CHIEF COMPLAINT: Upper GI bleed

PRESENT ILLNESS: Patient is a 38 year old female with known ETOH cirrhosis, Child
class B to C, complicated by known esophageal varices, portal
gastropathy, portal hypertension with ascites,
splenomegaly/thrombocytopenia who was admitted to the [**Location (un) 47**]
ICU with hematemesis x 5 after report of drinking ETOH on
[**2126-8-3**]. An EGD performed 1 month prior was reported to
demonstrate severe esophagitis with flat varices. The patient
was on presentation normotensive but tachycardic with subsequent
development of hypotension requiring multiple fluid boluses and
RBC transfusions. Admission vitals at OSH were 97/56, 92, 20,
99.2, 99% on RA. The patient was started on an octreotide gtt as
well as a Protonix gtt, received 2U FFP for INR of 1.8 and
transused 2U PRBCs. Patient's Hct on admission was 30.3 and most
recently 29.9 after 10U PRBCs in total thus far. The patient on
[**2126-8-3**] underwent EGD with banding and sclerotherapy after
receiving 2U PRBCs and 1U platelets. The following day, this
a.m. the patient continued to have ongoing hematemsis with
additional observation of frank aspiration for which the patient
was intubated for airway protection. The patient received 1 dose
of Clindamycin for this event as well. The patient has since
undergone a second attempt of EGD with repeat banding and
sclerotherapy with visualization of failed bands from previous
EGD. The patient is now being transferred to the [**Hospital1 18**] ICU for
ongoing management and possible TIPs with IR. On transfer
patient is being maintained with IV octreotide, protonix, and
received Methylprednisolone 20mg IV x1.

MEDICAL HISTORY: ETOH cirrhosis, Child's class B to C
Esophagitis
Bipolar Disorder
PTSD
PUD
Chronic Diarrhea

MEDICATION ON ADMISSION: none

ALLERGIES: Dilantin

PHYSICAL EXAM: Tc- 98.8 ; BP: 117/42 ; HR: 92
Vent: 500 x 12, FiO2 .40 PEEP 5, O2 100%
.
General - Patient is a young female, jaundiced, lying in bed,
intubated + sedated
HEENT: + ETT, +crusted blood in OP, around lips.
Pupils dilated, equal, minimally reactive to light. Conjunctiva
injected bilaterally.
Neck: No JVD, supple.
Chest: CTA Anterior and Laterally, fair air movement. +blanching
spider angioma over chest
Cor: RRR, no M/R/G appreciated
Abd: moderately distended. + Striae, + fluid wave. Soft, NT,
+BS. Liver tip firm, palpable 3-4cm below costal margin.
Rectum: Notable for bright red blood per rectum - approx 150cc
on [**Male First Name (un) **] currently, small clots
Ext: Trace pedal edema, extremities cool, pulses 1+ bilaterally.
+Right fem line, intact.
Access: Right fem line, PIV x 2, foley with [**Location (un) 2452**] urine

FAMILY HISTORY: Father died age 50 of MI. Mother alive and well. No fam hx of
ETOH or liver disease.

SOCIAL HISTORY: Reported to drink 2 glasses Vodka/day, last drink yesterday.
Patient is divorced, unemployed mother of 2, currently lives
with a friend. Reported to have had abusive partners previously.
Occasional smoking.
Acute and subacute necrosis of liver,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, unspecified,Esophageal varices in diseases classified elsewhere, with bleeding,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute gastric ulcer with hemorrhage, without mention of obstruction,Acute respiratory failure,Acquired coagulation factor deficiency,Pneumonitis due to inhalation of food or vomitus,Alcohol withdrawal,Portal hypertension,Esophagitis, unspecified,Bipolar disorder, unspecified,Infection with microorganisms resistant to penicillins,Diarrhea,Unspecified drug or medicinal substance causing adverse effects in therapeutic use
Acute necrosis of liver,Alcohol cirrhosis liver,Alcoh dep NEC/NOS-unspec,Bleed esoph var oth dis,Meth sus pneum d/t Staph,Ac stomach ulcer w hem,Acute respiratry failure,Acq coagul factor defic,Food/vomit pneumonitis,Alcohol withdrawal,Portal hypertension,Esophagitis, unspecified,Bipolar disorder NOS,Inf mcrg rstn pncllins,Diarrhea,Adv eff medicinal NOS
Admission Date:  [**2126-8-4**]              Discharge Date:   [**2126-9-1**]

Date of Birth:  [**2087-8-22**]             Sex:   F

Service: MEDICINE

Allergies:
Dilantin

Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Upper GI bleed

Major Surgical or Invasive Procedure:
Endoscopy
Intubation
Central line placement (Right IJ)

History of Present Illness:
Patient is a 38 year old female with known ETOH cirrhosis, Child
class B to C, complicated by known esophageal varices, portal
gastropathy, portal hypertension with ascites,
splenomegaly/thrombocytopenia who was admitted to the [**Location (un) 47**]
ICU with hematemesis x 5 after report of drinking ETOH on
[**2126-8-3**]. An EGD performed 1 month prior was reported to
demonstrate severe esophagitis with flat varices. The patient
was on presentation normotensive but tachycardic with subsequent
development of hypotension requiring multiple fluid boluses and
RBC transfusions. Admission vitals at OSH were 97/56, 92, 20,
99.2, 99% on RA. The patient was started on an octreotide gtt as
well as a Protonix gtt, received 2U FFP for INR of 1.8 and
transused 2U PRBCs. Patient's Hct on admission was 30.3 and most
recently 29.9 after 10U PRBCs in total thus far. The patient on
[**2126-8-3**] underwent EGD with banding and sclerotherapy after
receiving 2U PRBCs and 1U platelets. The following day, this
a.m. the patient continued to have ongoing hematemsis with
additional observation of frank aspiration for which the patient
was intubated for airway protection. The patient received 1 dose
of Clindamycin for this event as well. The patient has since
undergone a second attempt of EGD with repeat banding and
sclerotherapy with visualization of failed bands from previous
EGD. The patient is now being transferred to the [**Hospital1 18**] ICU for
ongoing management and possible TIPs with IR. On transfer
patient is being maintained with IV octreotide, protonix, and
received Methylprednisolone 20mg IV x1.

Past Medical History:
ETOH cirrhosis, Child's class B to C
Esophagitis
Bipolar Disorder
PTSD
PUD
Chronic Diarrhea


Social History:
Reported to drink 2 glasses Vodka/day, last drink yesterday.
Patient is divorced, unemployed mother of 2, currently lives
with a friend. Reported to have had abusive partners previously.
Occasional smoking.

Family History:
Father died age 50 of MI. Mother alive and well. No fam hx of
ETOH or liver disease.

Physical Exam:
Tc- 98.8 ; BP: 117/42 ; HR: 92
Vent: 500 x 12, FiO2 .40 PEEP 5, O2 100%
.
General - Patient is a young female, jaundiced, lying in bed,
intubated + sedated
HEENT: + ETT, +crusted blood in OP, around lips.
Pupils dilated, equal, minimally reactive to light. Conjunctiva
injected bilaterally.
Neck: No JVD, supple.
Chest: CTA Anterior and Laterally, fair air movement. +blanching
spider angioma over chest
Cor: RRR, no M/R/G appreciated
Abd: moderately distended. + Striae, + fluid wave. Soft, NT,
+BS. Liver tip firm, palpable 3-4cm below costal margin.
Rectum: Notable for bright red blood per rectum - approx 150cc
on [**Male First Name (un) **] currently, small clots
Ext: Trace pedal edema, extremities cool, pulses 1+ bilaterally.
+Right fem line, intact.
Access: Right fem line, PIV x 2, foley with [**Location (un) 2452**] urine


Pertinent Results:
Updated [**2126-8-25**]
==============
Interventions:
==============
TIPS procedure [**2126-8-6**].
IMPRESSION:
1.  Status post successful placement of TIPS with a 10 mm x 68
mm Wallstent lining the transparenchymal tract extending from
the right hepatic vein to the right portal vein.  Post-procedure
portosystemic gradient was 5 mm.
2.  Status post exchange of right internal jugular approach
triple lumen
central venous line.
3.  No post-procedural orders written.
.
EGD:  [**2126-8-23**]
Blood in the lower third of the esophagus and gastroesophageal
junction
Blood in the fundus
Ulcer in the cardia (injection)
Otherwise normal EGD to second part of the duodenum.
.
Radiology:
==========
Chest X-ray [**2126-8-5**]
CHEST:
The position of the endotracheal tube and IJ line is unchanged.
Since the prior chest x-ray there has been loss of the left
hemidiaphragm suggesting atelectasis and/or consolidation in
this region. The left costophrenic angle is not seen and there
may be also an effusion present.
IMPRESSION: Left` retrocardiac opacifications.
.
Abdominal Ultrasound [**2126-8-5**]
IMPRESSION:
1. Echogenic liver with no definite focal lesions seen.
2. Patent portal vein with hepatopetal flow.
3. Mildly distended gallbladder with gallbladder wall edema and
no gallstones demonstrated. Small pericholecystic fluid is also
seen in the presence of mild-to-moderate generalized ascites.
Gallbladder wall edema may be secondary to liver disease, and is
also demonstrated in the presence of right heart failure or
hypoproteinemic state. Correlation with LFTs and clinical exam
is recommended.
4. Approximately 2 cm focal mild bulge in the contour of the
right kidney at the interpolar region is incompletely
characterized. Correlation with other cross-sectional previous
imaging if available is recommended. If none is available,
further characterization may be performed with additional cross-
sectional imaging.
.
Abdominal Ultrasound [**2126-8-13**]
IMPRESSION:
1. Cirrhotic liver with ascites and TIPS with wall-to-wall color
flow.
2. Splenomegaly.
3. Right pleural effusion.
.
Microbiology:
=============
Positive:
Urine Culture [**2126-8-17**]  Yeast
Sputum culture [**2126-8-7**] and [**2126-8-9**] MRSA
.
CULTURES with no growth to date:
Central line Catheter tip Culture: [**Month (only) 462**]/13,19/[**2125**]
Blood Culture: [**Month (only) 462**]/3,6,7,8,10,16,18,19,21,22,23/[**2125**]
Urine Culture: [**Month (only) 462**]/3,4,6,8,10,18,21/[**2125**]
Ascites Culture:[**2126-8-21**]
Sputum Culture: 9/13,22/[**2125**]
C.Diff toxin negative: 9/8,16,17,19/[**2125**]
.
Blood tests:
============
On Admission:
[**2126-8-4**] 09:30PM WBC-3.5* RBC-3.01* Hgb-9.2* Hct-25.9* MCV-86
MCH-30.5 MCHC-35.5* RDW-19.5* Plt Ct-16*
[**2126-8-4**] 09:30PM PT-18.9* PTT-41.5* INR(PT)-1.8*
[**2126-8-4**] 09:30PM Glucose-136* UreaN-7 Creat-0.6 Na-141 K-3.8
Cl-107 HCO3-26 AnGap-12
[**2126-8-4**] 09:30PM ALT-26 AST-81* LD(LDH)-245 AlkPhos-70
Amylase-34 TotBili-7.4*
[**2126-8-4**] 09:30PM Albumin-2.8* Calcium-7.3* Phos-2.3* Mg-1.2*

Brief Hospital Course:
Patient is a 38 year old female with ETOH cirrhosis with known
portal [**Hospital **] transferred from OSH MICU s/p banding and
sclerotherapy x 2, now being transferred to the [**Hospital1 18**] ICU for
ongoing mangement/care and planned TIPS procedure with IR.
.
#. Variceal bleed - Initially had hematemesis, pt was intubated
HD1 for airway protection, Patient had EGD with banding and
sclerotherapy x 2 on HD2;
She was transfused four units of pRBC's, four units of FFP, and
two unit of platelets, as well as being given 10mg of sc vitamin
K over the first night of admission.  On day two, her hct
remained stable throughout much of the day.   However, variceal
bleed continued, it was decided that TIPS was necessary. Pt was
transfused with FFP until INR <1.5 for TIPS. She was taken to
TIPS and transferred from ICU to Hepatorenal service after 24h
stable observation. She was stable from a GIB stand point after
a transfusion of a total of 14 U in the setting of the acute
event, but she continued to be vent dependent and was found to
have a VAP from MRSA. During her MICU course she continued to be
febrile despite negative cultures for other then sputum with
MRSA and defervesced once started on Zosyn. Subsequently she was
weaned of the vent and was successfully extubated on [**8-13**] and
then transfered to the regular floor. There the pt was continued
on Vancomycin and Zosyn for a 14 day course anmd was further
diuresed. She was doing well until the [**8-19**] when she developed
fevers of unknown origin. She had a paracentesis, a CT of the
abdomen which did not reveal any infection. She was thought to
potentially have drug fever. After completion of her antibiotic
course, the low grade fevers discontinued.  Hepatology followed
throughout hospital course.
Throughout hospital course: Hct checked q 2 hours until stable,
then q4h; 2 18-20 gauge PIV x 2 were maintained, active T+X,
central access, IV Protonix
.
#. ETOH - Child class B to C, MELD score 18 at OSH;patient with
reported use of 2pints Vodka/day, last drink yesterday on day of
admission; patient intubated/sedated with propofol making CIWA
assessment limited; pt was initially maintained on octreotide,
protonix, and received Methylprednisolone 20mg IV x1.
After pt stabilized, MVI/Thiamine/potassium/magnesium
supplemented. Pt was without seizures throughout
hospitalization.
.
#. ETOH [**Name (NI) 52965**] pt was maintained on lactulose when stable.
.
#. Psych - social work and psychiatry were consulted; She was
maintained on Risperidone and Citalopram when she was stable;
She never endorsed sx of major dempresssion; She was stable from
psycyiatric perspective; felt that she did not have a good
support group at home beside her roommate who is a father figure
for her; referral was made to an Etoh support group near her
home during discharge planning.  She was agreeable to follow up
with them and was very hopeful for a "second chance at life".
.
#. Code: Full

Medications on Admission:
none

Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*6*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
8. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*6*


Discharge Disposition:
Home

Discharge Diagnosis:
ETOH cirrhosis
Esophageal varices s/p bleed
Gastric ulcer in cardia bleed
Ventilator associated pneumonia


Discharge Condition:
Good


Discharge Instructions:
Return to the ER if you have any vomiting of blood, blood in the
stool, dark black stool, fevers, other concerning symptoms.

Followup Instructions:
Call [**First Name8 (NamePattern2) 501**] [**Last Name (NamePattern1) 1637**], [**Telephone/Fax (1) 69143**] for a referral for ongoing
counseling and support.
{'Acute and subacute necrosis of liver,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, unspecified,Esophageal varices in diseases classified elsewhere, with bleeding,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute gastric ulcer with hemorrhage, without mention of obstruction,Acute respiratory failure,Acquired coagulation factor deficiency,Pneumonitis due to inhalation of food or vomitus,Alcohol withdrawal,Portal hypertension,Esophagitis, unspecified,Bipolar disorder, unspecified,Infection with microorganisms resistant to penicillins,Diarrhea,Unspecified drug or medicinal substance 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: Upper GI bleed

PRESENT ILLNESS: Patient is a 38 year old female with known ETOH cirrhosis, Child
class B to C, complicated by known esophageal varices, portal
gastropathy, portal hypertension with ascites,
splenomegaly/thrombocytopenia who was admitted to the [**Location (un) 47**]
ICU with hematemesis x 5 after report of drinking ETOH on
[**2126-8-3**]. An EGD performed 1 month prior was reported to
demonstrate severe esophagitis with flat varices. The patient
was on presentation normotensive but tachycardic with subsequent
development of hypotension requiring multiple fluid boluses and
RBC transfusions. Admission vitals at OSH were 97/56, 92, 20,
99.2, 99% on RA. The patient was started on an octreotide gtt as
well as a Protonix gtt, received 2U FFP for INR of 1.8 and
transused 2U PRBCs. Patient's Hct on admission was 30.3 and most
recently 29.9 after 10U PRBCs in total thus far. The patient on
[**2126-8-3**] underwent EGD with banding and sclerotherapy after
receiving 2U PRBCs and 1U platelets. The following day, this
a.m. the patient continued to have ongoing hematemsis with
additional observation of frank aspiration for which the patient
was intubated for airway protection. The patient received 1 dose
of Clindamycin for this event as well. The patient has since
undergone a second attempt of EGD with repeat banding and
sclerotherapy with visualization of failed bands from previous
EGD. The patient is now being transferred to the [**Hospital1 18**] ICU for
ongoing management and possible TIPs with IR. On transfer
patient is being maintained with IV octreotide, protonix, and
received Methylprednisolone 20mg IV x1.

MEDICAL HISTORY: ETOH cirrhosis, Child's class B to C
Esophagitis
Bipolar Disorder
PTSD
PUD
Chronic Diarrhea

MEDICATION ON ADMISSION: none

ALLERGIES: Dilantin

PHYSICAL EXAM: Tc- 98.8 ; BP: 117/42 ; HR: 92
Vent: 500 x 12, FiO2 .40 PEEP 5, O2 100%
.
General - Patient is a young female, jaundiced, lying in bed,
intubated + sedated
HEENT: + ETT, +crusted blood in OP, around lips.
Pupils dilated, equal, minimally reactive to light. Conjunctiva
injected bilaterally.
Neck: No JVD, supple.
Chest: CTA Anterior and Laterally, fair air movement. +blanching
spider angioma over chest
Cor: RRR, no M/R/G appreciated
Abd: moderately distended. + Striae, + fluid wave. Soft, NT,
+BS. Liver tip firm, palpable 3-4cm below costal margin.
Rectum: Notable for bright red blood per rectum - approx 150cc
on [**Male First Name (un) **] currently, small clots
Ext: Trace pedal edema, extremities cool, pulses 1+ bilaterally.
+Right fem line, intact.
Access: Right fem line, PIV x 2, foley with [**Location (un) 2452**] urine

FAMILY HISTORY: Father died age 50 of MI. Mother alive and well. No fam hx of
ETOH or liver disease.

SOCIAL HISTORY: Reported to drink 2 glasses Vodka/day, last drink yesterday.
Patient is divorced, unemployed mother of 2, currently lives
with a friend. Reported to have had abusive partners previously.
Occasional smoking. 

### Response:
{'Acute and subacute necrosis of liver,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, unspecified,Esophageal varices in diseases classified elsewhere, with bleeding,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute gastric ulcer with hemorrhage, without mention of obstruction,Acute respiratory failure,Acquired coagulation factor deficiency,Pneumonitis due to inhalation of food or vomitus,Alcohol withdrawal,Portal hypertension,Esophagitis, unspecified,Bipolar disorder, unspecified,Infection with microorganisms resistant to penicillins,Diarrhea,Unspecified drug or medicinal substance causing adverse effects in therapeutic use'}
