CHIEF COMPLAINT: Hematemesis.

PRESENT ILLNESS: This is a 48-year-old man
with a history of severe atherosclerosis, peripheral vascular
disease status post right below knee amputation and
mesenteric ischemia, who underwent revascularization for his
mesenteric ischemia with onset of an episode of hematemesis
on the day of admission.  He vomited times two prior to being
admitted.  The patient has also had episodes of bright red
bleeding per rectum and maroon-colored stools over the last
two days with subsequent nausea and vomiting.  He was seen at
[**Hospital3 15402**] on [**12-27**] through the 15th.  He had an upper
GI scope, which reportedly was inconclusive, secondary to
poor visualization and surgical changes, but consistent with
normal.  He has no previous history of GI bleed.  He has been
on Lovenox for his hypercoagulable state, which he self
discontinued three to four days prior to admission.  He
discontinued his aspirin.  The patient was seen in the
emergency room.  A nasogastric lavage was done with only
scant blood return.  He had a large amount of retained food
in the stomach, but there was no clear site for bleeding.  He
was hemodynamically stable.  The hematocrits were monitored.

MEDICAL HISTORY: 1.  Peripheral vascular disease status right below knee
amputation, status post aortobifemoral bypass graft, status
post right femoral popliteal bypass graft.
2.  History of peptic ulcer disease.
3.  Gastroesophageal reflux disease.
4.  History of pericarditis.
5.  History of mesenteric ischemia, status post right
hemicolectomy and small bowel resection, hypercoagulable
state.

MEDICATION ON ADMISSION: 1.  Aspirin, which was discontinued.
2.  Lovenox, had been discontinued.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is on disability. He has not had
alcohol for the last 17 years.  He does smoke one pack per
day of cigarettes.  He lives alone.
Other complications due to other vascular device, implant, and graft,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Paralytic ileus,Urinary tract infection, site not specified,Peripheral vascular disease, unspecified
Comp-oth vasc dev/graft,Gastrointest hemorr NOS,Ac posthemorrhag anemia,Paralytic ileus,Urin tract infection NOS,Periph vascular dis NOS
Admission Date:  [**2116-1-10**]       Discharge Date:

Date of Birth:   [**2067-9-11**]       Sex:  M

Service:  MEDICAL

CHIEF COMPLAINT:  Hematemesis.

HISTORY OF THE PRESENT ILLNESS:  This is a 48-year-old man
with a history of severe atherosclerosis, peripheral vascular
disease status post right below knee amputation and
mesenteric ischemia, who underwent revascularization for his
mesenteric ischemia with onset of an episode of hematemesis
on the day of admission.  He vomited times two prior to being
admitted.  The patient has also had episodes of bright red
bleeding per rectum and maroon-colored stools over the last
two days with subsequent nausea and vomiting.  He was seen at
[**Hospital3 15402**] on [**12-27**] through the 15th.  He had an upper
GI scope, which reportedly was inconclusive, secondary to
poor visualization and surgical changes, but consistent with
normal.  He has no previous history of GI bleed.  He has been
on Lovenox for his hypercoagulable state, which he self
discontinued three to four days prior to admission.  He
discontinued his aspirin.  The patient was seen in the
emergency room.  A nasogastric lavage was done with only
scant blood return.  He had a large amount of retained food
in the stomach, but there was no clear site for bleeding.  He
was hemodynamically stable.  The hematocrits were monitored.

PAST MEDICAL HISTORY:
1.  Peripheral vascular disease status right below knee
amputation, status post aortobifemoral bypass graft, status
post right femoral popliteal bypass graft.
2.  History of peptic ulcer disease.
3.  Gastroesophageal reflux disease.
4.  History of pericarditis.
5.  History of mesenteric ischemia, status post right
hemicolectomy and small bowel resection, hypercoagulable
state.

ALLERGIES:  The patient has no known drug allergies.

MEDICATIONS ON ADMISSION:
1.  Aspirin, which was discontinued.
2.  Lovenox, had been discontinued.

SOCIAL HISTORY:  The patient is on disability. He has not had
alcohol for the last 17 years.  He does smoke one pack per
day of cigarettes.  He lives alone.

PHYSICAL EXAMINATION:  Examination revealed the blood
pressure of 122/86, pulse rate 119, respirations 20, 94%
oxygen saturation on room air.  The patient was sleeping
easily and comfortable in no acute distress.  He felt
lightheaded.  HEENT:  Unremarkable.  CARDIAC:  Regular rate
and rhythm with tachycardia.  Chest was clear to auscultation
bilaterally.  ABDOMEN:  Soft, nontender, nondistended with
normal bowel sounds.  RECTAL:  Examination was guaiac
negative.

LABORATORY DATA:  Labs obtained included the following:  CBC,
13.9. hematocrit 36.8, platelet count 260,000, INR 1.1, BUN
28, creatinine 1.5, potassium 5.4, differential on the white
count was normal.  Repeat hematocrit two hours later was 31,
felt secondary to hemodilution post two liters normal saline.

HOSPITAL COURSE:  The patient was admitted to the medical
service.  He was made NPO.  Gastroenterology was requested to
see the patient.  He underwent an upper endoscopy, which
showed a graft erosion through the duodenal wall with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 15532**] esophagus.  Biopsy was obtained.  Pathology results
are pending.

The patient was begun on empiric antibiotic therapy of
Ampicillin 2 grams q.6h.; Ceftizoxime 1 gram q.24;
Flagyl  500 mg q.8h.

General Surgery was consulted and Vascular Surgery was
consulted.  The patient complained of left first toe pain and
ischemic changes.  He underwent, on [**2116-1-11**] exploratory
laparotomy with removal of the [**Doctor Last Name 4726**] Tex graft and duodenotomy
closure with a jejunostomy and duodenostomy.  He received one
unit of packed cells.  Fluconazole was begun on [**1-12**] for UTI.
He was transferred to the SICU on [**1-13**].  Tube feeds were
begun and the Department of Nutrition was consulted for
appropriate nutritional management.  The patient was begun on
Impact with fiber, goal-infusion rate 80 cc per hour.

On [**1-14**], the patient complained of abdominal pain.  CBC, Chem
7 and LFTs were obtained, which were normal.  The tube feeds
were held with improvement in her symptoms.  He was begun on
TPN.  Tube feeds were restarted over the next 48 hours.  The
patient required PICC line placement for long-term
antibiotics.

On [**1-17**], the NG tube was clamped and then discontinued.  On
[**1-18**], the patient had nausea, vomiting, and had emesis of
500 cc and the NG tube was replaced.  The patient, at that
time, had a temperature maximum of 101.6.  Blood and urine
cultures were obtained.  The CBC revealed normal white count.
CT of the abdomen was obtained on [**1-30**] and there was no
intra-abdominal fluid collection.  On [**2-2**], the NG tube was
clamped again.  Residuals were checked.  The patient had an
episode of emesis and the NG tube was placed to suction. Tube
feeds were changed at this time to ProMod with fiber.  He
received a second unit of packed cells on [**2116-1-25**].  He
underwent an upper GI with small-bowel follow through on
[**1-27**]. There was still some ileus, which remained.  He was
continued on his suction.  Hematology/oncology consultation
was placed regarding the history of hypercoagulability.
Recommendations were that he probably has hemosiderins and
antiphospholipid antibodies.  Anticoagulation should be
continued.  The hemosiderin should be treated with vitamin B
12, B complex and folate.  The patient should followup with
the hematology clinic upon discharge for long-term
monitoring.  Their number is [**Telephone/Fax (1) 15533**].

On [**1-28**] the NG tube was clamped again.  There were no
residuals.  He was placed to drainage.  On [**1-29**] because of
persistent ischemic left toe pain and progressive ischemic
changes of the toe and the foot, he underwent an arteriogram,
which demonstrated occluded infrarenal aorta, occluded celiac
SMA and a BF graft.  There was a distal flow in the foot on
the affected side.  He underwent ultrasound of the upper
extremities to determine patency of the subclavian arteries
and axillary veins and arteries.  They were patent.  On [**1-31**]
he underwent a left axillary to left common femoral artery
bypass graft with PTFE and a left femoral to AK popliteal
with PTFE.  Ultrasound was done at the bedside.  The graft
was patent.  The patient remained hemodynamically stable.  He
was transferred from the PACU to the VICU for continued
monitoring and care.  The patient was transferred out of the
VICU on [**2-2**] to regular nursing floor.  The nasogastric tube
was removed on [**2-3**] and he was again on clear sips, which he
tolerated.  On [**2-5**], regular diet was begun.  PO intake would
be monitored.  Tube feeds will be continued until the p.o.
intake was adequate.  Department of physical therapy was
requested to see the patient regarding independence of his
mobility and home safety.

PHYSICAL EXAMINATION:  Wounds were clean, dry, and intact.
Left first toe remained improved with circulation, but still
dusky and discoloration was noted.  Stool for C. difficile
was sent prior to discharge.  This was pending at the time of
dictation.

MEDICATIONS ON DISCHARGE:
1.  Roxicet 1 to 2 tsp q.4 to 6h.p.r.n.for pain.
2.  Folate 1 mg q.d.
3.  Thiamine 100 mg q.d.
4.  Flagyl 500 mg q.8h.
5.  Levofloxacin 500 mg q.d.
6.  Fluconazole 200 mg q.d.
7.  Percocet 30 mg q.d.
8.  Lopressor 25 mg b.i.d. hold for systolic blood pressure
less than 110, heart rate less than 55.
9.  Multivitamin tablet with B complex q.d.
10. Reglan 10 mg a.c. and h.s.

ADDENDUM:  Regarding tube feeds and follow-up evaluations
will be made in an addendum discharge on the day of
discharge.

DISCHARGE DIAGNOSES:
1.  Upper GI bleed secondary to graft erosion of the
duodenum, status post exploratory laparotomy with removal of
[**Doctor Last Name 4726**] Tex graft with a duodenotomy with closure and a
jejunostomy and duodenostomy.
2.  Postoperative ileus resolved.
3.  Blood-loss anemia transfused, corrected.
4.  History of hypercoagulable state, treated with Lovenox
100 b.i.d.
5.  Ischemic left toe status post angioplasty, status post
left axillofemoral with PTFE and left femoral AK popliteal
with PTFE.




                            [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3409**]

Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36

D:  [**2116-2-5**]  11:07
T:  [**2116-2-5**]  11:40
JOB#:  [**Job Number 15534**]


Admission Date:  [**2116-1-10**]       Discharge Date:  [**2116-2-10**]

Date of Birth:   [**2067-9-11**]       Sex:  M

Service:

                        ADDENDUM

CONDITION ON DISCHARGE:  The patient was discharged in stable
condition eating and tolerating a regular diet.  Tube feeds
were discontinued.  He will need no caloric supplements.
Wounds were clean, dry, and intact.  The left great toe was
mildly dusky in color.

DISCHARGE INSTRUCTIONS:  VNA will be requested for dressing
changes.  He has dressings to the sacral area, Duoderm with
normal saline dressing q.d., Bacitracin to left great toe
b.i.d., J-tube dressing, dry sterile dressing, q.d.  J-tube
care is to irrigate J-tube with normal saline 50 cc solution
q.d.  The right duodenostomy tube is not to be irrigated but
should have a dry sterile dressing.

FOLLOW-UP:  The patient is to follow-up with Dr. [**Last Name (STitle) **] on
[**2116-2-18**].  The patient should follow-up with the [**Hospital **]
Clinic in two weeks and with General Surgery in two weeks.

The PICC line was removed prior to discharge.

DISCHARGE MEDICATIONS:  The patient's antibiotics will be
continued until [**2116-2-26**].  These consists of Flagyl 500
mg q.8 hours, Levofloxacin 500 mg q.24, Fluconazole 200 mg
q.d.






                            [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3409**]

Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36

D:  [**2116-2-10**]  12:00
T:  [**2116-2-10**]  12:03
JOB#:  [**Job Number 6225**]
{'Other complications due to other vascular device, implant, and graft,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Paralytic ileus,Urinary tract infection, site not specified,Peripheral vascular disease, unspecified'}


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: Hematemesis.

PRESENT ILLNESS: This is a 48-year-old man
with a history of severe atherosclerosis, peripheral vascular
disease status post right below knee amputation and
mesenteric ischemia, who underwent revascularization for his
mesenteric ischemia with onset of an episode of hematemesis
on the day of admission.  He vomited times two prior to being
admitted.  The patient has also had episodes of bright red
bleeding per rectum and maroon-colored stools over the last
two days with subsequent nausea and vomiting.  He was seen at
[**Hospital3 15402**] on [**12-27**] through the 15th.  He had an upper
GI scope, which reportedly was inconclusive, secondary to
poor visualization and surgical changes, but consistent with
normal.  He has no previous history of GI bleed.  He has been
on Lovenox for his hypercoagulable state, which he self
discontinued three to four days prior to admission.  He
discontinued his aspirin.  The patient was seen in the
emergency room.  A nasogastric lavage was done with only
scant blood return.  He had a large amount of retained food
in the stomach, but there was no clear site for bleeding.  He
was hemodynamically stable.  The hematocrits were monitored.

MEDICAL HISTORY: 1.  Peripheral vascular disease status right below knee
amputation, status post aortobifemoral bypass graft, status
post right femoral popliteal bypass graft.
2.  History of peptic ulcer disease.
3.  Gastroesophageal reflux disease.
4.  History of pericarditis.
5.  History of mesenteric ischemia, status post right
hemicolectomy and small bowel resection, hypercoagulable
state.

MEDICATION ON ADMISSION: 1.  Aspirin, which was discontinued.
2.  Lovenox, had been discontinued.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is on disability. He has not had
alcohol for the last 17 years.  He does smoke one pack per
day of cigarettes.  He lives alone. 

### Response:
{'Other complications due to other vascular device, implant, and graft,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Paralytic ileus,Urinary tract infection, site not specified,Peripheral vascular disease, unspecified'}
