CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 62-year-old female
with a history of diverticulosis, iron-deficiency anemia,
status post gastric bypass in [**2142**] now presents with fatigue,
dyspnea on exertion, and dark black tarry stools times one.
The patient was in her usual state of health until [**2156-9-7**]
when she felt weak and shortness of breath.  She subsequently
went to the dentist later in the day and following the
procedure where a tooth was extracted and a dental implant
placed took Vioxx times one.  When she returned home she
experienced some nausea, some "rumbling in the stomach" and
then had a large black bowel movement.

MEDICAL HISTORY: 1.  Status post thyroidectomy, currently on Synthroid for
hormone replacement.
2.  Status post Roux-en-Y gastric bypass procedure in [**2142**].
3.  Asthma.
4.  Iron-deficiency anemia diagnosed in [**8-11**].  Colonoscopy,
EGD, small bowel follow through at that time was negative
except for diverticulosis.
5.  Status post cholecystectomy.
6.  Status post appendectomy.
7.  Status post total hysterectomy.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Notable for coronary artery disease and
cancer.

SOCIAL HISTORY: The patient lives alone, does not have any
children and occasional ETOH.  She also has a three pack per
day smoking history times 40 years, quit in [**2142**].
Blood in stool,Iron deficiency anemia secondary to blood loss (chronic),Diverticulosis of colon (without mention of hemorrhage),Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Intestinal bypass or anastomosis status
Blood in stool,Chr blood loss anemia,Dvrtclo colon w/o hmrhg,Hypertension NOS,Depressive disorder NEC,Intestinal bypass status
Admission Date:  [**2156-9-9**]     Discharge Date:  [**2156-9-13**]

Date of Birth:   [**2093-2-25**]     Sex:  F

Service:  [**Hospital1 212**]

HISTORY OF THE PRESENT ILLNESS:  This is a 62-year-old female
with a history of diverticulosis, iron-deficiency anemia,
status post gastric bypass in [**2142**] now presents with fatigue,
dyspnea on exertion, and dark black tarry stools times one.
The patient was in her usual state of health until [**2156-9-7**]
when she felt weak and shortness of breath.  She subsequently
went to the dentist later in the day and following the
procedure where a tooth was extracted and a dental implant
placed took Vioxx times one.  When she returned home she
experienced some nausea, some "rumbling in the stomach" and
then had a large black bowel movement.

The following morning, the morning of [**2156-9-8**], she continued
to feel fatigued.  She called her PCP who referred her to
[**Hospital1 18**] Emergency Department.  She denied having any chest
pain, abdominal pain, fevers, chills, or vomiting.  She had
no other prior episode of dark tarry stools.  At baseline,
before the events leading up to her admission to [**Hospital1 18**], she
was able to carry bags of groceries up two flights of stairs
without any shortness of breath or chest pain.

PAST MEDICAL HISTORY:
1.  Status post thyroidectomy, currently on Synthroid for
hormone replacement.
2.  Status post Roux-en-Y gastric bypass procedure in [**2142**].
3.  Asthma.
4.  Iron-deficiency anemia diagnosed in [**8-11**].  Colonoscopy,
EGD, small bowel follow through at that time was negative
except for diverticulosis.
5.  Status post cholecystectomy.
6.  Status post appendectomy.
7.  Status post total hysterectomy.

ALLERGIES:  The patient has no known drug allergies.

ADMISSION MEDICATIONS:
1.  Fluoxetine hydrochloride 20 mg p.o. q.d.
2.  Premarin.
3.  Doxycycline 100 mg p.o. q.h.s., duration five days to end
on [**2156-9-13**].
4.  Synthroid.
5.  Iron sulfate.
6.  Multivitamin.

SOCIAL HISTORY:  The patient lives alone, does not have any
children and occasional ETOH.  She also has a three pack per
day smoking history times 40 years, quit in [**2142**].

FAMILY HISTORY:  Notable for coronary artery disease and
cancer.

REVIEW OF SYSTEMS:  Previously feeling well, notable only for
occasionally feeling fatigue that she attributed to "getting
older".  She denied any fevers, chills, shortness of breath,
dyspnea on exertion, bright red blood per rectum.

PHYSICAL EXAMINATION IN THE EMERGENCY DEPARTMENT:  Vital
signs:  Temperature 97.9 degrees, pulse 82, blood pressure
98/54 which subsequently fell to 80/40 which after fluid
resuscitation came back up to 106/74.  General: She was a
pleasant female lying in bed in no apparent distress.  HEENT:
Pupils were equal and reactive to light.  The oropharynx was
clear without erythema.  Neck:  No lymphadenopathy with flat
neck veins.  Cardiovascular:  Normal S1, S2, soft II/VI
systolic ejection murmur loudest at the left upper sternal
border.  Chest:  The lungs were clear to auscultation
bilaterally.  Abdomen:  The abdomen was soft, nontender,
nondistended with positive bowel sounds.  Extremities:  Not
notable for any clubbing, cyanosis or edema.  Rectal:
Heme-positive stool.  Neurologic:  Grossly intact. Moving all
extremities.

LABORATORY/RADIOLOGIC DATA:  Her laboratory values were
notable for a white count of 6.0, hematocrit 25.3 which was
down from her baseline of 41.2 one year ago, platelet count
216,000.  Serum electrolytes revealed a sodium of 140,
potassium 4.2, chloride 102, bicarbonate 29, BUN 38,
creatinine 0.9, glucose 107.  Calcium, magnesium, and
phosphorus were all within normal limits.  Nasogastric
lavage:  Heme-negative with bilious return.

EKG revealed a normal sinus rhythm at 68 beats per minute,
normal axis, no ST changes or T wave changes.

HOSPITAL COURSE:  This is a 62-year-old woman with a history
of diverticulosis and iron-deficiency anemia status post
gastric bypass surgery who presents with one episode of
melena, weakness, and shortness of breath two days prior to
her admission.  Nasogastric tube lavage in the Emergency Room
was negative for any obvious bleeding.  She was transfused 3
units of packed red blood cells and given volume with normal
saline.

The Gastroenterology Service was consulted in the Emergency
Room.  She was urgently taken to endoscopy.  The remainder of
her hospital course will be discussed below by problem.

The patient was taken to Upper Endoscopy by the
Gastroenterology Service.  Following endoscopy, she was
admitted to the Medical Intensive Care Unit.  When the
patient was stabilized and her hematocrit was stable, she was
then transferred to the floor for further management.  The
hospital course will be discussed by problems listed below.

1.  GASTROINTESTINAL BLEEDING: The patient was taken to EGD
on the morning of [**2156-9-9**].  This examination did not
reveal any source of bleeding or any lesions in the upper GI
tract.  While she was in the ICU, she required several units
of blood for a falling hematocrit.  She was prepped for
colonoscopy to look for a lower gastrointestinal source.  At
that time, diverticulosis or arteriovenous malformation was
considered to be the most likely diagnoses.  Given the fact
that the patient was having melenic stool, the lesion was
suspected to be on the right side of the colon.

Furthermore, the patient was taken to Nuclear Medicine for a
tagged red blood cell scan to look for possible bleeding in
the ascending limb of the Roux-en-Y gastric bypass.  In
short, the colonoscopy which took place on [**2156-9-10**] was
negative for any lesion.  Furthermore, the tagged red blood
cell scan was also negative.

The patient underwent an abdominal CT with contrast to look
for any retroperitoneal bleeding or hematoma that may be
accumulating from a lesion originating in the bypassed
stomach.  This was also negative.  Between [**2156-9-10**] and
[**2156-9-11**], the patient's hematocrit fell from 29.3 to
25.5 overnight.  The patient was transfused one additional
unit of blood.

At that point, the patient was transfused 2 units to get her
hematocrit above 30 and serial hematocrit checks were done
every four to six hours as they had been for the duration of
her hospitalization.  In the early morning of [**2156-9-12**]
around midnight, her hematocrit had fallen from 30.3 to 28.5.
At that point, she was transfused one more unit of packed red
blood cells.

From that point forward, her hematocrits were stable at
around 33 until discharge.  No source was found for her
gastrointestinal bleed, as outlined above, despite multiple
testing modalities.  It is suspected that this GI bleed came
from either an arteriovenous malformation that had bled but
now was healed.  Alternatively, the bleeding may have
originated from a bleeding ulcer in the bypassed stomach but
has subsequently cleared.

2.  ANEMIA: The patient has a history of iron-deficiency
anemia.  Her anemia at this hospitalization was primarily due
to her acute blood loss into her GI tract.  Her anemia was
quite significant requiring a total of 6 units of packed red
blood cells during the duration of her stay here in the
hospital.  Furthermore, she had one episode of exertional
angina with her hematocrit in the upper 20s.  Her chest pain
completely resolved upon rest.  When her hematocrit stayed
above 30, she was able to walk around with minimal shortness
of breath and no reoccurrence of her chest pain.

3.  STATUS POST DENTAL IMPLANT ON [**2156-9-8**]:  During her
hospitalization, she was on doxycycline for infection
prevention.  Her last day of antibiotic therapy was [**2156-9-13**].

4.  HYPOTHYROIDISM:  The patient is status post
thyroidectomy.  While in the hospital, she continued on
Levoxyl.

5.  DEPRESSION:  She continued to take her Prozac while in
the hospital.

DISCHARGE STATUS:  To home.

DISCHARGE DIAGNOSIS:
1.  Gastrointestinal bleeding.
2.  Anemia secondary to acute blood loss.
3.  Hypothyroidism.
4.  Depression.

DISCHARGE MEDICATIONS:
1.  Levothyroxine sodium 75 micrograms p.o. q.d.
2.  Fluoxetine hydrochloride 20 mg p.o. q.d.
3.  Estrogen conjugated 0.625 mg p.o. q.d.
4.  Pantoprazole 40 mg p.o. q.d.

FOLLOW-UP PLANS:  The patient will follow-up with her primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in two days for a check of
her hematocrit.  She was instructed to return to the
Emergency Room at [**Hospital1 18**] if she experienced melenic stools
again or bright red blood per rectum.




                          [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 15868**]

Dictated By:[**Name8 (MD) 52183**]

MEDQUIST36

D:  [**2156-9-13**]  04:09
T:  [**2156-9-19**]  19:46
JOB#:  [**Job Number 101881**]
{'Blood in stool,Iron deficiency anemia secondary to blood loss (chronic),Diverticulosis of colon (without mention of hemorrhage),Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Intestinal bypass or anastomosis status'}


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 a 62-year-old female
with a history of diverticulosis, iron-deficiency anemia,
status post gastric bypass in [**2142**] now presents with fatigue,
dyspnea on exertion, and dark black tarry stools times one.
The patient was in her usual state of health until [**2156-9-7**]
when she felt weak and shortness of breath.  She subsequently
went to the dentist later in the day and following the
procedure where a tooth was extracted and a dental implant
placed took Vioxx times one.  When she returned home she
experienced some nausea, some "rumbling in the stomach" and
then had a large black bowel movement.

MEDICAL HISTORY: 1.  Status post thyroidectomy, currently on Synthroid for
hormone replacement.
2.  Status post Roux-en-Y gastric bypass procedure in [**2142**].
3.  Asthma.
4.  Iron-deficiency anemia diagnosed in [**8-11**].  Colonoscopy,
EGD, small bowel follow through at that time was negative
except for diverticulosis.
5.  Status post cholecystectomy.
6.  Status post appendectomy.
7.  Status post total hysterectomy.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Notable for coronary artery disease and
cancer.

SOCIAL HISTORY: The patient lives alone, does not have any
children and occasional ETOH.  She also has a three pack per
day smoking history times 40 years, quit in [**2142**]. 

### Response:
{'Blood in stool,Iron deficiency anemia secondary to blood loss (chronic),Diverticulosis of colon (without mention of hemorrhage),Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Intestinal bypass or anastomosis status'}
