CHIEF COMPLAINT: GI bleed

PRESENT ILLNESS: 71 year old woman with history of multiple diverticular bleeds,
type 2 diabetes mellitus, hypertension, hyperlipidemia, GERD and
recent DVT s/p right TKA who presents with bloody stools. The
patient had been started on Coumadin with Lovenox bridge
[**2193-10-23**] after developing a RLE DVT. The patient had stopped
Lovenox injections this past Monday when her INR 2.1 but when it
dropped to 1.8 on Thursday, she was restarted on Lovenox. The
patient woke up at 1pm today and felt the urge to have a bowel
movement. When she wiped, there were streaks of blood mixed with
stool on the toilet paper. She proceeded to have two more bowel
movements with blood mixed in her stools. The patient denies any
crampy abdominal pain, light headedness, chest pain, shortness
of breath with these episodes. She has not had any more bloody
stools since arrival to the [**Hospital1 18**]. She does have a history of
hemorrhoids as well.
.
In the ED, initial vs were: T 98.6 P 110 BP 149/61 R 18 O2 sat
100% on RA. Patient was given IVF. Her labs were drawn which
showed stable normocytic anemia from prior (Hct 27.8) and
therapeutic INR at 2.1. Her creatinine was slightly elevated at
1.2 (baseline 0.9). She received 2 liters of IVF with
improvement in her heart rate, two large bore PIVs were placed
and GI made aware.
.
On the floor, the patient was resting comfortably in bed.

MEDICAL HISTORY: * Right TKA [**2193-9-2**] with subsequent DVT (12/07-8/[**2192**])
* Diverticulosis
* Type 2 diabetes mellitus
* Benign essential hypertension
* Hyperlipidemia
* Degenerative joint disease (hip/knee)
* GERD
* History of LGIB X4 ([**7-/2183**], [**5-/2185**], [**4-/2186**], [**2186**], [**10/2192**]):
previously considered diverticular although [**10/2192**] bleed of
unclear source, ?splenic flexure bleed (on tagged RBC scan). No
interventions performed.

MEDICATION ON ADMISSION: * Atenolol 25mg daily
* Atorvastatin 20mg daily
* Fluocinonide cream 0.05% twice daily PRN
* Glyburide 5mg daily
* HCTZ 12.5mg daily
* Hydrocortisone acetate 25mg suppository twice daily PRN
hemorrhoids
* Lisinopril 10mg daily
* Metformin 1000mg twice daily
* Nifedipine 60mg ER daily
* Omeprazole 20mg daily
* Oxycodone 5-10mg daily q4-6 hours PRN pain
* Coumadin 2mg daily per INR
* Lovenox 70mg injections twice daily

ALLERGIES: Dairy

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, [**Last Name (un) **]/oropharynx clear
Neck: Soft, supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
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
Rectal: Guaiac positive and streaks of frank blood/small clots
in rectal vault, small hemorrhoids
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
RLE edema, greater than left. No TTP, surgical incision site
c/d/i, healing well.

FAMILY HISTORY: Diverticulosis in all three children, son (50s) and daughter
(40s) have had colectomies for LGIBs. Father may have had an MI.
No family history of colitis, Crohn's, ulcerative colitis. No
bleeding disorders or family history of malignancies.

SOCIAL HISTORY: Lives with husband, independent ADLs with [**Name (NI) 269**] currently to help
with Lovenox injections/Coumadin INR checks. Has three children.
Denies tobacco, alcohol or illicit drugs.
Diverticulosis of colon with hemorrhage,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Knee joint replacement
Dvrtclo colon w hmrhg,DMII wo cmp uncntrld,Hypertension NOS,Hyperlipidemia NEC/NOS,Esophageal reflux,Hx-ven thrombosis/embols,Long-term use anticoagul,Joint replaced knee
Admission Date:  [**2193-11-2**]              Discharge Date:   [**2193-11-5**]

Date of Birth:  [**2122-3-13**]             Sex:   F

Service: MEDICINE

Allergies:
Dairy

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
GI bleed

Major Surgical or Invasive Procedure:
colonoscopy
IVC filter placement


History of Present Illness:
71 year old woman with history of multiple diverticular bleeds,
type 2 diabetes mellitus, hypertension, hyperlipidemia, GERD and
recent DVT s/p right TKA who presents with bloody stools. The
patient had been started on Coumadin with Lovenox bridge
[**2193-10-23**] after developing a RLE DVT. The patient had stopped
Lovenox injections this past Monday when her INR 2.1 but when it
dropped to 1.8 on Thursday, she was restarted on Lovenox. The
patient woke up at 1pm today and felt the urge to have a bowel
movement. When she wiped, there were streaks of blood mixed with
stool on the toilet paper. She proceeded to have two more bowel
movements with blood mixed in her stools. The patient denies any
crampy abdominal pain, light headedness, chest pain, shortness
of breath with these episodes. She has not had any more bloody
stools since arrival to the [**Hospital1 18**]. She does have a history of
hemorrhoids as well.
.
In the ED, initial vs were: T 98.6 P 110 BP 149/61 R 18 O2 sat
100% on RA. Patient was given IVF. Her labs were drawn which
showed stable normocytic anemia from prior (Hct 27.8) and
therapeutic INR at 2.1. Her creatinine was slightly elevated at
1.2 (baseline 0.9). She received 2 liters of IVF with
improvement in her heart rate, two large bore PIVs were placed
and GI made aware.
.
On the floor, the patient was resting comfortably in bed.

Past Medical History:
* Right TKA [**2193-9-2**] with subsequent DVT (12/07-8/[**2192**])
* Diverticulosis
* Type 2 diabetes mellitus
* Benign essential hypertension
* Hyperlipidemia
* Degenerative joint disease (hip/knee)
* GERD
* History of LGIB X4 ([**7-/2183**], [**5-/2185**], [**4-/2186**], [**2186**], [**10/2192**]):
previously considered diverticular although [**10/2192**] bleed of
unclear source, ?splenic flexure bleed (on tagged RBC scan). No
interventions performed.

Social History:
Lives with husband, independent ADLs with [**Name (NI) 269**] currently to help
with Lovenox injections/Coumadin INR checks. Has three children.
Denies tobacco, alcohol or illicit drugs.


Family History:
Diverticulosis in all three children, son (50s) and daughter
(40s) have had colectomies for LGIBs. Father may have had an MI.
No family history of colitis, Crohn's, ulcerative colitis. No
bleeding disorders or family history of malignancies.


Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, [**Last Name (un) **]/oropharynx clear
Neck: Soft, supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
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
Rectal: Guaiac positive and streaks of frank blood/small clots
in rectal vault, small hemorrhoids
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
RLE edema, greater than left. No TTP, surgical incision site
c/d/i, healing well.

Pertinent Results:
[**2193-11-2**] 12:17PM   HCT-21.4*
[**2193-11-2**] 11:00AM   GLUCOSE-173* UREA N-31* CREAT-1.1 SODIUM-143
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-22 ANION GAP-16
[**2193-11-2**] 11:00AM   CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-1.2*
[**2193-11-2**] 11:00AM   WBC-UNABLE TO  RBC-UNABLE TO  HGB-UNABLE TO
HCT-UNABLE TO  MCV-UNABLE TO  MCH-UNABLE TO  MCHC-UNABLE TO
RDW-UNABLE TO
[**2193-11-2**] 11:00AM   PLT COUNT-UNABLE TO
[**2193-11-2**] 11:00AM   PT-24.2* PTT-29.1 INR(PT)-2.3*
[**2193-11-2**] 03:00AM   GLUCOSE-212* UREA N-30* CREAT-1.2* SODIUM-141
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
[**2193-11-2**] 03:00AM   estGFR-Using this
[**2193-11-2**] 03:00AM   WBC-9.2 RBC-3.06* HGB-9.1* HCT-27.8* MCV-91
MCH-29.5 MCHC-32.6 RDW-13.5
[**2193-11-2**] 03:00AM   NEUTS-68.9 LYMPHS-20.4 MONOS-4.5 EOS-5.1*
BASOS-1.1
[**2193-11-2**] 03:00AM   PLT COUNT-424#
[**2193-11-2**] 03:00AM   PT-22.1* PTT-33.9 INR(PT)-2.1*

Brief Hospital Course:
71 year old woman with history of multiple diverticular bleeds,
type 2 diabetes mellitus, hypertension, hyperlipidemia, GERD and
recent DVT s/p right TKA who presents with bloody stools.
.
# Bloody stools: She has a personal history of multiple GI
bleeds, thought to be diverticular in origin. Her most recent GI
bleed in [**10/2192**] did not have clear etiology, however. The
patient was being anticoagulated for her RLE DVT and
anticoagulation was held on admission. She also has small
hemorrhoids but they were not frankly bleeding from these on
rectal exam on admission.  On [**2193-11-2**], she had 300 cc of
melena/frank blood and her Hct dropped from 27.8 to 21.  CTA was
negative.  She was transfered to the ICU and transfused 5 units
PRBC and 3 units FFP.  An IVC filter was placed.  She was
transfered back to the floor when stable and her hematocrits
were monitored.  Her hematocrits were stable, ranging from 35 to
41.  She underwent a colonoscopy which did not reveal any active
bleeding.  Colonoscopy did show diverticula which were not
bleeding.  Her hematocrit was checked post-colonoscopy and was
stable.  She will be discharged with f/u appointments with her
PCP and plan to f/u with GI in [**12-19**] weeks.  She will have a
repeat Hct in 1 week, to be followed up upon by her PCP.  [**Name10 (NameIs) **]
will hold anticoagulation at discharge.  Given her history of GI
bleeding, she is likely not a good candidate for anticoagulation
in the future.  In addition, her DVT was provoked (in the
setting of surgery).  The IVC filter is temporary and can be
removed eventually.  At this time, we would recommend holding
anticoagulation, keeping the IVC filter in place for now and
repeating a lower extremity US in 3 months.  We will leave
management decisions regarding anticoagulation, the IVC filter,
and any repeat imaging to the PCP and outpatient GI team
however.
.
# Right TKA [**2193-9-2**] with subsequent DVT (12/07-8/[**2192**]):  INR
was therapeutic on admission and RLE exam stable.
Anticoagulation held given GI bleed.  Her INR was reversed with
FFP and an IVF filter was placed.  Oxycodone for pain control
was continued.  She will have f/u with orthopedic team as
previously scheduled.
.
# Hypertension/hyperlipidemia: Stable - her home medications
were held in the setting of GI bleeding.  Her blood pressures
were stable with SBPs around 150s.  Her home medications will be
restarted at discharge.
.
# Type 2 diabetes mellitus: Stable  - held metformin and
glipizide in-house, will restart at discharge.  Blood glucose
managed with SSI in house.
.
# GERD: Stable, no signs of upper GI bleed  - Continued home
omeprazole
.


Medications on Admission:
* Atenolol 25mg daily
* Atorvastatin 20mg daily
* Fluocinonide cream 0.05% twice daily PRN
* Glyburide 5mg daily
* HCTZ 12.5mg daily
* Hydrocortisone acetate 25mg suppository twice daily PRN
hemorrhoids
* Lisinopril 10mg daily
* Metformin 1000mg twice daily
* Nifedipine 60mg ER daily
* Omeprazole 20mg daily
* Oxycodone 5-10mg daily q4-6 hours PRN pain
* Coumadin 2mg daily per INR
* Lovenox 70mg injections twice daily

Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. fluocinonide 0.05 % Cream Sig: One (1) application Topical
twice a day.
4. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
6. hydrocortisone acetate 25 mg Suppository Sig: One (1)  Rectal
twice a day as needed for hemrrhoids.
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.

9. nifedipine 60 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
12. Outpatient Lab Work
Please check Hematocrit in 1 week.

Please send results to:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 250**]
Fax: [**Telephone/Fax (1) 3382**]
Email: [**University/College 97051**]

Please also send results to:
Name: Brain, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP
Location: [**Hospital3 249**]
Address: [**Location (un) **], [**Hospital Ward Name **] 6, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 97052**]
Fax: [**Telephone/Fax (1) 30662**]
Email: [**University/College 97053**]


Discharge Disposition:
Home With Service

Facility:
All Care [**University/College 269**] of Greater [**Location (un) **]

Discharge Diagnosis:
lower gastrointestinal bleeding, unclear etiology

* Right TKA [**2193-9-2**] with subsequent DVT (12/07-8/[**2192**])
* Diverticulosis
* Type 2 diabetes mellitus
* Benign essential hypertension
* Hyperlipidemia
* Degenerative joint disease (hip/knee)
* GERD
* History of LGIB X4 ([**7-/2183**], [**5-/2185**], [**4-/2186**], [**2186**], [**10/2192**]):
previously considered diverticular although [**10/2192**] bleed of
unclear source, ?splenic flexure bleed (on tagged RBC scan). No
interventions performed.


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

Discharge Instructions:
You were admitted to [**Hospital1 69**] for
bleeding from your rectum.  You were transfused blood and
monitored in the intensive care unit.  You had a filter placed
in the major vein in your body to prevent clots in your legs
from traveling to your lungs.  Your blood levels were monitored
and were stable.  You underwent a colonoscopy which did not show
active bleeding.

The following changes were made to your medications:
STOP Warfarin
STOP Lovenox

Please continue you other home medications

Followup Instructions:
The following appointments have been made for you:

Department: GASTROENTEROLOGY
When: MONDAY [**2193-11-25**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

Department: [**Hospital3 249**]
When: TUESDAY [**2193-11-19**] at 11:40 AM
With: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: TUESDAY [**2193-11-26**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], PA [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2193-12-11**] at 9:30 AM
With: EYE IMAGING [**Telephone/Fax (1) 253**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Diverticulosis of colon with hemorrhage,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Knee joint replacement'}


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

PRESENT ILLNESS: 71 year old woman with history of multiple diverticular bleeds,
type 2 diabetes mellitus, hypertension, hyperlipidemia, GERD and
recent DVT s/p right TKA who presents with bloody stools. The
patient had been started on Coumadin with Lovenox bridge
[**2193-10-23**] after developing a RLE DVT. The patient had stopped
Lovenox injections this past Monday when her INR 2.1 but when it
dropped to 1.8 on Thursday, she was restarted on Lovenox. The
patient woke up at 1pm today and felt the urge to have a bowel
movement. When she wiped, there were streaks of blood mixed with
stool on the toilet paper. She proceeded to have two more bowel
movements with blood mixed in her stools. The patient denies any
crampy abdominal pain, light headedness, chest pain, shortness
of breath with these episodes. She has not had any more bloody
stools since arrival to the [**Hospital1 18**]. She does have a history of
hemorrhoids as well.
.
In the ED, initial vs were: T 98.6 P 110 BP 149/61 R 18 O2 sat
100% on RA. Patient was given IVF. Her labs were drawn which
showed stable normocytic anemia from prior (Hct 27.8) and
therapeutic INR at 2.1. Her creatinine was slightly elevated at
1.2 (baseline 0.9). She received 2 liters of IVF with
improvement in her heart rate, two large bore PIVs were placed
and GI made aware.
.
On the floor, the patient was resting comfortably in bed.

MEDICAL HISTORY: * Right TKA [**2193-9-2**] with subsequent DVT (12/07-8/[**2192**])
* Diverticulosis
* Type 2 diabetes mellitus
* Benign essential hypertension
* Hyperlipidemia
* Degenerative joint disease (hip/knee)
* GERD
* History of LGIB X4 ([**7-/2183**], [**5-/2185**], [**4-/2186**], [**2186**], [**10/2192**]):
previously considered diverticular although [**10/2192**] bleed of
unclear source, ?splenic flexure bleed (on tagged RBC scan). No
interventions performed.

MEDICATION ON ADMISSION: * Atenolol 25mg daily
* Atorvastatin 20mg daily
* Fluocinonide cream 0.05% twice daily PRN
* Glyburide 5mg daily
* HCTZ 12.5mg daily
* Hydrocortisone acetate 25mg suppository twice daily PRN
hemorrhoids
* Lisinopril 10mg daily
* Metformin 1000mg twice daily
* Nifedipine 60mg ER daily
* Omeprazole 20mg daily
* Oxycodone 5-10mg daily q4-6 hours PRN pain
* Coumadin 2mg daily per INR
* Lovenox 70mg injections twice daily

ALLERGIES: Dairy

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, [**Last Name (un) **]/oropharynx clear
Neck: Soft, supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
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
Rectal: Guaiac positive and streaks of frank blood/small clots
in rectal vault, small hemorrhoids
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
RLE edema, greater than left. No TTP, surgical incision site
c/d/i, healing well.

FAMILY HISTORY: Diverticulosis in all three children, son (50s) and daughter
(40s) have had colectomies for LGIBs. Father may have had an MI.
No family history of colitis, Crohn's, ulcerative colitis. No
bleeding disorders or family history of malignancies.

SOCIAL HISTORY: Lives with husband, independent ADLs with [**Name (NI) 269**] currently to help
with Lovenox injections/Coumadin INR checks. Has three children.
Denies tobacco, alcohol or illicit drugs. 

### Response:
{'Diverticulosis of colon with hemorrhage,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Knee joint replacement'}
