CHIEF COMPLAINT: Gi bleed
jaw pain

PRESENT ILLNESS: Patient is a 79 yo russian speaking female, with h/o crohn's
(h/o GiB HCT 1 week ago 27.6), DVT's, MI (3 yrs ago) and CVA (3
yrs ago) who presented with jaw pain, left arm pain (pressure)
awoke pt. from sleep. Pt. with weakness. denies n/v,
diaphoresis, cp on exertion. Pt with melena and guaiac pos
stool. Per her daughter (history obtained from Attending note)
she has been noticing blood in her stools and checked hemoccult
at home. Stools were maroon in color intermittently. This Am
patient had cough and felt jaw and left arm pressure not
relieved by SL NTG so called 911.
.
In ED, patient was seen by cardiology, patient refused aspirin.
They felt that this was likely demand ischemia as no EKG changes
and recommended medical management, BB with goal HR in 60's,
SBP>90's, start lipitor. Got 1 U PRBC, on 2nd unit when
transferred to floor.
.
Of note, on prior admission for symptomatic anemia, refused
EGD/[**Last Name (un) **] and has h/o NSTEMI([**2189**]) and refused catheterization.
.
On the floor, the patient denies chest pain or arm pain, admits
to a small amount of jaw pain. Denies also, abdominal pain or
discomfort.

MEDICAL HISTORY: 1. Crohn's, last flare [**1-2**]
2. breast CA s/p s/p R lumpectomy and XRT 11 yrs ago
3. GERD
4. CAD s/p NSTEMI '[**89**] [stress [**4-2**]: mod, partially rev [**Month/Year (2) 15758**]

MEDICATION ON ADMISSION: 1. Metoprolol 12.5 mg PO TID
2. protonix 40 mg Po QD
3. prednisone 17 mg Po QD
4. Coumadin 3mg Po QD (not taking)
5. Procrit
6. Mesalamine 1200mg Po TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 96.8 BP 127/68 HR 86 RR 16 O2 sats 93%RA
GEN: NAD, resting comfortably
HEENT: EOMI, PERRL, no LAD, JVP at clavicle at 30 degrees, MMM,
op clear. No LAD.
LUNGS:CTAB no w/r/r
HEART: RRR, soft II/VI SEM at base of heart nonradiating, and
III/VI SEM at apex.
ABD:soft, mild TTP in mid-epigastrium to RUQ, no
rebound/guarding. hypoactive BS. Golfball sized mass just distal
to the umbilicus, nontender.
EXTR:left ankle with large soft-tissue swelling over lateral
malleolus, mild TTP. TTP over left shin, no calf tenderness,
erythema or swelling. no edema/c/c otherwise. wwp.
NEURO: AA&Ox3, CN II-XII in tact.
SKIN: Wwp, several seborrheic keratoses over chest. no rashes.

FAMILY HISTORY: NC

SOCIAL HISTORY: Former physician, [**Name10 (NameIs) **] at home with daughter who is HCP. no
tobacco, EtOh, drugs.
Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Chronic kidney disease, unspecified,Regional enteritis of unspecified site,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Esophageal reflux,Personal history of malignant neoplasm of breast,Old myocardial infarction
Subendo infarct, initial,Acute kidney failure NOS,Ac posthemorrhag anemia,Chronic kidney dis NOS,Regional enteritis NOS,Hy kid NOS w cr kid I-IV,Crnry athrscl natve vssl,Esophageal reflux,Hx of breast malignancy,Old myocardial infarct
Admission Date:  [**2192-1-5**]              Discharge Date:   [**2192-1-16**]

Date of Birth:  [**2112-2-19**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Gi bleed
jaw pain

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Patient is a 79 yo russian speaking female, with h/o crohn's
(h/o GiB HCT 1 week ago 27.6), DVT's, MI (3 yrs ago) and CVA (3
yrs ago) who presented with jaw pain, left arm pain (pressure)
awoke pt. from sleep. Pt. with weakness. denies n/v,
diaphoresis, cp on exertion. Pt with melena and guaiac pos
stool. Per her daughter (history obtained from Attending note)
she has been noticing blood in her stools and checked hemoccult
at home. Stools were maroon in color intermittently. This Am
patient had cough and felt jaw and left arm pressure not
relieved by SL NTG so called 911.
.
In ED, patient was seen by cardiology, patient refused aspirin.
They felt that this was likely demand ischemia as no EKG changes
and recommended medical management, BB with goal HR in 60's,
SBP>90's, start lipitor. Got 1 U PRBC, on 2nd unit when
transferred to floor.
.
Of note, on prior admission for symptomatic anemia, refused
EGD/[**Last Name (un) **] and has h/o NSTEMI([**2189**]) and refused catheterization.
.
On the floor, the patient denies chest pain or arm pain, admits
to a small amount of jaw pain. Denies also, abdominal pain or
discomfort.


Past Medical History:
1. Crohn's, last flare [**1-2**]
2. breast CA s/p s/p R lumpectomy and XRT 11 yrs ago
3. GERD
4. CAD s/p NSTEMI '[**89**] [stress [**4-2**]: mod, partially rev [**Month/Year (2) 15758**]

defect in apex w/ associated hypokinesis; ECHO [**4-2**]: EF 45-55%]

5. s/p CCY 10 yrs ago
6. HTN
7. hx of bilateral DVTs and saddle embolus in [**2190**], had been on
warfarin.
8. CRI, baseline cr 1.5-1.8
9. Anemia, due to renal failure and anemia of chronic disease,
on procrit weekly
10. MVA 20 years ago with intracranial bleed


Social History:
Former physician, [**Name10 (NameIs) **] at home with daughter who is HCP. no
tobacco, EtOh, drugs.


Family History:
NC

Physical Exam:
VS: T 96.8 BP 127/68 HR 86 RR 16 O2 sats 93%RA
GEN: NAD, resting comfortably
HEENT: EOMI, PERRL, no LAD, JVP at clavicle at 30 degrees, MMM,
op clear. No LAD.
LUNGS:CTAB no w/r/r
HEART: RRR, soft II/VI SEM at base of heart nonradiating, and
III/VI SEM at apex.
ABD:soft, mild TTP in mid-epigastrium to RUQ, no
rebound/guarding. hypoactive BS. Golfball sized mass just distal
to the umbilicus, nontender.
EXTR:left ankle with large soft-tissue swelling over lateral
malleolus, mild TTP. TTP over left shin, no calf tenderness,
erythema or swelling. no edema/c/c otherwise. wwp.
NEURO: AA&Ox3, CN II-XII in tact.
SKIN: Wwp, several seborrheic keratoses over chest. no rashes.


Pertinent Results:
[**2192-1-5**] 05:10AM   cTropnT-0.14*
[**2192-1-5**] 11:30AM   CK(CPK)-94
[**2192-1-5**] 11:30AM   cTropnT-0.43*
[**2192-1-5**] 08:50PM   CK(CPK)-181*
[**2192-1-5**] 08:50PM   CK-MB-35* MB INDX-19.3* cTropnT-0.80*
.

[**2192-1-5**] 05:10AM   WBC-9.0 RBC-2.17*# HGB-7.8* HCT-23.2*#
MCV-107* MCH-35.9* MCHC-33.7 RDW-23.4*
[**2192-1-5**] 05:10AM   PLT COUNT-428#
[**2192-1-5**] 05:10AM   GLUCOSE-101 UREA N-35* CREAT-2.1* SODIUM-142
POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-18* ANION GAP-18
[**2192-1-5**] 05:10AM   CALCIUM-8.5 PHOSPHATE-2.6* MAGNESIUM-2.1

Brief Hospital Course:
79 yo female russian speaking female, with h/o crohn's (h/o GiB
HCT 1 week ago 27.6), DVT's, MI and CVA (3 yrs ago) who
presented with maroon stools with worsening anemia and jaw pain.

.
# GIB: Patient has history of GIB and has refused EGD and
colonscopy in the past. Currently hemodynamically stable but has
had a 5 point HCT drop in the week preceding admission.
Her Crohn's disease was diagnosed in [**2176**], disease mainly distal
small bowel with possible strictures by a SBFT. Last colonoscopy
[**2187**] showed normal mucosa but active colitis by biopsy. Had
another Flex Sig at OSH with active disease (no records
available). Bleeding is felt to be intermittent hematochezia at
home but no diarrhea, abd pain or distention. Treated in the
past with cipro, asacol, pentasa. Now on prednisone and asacol.
The patient received 2 units pRBCs and was transfused to hct>30
given evidence of active ischemia. GI felt initially that
patient would need [**Last Name (un) **] versus SBFT/CT scan, but could be done
as an outpatient in addition to better managing her Crohn's
medications and mesalamine and prednisone were continued during
admission. Then pt experienced several episodes of BRBPR with a
drop in hct once again and she was brought to flex sig which
found no evidence of bleeding in the distal colon, although
there was a section of colitis. Per GI recs, IV solumedrol was
started, and patient went for tagged red cell scan to evaluate
the right colon and small bowel which found ?rectal bleeding,
not supported by flex sig findings. Patient improved clinically
with IV steroids, had one further episode of melena, hct stable.
Patient was discharged on oral prednisone to follow up with Dr.
[**Last Name (STitle) **].

.
# NSTEMI: No EKG changes but troponin peaked at 1.2. This was
attributed to demand in the setting of anemia from the GI bleed.
Regardless, patient is refusing catheterization to cardiology
who saw her in the ED and continued to refuse on the floor,
understanding the risks of not intervening with catheterization
(possible risk of continued ischemia and possible death). As a
result, we optimized her medical management with high dose
statin and aspirin (which patient intermittently refused to
take, again understanding the risk of her decision). We
attempted to start metoprolol, but blood pressure and heart rate
did not tolerate it resulting in a brief transfer to the MICU in
the setting of hypotension and bradycardia which resolved with
holding beta blockade. Transfusion goal was HCT >30 by ACS
protocol,
ECG showed no ischemic changes and TTE showed no evidence of
wall motion abnormalities and preserved ejection fraction.
.
# Acute on chronic renal failure: baseline Cr 1.5-1.8. Cr 2.1 on
admission. Likely pre-renal due to hypoperfusion in the setting
of GI bleed, improved with transfusions.
.
# Anemia: Has baseline anemia now worsened with GIB.
.
# h/o DVT/PE: Held coumadin in setting of GIB. Will need to
readdress anticoagulation in the setting of intermittent
hematochezia, which can be done as an outpatient. It seems that
patient had stopped taking coumadin on her own over 1 month
prior to admission.
.
# Code: Full, confirmed with patient


Medications on Admission:
1. Metoprolol 12.5 mg PO TID
2. protonix 40 mg Po QD
3. prednisone 17 mg Po QD
4. Coumadin 3mg Po QD (not taking)
5. Procrit
6. Mesalamine 1200mg Po TID


Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
3. PredniSONE 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital6 1952**], [**Location (un) 86**]

Discharge Diagnosis:
Primary:
GI bleed
NSTEMI
.
Secondary:
Crohn's Disease
h/o NSTEMI
h/o CVA
DVT's


Discharge Condition:
Stable


Discharge Instructions:
You were admitted for gastrointestinal bleeding and were found
to have cardiac ischemia on admission. You were given blood
transfusions and optimized on medical management, as you refused
catheterization. You were started on atorvastatin 80mg by mouth
once a day.
.
The gastroenterologists feel that the bleeding will need to be
explored further, but that this can be done on an outpatient
basis.
.
If you feel chest pain, shortness of breath, fevers, chills or
worsening bright red blood per rectum, please seek medical
attention.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 3357**], upon discharge. You can call
[**Telephone/Fax (1) 4606**] to schedule this appt.
.
Please follow up with Dr. [**Last Name (STitle) **] upon discharge. He will
determine how to taper the prednisone the patient was discharged
on.


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Chronic kidney disease, unspecified,Regional enteritis of unspecified site,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Esophageal reflux,Personal history of malignant neoplasm of breast,Old myocardial infarction'}


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: Gi bleed
jaw pain

PRESENT ILLNESS: Patient is a 79 yo russian speaking female, with h/o crohn's
(h/o GiB HCT 1 week ago 27.6), DVT's, MI (3 yrs ago) and CVA (3
yrs ago) who presented with jaw pain, left arm pain (pressure)
awoke pt. from sleep. Pt. with weakness. denies n/v,
diaphoresis, cp on exertion. Pt with melena and guaiac pos
stool. Per her daughter (history obtained from Attending note)
she has been noticing blood in her stools and checked hemoccult
at home. Stools were maroon in color intermittently. This Am
patient had cough and felt jaw and left arm pressure not
relieved by SL NTG so called 911.
.
In ED, patient was seen by cardiology, patient refused aspirin.
They felt that this was likely demand ischemia as no EKG changes
and recommended medical management, BB with goal HR in 60's,
SBP>90's, start lipitor. Got 1 U PRBC, on 2nd unit when
transferred to floor.
.
Of note, on prior admission for symptomatic anemia, refused
EGD/[**Last Name (un) **] and has h/o NSTEMI([**2189**]) and refused catheterization.
.
On the floor, the patient denies chest pain or arm pain, admits
to a small amount of jaw pain. Denies also, abdominal pain or
discomfort.

MEDICAL HISTORY: 1. Crohn's, last flare [**1-2**]
2. breast CA s/p s/p R lumpectomy and XRT 11 yrs ago
3. GERD
4. CAD s/p NSTEMI '[**89**] [stress [**4-2**]: mod, partially rev [**Month/Year (2) 15758**]

MEDICATION ON ADMISSION: 1. Metoprolol 12.5 mg PO TID
2. protonix 40 mg Po QD
3. prednisone 17 mg Po QD
4. Coumadin 3mg Po QD (not taking)
5. Procrit
6. Mesalamine 1200mg Po TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 96.8 BP 127/68 HR 86 RR 16 O2 sats 93%RA
GEN: NAD, resting comfortably
HEENT: EOMI, PERRL, no LAD, JVP at clavicle at 30 degrees, MMM,
op clear. No LAD.
LUNGS:CTAB no w/r/r
HEART: RRR, soft II/VI SEM at base of heart nonradiating, and
III/VI SEM at apex.
ABD:soft, mild TTP in mid-epigastrium to RUQ, no
rebound/guarding. hypoactive BS. Golfball sized mass just distal
to the umbilicus, nontender.
EXTR:left ankle with large soft-tissue swelling over lateral
malleolus, mild TTP. TTP over left shin, no calf tenderness,
erythema or swelling. no edema/c/c otherwise. wwp.
NEURO: AA&Ox3, CN II-XII in tact.
SKIN: Wwp, several seborrheic keratoses over chest. no rashes.

FAMILY HISTORY: NC

SOCIAL HISTORY: Former physician, [**Name10 (NameIs) **] at home with daughter who is HCP. no
tobacco, EtOh, drugs. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Chronic kidney disease, unspecified,Regional enteritis of unspecified site,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Esophageal reflux,Personal history of malignant neoplasm of breast,Old myocardial infarction'}
