CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is an 84-year-old
female with no significant past medical history who presents
with one-day history of generalized weakness prior to
admission.  On the day of admission patient experienced an
approximate two-minute episode of syncope without head injury
or trauma.  It was a witnessed episode; however, the witness
was not available for interview.  She was brought to the
Emergency Room where her blood pressure there was 108/62 with
a heart rate of 102.  Her fingerstick at that time was 263.

MEDICAL HISTORY: 1.  Right knee surgery.
2.  She did have colonoscopy in [**3-/2150**] which demonstrated a
6 mm pedunculated polyp which was removed.

MEDICATION ON ADMISSION: 

ALLERGIES: She has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Family history is positive for breast
cancer, colon cancer, diabetes, and coronary artery disease
in her brother.

SOCIAL HISTORY: She lives with her daughter and was working
as a waitress approximately 40 hours a week.  She has
approximately two to three drinks a day.  No tobacco history.
Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Subendocardial infarction, initial episode of care,Thrombocytopenia, unspecified,Urinary tract infection, site not specified,Mitral valve disorders,Diseases of tricuspid valve,Congestive heart failure, unspecified,Acute posthemorrhagic anemia
Chr stomach ulc w hem,Pneumococcal pneumonia,Subendo infarct, initial,Thrombocytopenia NOS,Urin tract infection NOS,Mitral valve disorder,Tricuspid valve disease,CHF NOS,Ac posthemorrhag anemia
Admission Date:  [**2159-10-7**]     Discharge Date:  [**2132-1-28**]


Service:  MICU

HISTORY OF PRESENT ILLNESS:  The patient is an 84-year-old
female with no significant past medical history who presents
with one-day history of generalized weakness prior to
admission.  On the day of admission patient experienced an
approximate two-minute episode of syncope without head injury
or trauma.  It was a witnessed episode; however, the witness
was not available for interview.  She was brought to the
Emergency Room where her blood pressure there was 108/62 with
a heart rate of 102.  Her fingerstick at that time was 263.

The patient also described having some chest pain radiating
to the back.  Chest x-ray was done which did not show a
widened mediastinum, and an EKG was performed which showed a
left bundle branch block with some ST changes in the lateral
precordial leads.  Patient was given one sublingual
nitroglycerin for the chest pain, and it was also noted that
she had had some blood around her lips and was guaiac
positive.  An nasogastric lavage was performed which
demonstrated gross blood which cleared after approximately
200 cc of normal saline lavage.  During this time her blood
pressure decreased to 67/48 and Dopamine was started
transiently, and a right internal jugular cordis was placed,
and she began receiving two units of packed red cells and
four liters of normal saline.  Hematocrit in the Emergency
Department was noted to be 18.8.

Patient denies any systemic symptoms such as fever, chills,
nausea, vomiting, diarrhea, shortness of breath.  She denies
hematochezia.  She denies any symptoms suggestive of
coagulopathy.

PAST MEDICAL HISTORY:
1.  Right knee surgery.
2.  She did have colonoscopy in [**3-/2150**] which demonstrated a
6 mm pedunculated polyp which was removed.

ALLERGIES:  She has no known drug allergies.

MEDICATIONS:  She does report taking nonsteroidal
anti-inflammatory drugs for many years for musculoskeletal
complaints.

SOCIAL HISTORY:  She lives with her daughter and was working
as a waitress approximately 40 hours a week.  She has
approximately two to three drinks a day.  No tobacco history.

FAMILY HISTORY:  Family history is positive for breast
cancer, colon cancer, diabetes, and coronary artery disease
in her brother.

PHYSICAL EXAMINATION:  Vitals on admission:  She is afebrile.
She has a blood pressure after fluid resuscitation of 128/71,
pulse of 101, respiratory rate of 20, she was satting 100% on
two liters nasal cannula.  HEENT:  Mucous membranes are
moist.  Oropharynx is clear.  Extraocular movements are full.
Pupils are equal, round, reactive.  She has pale
conjunctivae.  She is noted to have some dried blood around
her lips.  Neck:  No jugular venous distention; supple
without lymphadenopathy.  Cardiac exam:  She is sinus tach
with a II/VI systolic murmur at the left lower sternal
border.  Abdomen is soft, nontender; no masses.  Her
extremities reveal no edema; cool.  Neurological exam is
nonfocal.

LABORATORY DATA ON ADMISSION:  She had a white count of 10.6,
hematocrit of 18.8, platelets of 232.  Chem-7:  Sodium of
141, potassium of 4.1, chloride of 108, bicarbonate of 25,
BUN of 52, creatinine of 0.7, and glucose of 119.  Calcium,
magnesium and phosphorous of 8.9, 1.9, and 3.6.

EKG showed sinus rhythm at 90 with a left bundle branch block
with some EKG changes consistent with ischemia in the lateral
precordial leads; however, it is difficult to interpret in
the setting of a left bundle.  The left bundle was reported
to be old from outside reports.

Chest x-ray showed a non-widened mediastinum.

HOSPITAL COURSE BY ISSUE:
1.  Upper gastrointestinal bleed:  The patient was transfused
with a total of 12 units of packed red blood cells during the
course of her hospital stay.  She was evaluated by the GI
service which performed endoscopy times two.  First endoscopy
revealed an ulcer along the lesser curvature of the stomach
with a visible vessel.  This was clipped times two and
epinephrine was injected around the sites.  The patient
continued to bleed after this first intervention and required
a second endoscopy, at which time no further banding was
performed.  However, electric cautery was used to achieve
hemostasis.  She also received epinephrine injections at that
time.

The patient was also started on proton pump inhibitor for her
upper GI bleed, and throughout the course of her hospital
stay her hematocrit remained stable after this second
intervention by endoscopy with a stable hematocrit in the low
30s.  She should be scheduled for an EGD in six months to
reevaluate this ulcer.  It is believed that the etiology of
this ulcer is her heavy NSAID use and also alcohol use.  She
was also found to be positive for H. pylori, and she began
therapy with Pantoprazole, Clarithromycin, and Amoxicillin
for which she will complete a 14-day course.

2.  Her next issue is a pneumonia:  The patient was intubated
for airway protection prior to her second endoscopy.  She
tolerated extubation.  However, chest x-ray revealed left
lower lobe infiltrate.  Patient was initially started on
Zosyn and Vancomycin for presumed ventilator-associated
pneumonia.  Sputum cultures demonstrated Streptococcus
pneumoniae and a gram negative rod which was not speciated.
The Vancomycin was discontinued, and her Zosyn was
discontinued in the setting of her starting Amoxicillin and
Clarithromycin for H. pylori.  She will complete a 14-day
course of these antibiotics for H. pylori, which will
sufficiently cover for her pneumonia.  After a 14-day course
of these antibiotics, Ms. [**Known lastname **] will have received a total
of 21 days of antibiotic coverage.

3.  Acute myocardial infarction:  The patient did rule in by
enzymes.  She did have some EKG changes suggestive of
ischemia; however, it is difficult to interpret in the
setting of a left bundle branch block.  The patient was
started on a beta blocker.  However, aspirin was held due to
her upper GI bleed.

It is believed that the acute myocardial infarction is
secondary to demand ischemia in the setting of large blood
loss and reflux tachycardia.  The patient should be started
on low-dose ACE inhibitors as her pressure can tolerate and
should be followed up by Cardiology to evaluate the acute MI
now that her upper GI bleed has been stabilized.

4.  Thrombocytopenia:  The patient did have platelets in the
low 100s; however, this is in the setting of multiple rounds
of transfusions of red cells.  It is believed that the
thrombocytopenia is dilutional in the setting of repeated
blood transfusions.  Once the blood transfusions stopped her
platelets bumped appropriately to the mid 200s.

5.  Urinary tract infection:  Patient did have pansensitive
E. coli grown out in her urine.  She received a full five-day
course of antibiotics, three days of Zosyn, and two days of
ceftriaxone for this infection.

6.  Mental status changes:  The last two days of her
Intensive Care Unit stay patient did have some decreased
mental status.  It was believed this was secondary to
benzodiazepines that were given to the patient.  Once these
were discontinued, her mental status returned appropriately.

This discharge summary will be completed on discharge.
Further information, such as condition on discharge,
discharge status, discharge diagnosis, and discharge
medications, and follow-up plans, will be provided by the
discharging intern.





                          [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7585**]

Dictated By:[**Last Name (NamePattern1) 11207**]

MEDQUIST36

D:  [**2159-10-14**]  14:03
T:  [**2159-10-15**]  20:50
JOB#:  [**Job Number 93321**]


Name:  [**Known lastname **], [**Known firstname **]             Unit No:  [**Numeric Identifier 14723**]

Admission Date:  [**2159-10-7**]     Discharge Date:  [**2159-10-17**]

Date of Birth:   [**2075-2-25**]     Sex:  F

Service:  ICU/MED

ADDENDUM:  This is a continuation of the [**Hospital 1325**] hospital
course.

CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM
(CONTINUED):

1.  GASTROINTESTINAL BLEED ISSUES:  The patient had a
gastrointestinal bleed which was treated in the Intensive
Care Unit with clipping and cauterization.  The patient's
hematocrit remained stable; however, the patient did have an
episode of melena while on the floor.  Therefore, the patient
was taken back to endoscopy and again cauterization was
performed on ulceration.  The patient was continued on
lansoprazole 30 mg by mouth twice per day as well as with
clarithromycin, and amoxicillin for Helicobacter pylori
treatment.  The patient had no further episodes of bleeding.

2.  PNEUMONIA ISSUES:  In terms of her pneumonia, the patient
was being covered for pneumonia by her Helicobacter pylori
treatment.  The patient had improvement of her symptoms.  She
was continued for a full 14-day course of antibiotics on
discharge.

3.  MYOCARDIAL INFARCTION ISSUES:  In terms of her myocardial
infarction, the patient did have a myocardial infarction in
the setting of an acute gastrointestinal bleed with a
hematocrit drop of 36 to 18.  The patient remained stable.

The patient did have an echocardiogram as an inpatient which
documented an ejection fraction of 45% to 50%.  In addition,
the echocardiogram showed that the left atrium was mildly
dilated, the left ventricular cavity size was normal, and
there was mild regional left ventricular systolic
dysfunction.  The patient also had severe 3+ mitral
regurgitation as well as moderate 2+ tricuspid regurgitation.

The patient was scheduled to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 998**] as an outpatient.  The patient should also likely
have an exercise stress test as an outpatient.

CONDITION AT DISCHARGE:  The patient's condition on discharge
was stable.

DISCHARGE STATUS:  The patient was discharged to home with
services.

DISCHARGE DIAGNOSES:
1.  Gastrointestinal bleed.
2.  Gastric ulcer.
3.  Myocardial infarction.
4.  Mitral regurgitation (severe).

MEDICATIONS ON DISCHARGE:  (The patient was discharged on the
following medications)
 1.  Metoprolol 50 mg by mouth twice per day.
 2.  Lansoprazole 30-mg tablets one tablet by mouth twice per
day.
 3.  Clarithromycin 500 mg by mouth twice per day.
 4.  Amoxicillin 1000 mg by mouth twice per day (times 10
days).
 5.  Amoxicillin 2 g one hour before dental work (times one
dose in the event the patient has dental work in the future
given her mitral regurgitation).
 6.  Diovan 40 mg by mouth once per day.
 7.  Tylenol Extra-Strength 500-mg tablets one to two tablets
by mouth three times per day as needed (for pain).
 8.  Tessalon Perles 100-mg tablets one to two tablets by
mouth three times per day as needed (for cough).
 9.  Os-Cal one tablet by mouth twice per day.
10.  Iron sulfate 500 mg by mouth twice per day.
11.  Vitamin C.
12.  Folate.

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient was instructed to follow up for outpatient
laboratory work on the Monday following discharge for a
hematocrit check.
2.  The patient was scheduled to see Dr. [**Last Name (STitle) 14724**] as a primary
care physician on [**10-30**].
3.  The patient was also to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 998**] for cardiology followup given the myocardial
infarction in the setting of acute gastrointestinal bleeding.
4.  The patient was also instructed to follow up with her
gastroenterologist and was told to call if she noted any
further black or tarry stools or bright red blood per rectum
with her bowel movements or vomited any blood.
5.  The patient was also instructed to take the amoxicillin
antibiotic one hour prior to any dental procedure or teeth
cleaning.





                          [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 692**], M.D.  [**MD Number(2) 693**]

Dictated By:[**Name8 (MD) 1314**]

MEDQUIST36

D:  [**2159-10-18**]  14:25
T:  [**2159-10-19**]  12:08
JOB#:  [**Job Number 14725**]
{'Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Subendocardial infarction, initial episode of care,Thrombocytopenia, unspecified,Urinary tract infection, site not specified,Mitral valve disorders,Diseases of tricuspid valve,Congestive heart failure, unspecified,Acute posthemorrhagic anemia'}


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: 

PRESENT ILLNESS: The patient is an 84-year-old
female with no significant past medical history who presents
with one-day history of generalized weakness prior to
admission.  On the day of admission patient experienced an
approximate two-minute episode of syncope without head injury
or trauma.  It was a witnessed episode; however, the witness
was not available for interview.  She was brought to the
Emergency Room where her blood pressure there was 108/62 with
a heart rate of 102.  Her fingerstick at that time was 263.

MEDICAL HISTORY: 1.  Right knee surgery.
2.  She did have colonoscopy in [**3-/2150**] which demonstrated a
6 mm pedunculated polyp which was removed.

MEDICATION ON ADMISSION: 

ALLERGIES: She has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Family history is positive for breast
cancer, colon cancer, diabetes, and coronary artery disease
in her brother.

SOCIAL HISTORY: She lives with her daughter and was working
as a waitress approximately 40 hours a week.  She has
approximately two to three drinks a day.  No tobacco history. 

### Response:
{'Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Subendocardial infarction, initial episode of care,Thrombocytopenia, unspecified,Urinary tract infection, site not specified,Mitral valve disorders,Diseases of tricuspid valve,Congestive heart failure, unspecified,Acute posthemorrhagic anemia'}
