CHIEF COMPLAINT: Variceal Bleed

PRESENT ILLNESS: This is a 50 year old male with history of cirrhosis secondary
to alcohol and hep C who was admitted to [**Hospital 8641**] Hospital 2 [**1-30**]
weeks ago for a variceal bleed.  He underwent an EGD on that day
and underwent banding.  He had some further bleeding on the day
of admit and underwent another EGD and had some more banding.
He was eventually intubated for alcohol withdraw.  On [**2179-2-8**]
durring the day it was noticed that his hb was dropping (9.3
from 10).  He was started on an octreotide drip and his hb
continued to drop to 7.3.  He was Tx 2U PRBC and at approx 2am
had an episoide of bright red bloody emesis.  He was taken for
an emergent EGD which showed no active bleeding but ulcers in
the EG junction where his prior banding was.  There was some
venous blood seen that was not bleeding.  An attempt was made to
sclerose blood at which point the venous blood started activly
bleeding.  It was unable to be controlled endoscopically.  A
[**State **] was placed in the operating room.  A cordis was
placed.  Patient recieved 7U PRBC and 4 U FFP.  He recieved 1g
Anfec in the ED.  He was paralized with Vec for the Minessota
tube placement.  He was then transferred to [**Hospital1 18**] for further
management of his bleeding and anticipated TIPS placement.

MEDICAL HISTORY: Past Medical History:
- Cirrhosis (alcoholic/HCV)
- Hepatitis C virus
- Type II diabetes mellitus
- Alcohol abuse

MEDICATION ON ADMISSION: Flexeril
Neurontin
Insulin

ALLERGIES: Ketorolac / Codeine

PHYSICAL EXAM: General: sedated.
HEENT: Intubated.  [**State **] tube in place.  Sclera anicteric,
MMM.
Neck: supple, difficult to assess JVP.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen:  soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Dullness to percussion b/l on flanks consistent with ascities.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Patient is not married but has a girlfriend who works as a
nurse. He has a 13-year old daughter of whom he has sole custody
(her mother is about to go to prison); she is currently staying
with his 80-year old mother. [**Name (NI) **] is an active drinker of alcohol
with a history of abuse.
Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Hepatic encephalopathy,Other ascites,Other and unspecified alcohol dependence, unspecified,Chronic hepatitis C without mention of hepatic coma,Iron deficiency anemia secondary to blood loss (chronic),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Alcohol cirrhosis liver,Bleed esoph var oth dis,Hepatic encephalopathy,Ascites NEC,Alcoh dep NEC/NOS-unspec,Chrnc hpt C wo hpat coma,Chr blood loss anemia,DMII wo cmp nt st uncntr
Admission Date:  [**2179-2-9**]              Discharge Date:   [**2179-2-18**]

Date of Birth:  [**2128-7-17**]             Sex:   M

Service: MEDICINE

Allergies:
Ketorolac / Codeine

Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Variceal Bleed

Major Surgical or Invasive Procedure:
TIPS
Intubation
[**Last Name (un) **] Placement

History of Present Illness:
This is a 50 year old male with history of cirrhosis secondary
to alcohol and hep C who was admitted to [**Hospital 8641**] Hospital 2 [**1-30**]
weeks ago for a variceal bleed.  He underwent an EGD on that day
and underwent banding.  He had some further bleeding on the day
of admit and underwent another EGD and had some more banding.
He was eventually intubated for alcohol withdraw.  On [**2179-2-8**]
durring the day it was noticed that his hb was dropping (9.3
from 10).  He was started on an octreotide drip and his hb
continued to drop to 7.3.  He was Tx 2U PRBC and at approx 2am
had an episoide of bright red bloody emesis.  He was taken for
an emergent EGD which showed no active bleeding but ulcers in
the EG junction where his prior banding was.  There was some
venous blood seen that was not bleeding.  An attempt was made to
sclerose blood at which point the venous blood started activly
bleeding.  It was unable to be controlled endoscopically.  A
[**State **] was placed in the operating room.  A cordis was
placed.  Patient recieved 7U PRBC and 4 U FFP.  He recieved 1g
Anfec in the ED.  He was paralized with Vec for the Minessota
tube placement.  He was then transferred to [**Hospital1 18**] for further
management of his bleeding and anticipated TIPS placement.

Past Medical History:
Past Medical History:
- Cirrhosis (alcoholic/HCV)
- Hepatitis C virus
- Type II diabetes mellitus
- Alcohol abuse

Social History:
Patient is not married but has a girlfriend who works as a
nurse. He has a 13-year old daughter of whom he has sole custody
(her mother is about to go to prison); she is currently staying
with his 80-year old mother. [**Name (NI) **] is an active drinker of alcohol
with a history of abuse.

Family History:
Non-contributory.

Physical Exam:
General: sedated.
HEENT: Intubated.  [**State **] tube in place.  Sclera anicteric,
MMM.
Neck: supple, difficult to assess JVP.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen:  soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Dullness to percussion b/l on flanks consistent with ascities.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
Labs On Admission:
[**2179-2-9**] 07:08AM   FIBRINOGE-210
[**2179-2-9**] 07:08AM   PT-16.1* PTT-35.8* INR(PT)-1.4*
[**2179-2-9**] 07:08AM   PLT COUNT-150
[**2179-2-9**] 07:08AM   WBC-18.6* RBC-3.07* HGB-9.5* HCT-26.8* MCV-87
MCH-30.8 MCHC-35.2* RDW-15.7*
[**2179-2-9**] 07:08AM   ALBUMIN-2.3* CALCIUM-7.4* PHOSPHATE-5.1*
MAGNESIUM-1.8
[**2179-2-9**] 07:08AM   ALT(SGPT)-36 AST(SGOT)-63* LD(LDH)-289* ALK
PHOS-121 TOT BILI-4.1*
[**2179-2-9**] 07:08AM   estGFR-Using this
[**2179-2-9**] 07:08AM   GLUCOSE-170* UREA N-23* CREAT-1.1 SODIUM-141
POTASSIUM-5.3* CHLORIDE-107 TOTAL CO2-25 ANION GAP-14
[**2179-2-9**] 07:50AM   freeCa-0.96*
[**2179-2-9**] 07:50AM   TYPE-[**Last Name (un) **] TEMP-37.4 PH-7.37 COMMENTS-GREEN TOP
[**2179-2-9**] 10:00AM URINE  MUCOUS-FEW
[**2179-2-9**] 10:00AM URINE  HYALINE-107*
[**2179-2-9**] 10:00AM URINE  RBC-9* WBC-11* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-1
[**2179-2-9**] 10:00AM URINE  BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM  UROBILNGN-2* PH-5.5
LEUK-NEG
[**2179-2-9**] 10:00AM URINE  COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
[**2179-2-9**] 10:00AM URINE  bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2179-2-9**] 10:00AM URINE  GR HOLD-HOLD
[**2179-2-9**] 10:00AM URINE  HOURS-RANDOM
[**2179-2-9**] 10:00AM URINE  HOURS-RANDOM

Labs On Discharge:
[**2179-2-18**] 05:50AM BLOOD WBC-9.3 RBC-3.02* Hgb-9.1* Hct-27.2*
MCV-90 MCH-30.1 MCHC-33.4 RDW-18.1* Plt Ct-162
[**2179-2-18**] 05:50AM BLOOD PT-19.3* PTT-42.4* INR(PT)-1.8*
[**2179-2-18**] 05:50AM BLOOD Glucose-128* UreaN-16 Creat-1.0 Na-137
K-3.9 Cl-105 HCO3-25 AnGap-11
[**2179-2-18**] 05:50AM BLOOD ALT-48* AST-71* AlkPhos-143* TotBili-6.9*
[**2179-2-18**] 05:50AM BLOOD Calcium-7.0* Phos-2.6* Mg-1.8

Studies:

ECG [**2179-2-9**]: Sinus tachycardia with delayed R wave transition.
Low limb lead voltage. No previous tracing available for
comparison.

CXR [**2179-2-9**]:  FINDINGS: AP single view of the chest has been
obtained with patient in supine position. Right caliber special
tube has been introduced, reaching far below the diaphragm and
terminating out of the caudal border of the image.  Moderately
inflated balloon surrounds the tube at the level of the hiatus,
occupying the upper portion of the stomach fundus. The patient
is intubated, the ETT terminating in the trachea some 5 cm above
the level of the carina.  No pneumothorax is identified.
Pulmonary vasculature not congested. Heart size is moderately
enlarged with a marked prominence of left ventricular contour,
as well as that of the ascending aorta. Pleural effusion.
IMPRESSION: Moderate inflation of balloon of gastric tube
occupying the hiatal area.

ABDOMINAL US with Doppler [**2179-2-9**]:
IMPRESSION:
1. Patent hepatic vasculature.
2. Splenomegaly.
3. Large amount of ascites.
4. No liver lesion identified and no biliary dilatation.

TIPS [**2179-2-9**]:
Successful placement of TIPS; paracentesis with 3 L removed.
Post-TIPS
portosystemic gradient of 15 mmHg; however, minimal inflow of
varices on
post-TIPS portal venogram.

Paracentesis [**2179-2-9**]:
IMPRESSION:
1. Successful TIPS placement using 7+2, 10mm Viatorr stent
angioplasty to 10 mm.
2. Post-TIPS transhepatic portography with hemodynamics
demonstrating final portosystemic gradient of 15 mmHg (pre-TIPS
portosystemic gradient of 17 mmHg).
3. Placement of triple-lumen central venous line via the right
internal jugular access.
4. Portogram showing brisk flow up stent and substantial
reduction in flow to the coronary vein varix post-TIPS
placement.
5. Paracentesis with removal of 3 liters of clear yellow ascites
fluid.

Abdominal US with Doppler [**2179-2-14**]:
IMPRESSION:
1. Patent TIPS with appropriate directionality and flow in the
portal venous vasculature.
2. Cirrhosis, ascites.
3. Gallbladder wall edema and distention without cholelithiasis.
Findings
are nondiagnostic for acute cholecystitis given underlying
hepatic dysfunction can explain gallbladder wall changes due to
third spacing and distension may be due to a fasting state.
Clinical correlation or HIDA san as necessary is recommended.

Diagnostic paracentesis (US guided) [**2179-2-17**]:
IMPRESSION: Uncomplicated diagnostic and therapeutic
ultrasound-guided paracentesis with removal of 1250 mL of clear
yellow fluid.

Chest X-ray [**2179-2-17**]:
FINDINGS: In comparison with study of [**2-10**], there is continued
enlargement of the cardiac silhouette with left ventricular
prominence. The [**Last Name (un) **] tube has been removed. Some
atelectatic changes are seen at both bases. On the lateral view,
there are substantial pleural effusions bilaterally. No evidence
of acute focal pneumonia.

Microbiology:

Blood cx 1/4 bottles positive for enteroccous faecium
(sensitive) on [**2-9**]
Blood cx negative or NGTD from [**2-9**], [**2-10**], [**2-11**], [**2-13**], [**2-17**]
MRSA screen negative
Urine cx negative [**2-17**]
Peritoneal gram stain negative for organisms/PMNs [**2-17**] (cx
pending)

Brief Hospital Course:
50 yo M ELSD secondary to EtOH abuse admitted to OSH with
variceal bleed s/p EGD with banding x2 and subsequent alcohol
withdrawal transferred to [**Hospital1 18**] for management of recurrent
refractory UGIB s/p [**State **] tube placement and subsequent
removal one day later. TIPS performed although with modest drop
in gradient s/p procedure. Hct stable. Found to have AMS,
generating concern for benzo withdrawal vs. hepatic
encephalopathy. The following problems were addressed at this
admission:

# UGIB: Source was seen on endoscopy at OSH which was venous
blood that was attempted to be sclerosed, bu then opened up. GE
ulcers also seen on previous banding sites that were
non-bleeding. Patient had banding x2 at OSH. He received 7U
pRBCs and 4 FFP at OSH, and then was transferred here for
further management after a [**State **] tube was placed. He
received 2 more units of pRBC here and underwent TIPS.
Hematocrit remained stable the rest of patient's MICU stay, and
he remained hemodynamically stable. TIPS was performed [**2-9**],
[**State **] tube removed [**2-10**]. We continued PO PPI [**Hospital1 **] and treated
GIB with ceftriaxone. Patient continued to remain stable.
Ultrasound to evaluate TIPS patency on [**2-14**] showed patent TIPS.
Patient was transferred to the floor on [**2-15**]. He had stable Hct
and no further evidence of bleed.

# AMS: Patient had AMS s/p extubation. It was classic for
delirium; he had been picking at sheets, inattentive and showed
fluctuating mental status. Thus, was encephalopathic but without
asterixis and less likely due to hepatic dysfunction.
Respiratory status and renal function are also good. Given
alcohol history, also considered Korsakoff. We had obtained B12,
TSH. We continued Lactulose, Rifaximin, thiamine and PO Ativan
CIWA. On the floor, his mental status improved and he was
attentive and responding to questions appropriately. He was
oriented to person and place but was unable to correctly state
date and still displayed occasional word-finding difficulties
(e.g. In response to "What month is this?" he would answer "The
first one.").

# Positive blood culture. Patient had 1/4 bottles positive for
enterococcus faecium on [**2-9**]. All other cultures were negative.
This was felt to be possibly a contaminant. He was treated with
a 6-day course of vancomycin.

# Volume overload. Patient has ascites (1200 cc removed [**2-17**])
and peripheral edema, which may have been exacerbated by
pRBC/FFP/fluid rescusitation during his bleed. He will be
discharged on Lasix 40 mg PO daily and spironolactone 50 mg PO
daily with plan to monitor electrolytes, renal function and
increase as needed. Most recently, patient's weight is down 0.5
kg on this regimen over past 24 hours.

# Respiratory status: It was unclear whether the patient was
intubated for EtOH withdrawal or for EGD. Patient had received
paralysis for EGD and [**Location (un) **].  He was extubated successfully
and has had [**Last Name **] problem with oxygenation and no subjective SOB.
He received a 5 day course of ceftriaxone for ? infiltrate
(stopped on [**2-15**]).

# Cirrhosis: Secondary to alcohol and hepatitis C.  Unclear if
patient listed on transplant list.  As he has been an active
drinker, he is not currently a transplant candidate but this may
be considered if he is able to successfully quit drinking
alcohol in the future.

# EtOH withdrawal: The patient had a high benzodiazepine
requirement at the OSH.  He required intubation and multiple
drips. Here, he was continued on thiamine, folate, and CIWA
scale; at the time of discharge he was still mildly confused but
otherwise not showing signs of active withdrawal.

# Hepatitis C virus: Likely contributing to cirrhosis.  Unclear
if he has been treated in the past.

# Diabetes mellitus: The patient was placed on an insulin
sliding scale for the duration of his stay.

Medications on Admission:
Flexeril
Neurontin
Insulin

Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO TID
(3 times a day).
2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Insulin Lispro 100 unit/mL Solution Sig: According to sliding
scale  Subcutaneous ASDIR (AS DIRECTED).
7. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).


Discharge Disposition:
Extended Care

Discharge Diagnosis:
PRIMARY:
- Esophageal variceal bleed
- Hepatic encephalopathy
- Alcoholic/HCV cirrhosis

SECONDARY:
- Alcoholism
- Diabetes mellitus


Discharge Condition:
Mental Status: Confused - sometimes (has not been able to state
date correctly, but oriented to person/place)
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - PT consult has recommended walking
with supervision until discharged home to prevent falls


Discharge Instructions:
You were transferred to the medical intensive care unit at [**Hospital1 1535**] after efforts to stop massive
bleeding from esophageal varices were unsuccessful at [**Hospital 8641**]
hospital. You underwent a procedure called TIPS placement which
allowed the bleeding to stop. You received transfusion of two
units of red blood cells while you were here, and your blood
levels stabilized.  Your breathing tube was removed the
following day. After one week, you were transferred out of the
ICU to the liver service [**Hospital1 **]. Initially, you were very sleepy
and confused, but you steadily became more clear-headed.

At your request, we have arranged for you to be transferred back
to [**Location (un) 3844**].

Please note that it is extremely important that you stop
drinking alcohol. Even a small amount will be very dangerous to
your liver. As our social workers have discussed, there are many
resources to support you in your decision to stop drinking
alcohol. Please ask any of your health care providers for
additional hellp if you feel that you need it.

Followup Instructions:
Please follow up as directed following your discharge from
[**Hospital 8641**] Hospital.



Completed by:[**2179-2-18**]
{'Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Hepatic encephalopathy,Other ascites,Other and unspecified alcohol dependence, unspecified,Chronic hepatitis C without mention of hepatic coma,Iron deficiency anemia secondary to blood loss (chronic),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: Variceal Bleed

PRESENT ILLNESS: This is a 50 year old male with history of cirrhosis secondary
to alcohol and hep C who was admitted to [**Hospital 8641**] Hospital 2 [**1-30**]
weeks ago for a variceal bleed.  He underwent an EGD on that day
and underwent banding.  He had some further bleeding on the day
of admit and underwent another EGD and had some more banding.
He was eventually intubated for alcohol withdraw.  On [**2179-2-8**]
durring the day it was noticed that his hb was dropping (9.3
from 10).  He was started on an octreotide drip and his hb
continued to drop to 7.3.  He was Tx 2U PRBC and at approx 2am
had an episoide of bright red bloody emesis.  He was taken for
an emergent EGD which showed no active bleeding but ulcers in
the EG junction where his prior banding was.  There was some
venous blood seen that was not bleeding.  An attempt was made to
sclerose blood at which point the venous blood started activly
bleeding.  It was unable to be controlled endoscopically.  A
[**State **] was placed in the operating room.  A cordis was
placed.  Patient recieved 7U PRBC and 4 U FFP.  He recieved 1g
Anfec in the ED.  He was paralized with Vec for the Minessota
tube placement.  He was then transferred to [**Hospital1 18**] for further
management of his bleeding and anticipated TIPS placement.

MEDICAL HISTORY: Past Medical History:
- Cirrhosis (alcoholic/HCV)
- Hepatitis C virus
- Type II diabetes mellitus
- Alcohol abuse

MEDICATION ON ADMISSION: Flexeril
Neurontin
Insulin

ALLERGIES: Ketorolac / Codeine

PHYSICAL EXAM: General: sedated.
HEENT: Intubated.  [**State **] tube in place.  Sclera anicteric,
MMM.
Neck: supple, difficult to assess JVP.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen:  soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Dullness to percussion b/l on flanks consistent with ascities.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Patient is not married but has a girlfriend who works as a
nurse. He has a 13-year old daughter of whom he has sole custody
(her mother is about to go to prison); she is currently staying
with his 80-year old mother. [**Name (NI) **] is an active drinker of alcohol
with a history of abuse. 

### Response:
{'Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Hepatic encephalopathy,Other ascites,Other and unspecified alcohol dependence, unspecified,Chronic hepatitis C without mention of hepatic coma,Iron deficiency anemia secondary to blood loss (chronic),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
