CHIEF COMPLAINT: nausea and vomiting

PRESENT ILLNESS: Ms. [**Known lastname 634**] is a 47 year old female with past medical history
of hypothyrodism who was doing well until yesterday.  She had
three episodes of nonbloody emesis followed by fourth episode at
8 am with streak of blood.  She did well throughout the day
until 6 pm when she had one cup full of hematemesis leading her
to present to the ED.

MEDICAL HISTORY: Hypothyroidism s/p total thyroidectomy and RAI for thyroid
Cancer x 20 years ago

MEDICATION ON ADMISSION: .  Information was obtained from .
1. Levothyroxine Sodium 175 mcg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Petechiae under her tongue
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
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, finger-to-nose intact

FAMILY HISTORY: DM2, HTN

SOCIAL HISTORY: Works as a guidance counselor during the school year but on
vacation now.  Lives with husband and 3 kids ages 19 year old
son, 15 year old son and 13 year old daughter
Immune thrombocytopenic purpura,Gastroesophageal laceration-hemorrhage syndrome,Postsurgical hypothyroidism,Personal history of malignant neoplasm of thyroid,Helicobacter pylori [H. pylori],Leukocytosis, unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use
Immune thrombocyt purpra,Mallory-weiss syndrome,Postsurgical hypothyroid,Hx of thyroid malignancy,Helicobacter pylori,Leukocytosis NOS,Adv eff corticosteroids
Admission Date:  [**2189-8-5**]              Discharge Date:   [**2189-8-11**]

Date of Birth:  [**2142-2-22**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 633**]
Chief Complaint:
nausea and vomiting


Major Surgical or Invasive Procedure:
None


History of Present Illness:
Ms. [**Known lastname 634**] is a 47 year old female with past medical history
of hypothyrodism who was doing well until yesterday.  She had
three episodes of nonbloody emesis followed by fourth episode at
8 am with streak of blood.  She did well throughout the day
until 6 pm when she had one cup full of hematemesis leading her
to present to the ED.

In the ED, initial vitals were HR 66 and BP 121/72.  She had [**1-5**]
cup of hematemesis in the ED. Nasogastric lavage returned >300
cc coffee ground material.  Guiaic positive on rectal exam.  ROS
positive for heavy menstrual bleeding.  Labs notable for HCT of
39.5, normal coags but platelet of 5.   Hematology was consulted
and with high probability of ITP, gave IV solumedrol 125 mg for
ITP and jumbo pack of platelets.  She was given 1LNS. She was
subsequently transferred to MICU for further evaluation.

In the MICU, she reports no other complaints.  She does not
report history of easy bleeding, nose bleeds or bleeding gums.
Her only change in deit has been 2 week history of hawaiin punch
coolaid.  She does not drink tonic water.  Travel notable for
[**Hospital3 635**] two weeks ago when she had pedal edema for one day.
She does not report viral symptoms or sick contacts.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
Hypothyroidism s/p total thyroidectomy and RAI for thyroid
Cancer x 20 years ago


Social History:
Works as a guidance counselor during the school year but on
vacation now.  Lives with husband and 3 kids ages 19 year old
son, 15 year old son and 13 year old daughter


Family History:
DM2, HTN


Physical Exam:
ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Petechiae under her tongue
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
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, finger-to-nose intact

DISCHARGE:
VITALS: 98.2 (97.8-98.3), BP 134/83 (112/65 - 137/80), HR 50
(50-64), RR 16 (16-22), O2 99%RA (98-99%)
GEN: African American female, pleasant, alert and fully
oriented, in no acute distress.
HEENT: NCAT, Moist mucous membranes, EOMI, sclera anicteric, no
conjunctival abnormalities, Oropharynx clear, petechia on palate
NECK: supple, no JVD, no lymphadenopathy
LUNGS: Good aeration, clear to auscultation bilaterally, no
wheezes, rales, or ronchi
HEART: Regular rate and rhythm, normal S1/S2, no murmurs, rubs,
gallops
ABD: soft, NT, ND, hypoactive bowel sounds, no rebound
tenderness or guarding, no CVA tenderness
EXT: Upper and lower extremity pulses palpable bilaterally, no
clubbing, cyanosis, or edema. Moves extremities spontaneously
NEURO: Alert and oriented x3. CNII-XII normal. No focal
deficits. Motor function grossly normal
SKIN: clustered area of purpura on left forearm acquired during
hospital stay, which is now improving from over the wknd. Area
of petechia and ecchymosis on right arm. Dark rash on left side
of neck attributed to summertime eczema flares

Pertinent Results:
ADMISSION:
[**2189-8-5**] 07:57PM BLOOD WBC-4.9 RBC-4.86 Hgb-13.3 Hct-39.8 MCV-82
MCH-27.3 MCHC-33.3 RDW-13.1 Plt Ct-5*
[**2189-8-5**] 11:49PM BLOOD WBC-5.0 RBC-4.28 Hgb-11.7* Hct-35.2*
MCV-82 MCH-27.5 MCHC-33.4 RDW-13.0 Plt Ct-44*#
[**2189-8-5**] 07:57PM BLOOD Plt Smr-RARE Plt Ct-5*
[**2189-8-5**] 11:49PM BLOOD Plt Ct-44*#
[**2189-8-5**] 07:57PM BLOOD PT-12.2 PTT-30.2 INR(PT)-1.1
[**2189-8-5**] 07:57PM BLOOD ALT-19 AST-43* LD(LDH)-646* AlkPhos-61
TotBili-0.3
[**2189-8-5**] 07:57PM BLOOD Hapto-272*
[**2189-8-5**] 07:57PM BLOOD Albumin-4.0
[**2189-8-5**] 07:57PM BLOOD Glucose-87 UreaN-9 Creat-0.8 Na-139
K-5.5* Cl-107 HCO3-25 AnGap-13

DISCHARGE:

[**2189-8-11**] 07:00AM BLOOD WBC-12.2*# RBC-4.54 Hgb-12.6 Hct-37.0
MCV-81* MCH-27.8 MCHC-34.1 RDW-13.3 Plt Ct-81*
[**2189-8-9**] 07:20AM BLOOD Glucose-88 UreaN-10 Creat-0.7 Na-139
K-3.7 Cl-108 HCO3-26 AnGap-9
[**2189-8-6**] 04:25AM BLOOD HIV Ab-NEGATIVE
HCV-negative
.
CXR-negative
.
[**Doctor First Name **] positive at 1:40

Brief Hospital Course:
Ms. [**Known lastname 634**] is a 47 year old af am female with past medical
history of thyroid cancer s/p
thyroidecomy and RAI 20 years ago who presented with bloody
emesis after nausea and vomiting and noted to have severe
thrombocytopenia to 5. Initially managed in ICU with IVIG and
PLT transfusion, then transferred to the floor where a diagnosis
of ITP was made.
.
# Thrombocytopenia: Most likely due to immune thrombocytopenic
purpura.  Differential includeed aspartame induced
thrombocytopenia from her hawaiin cool aid, infections (HIV or
HepC) induced thromboyctopenia.  Peripheral smear without
shistocytes argued against TTP.  Normal coagulopathy. No new
medications to suspect cause of thrombocytopenia . In the ICU,
the patient was started on IV solumedrol 125 mg and gave 1 unit
of platelets.  PLT increased to 44 then trended back down, so pt
was started on IVIG.  No signs of active bleeding with stable
Hct. Pt was transitioned IV steroids to prednisone 100 mg po
qdaily (1mg/kg).   Checked HIV ab and HepC ab, HCV VL, HIV VL
(all negative).  After transfer from ICU, pt was continued on PO
Prednisone 1mg/kg, and PLTs trended up, and on discharge were
88.  On day of discharge Pt was at her home functional baseline,
tolerating a full diet, moving her bowels, and urinating.  There
were no s/s of bleeding. She was discharged on a regimen of 50mg
prednisone [**Hospital1 **] (pt preference to take [**Hospital1 **] rather than 100mg
daily).. Taper will be directed by hematology. She was
instructed to follow up for serial CBC monitoring. ITP could
have been promoted by H.pylori, see below.
++++ Pt should continue bactrim for PCP [**Name9 (PRE) **] as well as calcium
and vitamin D for bone health while on prednisone therapy.
.
# HEMATEMESIS/UGIB: Differential includes [**Doctor First Name **] [**Doctor Last Name **] tear
complicated by thrombocytopenia vs peptic ulcer disease vs
variceal bleeding vs gastitits vs dieulafoy's lesion, no history
of NSAID use. Initially managed in ICU. HCT and hemodynamically
stable during entire admission. Pt never experienced any
evidence of GIB during admission. HPylori test done and was
positive. Pt was started on triple therapy of Omeprazole PO,
Clarithromycin 500mg [**Hospital1 **], and Amoxicillin 1g [**Hospital1 **] x 14 days.  We
recommended the patient to follow up with GI for an EGD
.
#leukocytosis-likely a result of steroid use. No signs of
infection noticed during admission. Would monitor CBC after
discharge.
.
## TRANSITIONAL
- Discuss with your PCP about EGD to definitively evaluate for
cause of hematemesis and to evaluate for PUD.
- Discuss with Hematology regarding Prednisone taper/dosing
- Monitor your blood glucose since you are now on Prednisone.

Medications on Admission:
.  Information was obtained from .
1. Levothyroxine Sodium 175 mcg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY


Discharge Medications:
1. Levothyroxine Sodium 175 mcg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*27
Capsule Refills:*0
4. Clarithromycin 500 mg PO Q12H
RX *clarithromycin 500 mg 1 tablet(s) by mouth twice a day Disp
#*27 Tablet Refills:*0
5. Amoxicillin 1000 mg PO Q12H
RX *amoxicillin 500 mg 2 capsule(s) by mouth twice a day Disp
#*54 Capsule Refills:*0
6. PredniSONE 50 mg PO BID
RX *prednisone 50 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
7. Outpatient Lab Work
Labs: CBC

Please Fax Results To:
Dr. [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 637**]
[**Telephone/Fax (1) 638**]

ICD-9 287.31
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *Bactrim DS 800 mg-160 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY
- Idiopathic Thrombocytopenic Purpura
- Hematemesis


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Ms. [**Known lastname 634**],

Thank you for choosing [**Hospital1 18**]. You were admitted for vomiting
blood in the setting of a very low platelet count due to ITP
("immune thrombocytopnia"). You were stabilized in the Intensive
Care Unit with platelet transfusion, Intravenous immunoglobulin
(IVIG), and steroids.  With these interventions your platelet
count increased so you are safe for discharge home with
Hematology follow-up.  Please have outpatient blood tests done
in 3 days (on Friday [**8-14**]) to check your platelets, which will
be followed up by Hematology.  You have been given a lab slip
for this.

The cause of your initial vomiting and blood are unclear.  [**Name2 (NI) **]
might have had a viral illness causing wretching, resulting in a
small esophageal tear.  But it is also possible that you could
have peptic ulcers, which could be supported byt the fact that a
tests suggested that you have H.pylori, a bacteria which can
cause ulcers.  You should complete a 2 week course of
antibiotics/acid suppressors in order to eliminate this bacteria
(Amoxicillin, Clarithromycin, and Omeprazole).  In addition, you
should have an EGD (upper endoscopy), which has been scheduled
for you.

While on the antibiotics, you should be aware they can cause
side effects of easy sun burn, interactions with alcohol, and
birth defects. Please avoid the sun and use sunblock, minimize
or avoid alcohol consumption, and use two methods of
contraception.

MEDICATIONS
- Start Prednisone (this medication will be tapered down based
on your discussion at your upcoming Hematology appointment)
- Start Omeprazole, Amoxicillin, and Clarithromycin for 2 weeks

Followup Instructions:
PRIMARY CARE
Name: [**Last Name (LF) 639**],[**First Name3 (LF) 640**] N.
Specialty: Primary Care
When: Monday [**8-17**] at 9:10am
Location: [**Hospital1 641**]
Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**]
Phone: [**Telephone/Fax (1) 644**]

HEMATOLOGY
When: TUESDAY [**2189-8-18**] at 9:00 AM
With: [**Name6 (MD) 645**] [**Name8 (MD) 646**], MD/[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

GASTROENTEROLOGY
You need an EGD (upper endoscopy).
We have spoken with your Primary Cares office and they will
refer you to an Atrius Gastroenterologist next week when you go
for your PCP [**Name Initial (PRE) 648**].



Completed by:[**2189-8-18**]
{'Immune thrombocytopenic purpura,Gastroesophageal laceration-hemorrhage syndrome,Postsurgical hypothyroidism,Personal history of malignant neoplasm of thyroid,Helicobacter pylori [H. pylori],Leukocytosis, unspecified,Adrenal cortical steroids causing adverse effects in therapeutic 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: nausea and vomiting

PRESENT ILLNESS: Ms. [**Known lastname 634**] is a 47 year old female with past medical history
of hypothyrodism who was doing well until yesterday.  She had
three episodes of nonbloody emesis followed by fourth episode at
8 am with streak of blood.  She did well throughout the day
until 6 pm when she had one cup full of hematemesis leading her
to present to the ED.

MEDICAL HISTORY: Hypothyroidism s/p total thyroidectomy and RAI for thyroid
Cancer x 20 years ago

MEDICATION ON ADMISSION: .  Information was obtained from .
1. Levothyroxine Sodium 175 mcg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Petechiae under her tongue
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
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, finger-to-nose intact

FAMILY HISTORY: DM2, HTN

SOCIAL HISTORY: Works as a guidance counselor during the school year but on
vacation now.  Lives with husband and 3 kids ages 19 year old
son, 15 year old son and 13 year old daughter 

### Response:
{'Immune thrombocytopenic purpura,Gastroesophageal laceration-hemorrhage syndrome,Postsurgical hypothyroidism,Personal history of malignant neoplasm of thyroid,Helicobacter pylori [H. pylori],Leukocytosis, unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use'}
