CHIEF COMPLAINT: weakness, SOB

PRESENT ILLNESS: A 76-year-old male with history of hypertension, AFIB, CAD,
cardiomyopathy, valvular heart disease, CHF, hypothyroidism,
renal insufficiency, GI bleed, colon polyps, arthritis, and
anemia presents with 2 weeks of weakness, fatigue, SOB and chest
pain. Pt was recently d/c'd from [**Hospital1 18**] on [**2152-3-5**] for increased
ascites where he had an 11 liter paracentesis. He states that
since his discharge he has had increased fatigue, SOB, weakness
and upper chest pain. Has never had these symptoms in the past.
He felt that he was "having a heart attack and dying." His chest
pain began day PTA, radiated to neck, lasted a few minutes, had
associated SOB. Relieved with ice. Feels that his abd girth has
increased but he is not uncomfortable and has had no abd pain.
Pt was seen in clinic by PCP [**Last Name (NamePattern4) **] [**2152-3-15**] and continued on Lasix
and aldactone regimen. BP at that time was 85/37.
.
ROS positive for dizziness, constipation, one episode of
vomiting at dentist's office yesterday. Denies F/C/night sweats.
Denies diarrhea, abd pain, dysuria. Has not noted blood in stool
or change in color.
.
In ED, found to have HCT 14, most recent HCT 27 on [**2152-3-5**].
GUAIAC positive but no melena. ECHO done for hypotension and no
pericardial effusion seen.
.
Pt was noted to have guaiac positive stools on recent admission
in [**2-3**], when he had Hct of 21.6. Was advised to get an outpt
colonoscopy, but has not yet rec'd this.

MEDICAL HISTORY: 1. HTN
2. CAD -- s/p 3v-cabg
3. CHF -- Systolic and diastolic
4. AFib -- off warfarin
5. GIB -- H/o colon polyps, EGD with vascular ectasia
(cauterized)
6. Ascites -- Secondary to Right-sided CHF
7. CRI -- Baseline cr ~ 1.3
8. Anemia
9. Hypothyroidism s/p goiter excision at age 30
10. S/p left TKR

MEDICATION ON ADMISSION: 1. Aspirin 325 mg TabletQD
2. Amiodarone 200 mg QD
3. Pantoprazole 40 mg Tablet, QD
4. Atorvastatin 20 mg QD
5. Tamsulosin 0.4 mg Capsule, Sust. Release PO HS
6. Ferrous Sulfate 325 QD
7. Spironolactone 25 mg QD
8. Lasix 80 mg Tablet QPM.
9. Lasix 80 mg Tablet QAM.
10. Colace 100 mg Capsule [**Hospital1 **]
11. Oxygen-Air Delivery Systems 2L continous

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: EXAM: T 97.6, HR 70, BP 85/38, RR 22, O2sat=96% on RA
GEN: Alert and oriented, pale-appearing.
HEENT: Supple neck, distended EJs.
CV: distant Irreg, irreg.
LUNGS: Bibasliar crackles R>L, wheezes.
BACK: No CVAT
ABD: Soft, Nontender. Reducible umbilical hernia.
EXT: [**1-31**]+ pitting bilateral lower extremity edema to the distal
thighs.

FAMILY HISTORY: Mother with hypertension.

SOCIAL HISTORY: Pt lives with wife in [**Name (NI) 3146**], moved here from [**Country 3397**]. He smoked
about 1ppd x 40yrs, quit 15 yrs ago. No significant alcohol use.
Angiodysplasia of stomach and duodenum with hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Atrial fibrillation,Chronic kidney disease, unspecified,Diseases of tricuspid valve,Rheumatic heart failure (congestive),Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Benign neoplasm of duodenum, jejunum, and ileum,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension,Postsurgical hypothyroidism,Knee joint replacement
Angio stm/dudn w hmrhg,Chr blood loss anemia,Atrial fibrillation,Chronic kidney dis NOS,Tricuspid valve disease,Rheumatic heart failure,Acute kidney failure NOS,Hyposmolality,Benign neoplasm sm bowel,Cor ath unsp vsl ntv/gft,Hypertension NOS,Postsurgical hypothyroid,Joint replaced knee
Admission Date:  [**2152-3-18**]              Discharge Date:   [**2152-3-22**]

Date of Birth:  [**2075-5-19**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
weakness, SOB

Major Surgical or Invasive Procedure:
EGD s/p clip placed in second part of duodenum
colonoscopy s/p polyp removal in hepatic flexure
paracentesis s/p removal 7L fluid


History of Present Illness:
A 76-year-old male with history of hypertension, AFIB, CAD,
cardiomyopathy, valvular heart disease, CHF, hypothyroidism,
renal insufficiency, GI bleed, colon polyps, arthritis, and
anemia presents with 2 weeks of weakness, fatigue, SOB and chest
pain. Pt was recently d/c'd from [**Hospital1 18**] on [**2152-3-5**] for increased
ascites where he had an 11 liter paracentesis. He states that
since his discharge he has had increased fatigue, SOB, weakness
and upper chest pain. Has never had these symptoms in the past.
He felt that he was "having a heart attack and dying." His chest
pain began day PTA, radiated to neck, lasted a few minutes, had
associated SOB. Relieved with ice. Feels that his abd girth has
increased but he is not uncomfortable and has had no abd pain.
Pt was seen in clinic by PCP [**Last Name (NamePattern4) **] [**2152-3-15**] and continued on Lasix
and aldactone regimen. BP at that time was 85/37.
.
ROS positive for dizziness, constipation, one episode of
vomiting at dentist's office yesterday. Denies F/C/night sweats.
Denies diarrhea, abd pain, dysuria. Has not noted blood in stool
or change in color.
.
In ED, found to have HCT 14, most recent HCT 27 on [**2152-3-5**].
GUAIAC positive but no melena. ECHO done for hypotension and no
pericardial effusion seen.
.
Pt was noted to have guaiac positive stools on recent admission
in [**2-3**], when he had Hct of 21.6. Was advised to get an outpt
colonoscopy, but has not yet rec'd this.


Past Medical History:
1. HTN
2. CAD -- s/p 3v-cabg
3. CHF -- Systolic and diastolic
4. AFib -- off warfarin
5. GIB -- H/o colon polyps, EGD with vascular ectasia
(cauterized)
6. Ascites -- Secondary to Right-sided CHF
7. CRI -- Baseline cr ~ 1.3
8. Anemia
9. Hypothyroidism s/p goiter excision at age 30
10. S/p left TKR


Social History:
Pt lives with wife in [**Name (NI) 3146**], moved here from [**Country 3397**]. He smoked
about 1ppd x 40yrs, quit 15 yrs ago. No significant alcohol use.


Family History:
Mother with hypertension.

Physical Exam:
EXAM: T 97.6, HR 70, BP 85/38, RR 22, O2sat=96% on RA
GEN: Alert and oriented, pale-appearing.
HEENT: Supple neck, distended EJs.
CV: distant Irreg, irreg.
LUNGS: Bibasliar crackles R>L, wheezes.
BACK: No CVAT
ABD: Soft, Nontender. Reducible umbilical hernia.
EXT: [**1-31**]+ pitting bilateral lower extremity edema to the distal
thighs.


Pertinent Results:
Cspy results: polyps in the distal sigmoid colon not removed;
ulceration, erythema and congestion in the hepatic flexure and
ascending colon concerning for ischemia; polyp in the hepatic
flexure removed; stool in the cecum, ascending colon and hepatic
flexure limiting the views of the mucosa.
.
EGD results: polyps in the first part of the duodenum and second
part of the duodenum; angioectasias in the second part of the
duodenum - likely etiology of iron deficiency anemia and guaiac
positive stool. Clip placed.

[**2152-3-18**] 02:55AM BLOOD WBC-10.7 RBC-1.51*# Hgb-4.1*# Hct-14.0*#
MCV-93 MCH-27.4 MCHC-29.4* RDW-20.9* Plt Ct-336
[**2152-3-22**] 12:55PM BLOOD Hct-30.8*
[**2152-3-18**] 02:55AM BLOOD Neuts-88.6* Bands-0 Lymphs-7.0* Monos-3.6
Eos-0.7 Baso-0.2
[**2152-3-18**] 02:55AM BLOOD PT-13.7* PTT-29.4 INR(PT)-1.2*
[**2152-3-22**] 08:50AM BLOOD PT-13.3* PTT-31.0 INR(PT)-1.2*
[**2152-3-18**] 02:55AM BLOOD Glucose-113* UreaN-74* Creat-1.9* Na-129*
K-4.9 Cl-95* HCO3-20* AnGap-19
[**2152-3-22**] 06:10AM BLOOD UreaN-21* Creat-1.1 Na-131* K-3.4 Cl-97
HCO3-26 AnGap-11
[**2152-3-18**] 02:55AM BLOOD ALT-9 AST-17 LD(LDH)-202 CK(CPK)-46
AlkPhos-63 Amylase-134* TotBili-0.7
[**2152-3-18**] 02:55AM BLOOD Lipase-129*
[**2152-3-18**] 02:55AM BLOOD cTropnT-<0.01
[**2152-3-19**] 04:39AM BLOOD CK-MB-4 cTropnT-0.03*
[**2152-3-18**] 02:55AM BLOOD Albumin-3.0* Calcium-7.5* Phos-6.3*#
Mg-2.5 Iron-11*
[**2152-3-20**] 05:11AM BLOOD Calcium-7.2* Phos-3.7 Mg-2.1
[**2152-3-18**] 02:55AM BLOOD calTIBC-437 VitB12-596 Folate-12.7
Hapto-109 Ferritn-19* TRF-336
[**2152-3-18**] 02:55AM BLOOD TSH-25*
[**2152-3-18**] 02:55AM BLOOD T4-3.3*
[**2152-3-19**] 11:37PM BLOOD Na-130* K-3.3* Cl-95*

Brief Hospital Course:
76yo man with likely recurrent GI bleed causing profound anemia
which resolved after receiving transfusions and GI intervention.


Anemia: Hct at admission was 14 with associated symptoms such as
SOB, CP, weakness; his Hct increased appropriately after
receiving transfusions.  He was guaiac positive in the ED, and
given his history of GI bleeds, most likely source of blood loss
was from his GI tract.  He was monitored in the ICU for possible
hemodynamic instability while awaiting EGD and colonoscopy to
evaluate the source of his bleeding.  EGD demonstrated
angioectasias in the 2nd part of the duodenum which was the
likely source of blood loss - a clip was placed in this region.
On the colonoscopy, an area of ulceration, erythema and
congestion was seen in the hepatic flexure and ascending colon
which was concerning for ischemia.  Following these procedures,
his blood counts remained stable, and he was discharged to home
with an increased dose of protonix and instructions to
discontinue aspirin until instructed otherwise by his PCP.

CV:
a) CAD: h/o 3VD; He was ruled out by enzymes given his complaint
of chest pain.  He was transfused with pRBC to maintain Hct>27.
It was recommended that he avoid ASA secondary to bleeding; his
BB and ACEI were also held given his low blood pressure and
active GIB.
b) Afib: Continued Amiodarone, follow QT intervals with serial
EKGs; held anti-coag given active bleeding
c) CHF/hypotension: Pt has been evaluated in the past for TVR
though he was not felt to be a candidate given comorbidities.
Restarted outpatient diuretics once Hct and BP were stable.
d) PPx: as above, and continued statin

Abdominal ascites: This was evaluated in the past and was felt
to be secondary to R-sided CHF from 4+TR rather than cirrhosis.
He received an uncomplicated paracentesis during which 7 liters
of fluid were removed - this was mainly performed for the
patient's comfort.  Standing doses of spironolactone and lasix
were restarted prior to discharge.  He remained hemodynamically
stable, and there was no evidence of fluid reaccumulation
following the procedure.

ARF on CKD: His renal failure was most ikely attributable to
poor forward flow.  This was improved with IVF and blood
transfusions - creatinine trended towards his baseline of 1.3.
This remained stable as we avoided overdiuresis or nephrotoxic
medications.

Hypothyroidism: Continued outpatient dose of levothyroxine

Access: 3 peripheral IVs

FEN: Advanced diet slowly following GI procedures, and he was
given lasix as needed with his transfusions.

PPx: He was given pneumoboots and PPI [**Hospital1 **] for prophylaxis.

Communication: patient and wife

Code: FULL


Medications on Admission:
1. Aspirin 325 mg TabletQD
2. Amiodarone 200 mg QD
3. Pantoprazole 40 mg Tablet, QD
4. Atorvastatin 20 mg QD
5. Tamsulosin 0.4 mg Capsule, Sust. Release PO HS
6. Ferrous Sulfate 325 QD
7. Spironolactone 25 mg QD
8. Lasix 80 mg Tablet QPM.
9. Lasix 80 mg Tablet QAM.
10. Colace 100 mg Capsule [**Hospital1 **]
11. Oxygen-Air Delivery Systems 2L continous


Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
6. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
GI bleed - likely from angioectasias in duodenum
iron deficiency anemia
ascites [**3-2**] R heart failure
.
Secondary
CAD
HTN
CHF - Systolic and diastolic
AFib - off warfarin
CRI - Baseline cr 1.3
Hypothyroidism s/p goiter excision at age 30


Discharge Condition:
good; Hct stable between 28-31 w/ no further episodes of
bleeding


Discharge Instructions:
Please call Dr. [**Last Name (STitle) **] or go to the ED if you notice black or
tarry stool, feel dizzy, have shortness of breath, chest pain,
fainting, nausea, vomiting or any other symptoms that are
concerning to you.
.
Please note the following changes to your medications:
- spironolactone 50mg daily (increased from 25mg)
- pantoprazole 40mg TWICE a day (increased from once daily)
- DO NOT TAKE ASPIRIN
* Take other medications as your were prior to admission
.
You should keep the appointments that have been scheduled for
you - the details are provided below.

Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 9612**] MEDICINE (PRIVATE)
Date/Time:[**2152-3-30**] 10:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2152-4-10**] 3:45


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

Completed by:[**2152-6-14**]
{'Angiodysplasia of stomach and duodenum with hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Atrial fibrillation,Chronic kidney disease, unspecified,Diseases of tricuspid valve,Rheumatic heart failure (congestive),Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Benign neoplasm of duodenum, jejunum, and ileum,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension,Postsurgical hypothyroidism,Knee joint replacement'}


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: weakness, SOB

PRESENT ILLNESS: A 76-year-old male with history of hypertension, AFIB, CAD,
cardiomyopathy, valvular heart disease, CHF, hypothyroidism,
renal insufficiency, GI bleed, colon polyps, arthritis, and
anemia presents with 2 weeks of weakness, fatigue, SOB and chest
pain. Pt was recently d/c'd from [**Hospital1 18**] on [**2152-3-5**] for increased
ascites where he had an 11 liter paracentesis. He states that
since his discharge he has had increased fatigue, SOB, weakness
and upper chest pain. Has never had these symptoms in the past.
He felt that he was "having a heart attack and dying." His chest
pain began day PTA, radiated to neck, lasted a few minutes, had
associated SOB. Relieved with ice. Feels that his abd girth has
increased but he is not uncomfortable and has had no abd pain.
Pt was seen in clinic by PCP [**Last Name (NamePattern4) **] [**2152-3-15**] and continued on Lasix
and aldactone regimen. BP at that time was 85/37.
.
ROS positive for dizziness, constipation, one episode of
vomiting at dentist's office yesterday. Denies F/C/night sweats.
Denies diarrhea, abd pain, dysuria. Has not noted blood in stool
or change in color.
.
In ED, found to have HCT 14, most recent HCT 27 on [**2152-3-5**].
GUAIAC positive but no melena. ECHO done for hypotension and no
pericardial effusion seen.
.
Pt was noted to have guaiac positive stools on recent admission
in [**2-3**], when he had Hct of 21.6. Was advised to get an outpt
colonoscopy, but has not yet rec'd this.

MEDICAL HISTORY: 1. HTN
2. CAD -- s/p 3v-cabg
3. CHF -- Systolic and diastolic
4. AFib -- off warfarin
5. GIB -- H/o colon polyps, EGD with vascular ectasia
(cauterized)
6. Ascites -- Secondary to Right-sided CHF
7. CRI -- Baseline cr ~ 1.3
8. Anemia
9. Hypothyroidism s/p goiter excision at age 30
10. S/p left TKR

MEDICATION ON ADMISSION: 1. Aspirin 325 mg TabletQD
2. Amiodarone 200 mg QD
3. Pantoprazole 40 mg Tablet, QD
4. Atorvastatin 20 mg QD
5. Tamsulosin 0.4 mg Capsule, Sust. Release PO HS
6. Ferrous Sulfate 325 QD
7. Spironolactone 25 mg QD
8. Lasix 80 mg Tablet QPM.
9. Lasix 80 mg Tablet QAM.
10. Colace 100 mg Capsule [**Hospital1 **]
11. Oxygen-Air Delivery Systems 2L continous

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: EXAM: T 97.6, HR 70, BP 85/38, RR 22, O2sat=96% on RA
GEN: Alert and oriented, pale-appearing.
HEENT: Supple neck, distended EJs.
CV: distant Irreg, irreg.
LUNGS: Bibasliar crackles R>L, wheezes.
BACK: No CVAT
ABD: Soft, Nontender. Reducible umbilical hernia.
EXT: [**1-31**]+ pitting bilateral lower extremity edema to the distal
thighs.

FAMILY HISTORY: Mother with hypertension.

SOCIAL HISTORY: Pt lives with wife in [**Name (NI) 3146**], moved here from [**Country 3397**]. He smoked
about 1ppd x 40yrs, quit 15 yrs ago. No significant alcohol use. 

### Response:
{'Angiodysplasia of stomach and duodenum with hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Atrial fibrillation,Chronic kidney disease, unspecified,Diseases of tricuspid valve,Rheumatic heart failure (congestive),Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Benign neoplasm of duodenum, jejunum, and ileum,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension,Postsurgical hypothyroidism,Knee joint replacement'}
