CHIEF COMPLAINT: Melena and shortness of breath

PRESENT ILLNESS: This is a 77 year-old male with a history of bilateral deep
venous thrombosis, right MCA stroke with patent foramen ovale on
coumadin who presented with 2-3 days of melena and a 2 week
history of dyspnea on exertion.  He states that he was feeling
in his usual state of health until he noticed the insidious
onset of progressive dyspnea with exertion, originally after
climbing a flight of stairs, or playing handball.  However over
the past several weeks he has progressed to having dyspnea on
exertion with several stairs or in the beginning of his handball
matches.  He denies any chest pain, diaphoresis, paroxysmal
nocturnal dyspnea or orthopnea over the past several weeks.  His
melena began several days ago with "dark brown" stools.  He
denies any bright red blood per rectum or blood when he wipes.
He denies any nausea, vomiting, hematemesis, or abdominal pain.
His appetite has been good.  He denies any recent change in the
caliber of his stools with 1 formed bowel movement per day.
He further denies any fevers, chills, cough, sputum production,
abd pain, diarrhea, weight loss or night sweats.

MEDICAL HISTORY: 1. Right MCA territory stroke in [**2163**].  He had normal carotid
ultrasounds and MRA at the time.
2. Patent Foramen ovale - intervention on hold due to lack of
recurrent events on coumadin
3. Left femoral vein deep vein thrombosis, postoperative two
months following hernia in [**2141**], on Coumadin times three months.

MEDICATION ON ADMISSION: Aspirin 81 po qd
Coumadin 5 po qd
Flomax

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: Temperature:98.7 Pulse:77 Blood Pressure:123/101
Respiratory rate:16 Oxygen Saturation:99% on room air.
GENERAL: Well appearing male, in no acute distress, talking
comfortably in complete sentences
HEENT: Anicteric sclera bilaterally, pupils equal and reactive,
extraoccular movements intact, pale conjunctiva bilaterally,
moist mucous membranes.
NECK: No elevated JVP. No lymphadenopathy.
CARDIAC: Regular rate and rhythm, s1, s2, without murmurs, rubs,
or gallops.
RESPIRATORY: Clear to auscultation bilaterally with slightly
increased egophony over left mid zone.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds.
EXTREMITIES: No edema bilaterally. Pulses symmetric. Chronic
venous stasis changes present bilat lower extremities.
NEURO: Alert and oriented. Moves all extremities spontaneously.

FAMILY HISTORY: His mother had coronary artery disease at age 62.  His father
had a question of stomach cancer at the age of 92.

SOCIAL HISTORY: He is widowed and currently lives independently.  He quit
smoking 25 years ago and drinks wine or beer 3 times per week.
His son and daughter-in-law are
both physicians.
Unspecified gastritis and gastroduodenitis, with hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants
Gstr/ddnts NOS w hmrhg,Chr blood loss anemia,Hx-ven thrombosis/embols,Long-term use anticoagul
Admission Date:  [**2169-5-20**]              Discharge Date:   [**2169-5-23**]

Date of Birth:  [**2091-8-17**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Melena and shortness of breath

Major Surgical or Invasive Procedure:
Esophagastroduodenoscopy
Colonoscopy

History of Present Illness:
This is a 77 year-old male with a history of bilateral deep
venous thrombosis, right MCA stroke with patent foramen ovale on
coumadin who presented with 2-3 days of melena and a 2 week
history of dyspnea on exertion.  He states that he was feeling
in his usual state of health until he noticed the insidious
onset of progressive dyspnea with exertion, originally after
climbing a flight of stairs, or playing handball.  However over
the past several weeks he has progressed to having dyspnea on
exertion with several stairs or in the beginning of his handball
matches.  He denies any chest pain, diaphoresis, paroxysmal
nocturnal dyspnea or orthopnea over the past several weeks.  His
melena began several days ago with "dark brown" stools.  He
denies any bright red blood per rectum or blood when he wipes.
He denies any nausea, vomiting, hematemesis, or abdominal pain.
His appetite has been good.  He denies any recent change in the
caliber of his stools with 1 formed bowel movement per day.
He further denies any fevers, chills, cough, sputum production,
abd pain, diarrhea, weight loss or night sweats.

Past Medical History:
1. Right MCA territory stroke in [**2163**].  He had normal carotid
ultrasounds and MRA at the time.
2. Patent Foramen ovale - intervention on hold due to lack of
recurrent events on coumadin
3. Left femoral vein deep vein thrombosis, postoperative two
months following hernia in [**2141**], on Coumadin times three months.

4. Right calf deep vein thrombosis while on bed rest for disk
problems in [**2149**], on Coumadin.
5. Status post right middle lobe lobectomy, apparently for
bronchiectasis in [**2130**].
6. Negative hypercoaguable work-up


Social History:
He is widowed and currently lives independently.  He quit
smoking 25 years ago and drinks wine or beer 3 times per week.
His son and daughter-in-law are
both physicians.

Family History:
His mother had coronary artery disease at age 62.  His father
had a question of stomach cancer at the age of 92.

Physical Exam:
VITALS: Temperature:98.7 Pulse:77 Blood Pressure:123/101
Respiratory rate:16 Oxygen Saturation:99% on room air.
GENERAL: Well appearing male, in no acute distress, talking
comfortably in complete sentences
HEENT: Anicteric sclera bilaterally, pupils equal and reactive,
extraoccular movements intact, pale conjunctiva bilaterally,
moist mucous membranes.
NECK: No elevated JVP. No lymphadenopathy.
CARDIAC: Regular rate and rhythm, s1, s2, without murmurs, rubs,
or gallops.
RESPIRATORY: Clear to auscultation bilaterally with slightly
increased egophony over left mid zone.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds.
EXTREMITIES: No edema bilaterally. Pulses symmetric. Chronic
venous stasis changes present bilat lower extremities.
NEURO: Alert and oriented. Moves all extremities spontaneously.

RECTAL: Guiaic positive, no rectal masses.


Pertinent Results:
Hematology:
WBC-3.9 HGB-9.5 HCT-27.5 PLT COUNT-186
NEUTS-68.1 LYMPHS-26.2 MONOS-3.1 EOS-2.4 BASOS-0.3
RET AUT-4.0
.
Iron Studies:
IRON-50 calTIBC-285 VIT B12-252 FOLATE-19.7 FERRITIN-279 TRF-219
.
Chemistries:
SODIUM-142 POTASSIUM-4.4 GLUCOSE-96 UREA N-18 CREAT-1.1
CHLORIDE-107 TOTAL CO2-26
.
Coagulation:
PT-25.9 PTT-26.9 INR(PT)-2.6
.
Cardiac Enzymes
CK(CPK)-122 CK-MB-3 cTropnT-<0.01
.
EKG: Sinus bradycardia at 58 bpm with normal axis and intervals.
 No ischemic changes.
.
Chest x-ray: Calcified left pleural plague.  No infiltrate or
edema.

Brief Hospital Course:
This is a 77 year-old male with a history of bilateral deep
venous thrombosis, right MCA stroke with patent foramen ovale on
Coumadin who presented with 2-3 days of melena and a 2 week
history of dyspnea on exertion.
.
1. GI bleed: His presentation was most consistent with a chronic
slow GI bleed.  On admission, his hematocrit was 24, which was
down from his baseline of 40.  His symptoms of dyspnea on
exertion were attributed to his progressive anemia.  In the
emergency department, his Coumadin was reversed with vitamin K.
He also had a negative nasogastric lavage.  He was initially
admitted to the intensive care unit for monitoring.  He received
2 units of red cells with an appropriate bump in his hematocrit.
 An EGD showed gastritis.  A colonoscopy showed diverticuli and
a sessile polyp without any evidence of a bleeding source.  The
most likely cause of his slow bleed was his gastritis.  He was
started on a PPI.  He had no episodes of frank bleeding and his
hematocrit remained stable.  His aspirin and Coumadin were
restarted and he was monitored for 24 hours.
.
2. History of DVT: He is on chronic Coumadin given his history
of 2 DVTs and a history of a stroke with a patent foramen ovale.
 On admission, his Coumadin was reversed with vitamin K.  Once
his hematocrit remained stable and the likely source of his
bleeding was found, his Coumadin was restarted.  He was not
bridged with heparin as his risk for a stroke is small over a
few days.
.
3. FEN: His diet was advanced after his EGD and colonoscopy.
.
4. Access: Peripheral IVs.
.
5. Code: On admission, he was DNR/DNI; however, with
discussions, he reversed his code status to full.
.
6. Prophylaxis: Pneumoboots until Coumadin was restarted, PPI.
.
7. Dispo: He was discharged to home.

Medications on Admission:
Aspirin 81 po qd
Coumadin 5 po qd
Flomax

Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Gastritis


Discharge Condition:
Stable.  His hematocrit remained stable and he was
hemodynamically stable at the time of discharge.

Discharge Instructions:
Please take all medications as prescribed.  You were started on
a new medication, pantoprazole, to for the irritation in your
stomach.

Seek medical attention if you have any rectal bleeding or if you
have lightheadedness, shortness of breath, chest pain, or
anything else that you find worrisome.

Followup Instructions:
You should follow-up with your primary care physician [**Last Name (NamePattern4) **] [**1-21**]
weeks.


Completed by:[**2169-5-23**]
{'Unspecified gastritis and gastroduodenitis, with hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants'}


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: Melena and shortness of breath

PRESENT ILLNESS: This is a 77 year-old male with a history of bilateral deep
venous thrombosis, right MCA stroke with patent foramen ovale on
coumadin who presented with 2-3 days of melena and a 2 week
history of dyspnea on exertion.  He states that he was feeling
in his usual state of health until he noticed the insidious
onset of progressive dyspnea with exertion, originally after
climbing a flight of stairs, or playing handball.  However over
the past several weeks he has progressed to having dyspnea on
exertion with several stairs or in the beginning of his handball
matches.  He denies any chest pain, diaphoresis, paroxysmal
nocturnal dyspnea or orthopnea over the past several weeks.  His
melena began several days ago with "dark brown" stools.  He
denies any bright red blood per rectum or blood when he wipes.
He denies any nausea, vomiting, hematemesis, or abdominal pain.
His appetite has been good.  He denies any recent change in the
caliber of his stools with 1 formed bowel movement per day.
He further denies any fevers, chills, cough, sputum production,
abd pain, diarrhea, weight loss or night sweats.

MEDICAL HISTORY: 1. Right MCA territory stroke in [**2163**].  He had normal carotid
ultrasounds and MRA at the time.
2. Patent Foramen ovale - intervention on hold due to lack of
recurrent events on coumadin
3. Left femoral vein deep vein thrombosis, postoperative two
months following hernia in [**2141**], on Coumadin times three months.

MEDICATION ON ADMISSION: Aspirin 81 po qd
Coumadin 5 po qd
Flomax

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: Temperature:98.7 Pulse:77 Blood Pressure:123/101
Respiratory rate:16 Oxygen Saturation:99% on room air.
GENERAL: Well appearing male, in no acute distress, talking
comfortably in complete sentences
HEENT: Anicteric sclera bilaterally, pupils equal and reactive,
extraoccular movements intact, pale conjunctiva bilaterally,
moist mucous membranes.
NECK: No elevated JVP. No lymphadenopathy.
CARDIAC: Regular rate and rhythm, s1, s2, without murmurs, rubs,
or gallops.
RESPIRATORY: Clear to auscultation bilaterally with slightly
increased egophony over left mid zone.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds.
EXTREMITIES: No edema bilaterally. Pulses symmetric. Chronic
venous stasis changes present bilat lower extremities.
NEURO: Alert and oriented. Moves all extremities spontaneously.

FAMILY HISTORY: His mother had coronary artery disease at age 62.  His father
had a question of stomach cancer at the age of 92.

SOCIAL HISTORY: He is widowed and currently lives independently.  He quit
smoking 25 years ago and drinks wine or beer 3 times per week.
His son and daughter-in-law are
both physicians. 

### Response:
{'Unspecified gastritis and gastroduodenitis, with hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants'}
