CHIEF COMPLAINT: GI bleed

PRESENT ILLNESS: Ms. [**Known lastname 79825**] is a 54 year old female with history of pancreatic
cancer and portal vein thrombosis on warfarin admitted with
recent GI bleed and Hct drop.
.
She reports feeling generalized fatigue in the last two weeks
but noticed dark stool and "pink" urine about 4 days ago.  She
has been on coumadin since her diagnosis of portal vein
thrombosis on [**3-9**].  She denies any recent NSAID, iron or pepto
bismol use.  Patient reports light-headedness and being unsteady
on her feet at work recently.  Also report dyspnea on exertion.
CT A/P yesterday was overall unchanged- showed known portal vein
occlusion and liver lesions
.
She was diagnosed with pancreatic cancer in [**2109**]- underwent
Whipple in 12/[**2109**].  She has undergone chemotherapy with
gemcitabine (completed in [**7-18**]) and CyberKnife therapy ([**2-16**]).
She has known mets to her liver and lung but they have been
stable per recent CT scan.  She called her oncologist to report
her recent symptoms and was asked to come to the ED for further
evaluation.
.
In the ED, initial vs were: T- 97.8 P- 58 BP- 131/60 R- 20 O2
sat- 100% on RA.  Labwork significant for Hct of 23.4 (down from
30.9 on [**2112-4-22**]).  Also found to have mild transaminitis but it
is actually down from levels check in [**2112-2-8**].  Lastly, her
INR has been within 2 and 3 in the last 3 months (is 3.0 on
admission).
.
She is being admitted to the MICU for close monitoring and GI
scope to find source of bleed.
.
Review of systems:
(+) Per HPI- nausea, vomiting, dyspnea on exertion, mild
intermittent abdominal pain, dark stool, "pink" urine
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies dysuria, frequency,
or urgency. Denies arthralgias or myalgias. Denies rashes or
skin changes.

MEDICAL HISTORY: - Pancreatic cancer, s/p Whipple, chemotherapy, CyberKnife.
- Portal vein thrombosis
- Psoriasis
- Severe osteoporosis
- Hip fracture after a fall in [**2109-3-10**].
- Breast surgery (removal of mass, negative cytology) [**2103**]
- Tubal Ligation [**2091**]
- ERCP
- EUS Lap staging procedure [**9-16**]
- GERD

MEDICATION ON ADMISSION: 1.  Ativan 0.5 mg tablets 1-2 tablets by mouth every 4-6 hours
as needed for nausea, insomnia or anxiety,
2.  Warfarin 1 mg tablets 1 tablet by mouth 2-3 times daily,
dosage varies
3.  Acetaminophen as needed.
4.  Vitamin E- 800 units daily
5.  Nadolol 20mg- 1 tab daily
6.  Furosemide- 20mg PO daily
7.  Spironolactone- 50mg PO daily

ALLERGIES: Penicillins / Vancomycin / Dilaudid

PHYSICAL EXAM: Vitals: T: 97.2 BP: 114/67 P: 56 R: 12  O2 100% on RA:
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-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly.  Mildly tender to deep
palpation in epigastrim
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Her family medical history is significant for the patient's
mother who was diagnosed with rheumatoid arthritis and died last
year of vascular dementia at the age of 82.  Her father is 86
years old and has colon cancer with liver metastases and has
suffered from cardiovascular disease.  She has a sister who is
64 years old and only suffers from rheumatoid arthritis.

SOCIAL HISTORY: The patient lives in [**Location **], [**State 350**] with her husband.
She has 1 son who lives in [**Name (NI) 8449**] and 1 daughter who lives in
[**Name (NI) 8117**], [**Name (NI) 3844**].  She continues to work as a paralegal for
a medical device company.  She states that she eats a very
healthy diet and mostly because after her surgery it is very
difficult for her to tolerate foods that have a high-fat
content. She states that she is used to exercising often by
taking long walks;  however, at this point she is trying not to
because she needs to maintain her weight.  She states that she
has approximately [**12-12**] alcoholic beverages per week and has never
used intravenous drugs, intranasal cocaine or marijuana. The
patient does not smoke.
Esophageal varices without mention of bleeding,Blood in stool,Malignant neoplasm of liver, secondary,Precipitous drop in hematocrit,Portal hypertension,Long-term (current) use of anticoagulants,Osteoporosis, unspecified,Esophageal reflux,Personal history of venous thrombosis and embolism,Other psoriasis,Other specified disorders of stomach and duodenum,Personal history of malignant neoplasm of other gastrointestinal tract,Other chronic nonalcoholic liver disease
Esoph varices w/o bleed,Blood in stool,Second malig neo liver,Drop, hematocrit, precip,Portal hypertension,Long-term use anticoagul,Osteoporosis NOS,Esophageal reflux,Hx-ven thrombosis/embols,Other psoriasis,Gastroduodenal dis NEC,Hx of GI malignancy NEC,Chronic liver dis NEC
Admission Date:  [**2112-5-19**]              Discharge Date:   [**2112-5-20**]

Date of Birth:  [**2058-2-28**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Vancomycin / Dilaudid

Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
GI bleed

Major Surgical or Invasive Procedure:
EGD


History of Present Illness:
Ms. [**Known lastname 79825**] is a 54 year old female with history of pancreatic
cancer and portal vein thrombosis on warfarin admitted with
recent GI bleed and Hct drop.
.
She reports feeling generalized fatigue in the last two weeks
but noticed dark stool and "pink" urine about 4 days ago.  She
has been on coumadin since her diagnosis of portal vein
thrombosis on [**3-9**].  She denies any recent NSAID, iron or pepto
bismol use.  Patient reports light-headedness and being unsteady
on her feet at work recently.  Also report dyspnea on exertion.
CT A/P yesterday was overall unchanged- showed known portal vein
occlusion and liver lesions
.
She was diagnosed with pancreatic cancer in [**2109**]- underwent
Whipple in 12/[**2109**].  She has undergone chemotherapy with
gemcitabine (completed in [**7-18**]) and CyberKnife therapy ([**2-16**]).
She has known mets to her liver and lung but they have been
stable per recent CT scan.  She called her oncologist to report
her recent symptoms and was asked to come to the ED for further
evaluation.
.
In the ED, initial vs were: T- 97.8 P- 58 BP- 131/60 R- 20 O2
sat- 100% on RA.  Labwork significant for Hct of 23.4 (down from
30.9 on [**2112-4-22**]).  Also found to have mild transaminitis but it
is actually down from levels check in [**2112-2-8**].  Lastly, her
INR has been within 2 and 3 in the last 3 months (is 3.0 on
admission).
.
She is being admitted to the MICU for close monitoring and GI
scope to find source of bleed.
.
Review of systems:
(+) Per HPI- nausea, vomiting, dyspnea on exertion, mild
intermittent abdominal pain, dark stool, "pink" urine
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies dysuria, frequency,
or urgency. Denies arthralgias or myalgias. Denies rashes or
skin changes.


Past Medical History:
- Pancreatic cancer, s/p Whipple, chemotherapy, CyberKnife.
- Portal vein thrombosis
- Psoriasis
- Severe osteoporosis
- Hip fracture after a fall in [**2109-3-10**].
- Breast surgery (removal of mass, negative cytology) [**2103**]
- Tubal Ligation [**2091**]
- ERCP
- EUS Lap staging procedure [**9-16**]
- GERD


Social History:
The patient lives in [**Location **], [**State 350**] with her husband.
She has 1 son who lives in [**Name (NI) 8449**] and 1 daughter who lives in
[**Name (NI) 8117**], [**Name (NI) 3844**].  She continues to work as a paralegal for
a medical device company.  She states that she eats a very
healthy diet and mostly because after her surgery it is very
difficult for her to tolerate foods that have a high-fat
content. She states that she is used to exercising often by
taking long walks;  however, at this point she is trying not to
because she needs to maintain her weight.  She states that she
has approximately [**12-12**] alcoholic beverages per week and has never
used intravenous drugs, intranasal cocaine or marijuana. The
patient does not smoke.


Family History:
Her family medical history is significant for the patient's
mother who was diagnosed with rheumatoid arthritis and died last
year of vascular dementia at the age of 82.  Her father is 86
years old and has colon cancer with liver metastases and has
suffered from cardiovascular disease.  She has a sister who is
64 years old and only suffers from rheumatoid arthritis.

Physical Exam:
Vitals: T: 97.2 BP: 114/67 P: 56 R: 12  O2 100% on RA:
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-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly.  Mildly tender to deep
palpation in epigastrim
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
[**2112-5-18**] 08:40AM BLOOD WBC-3.9* RBC-2.61* Hgb-7.8* Hct-24.2*
MCV-93 MCH-29.9 MCHC-32.2 RDW-14.2 Plt Ct-116*
[**2112-5-19**] 11:45AM BLOOD WBC-5.1 RBC-2.63* Hgb-7.7* Hct-23.4*
MCV-89 MCH-29.3 MCHC-32.9 RDW-14.6 Plt Ct-165
[**2112-5-19**] 05:57PM BLOOD WBC-3.5* RBC-2.48* Hgb-7.5* Hct-22.4*
MCV-90 MCH-30.1 MCHC-33.3 RDW-14.7 Plt Ct-105*
[**2112-5-20**] 02:36AM BLOOD WBC-3.1* RBC-3.26*# Hgb-9.8*# Hct-28.5*#
MCV-88 MCH-30.1 MCHC-34.3 RDW-15.2 Plt Ct-102*
[**2112-5-18**] 08:40AM BLOOD PT-28.3* INR(PT)-2.8*
[**2112-5-19**] 12:58PM BLOOD PT-30.4* PTT-44.1* INR(PT)-3.0*
[**2112-5-19**] 05:57PM BLOOD PT-22.1* PTT-29.1 INR(PT)-2.1*
[**2112-5-19**] 05:57PM BLOOD Plt Ct-105*
[**2112-5-20**] 02:36AM BLOOD PT-17.2* PTT-25.1 INR(PT)-1.5*
[**2112-5-18**] 08:40AM BLOOD UreaN-22* Creat-0.7 Na-135 K-4.3 Cl-104
HCO3-25 AnGap-10
[**2112-5-19**] 11:45AM BLOOD Glucose-109* UreaN-19 Creat-0.6 Na-134
K-4.1 Cl-103 HCO3-27 AnGap-8
[**2112-5-19**] 05:57PM BLOOD Glucose-100 UreaN-14 Creat-0.5 Na-138
K-4.1 Cl-107 HCO3-24 AnGap-11
[**2112-5-20**] 02:36AM BLOOD Glucose-154* UreaN-17 Creat-0.6 Na-135
K-4.2 Cl-105 HCO3-24 AnGap-10
[**2112-5-18**] 08:40AM BLOOD ALT-93* AST-47* AlkPhos-154* TotBili-0.4
[**2112-5-19**] 11:45AM BLOOD ALT-101* AST-56* LD(LDH)-127 AlkPhos-159*
TotBili-0.5
[**2112-5-20**] 02:36AM BLOOD ALT-84* AST-48* AlkPhos-152* TotBili-2.7*
[**2112-5-18**] 08:40AM BLOOD Albumin-3.7
[**2112-5-20**] 02:36AM BLOOD Albumin-3.3* Calcium-9.4 Phos-3.3 Mg-1.9

EGD- 1.  Varices at the lower third of the esophagus and
gastroesophageal junction (ligation)
2.  Varices at the gastroesophageal junction and lower third of
the esophagus
3.  Erythema, congestion, abnormal vascularity and mosaic
appearance in the whole stomach compatible with portal
gastropathy
    Otherwise normal EGD to second part of the duodenum

Brief Hospital Course:
1.  GI Bleed-  Patient reports dark stool for 4 days.  Has no
history of GI bleed.  She was started on coumadin in recent
months but her INR has been therapeutic since initiation of
therapy.  Found to have ~10 point Hct drop since [**4-22**] (31 to 23)
and was symptomatic.  She was admitted to the MICU and underwent
a EGD which showed grade 1 and grade 2 esophageal and gastric
varices.  She underwent banding x 1 and was started on IV
protonix [**Hospital1 **] and octreotide gtt.  Octreotide was stopped at
midnight.  She received two units PRBCs and Hct bumped
appropriately.  Liver team would like her to be discharged from
the ICU on carafate x 10 days, iron supplementation x 7 days,
protonix 40mg PO daily.  We are holding her coumadin in the
setting of recent GI bleed.  She has follow-up with Dr. [**Last Name (STitle) **]
on [**5-25**] and scheduled an EGD for [**5-31**].

2.  Portal venous thrombosis-  Started on coumadin in [**2-17**] (3mg
per day except for Friday when she takes 2mg per day).  Her INR
has remained within therapeutic range while on anticoagulation.
She had presented to clinic with increased fluid overload and
was started on lasix, spironolactone and nadolol about 30 days
ago.  While here, we held her coumadin (in the setting of bleed)
as well as her home lasix, spironolactone, and nadolol.  Her
pressures improved with blood products.  Given recent bleed, we
are only resuming home lasix and nadolol on discharge.  She will
re-evaluate spironolactone when she shes outpatient providers
within 1 week of discharge.

3.  Pancreatic cancer- Patient not currently on active therapy.
Has not been on since 8/[**2110**].  Had CT on [**5-18**] with final read
pending at the time of discharge.


Medications on Admission:
1.  Ativan 0.5 mg tablets 1-2 tablets by mouth every 4-6 hours
as needed for nausea, insomnia or anxiety,
2.  Warfarin 1 mg tablets 1 tablet by mouth 2-3 times daily,
dosage varies
3.  Acetaminophen as needed.
4.  Vitamin E- 800 units daily
5.  Nadolol 20mg- 1 tab daily
6.  Furosemide- 20mg PO daily
7.  Spironolactone- 50mg PO daily

Discharge Medications:
1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 9 days.
Disp:*36 Tablet(s)* Refills:*0*
2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Vitamin E 800 unit Capsule Sig: One (1) Capsule PO once a
day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a
day for 7 days.
Disp:*7 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:  GI bleed
Secondary:  Pancreatic cancer


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


Discharge Instructions:
You were admitted to the hospital with a GI bleed.  While here,
you were monitored closely in the ICU and did well.  You
underwent a scope which showed an esophageal varix with no signs
of active bleed.  You received blood here and responded
appropriately.  Upon discharge, you were stable and comfortable.

The following changes were made to your medications:
1.  Please hold your coumadin in the setting of this GI bleed.
2.  Please start taking carafate 1g four times a day for 9 more
days
3.  Please start taking iron supplementation for 7 total days
4.  Please start taking pantoprazole 40mg by mouth daily
5.  Please do not take your home spironolactone until you are
seeing by your outpatient [**Provider Number 35338**].  You may resume your home dose of lasix and nadolol.

Please contact your primary outpatient physician or go to the
emergency department if you experience persistent/worsened GI
bleed, dizziness, chest pain, shortness of breath or any other
medically concerning symptom.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] on [**2112-5-25**] at 2:30pm to get
your labs checked.

You will be scheduled for a follow-up scope on [**5-31**] at 10:30am
with Dr. [**Last Name (STitle) **].
{'Esophageal varices without mention of bleeding,Blood in stool,Malignant neoplasm of liver, secondary,Precipitous drop in hematocrit,Portal hypertension,Long-term (current) use of anticoagulants,Osteoporosis, unspecified,Esophageal reflux,Personal history of venous thrombosis and embolism,Other psoriasis,Other specified disorders of stomach and duodenum,Personal history of malignant neoplasm of other gastrointestinal tract,Other chronic nonalcoholic liver disease'}


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: Ms. [**Known lastname 79825**] is a 54 year old female with history of pancreatic
cancer and portal vein thrombosis on warfarin admitted with
recent GI bleed and Hct drop.
.
She reports feeling generalized fatigue in the last two weeks
but noticed dark stool and "pink" urine about 4 days ago.  She
has been on coumadin since her diagnosis of portal vein
thrombosis on [**3-9**].  She denies any recent NSAID, iron or pepto
bismol use.  Patient reports light-headedness and being unsteady
on her feet at work recently.  Also report dyspnea on exertion.
CT A/P yesterday was overall unchanged- showed known portal vein
occlusion and liver lesions
.
She was diagnosed with pancreatic cancer in [**2109**]- underwent
Whipple in 12/[**2109**].  She has undergone chemotherapy with
gemcitabine (completed in [**7-18**]) and CyberKnife therapy ([**2-16**]).
She has known mets to her liver and lung but they have been
stable per recent CT scan.  She called her oncologist to report
her recent symptoms and was asked to come to the ED for further
evaluation.
.
In the ED, initial vs were: T- 97.8 P- 58 BP- 131/60 R- 20 O2
sat- 100% on RA.  Labwork significant for Hct of 23.4 (down from
30.9 on [**2112-4-22**]).  Also found to have mild transaminitis but it
is actually down from levels check in [**2112-2-8**].  Lastly, her
INR has been within 2 and 3 in the last 3 months (is 3.0 on
admission).
.
She is being admitted to the MICU for close monitoring and GI
scope to find source of bleed.
.
Review of systems:
(+) Per HPI- nausea, vomiting, dyspnea on exertion, mild
intermittent abdominal pain, dark stool, "pink" urine
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies dysuria, frequency,
or urgency. Denies arthralgias or myalgias. Denies rashes or
skin changes.

MEDICAL HISTORY: - Pancreatic cancer, s/p Whipple, chemotherapy, CyberKnife.
- Portal vein thrombosis
- Psoriasis
- Severe osteoporosis
- Hip fracture after a fall in [**2109-3-10**].
- Breast surgery (removal of mass, negative cytology) [**2103**]
- Tubal Ligation [**2091**]
- ERCP
- EUS Lap staging procedure [**9-16**]
- GERD

MEDICATION ON ADMISSION: 1.  Ativan 0.5 mg tablets 1-2 tablets by mouth every 4-6 hours
as needed for nausea, insomnia or anxiety,
2.  Warfarin 1 mg tablets 1 tablet by mouth 2-3 times daily,
dosage varies
3.  Acetaminophen as needed.
4.  Vitamin E- 800 units daily
5.  Nadolol 20mg- 1 tab daily
6.  Furosemide- 20mg PO daily
7.  Spironolactone- 50mg PO daily

ALLERGIES: Penicillins / Vancomycin / Dilaudid

PHYSICAL EXAM: Vitals: T: 97.2 BP: 114/67 P: 56 R: 12  O2 100% on RA:
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-distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly.  Mildly tender to deep
palpation in epigastrim
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Her family medical history is significant for the patient's
mother who was diagnosed with rheumatoid arthritis and died last
year of vascular dementia at the age of 82.  Her father is 86
years old and has colon cancer with liver metastases and has
suffered from cardiovascular disease.  She has a sister who is
64 years old and only suffers from rheumatoid arthritis.

SOCIAL HISTORY: The patient lives in [**Location **], [**State 350**] with her husband.
She has 1 son who lives in [**Name (NI) 8449**] and 1 daughter who lives in
[**Name (NI) 8117**], [**Name (NI) 3844**].  She continues to work as a paralegal for
a medical device company.  She states that she eats a very
healthy diet and mostly because after her surgery it is very
difficult for her to tolerate foods that have a high-fat
content. She states that she is used to exercising often by
taking long walks;  however, at this point she is trying not to
because she needs to maintain her weight.  She states that she
has approximately [**12-12**] alcoholic beverages per week and has never
used intravenous drugs, intranasal cocaine or marijuana. The
patient does not smoke. 

### Response:
{'Esophageal varices without mention of bleeding,Blood in stool,Malignant neoplasm of liver, secondary,Precipitous drop in hematocrit,Portal hypertension,Long-term (current) use of anticoagulants,Osteoporosis, unspecified,Esophageal reflux,Personal history of venous thrombosis and embolism,Other psoriasis,Other specified disorders of stomach and duodenum,Personal history of malignant neoplasm of other gastrointestinal tract,Other chronic nonalcoholic liver disease'}
