CHIEF COMPLAINT: Melena

PRESENT ILLNESS: 69 year-old woman with a history of CAD, CHF, AVM, achalasia
anemia, new large brain mass affecting sella turcica and
impinging on optic chiasm who presents with melena. Patient was
seen at [**Company 191**] today from rehab. Patient had been constipated for 5
days without BM, then last night was given 4 enemas and is now
incontinent of stool, diarrhea. At [**Company 191**] she was noted to have
guaiac positive melanotic stools. She was therefore sent to ED.
Here only complaint at this time is generalized fatigue. She
denied any LH, dizziness, syncope. No CP, SOB, abd pain. States
that she has had some recent nausea, but no vomiting.
.
Recently admitted for work-up or large brain mass which was
found to be pituitary adenoma on biopsy. To be seen by Dr. [**Last Name (STitle) 724**]
next week.
.
In the ED she was NG lavage and was positive for bright red
blood clots and coffee grounds. ECG showed questionable ST
elevations in V1-2 unchanged. 2 large bore IV's were placed. IV
PPI was given. Also given levoquin given WBC of 16.6.
.
In the MICU the patient's hct was monitored and remained stable.
She was continued on IV PPI and underwent EGD that showed Grade
4 esophagitis with contact bleeding in the lower third of the
esophagus. She was kept NPO.

MEDICAL HISTORY: 1. Coronary artery disease with history of V. fib arrest, S/P
LAD stent and repeat cath in [**10/2159**]
2. CHF - EF 30-35% in [**2159**].
3. Osteoporosis - early menopause, no history of hip fractures
but verterbral compression fractures noted earlier this month.
4. Depression
5. History of colonic AVM and anemia of chronic blood loss
6. S/P Appendectomy
7. Hypertension
8. H/o achalasia, peptic stricture at EG junction
9. h/o TAH and bilateral oopherectomy in her 30s

MEDICATION ON ADMISSION: 1. Calcium Carbonate 500 mg TID
2. Citalopram 10 mg Tab Qday
3. Ferrous Sulfate 325 mg qday
4. Mirtazapine 7.5 mg QHS
5. Nortriptyline 20 mg QHS
6. Simvastatin 40 mg Qday
7. Sucralfate 1 g [**Hospital1 **]
8. Ergocalciferol (Vitamin D2) 50,000 unit PO QSat
9. Oxycodone 5 mg prn
10. Zolpidem 5 mg qhs
11. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
12. Nexium 40 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 97.5 BP 116/59 HR 98 RR 16 O2sats 100% RA
Gen: Chronically ill appearing, cachectic, NAD
HEENT: NG tube in place, dry mm, PERRL, EOMI
Lungs: CTAB
Heart: Tachy no m/r/g
Abd: Soft, NT, ND + BS, no HSM
Ext: No edema, normal peripheral pulses
Neuro: A&O times 3, sensation intact, strength normal, moving
all 4 extremeties

FAMILY HISTORY: FHx - multiple members in the family with who has had early TAH
and bilateral oopherectomy

SOCIAL HISTORY: Soc: Patient lives with her brother and sister-in-law.  She has
60 pack-year tobacco history but quit 20 yrs ago; denies EtoH
and drug use
Esophagitis, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Benign neoplasm of pituitary gland and craniopharyngeal duct,Coronary atherosclerosis of native coronary artery,Gastrointestinal vessel anomaly,Senile osteoporosis,Depressive disorder, not elsewhere classified,Percutaneous transluminal coronary angioplasty status,Personal history of tobacco use
Esophagitis, unspecified,Chr blood loss anemia,Urin tract infection NOS,Hyposmolality,Benign neo pituitary,Crnry athrscl natve vssl,Gstrontest vesl anomaly,Senile osteoporosis,Depressive disorder NEC,Status-post ptca,History of tobacco use
Admission Date:  [**2161-4-1**]              Discharge Date:   [**2161-4-6**]

Date of Birth:  [**2091-5-12**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5266**]
Chief Complaint:
Melena

Major Surgical or Invasive Procedure:
PICC placement for TPN


History of Present Illness:
69 year-old woman with a history of CAD, CHF, AVM, achalasia
anemia, new large brain mass affecting sella turcica and
impinging on optic chiasm who presents with melena. Patient was
seen at [**Company 191**] today from rehab. Patient had been constipated for 5
days without BM, then last night was given 4 enemas and is now
incontinent of stool, diarrhea. At [**Company 191**] she was noted to have
guaiac positive melanotic stools. She was therefore sent to ED.
Here only complaint at this time is generalized fatigue. She
denied any LH, dizziness, syncope. No CP, SOB, abd pain. States
that she has had some recent nausea, but no vomiting.
.
Recently admitted for work-up or large brain mass which was
found to be pituitary adenoma on biopsy. To be seen by Dr. [**Last Name (STitle) 724**]
next week.
.
In the ED she was NG lavage and was positive for bright red
blood clots and coffee grounds. ECG showed questionable ST
elevations in V1-2 unchanged. 2 large bore IV's were placed. IV
PPI was given. Also given levoquin given WBC of 16.6.
.
In the MICU the patient's hct was monitored and remained stable.
She was continued on IV PPI and underwent EGD that showed Grade
4 esophagitis with contact bleeding in the lower third of the
esophagus. She was kept NPO.


Past Medical History:
1. Coronary artery disease with history of V. fib arrest, S/P
LAD stent and repeat cath in [**10/2159**]
2. CHF - EF 30-35% in [**2159**].
3. Osteoporosis - early menopause, no history of hip fractures
but verterbral compression fractures noted earlier this month.
4. Depression
5. History of colonic AVM and anemia of chronic blood loss
6. S/P Appendectomy
7. Hypertension
8. H/o achalasia, peptic stricture at EG junction
9. h/o TAH and bilateral oopherectomy in her 30s


Social History:
Soc: Patient lives with her brother and sister-in-law.  She has
60 pack-year tobacco history but quit 20 yrs ago; denies EtoH
and drug use


Family History:
FHx - multiple members in the family with who has had early TAH
and bilateral oopherectomy

Physical Exam:
T 97.5 BP 116/59 HR 98 RR 16 O2sats 100% RA
Gen: Chronically ill appearing, cachectic, NAD
HEENT: NG tube in place, dry mm, PERRL, EOMI
Lungs: CTAB
Heart: Tachy no m/r/g
Abd: Soft, NT, ND + BS, no HSM
Ext: No edema, normal peripheral pulses
Neuro: A&O times 3, sensation intact, strength normal, moving
all 4 extremeties


Pertinent Results:
NG lavage in ED- 300cc with small amount of coffee grounds.
After CXR revealed NG tube in esophagus this was removed.
.
ECG: Sinus tachy at 107nl axis, nl intervals, LVH, Twave
inversion in lateral leads old.
.
CXR- NG tube is curled in the esophogus
.
EGD [**4-2**]:
Dilation at the lower third of the esophagus
Grade 4 esophagitis in the lower third of the esophagus
Erythema in the stomach body compatible with NG trauma
Food in the antrum
Otherwise normal EGD to second part of the duodenum


Brief Hospital Course:
A/P 69 year-old woman with a history of CAD, CHF, AVM, achalasia

anemia, new large brain mass affecting sella turcica and
impinging on optic chiasm who presents with melena.
.
# [**Name (NI) 4056**] Pt has a long history of GIBs from AVM's. Also history of
achalasia and peptic stricture, which caused NGT to become
curled in esophagus and had to subsequently be removed. Pt
admitted with guaiac positive stool and positive NG lavage. She
was admitted to the MICU for close monitoring of her hct and
vital signs.  She was given 2 large bore IVs.  Her hct was
monitored q 4hr and remained stable.  She was kept NPO and given
IV PPI [**Hospital1 **] per GI.  She underwent EGD that showed grade 4
esophagitis. GI recommended QID sucralfate and [**Hospital1 **] PPI. Given
her achalasia and poor PO intake they recommended that the
patient receive TPN for nutritional repletion given low albumin.
 Once nutritionally replete may need G-tube in medium term.  She
was advanced to a regular diet and started on TPN following PICC
placement.  She was transferred to a regular medicine floor.
Her hct trended down to 24.9 and given her cardiac history she
was transfused one unit of packed RBCs.  She had an appropriate
bump in her hct to 29.8 and this remained stable >30 since.
.
# [**Name (NI) 27035**] Pt with recent luekocytosis during her last
hospitalization but normalized on discharge. Admitted with WBC
of 16 with left shift. She received a dose of levaquin, however
her leukocytosis resolved and she was afebrile.  There was no
obvious signs of infection. CXR showed no pneumonia. Her
leukocytosis resolved and she remained afebrile.  Blood cultures
were sent and remained NGTD. Levofloxacin was discontinued given
no clear infectious source.  On the day prior to discharge, Ms.
[**Name14 (STitle) 27036**] had leukocytosis with a U/A consistent with a UTI (see
below).  Her WBCs at time of discharge remain 12.7 but this is
only after 1 day of treatment.  CXR done was read as:
"IMPRESSION: Markedly limited study secondary to positioning. As
best can be determined there is no definite new focal opacity.
There is a new indwelling PICC line as above" and the
leukocytosis upon discharge is being attributed to a UTI.
.
# UTI: On the day prior to discharge, Ms. [**Name14 (STitle) 27036**] had
leukocytosis with a U/A consistent with a UTI.  At time of
discharge she has gram negative rods growing (speciation and
sensitivities pending at time of discharge which should be
followed post-discharge).  We started a course of Bactrim and
she should continue this for 3 days and have follow up U/A and
cultures in a week's time.
.
# Hyponatremia- Patient was initially hyponatremic to 132 on
admission.  Resolved with hydration so it was thought to be
secondary to hypovolemia.
.
# Brain Mass- Worked up recently completed. Recent biopsies
showed pituitary adenoma. TSH/T4, [**Last Name (un) 104**] stim were normal during
last admission. LH/FSH were low.  Of note, sutures removed by
neurosurg on day of discharge.
-- Follow up with Dr. [**Last Name (STitle) 27037**] no urgent need for intervention.
-- Outpatient appointment scheduled and please call to confirm
this.
.
# CHF- EF 30-35%. No signs of failure at this time.
-- Watch for need of lasix given fluid resusitation
.
# Anemia- Chronic Fe deficicient anemia, likely from chronic
GIB.  Iron supplemntation was restarted following endoscopy.
.
# [**Name (NI) **] Pt with no recent chest pain or ECG changes.
-- cardiac enzymes negative x2
-- No ASA given UGIB
.
# FEN- Patient was initially kept NPO for her procedure.  Given
her achalasia, the patient is only able to tolerate small
amounts of food at one time.  Her GI doctors [**Name5 (PTitle) 2985**] that she had
had significant worsening of her nutritional status with low
albumin and weight loss.  It was felt that she will likely need
a feeding tube for nutritional support as she is unable to meet
her needs by mouth, however GI did not want to place a tube
while her nutritional status was so poor.  Therefore, a PICC was
placed for TPN.  She will likely need a few weeks of TPN to
improve her nutritional status prior to g-tube placement.  She
was advanced to a regular diet given there was no
contraindication to this and she was started on TPN.
.
# PPx- Pneumoboots (held Heparin s/p GIB); ambulate with PT
daily
.
# Access- 2 PIV's
.
# Code- DNR/DNI
.
# Dispo- To rehab today
.

Medications on Admission:
1. Calcium Carbonate 500 mg TID
2. Citalopram 10 mg Tab Qday
3. Ferrous Sulfate 325 mg qday
4. Mirtazapine 7.5 mg QHS
5. Nortriptyline 20 mg QHS
6. Simvastatin 40 mg Qday
7. Sucralfate 1 g [**Hospital1 **]
8. Ergocalciferol (Vitamin D2) 50,000 unit PO QSat
9. Oxycodone 5 mg prn
10. Zolpidem 5 mg qhs
11. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
12. Nexium 40 mg [**Hospital1 **]


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]

Discharge Diagnosis:
Primary:
UGIB
Grade 4 esophagitis
Pituitary adenoma
Anemia
Achalasia
.
Secondary:
CAD
CHF
HTN


Discharge Condition:
Stable


Discharge Instructions:
Please continue to take your medications as directed.
.
If you experience blood in your stool, difficulty breathing,
chest pain, fainting, high fevers or other concerning symptoms
call you doctor or come to the emergency room.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2161-4-6**]
2:00

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2161-4-14**] 10:20

Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] WEST Date/Time:[**2161-4-15**]
9:45
{'Esophagitis, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Benign neoplasm of pituitary gland and craniopharyngeal duct,Coronary atherosclerosis of native coronary artery,Gastrointestinal vessel anomaly,Senile osteoporosis,Depressive disorder, not elsewhere classified,Percutaneous transluminal coronary angioplasty status,Personal history of tobacco 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: Melena

PRESENT ILLNESS: 69 year-old woman with a history of CAD, CHF, AVM, achalasia
anemia, new large brain mass affecting sella turcica and
impinging on optic chiasm who presents with melena. Patient was
seen at [**Company 191**] today from rehab. Patient had been constipated for 5
days without BM, then last night was given 4 enemas and is now
incontinent of stool, diarrhea. At [**Company 191**] she was noted to have
guaiac positive melanotic stools. She was therefore sent to ED.
Here only complaint at this time is generalized fatigue. She
denied any LH, dizziness, syncope. No CP, SOB, abd pain. States
that she has had some recent nausea, but no vomiting.
.
Recently admitted for work-up or large brain mass which was
found to be pituitary adenoma on biopsy. To be seen by Dr. [**Last Name (STitle) 724**]
next week.
.
In the ED she was NG lavage and was positive for bright red
blood clots and coffee grounds. ECG showed questionable ST
elevations in V1-2 unchanged. 2 large bore IV's were placed. IV
PPI was given. Also given levoquin given WBC of 16.6.
.
In the MICU the patient's hct was monitored and remained stable.
She was continued on IV PPI and underwent EGD that showed Grade
4 esophagitis with contact bleeding in the lower third of the
esophagus. She was kept NPO.

MEDICAL HISTORY: 1. Coronary artery disease with history of V. fib arrest, S/P
LAD stent and repeat cath in [**10/2159**]
2. CHF - EF 30-35% in [**2159**].
3. Osteoporosis - early menopause, no history of hip fractures
but verterbral compression fractures noted earlier this month.
4. Depression
5. History of colonic AVM and anemia of chronic blood loss
6. S/P Appendectomy
7. Hypertension
8. H/o achalasia, peptic stricture at EG junction
9. h/o TAH and bilateral oopherectomy in her 30s

MEDICATION ON ADMISSION: 1. Calcium Carbonate 500 mg TID
2. Citalopram 10 mg Tab Qday
3. Ferrous Sulfate 325 mg qday
4. Mirtazapine 7.5 mg QHS
5. Nortriptyline 20 mg QHS
6. Simvastatin 40 mg Qday
7. Sucralfate 1 g [**Hospital1 **]
8. Ergocalciferol (Vitamin D2) 50,000 unit PO QSat
9. Oxycodone 5 mg prn
10. Zolpidem 5 mg qhs
11. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
12. Nexium 40 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 97.5 BP 116/59 HR 98 RR 16 O2sats 100% RA
Gen: Chronically ill appearing, cachectic, NAD
HEENT: NG tube in place, dry mm, PERRL, EOMI
Lungs: CTAB
Heart: Tachy no m/r/g
Abd: Soft, NT, ND + BS, no HSM
Ext: No edema, normal peripheral pulses
Neuro: A&O times 3, sensation intact, strength normal, moving
all 4 extremeties

FAMILY HISTORY: FHx - multiple members in the family with who has had early TAH
and bilateral oopherectomy

SOCIAL HISTORY: Soc: Patient lives with her brother and sister-in-law.  She has
60 pack-year tobacco history but quit 20 yrs ago; denies EtoH
and drug use 

### Response:
{'Esophagitis, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Benign neoplasm of pituitary gland and craniopharyngeal duct,Coronary atherosclerosis of native coronary artery,Gastrointestinal vessel anomaly,Senile osteoporosis,Depressive disorder, not elsewhere classified,Percutaneous transluminal coronary angioplasty status,Personal history of tobacco use'}
