CHIEF COMPLAINT: 

PRESENT ILLNESS: This is an 85-year-old female
with history of CAD, hypertension, atrial fibrillation status
post pacemaker implantation, who awoke the morning of [**2-17**] with blood on her hands, reportedly called a taxi cab,
but sounded confused on the telephone, and therefore the cab
called 911.  The patient was taken to Wooden, where she
received anterior packing for epistaxis.

MEDICAL HISTORY: 1. Coronary artery disease, PTCA and stent of PDA, posterior
LAD, and anterior RCA in 03/98.
2. Hypertension.
3. Atrial fibrillation status post A-V ablation with
pacemaker implantation [**11/2131**].
4. Dementia.
5. High cholesterol.
6. CVA secondary to hypotension in the watershed area.  No
history of embolic cerebrovascular accidents [**10/2130**].
7. AAA 3.2 x 3.6 [**3-3**].
8. Hematuria.
9. Epistaxis.
10. Antral gastritis.
11. Diverticulosis.
12. Pleural effusion.

MEDICATION ON ADMISSION: 1. Aspirin 81 mg p.o. q.d.
2. Lipitor 10 mg p.o. q.d.
3. Coumadin 2 mg Monday, Tuesday, Wednesday, and Friday, 3 mg
on Saturday and Sunday.
4. Lisinopril 20 mg p.o. q.d.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: On physical exam, her vital signs were
afebrile, pulse at 71, blood pressure 146/72, and oxygen
saturation 100%, respiratory rate 18.  General:  She was in
no apparent distress.  Her HEENT:  Pupils are equal, round,
and reactive to light.  Extraocular muscles are intact.  Her
mucous membranes were dry.  There was dried blood in the
posterior oropharynx.  There was a Foley in her left nares
with no visible acute bleeding.  She had no lymphadenopathy
on neck examination.  Cardiovascular is regular rate and
rhythm, normal S1, S2, no murmurs, rubs, or gallops.  Lung
examination is clear to auscultation bilaterally.  Abdomen is
soft, nontender, and nondistended with active bowel sounds.
Extremities are warm with no clubbing, cyanosis, or edema.
Neurological examination:  She was awoken to voice, oriented
x1.

FAMILY HISTORY: Diabetes, cancer, and leukemia.

SOCIAL HISTORY: She smoked two packs per day x50 years.  No
alcohol.  She lives alone.  She has VNA visit her.
Epistaxis,Atrial fibrillation,Percutaneous transluminal coronary angioplasty status,Coronary atherosclerosis of native coronary artery,Cardiac pacemaker in situ,Unspecified essential hypertension,Abdominal aneurysm without mention of rupture,Abnormal coagulation profile
Epistaxis,Atrial fibrillation,Status-post ptca,Crnry athrscl natve vssl,Status cardiac pacemaker,Hypertension NOS,Abdom aortic aneurysm,Abnrml coagultion prfile
Admission Date:  [**2135-2-17**]       Discharge Date:  [**2135-2-23**]


Service:  Medical Intensive Care Unit and then transferred to
the Medical service

HISTORY OF PRESENT ILLNESS:  This is an 85-year-old female
with history of CAD, hypertension, atrial fibrillation status
post pacemaker implantation, who awoke the morning of [**2-17**] with blood on her hands, reportedly called a taxi cab,
but sounded confused on the telephone, and therefore the cab
called 911.  The patient was taken to Wooden, where she
received anterior packing for epistaxis.

This afternoon after discharge from Wooden Hospital Emergency
Department, the VNA visited the patient and noted increasing
blood on the packing and blood on the patient.  The patient
was taken to the [**Hospital1 18**] Emergency Department.

Vital signs on arrival in the Emergency Department were a
pulse of 78, blood pressure 153/75, oxygen saturation 98% on
room air.  Otolaryngology was consulted and an acute
posterior bleeding was noted on exam.  ENT placed posterior
nasal packing to stop the bleeding.

Review of systems via daughter was entirely negative.  There
was some question about a report of patient having fallen.
Patient denied fall multiple times, but had mentioned a fall
once to her daughter.  There was no evidence of trauma.  At
baseline, the patient has some confusion with her
medications, places, dates, and names.

PHYSICAL EXAM:  On physical exam, her vital signs were
afebrile, pulse at 71, blood pressure 146/72, and oxygen
saturation 100%, respiratory rate 18.  General:  She was in
no apparent distress.  Her HEENT:  Pupils are equal, round,
and reactive to light.  Extraocular muscles are intact.  Her
mucous membranes were dry.  There was dried blood in the
posterior oropharynx.  There was a Foley in her left nares
with no visible acute bleeding.  She had no lymphadenopathy
on neck examination.  Cardiovascular is regular rate and
rhythm, normal S1, S2, no murmurs, rubs, or gallops.  Lung
examination is clear to auscultation bilaterally.  Abdomen is
soft, nontender, and nondistended with active bowel sounds.
Extremities are warm with no clubbing, cyanosis, or edema.
Neurological examination:  She was awoken to voice, oriented
x1.

PAST MEDICAL HISTORY:
1. Coronary artery disease, PTCA and stent of PDA, posterior
LAD, and anterior RCA in 03/98.
2. Hypertension.
3. Atrial fibrillation status post A-V ablation with
pacemaker implantation [**11/2131**].
4. Dementia.
5. High cholesterol.
6. CVA secondary to hypotension in the watershed area.  No
history of embolic cerebrovascular accidents [**10/2130**].
7. AAA 3.2 x 3.6 [**3-3**].
8. Hematuria.
9. Epistaxis.
10. Antral gastritis.
11. Diverticulosis.
12. Pleural effusion.

MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg p.o. q.d.
2. Lipitor 10 mg p.o. q.d.
3. Coumadin 2 mg Monday, Tuesday, Wednesday, and Friday, 3 mg
on Saturday and Sunday.
4. Lisinopril 20 mg p.o. q.d.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  She smoked two packs per day x50 years.  No
alcohol.  She lives alone.  She has VNA visit her.

FAMILY HISTORY:  Diabetes, cancer, and leukemia.

LABORATORIES ON ADMISSION:  Her white blood cell count was
7.6, hematocrit 40.4, platelets 276.  Chem-7:  Sodium 142,
potassium 5.0, chloride 107, bicarb 26, BUN 54, creatinine
1.2.  Glucose 78.  INR of 2.7.  Differential was 71.7
neutrophils, 20.7 lymphocytes.

HOSPITAL COURSE:  This 85 year old presented with epistaxis
of unclear etiology.  There was some question whether it was
secondary to her Coumadin, but her INR was excessively high.
It was 2.7 on admission.  Spontaneous bleed is possible, but
there is a possibility of trauma, however, by history this
seems unlikely.  She also had dry mucous membranes, which may
be contributing.

1. Epistaxis:  The patient was seen by Otolaryngology upon
admission.  He had posterior-anterior left nares packing
placed as well as a Foley catheter for posterior pressure.
The patient's bleeding was stable with the packing.  She had
two IVs placed, and she was typed and crossed when she had
bleeding.  On admission, her hematocrit was 40.4.

On the following day it had dropped to 25.7.  The patient was
transfused to bring her hematocrit up.  Her hematocrit was
followed closely while she was in the ICU and she was stable.
She was transferred to the general medical floor for further
followup.  On the medical floor, her hematocrit remained
largely stable, however, it did trend down slightly the day
prior to discharge, therefore the patient was transfused two
additional units, which brought her hematocrit up
appropriately.

On [**2135-2-22**], Otolaryngology removed her nasal packing.  The
patient had no epistaxis overnight.  A plan was made to hold
both her aspirin for two additional weeks.  She will restart
this on [**3-7**].  In addition, her Coumadin was
discontinued.  It was felt that given he age and her mental
status, difficulty taking the Coumadin, a decision was made
to stop the Coumadin from long-term anticoagulation and
instead prevent embolic events with aspirin alone.

2. Hypertension:  The patient's blood pressure was followed
closely to keep the blood pressure less than 150/90 given the
increased blood pressure will contribute to further
epistaxis.  Her blood pressure was well controlled with
captopril, which was titrated up while she was in-house.  The
blood pressure had been several for several days on captopril
100 t.i.d. and was changed to lisinopril 30 q.d. prior to
discharge.  This medication should be titrated up to 40 mg
p.o. q.d. if her blood pressure does not appear adequately
controlled on 30 q.d.

3. Coronary artery disease:  The patient had a history of
ischemic coronary artery disease.  She had been on aspirin
and Lipitor for secondary prevention for further coronary
events.  The Lipitor was continued while the patient was
in-house.  Her aspirin was on hold.  She will restart this on
[**3-7**] with 325 mg p.o. q.d.

4. Abdominal aortic aneurysm:  The patient has a history of
abdominal aortic aneurysm.  Her blood pressure was followed
closely to make sure that she does not become hypertensive
during this hospital stay.

5. Atrial fibrillation:  The patient's atrial fibrillation is
well rate controlled with a ventricular pacemaker.  Her heart
rate was regular rate and rhythm throughout her hospital
stay.  She will need to resume aspirin 325 mg p.o. q.d. for
long-term prevention of embolic events.

6. Renal:  On admission, the patient's BUN and creatinine
were noted to be elevated.  Her BUN was 54 and her creatinine
was 1.2.  Likely the patient was dehydrated on admission and
that some of the elevated BUN may have been secondary to the
bleeding.  The patient was encouraged to take good p.o. and
her BUN was noted to decrease from 54 to 33 prior to
discharge.  Her creatinine remained stable at about 1.1.  Her
baseline ranges from 0.8 to 1.1 by past hospital data.

7. Nutrition:  Initially, the patient was kept NPO secondary
to the epistaxis.  Her diet was advanced to liquids and then
to soft solids.  The patient was noted to be tolerating soft
solids well prior to discharge.  She did need some
encouragement to take adequate p.o.  The patient will be
continued on a soft solid diet, and she should receive Boost
Plus supplements t.i.d. after discharge.

8. Mental status changes:  During the hospital stay, the
patient was noted to be increasingly confused.  Given her
baseline status is oriented x1, it was likely related to
disorientation from being in the hospital.  She was given a
dose of Zyprexa to decrease her agitation given patient was
trying to pull out her packing.  The Zyprexa dose made the
patient quite somnolent for about 24 hours.  The head CT was
done to rule out any possible bleed given the prolonged
effect of the Zyprexa on the patient.

By report, the head CT was negative for bleed.  Patient's
mental status significantly improved with the discontinuation
of the packing and the discontinuation of any
antipsychotics or benzodiazepines.  The patient was
appropriate, cooperative, and oriented x1 prior to discharge.

9. Infectious disease:  The patient was started
prophylactically on the course of Ancef given that the
patient had nasal packing in place and the concern for
possibility of toxic shock syndrome with nasal packing.  Post
packing removal, the patient will be continued on a one-week
course of Keflex 500 mg p.o. q.i.d. to prevent any sinusitis
from related to the packing.

10. Code status:  The patient had a very coherent
conversation with Dr. [**Last Name (STitle) **] regarding her wishes for
end-of-life care.  She decided that she would prefer to be
DNR/DNI, and this was documented in the medical chart.

DISCHARGE CONDITION:  Stable.  Patient is alert, cooperative,
and oriented x1, and taking good p.o.

DISCHARGE STATUS:  To extended care facility.

DISCHARGE MEDICATIONS:
1. Lipitor 10 mg p.o. q.d.
2. Pantoprazole 40 mg p.o. q.d.
3. Docusate 100 mg p.o. b.i.d.
4. Multivitamin one p.o. q.d.
5. Keflex 500 mg p.o. q.i.d. x7 days.
6. Lisinopril 30 mg p.o. q.d.
7. Aspirin enteric coated 325 mg p.o. q.d. to start [**2135-3-7**],
please hold until [**2135-3-7**] secondary to recent
nosebleed.

DISCHARGE FOLLOWUP:  The patient's daughter should arrange
followup with Dr. [**Last Name (STitle) **] within the month following
discharge.



                            [**Name6 (MD) 251**] [**Name8 (MD) **], M.D.  [**MD Number(1) 1197**]

Dictated By:[**Name8 (MD) 3482**]
MEDQUIST36

D:  [**2135-2-23**]  09:45
T:  [**2135-2-23**]  09:43
JOB#:  [**Job Number 15654**]
{'Epistaxis,Atrial fibrillation,Percutaneous transluminal coronary angioplasty status,Coronary atherosclerosis of native coronary artery,Cardiac pacemaker in situ,Unspecified essential hypertension,Abdominal aneurysm without mention of rupture,Abnormal coagulation profile'}


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: This is an 85-year-old female
with history of CAD, hypertension, atrial fibrillation status
post pacemaker implantation, who awoke the morning of [**2-17**] with blood on her hands, reportedly called a taxi cab,
but sounded confused on the telephone, and therefore the cab
called 911.  The patient was taken to Wooden, where she
received anterior packing for epistaxis.

MEDICAL HISTORY: 1. Coronary artery disease, PTCA and stent of PDA, posterior
LAD, and anterior RCA in 03/98.
2. Hypertension.
3. Atrial fibrillation status post A-V ablation with
pacemaker implantation [**11/2131**].
4. Dementia.
5. High cholesterol.
6. CVA secondary to hypotension in the watershed area.  No
history of embolic cerebrovascular accidents [**10/2130**].
7. AAA 3.2 x 3.6 [**3-3**].
8. Hematuria.
9. Epistaxis.
10. Antral gastritis.
11. Diverticulosis.
12. Pleural effusion.

MEDICATION ON ADMISSION: 1. Aspirin 81 mg p.o. q.d.
2. Lipitor 10 mg p.o. q.d.
3. Coumadin 2 mg Monday, Tuesday, Wednesday, and Friday, 3 mg
on Saturday and Sunday.
4. Lisinopril 20 mg p.o. q.d.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: On physical exam, her vital signs were
afebrile, pulse at 71, blood pressure 146/72, and oxygen
saturation 100%, respiratory rate 18.  General:  She was in
no apparent distress.  Her HEENT:  Pupils are equal, round,
and reactive to light.  Extraocular muscles are intact.  Her
mucous membranes were dry.  There was dried blood in the
posterior oropharynx.  There was a Foley in her left nares
with no visible acute bleeding.  She had no lymphadenopathy
on neck examination.  Cardiovascular is regular rate and
rhythm, normal S1, S2, no murmurs, rubs, or gallops.  Lung
examination is clear to auscultation bilaterally.  Abdomen is
soft, nontender, and nondistended with active bowel sounds.
Extremities are warm with no clubbing, cyanosis, or edema.
Neurological examination:  She was awoken to voice, oriented
x1.

FAMILY HISTORY: Diabetes, cancer, and leukemia.

SOCIAL HISTORY: She smoked two packs per day x50 years.  No
alcohol.  She lives alone.  She has VNA visit her. 

### Response:
{'Epistaxis,Atrial fibrillation,Percutaneous transluminal coronary angioplasty status,Coronary atherosclerosis of native coronary artery,Cardiac pacemaker in situ,Unspecified essential hypertension,Abdominal aneurysm without mention of rupture,Abnormal coagulation profile'}
