CHIEF COMPLAINT: Blood stools

PRESENT ILLNESS: Mr. [**Known lastname 101054**] is a 64 male with DMII, ESRD on HD, Hep C and Hep
B, who presented from dialysis after having blood streaked stool
and Hct drop of 27 to 20. The patient also has a PMH significant
for chronic anemia, internal hemorrhoids, gastritis, ischemic
colitis, and AVMs in his small bowel and colon. Of note, Mr
[**Known lastname 101054**] received a colonoscopy 2 weeks ago for acute on chronic
anemia (his Hct had drifted down to 17.9), and his colonoscopy
was normal. Prior to the current episode of bloody stool, Mr
[**Known lastname 101054**] denied history of melena. His last EGD one year ago in
[**2188-12-25**] was unremarkable. While having the bloody stool
yesterday the pt denied nausea, vomiting, abdoinal pain or
discomfort. He came to the Ed at [**Hospital1 18**] [**2190-2-9**] where initial VS
98.1, 75, 157/88, 18 and 100/RA. He had one maroon stool in ED.
Rectal exam notable for guaiac + brown to marroon stool but
otherwise abdomen benign. Refused NG lavage. Access obtained
with 2 x 16g peripherals. His Hct in the ED was found to be 20.
He was transferred to the MICU where he received 3 units of
blood with hematocrit increasing from 20 to 27.

MEDICAL HISTORY: -- CKD V from diabetic nephropathy on HD since [**5-/2183**]
-- DM2 for over 20 years on insulin
-- Hepatitis C genotype 4; liver biopsy [**2186-8-10**] revealed grade

MEDICATION ON ADMISSION: 1. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Cephalosporins / Metoclopramide / Infed

PHYSICAL EXAM: ADMISSION EXAMVitals:
T:98.4 P: 80 BP:124/62 R: 18 SaO2:85% on RA --> 94% 2L (does not
use O2 at home)
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, Mildly dry MM, no lesions noted in OP
Neck: supple, no JVD
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: bilateral BKAs, no edema
Lymphatics: No cervical, supraclavicular lymphadenopathy noted.

FAMILY HISTORY: Several siblings with diabetes

SOCIAL HISTORY: Retired computer worker. Smokes 5 cigarettes per day x 10+
years; denies alcohol use; former IVDU. Came to [**Hospital1 18**] from [**Hospital1 1501**]
the Embassy House in [**Hospital1 1474**]
Portal hypertension,Esophageal varices in diseases classified elsewhere, with bleeding,Duodenitis, with hemorrhage,End stage renal disease,Acute posthemorrhagic anemia,Hyperpotassemia,Renal dialysis status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified disease of pancreas,Chronic hepatitis C without mention of hepatic coma,Tobacco use disorder,Below knee amputation status
Portal hypertension,Bleed esoph var oth dis,Duodenitis w hmrhg,End stage renal disease,Ac posthemorrhag anemia,Hyperpotassemia,Renal dialysis status,DMII wo cmp nt st uncntr,Pancreatic disease NOS,Chrnc hpt C wo hpat coma,Tobacco use disorder,Status amput below knee
Admission Date:  [**2190-2-9**]              Discharge Date:   [**2190-2-11**]

Date of Birth:  [**2125-5-16**]             Sex:   M

Service: MEDICINE

Allergies:
Cephalosporins / Metoclopramide / Infed

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Blood stools

Major Surgical or Invasive Procedure:
EGD [**2190-2-10**]

History of Present Illness:
Mr. [**Known lastname 101054**] is a 64 male with DMII, ESRD on HD, Hep C and Hep
B, who presented from dialysis after having blood streaked stool
and Hct drop of 27 to 20. The patient also has a PMH significant
for chronic anemia, internal hemorrhoids, gastritis, ischemic
colitis, and AVMs in his small bowel and colon. Of note, Mr
[**Known lastname 101054**] received a colonoscopy 2 weeks ago for acute on chronic
anemia (his Hct had drifted down to 17.9), and his colonoscopy
was normal. Prior to the current episode of bloody stool, Mr
[**Known lastname 101054**] denied history of melena. His last EGD one year ago in
[**2188-12-25**] was unremarkable. While having the bloody stool
yesterday the pt denied nausea, vomiting, abdoinal pain or
discomfort. He came to the Ed at [**Hospital1 18**] [**2190-2-9**] where initial VS
98.1, 75, 157/88, 18 and 100/RA. He had one maroon stool in ED.
Rectal exam notable for guaiac + brown to marroon stool but
otherwise abdomen benign. Refused NG lavage. Access obtained
with 2 x 16g peripherals. His Hct in the ED was found to be 20.
He was transferred to the MICU where he received 3 units of
blood with hematocrit increasing from 20 to 27.

GI was consulted in the ED and plans were made to do EGD. Pt
underwent EGD today which showed gastritis but no active
bleeding.
Of note, he did not get full dialysis yesterday and states that
his last dialysis was Saturday.

ROS:
(+)As per HPI. Also + for chronic diarrhea over the past 6
months (pt thinks this has correlated with decreasing his
methadone dose).

Past Medical History:
-- CKD V from diabetic nephropathy on HD since [**5-/2183**]
-- DM2 for over 20 years on insulin
-- Hepatitis C genotype 4; liver biopsy [**2186-8-10**] revealed grade

1 inflammation and stage III fibrosis; never treated with IFN
-- S/p bilat BKA ([**2179**], [**2183**]) for polymicrobial chronic
osteomyelitis; wears prostheses and uses walker
-- H/o ischemic colitis with GIB (approx [**2180**]), occ BRBPR; known
small bowel AVMs
-- HTN
-- H/o TB (age 15, Rx with PAS/INH x 2 yrs)
-- Hep B core Ab positive (negative viral load in [**2185**])
-- H/o IV drug use (heroin), on methadone since [**2159**] (100 mg
daily; does not recall name/number of methadone program)
-- Prior right AV fistula infection
-- H/o VRE and MRSA
-- Chronic anemia
-- Prior MSSA HD line infection
-- Prior ESBL Klebsiella wound infections
-- s/p penectomy for necrosis [**1-26**] arterial insufficiency

Social History:
Retired computer worker. Smokes 5 cigarettes per day x 10+
years; denies alcohol use; former IVDU. Came to [**Hospital1 18**] from [**Hospital1 1501**]
the Embassy House in [**Hospital1 1474**]

Family History:
Several siblings with diabetes

Physical Exam:
ADMISSION EXAMVitals:
T:98.4 P: 80 BP:124/62 R: 18 SaO2:85% on RA --> 94% 2L (does not
use O2 at home)
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, Mildly dry MM, no lesions noted in OP
Neck: supple, no JVD
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: bilateral BKAs, no edema
Lymphatics: No cervical, supraclavicular lymphadenopathy noted.

Skin: fleshy, crusty papular lesions along right forearm and
left knuckles.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
slowly
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. movign all
extremities


Pertinent Results:
ADMISSION LABS
[**2190-2-9**] 08:41AM BLOOD WBC-4.6 RBC-2.23* Hgb-6.5* Hct-20.7*
MCV-93 MCH-29.3 MCHC-31.5 RDW-17.5* Plt Ct-209

[**2190-2-9**] 08:41AM BLOOD PT-15.6* PTT-35.8* INR(PT)-1.4*

[**2190-2-9**] 08:41AM BLOOD Glucose-132* UreaN-74* Creat-8.0*# Na-145
K-6.9* Cl-109* HCO3-23 AnGap-20

[**2190-2-9**] 08:47AM BLOOD Glucose-129* Lactate-1.3 Na-145 K-6.9*
Cl-108 calHCO3-24

Brief Hospital Course:
64 yo M with PMH of ESRD, DM2, Hepatitis C as well as gastritis,
colonic AVM and internal hemorrhoids, who presented [**2190-2-9**] from
HD after having brown to marroon stools.

# GI bleed:  Given hematocrit drop to 20.7 from most recent of
27.4, patient was admitted to ICU.  During first day of
admission, patient was treated with IV Pantoprazole and 3U PRBC.
 Hct improved appropriately.  The following day, he underwent
EGD and was found to have esophageal varices, erosive gastritis
in the setting of portal hypertensive gastritis, duodenitis but
otherwise normal EGD to second part of the duodenum.  Given
concern that esophageal varices may represent worsening liver
disease, liver ultrasound was obtained.  This showed slightly
nodular surface and enlargement of the left lobe, suggesting
cirrhosis, without evidence of a focal lesions.  The portal vein
demonstrated normal hepatopetal flow and was patent.  An
incidental finding was a hypoechoic region that measured 3.0 x
2.8 x 1.9 cm (see below). GI recommended that the patient get a
capsule endoscopy as an outpatient given concern for AV
malformations or other small bowel pathology causing the melena.
 The patient was restarted on a clear diet then advanced to
regular cardiac/diabetic diet.  He tolerated this well.  He did
finally have one small melenotic stool the afternoon of [**2190-2-11**],
but his hematocrit was stable at 28 on discharge.  The patient
was given the number to call and schedule his capsule endoscopy
in the next 1 to 2 weeks and was scheduled GI follow up on [**3-17**] [**2189**].  The patient was told to not restart his aspirin
given the bleeding until he talks with his primary care doctor.
He was discharged on twice daily 40 mg omeprazole.  He should
continue to get daily hematocrit checks until his melena stops
and his hematocrit is stable.
.
# Pancreatic mass: An incidental finding on the patient's liver
ultrasound was a hypoechoic region that measured 3.0 x 2.8 x 1.9
cm.  It was difficult to assess whether this region represented
part of the duodenum or arises from the pancreatic head or
ampulla. Further imaging was recommended, however the patient
did not want to stay in the hospital for this test.  He was
given the number to call and schedule this as an outpatient.  He
should get a CT abdomen with contrast with pancreatic
sequencing.  It would be preferable that he schedule this test
on a day before he has hemodialysis.
.
# Hepatitis:  The patient has suggestion of cirrhosis on liver
ultrasound.  He does not follow with a hepatologist and has
never had therapy for his hepatitis. He was scheduled an
outpatient appointment with Dr. [**Last Name (STitle) 7033**] in hepatology on [**3-10**].
.
# End stage renal disease: The patient normally receives
dialysis on T/Th/Saturday. He was dialyzed the morning of
[**2190-2-11**].  His outpatient medications, Sevelamer and Cinacalcet,
were continued.
.
# Diabetes type II: The patient's last HbA1c was 5.5 on [**11-2**].
He was continued on his home dose insulin.
.
# History of IV drug use. The patient was continued on his home
dose of methadone 10 mg twice a day.
.
# Upper extremity edema/facial edema. The patient was noted to
have significant left arm and facial edema.  Per OMR records he
presented with this back in Novermber [**2188**] and underwent full
work up with ultrasound, CT and MR venography which all did not
show evidence of clot.  The patient was not on coumadin.  He did
not receive DVT prophylactic anticoagulation during this
hospitalization given the concern for GI bleeding.
.
# Code: full code


Medications on Admission:
1. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two
(2)Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)

Intravenous HD PROTOCOL (HD Protochol) -- Through [**2190-1-31**]
13. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-26**] Sprays Nasal
QID (4 times a day) as needed for congestion.
14. Aranesp (Polysorbate) 100 mcg/mL Solution Sig: One (1) ml
Injection once a week.
15. Insulin
Insulin Glargine (Lantus) 15mg subcutaneous, qhs
16. Insulin
Insulin Lispro (Humalog) Administer according to the following
sliding scale: 2 units for BS 151-200, 4 units for BS 201-250, 6

units for BS 251-300, 8 units for BS 301-350, 10 units for BS
351-400. Please check fingerstick blood sugars qid
17. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.
19. Doxepin 10 mg Capsule Sig: One (1) Capsule PO at bedtime
20. Vitamin B12 1000mg daily.
21.  Ferrous sulfate 325 mg po daily.

Discharge Medications:
1. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lo-Peramide 2 mg Tablet Sig: Two (2) Tablet PO four times a
day as needed for diarrhea.
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Aranesp (Polysorbate) 100 mcg/mL Solution Sig: One (1)
injection Injection once a week: on Tuesdays.
9. Doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. Ferrous Sulfate 300  mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime.
14. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Rehab

Discharge Diagnosis:
Primary diagnosis:
Gastritis
Esophageal varices
Duodinitis
Pancreatic lesion

Secondary diagnosis:
End stage renal disease
Diabetes


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair


Discharge Instructions:
You came to the hospital because you were having bright red
blood in your stool at hemodialysis.  You had an upper endoscopy
which showed that you have Esophageal varices, Erosive gastritis
in the setting of portal hypertensive gastritis, and Duodenitis.
 It is possible that these are the sources of your bleeding.
However, the GI doctors would [**Name5 (PTitle) **] [**Name5 (PTitle) **] to have another study
called a capsule endoscopy to varify this.  You are on a
medication called pantoprazole to help protect your stomach from
bleeding.

While you were here you also had a liver ultrasound.  This
showed that your liver may have some cirrhosis.  It also showed
an incidental finding of a lesion that is near your pancreas.
Further studies need to be obtained to find out if this is a
mass or tumor.  We would like you to have a CT scan to better
assess what this lesion is.  You can have this done as an
outpatient.

The following changes have been made to your medications:
Please increase omeprazole to 40 mg twice a day
Please stop aspirin and talk to your primary care doctor about
when to restart this medication

Please follow up with your primary care doctor.  You should also
follow up with the gastroenterologists as well as a
hepatologist.


Followup Instructions:
Please follow up with your primary care doctor in the next 1 to
2 weeks.  Someone will call you from his office to schedule this
appointment.  If you do not get a phonecall please call his
office at [**Telephone/Fax (1) 6019**].

Please also schedule your capsule endoscopy study for sometime
in the next 1 to 2 weeks.  To do this you need to call ([**Telephone/Fax (1) 26817**] and hit the number #[**Serial Number **].  This will take you to the
receptionist (named [**Name (NI) 13544**]) who will make the appointment for
you.  At least 2 weeks after you have this study you will need
to follow up with the gastroenterologists.  We have made a
follow up appointment for you on [**3-17**], at 2pm with Dr.
[**Last Name (STitle) 101145**] [**Name (STitle) **].  Please come to the RA [**Hospital Unit Name **]
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]  for this appointment.

You also should follow up with a liver doctor for your hepatitis
and liver cirrhosis.  We have made an appointment for you on
[**3-10**] at 8:30 am at the Liver Center in the [**Hospital Unit Name **],
located at [**Last Name (NamePattern1) **] on the [**Location (un) **], Suite 8E.  You will
be seeing Dr. [**Last Name (STitle) 7033**].

In addition, you stated that you did not want to stay in the
hospital to have a CT scan of your abdomen.  You will still need
to get this CT scan to better evaluate the mass seen on your
liver ultrasound. Please call to schedule a time to get this
scan.  The number to call is [**Telephone/Fax (1) 327**].  Please hit #1 when
prompted to get to the scheduler.


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
{'Portal hypertension,Esophageal varices in diseases classified elsewhere, with bleeding,Duodenitis, with hemorrhage,End stage renal disease,Acute posthemorrhagic anemia,Hyperpotassemia,Renal dialysis status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified disease of pancreas,Chronic hepatitis C without mention of hepatic coma,Tobacco use disorder,Below knee amputation status'}


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: Blood stools

PRESENT ILLNESS: Mr. [**Known lastname 101054**] is a 64 male with DMII, ESRD on HD, Hep C and Hep
B, who presented from dialysis after having blood streaked stool
and Hct drop of 27 to 20. The patient also has a PMH significant
for chronic anemia, internal hemorrhoids, gastritis, ischemic
colitis, and AVMs in his small bowel and colon. Of note, Mr
[**Known lastname 101054**] received a colonoscopy 2 weeks ago for acute on chronic
anemia (his Hct had drifted down to 17.9), and his colonoscopy
was normal. Prior to the current episode of bloody stool, Mr
[**Known lastname 101054**] denied history of melena. His last EGD one year ago in
[**2188-12-25**] was unremarkable. While having the bloody stool
yesterday the pt denied nausea, vomiting, abdoinal pain or
discomfort. He came to the Ed at [**Hospital1 18**] [**2190-2-9**] where initial VS
98.1, 75, 157/88, 18 and 100/RA. He had one maroon stool in ED.
Rectal exam notable for guaiac + brown to marroon stool but
otherwise abdomen benign. Refused NG lavage. Access obtained
with 2 x 16g peripherals. His Hct in the ED was found to be 20.
He was transferred to the MICU where he received 3 units of
blood with hematocrit increasing from 20 to 27.

MEDICAL HISTORY: -- CKD V from diabetic nephropathy on HD since [**5-/2183**]
-- DM2 for over 20 years on insulin
-- Hepatitis C genotype 4; liver biopsy [**2186-8-10**] revealed grade

MEDICATION ON ADMISSION: 1. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Cephalosporins / Metoclopramide / Infed

PHYSICAL EXAM: ADMISSION EXAMVitals:
T:98.4 P: 80 BP:124/62 R: 18 SaO2:85% on RA --> 94% 2L (does not
use O2 at home)
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, Mildly dry MM, no lesions noted in OP
Neck: supple, no JVD
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: bilateral BKAs, no edema
Lymphatics: No cervical, supraclavicular lymphadenopathy noted.

FAMILY HISTORY: Several siblings with diabetes

SOCIAL HISTORY: Retired computer worker. Smokes 5 cigarettes per day x 10+
years; denies alcohol use; former IVDU. Came to [**Hospital1 18**] from [**Hospital1 1501**]
the Embassy House in [**Hospital1 1474**] 

### Response:
{'Portal hypertension,Esophageal varices in diseases classified elsewhere, with bleeding,Duodenitis, with hemorrhage,End stage renal disease,Acute posthemorrhagic anemia,Hyperpotassemia,Renal dialysis status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified disease of pancreas,Chronic hepatitis C without mention of hepatic coma,Tobacco use disorder,Below knee amputation status'}
