CHIEF COMPLAINT: dyspnea and vaginal bleeding

PRESENT ILLNESS: Patient is a 54 yo F with a history of dysfunctional uterine
bleeding presents with increasing dyspnea. Patient was admitted
to GYN [**2076-11-24**] with uterine bleeding. A Mirena IUD was placed
with some difficulty and uterine tissue revealed uterine polyps.

MEDICAL HISTORY: GynHx: LMP [**2157**], age 50. Denies h/o abnl paps, last pap [**2155**].
No h/o fibroids or polyps. No h/o STDs. Has not been sexually
active since [**2155**].

MEDICATION ON ADMISSION: -ASA 325 QD
-Furosemide 120 [**Hospital1 **]
-Glyburide-Metformin 5/500 (2 tabs QD)
-Humalog sliding scale
-Vicodin (up to 6 tabs per day prn back pain)
-Lantus 100 U QD
-Lipitor 40 QD
-Lisinopril 20 QD
-Magnesium OTC
-Norpace 100 mg (2 tabs [**Hospital1 **])
-Omeprazole 20 QD
-Toprol XL 50 QD
-Venlafaxine 75 QD
-Warfarin 5 mg
- Ferrous sulfate 325 mg daily
- colace [**1-6**] daily

ALLERGIES: Vioxx

PHYSICAL EXAM: T 99.1 BP 150/52 HR 81 RR 22 O2 sat 98% 5L
Gen - Morbidly Obese, alert, oriented x 3, in NAD
HEENT - OP clear, pale mucous membranes. neck obese without
lymphadenopathy
CV - distant HR, regular rate
Lungs - clear bilaterally
Abd - obese, soft, non-tender
Back - no tenderness
Rectal - deferred
Ext - no edema, 2+ pulses
Neuro - intact strength and sensation bilaterally UE/LE,
reflexes 2+
Skin - no rashes, pale

FAMILY HISTORY: Mother: [**Name (NI) 430**] and neck ca, breast ca, colon CA and
myelodysplasia; Father: MI 49yo ([**Month (only) **]), ETOH; healthy siblings.

SOCIAL HISTORY: Pt present in ED with her sister, [**Name (NI) **]. [**Name2 (NI) **] two daughters.
Separated from husband. [**Name (NI) **] t/e/d. Ex-husband [**Name (NI) **] [**Name (NI) 76430**] is
the [**Hospital 228**] health care proxy.
Postmenopausal bleeding,Chronic diastolic heart failure,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Polyp of corpus uteri,Iron deficiency anemia secondary to blood loss (chronic),Atrial fibrillation,Unspecified essential hypertension,Morbid obesity,Other and unspecified hyperlipidemia,Esophageal reflux,Other diseases of lung, not elsewhere classified,Onychia and paronychia of toe,Dysthymic disorder,Internal hemorrhoids without mention of complication,Leukocytosis, unspecified,Long-term (current) use of insulin
Postmenopausal bleeding,Chr diastolic hrt fail,DMII wo cmp uncntrld,Polyp of corpus uteri,Chr blood loss anemia,Atrial fibrillation,Hypertension NOS,Morbid obesity,Hyperlipidemia NEC/NOS,Esophageal reflux,Other lung disease NEC,Onychia of toe,Dysthymic disorder,Int hemorrhoid w/o compl,Leukocytosis NOS,Long-term use of insulin
Admission Date:  [**2161-12-15**]              Discharge Date:   [**2161-12-24**]

Date of Birth:  [**2107-7-26**]             Sex:   F

Service: OBSTETRICS/GYNECOLOGY

Allergies:
Vioxx

Attending:[**First Name3 (LF) 36695**]
Chief Complaint:
dyspnea and vaginal bleeding

Major Surgical or Invasive Procedure:
Dilation and Curretage
IUD removal
operative hysteroscopy
Polypectomy
13 units PRBC transfusion


History of Present Illness:
Patient is a 54 yo F with a history of dysfunctional uterine
bleeding presents with increasing dyspnea. Patient was admitted
to GYN [**2076-11-24**] with uterine bleeding. A Mirena IUD was placed
with some difficulty and uterine tissue revealed uterine polyps.

Per patient the bleeding has continued and she has used [**4-9**] pads
daily since discharge. The bleeding was somewhat better after
the IUD placement, but started having clots and cramping again
in the last 3-4 days (both were severe prior to IUD placement).
With the continued bleeding she has began to feel more
symptomatic with dizziness and dyspnea on exertion. She reports
that the symptoms became significant approximately 4 days ago.
She denies any history of chest pain or dyspnea at rest. She
does have occasional palpitations similar to her previous
episodes of atrial fibrillation.
.
In the ED initial vitals were t 98.5 Hr 79 BP 139/52 RR 26 O2
100% 5L
She was seen by the OB/GYN consult resident who recommended
evaluation of the IUD placement. It was not seen on pelvic u/s
but pelvic CT showed proper placement of the IUD. Additionally
gyn recommended treatment with provera to allow Mirena IUD to
help decrease the bleeding. In the ED she received ativan 1 mg
IV, provera 20 mg PO and received 1 U PRBCs.
.
Currently she has back pain. It is a [**7-14**] and is located in her
lower back. It radiates to her legs but is not associated with
any weakness or incontenence.
.
ROS: Positive for nocturia (takes lasix at night), Denies chest
pain, syncope, presyncope, dysuria, headache, blurry vision. Has
had elevated glucose to 400s in the last few days, no diarrhea,
constipated. No edema, no orthopnea, no PND. Has had decreased
appetite but drinking lots of water.

Past Medical History:
GynHx: LMP [**2157**], age 50. Denies h/o abnl paps, last pap [**2155**].
No h/o fibroids or polyps. No h/o STDs. Has not been sexually
active since [**2155**].

ObHx:
-FT SVD x 2, no complications

PMH:
- Moderate restrictive lung disease and severely impaired
diffusion capaciy. On 4 liters home O2 at baseline Last PFTS
[**3-11**]: FVC 1.37 33% predicted
FEV1 1.09 35% predicted
- CHF - diastolic dysfunction, EF >55%
- Atrial fibrillation/Aflutter, s/p cardioversion [**2-9**] and [**5-9**],
on anticoagulation (Neg holter [**5-9**])
- DM type 2, on insulin followed at [**Last Name (un) 387**], last HbA1C 9.8%
10/07
- HTN
- Morbid obesity
- Low back pain
- Depression/anxiety - stable, no suicidal ideation
- Hyperlipidemia
- GERD

Social History:
Pt present in ED with her sister, [**Name (NI) **]. [**Name2 (NI) **] two daughters.
Separated from husband. [**Name (NI) **] t/e/d. Ex-husband [**Name (NI) **] [**Name (NI) 76430**] is
the [**Hospital 228**] health care proxy.

Family History:
Mother: [**Name (NI) 430**] and neck ca, breast ca, colon CA and
myelodysplasia; Father: MI 49yo ([**Month (only) **]), ETOH; healthy siblings.

Physical Exam:
T 99.1 BP 150/52 HR 81 RR 22 O2 sat 98% 5L
Gen - Morbidly Obese, alert, oriented x 3, in NAD
HEENT - OP clear, pale mucous membranes. neck obese without
lymphadenopathy
CV - distant HR, regular rate
Lungs - clear bilaterally
Abd - obese, soft, non-tender
Back - no tenderness
Rectal - deferred
Ext - no edema, 2+ pulses
Neuro - intact strength and sensation bilaterally UE/LE,
reflexes 2+
Skin - no rashes, pale

Pertinent Results:
HCT: 25.3 on admission, 24.1 post 1st unit PRBC, 23.1 post 2nd
unit PRBC,
WBC
Cr
.
.
RADS:
.
US Pelvis [**2161-12-15**]: There is no hydronephrosis in either kidney.
 The endometrium measures 10 mm. The uterus measures 10.3 x 5.7
x 6.2 cm.  The right ovary is not definitely seen. Intrauterine
device is not definitely seen. Cystic structure measuring 3.7 x
3.0 cm is seen adjacent to the left adnexa, likely representing
paraovarian cyst. IMPRESSION: 1. IUD not definitely seen. 2.
Probable left paraovarian cyst. 3. Right ovary not seen.
.
CT Pelvis [**2161-12-15**]: Intrauterine device is present within the
uterus.There is left paraovarian cyst as seen on the ultrasound.
 The rectum and visualized sigmoid colon are unremarkable. There
is no free pelvic fluid. Urinary bladder is distended.
IMPRESSION: 1. Intrauterine device within the uterus. 2. Left
paraovarian cyst as seen on the ultrasound.
.
CXR [**2161-12-15**]: In comparison with the study of [**2161-8-14**], there is
little change. Enlargement of the cardiac silhouette with
dilatation of pulmonary vessels persists.  No evidence of acute
focal pneumonia.


Brief Hospital Course:
54 yo F with h/o atrial fibrillation, uncontrolled diabetes
mellitus, morbid obesity, restrictive lung disease, with vaginal
bleeding s/p IUD placement on prior hospitalization, admitted
with symptomatic blood loss anemia, treated with blood
transfusions and Provera.

# Dysfunctional uterine bleeding: Bleeding likely secondary to
excess estrogen in the setting of high peripheral conversion. In
addition, INR supra therapeutic on Coumadin. On prior
hospitalization for DUB, the patient had suction D&C with
endometrial biopsy negative for cancer, as well as placement of
Mirena IUD for long-term control of bleeding. On presentation,
GYN service was consulted. The patient was initially admitted
the Medicine with GYN consult because of her complex medical
issues. CT pelvis confirmed IUD well placed. Provera 20mg PO
daily x10days was started on [**2161-12-15**]. The patient was
transfused 6 units of PRBC's without complication. The patient
was also maintained on iron supplementation and a bowel regimen.
The patient's HCT improved from 25.3 on admission to 31.7 prior
to 6th unit.

Patient continued to bleed heavily. She was transferred to the
GYN service. On [**2161-12-19**] patient was noted to have weakness,
dizziness, and lightheadedness. Patient became hypotensive to
103/57 with a heart rate of 95. EKG showed normal sinus rhythm.
Hematocrit decreased from 31.7 to 22.6. Given the rapid
bleeding, decision was made to go to the operating room
emergently. Patient underwent a dilation and curettage and an
operative hysteroscopy with a polypectomy. The IUD was removed.
Please see the Operative note on [**2161-12-19**] for further detail. At
the time of this discharge, the pathology report is pending. The
surgery was uncomplicated. The patient received 2 units of blood
intraoperatively.

She was transferred to the ICU for continuous monitoring, and
received 4 more units in the ICU with the hematocrit improvement
to 28. Provera was also increased to 40mg PO daily. Vaginal
bleeding had improved dramatically. Patient was transferred to
the floor. However, the hematocrit trended down to 26, and she
received 1 more unit PRBC while on the floor. Follow up
hematocrits remained stable, increasing to 31.

In summary, patient received 6 units pre-operatively, and 7
units post-operatively. On discharge, she was no longer
bleeding, and hemodynamically stable.

# Mild Leukocytosis: On HD2, the patient's WBC increased to 12.4
and the patient had a low grade temperature of 100.1. The
patient had not received blood products in several hours. No
localizing symptoms. UA was negative. WBC decreased to 8.

# Dyspnea: The patient has restrictive lung disease with a home
O2 requirement. Symptoms of dyspnea likely secondary to blood
loss anemia. Chest x-ray was showed little change, without acute
focal pneumonia, though cardiac silhouette increased and
pulmonary vessels were dilated. Dyspnea was treated with O2 to
maintain sats and HCT correction with transfusions, Provera and
IUD as described above. If the patient remains dyspneic,
consider ECHO.

# Chronic diastolic heart failure: Currently the patient is
compensated. Lungs clear without signs of volume overload. Lasix
was continued. Beta-blocker was resumed the evening of
admission. The patient was monitored for signs and symptoms of
fluid overload.

# Atrial fibrillation: The patient has a history of AF with
three cardioversions. The patient reports last episode of
palpitations the Sunday prior to admission. On telemetry, the
patient was in sinus rhythm and her rate was well controlled
throughout the hospitalization. She was maintained on her
outpatient Norpace and beta-blocker. Admission INR was supra
therapeutic. Coumadin was held. When bleeding did not decrease,
anticoagulation was reversed with vitamin K. The patient's
cardiologist, Dr. [**Last Name (STitle) **] was consulted. Decision to hold
Coumadin indefinitely was made as the risk of hemorrhage was
felt to be greater than the risk of clot formation, given
patient was in normal sinus rhythm throughout her entire
hospitalization. The INR was reversed to 1.0 Patient's PCP [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], will be following the patient closely, with the plan
of potentially restarting Coumadin as needed should the patient
revert to atrial fibrillation.

# Diabetes: The patient has poorly controlled diabetes with a
very high insulin requirement. [**Last Name (un) **] was consulted. Lantus was
increased to 90 Units [**Hospital1 **], and sliding scale was aggressive, but
FSG remained in the 200-300's. The patient had glucosuria on UA.

# HTN: The patient was continued on lisinopril and Lasix. She
was restarted on her beta-blocker the evening of admission. It
was initially held in the setting of symptomatic anemia.

# L toe Paronychia: The patient complained of ongoing L great
toe pain, redness. Podiatry was consulted, and removed the L toe
paronychia. Daily dressing changes were initiated. Patient was
started on a 10 day course of antibiotics. She initially
received Unasyn IV, and was transitioned to Augmentin. Foot Xray
did not reveal evidence of osteomyelitis. Patient is to follow
up with Podiatry in one week after discharge.

# Depression/anxiety: The patient said she felt safe and that
she felt reassured knowing the plan. She was continued on
venlafaxine.

# Gastroesophageal reflux: The patient was continued on
pantoprazole for GERD.

# FEN/GI: The patient remained euvolemic. Electrolytes were
repleted PRN. She tolerated a diabetic cardiac diet.


Medications on Admission:
-ASA 325 QD
-Furosemide 120 [**Hospital1 **]
-Glyburide-Metformin 5/500 (2 tabs QD)
-Humalog sliding scale
-Vicodin (up to 6 tabs per day prn back pain)
-Lantus 100 U QD
-Lipitor 40 QD
-Lisinopril 20 QD
-Magnesium OTC
-Norpace 100 mg (2 tabs [**Hospital1 **])
-Omeprazole 20 QD
-Toprol XL 50 QD
-Venlafaxine 75 QD
-Warfarin 5 mg
- Ferrous sulfate 325 mg daily
- colace [**1-6**] daily

Discharge Medications:
1. Home oxygen
O2 at 5-6 L/min continuous
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Disopyramide 100 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO Q12H (every 12 hours).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
7. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) as needed for anemia.
Disp:*60 Tablet(s)* Refills:*3*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Clotrimazole 1 % Cream Sig: One (1) Appl Topical DAILY
(Daily).
Disp:*QS 2 month supply * Refills:*2*
11. Medroxyprogesterone 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
14. Sterile Gauze Pad 4 X 4   Bandage Sig: QS 2 months  Topical
change dressing q day.
Disp:*QS 1 month * Refills:*2*
15. Bacitracin 500 unit/g Ointment Sig: QS 1 month  Topical once
a day.
Disp:*QS 1 month * Refills:*2*
16. Saline Solution [**1-5**] % Solution Sig: QS 1 month
Miscellaneous qs 1 month.
Disp:*QS 1 month * Refills:*2*
17. Insulin Glargine 100 unit/mL Solution Sig: One (1) mL
Subcutaneous twice a day.
Disp:*QS 1 mon supply * Refills:*2*
18. Syringe with Needle (Disp) 1 mL 26 x [**1-6**]  Syringe Sig: QS 1
month supply  Miscellaneous once a day.
Disp:*QS 1 mo supply * Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Dysfunctional uterine bleeding
.
Secondary:
Diabetes mellitus, type two
Chronic diastolic congestive heart failure
Gastroesophageal reflux disease
Hyperlipidemia
Hypertension
Depression
Anxiety
Anemia
Chronic lower back pain
Morbid obesity
Atrial fibrillation/flutter requiring anticoagulation
Moderate restrictive lung disease requiring home oxygen


Discharge Condition:
Stable, satting at her baseline, ambulatory.


Discharge Instructions:
You were admitted to the hospital because of vaginal bleeding
and symptomatic anemia. It is thought that the bleeding was
related to high levels of the hormone estrogen in the setting of
obesity. You had an intrauterine device placed to reduce the
bleeding during uour previous hospitalization. The position of
this device was confirmed. You were taken to the operating room
to get a sample of the endometrial lining, as well as remove a
polyp. At the time of your discharge the pathology report is
pending. The IUD was removed during this procedure. You were
given Provera for a continuous course until told otherwise. Your
symptomatic anemia was likely the result of chronic vaginal
bleeding. You were given blood transfusions to improve your
symptoms and correct your anemia. You were also treated for your
other medical conditions.
.
You should follow your pre-admission congestive heart failure
regimen. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3
lbs. Adhere to 2 gm sodium diet. You should restrict your fluid
intake as described by your physician.
.
You should follow up with your Gynecologist and Primary Care
Provider as instructed.
.
You should continue daily dressing changes of the left big toe.
Please wash the toe with Saline, dry in, and apply bacitracin
covered with sterilze gauze. Continue doing so until you see
podiatry. You will also need to finish a 10 day course of
Augmentin (antibiotics). You have received 3 days of antibiotics
in the hospital and will have 7 more days at home.
.
Return to the emergency room if you have a return of your
symptoms, worsening of your vaginal bleeding, persistent
bleeding after discontinuation of your Provera, dizziness,
lightheadedness, shortness of breath, palpitations, chest pain,
fever, chills or any other concerning symptoms.

Followup Instructions:
Please call [**Telephone/Fax (1) 543**] to set up a follow up podiatry
appointment for an appointment 1 week after your discharge

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD Phone:[**Telephone/Fax (1) 142**]
Date/Time:[**2162-2-9**] 9:30

Provider: [**Name Initial (NameIs) 703**] (C4) TCC RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2162-2-3**] 10:15

Provider: [**First Name8 (NamePattern2) 3130**] [**Last Name (NamePattern1) 3131**], MD Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2162-2-3**] 2:30

Please call to set up a follow up appointment with [**Last Name (un) **] ([**Telephone/Fax (1) 17256**]
{'Postmenopausal bleeding,Chronic diastolic heart failure,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Polyp of corpus uteri,Iron deficiency anemia secondary to blood loss (chronic),Atrial fibrillation,Unspecified essential hypertension,Morbid obesity,Other and unspecified hyperlipidemia,Esophageal reflux,Other diseases of lung, not elsewhere classified,Onychia and paronychia of toe,Dysthymic disorder,Internal hemorrhoids without mention of complication,Leukocytosis, unspecified,Long-term (current) use of insulin'}


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: dyspnea and vaginal bleeding

PRESENT ILLNESS: Patient is a 54 yo F with a history of dysfunctional uterine
bleeding presents with increasing dyspnea. Patient was admitted
to GYN [**2076-11-24**] with uterine bleeding. A Mirena IUD was placed
with some difficulty and uterine tissue revealed uterine polyps.

MEDICAL HISTORY: GynHx: LMP [**2157**], age 50. Denies h/o abnl paps, last pap [**2155**].
No h/o fibroids or polyps. No h/o STDs. Has not been sexually
active since [**2155**].

MEDICATION ON ADMISSION: -ASA 325 QD
-Furosemide 120 [**Hospital1 **]
-Glyburide-Metformin 5/500 (2 tabs QD)
-Humalog sliding scale
-Vicodin (up to 6 tabs per day prn back pain)
-Lantus 100 U QD
-Lipitor 40 QD
-Lisinopril 20 QD
-Magnesium OTC
-Norpace 100 mg (2 tabs [**Hospital1 **])
-Omeprazole 20 QD
-Toprol XL 50 QD
-Venlafaxine 75 QD
-Warfarin 5 mg
- Ferrous sulfate 325 mg daily
- colace [**1-6**] daily

ALLERGIES: Vioxx

PHYSICAL EXAM: T 99.1 BP 150/52 HR 81 RR 22 O2 sat 98% 5L
Gen - Morbidly Obese, alert, oriented x 3, in NAD
HEENT - OP clear, pale mucous membranes. neck obese without
lymphadenopathy
CV - distant HR, regular rate
Lungs - clear bilaterally
Abd - obese, soft, non-tender
Back - no tenderness
Rectal - deferred
Ext - no edema, 2+ pulses
Neuro - intact strength and sensation bilaterally UE/LE,
reflexes 2+
Skin - no rashes, pale

FAMILY HISTORY: Mother: [**Name (NI) 430**] and neck ca, breast ca, colon CA and
myelodysplasia; Father: MI 49yo ([**Month (only) **]), ETOH; healthy siblings.

SOCIAL HISTORY: Pt present in ED with her sister, [**Name (NI) **]. [**Name2 (NI) **] two daughters.
Separated from husband. [**Name (NI) **] t/e/d. Ex-husband [**Name (NI) **] [**Name (NI) 76430**] is
the [**Hospital 228**] health care proxy. 

### Response:
{'Postmenopausal bleeding,Chronic diastolic heart failure,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Polyp of corpus uteri,Iron deficiency anemia secondary to blood loss (chronic),Atrial fibrillation,Unspecified essential hypertension,Morbid obesity,Other and unspecified hyperlipidemia,Esophageal reflux,Other diseases of lung, not elsewhere classified,Onychia and paronychia of toe,Dysthymic disorder,Internal hemorrhoids without mention of complication,Leukocytosis, unspecified,Long-term (current) use of insulin'}
