.8, 97, 101/55, 20, 100% on RA.
In the ER her exam was notable for a grossly bloody rectal exam.
 Labs showed a white count of 16.6, HCT of 33.3, from a baseline
of 41, and Cr of 2.1 from baseline of 1.6.  Her EKG was sinus
tachycardia at 103bpm, q waves in III and aVF.  Per the patient
and her family she is full code but does not want any heroic
measures such as a colonoscopy.  She received 300cc's of IVF and
plan is to transfuse 2 units PRBC's, GI is aware of the patient.
 VS on transfer: 85, 96/54, 26, 99% on RA.
.
On arrival to the ICU her initial VS were: 96.9, 86, 105/57, 28,
100% on 2LNC.  Shortly after arrival she had a large bowel
movement with dark, red blood and clots, on returning from the
commode she became lightheaded and her systolic blood pressure
dropped into the 80's.  She says that the last time she had a
stent placed was after her CABG in [**2140**], she continues to be
followed by Dr. [**Last Name (STitle) **] for her cardiac issues,  she says that she
has been told she has a heart murmur and has had one for awhile
but she does not know which type.  No GERD sx, no n/v/d,
constipation.
.
Review of systems:
(+) Per HPI and for lightheadedness/dizziness
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.

MEDICAL HISTORY: CAD s/p CABG x 3 and stents x 2 to his LIMA
CRI - baseline Cr is 1.6
HTN
HL
Heart Murmur - ?Aortic Stenosis

MEDICATION ON ADMISSION: Aspirin 81mg daily
Diltiazem 120mg daily
Lipitor 20mg daily
Zetia 10mg daily
[**Date Range **] 75mg daily
Lisinopril 5mg daily
HCTZ 25mg daily
Albuterol MDI prn SOB

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Physical Exam:

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: no smoking, no ETOH, married, lives w/husband, very active
Unspecified vascular insufficiency of intestine,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Hypovolemia,Chronic airway obstruction, not elsewhere classified,Internal hemorrhoids without mention of complication,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ,Other and unspecified hyperlipidemia,Chronic kidney disease, unspecified,Diverticulosis of colon (without mention of hemorrhage),Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified
Vasc insuff intest NOS,Acute kidney failure NOS,Ac posthemorrhag anemia,Hypovolemia,Chr airway obstruct NEC,Int hemorrhoid w/o compl,Aortocoronary bypass,Status autm crd dfbrltr,Hyperlipidemia NEC/NOS,Chronic kidney dis NOS,Dvrtclo colon w/o hmrhg,Ben hy kid w cr kid I-IV
Admission Date:  [**2147-8-7**]              Discharge Date:   [**2147-8-12**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Bright red blood per rectum

Major Surgical or Invasive Procedure:
Colonoscopy

History of Present Illness:
Ms. [**Known lastname 59441**] is a [**Age over 90 **] y/o F with a h/o CAD s/p CABGx3 in [**2140**]
that was complicated by post-op occlusion of her LIMA requiring
2 stents and AICD/Pacer placed for recurrent VT, h/o prior lower
GI bleed on coumadin (during CABG), HTN and HL who presented
from home with BRBPR.  Last night before she went to bed and
felt fine, got up in the night to go to the bathroom and she had
a bloody/tarry bowel movement and had some blood on her
underwear and in the toilet bowl.  She then pressed her life
line and was brought in by ambulance to the [**Hospital1 18**] ER, this
morning she is complaining of feeling tired and fatigued.  She
has never had a colonoscopy.
.
In the ED, initial vs were: 97.8, 97, 101/55, 20, 100% on RA.
In the ER her exam was notable for a grossly bloody rectal exam.
 Labs showed a white count of 16.6, HCT of 33.3, from a baseline
of 41, and Cr of 2.1 from baseline of 1.6.  Her EKG was sinus
tachycardia at 103bpm, q waves in III and aVF.  Per the patient
and her family she is full code but does not want any heroic
measures such as a colonoscopy.  She received 300cc's of IVF and
plan is to transfuse 2 units PRBC's, GI is aware of the patient.
 VS on transfer: 85, 96/54, 26, 99% on RA.
.
On arrival to the ICU her initial VS were: 96.9, 86, 105/57, 28,
100% on 2LNC.  Shortly after arrival she had a large bowel
movement with dark, red blood and clots, on returning from the
commode she became lightheaded and her systolic blood pressure
dropped into the 80's.  She says that the last time she had a
stent placed was after her CABG in [**2140**], she continues to be
followed by Dr. [**Last Name (STitle) **] for her cardiac issues,  she says that she
has been told she has a heart murmur and has had one for awhile
but she does not know which type.  No GERD sx, no n/v/d,
constipation.
.
Review of systems:
(+) Per HPI and for lightheadedness/dizziness
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.


Past Medical History:
CAD s/p CABG x 3 and stents x 2 to his LIMA
CRI - baseline Cr is 1.6
HTN
HL
Heart Murmur - ?Aortic Stenosis


Social History:
no smoking, no ETOH, married, lives w/husband, very active


Family History:
non-contributory

Physical Exam:
Physical Exam on Admission:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Physical Exam:


Pertinent Results:
Labs on Admission: [**2147-8-7**] 05:30AM
WBC-16.6* RBC-3.75* HGB-11.7* HCT-33.3* MCV-89 MCH-31.0
MCHC-35.0 RDW-12.7
PT-12.2 PTT-21.7* INR(PT)-1.0
cTropnT-<0.01
GLUCOSE-188* UREA N-53* CREAT-2.1*# SODIUM-142 POTASSIUM-4.5
CL-105 CO2-22
CALCIUM-7.7* PHOSPHATE-2.9 MAGNESIUM-1.9
ALT(SGPT)-16 AST(SGOT)-19 LD(LDH)-147 ALK PHOS-71 TOT BILI-0.3

Imaging:
EGD ([**8-9**]):  Normal esophagus.  Normal stomach. Normal duodenum.
Normal EGD to third part of the duodenum

Colonoscopy ([**8-9**]): Diverticulosis of the whole colon Grade 1
internal hemorrhoids. In the proximal ascending colon/cecum was
diffuse erythema, nodularity, ulceration and an area of
fullness. this involved a 6 cm region. Proximal to this was
normal mucosa and then in the distal ascending colon was another
3 cm area of erythema, ulceration. (biopsy)
Otherwise normal colonoscopy to cecum and distal 8 cm of ileum
Recommendations: follow up biopsies per the team. this may all
be consistent with ischemic colitis, less likely malignancy to
explain her GI bleeding.

EKG: sinus tachycardia at 103bpm, q waves in III and aVF

Microbiology: Stool cultures pending at the time of discharge,
no growth to date

Discharge Labs: [**2147-8-12**] 06:55AM
WBC-13.1* RBC-3.87* Hgb-12.0 Hct-34.3* MCV-89 Plt Ct-165
Glucose-77 UreaN-10 Creat-1.1 Na-141 K-3.8 Cl-112* HCO3-22
AnGap-11

Brief Hospital Course:
Ms. [**Known lastname 59441**] is a [**Age over 90 **] y/o F with a significant cardiac history
who presents from home with BRBPR.

#) BRBPR: DDx initially included diverticular disease,
embolic/ischemic event, hemorrhoids (although large amount makes
this less likely), AVM's or colon cancer.  As her most recent
Hct was 41, she had lost a substantial amount of blood at
presentation given her Hct of 33. She received a total of 7
units of PRBCs, 1 unit FFP, and 1 unit platelets during her
stay.  By the third day of her admission, her bleeding was
stabilized with no further transfusion requirement and a stable
Hct at 32. She advanced her diet without evidence of further
bleeding.

The gastroenterology team was consulted and recommended both EGD
and colonoscopy.  The preparation for colonoscopy was prolonged,
as she continued to produce bright red blood and clots for more
than 24 hours.  These tests were performed on [**8-9**], and
revealed that the likely cause of her bleeding was an ulceration
in the ascending colon near the cecum, possibly secondary to
ischemic colitis.  Malignancy could not be excluded by this
study.  Biopsies were sent for pathologic study and were
consistent with ischemic colitis. Stool cultures were also sent
and were pending at the time of discharge.

On discussion with the patient's outpatient Cardiologist, Dr
[**Last Name (STitle) **], it was determined that she does not require multiple
anti-platelet agents, particularly given her risk of further
bleeding.  He recommended stopping [**Last Name (STitle) **] and continuing [**Last Name (STitle) **].
He will continue to follow her.

#) Acute on Chronic Renal Failure:The patient's most recent Cr
at PCP [**Name Initial (PRE) **] 1.58, but on initial presentation her Cr was 2.1.
This rapidly returned to baseline with hydration. The etiology
was likely acute on chronic renal failure from hypovolemia.
During her stay her renal function and urine output was
monitored, and her medications dosed for her renal function.

#) Leukocytosis: Her white count was elevated on admission at
16.6, likely due to a stress response. This dropped rapidly.
During her admission she remained afebrile with no localizing
signs or symptoms of infection. As noted above, stool cultures
were pending at the time of discharge, but her GI symptoms had
completely resolved.

#) CAD s/p CABG and stents x 2 to LIMA: On admission she had no
chest pain, and reported no chest pain or other limiting
symptoms with exertion at baseline.  Her home statin was
continued.  Her [**Name Initial (PRE) **] and [**Name Initial (PRE) **] were held on admission.  Per
discussion with her outpatient cardiologist, Dr [**Last Name (STitle) **], her [**Last Name (STitle) **]
was discontinued and her [**Last Name (STitle) **] continued (as discussed above).

#) Hypertension: The patient has a history of hypertension,
treated with HCTZ, Lisinopril and Diltiazem at home.  In the
setting of her GI bleed and hypotension these were initialy held
during her stay. Her Lisinopril was re-started on [**2147-8-11**],
which she tolerated well. HCTZ and Diltiazem continue to be held
at discharge. The patient was instructed to follow-up with her
PCP early next week for a blood pressure check and further
discussion as to whether to re-start these medications.

#) COPD: The patient has a history of COPD, treated with
albuterol PRN.  She had no hypoxia during her stay.

Transitional Issues:
- Follow-up pending stool cultures
- Repeat blood pressure check and determine whether to re-start
Diltiazem and HCTZ
- Continue to hold [**Date Range **] indefinitely


Medications on Admission:
Aspirin 81mg daily
Diltiazem 120mg daily
Lipitor 20mg daily
Zetia 10mg daily
[**Date Range **] 75mg daily
Lisinopril 5mg daily
HCTZ 25mg daily
Albuterol MDI prn SOB


Discharge Medications:
per cardiologist, d/c [**Date Range **], continue [**Date Range **]

Discharge Disposition:
Home

Discharge Diagnosis:
Ischemic Colitis
Coronary artery disease

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

Discharge Instructions:
You were admitted to the hospital with a gastrointestinal bleed
requiring blood transfusions. You underwent an endoscopy and
colonoscopy that was significant for an area of ischemia in your
colon (called ischemic colitis). You were treated supportively
with IV fluids and blood transfusions, and over time your
bleeding stopped.

One of your medications, [**Date Range **], was discontinued, and you were
started on a cream for your back called Sarna. Due to your
bleeding, your blood pressure was lower in the hospital, and two
of your blood pressure medications, Hydrochlorothiazide and
Diltiazem, were held. You should not take these until your blood
pressure is re-checked in your primary care doctor's office.
They may decide to re-start one or both of them at that time. No
other changes were made to your home medications.

Followup Instructions:
Please follow-up with your primary care doctor within three to
five days of discharge to discuss the changes to your
medications and to ensure you have not had any more bleeding.
{'Unspecified vascular insufficiency of intestine,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Hypovolemia,Chronic airway obstruction, not elsewhere classified,Internal hemorrhoids without mention of complication,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ,Other and unspecified hyperlipidemia,Chronic kidney disease, unspecified,Diverticulosis of colon (without mention of hemorrhage),Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or 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: Bright red blood per rectum

PRESENT ILLNESS: Ms. [**Known lastname 59441**] is a [**Age over 90 **] y/o F with a h/o CAD s/p CABGx3 in [**2140**]
that was complicated by post-op occlusion of her LIMA requiring
2 stents and AICD/Pacer placed for recurrent VT, h/o prior lower
GI bleed on coumadin (during CABG), HTN and HL who presented
from home with BRBPR.  Last night before she went to bed and
felt fine, got up in the night to go to the bathroom and she had
a bloody/tarry bowel movement and had some blood on her
underwear and in the toilet bowl.  She then pressed her life
line and was brought in by ambulance to the [**Hospital1 18**] ER, this
morning she is complaining of feeling tired and fatigued.  She
has never had a colonoscopy.
.
In the ED, initial vs were: 97.8, 97, 101/55, 20, 100% on RA.
In the ER her exam was notable for a grossly bloody rectal exam.
 Labs showed a white count of 16.6, HCT of 33.3, from a baseline
of 41, and Cr of 2.1 from baseline of 1.6.  Her EKG was sinus
tachycardia at 103bpm, q waves in III and aVF.  Per the patient
and her family she is full code but does not want any heroic
measures such as a colonoscopy.  She received 300cc's of IVF and
plan is to transfuse 2 units PRBC's, GI is aware of the patient.
 VS on transfer: 85, 96/54, 26, 99% on RA.
.
On arrival to the ICU her initial VS were: 96.9, 86, 105/57, 28,
100% on 2LNC.  Shortly after arrival she had a large bowel
movement with dark, red blood and clots, on returning from the
commode she became lightheaded and her systolic blood pressure
dropped into the 80's.  She says that the last time she had a
stent placed was after her CABG in [**2140**], she continues to be
followed by Dr. [**Last Name (STitle) **] for her cardiac issues,  she says that she
has been told she has a heart murmur and has had one for awhile
but she does not know which type.  No GERD sx, no n/v/d,
constipation.
.
Review of systems:
(+) Per HPI and for lightheadedness/dizziness
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.

MEDICAL HISTORY: CAD s/p CABG x 3 and stents x 2 to his LIMA
CRI - baseline Cr is 1.6
HTN
HL
Heart Murmur - ?Aortic Stenosis

MEDICATION ON ADMISSION: Aspirin 81mg daily
Diltiazem 120mg daily
Lipitor 20mg daily
Zetia 10mg daily
[**Date Range **] 75mg daily
Lisinopril 5mg daily
HCTZ 25mg daily
Albuterol MDI prn SOB

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam on Admission:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Physical Exam:

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: no smoking, no ETOH, married, lives w/husband, very active 

### Response:
{'Unspecified vascular insufficiency of intestine,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Hypovolemia,Chronic airway obstruction, not elsewhere classified,Internal hemorrhoids without mention of complication,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ,Other and unspecified hyperlipidemia,Chronic kidney disease, unspecified,Diverticulosis of colon (without mention of hemorrhage),Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified'}
