CHIEF COMPLAINT: BRBPR

PRESENT ILLNESS: [**Age over 90 **] male with h/o PVD, CAD, AFib s/p ablation, recent GIB, who
presents with several episodes of BRBPR.  He was recently
discharged from [**Hospital1 18**] on [**2146-10-20**].  He had several episodes of
hematochezia at his nursing home today, and was subsequently
sent in to the ED.  He denied any chest pain, SOB,
lighthededness, diarrhea, abdominal pain, fevers, chills, back
pain.
.
Last week he also presented with BRBPR, and he was discharged
yesterday. Initially, a tagged red blood cell scan showed
bleeding from the rectum. However, subsequent angiography was
unable to localize and embolize the source of bleed. A fexible
sigmoidoscopy showed an actively bleeding Dielafoys lesion which
was successfully clipped. The patient subsequently remained
hemodynamically stable, with minimal further RBC transfusions.
Coumadin, aspirin, and Plavix were initially held. Aspirin and
Plavix were resumed prior to discharge.
.
ED course: He was found to have a stable hct from last
admission.  He had several large BRBPR episodes in ED, and his
SBP went from 140 to 110.  He was give 1 liter of NS.  GI was
called, and planned for scope in AM.  He was admitted to MICU
for close observation.

MEDICAL HISTORY: 1.Severe PVD: [**9-9**]: R BKPO-DP bypass w/ RSVG
2.10/2 Achilles tendon w/ abscess excision w/ VAC placement
3.Aortic Stenosis: Echo: [**12-19**]: moderate AS, aortic regurg,
mitral regurg, moderate pericardial effusion.
4.CAD: s/p cardiac cath: 90% distal LMCA, 80% LCX, Stent in
LMCA/LAD Cypher drug-eluting stent.
5.Carotid artery stenosis: Chronically occluded right internal
carotid artery. Left, with 40-59% carotid stenosis.
6. Hypercholesterolemia
7. Hypothyroidism
8. Chronic low back pain
9. AFib s/p ablation
[**48**]. s/p cholecystectomy
[**49**]. s/p bilateral carotid endartectomies
12. s/p left knee arthroscopy
13. s/p lumbar decompression '[**34**]
14. s/p left leg thrombectomy
15. s/p Dielafoys lesion banding [**10-19**]

MEDICATION ON ADMISSION: 1. Aspirin 81 mg
2. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY

ALLERGIES: Levaquin

PHYSICAL EXAM: On admission:
Vs- 145/55  65  12  100% 2L NC
Gen- Well appearing elderly male lying in bed, NAD
Heent- dry MM, anicteric, PERRL
Neck- Supple, no LAD, no JVP elevation, bilateral carotid
bruits, bandage on right neck from prior IJ
Cor- RRR, high pitched SEM at LLSB, heard throughout precordium
Chest- Relatively clear bilaterally
Abd- soft, NT, ND, pos BS, ventral hernia, no organomegaly
Ext- Right heel with 1+ edema, open wound on heel, boot on,
wound vac in place.  Left with no swelling.
Neuro- AAO x 2, confused about place and exact date.
Skin- Hyperpigmented lesion on left anterior chest, mildly
raised

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Previous 30 pack-year tobacco, quit 40 [**Month/Year (2) 1686**] ago. Occasional EtOH.
Currently at [**Hospital 169**] Center. Previously lived in the
basement of his daughter's house. Walks with a cane.
Dieulafoy lesion (hemorrhagic) of intestine,Pressure ulcer, ankle,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Atrial fibrillation,Retention of urine, unspecified,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Multiple involvement of mitral and aortic valves,Peripheral vascular disease, unspecified
Dieulafoy les, intestine,Pressure ulcer, ankle,Ac posthemorrhag anemia,Urin tract infection NOS,Atrial fibrillation,Retention urine NOS,Hypothyroidism NOS,Pure hypercholesterolem,Crnry athrscl natve vssl,Status-post ptca,Ocl crtd art wo infrct,Mitr/aortic mult involv,Periph vascular dis NOS
Admission Date:  [**2146-10-22**]              Discharge Date:   [**2146-10-25**]


Service: MEDICINE

Allergies:
Levaquin

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
BRBPR

Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy


History of Present Illness:
[**Age over 90 **] male with h/o PVD, CAD, AFib s/p ablation, recent GIB, who
presents with several episodes of BRBPR.  He was recently
discharged from [**Hospital1 18**] on [**2146-10-20**].  He had several episodes of
hematochezia at his nursing home today, and was subsequently
sent in to the ED.  He denied any chest pain, SOB,
lighthededness, diarrhea, abdominal pain, fevers, chills, back
pain.
.
Last week he also presented with BRBPR, and he was discharged
yesterday. Initially, a tagged red blood cell scan showed
bleeding from the rectum. However, subsequent angiography was
unable to localize and embolize the source of bleed. A fexible
sigmoidoscopy showed an actively bleeding Dielafoys lesion which
was successfully clipped. The patient subsequently remained
hemodynamically stable, with minimal further RBC transfusions.
Coumadin, aspirin, and Plavix were initially held. Aspirin and
Plavix were resumed prior to discharge.
.
ED course: He was found to have a stable hct from last
admission.  He had several large BRBPR episodes in ED, and his
SBP went from 140 to 110.  He was give 1 liter of NS.  GI was
called, and planned for scope in AM.  He was admitted to MICU
for close observation.

Past Medical History:
1.Severe PVD: [**9-9**]: R BKPO-DP bypass w/ RSVG
2.10/2 Achilles tendon w/ abscess excision w/ VAC placement
3.Aortic Stenosis: Echo: [**12-19**]: moderate AS, aortic regurg,
mitral regurg, moderate pericardial effusion.
4.CAD: s/p cardiac cath: 90% distal LMCA, 80% LCX, Stent in
LMCA/LAD Cypher drug-eluting stent.
5.Carotid artery stenosis: Chronically occluded right internal
carotid artery. Left, with 40-59% carotid stenosis.
6. Hypercholesterolemia
7. Hypothyroidism
8. Chronic low back pain
9. AFib s/p ablation
[**48**]. s/p cholecystectomy
[**49**]. s/p bilateral carotid endartectomies
12. s/p left knee arthroscopy
13. s/p lumbar decompression '[**34**]
14. s/p left leg thrombectomy
15. s/p Dielafoys lesion banding [**10-19**]

Social History:
Previous 30 pack-year tobacco, quit 40 [**Month/Year (2) 1686**] ago. Occasional EtOH.
Currently at [**Hospital 169**] Center. Previously lived in the
basement of his daughter's house. Walks with a cane.


Family History:
Non-contributory

Physical Exam:
On admission:
Vs- 145/55  65  12  100% 2L NC
Gen- Well appearing elderly male lying in bed, NAD
Heent- dry MM, anicteric, PERRL
Neck- Supple, no LAD, no JVP elevation, bilateral carotid
bruits, bandage on right neck from prior IJ
Cor- RRR, high pitched SEM at LLSB, heard throughout precordium
Chest- Relatively clear bilaterally
Abd- soft, NT, ND, pos BS, ventral hernia, no organomegaly
Ext- Right heel with 1+ edema, open wound on heel, boot on,
wound vac in place.  Left with no swelling.
Neuro- AAO x 2, confused about place and exact date.
Skin- Hyperpigmented lesion on left anterior chest, mildly
raised

On discharge:
VS: 97.4  124/60  74  18  96%RA
Exam was largely unchanged on discharge.  Patient was oriented
to self and place.  He is slightly confused about the date.

Pertinent Results:
ECG: NSR, nl axis, nl interval, STd V4-V6.  Compared with prior,
ST depressions new.
.
Studies~
Flexible sigmoidoscopy [**2146-10-24**]: Stool in the rectum. The scope
was advanced up to proximal rectum. There was yellow stool
noticed. No evidence of active bleeding noted. Otherwise normal
sigmoidoscopy to rectum.
.
Bleeding scan [**2146-10-13**] (prior admission): Positive bleeding scan,
from rectum within the first 5 minutes
.
Mesenteric angiogram [**2146-10-13**]:
1.  Diffuse atherosclerotic disease including extensive [**Month/Day/Year 1106**]
calcification.
2.  Selective angiograms of the superior mesenteric artery and
inferior mesenteric artery demonstrate no foci of active
bleeding.  Incidental note is made of probable occlusion of the
celiac artery as evidenced by collaterals formed between the
common hepatic artery and superior mesenteric artery.

[**2146-10-22**] 07:39PM   HCT-28.4*
[**2146-10-22**] 11:59AM   HCT-29.3*
[**2146-10-22**] 05:20AM   GLUCOSE-88 UREA N-11 CREAT-0.9 SODIUM-137
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-26 ANION GAP-9
[**2146-10-22**] 05:20AM   CK(CPK)-45
[**2146-10-22**] 05:20AM   CK-MB-NotDone cTropnT-0.05*
[**2146-10-22**] 05:20AM   CALCIUM-7.8* PHOSPHATE-2.4* MAGNESIUM-2.0
[**2146-10-22**] 05:20AM   WBC-5.2 RBC-3.12* HGB-9.6* HCT-28.3* MCV-91
MCH-30.9 MCHC-34.0 RDW-17.6*
[**2146-10-22**] 05:20AM   PLT COUNT-157
[**2146-10-22**] 05:20AM   PT-12.8 PTT-30.3 INR(PT)-1.1
[**2146-10-22**] 02:35AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029
[**2146-10-22**] 02:35AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2146-10-22**] 02:35AM URINE  RBC-0 WBC-[**11-1**]* BACTERIA-OCC YEAST-MANY
EPI-<1
[**2146-10-22**] 02:25AM   WBC-5.0 RBC-3.26* HGB-10.2* HCT-29.5* MCV-91
MCH-31.5 MCHC-34.7 RDW-17.6*
[**2146-10-22**] 02:25AM   NEUTS-65.3 LYMPHS-23.4 MONOS-7.2 EOS-4.1*
BASOS-0.1
[**2146-10-22**] 02:25AM   PLT COUNT-155
[**2146-10-21**] 08:43PM   GLUCOSE-109* UREA N-13 CREAT-1.0 SODIUM-135
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-24 ANION GAP-12
[**2146-10-21**] 08:43PM   CK(CPK)-50
[**2146-10-21**] 08:43PM   cTropnT-0.03*
[**2146-10-21**] 08:43PM   WBC-6.4 RBC-3.51* HGB-10.9* HCT-32.1* MCV-91
MCH-31.1 MCHC-34.1 RDW-17.5*
[**2146-10-21**] 08:43PM   NEUTS-70.5* LYMPHS-19.3 MONOS-6.4 EOS-3.6
BASOS-0.2
[**2146-10-21**] 08:43PM   PLT COUNT-176
[**2146-10-21**] 08:43PM   PT-12.5 PTT-32.8 INR(PT)-1.1

Brief Hospital Course:
[**Age over 90 **] male with CAD, severe PVD, Achilles abscess on Zosyn, who was
recently admitted with a lower GIB presented with another
episode of BRBPR from his extended care facility.
.
#GI Bleed: This was most likely a re-bleed from his Dieulafoy's'
lesion that was banded last admission.  Flexible sigmoidoscopy
did not demonstrate any further bleeding from his previously
banded lesion.  The patient was initially admitted to the MICU
for close monitoring, where he was transfused one unit of blood.
 Since transfer from the MICU, the patient has not had any
further episodes of GI bleeding. His Plavix was stopped, per
cardiology recs, and aspirin is being held for another week in
the setting of recent bleeding. His hematocrit remained stable
while on the floor.
.
#CAD: The patient has been chest pain free since his admission.
He was ruled out for MI with cardiac enzymes.  In the MICU, he
was noted to have some lateral ST depressions/TWF, but V4 was
suspected to be due to lead placement changes.  No further
intervention occurred.  Per his cardiologist,  aspirin should be
restarted in one week. Plavix has been stopped permanently (per
cardiology recommendations).
.
#Urinary retention: He was seen by Urology in [**Month (only) **], and had
failed several voiding trials.  He failed another voiding trial
in the MICU.  He will be discharged with a foley catheter to
follow up as an outpatient with urology.  His Foley catheter was
changed on [**10-23**] without difficulty, and Flomax was restarted.
.
#Nonhealing heel ulcer: He was recently operated on by [**Month/Year (2) 1106**]
surgery for bypass.  He also has a nonhealing ulcer.  Secondary
to pseudomonas on wound culture, the patient was started on
Zosyn to complete a course until [**2146-11-2**].  His wound vac was
replaced while in the hospital.
.
#AFib: The patient carries a history of atrial fibrillation,
status post ablation. He has been stable in sinus rhythm
throughout his hospitalization.  His coumadin was stopped during
his previous hospitalization.  We continued to hold his coumadin
in light of his GI bleeding.
.
#Hypothyroidism: His outpatient thyroid replacement was
continued. Based on thyroid studies from previous admission
(high TSH, low T4), the patient may require titration of his
medications when not in an acute setting.
.
# HTN: In the setting of acute bleeding, antihypertensives were
initially held, prior to discharge the patients home dose of
Imdur and metoprolol.
.


Medications on Admission:
1. Aspirin 81 mg
2. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY

3. Acetaminophen 325 mg prn
4. Zinc Sulfate 220 (50) mg qd
5. Tamsulosin 0.4 mg Capsule, qhs
6. Piperacillin-Tazobactam 2.25 gram 1 q 6h until [**2146-11-2**]
7. Ascorbic Acid 500 mg Tablet daily
8. Prilosec 40 mg Capsule, qd
9. Toprol XL 50 mg Tablet Sustained Release qd
10. Clopidogrel 75 mg Tablet qd
11. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. Levothyroxine 150 mcg qd
13. Isosorbide Mononitrate 30 mg qd
14. Docusate Sodium 100 mg [**Hospital1 **]
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]

Discharge Diagnosis:
Primary Diagnosis: Bleeding from a rectal Dieulafoy lesion
.
Secondary diagnoses:
Right achilles tendon pressure ulcer
PVD s/p PO-DP bypass graft
Aortic stenosis
Hypercholesterolemia
Hypothyroidism
Hypertension


Discharge Condition:
Stable, with no active bleeding


Discharge Instructions:
You were admitted to the hospital for gastrointestinal bleeding.

You had a sigmoidoscopy that showed your Dieulefoy lesion was
bleeding. You received one unit of blood while you were in the
hospital.

Please do not take your Coumadin.  Please restart your aspirin
in seven days, on [**2146-11-1**].

The remainder of your home medications have been continued.

You will also need to complete three weeks of antibiotics for
your
ankle wound, until [**11-2**].

You should also follow up with gastroenterology as needed.

If you experience any additional bleeding, changes in thinking
or behavior, experience shortness of breath, chest pain, or
lightheadedness, or other concerning symptoms please consult
your primary care physician or return to the emergency room.

Please follow up with the following doctors once [**Name5 (PTitle) **] are
discharged from the rehabilitation hospital.

Watch for the following signs and symptoms in your wound and
notify your doctor if these occur:
Temperature over 101.5 F or chills
Foul-smelling drainage or fluid from the wound
Increased redness or swelling of the wound or skin around it
Increasing tenderness or pain in or around the wound.




Followup Instructions:
You will need to make follow up appointments with the following
providers once you are discharged from rehab.

Gastroenterology (as needed): [**Telephone/Fax (1) 13246**]
[**First Name4 (NamePattern1) 21976**] [**Last Name (NamePattern1) 11679**] (primary care): [**Telephone/Fax (1) 26860**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiology): [**Telephone/Fax (1) 2394**]
Dermatology: ([**Telephone/Fax (1) 45763**]
.
You have the following appointments scheduled:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2146-11-10**] 1:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2146-11-10**] 2:00

You also have an appointment with Dr. [**Last Name (STitle) 11679**] on Monday,
[**10-31**] at 2:45 pm.  Please have him check a hematocrit
level at that time.  Please also discuss your thyroid medication
with him at that time.

Please call Dr[**Name (NI) 23059**] office at ([**Telephone/Fax (1) 4335**] to schedule an
appointment within the next two weeks.

Please have patient follow up with [**Hospital 159**] Clinic [**Telephone/Fax (1) 164**]
in two weeks for Foley management.
{'Dieulafoy lesion (hemorrhagic) of intestine,Pressure ulcer, ankle,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Atrial fibrillation,Retention of urine, unspecified,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Multiple involvement of mitral and aortic valves,Peripheral vascular disease, unspecified'}


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: BRBPR

PRESENT ILLNESS: [**Age over 90 **] male with h/o PVD, CAD, AFib s/p ablation, recent GIB, who
presents with several episodes of BRBPR.  He was recently
discharged from [**Hospital1 18**] on [**2146-10-20**].  He had several episodes of
hematochezia at his nursing home today, and was subsequently
sent in to the ED.  He denied any chest pain, SOB,
lighthededness, diarrhea, abdominal pain, fevers, chills, back
pain.
.
Last week he also presented with BRBPR, and he was discharged
yesterday. Initially, a tagged red blood cell scan showed
bleeding from the rectum. However, subsequent angiography was
unable to localize and embolize the source of bleed. A fexible
sigmoidoscopy showed an actively bleeding Dielafoys lesion which
was successfully clipped. The patient subsequently remained
hemodynamically stable, with minimal further RBC transfusions.
Coumadin, aspirin, and Plavix were initially held. Aspirin and
Plavix were resumed prior to discharge.
.
ED course: He was found to have a stable hct from last
admission.  He had several large BRBPR episodes in ED, and his
SBP went from 140 to 110.  He was give 1 liter of NS.  GI was
called, and planned for scope in AM.  He was admitted to MICU
for close observation.

MEDICAL HISTORY: 1.Severe PVD: [**9-9**]: R BKPO-DP bypass w/ RSVG
2.10/2 Achilles tendon w/ abscess excision w/ VAC placement
3.Aortic Stenosis: Echo: [**12-19**]: moderate AS, aortic regurg,
mitral regurg, moderate pericardial effusion.
4.CAD: s/p cardiac cath: 90% distal LMCA, 80% LCX, Stent in
LMCA/LAD Cypher drug-eluting stent.
5.Carotid artery stenosis: Chronically occluded right internal
carotid artery. Left, with 40-59% carotid stenosis.
6. Hypercholesterolemia
7. Hypothyroidism
8. Chronic low back pain
9. AFib s/p ablation
[**48**]. s/p cholecystectomy
[**49**]. s/p bilateral carotid endartectomies
12. s/p left knee arthroscopy
13. s/p lumbar decompression '[**34**]
14. s/p left leg thrombectomy
15. s/p Dielafoys lesion banding [**10-19**]

MEDICATION ON ADMISSION: 1. Aspirin 81 mg
2. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY

ALLERGIES: Levaquin

PHYSICAL EXAM: On admission:
Vs- 145/55  65  12  100% 2L NC
Gen- Well appearing elderly male lying in bed, NAD
Heent- dry MM, anicteric, PERRL
Neck- Supple, no LAD, no JVP elevation, bilateral carotid
bruits, bandage on right neck from prior IJ
Cor- RRR, high pitched SEM at LLSB, heard throughout precordium
Chest- Relatively clear bilaterally
Abd- soft, NT, ND, pos BS, ventral hernia, no organomegaly
Ext- Right heel with 1+ edema, open wound on heel, boot on,
wound vac in place.  Left with no swelling.
Neuro- AAO x 2, confused about place and exact date.
Skin- Hyperpigmented lesion on left anterior chest, mildly
raised

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Previous 30 pack-year tobacco, quit 40 [**Month/Year (2) 1686**] ago. Occasional EtOH.
Currently at [**Hospital 169**] Center. Previously lived in the
basement of his daughter's house. Walks with a cane. 

### Response:
{'Dieulafoy lesion (hemorrhagic) of intestine,Pressure ulcer, ankle,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Atrial fibrillation,Retention of urine, unspecified,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Multiple involvement of mitral and aortic valves,Peripheral vascular disease, unspecified'}
