CHIEF COMPLAINT: melena, chest pains

PRESENT ILLNESS: Mr. [**Known lastname **] is an 85M with h/o CAD, DM, PE on warfarin, and CRI
who was admitted on [**5-8**] with complaints of lightheadedness at
home and recent chest pains. Patient apparently developed dark
stools approximatley 1 week prior to presentation. One day prior
to presentation, he had an episode of lightheadedness on
ambulation leading to a fall. Of note, he had intermittent dull
discomfort in his abdomen for which he was taking Maalox. He
also reported chest discomfort on ambulation and had been taking
sublingual nitroglycerin at home.
.
On ROS, patient denies recent change to his medications
including warfarin, EtoH consumption, history of liver disease.
He has never had a colonoscopy. He does use ibuprofen
occasionally. Had been having increased frequency of BMs at
home, no constipation, nausea, vomiting, fevers.
.
In the ED, patient was hemodynamically stable. Rectal exam
showed guiac positive stool. Admission labs were notable for Hct
of 20 with INR of 3.6. EKG at admission showed ST depressions in
precordial and lateral leads. He received 2units PRBCs, 2units
FFP, and 5mg vitamin K and was started on IV pantoprazole. The
patient was admitted to the MICU for further monitoring.
.
In the MICU, blood pressures remained stable. He was transfused
and additional 2 units PRBCs with lasix (given EF 25%). MI was
ruled out with serial cardiac enzymes. ASA and plavix were held.
He was seen by the GI consult service who plan EGD.
.
Current, the patient has no complaints. He denies chest or
abdominal discomfort or dyspnea.

MEDICAL HISTORY: Diabetes Mellitus- most recent HgbA1c 6.3
Hypertension
Coronary Artery Disease
- s/p 3v CABG in [**2142**] (SVG->LAD, PDA, and OM)
- s/p cath [**2148-1-25**]: 3VD, no intervention
Pulmonary artery hypertension
Hyperlipidemia
Chronic renal insufficiency, b/l Cr 1.8
H/o pulmonary embolus ([**1-20**])
Gout
Right carotid artery stenosis: 100%
h/o focal motor seizure x 1 in [**7-/2143**]

MEDICATION ON ADMISSION: ASA 325 QD
Metoprolol 12.5 [**Hospital1 **]
Insulin humalin 70/30 15 U qam, 10 U qhs
Imdur 30 qam
Lipitor 80 qd
plavix 75 qday
Coumadin 2 mg daily
Colchicine 0.6 prn
Triamterene-Hydrochlorothiazide 37.5/25 daily
SLNTG prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam on transfer from MICU
T 99.2 P 94 BP 108/58 RR 20 O2 100% on RA
General: Comfortable appearing elderly man in no acute distress
HEENT: Sclera white, conjunctiva pale, MMM
Neck: JVP ~7
CV: Regular tachycardic, no m/r/g appreciated
Pulm: Lungs with few rales R base, no wheezing
Abd: Soft, nontender, +bowel sounds, no organomegaly or masses
Extrem: Warm, no edema, 2+ distal pulses
Neuro: Alert, answering appropriately, moving all extremities
without gross deficits. Hard of hearing.
Has foley in place

FAMILY HISTORY: No known colon cancer. Son, deceased with ?pancreatic cancer.
Father and sister with heart disease, details unknown.

SOCIAL HISTORY: Son lives with him at home. Needs some help with cooking, but
otherwise fairly independent. Ambulates with cane. Quit smoking
cigars years ago, no EtoH.
Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Other and unspecified angina pectoris,Chronic kidney disease, unspecified,Aortocoronary bypass status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Benign neoplasm of colon,Gout, unspecified,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism
Gastrointest hemorr NOS,Acute kidney failure NOS,Ac posthemorrhag anemia,Angina pectoris NEC/NOS,Chronic kidney dis NOS,Aortocoronary bypass,DMII wo cmp nt st uncntr,Abnrml coagultion prfile,Adv eff anticoagulants,Benign neoplasm lg bowel,Gout NOS,Hyperlipidemia NEC/NOS,Long-term use anticoagul,Hx-ven thrombosis/embols
Admission Date:  [**2149-5-11**]              Discharge Date:   [**2149-5-18**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 663**]
Chief Complaint:
melena, chest pains

Major Surgical or Invasive Procedure:
esophagogastroduodenoscopy
colonoscopy


History of Present Illness:
Mr. [**Known lastname **] is an 85M with h/o CAD, DM, PE on warfarin, and CRI
who was admitted on [**5-8**] with complaints of lightheadedness at
home and recent chest pains. Patient apparently developed dark
stools approximatley 1 week prior to presentation. One day prior
to presentation, he had an episode of lightheadedness on
ambulation leading to a fall. Of note, he had intermittent dull
discomfort in his abdomen for which he was taking Maalox. He
also reported chest discomfort on ambulation and had been taking
sublingual nitroglycerin at home.
.
On ROS, patient denies recent change to his medications
including warfarin, EtoH consumption, history of liver disease.
He has never had a colonoscopy. He does use ibuprofen
occasionally. Had been having increased frequency of BMs at
home, no constipation, nausea, vomiting, fevers.
.
In the ED, patient was hemodynamically stable. Rectal exam
showed guiac positive stool. Admission labs were notable for Hct
of 20 with INR of 3.6. EKG at admission showed ST depressions in
precordial and lateral leads. He received 2units PRBCs, 2units
FFP, and 5mg vitamin K and was started on IV pantoprazole. The
patient was admitted to the MICU for further monitoring.
.
In the MICU, blood pressures remained stable. He was transfused
and additional 2 units PRBCs with lasix (given EF 25%). MI was
ruled out with serial cardiac enzymes. ASA and plavix were held.
He was seen by the GI consult service who plan EGD.
.
Current, the patient has no complaints. He denies chest or
abdominal discomfort or dyspnea.

Past Medical History:
Diabetes Mellitus- most recent HgbA1c 6.3
Hypertension
Coronary Artery Disease
- s/p 3v CABG in [**2142**] (SVG->LAD, PDA, and OM)
- s/p cath [**2148-1-25**]: 3VD, no intervention
Pulmonary artery hypertension
Hyperlipidemia
Chronic renal insufficiency, b/l Cr 1.8
H/o pulmonary embolus ([**1-20**])
Gout
Right carotid artery stenosis: 100%
h/o focal motor seizure x 1 in [**7-/2143**]

Social History:
Son lives with him at home. Needs some help with cooking, but
otherwise fairly independent. Ambulates with cane. Quit smoking
cigars years ago, no EtoH.

Family History:
No known colon cancer. Son, deceased with ?pancreatic cancer.
Father and sister with heart disease, details unknown.

Physical Exam:
Exam on transfer from MICU
T 99.2 P 94 BP 108/58 RR 20 O2 100% on RA
General: Comfortable appearing elderly man in no acute distress
HEENT: Sclera white, conjunctiva pale, MMM
Neck: JVP ~7
CV: Regular tachycardic, no m/r/g appreciated
Pulm: Lungs with few rales R base, no wheezing
Abd: Soft, nontender, +bowel sounds, no organomegaly or masses
Extrem: Warm, no edema, 2+ distal pulses
Neuro: Alert, answering appropriately, moving all extremities
without gross deficits. Hard of hearing.
Has foley in place

Pertinent Results:
[**2149-5-11**] 11:50AM   WBC-8.6 RBC-2.44* HGB-6.8*# HCT-20.8* MCV-85
MCH-27.8 MCHC-32.6 RDW-15.7*
[**2149-5-11**] 11:50AM   PLT COUNT-385
[**2149-5-11**] 11:50AM   HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL SCHISTOCY-1+
[**2149-5-11**] 11:50AM   NEUTS-64.1 BANDS-0 LYMPHS-27.2 MONOS-6.8
EOS-1.5 BASOS-0.4
[**2149-5-11**] 11:50AM   PT-34.2* PTT-36.3* INR(PT)-3.6*
[**2149-5-11**] 11:50AM   CK(CPK)-218*
[**2149-5-11**] 11:50AM   CK-MB-3
[**2149-5-11**] 11:50AM   CK(CPK)-218*
[**2149-5-11**] 11:50AM   GLUCOSE-240* UREA N-40* CREAT-2.5* SODIUM-136
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-21* ANION GAP-17
[**2149-5-11**] 11:58AM   LACTATE-3.5*
[**2149-5-11**] 12:50PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2149-5-11**] 12:50PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2149-5-11**] 12:50PM URINE  RBC-<1 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
.
[**2069-5-10**] Tropn 0.02->0.08->0.03
[**5-16**] 5p CK 187 MB 3 Tropn <0.01
[**5-17**] 9a CK 175 MB 3 Tropn <0.01
.
Discharge labs
WBC 8.5, Hct 34, Plts 318, Cr 1.5
.
[**5-14**] H. pylori antibody negative
Micro
4/27,[**5-12**] blood cx no growth
4/27,[**5-12**] urine cx no growth
[**5-13**] urine cx mixed flora
.
[**5-16**] Colonoscopy
Findings:
 Mucosa: Edematous mucosa with decreased vascularity and mild
patchy erythema with no bleeding were noted in the cecum,
proximal ascending colon, splenic flexure and descending colon.
Cold forceps biopsies were performed for histology at the
ascending colon and splenic flexure .
 Protruding Lesions A single sessile 3 mm non-bleeding polyp of
benign appearance was found in the cecum. A single-piece
polypectomy was performed using a cold forceps. The polyp was
completely removed.
Impression: Polyp in the cecum (polypectomy)
Edematous mucosa with decreased vascularity and mild patchy
erythema in the cecum, proximal ascending colon, splenic flexure
and descending colon (biopsy)
Otherwise normal colonoscopy to terminal ileum
.
[**5-14**] EGD
Findings: Esophagus: Normal esophagus.
Stomach:
 Excavated Lesions A few small, non-bleeding erosions were noted
in the antrum.
 Other Gastric folds converging on a 1cm depression along the
greater curvature of the stomach body were noted. These findings
are consistent with a healed ulcer. Biopsies were not taken
because the patient's INR is 2.2.
Duodenum: Normal duodenum.
Impression: Erosions in the antrum
Healed gastric ulcer
Otherwise normal EGD to third part of the duodenum
.
[**5-11**] CXR
IMPRESSION: No acute intrathoracic pathology is identified.
.
[**5-11**] EKG SR nl axis and intervals, ST depressions V2-V6, I, vL.


Brief Hospital Course:
1. Gastrointestinal bleeding
The patient presented with Hct of 20 down nearly 7 points from
prior Hct 9/[**2148**]. Of note, he was taking both warfarin, aspirin,
and plavix. His initial INR was supratherapeutic at 3.6. Given
melena, initial concern was for upper source vs slow lower
bleed. His antiplatelet agents and warfarin were held, IV PPI
was initiated, and he was given FFP, vitamin K, and transfused
PRBCs. He was initially admitted to the MICU for close
monitoring; he remained hemodynamically stable there. On the
medical floor, his hematocrit remained stable and he required no
further RBC transfusions. He underwent EGD which showed some
antral erosions and a healed ulcer, but no active bleeding.
Serology showed no evidence of H. pylori infection. He
subsequently underwent a colonoscopy which also showed no source
of active bleeding. A benign-appearing 3mm cecal polyp was
removed, the pathology of which remains PENDING at discharge and
will need to be followed up by his outpatient providers. He will
need to follow up with GI as an outpatient for consideration of
a possible capsule study. He was given instructions to call for
any further concerns of melena or other bleeding. He will NOT be
continuing warfarin, but was restarted on aspirin and plavix
prior to discharge and will continue taking a PPI.
.
2. CAD
The patient reported worsening symptoms of chest discomfort at
home requiring nitroglycerin. He was ruled out for myocardial
infarction. It is likely that his angina was provoked by his GI
bleeding. His antiplatelet agents, metoprolol, and imdur were
initially held. He did experience chest discomfort during
admission that reponded to nitroglycerin, and repeat cardiac
enzymes were again negative. He resumed his home metoprolol,
imdur, and antiplatelet agents following colonoscopy. Both
metoprolol and isosorbide were subsequently increased. He will
need to follow up with his PCP and cardiology for further
treatment of his CAD.
.
3. Acute on chronic renal failure
The patient's creatinine was elevated at 2.5 at admission,
returning to baseline 1.5 at discharge. He was likely pre-renal
at admission, improved with blood and IV fluids.
.
4. Fever
The patient experienced low grade fever following transfer from
the MICU. Of note, he had had a foley catheter. As his
urinalysis showed pyuria, he was empirically treated with
ceftriaxone for suspected UTI. Ceftriaxone was subsequently
discontinued when the urine culture returned negative. His blood
culture was negative. He had no significant fevers at discharge
and was hemodynamically stable.
.
5. History of PE
Patient will not resume warfarin at discharge per discussion
with PCP given concern for increased risk of GI bleeding.
.
6. Tachycardia
Of note, patient had frequent atrial ectopy on telemetry with
occasional brief episodes of atrial tachycardia. His metoprolol
was increased and he may benefit from changing to metoprolol
succinate. He will follow up with cardiology for further
evaluation and treatment as needed.
.
7. DM Patient was continued on insulin, to continue prior home
schedule at discharge

Medications on Admission:
ASA 325 QD
Metoprolol 12.5 [**Hospital1 **]
Insulin humalin 70/30 15 U qam, 10 U qhs
Imdur 30 qam
Lipitor 80 qd
plavix 75 qday
Coumadin 2 mg daily
Colchicine 0.6 prn
Triamterene-Hydrochlorothiazide 37.5/25 daily
SLNTG prn

Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual as directed: Take 1 tab for chest pain,
may take up to 3 tabs every 5 minutes if no relief. Call 911 if
chest pain not relieved 5 minutes after 1 tab taken. Sit down to
take.
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: as below units Subcutaneous as directed: 15 units in the
morning, 10 units in the evening.
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Primary
1. Upper GI bleed
2. Coronary artery disease
3. Acute on chronic renal failure
4. Colon polyp
5. Tachycardia


Discharge Condition:
Fair, with pain under control and with stable hematocrit, no
gross bleeding


Discharge Instructions:
You came into the hospital because of black stools,
lightheadedness, and chest pain at home. You were found to be
very anemic and were given blood. You had endoscopy studies to
determine the source of bleeding in your gut. You had some
irritation of the stomache that might have been responsible for
the bleeding, but you will need to follow up with the
gastroenterology clinic for further testing. You had a small
colon polyp removed as well.
.
In the hospital you had blood tests and EKG tests that showed no
evidence of a heart attack. It is very important that you
followup with your heart doctor for further treatment of your
heart disease.
.
Take your medications as directed and keep your followup
appointments
**** IMPORTANT **** Please stop taking your warfarin (coumadin).
 In the hospital, your Metoprolol was changed from 12.5mg twice
a day to 25mg twice a day.  Your Isosorbide Mononitrate was
changed from 30mg to 60mg once a day.  You were started on
omeprazole once a day.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases more
than 3 lbs. Adhere to 2 gm sodium diet
.
Call Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 250**] and seek medical attention if you
develop:
Recurrent black or bloody stools, abdominal pain,
lightheadedness, dizziness, fainting, chest pain or shortness of
breath, or any other symptoms that worry you or your family`

Followup Instructions:
Please call Dr.[**Name (NI) 17410**] office at [**Telephone/Fax (1) 250**] Monday morning
[**2149-5-19**] to be seen in clinic as soon as possible that week.

You also need to followup with the gastroenterology and
cardiology clinics in the next 1-2 weeks. Dr.[**Name (NI) 17410**] office
can help you set this up.

You also have the following appointments
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2149-5-26**] 10:00
{'Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Other and unspecified angina pectoris,Chronic kidney disease, unspecified,Aortocoronary bypass status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Benign neoplasm of colon,Gout, unspecified,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism'}


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, chest pains

PRESENT ILLNESS: Mr. [**Known lastname **] is an 85M with h/o CAD, DM, PE on warfarin, and CRI
who was admitted on [**5-8**] with complaints of lightheadedness at
home and recent chest pains. Patient apparently developed dark
stools approximatley 1 week prior to presentation. One day prior
to presentation, he had an episode of lightheadedness on
ambulation leading to a fall. Of note, he had intermittent dull
discomfort in his abdomen for which he was taking Maalox. He
also reported chest discomfort on ambulation and had been taking
sublingual nitroglycerin at home.
.
On ROS, patient denies recent change to his medications
including warfarin, EtoH consumption, history of liver disease.
He has never had a colonoscopy. He does use ibuprofen
occasionally. Had been having increased frequency of BMs at
home, no constipation, nausea, vomiting, fevers.
.
In the ED, patient was hemodynamically stable. Rectal exam
showed guiac positive stool. Admission labs were notable for Hct
of 20 with INR of 3.6. EKG at admission showed ST depressions in
precordial and lateral leads. He received 2units PRBCs, 2units
FFP, and 5mg vitamin K and was started on IV pantoprazole. The
patient was admitted to the MICU for further monitoring.
.
In the MICU, blood pressures remained stable. He was transfused
and additional 2 units PRBCs with lasix (given EF 25%). MI was
ruled out with serial cardiac enzymes. ASA and plavix were held.
He was seen by the GI consult service who plan EGD.
.
Current, the patient has no complaints. He denies chest or
abdominal discomfort or dyspnea.

MEDICAL HISTORY: Diabetes Mellitus- most recent HgbA1c 6.3
Hypertension
Coronary Artery Disease
- s/p 3v CABG in [**2142**] (SVG->LAD, PDA, and OM)
- s/p cath [**2148-1-25**]: 3VD, no intervention
Pulmonary artery hypertension
Hyperlipidemia
Chronic renal insufficiency, b/l Cr 1.8
H/o pulmonary embolus ([**1-20**])
Gout
Right carotid artery stenosis: 100%
h/o focal motor seizure x 1 in [**7-/2143**]

MEDICATION ON ADMISSION: ASA 325 QD
Metoprolol 12.5 [**Hospital1 **]
Insulin humalin 70/30 15 U qam, 10 U qhs
Imdur 30 qam
Lipitor 80 qd
plavix 75 qday
Coumadin 2 mg daily
Colchicine 0.6 prn
Triamterene-Hydrochlorothiazide 37.5/25 daily
SLNTG prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam on transfer from MICU
T 99.2 P 94 BP 108/58 RR 20 O2 100% on RA
General: Comfortable appearing elderly man in no acute distress
HEENT: Sclera white, conjunctiva pale, MMM
Neck: JVP ~7
CV: Regular tachycardic, no m/r/g appreciated
Pulm: Lungs with few rales R base, no wheezing
Abd: Soft, nontender, +bowel sounds, no organomegaly or masses
Extrem: Warm, no edema, 2+ distal pulses
Neuro: Alert, answering appropriately, moving all extremities
without gross deficits. Hard of hearing.
Has foley in place

FAMILY HISTORY: No known colon cancer. Son, deceased with ?pancreatic cancer.
Father and sister with heart disease, details unknown.

SOCIAL HISTORY: Son lives with him at home. Needs some help with cooking, but
otherwise fairly independent. Ambulates with cane. Quit smoking
cigars years ago, no EtoH. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Acute posthemorrhagic anemia,Other and unspecified angina pectoris,Chronic kidney disease, unspecified,Aortocoronary bypass status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Benign neoplasm of colon,Gout, unspecified,Other and unspecified hyperlipidemia,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism'}
