CHIEF COMPLAINT: Coffee ground emesis.

PRESENT ILLNESS: This is a 32-year-old man with
multiple comorbidities including end-stage renal disease
secondary to type 1 diabetes mellitus since age two, and has
been on hemodialysis since [**2098**].  The patient also has
vascular access thrombosis and is currently on
anticoagulation.  The patient is here with 24 hours of
worsening coffee ground emesis, weakness and abdominal pain.
The symptoms began at 6 PM on [**2103-10-15**] with vomiting,
diarrhea (watery without mucus or blood), poor appetite, leg
cramps and abdominal pain.  These symptoms have been present
for the past month or so but have intensified over the last
24 hours.  The mother reports three to four similar episodes
in the past, but none have been as debilitating as this one.
The patient reports two episodes of nonbloody emesis
yesterday, today dark emesis, two large emesis episodes in
the Emergency Department of about 500 cc each.  The mother
reports variable sugar levels this morning; 6 AM was 476, 10
AM 38, 12 PM 18.  The patient reported chills and weight
loss.  He denied any use of aspirin or ibuprofen, any fevers,
shortness of breath, chest pain, palpitations, change in
vision or history of irritable bowel syndrome or gallbladder
disease.  He reports prior alcohol use but would not specify
quantity.  He denies history of cirrhosis, history of gastric
ulcers or varices.

MEDICAL HISTORY: Type 1 diabetes mellitus since age
two, chronic renal failure, end-stage renal disease on
hemodialysis since [**2098**].  He has a history of hypertension
with hypertensive crisis in [**2089**] complicated by a myocardial
infarction in [**2098**]-98.  He had three cerebrovascular
accidents, one of them reported in [**2099**].  He has a history of
gastrointestinal bleeds and arteriovenous fistula bleeding.
He has a history of gastritis and gastroesophageal reflux
disease, possible sickle cell trait, pancreatitis, deep
venous thrombosis, medical noncompliance, hypoglycemic
seizures, superior vena cava syndrome and acquired perforated
skin disease.  He also has protein S deficiency.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: His father had liver cancer/cirrhosis, type
1 diabetes mellitus.  There is no history of bleeding
diseases in his family.

SOCIAL HISTORY: He is currently a smoker.  He smokes about
one pack every three days.  He is a former alcohol user.  He
lives at home with his mother and he is currently unemployed.
Hematemesis,Other and unspecified coagulation defects,Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Background diabetic retinopathy,Reflux esophagitis,Old myocardial infarction
Hematemesis,Coagulat defect NEC/NOS,DMI ophth nt st uncntrld,Hyp kid NOS w cr kid V,Diabetic retinopathy NOS,Reflux esophagitis,Old myocardial infarct
Admission Date:  [**2103-10-16**]     Discharge Date:  [**2103-10-18**]

Date of Birth:   [**2072-5-28**]     Sex:  M

Service:

CHIEF COMPLAINT:  Coffee ground emesis.

HISTORY OF PRESENT ILLNESS:  This is a 32-year-old man with
multiple comorbidities including end-stage renal disease
secondary to type 1 diabetes mellitus since age two, and has
been on hemodialysis since [**2098**].  The patient also has
vascular access thrombosis and is currently on
anticoagulation.  The patient is here with 24 hours of
worsening coffee ground emesis, weakness and abdominal pain.
The symptoms began at 6 PM on [**2103-10-15**] with vomiting,
diarrhea (watery without mucus or blood), poor appetite, leg
cramps and abdominal pain.  These symptoms have been present
for the past month or so but have intensified over the last
24 hours.  The mother reports three to four similar episodes
in the past, but none have been as debilitating as this one.
The patient reports two episodes of nonbloody emesis
yesterday, today dark emesis, two large emesis episodes in
the Emergency Department of about 500 cc each.  The mother
reports variable sugar levels this morning; 6 AM was 476, 10
AM 38, 12 PM 18.  The patient reported chills and weight
loss.  He denied any use of aspirin or ibuprofen, any fevers,
shortness of breath, chest pain, palpitations, change in
vision or history of irritable bowel syndrome or gallbladder
disease.  He reports prior alcohol use but would not specify
quantity.  He denies history of cirrhosis, history of gastric
ulcers or varices.

EMERGENCY DEPARTMENT COURSE:  He was brought to [**Hospital1 346**] by ambulance this afternoon at
around 2 PM.  He was initially hemodynamically stable and had
two large episodes of emesis, 500 cc each, with coffee
grounds and his blood pressure decreased to 70s/50s and his
heart rate was in the 120s.  A femoral line was placed and
the patient refused a nasogastric tube.  He was resuscitated
with intravenous fluids, one unit of packed red blood cells
and one unit of fresh frozen plasma.  Just before transfer to
the coronary care unit he had another large episode of emesis
greater than 600 cc.  He was brought to the coronary care
unit, stabilized there and he continued to have diarrhea.

Prior information from the [**Hospital1 756**] where he is normally seen
shows his last admission there was in [**2103-9-16**] for
diabetic ketoacidosis.  He has also had prior admissions for
pancreatitis.  In [**3-17**] he had an admission for
colitis/coffee ground emesis with a flexible sigmoidoscopy
and a colonoscopy which revealed erythematous patches in the
descending colon.  He had a colon biopsy which was negative
and it was unclear if he had an esophagogastroduodenoscopy at
that time.  In [**4-17**] he had an angiogram which was negative
and an echocardiogram in [**2101**] which was normal.  This was all
at the [**Hospital1 756**].

PAST MEDICAL HISTORY:  Type 1 diabetes mellitus since age
two, chronic renal failure, end-stage renal disease on
hemodialysis since [**2098**].  He has a history of hypertension
with hypertensive crisis in [**2089**] complicated by a myocardial
infarction in [**2098**]-98.  He had three cerebrovascular
accidents, one of them reported in [**2099**].  He has a history of
gastrointestinal bleeds and arteriovenous fistula bleeding.
He has a history of gastritis and gastroesophageal reflux
disease, possible sickle cell trait, pancreatitis, deep
venous thrombosis, medical noncompliance, hypoglycemic
seizures, superior vena cava syndrome and acquired perforated
skin disease.  He also has protein S deficiency.

PAST SURGICAL HISTORY:  He has a stent placed for superior
vena cava syndrome.  He has a left arteriovenous fistula.  He
has a left thoracotomy on his back.  He has had abscess
drainage, as well as laser eye surgery.

MEDICATIONS:  The medications he was taking as of [**2103-1-22**] include:  PhosLo 660 7 mg p.o. three tablets per day;
Dilantin 100 mg t.i.d.; Humalog, NPH and Regular Insulin;
Nephrocaps q.d.; thiamine 100 mg p.o. q.d.; Nexium 20 mg p.o.
q.d.; magnesium oxide 420 mg p.o. q.d.; quinine 325 mg p.o.
q.d.; Tylenol 325-650 mg p.o. q. 8 hours p.r.n.; Benadryl 125
mg q.h.s.; Warfarin 1 mg, he took three tablets on Monday,
Wednesday, Thursday, Saturday and Sunday and four tablets on
Tuesday and Friday.

ALLERGIES:  The patient has no known drug allergies.

FAMILY HISTORY:  His father had liver cancer/cirrhosis, type
1 diabetes mellitus.  There is no history of bleeding
diseases in his family.

SOCIAL HISTORY:  He is currently a smoker.  He smokes about
one pack every three days.  He is a former alcohol user.  He
lives at home with his mother and he is currently unemployed.

REVIEW OF SYSTEMS:  On admission in general he reports poor
diet, appetite, sleep; no fevers or night sweats, but did
report some chills.  Head, eyes, ears, nose and throat
examination showed no recent head trauma, change in vision,
trouble speaking, ulcers or bleeding.  Skin:  He reports
multiple lesions over his entire body with pruritus of lower
extremities and preserved sensation.  Cardiovascular:  His
mother reports prior "heart clot with shunt".  No
palpitations, chest pain or syncope.  Lungs:  He reported no
trouble breathing or shortness of breath.  Abdomen:  He had
positive abdominal pain transversely through his umbilicus.
Genitourinary:  He was anuric.  He had no active infection or
symptoms of infection, no urinary symptoms.  Extremities:  He
had preserved motor and sensory functions.

PHYSICAL EXAMINATION:  On admission his temperature was 98.6,
blood pressure 108/70, pulse 87, respiratory rate 18, O2
saturation 98%.  General:  He was alert and oriented and
appropriate, however very cachectic looking.  Head, eyes,
ears, nose and throat:  His head was normocephalic, no
lymphadenopathy.  Eyes had bilateral scleral icterus and
PERRLA bilaterally.  His throat examination showed dry mucosa
and the palate had purplish petechiae.  Neck:  Supple, soft
without lymphadenopathy.  Skin:  He had multiple discolored
lesions throughout his entire body including his face, back
and head.  These lesions had no discharge.  On his back he
had a left thoracotomy scar on the subscapular area.
Cardiovascular:  He was tachycardic with a regular rhythm;
normal S1 and S2.  Lungs:  Clear.  Abdomen:  Positive bowel
sounds.  He had voluntary guarding.  It was nondistended but
diffusely tender and had no peritoneal signs.  Extremities:
No edema.  His pulses were palpable.  Sensation was intact.
Motor strength was [**5-20**] in extremities.  He had a right
femoral line and a left arteriovenous fistula.  Neurological:
cranial nerves two through 12 were intact and strength was
also intact at the extremities.

LABORATORY DATA:  Chest x-ray showed that he had mesh
overlying his AC but no other acute processes.  His
electrocardiogram on admission showed sinus tachycardia,
decreased T waves in 2, 3 and aVF and aVL with no ST changes.

ASSESSMENT:  Our overall assessment of him on admission was a
32-year-old male with multiple comorbidities including
end-stage renal disease and access issues, here with coffee
ground emesis over the past 24 hours.  He was hemodynamically
stable on admission but deteriorated with repeat episodes of
emesis and a consequent drop in blood pressure and
tachycardia.  He was being resuscitated with blood products
and fluids and GI was following.  The patient ended up
leaving against medical advice and was given a prescription
for a proton pump inhibitor and advised to follow up with his
nephrologist on Monday morning when he got hemodialysis, to
recheck his coagulation studies.

HOSPITAL COURSE:  GI:  After having an upper gastrointestinal
evaluation and esophagogastroduodenoscopy he was found to
have reflux esophagitis with no active evidence of bleeding.
GI recommended a proton pump inhibitor to treat his reflux
and an esophageal biopsy was obtained at that time.  He was
sent home on a proton pump inhibitor and Zofran for nausea.
His diarrhea was resolving throughout his course here.

Hematologic:  He was found to have, per consultation with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 29204**] at the [**Hospital1 756**], a protein
S deficiency diagnosed in [**2103**].  He required one unit of
packed red blood cells on admission and his INR over his
course here was reversed with one unit of fresh frozen
plasma, and vitamin K was currently at 1.3 when he left the
hospital.

Cardiovascular:  He had a history of hypertensive crisis
which induced a myocardial infarction in [**2098**]-98.  On
admission he was anuric and he was resuscitated with large
amounts of volume.  He had a labile blood pressure and heart
rate throughout his course here but was stable upon leaving
the hospital against medical advice.

Renal:  He is a type 1 diabetic with end-stage renal disease
on hemodialysis on Monday, Wednesday and Friday, and he is
anuric.  He had hemodialysis on his last day at the hospital
which was [**2103-10-18**].  This is the day he left against medical
advice.  He did not complete that treatment at that time and
we could not check his electrolytes any more because we lost
access because he insisted on having his femoral line
removed.  Additionally on that day his femoral line clotted
off so we could not draw from it but we could inject things
into it.

Pulmonary:  He did report some pleuritic chest pain overnight
but this resolved over the course of the day.

Endocrine:  He had a long history of poorly-controlled
diabetes, which we controlled over his course here and his
fingersticks were well controlled by the time he left here.

Infectious disease:  He had an increased white count but was
afebrile over the course here.  His white count went up to
22.1.  We continued to follow that clinically.  He had a
chest x-ray which showed no evidence of any active process.
The patient was asymptomatic over his course here and left
against medical advice.

Neurologic:  He reported a history of seizures but had no
acute issues while in house.

Dermatologic:  He was seen in dermatology consultation which
found his skin lesions to be consistent with acquired
perforated skin disorder.  He was advised to follow up with a
dermatologist for that.

Fluids, electrolytes and nutrition:  No issues.  He was full
code while he was in the hospital.

His primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 29204**] at the [**Hospital1 756**]
[**Numeric Identifier 29205**]; his nephrologist is Dr. [**Last Name (STitle) 29206**]
at the [**Hospital1 756**].




                          [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 4561**]

Dictated By:[**Last Name (NamePattern4) 26613**]

MEDQUIST36

D:  [**2103-11-2**]  16:54
T:  [**2103-11-9**]  09:33
JOB#:  [**Job Number 29207**]
{'Hematemesis,Other and unspecified coagulation defects,Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Background diabetic retinopathy,Reflux esophagitis,Old myocardial infarction'}


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: Coffee ground emesis.

PRESENT ILLNESS: This is a 32-year-old man with
multiple comorbidities including end-stage renal disease
secondary to type 1 diabetes mellitus since age two, and has
been on hemodialysis since [**2098**].  The patient also has
vascular access thrombosis and is currently on
anticoagulation.  The patient is here with 24 hours of
worsening coffee ground emesis, weakness and abdominal pain.
The symptoms began at 6 PM on [**2103-10-15**] with vomiting,
diarrhea (watery without mucus or blood), poor appetite, leg
cramps and abdominal pain.  These symptoms have been present
for the past month or so but have intensified over the last
24 hours.  The mother reports three to four similar episodes
in the past, but none have been as debilitating as this one.
The patient reports two episodes of nonbloody emesis
yesterday, today dark emesis, two large emesis episodes in
the Emergency Department of about 500 cc each.  The mother
reports variable sugar levels this morning; 6 AM was 476, 10
AM 38, 12 PM 18.  The patient reported chills and weight
loss.  He denied any use of aspirin or ibuprofen, any fevers,
shortness of breath, chest pain, palpitations, change in
vision or history of irritable bowel syndrome or gallbladder
disease.  He reports prior alcohol use but would not specify
quantity.  He denies history of cirrhosis, history of gastric
ulcers or varices.

MEDICAL HISTORY: Type 1 diabetes mellitus since age
two, chronic renal failure, end-stage renal disease on
hemodialysis since [**2098**].  He has a history of hypertension
with hypertensive crisis in [**2089**] complicated by a myocardial
infarction in [**2098**]-98.  He had three cerebrovascular
accidents, one of them reported in [**2099**].  He has a history of
gastrointestinal bleeds and arteriovenous fistula bleeding.
He has a history of gastritis and gastroesophageal reflux
disease, possible sickle cell trait, pancreatitis, deep
venous thrombosis, medical noncompliance, hypoglycemic
seizures, superior vena cava syndrome and acquired perforated
skin disease.  He also has protein S deficiency.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: His father had liver cancer/cirrhosis, type
1 diabetes mellitus.  There is no history of bleeding
diseases in his family.

SOCIAL HISTORY: He is currently a smoker.  He smokes about
one pack every three days.  He is a former alcohol user.  He
lives at home with his mother and he is currently unemployed. 

### Response:
{'Hematemesis,Other and unspecified coagulation defects,Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Background diabetic retinopathy,Reflux esophagitis,Old myocardial infarction'}
