CHIEF COMPLAINT: Weakness

PRESENT ILLNESS: 85 yof with hisory of DM2, Afib on Coumadin, HTN, HL, CKD with
baseline 2.8-3.5, hx of Anemia with baseline HCT 25, ?hx of LGIB
who presents from home with weakness.  Patient reports weakness
x 6 weeks along with dark stools.  She contact[**Name (NI) **] her [**Name (NI) **]
endocrinologist today who then referred her to the ED.

MEDICAL HISTORY: - Type 2 Diabetes Mellitus
- Atrial Fibrillation on Coumadin
- Hypertension
- Hyperlipidemia
- Pulmonary arterial hypertension
- Chronic kidney disease
- Anemia
- Hyperparathyroidism s/p parathyroidectomy [**6-21**]
- Pelvic fracture lateral compression type I and a left proximal

MEDICATION ON ADMISSION: Digoxin 125 mcg PO DAILY
Cholecalciferol 50,000u qweek
Folic Acid 1mg  PO DAILY
Furosemide 80mg PO DAILY
Hydralazine 50mg PO TID
Lispro Protam & Lispro (75-25) Suspension 25U qAM, 40U qPM
Nifedipine 90mg PO DAILY
Pantoprazole 40mg PO BID
Warfarin 2.5mg PO DAILY
Diovan 320mg PO DAILY
Simvastatin 40mg PO qHS
Propanolol 80mg PO DAILY
Calcium Carbonate 600 PO BID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: 97.7, 103 (afib), 119/49, 13, 100% room air
General: Alert, oriented, [**Last Name (un) 664**], appropriate, no acute
distress
HEENT: +conjunctival pallor. Sclera anicteric, MMM, OP clear. No
tonsillar exudate
Neck: supple, no appreciable JVD or LAD
Lungs: CTAB, no wheezes, rales, rhonchi. Good inspiratory effort
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, symmetric 2+ radial/DP/PT pulses, no
clubbing, cyanosis or edema. No joint effusions.

FAMILY HISTORY: Her mother had hypertension, died at 89. Her father had lung
cancer, died at 74. Denies colon cancer, colon polyps in family.

SOCIAL HISTORY: Denies tobacco or illicit drug use. Occasional EtOH use.  Lives
with sister, walks on her own
Benign neoplasm of stomach,Internal hemorrhoids without mention of complication,Diverticulosis of colon (without mention of hemorrhage),Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other and unspecified hyperlipidemia,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Angiodysplasia of intestine with hemorrhage,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Volume depletion, unspecified
Benign neoplasm stomach,Int hemorrhoid w/o compl,Dvrtclo colon w/o hmrhg,Chr pulmon heart dis NEC,DMII wo cmp nt st uncntr,Atrial fibrillation,Long-term use anticoagul,Hy kid NOS w cr kid I-IV,Hyperlipidemia NEC/NOS,Chronic kidney dis NOS,Anemia in chr kidney dis,Angio intes w hmrhg,Acute kidney failure NOS,Urin tract infection NOS,Volume depletion NOS
Admission Date:  [**2139-7-8**]              Discharge Date:   [**2139-7-15**]

Date of Birth:  [**2054-4-12**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Weakness

Major Surgical or Invasive Procedure:
Upper and lower endoscopy [**2139-7-14**]

History of Present Illness:
85 yof with hisory of DM2, Afib on Coumadin, HTN, HL, CKD with
baseline 2.8-3.5, hx of Anemia with baseline HCT 25, ?hx of LGIB
who presents from home with weakness.  Patient reports weakness
x 6 weeks along with dark stools.  She contact[**Name (NI) **] her [**Name (NI) **]
endocrinologist today who then referred her to the ED.

In the ED, initial vs were: T 98.4, P 96, BP 115/35, R 16 O2
sat. 100%.  Hct found to be 13.0, INR 1.8. Patient was given
1uPRBC, vitamin K 10 mg IV. Rectal exam revealed maroon stool,
guaiac +.  NGL negative.  GI was consulted, and recommended
transfusing to keep Hct > 25-28%, and to consider colonoscopy
and possible EGD later in the week.

On the floor, the patient's vitals are 97.7, 103 (afib), 119/49,
13, 100% room air. She endorses chronic generalized weakness
over past six weeks, but denies any acute worsening. Denies
lightheadedness, dizziness, dyspnea, chest pain, or
palpitations. Denies fevers, chills, sweats, weight changes, or
change in bowel or bladder habits.

Review of sytems:
(+) Per HPI. Also endorses chronic knee pain from
osteoarthritis.
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, nausea, vomiting, or abdominal pain. No dysuria.

Past Medical History:
- Type 2 Diabetes Mellitus
- Atrial Fibrillation on Coumadin
- Hypertension
- Hyperlipidemia
- Pulmonary arterial hypertension
- Chronic kidney disease
- Anemia
- Hyperparathyroidism s/p parathyroidectomy [**6-21**]
- Pelvic fracture lateral compression type I and a left proximal

humerus fracture [**10-21**]
- s/p Hysterectomy


Social History:
Denies tobacco or illicit drug use. Occasional EtOH use.  Lives
with sister, walks on her own

Family History:
Her mother had hypertension, died at 89. Her father had lung
cancer, died at 74. Denies colon cancer, colon polyps in family.


Physical Exam:
Vitals: 97.7, 103 (afib), 119/49, 13, 100% room air
General: Alert, oriented, [**Last Name (un) 664**], appropriate, no acute
distress
HEENT: +conjunctival pallor. Sclera anicteric, MMM, OP clear. No
tonsillar exudate
Neck: supple, no appreciable JVD or LAD
Lungs: CTAB, no wheezes, rales, rhonchi. Good inspiratory effort
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, symmetric 2+ radial/DP/PT pulses, no
clubbing, cyanosis or edema. No joint effusions.

Pertinent Results:
[**2139-7-8**]:
WBC 6.6, HCT 13, PLT 324, MCV 101
Na 138, K 4.8, Cl 104, Bicarb 21, BUN 116, Cr 5.1, Gluc 107
Ca [**39**].3, Mg 2.2, P 4.6
PT 19.5, PTT 29.1, INR 1.8

[**2139-7-14**]
WBC-7.2 Hct-32.3* MCV-91 Plt Ct-143*

[**2139-7-15**]
Hct-32.6*
Glu-85 UreaN-38* Cr-2.5* Na-137 K-4.2 Cl-104 HCO3-21*

EKG: Afib @ 95 bpm, normal axis, normal interval, TWI II, III,
AVF, new ST depressions V4-V6

CXR [**2139-7-8**]: No acute cardiopulmonary abnormality. No definite
evidence of
free air beneath the diaphragms, given semi-upright study.

EGD [**2139-7-14**]:
Normal mucosa in the esophagus
A few small fundic gland polyps in the stomach
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum

COLONOSCOPY [**2139-7-14**]:
Diverticulosis of the sigmoid colon, descending colon and
transverse colon
Several AVMs were noted in the cecum, with some of them actively
oozing. Bicap was applied over the bleeding AVMs and hemostasis
achieved.
Internal hemorrhoids
Otherwise normal colonoscopy to cecum

Brief Hospital Course:
Ms. [**Known lastname **] is an 85 year-old lady with DM2, Afib on Coumadin,
HTN, HL, CKD(baseline Cr 2.8-3.5) anemia (baseline HCT 25) and
prior lower gastrointestinal bleeds who presented from home with
weakness and was found to be profoundly anemic in the ED, with
HCT of 13.  The patient was admitted to the ICU for active GIB.
She was given 7 units PRBC and HCT stabilized in the 30's.  She
was subsequently transferred to the floor.  Her HCT was stable
in the 30's over the weekend while she waited for
EGD/Colonoscopy.  EGD/Colonoscopy revealed active oozing of
blood from AVMs in the colon.  HCT remained stable for 24 hours
after the procedure and the patient was discharged home with
services.

PROBLEM LIST:
1. LOWER GI BLEED [**3-17**] bleeding AVMs in colon: Ms. [**Known lastname **]
presented with weakness, maroon stools and HCT 13, which was
concerning for GI Bleed. Given her prior colonoscopy reports,
she has known polyps and diverticuli. The most likely source of
her LGIB was diverticular bleed and also on the differential are
arteriovenous malformations. Per report from GI fellow and ED
resident, she had guiac positive maroon stools with fresh clot
on presentation. She required a total of 7unts of PRBC over 48
hours given tachycardia and continued maroon stools.  Her
tachycardia resolved and her hct stabalized out.  In the ICU she
continued to have some bloody bowel movements but was otherwise
stabe and so transferred to the medical floor.  Endoscopies were
performed and found bleeding AVMs.  It is recommended that the
patient undergo capsule enteroscopy to evaluate for AVMs in the
small intestine.  Anticoagulation for Afib will be deferred to
PCP.  [**Name10 (NameIs) **] that the patient stay off of anticoagulation for
at least several weeks to allow areas of bleed to heal.

2. ATRIAL FIBRILLATION ON COUMADIN/EKG CHANGES: Pt's INR  was
1.8 on admission and she received Vit K 10mg IV x 1 and 2u FFP.
Her INR was 1.3 on 2nd hospital day and coumadin was held. Her
baseline ECG had some ST depressions which were more pronounced
in the setting of tachycardia and GI bleed.  Her cardiac enzymes
were negative and a repeat ECG did not show any dynamic changes.
 The patient had episodes of RVR that were controlled with her
home dose of propranolol.  Anticoagulation has been discontinued
because of the recent severity of GIB.  Pt to discuss with PCP
regarding safety of restarting anticoagulation.

3. [**Name (NI) **] Pt was normoglycemic on admission labs. Humalog
dose was decreased while in-house.  Blood sugars were not too
elevated on reduced dosing, so patient discharged on reduced
dose.  PCP to increase dose as needed for optimal control.

4. ACUTE ON CHRONIC RENAL INSUFFICIENCY: Baseline creatinine
appears to be ~3.0. Was 5.1 on admission labs. Perfusion-related
renal injury given significant anemia seems most likely. Pt's
creatinine was closely monitored and improved with volume
resuscitation. The Cr reached a nadir of 2.3.

5. HYPERTENSION: pt has hx hypertension but was hypotensive
(relative to her baseline) in the ICU, likely in the setting of
volume depletion from blood loss. BP was closely monitored and
improved with volume resuscitation. Home anti-hypertensive
regimen including diovan, nifedipine, furosemide and hydralazine
was held in ICU.  Pt was restarted on hydralazine, propranolol,
and half dose of valsartan by the end of hospitalization.
Nifedipine and Furosemide were held during the entire
hospitalization and may be restarted by PCP as indicated.

Medications on Admission:
Digoxin 125 mcg PO DAILY
Cholecalciferol 50,000u qweek
Folic Acid 1mg  PO DAILY
Furosemide 80mg PO DAILY
Hydralazine 50mg PO TID
Lispro Protam & Lispro (75-25) Suspension 25U qAM, 40U qPM
Nifedipine 90mg PO DAILY
Pantoprazole 40mg PO BID
Warfarin 2.5mg PO DAILY
Diovan 320mg PO DAILY
Simvastatin 40mg PO qHS
Propanolol 80mg PO DAILY
Calcium Carbonate 600 PO BID

Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Cholecalciferol (Vitamin D3) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig:
Subcutaneous  : 25 units each morning and 40 units each evening.

6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Propranolol 80 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
9. Calcium Carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO twice a day.
10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Previous dose was 320mg daily.

Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Lower gastrointestinal bleeding, from arteriovenous
malformations
- Anemia, severe, from acute blood loss and chronic kidney
disease

SECONDARY DIAGNOSES:
- Type 2 diabetes mellitus
- Atrial fibrillation
- Hypertension
- Hyperlipidemia
- Pulmonary arterial hypertension
- Chronic kidney disease

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).

Discharge Instructions:
You were presented to the [**Hospital1 69**]
with a lower gastrointestinal bleed and a critically low
hematocrit of 13.  You were admitted to the ICU for close
monitoring.  You received a total transfusion with 7 units of
packed red blood cells.  Your hematocrit stabilized in the low
30's.

Upper and lower endoscopies were performed on [**2139-7-14**].  Active
bleeding was seen in the colon from what is called an AVM
(arteriovenous malformation) and were stopped.  You should
follow up with a gastroenterologist for follow up.  AVMs may
also be present in the small intestine, so you may discuss with
your primary care physician or GI doctor regarding the utility
of a capsule enteroscopy in assessing for AVMs in the small
intestine.

MEDICATION CHANGES (Do not restart STOPPED medications until
discussing them with your primary care physician):
1. REDUCED DOSE: Insulin 75/25: take 10 units in the morning and
15 units in the evening (previously 25 units in the morning and
40 units in the evening)
2. REDUCED DOSE: Valsartan (Diovan) 160mg daily (previously
320mg daily)
3. STOPPED: Furosemide (Lasix) 80mg daily
4. STOPPED: Nifedipine 90mg daily
5. STOPPED: Warfarin (Coumadin) 2.5mg daily

Followup Instructions:
APPOINTMENT #1:
Department: [**Hospital3 249**]
When: TUESDAY [**2139-7-21**] at 1:10 PM
With: [**Company 191**] POST [**Hospital 894**] CLINIC with Dr [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**]
Phone: [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
 [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up.

APPOINTMENT #2:
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2139-7-28**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage
{'Benign neoplasm of stomach,Internal hemorrhoids without mention of complication,Diverticulosis of colon (without mention of hemorrhage),Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other and unspecified hyperlipidemia,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Angiodysplasia of intestine with hemorrhage,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Volume depletion, 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: Weakness

PRESENT ILLNESS: 85 yof with hisory of DM2, Afib on Coumadin, HTN, HL, CKD with
baseline 2.8-3.5, hx of Anemia with baseline HCT 25, ?hx of LGIB
who presents from home with weakness.  Patient reports weakness
x 6 weeks along with dark stools.  She contact[**Name (NI) **] her [**Name (NI) **]
endocrinologist today who then referred her to the ED.

MEDICAL HISTORY: - Type 2 Diabetes Mellitus
- Atrial Fibrillation on Coumadin
- Hypertension
- Hyperlipidemia
- Pulmonary arterial hypertension
- Chronic kidney disease
- Anemia
- Hyperparathyroidism s/p parathyroidectomy [**6-21**]
- Pelvic fracture lateral compression type I and a left proximal

MEDICATION ON ADMISSION: Digoxin 125 mcg PO DAILY
Cholecalciferol 50,000u qweek
Folic Acid 1mg  PO DAILY
Furosemide 80mg PO DAILY
Hydralazine 50mg PO TID
Lispro Protam & Lispro (75-25) Suspension 25U qAM, 40U qPM
Nifedipine 90mg PO DAILY
Pantoprazole 40mg PO BID
Warfarin 2.5mg PO DAILY
Diovan 320mg PO DAILY
Simvastatin 40mg PO qHS
Propanolol 80mg PO DAILY
Calcium Carbonate 600 PO BID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: 97.7, 103 (afib), 119/49, 13, 100% room air
General: Alert, oriented, [**Last Name (un) 664**], appropriate, no acute
distress
HEENT: +conjunctival pallor. Sclera anicteric, MMM, OP clear. No
tonsillar exudate
Neck: supple, no appreciable JVD or LAD
Lungs: CTAB, no wheezes, rales, rhonchi. Good inspiratory effort
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, symmetric 2+ radial/DP/PT pulses, no
clubbing, cyanosis or edema. No joint effusions.

FAMILY HISTORY: Her mother had hypertension, died at 89. Her father had lung
cancer, died at 74. Denies colon cancer, colon polyps in family.

SOCIAL HISTORY: Denies tobacco or illicit drug use. Occasional EtOH use.  Lives
with sister, walks on her own 

### Response:
{'Benign neoplasm of stomach,Internal hemorrhoids without mention of complication,Diverticulosis of colon (without mention of hemorrhage),Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other and unspecified hyperlipidemia,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Angiodysplasia of intestine with hemorrhage,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Volume depletion, unspecified'}
