CHIEF COMPLAINT: Black stool

PRESENT ILLNESS: The patient is a 78M with a history of atrial fibrillation on
coumadin, h/o multiple CVAs, steroid-dependent asthma (FEV1
59%), HTN who presents with dizziness and tarry-colored stool
over last two days. Patient reports yesterday he began feeling
dizzy while ambulating to the bathroom. He subsequently had a
tarry bowel movement. He had no further bowel movements
yesterday, but did continue to report a feeling of dizziness to
his family. On the day of admission, he had an additional
tarry-colored bowel movement. He reports mild alcohol use on the
evening prior to admission. He denies recent NSAID use. The
patient denies ever having a colonoscopy. No abdominal pain,
hematemesis, fevers/chills, recent weight loss.
.
In the ED, initial VS were: 96.0 120 96/62 18. On guaiac exam,
the patient had grossly tarry stool. NG lavage was negative. The
patient was given 2 U FFP, vitamin K 10 mg IV, 1U PRBCs. The
patient's SBP increased to 115-135 with 2L NS (3rd liter hanging
at time of transfer) and blood products. Labs were significant
for for HCT 27.2 (HCT 41.6 in [**8-5**]), INR 4.7, Cr 1.3, Trop
<0.01. EKG showed A.Fib with rate 123. Patient has a 16G on L
and 18U on R.

MEDICAL HISTORY: - hypertension
- severe asthma (FVC 80, FEV1 59, FEV1/FVC 73)
- hyperlipidemia
- a. fib on coumadin
- ASD per echo ([**2149-3-28**])
- possible midline cerebellar TIA [**2149**] - presented with
bilateral
lower extremity weakness/inability to rise from chair and
slurred speech
- ischemia of third nerve fascicle [**2143**] - presented as right
ptosis and exophoria (residual right ptosis per daughter)
- right MCA embolic stroke with some residual speech
difficulties
- cataracts bilaterally

MEDICATION ON ADMISSION: ALBUTEROL SULFATE 90 mcg 2 puff q4h
BUDESONIDE 180 mcg 2 puff [**Hospital1 **]
PREDNISONE 20 mg daily
SILDENAFIL 100 mg prn
VERAPAMIL 120 mg daily
WARFARIN 4 mg daily
CALCIUM CARBONATE 600 mg daily
CETIRIZINE 10 mg daily prn allergies
CHOLECALCIFEROL (VITAMIN D3)
MULTIVITAMIN daily
OMEGA-3 FATTY ACIDS-VITAMIN E

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On MICU admission:
Vitals: T: 98.2 BP: 124/85 P: 129 R: 22 O2: 100%RA
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irregularly irregular, no murmurs, rubs, gallops
Lungs: Mild expiratory wheeze, bibasilar rales
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ edema b/l
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation

FAMILY HISTORY: positive for stroke (brother had stroke at 52 years, is now
deceased)

SOCIAL HISTORY: lives with wife
- has three daughters
- former fashion designer for [**Name (NI) 14971**]
- first language is Arabic but speaks fluent English at baseline
- Tobacco Use: remote (smoked until age 30 years)
- Alcohol Use: about 8 oz hard liquor daily
- Recreational Drug Use: negative
Chronic or unspecified peptic ulcer of unspecified site with hemorrhage, without mention of obstruction,Acute posthemorrhagic anemia,Hyperosmolality and/or hypernatremia,Atrial fibrillation,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Helicobacter pylori [H. pylori],Long-term (current) use of anticoagulants,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use
Chr peptic ulcer w hem,Ac posthemorrhag anemia,Hyperosmolality,Atrial fibrillation,Asthma NOS,Hypertension NOS,Hyperlipidemia NEC/NOS,Helicobacter pylori,Long-term use anticoagul,Hx TIA/stroke w/o resid,Abnrml coagultion prfile,Adv eff anticoagulants
Admission Date:  [**2153-11-10**]              Discharge Date:   [**2153-11-14**]

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

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 9157**]
Chief Complaint:
Black stool

Major Surgical or Invasive Procedure:
EGD

History of Present Illness:
The patient is a 78M with a history of atrial fibrillation on
coumadin, h/o multiple CVAs, steroid-dependent asthma (FEV1
59%), HTN who presents with dizziness and tarry-colored stool
over last two days. Patient reports yesterday he began feeling
dizzy while ambulating to the bathroom. He subsequently had a
tarry bowel movement. He had no further bowel movements
yesterday, but did continue to report a feeling of dizziness to
his family. On the day of admission, he had an additional
tarry-colored bowel movement. He reports mild alcohol use on the
evening prior to admission. He denies recent NSAID use. The
patient denies ever having a colonoscopy. No abdominal pain,
hematemesis, fevers/chills, recent weight loss.
.
In the ED, initial VS were: 96.0 120 96/62 18. On guaiac exam,
the patient had grossly tarry stool. NG lavage was negative. The
patient was given 2 U FFP, vitamin K 10 mg IV, 1U PRBCs. The
patient's SBP increased to 115-135 with 2L NS (3rd liter hanging
at time of transfer) and blood products. Labs were significant
for for HCT 27.2 (HCT 41.6 in [**8-5**]), INR 4.7, Cr 1.3, Trop
<0.01. EKG showed A.Fib with rate 123. Patient has a 16G on L
and 18U on R.

On arrival to the MICU, the patient reports no further episodes
of tarry stool. He reports feeling no current dizziness. He
denies any other symptoms at this time.


Past Medical History:
- hypertension
- severe asthma (FVC 80, FEV1 59, FEV1/FVC 73)
- hyperlipidemia
- a. fib on coumadin
- ASD per echo ([**2149-3-28**])
- possible midline cerebellar TIA [**2149**] - presented with
bilateral
lower extremity weakness/inability to rise from chair and
slurred speech
- ischemia of third nerve fascicle [**2143**] - presented as right
ptosis and exophoria (residual right ptosis per daughter)
- right MCA embolic stroke with some residual speech
difficulties
- cataracts bilaterally


Social History:
 lives with wife
- has three daughters
- former fashion designer for [**Name (NI) 14971**]
- first language is Arabic but speaks fluent English at baseline
- Tobacco Use: remote (smoked until age 30 years)
- Alcohol Use: about 8 oz hard liquor daily
- Recreational Drug Use: negative


Family History:
positive for stroke (brother had stroke at 52 years, is now
deceased)


Physical Exam:
On MICU admission:
Vitals: T: 98.2 BP: 124/85 P: 129 R: 22 O2: 100%RA
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irregularly irregular, no murmurs, rubs, gallops
Lungs: Mild expiratory wheeze, bibasilar rales
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ edema b/l
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation

DISCHARGE EXAM:
VSS WNL
GEN: Well-appearing man resting in bed in NAD.
HEENT: NCAT, MMM
COR: +S1S2, no m/g/r.
PULM: Diffusely wheezey throughout both lung fields, R worse
than L. No crackles.
[**Last Name (un) **]: +NABS in 4Q. Soft, NTND.
EXT: 1+ bilateral edema, otherwise no c/c.
NEURO: Awake, alert, MAEE.

Pertinent Results:
[**2153-11-10**] 06:50PM BLOOD WBC-10.8 RBC-2.83*# Hgb-9.1*# Hct-27.2*#
MCV-96 MCH-32.3* MCHC-33.6 RDW-14.4 Plt Ct-222
[**2153-11-11**] 01:32AM BLOOD WBC-8.8 RBC-2.41* Hgb-7.7* Hct-23.3*
MCV-97 MCH-32.0 MCHC-33.0 RDW-14.7 Plt Ct-189
[**2153-11-11**] 07:11AM BLOOD WBC-7.9 RBC-2.99* Hgb-9.5* Hct-27.9*
MCV-93 MCH-31.8 MCHC-34.2 RDW-15.8* Plt Ct-163
[**2153-11-11**] 11:24AM BLOOD WBC-8.8 RBC-2.93* Hgb-9.3* Hct-27.2*
MCV-93 MCH-31.6 MCHC-34.1 RDW-15.9* Plt Ct-174
[**2153-11-11**] 04:30PM BLOOD WBC-7.7 RBC-2.79* Hgb-8.7* Hct-26.9*
MCV-96 MCH-31.2 MCHC-32.4 RDW-15.4 Plt Ct-186
[**2153-11-11**] 06:23PM BLOOD WBC-8.3 RBC-2.92* Hgb-9.3* Hct-28.2*
MCV-96 MCH-31.8 MCHC-33.0 RDW-15.2 Plt Ct-192
[**2153-11-10**] 06:50PM BLOOD Neuts-70.7* Lymphs-23.1 Monos-4.3 Eos-1.4
Baso-0.4
[**2153-11-11**] 11:56PM BLOOD PTT-99.6*
[**2153-11-11**] 06:23PM BLOOD Plt Ct-192
[**2153-11-11**] 07:11AM BLOOD Glucose-89 UreaN-45* Creat-1.1 Na-148*
K-3.8 Cl-112* HCO3-30 AnGap-10
[**2153-11-10**] 06:55PM BLOOD Glucose-120*
[**2153-11-10**] 06:55PM BLOOD Hgb-9.0* calcHCT-27

EGD [**2153-11-11**]:
Impression: Normal mucosa in the esophagus
Ulcer in the pylorus
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum

Chest x-ray [**2153-11-10**]:
FINDINGS: AP semi-erect portable views of the chest are
obtained. An
enterogastric tube is seen coursing below the level of the
diaphragm, distal
aspect not included on the image. There may be minimal pulmonary
vascular
congestion. Bibasilar atelectasis is seen. No definite focal
consolidation
is seen, although minimal aspiration would be difficult to
exclude. No
pleural effusion or pneumothorax. Cardiac and mediastinal
silhouettes are
stable.


Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
78-yo M with afib on coumadin, h/o multiple CVAs,
steroid-dependent asthma initially admitted to MICU for melena
in the setting of INR = 4.7.

ACUTE DIAGNOSES:

# GI Bleed: The patient's initial HCT was 27.1 (last known Hct
41 in [**2152**]). In the ED, NG lavage was negative; rectal exam
demonstrated melanotic stool.  He received 2 units of PRBCs &
his INR was reversed with FFP & vitamin K (initial INR was 4.7).
  GI evaluated the patient & an EGD was performed on [**11-11**] which
revealed a small non-bleeding gastric ulcer.  Over the course of
his hospitalization, the patient received a total of 3 units of
pRBCs.  His HCT at discharge was 29.7; his stools were of normal
color with no further melena.  It is possible that the ulcer was
the cause for the GI bleed, vs. another upper GI pathology.  The
patient will follow-up with GI as an outpatient; he will likely
have a repeat EGD and/or colonoscopy.

# H. Pylori Infection: As part of his GI work-up, the patient's
blood was sent for H. Pylori serologies, which resulted
positive.  As such, he was started on amoxicillin,
clarithromycin, & continued on his PPI.  He was instructed to
continue the antibiotics for a total of 2 weeks; he will be
continued on a PPI from this point forward.

CHRONIC DIAGNOSES:

# Atrial Fib with RVR:  The patient's initial heart rate was in
the 120s.  Coumadin was held in the setting of a
supratherapeutic INR.  The patient takes verapamil as an
outpatient for rate control, which was held .  In the MICU, he
developed asymptomatic tachycardia, so he was started on
diltiazem.  Mr. [**Known lastname 14972**] did not tolerate diltiazem due to nausea,
so his verapamil was restarted on the floor.  Given his CHADS2
score of 4 & history of prior CVA, he was initially started on a
heparin drip (upon approval from GI).  The patient, however,
wished to return home & was not interested in lovenox
injections.  It was not thought that he required a bridge to
coumadin; he was discharged on 3 mg coumadin QD with a plan to
have his PCP follow his INR closely.

# Asthma: The patient's lung exam revealed diffuse wheeze.  He
was continued on his home MDI & steroids. His steroid dose was
increased from 10 mg to 20 mg given that he had ongoing wheeze &
briefly required oxygen.  He will follow-up with his
pulmonologist upon discharge.  In addition to his calcium &
vitamin D prophylaxis, he may also need antibiotic prophylaxis
in the setting of long-term antibiotics.

TRANSITIONAL ISSUES:

# INR Monitoring: Given that the patient came in with a
supratherapeutic INR, it will be important for his INR &
coumadin dosing to be followed closely.  He was discharged with
instructions to check his INR several times before his follow-up
appointment with his primary care doctor.

# Follow Up: The patient will follow up with his PCP,
[**Name Initial (NameIs) **], & pulmonology.  Please refer to discharge
worksheet section for appointments.

# Code Status: Full code.


Medications on Admission:
ALBUTEROL SULFATE 90 mcg 2 puff q4h
BUDESONIDE 180 mcg 2 puff [**Hospital1 **]
PREDNISONE 20 mg daily
SILDENAFIL 100 mg prn
VERAPAMIL 120 mg daily
WARFARIN 4 mg daily
CALCIUM CARBONATE 600 mg daily
CETIRIZINE 10 mg daily prn allergies
CHOLECALCIFEROL (VITAMIN D3)
MULTIVITAMIN daily
OMEGA-3 FATTY ACIDS-VITAMIN E


Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours).
2. budesonide 180 mcg/Inhalation Aerosol Powdr Breath Activated
Sig: Two (2) puffs Inhalation twice a day.
3. prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. sildenafil 100 mg Tablet Sig: One (1) Tablet PO as directed
as needed for sexual activity: 1 pill 30 minutes before sexual
activity.
5. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q24H (every 24 hours).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
7. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
8. Omega 3 Fish Oil  Oral
9. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
Please take 3mg daily for now, until otherwise instructed by
your primary care doctor.
10. clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*48 Tablet(s)* Refills:*0*
11. amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 12 days.
Disp:*96 Capsule(s)* Refills:*0*
12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
Please take twice a day for 12 more days.  Then you may take
this medication once daily.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. cholecalciferol (vitamin D3)  Oral


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- GI bleed (likely upper source)
- H. Pylori infection

SECONDARY DIAGNOSES:
- Atrial fibrillation requiring coumadin


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Mr. [**Known lastname 14972**], it was a pleasure to participate in your care while
you were at the hospital.  You came to the hospital because you
had an episode of dark stool, which usually means you were
bleeding in the upper part of your GI tract. Your coumadin level
was too high, which may have contributed to your GI bleed. While
you were here we reversed the effects of coumadin with
medications & blood products.  Our gastroenterologists evaluated
while you were here & you underwent an upper encoscopy that
showed an ulcer in your stomach.  Blood testing also showed that
you have an infection with a bacteria called "H. pylori" for
which you will need antibiotics for 14 days.  You should
continue to take omeprazole indefinitely.

We have made the following changes to your medications:
-START coumadin at 3mg daily for now.  You will be followedly
closely by Dr. [**Last Name (STitle) 14973**] until your blood levels (INR) is back to
its goal of [**3-1**].

Please report to your doctor's office on Friday ([**11-16**]) and
[**Month/Year (2) 766**] ([**11-19**]) to get your INR checked.  They will follow-up
with you about changing your coumadin dosing if needed.

The gastroenterologists will repeat an endoscopy in [**Month (only) 1096**] to
ensure that your ulcer is healing.

Followup Instructions:
We have made the following appointments for you:

PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**Last Name (STitle) 14973**]
[**Name (STitle) 766**], [**11-19**] at 10:15am

Pulmonary
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2153-12-27**] at 9:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES
When: THURSDAY [**2153-12-27**] at 9:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: PFT
When: THURSDAY [**2153-12-27**] at 9:30 AM

[**Year (4 digits) **]
[**2154-1-1**]  12:30p   WPC ROOM,THREE
  [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **]
  WPC ROOMS/BAYS
[**2154-1-1**]  12:30p   [**First Name8 (NamePattern2) **] [**Location (un) **],WPC WEST
  [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **]
  ENDOSCOPY SUITES
[**2154-1-9**]  01:30p   GI,[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**]
  RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
  GI [**Hospital 14974**] CLINIC (SB)

Please call your [**Hospital1 18**] cardiologist to set up an appointment at
your convenience.  He wanted you to start a medication (digoxin)
that you have not started yet and you should discuss this
further with him.
{'Chronic or unspecified peptic ulcer of unspecified site with hemorrhage, without mention of obstruction,Acute posthemorrhagic anemia,Hyperosmolality and/or hypernatremia,Atrial fibrillation,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Helicobacter pylori [H. pylori],Long-term (current) use of anticoagulants,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use'}


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: Black stool

PRESENT ILLNESS: The patient is a 78M with a history of atrial fibrillation on
coumadin, h/o multiple CVAs, steroid-dependent asthma (FEV1
59%), HTN who presents with dizziness and tarry-colored stool
over last two days. Patient reports yesterday he began feeling
dizzy while ambulating to the bathroom. He subsequently had a
tarry bowel movement. He had no further bowel movements
yesterday, but did continue to report a feeling of dizziness to
his family. On the day of admission, he had an additional
tarry-colored bowel movement. He reports mild alcohol use on the
evening prior to admission. He denies recent NSAID use. The
patient denies ever having a colonoscopy. No abdominal pain,
hematemesis, fevers/chills, recent weight loss.
.
In the ED, initial VS were: 96.0 120 96/62 18. On guaiac exam,
the patient had grossly tarry stool. NG lavage was negative. The
patient was given 2 U FFP, vitamin K 10 mg IV, 1U PRBCs. The
patient's SBP increased to 115-135 with 2L NS (3rd liter hanging
at time of transfer) and blood products. Labs were significant
for for HCT 27.2 (HCT 41.6 in [**8-5**]), INR 4.7, Cr 1.3, Trop
<0.01. EKG showed A.Fib with rate 123. Patient has a 16G on L
and 18U on R.

MEDICAL HISTORY: - hypertension
- severe asthma (FVC 80, FEV1 59, FEV1/FVC 73)
- hyperlipidemia
- a. fib on coumadin
- ASD per echo ([**2149-3-28**])
- possible midline cerebellar TIA [**2149**] - presented with
bilateral
lower extremity weakness/inability to rise from chair and
slurred speech
- ischemia of third nerve fascicle [**2143**] - presented as right
ptosis and exophoria (residual right ptosis per daughter)
- right MCA embolic stroke with some residual speech
difficulties
- cataracts bilaterally

MEDICATION ON ADMISSION: ALBUTEROL SULFATE 90 mcg 2 puff q4h
BUDESONIDE 180 mcg 2 puff [**Hospital1 **]
PREDNISONE 20 mg daily
SILDENAFIL 100 mg prn
VERAPAMIL 120 mg daily
WARFARIN 4 mg daily
CALCIUM CARBONATE 600 mg daily
CETIRIZINE 10 mg daily prn allergies
CHOLECALCIFEROL (VITAMIN D3)
MULTIVITAMIN daily
OMEGA-3 FATTY ACIDS-VITAMIN E

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On MICU admission:
Vitals: T: 98.2 BP: 124/85 P: 129 R: 22 O2: 100%RA
General: Alert, oriented, no acute distress
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: irregularly irregular, no murmurs, rubs, gallops
Lungs: Mild expiratory wheeze, bibasilar rales
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ edema b/l
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation

FAMILY HISTORY: positive for stroke (brother had stroke at 52 years, is now
deceased)

SOCIAL HISTORY: lives with wife
- has three daughters
- former fashion designer for [**Name (NI) 14971**]
- first language is Arabic but speaks fluent English at baseline
- Tobacco Use: remote (smoked until age 30 years)
- Alcohol Use: about 8 oz hard liquor daily
- Recreational Drug Use: negative 

### Response:
{'Chronic or unspecified peptic ulcer of unspecified site with hemorrhage, without mention of obstruction,Acute posthemorrhagic anemia,Hyperosmolality and/or hypernatremia,Atrial fibrillation,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Helicobacter pylori [H. pylori],Long-term (current) use of anticoagulants,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use'}
