CHIEF COMPLAINT: Bleeding from the left ear

PRESENT ILLNESS: [**Age over 90 **] year old female with PMH significant for HTN, atrial fib on
coumadin, and CHF (EF 20%) admitted to the [**Hospital Unit Name 153**] on [**10-19**] with a
Hct of 20. Pt was in her normal state of health until four days
prior to admission when her ear began bleeding after she cleaned
it with a Qtip. Pt denies pain or decrease in hearing from this
ear. She presented to the ED on [**10-19**] for evaluation of the
continued bleeding.

MEDICAL HISTORY: 1. Hypertension
2. CHF- LVEF 20%
3. Mitral Regurgitation documented on prior echo
4. Recent ([**8-17**]) hospitalization for CP. This was felt to be
musculoskeletal.
5. Atrial fib- Diagnosed in [**1-17**] and thought to be secondary to
mitral regurgitation. Pt has been anticoagulated on coumadin.
6. Hemicolectomy 10 y ago for diverticular bleed. No malignancy
found, per pt.
7. Colonoscopy [**2176**]- Previous side to end ileo-colonic
anastomosis of the ascending colon
Polyp in the rectum (polypectomy)
Diverticulosis of the sigmoid colon and descending colon
Grade 2 internal hemorrhoids
Otherwise normal Colonoscopy to ascending colon.
8. S/P left hip replacement

MEDICATION ON ADMISSION: 1. Metoprolol Tartrate 25 mg [**Hospital1 **]
2. Sertraline 50 mg daily
3. Verapamil 40 mg Q12H
4. Warfarin Sodium 2 mg Sun, Thurs, and Fri
5. Warfarin Sodium 1 mg Mon, Wed, and Sat
6. Lasix 20 mg daily
7. Lisinopril
8. Aspirin 81 mg qd

ALLERGIES: Penicillins

PHYSICAL EXAM: Gen- Pleasant lady resting in bed. Alert and oriented. NAD.
Heent- PERRL, EOMI, mmm, OP clear
Cardiac- Irreguraly irregular. II/VI SEM.
Pulm- CTAB. No wheezes, rales, or rhonchi.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- No c/c/e.
Neuro- AOX3, nonfocal exam.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Lived with her husband until he passed away in [**Month (only) 359**]. Pt now
lives alone. Her sons and daughter-in-law are involved in her
care. Non-smoker. Occassional EtOH.
Blood in stool,Atrial fibrillation,Congestive heart failure, unspecified,Acute posthemorrhagic anemia,Unspecified essential hypertension,Long-term (current) use of anticoagulants,Internal hemorrhoids without mention of complication,Diverticulosis of colon (without mention of hemorrhage),Other otorrhea
Blood in stool,Atrial fibrillation,CHF NOS,Ac posthemorrhag anemia,Hypertension NOS,Long-term use anticoagul,Int hemorrhoid w/o compl,Dvrtclo colon w/o hmrhg,Otorrhea NEC
Admission Date:  [**2181-10-19**]              Discharge Date:   [**2181-10-23**]


Service: MEDICINE

Allergies:
Penicillins

Attending:[**Doctor Last Name 10493**]
Chief Complaint:
Bleeding from the left ear

Major Surgical or Invasive Procedure:
1. Upper endoscopy [**2181-10-19**]
2. Colonoscopy [**2181-10-22**]


History of Present Illness:
[**Age over 90 **] year old female with PMH significant for HTN, atrial fib on
coumadin, and CHF (EF 20%) admitted to the [**Hospital Unit Name 153**] on [**10-19**] with a
Hct of 20. Pt was in her normal state of health until four days
prior to admission when her ear began bleeding after she cleaned
it with a Qtip. Pt denies pain or decrease in hearing from this
ear. She presented to the ED on [**10-19**] for evaluation of the
continued bleeding.

In the [**Name (NI) **], pt was found to have a Hct of 20--- it was 33.5 on
[**2181-8-25**]. Rectal exam showed melena. NG lavage was negative
showeing clear fluid and no bile. Pt denied any abdominal pain.
Pt's INR was 3.3 and she was given vit K 1 mg, 2U FFP, and 1U
PRBC. Her post-transfusion Hct was 22. Pt then had an EGD which
showed normal mucosa in the stomach, possible gastric inlet
patch 17 cm from incisors, 20 mm in diameter, erythematous and
not friable (unlikely to have caused her bleeding), normal
mucosa in the duodenum and spots in the stomach. After EGD, pt
desatted and became tachycardic to the 170s. She responded well
to a NRB and lasix.

In further discussion, pt had noted two "purple colored" stools
prior to admission and several maroon colored stools. She also
noted feeling week and fatigued. She has felt lightheaded for
approximately six months. Pt has had a significant weight loss
over the past few months from 130 to 90 pounds. She notes a
decrease in her appetite and intrest in activities since her
husband's death last year.


Past Medical History:
1. Hypertension
2. CHF- LVEF 20%
3. Mitral Regurgitation documented on prior echo
4. Recent ([**8-17**]) hospitalization for CP. This was felt to be
musculoskeletal.
5. Atrial fib- Diagnosed in [**1-17**] and thought to be secondary to
mitral regurgitation. Pt has been anticoagulated on coumadin.
6. Hemicolectomy 10 y ago for diverticular bleed. No malignancy
found, per pt.
7. Colonoscopy [**2176**]- Previous side to end ileo-colonic
anastomosis of the ascending colon
Polyp in the rectum (polypectomy)
Diverticulosis of the sigmoid colon and descending colon
Grade 2 internal hemorrhoids
Otherwise normal Colonoscopy to ascending colon.
8. S/P left hip replacement

Social History:
Lived with her husband until he passed away in [**Month (only) 359**]. Pt now
lives alone. Her sons and daughter-in-law are involved in her
care. Non-smoker. Occassional EtOH.

Family History:
Non-contributory.

Physical Exam:
Gen- Pleasant lady resting in bed. Alert and oriented. NAD.
Heent- PERRL, EOMI, mmm, OP clear
Cardiac- Irreguraly irregular. II/VI SEM.
Pulm- CTAB. No wheezes, rales, or rhonchi.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- No c/c/e.
Neuro- AOX3, nonfocal exam.

Pertinent Results:
[**2181-10-19**] 08:45AM BLOOD WBC-4.1 RBC-2.74*# Hgb-6.1*# Hct-20.0*#
MCV-73* MCH-22.2* MCHC-30.4* RDW-15.5 Plt Ct-151
[**2181-10-19**] 08:45AM BLOOD Neuts-78.6* Lymphs-15.6* Monos-5.1
Eos-0.7 Baso-0.1
[**2181-10-19**] 08:45AM BLOOD Hypochr-3+ Poiklo-1+ Microcy-2+
[**2181-10-19**] 08:45AM BLOOD PT-21.6* PTT-33.4 INR(PT)-3.3
[**2181-10-19**] 09:21PM BLOOD Glucose-96 UreaN-17 Creat-0.9 Na-144
K-4.0 Cl-107 HCO3-24 AnGap-17
[**2181-10-19**] 09:21PM BLOOD ALT-19 AST-26 LD(LDH)-206 AlkPhos-76
Amylase-88 TotBili-1.2
[**2181-10-19**] 06:50PM BLOOD CK(CPK)-112
[**2181-10-19**] 09:21PM BLOOD Lipase-41
[**2181-10-19**] 06:50PM BLOOD CK-MB-3 cTropnT-<0.01
[**2181-10-19**] 09:21PM BLOOD Calcium-8.8 Phos-3.1 Mg-1.7
[**2181-10-19**] 09:56AM BLOOD Hgb-6.0* calcHCT-18
.
CHEST (PORTABLE AP)  [**2181-10-19**] 8:47 PM
Reason: Evaluate for pulm edema.
IMPRESSION: Mild pulmonary edema and bilateral pleural
effusions.
.
EKG [**2181-10-19**]
Atrial fibrillation with a rapid ventricular response.
Ventricular premature beats. Left anterior fascicular block.
Left ventricular hypertrophy. Poor R wave progression, cannot
exclude old anteroseptal myocardial infarction but could be due
to left ventricular hypertrophy. Compared to the previous
tracing of [**2181-8-24**] the rate is faster.
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
109 0 96 332/396.28 0 -37 128
.
CHEST (PORTABLE AP)  [**2181-10-21**] 5:58 AM
Reason: pulm edema, with GI bleed
Improving CHF.


Brief Hospital Course:
This is a [**Age over 90 **] year old female with past medical history
significant for hypertension, atrial fibrillation on coumadin,
and congestive heart failure (ejection fraction of 20%) admitted
to the [**Hospital Unit Name 153**] on [**10-19**] with a Hct 20 down from 34 and INR 3.3. NG
lavage was clear without bile. An upper endoscopy was performed
which was negative for source of bleed and patient suffered post
procedure flash pulm edema which resolved with IV lasix. Patient
received another 2 units of PRBC with an appropriate increase in
her Hct. Pt received 40 mg IV lasix between these units of blood
and her respiratory status remained stable. Patient's hematocrit
remained stable with no further bleeding. Pt was transferred to
the floor on [**10-21**] for further care.
.
1. GI bleed- Patient presented with melanotic stools. Patient
was at high risk for bleed given anticoagulation with coumadin.
Negative NG lavage and no evidence of active bleeding on EGD
[**10-19**]. Differential diagnosis of lower source of bleeding
included diverticular bleed, AVM or internal hemorrhoids. A
colonoscopy was performed on [**10-22**] with diverticulosis of the
sigmoid and descending colon and grade 2 internal hemorrhoids
without active bleed. Per GI, colonscopy findings Were
nonbleeding but could have caused bleed per GI. Patient was
continued on IV protonix twice daily and her Hct was followed
every 6 hours with a transfusion threshold of Hct 30. Patient's
hematocrit remained stable after colonoscopy until day of
discharge.
.
2. [**Name (NI) 4964**] Pt with LVEF of 20%. Her respiratory status is stable at
this time but need to monitor closely for any fluid overload.
Will give IV lasix with any needed blood transfusions.
.
3. Atrial fib- Pt was well rate controlled. Since she was
hemodynamically stable and no evidence of further bleeding, she
was continued on her beta blocker. Coumadin was held. Patient
was not resumed on her coumadin at discharge given her risk of
GI bleed in the setting of recent bleed. She will follow-up with
her PCP and discuss long term plans for anti-coagulation.
.
4. HTN- Continued on beta blocker at this time as vitals stable
and no further active bleeding. Held lisinopril, CCB.
.
5. CAD- Continued on beta blocker given stable vitals but
holding ASA.
.
6. Ear bleeding- Traumatic in nature. Was irrigated in the ED
with removal of several clots. Scant bleeding since that time.
.
7. FEN- Full liquids. Electrolyte replacement as needed.
.
8. Proph- Pneumoboots; PPI
.
9. Code status- DNR/DNI.

Medications on Admission:
1. Metoprolol Tartrate 25 mg [**Hospital1 **]
2. Sertraline 50 mg daily
3. Verapamil 40 mg Q12H
4. Warfarin Sodium 2 mg Sun, Thurs, and Fri
5. Warfarin Sodium 1 mg Mon, Wed, and Sat
6. Lasix 20 mg daily
7. Lisinopril
8. Aspirin 81 mg qd

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed: Not to exceed 4g/day.
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Verapamil 40 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary diagnosis:
1. Melena
2. Diverticulosis of sigmoid and descending colon
3. Grade 2 internal hemorrhoids

Secondary diagnosis:
1. Afib
2. CHF with EF 20%
3. History of diverticular bleed status post partial colectomy
4. Hypertension


Discharge Condition:
Stable


Discharge Instructions:
1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

2. Please take medications as prescribed.

3. Please call your PCP or return to the ED if you have bright
red blood in your stool, black tarry stools, chest pain,
shortness of breath or any other worrying symptoms.

4. You have been taken off of your coumadin as it can contribute
to bleeding. Please do not take any more of this medication.

Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**] in
[**Telephone/Fax (1) 10492**] in one week. Call his office at [**Telephone/Fax (1) 10492**] to
make the appointment. I have spoke with Dr. [**Last Name (STitle) 1007**] and they will
be expecting your call.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]

Completed by:[**2181-10-24**]
{'Blood in stool,Atrial fibrillation,Congestive heart failure, unspecified,Acute posthemorrhagic anemia,Unspecified essential hypertension,Long-term (current) use of anticoagulants,Internal hemorrhoids without mention of complication,Diverticulosis of colon (without mention of hemorrhage),Other otorrhea'}


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: Bleeding from the left ear

PRESENT ILLNESS: [**Age over 90 **] year old female with PMH significant for HTN, atrial fib on
coumadin, and CHF (EF 20%) admitted to the [**Hospital Unit Name 153**] on [**10-19**] with a
Hct of 20. Pt was in her normal state of health until four days
prior to admission when her ear began bleeding after she cleaned
it with a Qtip. Pt denies pain or decrease in hearing from this
ear. She presented to the ED on [**10-19**] for evaluation of the
continued bleeding.

MEDICAL HISTORY: 1. Hypertension
2. CHF- LVEF 20%
3. Mitral Regurgitation documented on prior echo
4. Recent ([**8-17**]) hospitalization for CP. This was felt to be
musculoskeletal.
5. Atrial fib- Diagnosed in [**1-17**] and thought to be secondary to
mitral regurgitation. Pt has been anticoagulated on coumadin.
6. Hemicolectomy 10 y ago for diverticular bleed. No malignancy
found, per pt.
7. Colonoscopy [**2176**]- Previous side to end ileo-colonic
anastomosis of the ascending colon
Polyp in the rectum (polypectomy)
Diverticulosis of the sigmoid colon and descending colon
Grade 2 internal hemorrhoids
Otherwise normal Colonoscopy to ascending colon.
8. S/P left hip replacement

MEDICATION ON ADMISSION: 1. Metoprolol Tartrate 25 mg [**Hospital1 **]
2. Sertraline 50 mg daily
3. Verapamil 40 mg Q12H
4. Warfarin Sodium 2 mg Sun, Thurs, and Fri
5. Warfarin Sodium 1 mg Mon, Wed, and Sat
6. Lasix 20 mg daily
7. Lisinopril
8. Aspirin 81 mg qd

ALLERGIES: Penicillins

PHYSICAL EXAM: Gen- Pleasant lady resting in bed. Alert and oriented. NAD.
Heent- PERRL, EOMI, mmm, OP clear
Cardiac- Irreguraly irregular. II/VI SEM.
Pulm- CTAB. No wheezes, rales, or rhonchi.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- No c/c/e.
Neuro- AOX3, nonfocal exam.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Lived with her husband until he passed away in [**Month (only) 359**]. Pt now
lives alone. Her sons and daughter-in-law are involved in her
care. Non-smoker. Occassional EtOH. 

### Response:
{'Blood in stool,Atrial fibrillation,Congestive heart failure, unspecified,Acute posthemorrhagic anemia,Unspecified essential hypertension,Long-term (current) use of anticoagulants,Internal hemorrhoids without mention of complication,Diverticulosis of colon (without mention of hemorrhage),Other otorrhea'}
