CHIEF COMPLAINT: bright red blood per rectum

PRESENT ILLNESS: 81 year old female hx of Afib on coumadin, diverticulosis, and
myasthenia [**Last Name (un) 2902**] presented to PCP [**Name Initial (PRE) 151**] 2 d BRBPR.  Per her
report she was reccently started on a new medication for her MG
(mestinon 30 mg QID) earlier in the week.  The week prior to her
presentation her INR had been at goal of 2.0, she then noticed
blood in her stool and red blood on the paper towel.  The next
morning she was continuing to have blood on the toilet paper and
noticed the toilet water was red tinged.  She called her PCP who
checked an INR which was elevated to 8.0.  She went to [**Hospital3 635**]
hospital where crit was 29.0 and INR was 6.1. She was given 2 U
FFP, 5 of Vitamin K PO and transferred to [**Hospital1 18**].
.
In the ED, initial VS were:  94 in sinus, 166/68, 20, 97% 3LNC
Hematocrit was 24.0 and INR 2.5
.
She got a CXR, was type and screened and cross matched for 2
units.  Guiaic showed flecks of BRB, no active bleeding.  GI was
consulted who said they will evaluate her in the morning.  Did
go into Afib with RVR to the 160s before being transferred to
ICU and was transfused 2 units of pRBCs.
.
On arrival to the MICU, patient's VS: 98.1, 184 afib, 154/80,
98% 4L NC.  She was intially given 5 mg IV lopressor with
immediate conversion to sinus rhythm.

MEDICAL HISTORY: -Afib on coumadin, diagnosed post operatively for a hip fracture
in [**2099-2-7**].  Not on cardiac meds, follows with Dr.
[**Last Name (STitle) 13834**] in Tuscon AZ for management of her coumadin.
-Diverticulosis - diagnosed many years ago, has had 3
colonoscopies in past 10-15 years
-Myasthenia [**Last Name (un) **] - diagnosed [**8-24**] of this year by
-Neurologist (Dr. [**Last Name (STitle) **], [**Location (un) 9101**]).  As per daughter, had
positive [**Name (NI) 111965**]  antibodies.

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 2.5 mg PO DAILY
2. FoLIC Acid 400 mcg PO DAILY
3. Warfarin 2 mg PO DAILY16
4. ALPRAZolam 0.25 mg PO QHS
5. Paroxetine 10 mg PO DAILY
6. Pyridostigmine Bromide 30 mg PO Q6H
7. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral qd

ALLERGIES: Penicillins / Vicodin / Cipro / Polysporin

PHYSICAL EXAM: On Admission
Vitals:  98.1, 184 afib, 154/80, 98% 4L NC.
General: Alert, oriented, no acute distress, very thin and frail
appearing.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
symmetric pstosis.
Neck: supple, JVP not elevated, no LAD
CV: irregular, tachycardic unable to appreciate murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: father had CHF, mother died of MI, siblings had pulmonary
fibrosis

SOCIAL HISTORY: former smoker, quit 25-30 years ago, denies EtOH, denies drugs
Blood in stool,Dissection of aorta, thoracoabdominal,Precipitous drop in hematocrit,Unspecified disease of pericardium,Other pulmonary insufficiency, not elsewhere classified,Unspecified pleural effusion,Anticoagulants causing adverse effects in therapeutic use,Diverticulosis of colon with hemorrhage,Angiodysplasia of intestine with hemorrhage,Atrial fibrillation,Aortic valve disorders,Other chronic pulmonary heart diseases,Unspecified essential hypertension,Myasthenia gravis without (acute) exacerbation,Myogenic ptosis,Dysphagia, oropharyngeal phase,Loss of weight,Diplopia,Personal history of other malignant neoplasm of skin,Personal history of traumatic fracture,Personal history of tobacco use,Stricture and stenosis of esophagus,Surgical or other procedure not carried out because of patient's decision,Other fluid overload,Do not resuscitate status,Encounter for palliative care
Blood in stool,Dsct of thoracoabd aorta,Drop, hematocrit, precip,Pericardial disease NOS,Other pulmonary insuff,Pleural effusion NOS,Adv eff anticoagulants,Dvrtclo colon w hmrhg,Angio intes w hmrhg,Atrial fibrillation,Aortic valve disorder,Chr pulmon heart dis NEC,Hypertension NOS,Mysthna grvs w/o ac exac,Myogenic ptosis,Dysphagia, oropharyngeal,Abnormal loss of weight,Diplopia,Hx-skin malignancy NEC,Hx traumatic fracture,History of tobacco use,Esophageal stricture,No proc/patient decision,Fluid overload NEC,Do not resusctate status,Encountr palliative care
Admission Date:  [**2100-9-22**]              Discharge Date:   [**2100-9-28**]

Date of Birth:  [**2019-1-26**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Vicodin / Cipro / Polysporin

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
bright red blood per rectum

Major Surgical or Invasive Procedure:
None

History of Present Illness:
81 year old female hx of Afib on coumadin, diverticulosis, and
myasthenia [**Last Name (un) 2902**] presented to PCP [**Name Initial (PRE) 151**] 2 d BRBPR.  Per her
report she was reccently started on a new medication for her MG
(mestinon 30 mg QID) earlier in the week.  The week prior to her
presentation her INR had been at goal of 2.0, she then noticed
blood in her stool and red blood on the paper towel.  The next
morning she was continuing to have blood on the toilet paper and
noticed the toilet water was red tinged.  She called her PCP who
checked an INR which was elevated to 8.0.  She went to [**Hospital3 635**]
hospital where crit was 29.0 and INR was 6.1. She was given 2 U
FFP, 5 of Vitamin K PO and transferred to [**Hospital1 18**].
.
In the ED, initial VS were:  94 in sinus, 166/68, 20, 97% 3LNC
Hematocrit was 24.0 and INR 2.5
.
She got a CXR, was type and screened and cross matched for 2
units.  Guiaic showed flecks of BRB, no active bleeding.  GI was
consulted who said they will evaluate her in the morning.  Did
go into Afib with RVR to the 160s before being transferred to
ICU and was transfused 2 units of pRBCs.
.
On arrival to the MICU, patient's VS: 98.1, 184 afib, 154/80,
98% 4L NC.  She was intially given 5 mg IV lopressor with
immediate conversion to sinus rhythm.

Past Medical History:
-Afib on coumadin, diagnosed post operatively for a hip fracture
in [**2099-2-7**].  Not on cardiac meds, follows with Dr.
[**Last Name (STitle) 13834**] in Tuscon AZ for management of her coumadin.
-Diverticulosis - diagnosed many years ago, has had 3
colonoscopies in past 10-15 years
-Myasthenia [**Last Name (un) **] - diagnosed [**8-24**] of this year by
-Neurologist (Dr. [**Last Name (STitle) **], [**Location (un) 9101**]).  As per daughter, had
positive [**Name (NI) 111965**]  antibodies.


Social History:
former smoker, quit 25-30 years ago, denies EtOH, denies drugs


Family History:
father had CHF, mother died of MI, siblings had pulmonary
fibrosis


Physical Exam:
On Admission
Vitals:  98.1, 184 afib, 154/80, 98% 4L NC.
General: Alert, oriented, no acute distress, very thin and frail
appearing.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
symmetric pstosis.
Neck: supple, JVP not elevated, no LAD
CV: irregular, tachycardic unable to appreciate murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

On Discharge:

Pertinent Results:
Admission Labs:
[**2100-9-21**] 11:45PM   PT-25.8* PTT-36.6* INR(PT)-2.5*
[**2100-9-21**] 11:45PM   PLT COUNT-423
[**2100-9-21**] 11:45PM   NEUTS-74.6* LYMPHS-18.4 MONOS-5.2 EOS-1.1
BASOS-0.7
[**2100-9-21**] 11:45PM   WBC-6.5 RBC-2.81* HGB-8.1* HCT-24.2* MCV-86
MCH-28.7 MCHC-33.3 RDW-15.1
[**2100-9-21**] 11:45PM   ALBUMIN-2.6*
[**2100-9-21**] 11:45PM   ALT(SGPT)-39 AST(SGOT)-79* ALK PHOS-151* TOT
BILI-0.4
[**2100-9-21**] 11:45PM   estGFR-Using this
[**2100-9-21**] 11:45PM   GLUCOSE-108* UREA N-17 CREAT-0.6 SODIUM-135
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-12
[**2100-9-22**] 04:00PM   GLUCOSE-186* UREA N-21* CREAT-0.6 SODIUM-137
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-26 ANION GAP-12
[**2100-9-22**] 04:00PM   CALCIUM-8.2* PHOSPHATE-3.3 MAGNESIUM-2.0
[**2100-9-22**] 03:39PM   TYPE-ART TEMP-36.6 O2 FLOW-7 PO2-75* PCO2-36
PH-7.48* TOTAL CO2-28 BASE XS-3 INTUBATED-NOT INTUBA
[**2100-9-22**] 03:39PM   GLUCOSE-207* LACTATE-1.4 NA+-135 K+-3.8
CL--102

Discharge Labs:

Imaging:


Preliminary Report:
CT CHEST W/O CONTRAST Study Date of [**2100-9-22**]
CONCLUSION:
1. Moderate-to-severe circumferential pericardial effusion is
nonhemorrhagic. This study is not tailored to rule out
tamponade. However, we do not have any  indirect sign of
tamponade. A cardiac son[**Name (NI) **] is suggested.
2. Ascending aorta is dilated up to 5.8 cm and its border is not
well
Preliminary Reportdefined. If clinical concern of acute aortic
process remains, a C+ exam is suggested.
3. Bilateral moderate pleural effusion is more prominent on the
left side.

Portable TTE (Complete) Done [**2100-9-23**]
IMPRESSION: Low-normal left ventricular systolic function.
Dilated aortic root with probable small sinus of Valsalva
aneurysm of the right coronary cusp and severe aortic
regurgitation. At least mild mitral regurgitation - diastolic
mitral regurgitation is present, in keeping with severe aortic
regurgitation. There is a moderate circumferential pericardial
effusion without frank tamponade. However, the RV wall looks
hypertrophied, suggesting pulmonary hypertension (signs of
tamponade may be absent with elevated right sided pressures).
Also, the presence of severe aortic regurgitation means that
pulsus paradoxus is insensitive to assess inter-ventricular
interaction.
Compared with the prior study (images reviewed) of [**2100-9-22**],
the current study is more complete. The findings are probably
unchanged.

CHEST (PA & LAT) Study Date of [**2100-9-22**]
FINDINGS:  There is moderate cardiomegaly, possible pericardial
effusion, and a moderate left and small right pleural effusion.
A tortuous aorta is seen with aortic arch calcifications.  There
is no pneumothorax and no focal lung consolidation.
Vertebroplasty material is seen in the upper lumbar spine.

Portable TTE (Focused views) Done [**2100-9-22**]
IMPRESSION: Suboptimal image quality. There is probably
moderate/severe aortic regurgitation with a a sinus of Valsalva
aneurysm of the right coronary cusp. Mildly hypokinetic
ventricular function. Moderate-sized pericardial effusion
without evidence of frank tamponade, although the right atrium
does not fully dilate during atrial diastole, suggesting either
low filling pressures or early tamponade.

Brief Hospital Course:
#Pericardial Effusion:  A CXR done on admission noted a left
pleural effusion.  A bedside thoracentesis was to be performed,
however on ultrasound the heart was noted to be close to the
wall. A chest CT was done [**9-22**] which was remarkable for a small
to moderate left effusion with a significant pericardial
effusion and ascending thoracic aorta aneurysm.  An echo was
performed [**9-22**] at the bedside due to concern for tamponade which
showed probable moderate/severe aortic regurgitation with a a
sinus of Valsalva aneurysm of the right coronary cusp, moderate
sized pericardial effusion without evidence of frank tamponade,
although the right atrium does not fully dilate during atrial
diastole, suggesting either low filling pressures or early
tamponade. A formal echo was performed on [**9-23**] dialted aortic
root with probable small sinus of Valsalva aneurysm of the right
coronary cusp and severe aortic regurgitaton, a moderate
circumferential pericardial effusion without frank tamponade.
Cardiology was consulted who recommended CT with contrast due to
concern for dissection; CT showed dissection of the thoracic
ascending aorta with possible rupture into pericardium.  CT
surgery was consulted who recomended surgery but the patient
declined. She was medically managed with HR and blood pressure
control but continued to decline over the next several days with
increasing oxygen requirements eventually requiring 100% on a
non-rebreather. The patient and her family made the decision to
be made comfort measures only on [**9-27**]. She was given morphine
and she passed away with her family at her side on the morning
of [**2100-9-28**].

# Atrial fibrillation with RVR: Patient has history of atrial
fibrillation on coumadin diagnosed post operatively for a hip
fracture in [**2099-2-7**].  Coumadin was held in setting of GI
bleed.  She was given 5 mg IV metoprolol x2 and rates slowed to
the 120's.  She then had a likely vagal episode and became
acutely bradycardic with a 6 second pause.  The episode resolved
spontaneously and the patient reverted back to atrial
fibrillation.  The patient was transitioned to 25 mg metoprolol
TID but remained in a-fib with rvr. She was placed intermitantly
on diltizem drip and converted to NSR with rates in the 60s.
When the decision was made to make her CMO, these were
discontinued.

#Bright red blood per rectum: The patient present with bright
red blood per rectum in the setting of an elevated INR of 8.0
and HCT of 29.0.  Her hematocrit dropped to 24.2.  She received
2 units pRBCs and had an appropriate rise in hematocrit.  The
INR was corrected with 2 units FFP and 5 mg vitamin K x 2.
Gastroenterology was consulted  who felt this was likely a lower
GI bleed, most likely diverticular or AVM, exacerbated in the
setting of elevated INR. Also on the differential diagnosis are
hemorrhoids and malignancy.  She did have a colonoscopy in [**2098**]
that did not show any polyps, making malignancy unlikely.  The
patient's hematocrit stabled and she had no further episodes of
bleeding.

# Hypoxia: Patient with intermittent desaturation.  Etiology
likely multifactorial secondary to pericardial effusion and poor
reserve with underlying myasthenia.  The CXR did not show any
evidence of acute infection.  She was placed on nasal cannula to
maintain oxygen saturation >92%.  Please see above, but the
patient had increasing oxygen requirments eventually requiring
100% on a non-rebreather. At that time the patient made the
decision to be made CMO.

# Myasthenia [**Last Name (un) **]: The patient was recently diagnosed with
myasthenia after 3 years of progressive symptoms.  She had a
positive anti-acetylchoine receptor antibody and was started on
pyridostigmine with little improvement. She was recently starte
on mestinon.  Neurology was consulted regarding diagnosis and
treatment and concern for underlying malignancy with
paraneoplastic syndrome.  They recommended monitoring vital
capacity and negative inspiratory force.  Neurology weighed in
regarding possibe surgery and advised that the patient may have
a slower recovery coming off of the vent.  The patient and her
family made the decision to be made comfort measures only on
[**9-27**]. She was given morphine and she passed away with her family
at her side on the morning of [**2100-9-28**].

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 2.5 mg PO DAILY
2. FoLIC Acid 400 mcg PO DAILY
3. Warfarin 2 mg PO DAILY16
4. ALPRAZolam 0.25 mg PO QHS
5. Paroxetine 10 mg PO DAILY
6. Pyridostigmine Bromide 30 mg PO Q6H
7. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral qd


Discharge Medications:
Deceased

Discharge Disposition:
Expired

Discharge Diagnosis:
Deceased

Discharge Condition:
Deceased

Discharge Instructions:
Deceased

Followup Instructions:
Deceased
{"Blood in stool,Dissection of aorta, thoracoabdominal,Precipitous drop in hematocrit,Unspecified disease of pericardium,Other pulmonary insufficiency, not elsewhere classified,Unspecified pleural effusion,Anticoagulants causing adverse effects in therapeutic use,Diverticulosis of colon with hemorrhage,Angiodysplasia of intestine with hemorrhage,Atrial fibrillation,Aortic valve disorders,Other chronic pulmonary heart diseases,Unspecified essential hypertension,Myasthenia gravis without (acute) exacerbation,Myogenic ptosis,Dysphagia, oropharyngeal phase,Loss of weight,Diplopia,Personal history of other malignant neoplasm of skin,Personal history of traumatic fracture,Personal history of tobacco use,Stricture and stenosis of esophagus,Surgical or other procedure not carried out because of patient's decision,Other fluid overload,Do not resuscitate status,Encounter for palliative care"}


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: bright red blood per rectum

PRESENT ILLNESS: 81 year old female hx of Afib on coumadin, diverticulosis, and
myasthenia [**Last Name (un) 2902**] presented to PCP [**Name Initial (PRE) 151**] 2 d BRBPR.  Per her
report she was reccently started on a new medication for her MG
(mestinon 30 mg QID) earlier in the week.  The week prior to her
presentation her INR had been at goal of 2.0, she then noticed
blood in her stool and red blood on the paper towel.  The next
morning she was continuing to have blood on the toilet paper and
noticed the toilet water was red tinged.  She called her PCP who
checked an INR which was elevated to 8.0.  She went to [**Hospital3 635**]
hospital where crit was 29.0 and INR was 6.1. She was given 2 U
FFP, 5 of Vitamin K PO and transferred to [**Hospital1 18**].
.
In the ED, initial VS were:  94 in sinus, 166/68, 20, 97% 3LNC
Hematocrit was 24.0 and INR 2.5
.
She got a CXR, was type and screened and cross matched for 2
units.  Guiaic showed flecks of BRB, no active bleeding.  GI was
consulted who said they will evaluate her in the morning.  Did
go into Afib with RVR to the 160s before being transferred to
ICU and was transfused 2 units of pRBCs.
.
On arrival to the MICU, patient's VS: 98.1, 184 afib, 154/80,
98% 4L NC.  She was intially given 5 mg IV lopressor with
immediate conversion to sinus rhythm.

MEDICAL HISTORY: -Afib on coumadin, diagnosed post operatively for a hip fracture
in [**2099-2-7**].  Not on cardiac meds, follows with Dr.
[**Last Name (STitle) 13834**] in Tuscon AZ for management of her coumadin.
-Diverticulosis - diagnosed many years ago, has had 3
colonoscopies in past 10-15 years
-Myasthenia [**Last Name (un) **] - diagnosed [**8-24**] of this year by
-Neurologist (Dr. [**Last Name (STitle) **], [**Location (un) 9101**]).  As per daughter, had
positive [**Name (NI) 111965**]  antibodies.

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Amlodipine 2.5 mg PO DAILY
2. FoLIC Acid 400 mcg PO DAILY
3. Warfarin 2 mg PO DAILY16
4. ALPRAZolam 0.25 mg PO QHS
5. Paroxetine 10 mg PO DAILY
6. Pyridostigmine Bromide 30 mg PO Q6H
7. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit Oral qd

ALLERGIES: Penicillins / Vicodin / Cipro / Polysporin

PHYSICAL EXAM: On Admission
Vitals:  98.1, 184 afib, 154/80, 98% 4L NC.
General: Alert, oriented, no acute distress, very thin and frail
appearing.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
symmetric pstosis.
Neck: supple, JVP not elevated, no LAD
CV: irregular, tachycardic unable to appreciate murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: father had CHF, mother died of MI, siblings had pulmonary
fibrosis

SOCIAL HISTORY: former smoker, quit 25-30 years ago, denies EtOH, denies drugs 

### Response:
{"Blood in stool,Dissection of aorta, thoracoabdominal,Precipitous drop in hematocrit,Unspecified disease of pericardium,Other pulmonary insufficiency, not elsewhere classified,Unspecified pleural effusion,Anticoagulants causing adverse effects in therapeutic use,Diverticulosis of colon with hemorrhage,Angiodysplasia of intestine with hemorrhage,Atrial fibrillation,Aortic valve disorders,Other chronic pulmonary heart diseases,Unspecified essential hypertension,Myasthenia gravis without (acute) exacerbation,Myogenic ptosis,Dysphagia, oropharyngeal phase,Loss of weight,Diplopia,Personal history of other malignant neoplasm of skin,Personal history of traumatic fracture,Personal history of tobacco use,Stricture and stenosis of esophagus,Surgical or other procedure not carried out because of patient's decision,Other fluid overload,Do not resuscitate status,Encounter for palliative care"}
