CHIEF COMPLAINT: Melena

PRESENT ILLNESS: Ms [**Known lastname **] is a 80 year old female who is presenting to us from
rehab ([**Hospital3 2558**]) with new melena.

MEDICAL HISTORY: 1. diabetes
2. congestive heart failure
3. hyperlipidemia
4. hypertension
5. type II diabetes
6. GAVE
7. coronary artery disease s/p 2 stents - [**2116**] in circumflex,
and LAD
8. aortic stenosis s/p AVR (bioprosthetic)
9. stage III CKD
10. hx of CVA

MEDICATION ON ADMISSION: 1. digoxin .125 mg wmf
2. lasix 80 mg daily TID
3. crestor 10 mg daily
4. labetalol 200 mg [**Hospital1 **]
5. sucralfate 1 gm daily
6. amlodipine 10 mg daily
7. lantus 20 units daily
8. humalog insulin sliding scale
9. prilosec 40 mg daily
10. ferrous sulfate 325 mg daily
11. xalatan 0.005%
12. fish oil 1000/1200 mg
13. vitamin D 1000 U
14. colace 200 mg daily
15. tylenol 500 mg daily
16. amoxicillin 500 mg daily

ALLERGIES: Latex

PHYSICAL EXAM: On admission:
Vitals reveal a regular pulse 60-70.  Systolic ejection murmur
is heard best in aortic area.
Respiratory rate is 18 with no significant accessory muscle use.
 Oxygen saturation is 98% on 2 L of oxygen.
Her blood pressure reveals a wide pulse pressure with systolic
of 140 and diastolic of 30-40.
In general, she is Caucasian, a thin, pleasant, elderly woman,
appropriate to conversation, inquisitive, alert, and oriented to
person, place and time.
Cardiovascular exam shows no appreciable JVP, pulses 2+ and
equal bilaterally, with a systolic ejection murmur without
clicks loudest in aortic area.   Pulmonary exam reveals mild
crackles at bases bilaterally, free of wheezes, with respiratory
rate of 18.  Abdominal exam shows a distended, tympanic abdomen,
with no appreciable masses or tenderness.  Extremities are quite
swollen, with 3+ pitting edema to the thighs bilaterally.  No
cyanosis, warm fingers and toes.  Neurologically non-focal.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: She lives in [**Hospital1 **] with her younger sister.  She has
been back and forth between [**Hospital3 2558**] and [**Hospital3 60734**].  She used to work in a publishing house until age 75.
Angiodysplasia of stomach and duodenum with hemorrhage,Acute on chronic diastolic heart failure,Other malignant lymphomas, lymph nodes of multiple sites,Other and unspecified coagulation defects,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Long-term (current) use of insulin,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Thrombocytopenia, unspecified
Angio stm/dudn w hmrhg,Ac on chr diast hrt fail,Lymphomas NEC mult,Coagulat defect NEC/NOS,DMII renl nt st uncntrld,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Long-term use of insulin,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Hx TIA/stroke w/o resid,Thrombocytopenia NOS
Admission Date:  [**2132-4-14**]              Discharge Date:   [**2132-4-29**]

Date of Birth:  [**2051-6-1**]             Sex:   F

Service: MEDICINE

Allergies:
Latex

Attending:[**First Name3 (LF) 31014**]
Chief Complaint:
Melena

Major Surgical or Invasive Procedure:
Inguinal Lymph Node Biopsy


History of Present Illness:
Ms [**Known lastname **] is a 80 year old female who is presenting to us from
rehab ([**Hospital3 2558**]) with new melena.

She has a history of GAVE diagnosed in [**Month (only) 956**] of this year at
[**Hospital6 2561**] diagnosed on endoscopy after her
hematocrits were noted to be low near 27.  Her GAVE was
cauterized at this time by her gastroenterologist.

Her past medical history is also significant for coronary artery
disease with stents placed in [**2116**], congestive heart failure,
and stage III chronic kidney disease.

Ms [**Known lastname **] presents today after 2 episodes of melena at [**Hospital 7137**].  This morning she had crampy abdominal pain lasting
minutes throughout her abdomen with rectal urgency.  She passed
2 bowel movements and the pain subsided.  Her nurse noted the
stool to be black although Ms [**Known lastname **] states the stool is always
black because of her ferrous supplements.  Stool guiaiac was
positive; apparently in the past it has been negative.  No
diarrhea, nausea, vomiting, or hematemesis.  No fevers, chills,
shortness of breath, lightheadedness, chest pain, chest
pressure, or dizziness.

She was recently hospitalized at [**Hospital3 **] on [**3-25**] for
an exacerbation of congestive heart failure, during which time a
pleural effusion was tapped; thoracentesis revealed a transudate
with negative cytology.  Her creatinine was elevated to 2.2.
Renal ultrasound revealed a left renal hilum mass measuring 10.3
x 4.6 x 4.9 cm as well as lesions in the liver and pancreas.  A
CT contrast to evaluate these further could not be performed
because of her acute kidney injury.  She was discharged with
instructions to follow up with her primary care doctor to
further evaluate these lesions.

Over the past two months, Ms [**Known lastname 110511**] appetite has waned.  Her
weight has dropped around 10 lbs.  She has not had any prior
episodes of melena or hematochezia.  No hematemesis history.
Denies abdominal pain.   Other than the two episodes today, she
feels well at time of transfer to MICU.


Past Medical History:
1. diabetes
2. congestive heart failure
3. hyperlipidemia
4. hypertension
5. type II diabetes
6. GAVE
7. coronary artery disease s/p 2 stents - [**2116**] in circumflex,
and LAD
8. aortic stenosis s/p AVR (bioprosthetic)
9. stage III CKD
10. hx of CVA


Social History:
She lives in [**Hospital1 **] with her younger sister.  She has
been back and forth between [**Hospital3 2558**] and [**Hospital3 60734**].  She used to work in a publishing house until age 75.

Family History:
Noncontributory

Physical Exam:
On admission:
Vitals reveal a regular pulse 60-70.  Systolic ejection murmur
is heard best in aortic area.
Respiratory rate is 18 with no significant accessory muscle use.
 Oxygen saturation is 98% on 2 L of oxygen.
Her blood pressure reveals a wide pulse pressure with systolic
of 140 and diastolic of 30-40.
In general, she is Caucasian, a thin, pleasant, elderly woman,
appropriate to conversation, inquisitive, alert, and oriented to
person, place and time.
Cardiovascular exam shows no appreciable JVP, pulses 2+ and
equal bilaterally, with a systolic ejection murmur without
clicks loudest in aortic area.   Pulmonary exam reveals mild
crackles at bases bilaterally, free of wheezes, with respiratory
rate of 18.  Abdominal exam shows a distended, tympanic abdomen,
with no appreciable masses or tenderness.  Extremities are quite
swollen, with 3+ pitting edema to the thighs bilaterally.  No
cyanosis, warm fingers and toes.  Neurologically non-focal.

On Discharge:wt 73kg
98.8, 128/89, 72, 20
General: Less anxious than yesterday. AOx3, not tachypneic
HEENT:  PEERLA, MMM
Cardiac: RRR, 3/6 systolic murmur at the LUSB, with split s2
Lungs: bibasilar crackles
Abd: Protuberant. tympanitic, nontender, unchanged from
yesterday
Extremities: 2+ peripheral edema to the thighs bilaterally, 2+DP
pulses bilaterally

Pertinent Results:
On Admission:
[**2132-4-14**] 06:00PM BLOOD WBC-11.2* RBC-3.04* Hgb-7.2* Hct-25.3*
MCV-80* MCH-23.6* MCHC-29.6* RDW-15.4 Plt Ct-367
[**2132-4-14**] 06:00PM BLOOD Neuts-87.2* Lymphs-6.1* Monos-1.6*
Eos-4.9* Baso-0.3
[**2132-4-14**] 06:00PM BLOOD PT-16.3* PTT-37.3* INR(PT)-1.5*
[**2132-4-14**] 06:00PM BLOOD Glucose-167* UreaN-88* Creat-2.4* Na-139
K-4.1 Cl-103 HCO3-20* AnGap-20
[**2132-4-14**] 06:00PM BLOOD ALT-20 AST-41* AlkPhos-66 TotBili-0.3
[**2132-4-14**] 06:00PM BLOOD proBNP-[**Numeric Identifier 87864**]*
[**2132-4-14**] 06:00PM BLOOD cTropnT-0.02*
[**2132-4-15**] 02:59AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.4
[**2132-4-14**] 06:00PM BLOOD Albumin-2.9*
[**2132-4-16**] 05:50AM BLOOD CEA-<1.0
[**2132-4-15**] 02:59AM BLOOD Digoxin-1.0
[**2132-4-14**] 07:11PM BLOOD Lactate-2.2*

Studies:

CT Abd/Pelv - IMPRESSION: 1. Splenomegaly and extensive
lymphadenopathy involving the root of the mesentery,
retroperitoneum, pelvis, and inguinal areas most consistent with
lymphoma or lymphoproliferative disease. 2. Evaluation for liver
and kidney mass is limited due to lack of IV contrast. 11-mm
hepatic hypodensity is a nonspecific finding. If prior imaging
from outside hospital is made available, a direct comparison can
be made. 3. Small bilateral pleural effusions and left basilar
atelectasis. Consolidation cannot be excluded. 4. Low volume
ascites.

CXR - FINDINGS: Frontal and lateral views of the chest were
obtained. Relatively low lung volumes. The patient is status
post median sternotomy and cardiac valve replacement. There is
some obscuration of the left hemidiaphragm, which may be due to
a left pleural effusion with atelectasis. No large right pleural
effusion is seen, although a small one would be difficult to
exclude. There is prominence of the central pulmonary
vasculature.

LENI - IMPRESSION: No DVT in the right or left lower extremity.
Right calf veins could not be seen.

[**2132-4-23**]
Echo
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The right
ventricular free wall is hypertrophied. A bioprosthetic aortic
valve prosthesis is present. The transaortic gradient is higher
than expected for this type of prosthesis. The mitral valve
leaflets are mildly thickened. There is mild functional mitral
stenosis (mean gradient 7mmHg) due to mitral annular
calcification. Mild to moderate ([**12-17**]+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.

IMPRESSION: Mild symmetric right and left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. Mild-to-moderate mitral regurgitation.
Well-seated aortic valve bioprosthesis with higher-than-expected
gradients. Mild functional mitral stenosis from annular
calcification. Moderate pulmonary artery systolic hypertension.


[**2132-4-23**] CT Chest
IMPRESSION:
1.  Extensive mediastinal lymphadenopathy as described above.
2.  Moderate left-sided pleural effusion.
3.  Left lower lobe ground glass opacities which could be
infectious or
atelectasis due to poor inspiratory effort.

Left inguinal node biopsy
Lymph node, left inguinal, biopsies (A-C):

Diffuse Large B-cell lymphoma (See note).

Note:  The lymph node sections show areas of effacement of
normal architecture by medium to large lymphoid cells, with
abundant cytoplasm, oval to round nuclei with irregular nuclear
membrane, vesicular chromatin and prominent nucleoli.  Admixed
are small mature lymphocytes.  There are focal areas of
nodularity seen.  The immunohistochemical stains show diffusely
CD20 positive large B-cells, which are dimly positive for bcl-2
and CD21 (which especially highlights the nodular pattern), and
negative for bcl-1, CD5 and CD138.  CD3 highlights background of
scattered T-lymphocytes.  CD10 shows stroma staining and is
positive within residual follicles.  Kappa and Lambda stains are
uninformative.

MIB-1 staining is variable, with a proliferation rate of 30% in
follicle [**Doctor First Name **] areas, and up to 80% in other areas; the overall
proliferation index is 60-70%.

The above findings of focal nodular areas and higher grade
diffuse areas with large B-cell suggests that this is large
B-cell lymphoma arising from either marginal zone lymphoma (CD10
and CD5 negative) or CD10 negative follicular lymphoma.
Clinical correlation is suggested.

ADDENDUM:

This may be consistent with a large B-cell lymphoma associated
with the elderly.  [**Last Name (un) **] highlights several large cells
positively hybridized.  The overall diagnosis as above remains
unchanged.
Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl
Date: [**2132-4-29**]

Clinical:   left inguinal lymph node.
Gross:   The specimen is received fresh in a container labeled
with the patient's name, "[**Known lastname **], [**Known firstname 110512**]", the medical
record number,  and "left inguinal lymph node".  It consists of
a single lymph node measuring 2.6 x 2.4 x 1.5 cm.  A lymphoma
work up is done.  The specimen is serially sectioned and
entirely submitted in cassettes A-C.

FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed:  HLA-DR, FMC-7,
Kappa, Lambda, and CD antigens 2, 3, 5, 7, 10, 19, 20, 23, 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.

B cells comprise 76% of lymphoid-gated events.  B cells
demonstrate a monoclonal lambda light chain restricted
population.  They co-express pan-B cell markers CD19, 20 along
with CD10 (very dim), FMC7.  They do not express any other
antigens including CD5, CD23.

 T cells comprise 24% of lymphoid gated events.

INTERPRETATION

 Immunophenotypic findings consistent with involvement by:
Lambda light chain restricted B-cell lymphoma.  Correlation with
tissue morphologic diagnosis is recommended.

[**2132-4-29**] 06:55AM BLOOD Fact II-67* Fact V-93 FactVII-80 Fact
X-82
[**2132-4-25**] 06:50AM BLOOD LD(LDH)-311*
[**2132-4-23**] 10:00PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
[**2132-4-20**] 06:17AM BLOOD Hapto-391*
[**2132-4-16**] 05:50AM BLOOD CEA-<1.0
[**2132-4-24**] 12:45PM BLOOD HIV Ab-NEGATIVE
[**2132-4-23**] 10:00PM BLOOD HCV Ab-NEGATIVE
[**2132-4-16**] 05:50AM BLOOD CA [**38**]-9 -Test

Discharge

[**2132-4-29**] 11:00AM BLOOD WBC-12.0* RBC-3.41* Hgb-8.3* Hct-28.0*
MCV-82 MCH-24.5* MCHC-29.8* RDW-16.3* Plt Ct-446*
[**2132-4-27**] 03:10PM BLOOD Neuts-87.0* Lymphs-6.2* Monos-2.0
Eos-4.7* Baso-0.2
[**2132-4-29**] 11:00AM BLOOD Plt Ct-446*
[**2132-4-29**] 06:55AM BLOOD Glucose-47* UreaN-53* Creat-1.8* Na-138
K-4.5 Cl-101 HCO3-25 AnGap-17
[**2132-4-29**] 06:55AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.0

Brief Hospital Course:
Ms [**Known lastname **] is a pleasant, elderly female with a history of GAVE
presenting with 1 day of guiaic positive stool with hematocrit
slightly depressed below baseline of 27-30 (currently 25) and
possible melena at [**Hospital3 2558**] (confounded by her iron
supplementation).

#  Melena: Pt presented with reported melena from rehab and was
guaiac positive.  Significance of her GI bleed was unclear as
her stools have always been dark due to ferrous supplementation.
She has known GAVE which is likely source of her GI bleed.  Hct
initially was at  her baseline in the high 20s.  However, it
fell to 22 and she was transfused 1 unit PRBC while she was in
ICU.  She was placed on PPI drip.  GI was consulted who
recommended that EGD be deferred until pt was more optimized in
terms of her CHF.  She remained hemodynamically stable with no
BMs while in ICU. On floor, pts crits remained stable around
25-28, and had two consecutive crits of 21 on [**5-5**].  Her stools
were guiaic negative and did not have BRBPR or melena.  No other
source of bleed was identified.  She was transfused on unit and
her crits remained stable from 25-28.  She remained
hemodynamically stable and was discharged on home sucrulfate
dose and pantoprazole 40mg po BID.
.
# acute diastolic congestive heart failure: Pt had frequent
hospitalizations for CHF exacerbation, most recently at [**Hospital3 10959**] in early [**Month (only) 547**].  She appeared volume overloaded and BNP
was elevated. As there was concern for GI bleed and need for
transfusion, she was admitted to the ICU.  She received 100mg iv
lasix in ED.  She was placed on lasix gtt at 5units/hr while in
ICU.  She diuresed minimally in ICU. On the cardiology floor the
patient was initially continued on a lasix drip with good
output. Her drip was converted to intra-venous bolus of lasix
40-80 IV.  She diuresed well and had repeat echo that showed
ef>55%.  She was transitioned to home dose lasix of 80mg PO TID
and was discharged to rehab.  At time of discharge, she was
euvolemic, lungs were clear and she was satting in high 90s on
room air.
.
#  Lymphoma: During her recent hospitalization at OSH, a renal
ultrasound revealed a left renal hilum mass measuring 10.3 x 4.6
x 4.9 cm as well as lesions in the liver and pancreas.  A CT
contrast to evaluate these further could not be performed
because of her acute kidney injury at that time. A non-contrast
CT was performed here that revealed bulky [**Doctor First Name **] in the mesentery
concerning for lymphoma. The patient underwent inguinal LN
biopsy that revealed diffuse b-cell lymphoma.  Pt underwent
heme/onc evaluation while in house.  It was determined that pt
was not currently symptomatic from her disease burden.  Her ldh
and uric acid were elevated, but she has history of
hyperuricemia documented as outpt.  potassium and renal function
remained stable, and it was determined that she did not have
tumor lysis syndrome.  Treatment options were discussed with pt
and her family by heme onc attending, Dr. [**Last Name (STitle) **] [**Name (STitle) 84995**] and it was
determined that for the time being, treatment will be held as
she does not need urgent chemotherapy.  After rehab stay, she
will follow up as outpt with Dr. [**Last Name (STitle) 84995**] to make decision if
rituxim will be started.  If so, she will require inpt
treatment.
.
# Stage III CKD - Creatinine was initially elevated above
baseline but improved over the course of her hospital stay.
Creatinine remained 1.8-1.9.
.
# Coronary artery disease: She was continued on digoxin and
statin.  Dig level was wnl.  Labetalol and amlodipine were
initially held given concern for GI bleed.  It was unclear if
she was taking aspirin at home given her GAVE; this was not in
her medicines at home so was held at discharge.

# Diabetes: She was continued on insulin humalog sliding scale
and evening lantus.
.
.
FULL CODE:
transitional issues
- needs to follow up with Dr [**Last Name (STitle) 84995**] to discuss chemotherapy
options after rehab stay.
- pt had a VRE + dirty U/A during hospitalization.  repeat cx
pending at time of discharge.  Pt was asymptomatic so she was
not treated

Medications on Admission:
1. digoxin .125 mg wmf
2. lasix 80 mg daily TID
3. crestor 10 mg daily
4. labetalol 200 mg [**Hospital1 **]
5. sucralfate 1 gm daily
6. amlodipine 10 mg daily
7. lantus 20 units daily
8. humalog insulin sliding scale
9. prilosec 40 mg daily
10. ferrous sulfate 325 mg daily
11. xalatan 0.005%
12. fish oil 1000/1200 mg
13. vitamin D 1000 U
14. colace 200 mg daily
15. tylenol 500 mg daily
16. amoxicillin 500 mg daily


Discharge Medications:
1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO MWF.
2. rosuvastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day.
5. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. insulin glargine 100 unit/mL Solution Sig: Twenty (20) U
Subcutaneous once a day.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. insulin lispro 100 unit/mL Solution Sig: 2-10 units
Subcutaneous once a day: Sliding scale insulin: 0-200 no units;
201-250= 2 units; 251-300=4 units; 301-350= 6 units; 351-400= 8
units; 401-450=10units; >450 call PCP.
13. furosemide 80 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Diastolic Congestive Heart Failure
diffuse large b-cell lymphoma


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]!

You were admitted due to a gastro-intestinal bleed. You were
monitored carefully in the intensive care unit and had no
further bleeding. You were transferred to the cardiology
service.

On the cardiology service it was noted that you had too much
fluid on your body. You received diuretics with good response.
Additionally, a CT scan of your abdomen showed enlarged lymph
nodes.  We performed a inguinal lymph node biopsy which revealed
lymphoma.  We consulted the hematology/oncology department and
it was determined that your cancer is not causing any of your
current symptoms and can be treated as an outpatient.

See below for changes made to your home medication regimen:
stop omeprazole and start pantoprazole 40mg by mouth twice daily
stop amoxicillin
stop amlodipine

please see below for follow up instructions

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) **], MD, the Atrius oncology
attending that consulted during this hospitalization.

Name:[**Name6 (MD) **] [**Name8 (MD) 84995**], MD
Specialty: Hematology/Oncology
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3468**]
When: We are working on a follow up appointment.  You will be
notified of the appointment.  If you have not heard in two
business days, please call above number for status.
{'Angiodysplasia of stomach and duodenum with hemorrhage,Acute on chronic diastolic heart failure,Other malignant lymphomas, lymph nodes of multiple sites,Other and unspecified coagulation defects,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Long-term (current) use of insulin,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Thrombocytopenia, 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: Melena

PRESENT ILLNESS: Ms [**Known lastname **] is a 80 year old female who is presenting to us from
rehab ([**Hospital3 2558**]) with new melena.

MEDICAL HISTORY: 1. diabetes
2. congestive heart failure
3. hyperlipidemia
4. hypertension
5. type II diabetes
6. GAVE
7. coronary artery disease s/p 2 stents - [**2116**] in circumflex,
and LAD
8. aortic stenosis s/p AVR (bioprosthetic)
9. stage III CKD
10. hx of CVA

MEDICATION ON ADMISSION: 1. digoxin .125 mg wmf
2. lasix 80 mg daily TID
3. crestor 10 mg daily
4. labetalol 200 mg [**Hospital1 **]
5. sucralfate 1 gm daily
6. amlodipine 10 mg daily
7. lantus 20 units daily
8. humalog insulin sliding scale
9. prilosec 40 mg daily
10. ferrous sulfate 325 mg daily
11. xalatan 0.005%
12. fish oil 1000/1200 mg
13. vitamin D 1000 U
14. colace 200 mg daily
15. tylenol 500 mg daily
16. amoxicillin 500 mg daily

ALLERGIES: Latex

PHYSICAL EXAM: On admission:
Vitals reveal a regular pulse 60-70.  Systolic ejection murmur
is heard best in aortic area.
Respiratory rate is 18 with no significant accessory muscle use.
 Oxygen saturation is 98% on 2 L of oxygen.
Her blood pressure reveals a wide pulse pressure with systolic
of 140 and diastolic of 30-40.
In general, she is Caucasian, a thin, pleasant, elderly woman,
appropriate to conversation, inquisitive, alert, and oriented to
person, place and time.
Cardiovascular exam shows no appreciable JVP, pulses 2+ and
equal bilaterally, with a systolic ejection murmur without
clicks loudest in aortic area.   Pulmonary exam reveals mild
crackles at bases bilaterally, free of wheezes, with respiratory
rate of 18.  Abdominal exam shows a distended, tympanic abdomen,
with no appreciable masses or tenderness.  Extremities are quite
swollen, with 3+ pitting edema to the thighs bilaterally.  No
cyanosis, warm fingers and toes.  Neurologically non-focal.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: She lives in [**Hospital1 **] with her younger sister.  She has
been back and forth between [**Hospital3 2558**] and [**Hospital3 60734**].  She used to work in a publishing house until age 75. 

### Response:
{'Angiodysplasia of stomach and duodenum with hemorrhage,Acute on chronic diastolic heart failure,Other malignant lymphomas, lymph nodes of multiple sites,Other and unspecified coagulation defects,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Long-term (current) use of insulin,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Thrombocytopenia, unspecified'}
