CHIEF COMPLAINT: Gastrointestinal bleed.

PRESENT ILLNESS: The patient is a 76-year-old
male with a history of multiple GI bleeds through his
end-ileostomy who presents with bleeding from his ileostomy
starting the morning of admission.  The last episode was
three weeks prior.  No complaints of nausea, vomiting, fever,
chills, dyspnea, or diarrhea.  Positive flatus and stool in
the bag.  No dizziness or history of fall.  Not on
anticoagulation.

MEDICAL HISTORY: 1.  Ulcerative colitis, status post colectomy and ileostomy.
2.  Diabetes type 2.
3.  Coronary artery disease.
4.  Chronic renal failure.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: No smoking or alcohol.
Hemorrhage of gastrointestinal tract, unspecified,Other postoperative infection,Acute kidney failure, unspecified,Paroxysmal ventricular tachycardia,Unspecified septicemia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Acute posthemorrhagic anemia,Acidosis,Peritoneal adhesions (postoperative) (postinfection)
Gastrointest hemorr NOS,Other postop infection,Acute kidney failure NOS,Parox ventric tachycard,Septicemia NOS,React-oth vasc dev/graft,Ac posthemorrhag anemia,Acidosis,Peritoneal adhesions
Admission Date:  [**2106-1-15**]       Discharge Date:  [**2106-2-10**]

Date of Birth:   [**2029-6-3**]       Sex:  M

Service:

CHIEF COMPLAINT:  Gastrointestinal bleed.

HISTORY OF THE PRESENT ILLNESS:  The patient is a 76-year-old
male with a history of multiple GI bleeds through his
end-ileostomy who presents with bleeding from his ileostomy
starting the morning of admission.  The last episode was
three weeks prior.  No complaints of nausea, vomiting, fever,
chills, dyspnea, or diarrhea.  Positive flatus and stool in
the bag.  No dizziness or history of fall.  Not on
anticoagulation.

PAST MEDICAL HISTORY:
1.  Ulcerative colitis, status post colectomy and ileostomy.
2.  Diabetes type 2.
3.  Coronary artery disease.
4.  Chronic renal failure.

PAST SURGICAL HISTORY:
1.  CABG.
2.  Cholecystectomy.
3.  Colectomy with end-ileostomy in [**2101**].

ADMISSION MEDICATIONS:
1.  Lopressor 25 mg b.i.d.
2.  Glyburide 5 mg b.i.d.
3.  Ativan p.r.n.
4.  Prilosec 20 mg q.d.
5.  Iron sulfate.
6.  Flomax.
7.  Imdur 30 mg q.d.

ALLERGIES:  The patient has no known drug allergies.

SOCIAL HISTORY:  No smoking or alcohol.

PHYSICAL EXAMINATION ON ADMISSION:  Vital signs:  Temperature
97.4, pulse 59, blood pressure 112/52, respiratory rate 16,
saturating 100% on room air.  General:  The patient is an
elderly man, pleasant, in no acute distress.  Heart:  Regular
rate and rhythm.  Lungs:  Clear to auscultation bilaterally.
Abdomen:  Minimally distended.  No masses palpable.
Nontender.  Rectal:  No mass.  Extremities:  Warm, well
perfused.

LABORATORY/RADIOLOGIC DATA:  White count 5.3, hematocrit 34,
platelets 136,000.  INR 2.8.  On repeat the sugar was still
329.

HOSPITAL COURSE:  This is a 76-year-old male with colectomy
and ileostomy with a history of numerous admissions of
bleeding per ostomy and has an extensive workup in the past
including nuclear medicine scans, CT scans, EGD, and
angiogram which have all failed to demonstrate a source.  The
patient was admitted for serial hematocrits, IV fluid, blood
product replacement.  He was made n.p.o. and followed.

Once in the hospital, there was no further bleeding from his
ostomy.  The patient's hematocrit stabilized and had adequate
urine output.  In light of the numerous admissions for GI
bleeding as well as the negative workup, a long discussion
between Dr. [**Last Name (STitle) 1888**] and the patient ensued discussing the
options of possible surgical intervention with intraoperative
enteroscopy to run the bowel and look for a source of
bleeding as well as the potential of heparinizing the patient
in order to find the source.

The patient agreed to this plan and a Cardiology consult was
obtained for suggestions prior to surgery which included
adequate beta blockade to a heart rate of 50-60 as well as
restarting aspirin as soon after the procedure as possible
and they felt that since it was less than five years since
his CABG he was adequately revascularized.  Also, an EGD was
obtained to ensure no obvious source of upper GI bleeding.
The EGD showed some polyps in the antrum and stomach body but
otherwise normal to the second part of the duodenum and does
not correlate with his clinical presentation.  The patient
also received a colonoscopy which was a normal colonoscopy to
the terminal ileum.

Therefore, the patient was typed and crossed for 6 units of
packed red blood cells, 6 units of FFP, and was taken to the
Operating Room on [**2106-1-21**] for laparotomy, intraoperative
enteroscopy for search of source of GI bleed.  The operation
entailed lysis of adhesions with intraoperative enteroscopy
as well as planned enterotomy.  The estimated blood loss was
1,000 cc.  However, no bleeding segment was found.  The
patient was transfused 3 units of packed red blood cells and
received 9 liters of normal saline intraoperatively.

His condition during the surgery was fair.  He was taken to
the SICU for postoperative care.  Also, intraoperatively, the
patient had an increased lactate level with acidosis and was
aggressively resuscitated.  The patient was taken to the SICU
intubated and sedated.

The postoperative EKG was negative for a MI.  On
postoperative day number one, the patient was continued on
the vent with improving lactic acidosis.  The patient was
extubated on postoperative day number two without event.  The
patient was diuresed over the next couple of days in the ICU,
was net negative and was oxygenating well without crackles or
wheezes and was transferred to the floor on postoperative day
number four in stable condition. TPN was started and physical
therapy was initiated.

On postoperative day number six, on the floor, the patient
had an episode of chest pain as well as tachycardia with
strength heart rate of 150 beats per minute for short bursts,
unable to do a 12-lead EKG with this rhythm.  Cardiology was
consulted and from the rhythm strip, it was unable to
determine whether it was a V tach or a supraventricular
rhythm and the plan was to assume V tach until proven
otherwise.  The patient's electrolytes were checked and
repleted.  The patient's Lopressor was increased to q. four
hours and the patient's chest pain improved.  Troponins were
cycled.  The first one was 0.9.  The second one was 1.3.  The
next one was 0.8.

The patient had an echocardiogram on [**2106-1-28**] which showed
LVEF of 50% and was consistent with an inferior posterior
infarct but overall with a well preserved ventricular
contractile function.  The EPS Service was consulted and
suggested the patient would need an implantable
defibrillator, however, did not feel that it needed to be
done emergently.

On postoperative day number eight, the patient's wound was
noted to have purulent discharge and was packed with
wet-to-dry dressing changes and at this time Lopressor was
continued q. four hours as well as electrolyte repletion for
the episodes of nonsustained ventricular tachycardia.  The
patient's TPN was discontinued on postoperative day number 12
as the patient was taking adequate p.o.

On postoperative day number 13, Mr. [**Known lastname **] complained that
he had not been feeling well and complained of abdominal pain
and over the days the pain has worsened.  The stoma output
was minimal and he was more nauseated.  The KUB has not shown
obstruction but clinically he seems obstructed.  The
patient's K had been rising over the past couple of days and
on that day it was 6.1 with a creatinine of 2.4, baseline
creatinine 1.5.  His urine output was also low.  The patient
was given Kayexalate.  His EKG did not show peak T waves and
he was transferred to the ICU for further management.  The
patient got a CAT scan with p.o. contrast which showed
ascites in the pelvis and abdomen, functional obstruction, no
dilated loops.

With the increasing abdominal pain, a wound infection as well
as white count of 13, the patient had abdominal ascites
aspirated.  The patient's clinical picture was consistent
with sepsis with renal failure.  The patient was started on
Zosyn.  His central line was discontinued and cultured which
grew back gram-positive cocci.  At that time, vancomycin was
started.

Over the next three days, with the treatment of vancomycin
and Zosyn, the patient's abdomen improved.  The patient's
creatinine also improved.  His ostomy was again putting out
normal output.  The patient was advanced to a regular diet
and transferred to the floor on postoperative day number 17.
He did well on the floor with a couple more days of TPN which
was discontinued as he tolerated a regular diet.  He was
afebrile and was discharged to rehabilitation with wet-to-dry
dressing changes for his wound.

FOLLOW-UP:  On discharge, the patient was to follow-up with
his primary care physician, [**Name10 (NameIs) **] cardiologist for possible
defibrillator placement, as well as Dr. [**Last Name (STitle) 1888**].

DISCHARGE DIAGNOSIS:
1.  Gastrointestinal bleed.
2.  Status post exploratory laparotomy with lysis of
adhesions and enteroscopy.
3.  Diabetes mellitus type 2.
4.  Coronary artery disease.
5.  Acute renal failure.
6.  Chronic renal failure.
7.  Surgical wound infection.
8.  Line-related sepsis.
9.  Malnutrition requiring total parenteral nutrition.
10. Nonsustained ventricular tachycardia.




                            [**Last Name (NamePattern4) 1889**], M.D.  [**MD Number(1) 1890**]

Dictated By:[**Last Name (NamePattern1) 7241**]
MEDQUIST36

D:  [**2106-6-19**]  03:09
T:  [**2106-6-19**]  15:29
JOB#:  [**Job Number 38014**]
{'Hemorrhage of gastrointestinal tract, unspecified,Other postoperative infection,Acute kidney failure, unspecified,Paroxysmal ventricular tachycardia,Unspecified septicemia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Acute posthemorrhagic anemia,Acidosis,Peritoneal adhesions (postoperative) (postinfection)'}


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: Gastrointestinal bleed.

PRESENT ILLNESS: The patient is a 76-year-old
male with a history of multiple GI bleeds through his
end-ileostomy who presents with bleeding from his ileostomy
starting the morning of admission.  The last episode was
three weeks prior.  No complaints of nausea, vomiting, fever,
chills, dyspnea, or diarrhea.  Positive flatus and stool in
the bag.  No dizziness or history of fall.  Not on
anticoagulation.

MEDICAL HISTORY: 1.  Ulcerative colitis, status post colectomy and ileostomy.
2.  Diabetes type 2.
3.  Coronary artery disease.
4.  Chronic renal failure.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: No smoking or alcohol. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Other postoperative infection,Acute kidney failure, unspecified,Paroxysmal ventricular tachycardia,Unspecified septicemia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Acute posthemorrhagic anemia,Acidosis,Peritoneal adhesions (postoperative) (postinfection)'}
