CHIEF COMPLAINT: BRBPR

PRESENT ILLNESS: 56 y/o M with hx of afib, on coumadin, and SBOs s/p Meckle's
diverticulum repair in the past who presents with two days of
BRBPR and syncope today.  Starting last weekend, he had noticed
some blood in his stool that resolved on it's own.  Then two
days ago had similiar blood in his stool, but this time did not
stop.  He felt dizzy all day the day prior to admission.  He
passed out once after urinating.  Then again he had a large
bloody bowel movement and syncopized while on the toilet.  He
hit his head.  EMS reported a SBP of about 70 at the time of
initial evaluation.  His BPs have been stable since arrival to
the ED.
.
In general, he feels poorly.  He is cold and tired and has
shortness of breath.  He is in afib and is supertherapeutic on
his coumadin to 6.0 today.  After hitting his head, he denies
headache, dizziness, vision changes.
.
In the ED, initial vs were 94.5 orally, 111/65, 83, 18 and 99%
on RA. Patient was given 2 units of O negative PRBCs, 2 units of
FFP, profiline 30un/kg, 10 mg IV vitamin K and 40 mg IV
protonix.  He received a total of 3L IVFs.  He did not tolerate
an NG lavage but did vomit bilious heme negative vomit while in
the ED.
.
On the floor, he is feeling well.  He has had no more rectal
bleeding since arriving to the ED.

MEDICAL HISTORY: # SBOs managed non-operatively
# hx of gastric antral vasular esctasia
# iron deficiency anemia
# low back pain secondary to disc degeneration
# sleep apnea (uses CPAP)
# genital herpes
# hematuria ([**First Name3 (LF) 37566**] with GU [**Doctor Last Name 3748**] negative)
PSH:
s/p R knee replacement
s/p arthroscopic surgery L knee
s/p resection Meckel's diverticulum '[**01**]
s/p R thyroid lobectomy [**3-12**] ([**Doctor Last Name **])
Closed reduction and percutaneous pinning of left distal
interphalangeal joint ([**2139-1-29**])

MEDICATION ON ADMISSION: Coumadin 5 mg daily
ASA 81 mg daily
Metoprolol 12.5 mg daily
Percocet PRN, not using any

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 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

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: married with two children (son and [**Name2 (NI) **]), works as civil engineer
- Tobacco: none
- Alcohol: occasional, 3drinks/wk
- Illicits: none
Blood in stool,Pneumonia, organism unspecified,Iron deficiency anemia, unspecified,Lumbago,Atrial fibrillation,Long-term (current) use of anticoagulants,Diverticulosis of colon (without mention of hemorrhage),Internal hemorrhoids without mention of complication,Obstructive sleep apnea (adult)(pediatric),Angiodysplasia of stomach and duodenum without mention of hemorrhage
Blood in stool,Pneumonia, organism NOS,Iron defic anemia NOS,Lumbago,Atrial fibrillation,Long-term use anticoagul,Dvrtclo colon w/o hmrhg,Int hemorrhoid w/o compl,Obstructive sleep apnea,Angio stm/dudn w/o hmrhg
Admission Date:  [**2139-2-16**]              Discharge Date:   [**2139-2-19**]

Date of Birth:  [**2082-10-26**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
BRBPR

Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Blood Transfusion


History of Present Illness:
56 y/o M with hx of afib, on coumadin, and SBOs s/p Meckle's
diverticulum repair in the past who presents with two days of
BRBPR and syncope today.  Starting last weekend, he had noticed
some blood in his stool that resolved on it's own.  Then two
days ago had similiar blood in his stool, but this time did not
stop.  He felt dizzy all day the day prior to admission.  He
passed out once after urinating.  Then again he had a large
bloody bowel movement and syncopized while on the toilet.  He
hit his head.  EMS reported a SBP of about 70 at the time of
initial evaluation.  His BPs have been stable since arrival to
the ED.
.
In general, he feels poorly.  He is cold and tired and has
shortness of breath.  He is in afib and is supertherapeutic on
his coumadin to 6.0 today.  After hitting his head, he denies
headache, dizziness, vision changes.
.
In the ED, initial vs were 94.5 orally, 111/65, 83, 18 and 99%
on RA. Patient was given 2 units of O negative PRBCs, 2 units of
FFP, profiline 30un/kg, 10 mg IV vitamin K and 40 mg IV
protonix.  He received a total of 3L IVFs.  He did not tolerate
an NG lavage but did vomit bilious heme negative vomit while in
the ED.
.
On the floor, he is feeling well.  He has had no more rectal
bleeding since arriving to the ED.


Past Medical History:
# SBOs managed non-operatively
# hx of gastric antral vasular esctasia
# iron deficiency anemia
# low back pain secondary to disc degeneration
# sleep apnea (uses CPAP)
# genital herpes
# hematuria ([**First Name3 (LF) 37566**] with GU [**Doctor Last Name 3748**] negative)
PSH:
s/p R knee replacement
s/p arthroscopic surgery L knee
s/p resection Meckel's diverticulum '[**01**]
s/p R thyroid lobectomy [**3-12**] ([**Doctor Last Name **])
Closed reduction and percutaneous pinning of left distal
interphalangeal joint ([**2139-1-29**])


Social History:
married with two children (son and [**Name2 (NI) **]), works as civil engineer
- Tobacco: none
- Alcohol: occasional, 3drinks/wk
- Illicits: none


Family History:
non-contributory


Physical Exam:
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

Pertinent Results:
On admission:
[**2139-2-16**] 03:50AM BLOOD WBC-9.4 RBC-3.17*# Hgb-8.9*# Hct-26.6*#
MCV-84# MCH-28.0# MCHC-33.4 RDW-12.5 Plt Ct-298
[**2139-2-16**] 03:50AM BLOOD PT-53.9* PTT-34.1 INR(PT)-6.0*
[**2139-2-16**] 03:50AM BLOOD Glucose-131* UreaN-27* Creat-1.3* Na-141
K-3.8 Cl-110* HCO3-23 AnGap-12
[**2139-2-16**] 03:50AM BLOOD ALT-15 AST-17 AlkPhos-32* TotBili-0.3
[**2139-2-16**] 07:26AM BLOOD Calcium-7.5* Phos-2.2* Mg-1.9
[**2139-2-16**] 03:55AM BLOOD pH-7.49*
[**2139-2-16**] 03:55AM BLOOD Lactate-2.3* Na-137 K-3.8 Cl-107
calHCO3-21

[**2139-2-18**] EGD: Abnormal mucosa in the stomach. Otherwise normal
EGD to second part of the duodenum.
[**2139-2-18**] Colonoscopy: Diverticulosis of the sigmoid colon. No
evidence of bleeding. Grade 1 internal hemorrhoids. Otherwise
normal colonoscopy to terminal ileum.

Brief Hospital Course:
56-year-old male with a past medical history of atrial
fibrillation, on coumadin, Meckles diverticulum repair with
recurrent SBOs who presents with BRBPR in the setting of an
elevated INR.

# GI bleed: The patient was admitted to the ICU. He recieved 3 [**Location **] for a low hematocrit. His INR was elevated to 6.0 and
it was reversed with vitamin K. The bleeding appeared to stop
and the patient was stable. The patient was started on IV PPI
and had serial Hct drawn. He was stable and felt better and was
transferred to the regular floor. He was prepped and had a
colonoscopy and EGD without further bleeding. There was no
obvious source for the bleed. His hct was watched and he
continued to feel well. The patient was discharged with close
follow up. His cardiologist with contact him in regards to
restarting the coumadin. The patient also needs an outpatient
capsule endoscopy. This will be set up through his GI physician.

# Fever: The patient developed a fever and felt unwell. He had
rigors and was started on levofloxacin and metronidazole. He was
given IVF. He had a chest x-ray which showed a pneumonia. He was
treated with a 5 day course of antibiotics. He felt much better
and was afebrile the following day. He was discharged with close
follow up with his primary care physician.

# Atrial fibrillation: The patient had atrial fibrillation and
was on coumadin for a planned cardioversion. His INR was
elevated and was reversed due to the GI bleed. He was maintained
on a low dose of beta blocker for rate control. When he would
stand up he would become tachycardic to the 150s and thus had
his beta blocker dose increased. He was also given IVF. He was
well rate controlled on an increased dose of metoprolol at
discharge. He may need a cardiac monitor which will be set up by
his cardiologist. His cardiologist will also contact him in
regards to when to restart coumadin. He will likely need
cardioversion in the future.

# Syncope: This was likely in the setting of hypovolemia and
anemia, but may also be due to a tachyarrhythmia. He was
corrected per above. He felt well and have no further episodes
of syncope.

# SOB: The patient was SOB on admission. This was likely
secondary to symptomatic anemia. He was had a normal sat on 2L
NC. He was quickly weaned from oxygen and felt well after
administration of blood products.

# OSA: Continued CPAP per home settings


Medications on Admission:
Coumadin 5 mg daily
ASA 81 mg daily
Metoprolol 12.5 mg daily
Percocet PRN, not using any

Discharge Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
2. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
3. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Change as directed per Dr. [**Last Name (STitle) 131**].
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
1. GI bleed
2. Pneumonia

Secondary Diagnosis:
1. Iron deficiency anemia
2. low back pain
3. sleep apnea


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


Discharge Instructions:
You were admitted with a GI bleed. You were admitted to the ICU
and were transfused blood. You were found to have an elevated
INR, or high warfarin level. You had an endoscopy and
colonoscopy to look for the site of the bleed. No area of
bleeding was found. You were monitored and had no further
evidence of bleeding.

You then developed a fever and felt unwell. It was found that
you had a pneumonia. You were started on antibiotics called
levofloxacin and metronidazole. You improved and felt well
enought to be discharged.

You will need to have a capsule endoscopy as an outpatient. The
GI group will call you and set up an appointment to have this
done.

You will also need to follow up with your cardiologist Dr.
[**Last Name (STitle) **].  His office will call you to arrange this. You will
need to wear a heart monitor to evaluate your rhythm. The
cardiology group will mail this to your house with instructions.


The following changes were made to your medications:
1. INCREASE: Metoprolol succinate 25mg by mouth daily
2. START: Omeprazole 40mg by mouth twice a day
3. START: Levofloxacin 750mg by mouth daily for 4 days, last
dose [**2139-2-22**]
4. START: Metronidazole 500mg by mouth three times a day for 4
days, last dose [**2139-2-22**]
5. CHANGED: Coumadin changed to 2.5mg (you were on 5mg a day).
Dr. [**Last Name (STitle) 131**] will adjust this as needed. You INR will be followed by
Dr. [**Last Name (STitle) 131**] as below.

Followup Instructions:
Dr.[**Name (NI) 33376**] office will follow your INR.  Please go to the lab at
his office on MONDAY, [**2-23**] to have your INR drawn.  Dr.
[**Last Name (STitle) 131**] has already placed the order.  His office will call you to
adjust your coumadin dose.

You will need to follow up with Dr. [**Last Name (STitle) **], in the section of
cardiology. His office will call and set up an appointment with
you. If you do not hear from his by the beginning of next week
please call ([**Telephone/Fax (1) 2037**].

For Capsule Endoscopy;
ERCP 2 (ST-4) GI ROOMS
Date/Time:[**2139-3-3**] 8:00AM

Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD
Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2139-3-3**] 8:00

PAT-PREADMISSION TESTING
Phone:[**Telephone/Fax (1) 2289**]
Date/Time:[**2139-3-30**] 8:30
{'Blood in stool,Pneumonia, organism unspecified,Iron deficiency anemia, unspecified,Lumbago,Atrial fibrillation,Long-term (current) use of anticoagulants,Diverticulosis of colon (without mention of hemorrhage),Internal hemorrhoids without mention of complication,Obstructive sleep apnea (adult)(pediatric),Angiodysplasia of stomach and duodenum without mention of hemorrhage'}


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: 56 y/o M with hx of afib, on coumadin, and SBOs s/p Meckle's
diverticulum repair in the past who presents with two days of
BRBPR and syncope today.  Starting last weekend, he had noticed
some blood in his stool that resolved on it's own.  Then two
days ago had similiar blood in his stool, but this time did not
stop.  He felt dizzy all day the day prior to admission.  He
passed out once after urinating.  Then again he had a large
bloody bowel movement and syncopized while on the toilet.  He
hit his head.  EMS reported a SBP of about 70 at the time of
initial evaluation.  His BPs have been stable since arrival to
the ED.
.
In general, he feels poorly.  He is cold and tired and has
shortness of breath.  He is in afib and is supertherapeutic on
his coumadin to 6.0 today.  After hitting his head, he denies
headache, dizziness, vision changes.
.
In the ED, initial vs were 94.5 orally, 111/65, 83, 18 and 99%
on RA. Patient was given 2 units of O negative PRBCs, 2 units of
FFP, profiline 30un/kg, 10 mg IV vitamin K and 40 mg IV
protonix.  He received a total of 3L IVFs.  He did not tolerate
an NG lavage but did vomit bilious heme negative vomit while in
the ED.
.
On the floor, he is feeling well.  He has had no more rectal
bleeding since arriving to the ED.

MEDICAL HISTORY: # SBOs managed non-operatively
# hx of gastric antral vasular esctasia
# iron deficiency anemia
# low back pain secondary to disc degeneration
# sleep apnea (uses CPAP)
# genital herpes
# hematuria ([**First Name3 (LF) 37566**] with GU [**Doctor Last Name 3748**] negative)
PSH:
s/p R knee replacement
s/p arthroscopic surgery L knee
s/p resection Meckel's diverticulum '[**01**]
s/p R thyroid lobectomy [**3-12**] ([**Doctor Last Name **])
Closed reduction and percutaneous pinning of left distal
interphalangeal joint ([**2139-1-29**])

MEDICATION ON ADMISSION: Coumadin 5 mg daily
ASA 81 mg daily
Metoprolol 12.5 mg daily
Percocet PRN, not using any

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 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

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: married with two children (son and [**Name2 (NI) **]), works as civil engineer
- Tobacco: none
- Alcohol: occasional, 3drinks/wk
- Illicits: none 

### Response:
{'Blood in stool,Pneumonia, organism unspecified,Iron deficiency anemia, unspecified,Lumbago,Atrial fibrillation,Long-term (current) use of anticoagulants,Diverticulosis of colon (without mention of hemorrhage),Internal hemorrhoids without mention of complication,Obstructive sleep apnea (adult)(pediatric),Angiodysplasia of stomach and duodenum without mention of hemorrhage'}
