CHIEF COMPLAINT: RP Bleed

PRESENT ILLNESS: 39 F w/ ETOH cirrhosis, Child's C w/ recent admission ([**Date range (1) **])
from a massive UGI bleed sp TIPS [**8-6**] and epi injection of a
bleeding gastric ulcer, known esophageal varices, portal
gastropathy, portal hypertension with ascites,
splenomegaly/thrombocytopenia trasnferred from OSH with several
falls, abd pain and Hct 20.  Has been drinking since admission
and fell down 7 steps 2 days prior to admission without seeking
medical attention.  On Thursday she was intoxicated and standing
up in kitchen and slipped and fell on water, she remembers
little else although has had abdominal pain since.  She denies
fevers but tachycardic, lactate 3.5 and has a history of recent
pneumonia at [**Hospital1 **] and h/o MRSA PNA in [**8-7**] so was given
Vanc/levo/flagyl in ED.  Blood pressure stable 130's in ED.  She
is coagulopathic from intrinsic liver disease.
.
Surgery was consulted in the ED for RP bleed seen on CT and
possible active bleeding but given extent of liver disease and
area of bleed felt that she was an undesirable candidate and
that she should be monitored in the MICU with possible need for
serial scans.  In the ED she received 1 unit pRBCs at OSH, 4
units FFP, and Vit K 10 sc x 1 at [**Hospital1 18**] ED.  Hepatology aware of
patient.

MEDICAL HISTORY: ETOH cirrhosis, Child's class B to C
esophageal varices/portal hypertension
portal gastropathy
ascites
splenomegaly/thrombocytopenia
Esophagitis
Bipolar Disorder
PTSD
PUD
Chronic Diarrhea

MEDICATION ON ADMISSION: lasix 20mg po qday
spironolactone 50mg po qday
risperdal 5mg po bid
magnesium oxide 900mg po bid
celexa 20mg po qday
trazodone 150mg po qhs
propranolol 20 mg po qday
omeprazole 20mg po qday
lactulose [**Hospital1 **] (pt holdinf for diarrhea)
piroxicam tid
levofloxacin (from d/c summary, but pt not taking daily -->
completed levoflox treatment for PNA last week, though)

ALLERGIES: Dilantin

PHYSICAL EXAM: Vitals: HR 166 BP 121/53  RR 18  95%/2L n.c.
Gen: awake, oriented, tremulous, mild discomfort
HEENT: Pupils equal, round, dilated, reactive, icteric sclera,
OP clear, MM dry
Neck: prominent carotid pulse, JVP ?8cm
CV: Regular, tachycardic, systolic murmur
Pulm: bibasilar crackles L>R
Abd: Normoactive bowel sounds, firm area on right side of
abdomen otherwise soft, distended, palpable spleen tip,
voluntary guarding right sided, no rebound
Ext: WWP, no edema
skin: mult spider angiomas on chest, no caput medusa
guaiac: negative in ED

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

SOCIAL HISTORY: Lives with a friend, divorced, [**Name2 (NI) 69144**] mother of two.  2 L
Vodka/day, occasional tobacco.
Injury to other intra-abdominal organs without mention of open wound into cavity, retroperitoneum,Fall from other slipping, tripping, or stumbling,Acute alcoholic intoxication in alcoholism, continuous,Alcoholic cirrhosis of liver,Hyposmolality and/or hyponatremia,Hepatic encephalopathy,Alcohol withdrawal,Pneumonitis due to inhalation of food or vomitus,Tachycardia, unspecified,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Depressive disorder, not elsewhere classified,Other specified disorders of stomach and duodenum,Posttraumatic stress disorder,Infection with microorganisms resistant to penicillins
Retroperitoneum inj-cl,Fall from slipping NEC,Ac alcohol intox-contin,Alcohol cirrhosis liver,Hyposmolality,Hepatic encephalopathy,Alcohol withdrawal,Food/vomit pneumonitis,Tachycardia NOS,Esoph varice oth dis NOS,Depressive disorder NEC,Gastroduodenal dis NEC,Posttraumatic stress dis,Inf mcrg rstn pncllins
Admission Date:  [**2126-10-25**]              Discharge Date:   [**2126-11-5**]

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

Service: MEDICINE

Allergies:
Dilantin

Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
RP Bleed

Major Surgical or Invasive Procedure:
Angiography with embolectomy

History of Present Illness:
39 F w/ ETOH cirrhosis, Child's C w/ recent admission ([**Date range (1) **])
from a massive UGI bleed sp TIPS [**8-6**] and epi injection of a
bleeding gastric ulcer, known esophageal varices, portal
gastropathy, portal hypertension with ascites,
splenomegaly/thrombocytopenia trasnferred from OSH with several
falls, abd pain and Hct 20.  Has been drinking since admission
and fell down 7 steps 2 days prior to admission without seeking
medical attention.  On Thursday she was intoxicated and standing
up in kitchen and slipped and fell on water, she remembers
little else although has had abdominal pain since.  She denies
fevers but tachycardic, lactate 3.5 and has a history of recent
pneumonia at [**Hospital1 **] and h/o MRSA PNA in [**8-7**] so was given
Vanc/levo/flagyl in ED.  Blood pressure stable 130's in ED.  She
is coagulopathic from intrinsic liver disease.
.
Surgery was consulted in the ED for RP bleed seen on CT and
possible active bleeding but given extent of liver disease and
area of bleed felt that she was an undesirable candidate and
that she should be monitored in the MICU with possible need for
serial scans.  In the ED she received 1 unit pRBCs at OSH, 4
units FFP, and Vit K 10 sc x 1 at [**Hospital1 18**] ED.  Hepatology aware of
patient.


Past Medical History:
ETOH cirrhosis, Child's class B to C
esophageal varices/portal hypertension
portal gastropathy
ascites
splenomegaly/thrombocytopenia
Esophagitis
Bipolar Disorder
PTSD
PUD
Chronic Diarrhea


Social History:
 Lives with a friend, divorced, [**Name2 (NI) 69144**] mother of two.  2 L
Vodka/day, occasional tobacco.

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


Physical Exam:
Vitals: HR 166 BP 121/53  RR 18  95%/2L n.c.
Gen: awake, oriented, tremulous, mild discomfort
HEENT: Pupils equal, round, dilated, reactive, icteric sclera,
OP clear, MM dry
Neck: prominent carotid pulse, JVP ?8cm
CV: Regular, tachycardic, systolic murmur
Pulm: bibasilar crackles L>R
Abd: Normoactive bowel sounds, firm area on right side of
abdomen otherwise soft, distended, palpable spleen tip,
voluntary guarding right sided, no rebound
Ext: WWP, no edema
skin: mult spider angiomas on chest, no caput medusa
guaiac: negative in ED

Pertinent Results:
[**2126-10-25**] 05:14PM   GLUCOSE-127* UREA N-5* CREAT-0.4 SODIUM-136
POTASSIUM-3.1* CHLORIDE-95* TOTAL CO2-34* ANION GAP-10
[**2126-10-25**] 05:14PM   CALCIUM-7.6* PHOSPHATE-2.8 MAGNESIUM-2.3
[**2126-10-25**] 05:14PM   HCT-21.8*
[**2126-10-25**] 05:14PM   PLT COUNT-30*
[**2126-10-25**] 05:14PM   PT-19.8* INR(PT)-1.9*
[**2126-10-25**] 05:14PM   FIBRINOGE-122*
[**2126-10-25**] 04:30AM   GLUCOSE-153* UREA N-5* CREAT-0.6 SODIUM-136
POTASSIUM-3.0* CHLORIDE-92* TOTAL CO2-35* ANION GAP-12
[**2126-10-25**] 04:30AM   ALT(SGPT)-25 AST(SGOT)-79* ALK PHOS-89 TOT
BILI-11.6*
[**2126-10-25**] 04:30AM   CALCIUM-8.1* PHOSPHATE-2.8 MAGNESIUM-1.6
[**2126-10-25**] 04:30AM   WBC-5.5 RBC-2.06* HGB-7.5* HCT-20.2* MCV-98#
MCH-36.2* MCHC-37.0* RDW-24.0*
[**2126-10-25**] 04:30AM   PLT COUNT-60*
[**2126-10-25**] 04:30AM   PT-18.6* PTT-34.2 INR(PT)-1.8*
[**2126-10-25**] 12:35AM URINE  COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.032
[**2126-10-25**] 12:35AM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-12* PH-6.5
LEUK-NEG
[**2126-10-25**] 12:35AM URINE  RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2126-10-24**] 11:17PM   LACTATE-3.5*
[**2126-10-24**] 10:55PM   GLUCOSE-131* UREA N-4* CREAT-0.5 SODIUM-136
POTASSIUM-3.3 CHLORIDE-92* TOTAL CO2-32 ANION GAP-15
[**2126-10-24**] 10:55PM   estGFR-Using this
[**2126-10-24**] 10:55PM   ALT(SGPT)-34 AST(SGOT)-115* CK(CPK)-118 ALK
PHOS-104 AMYLASE-50 TOT BILI-12.6* DIR BILI-4.0* INDIR BIL-8.6
[**2126-10-24**] 10:55PM   LIPASE-21
[**2126-10-24**] 10:55PM   CK-MB-4
[**2126-10-24**] 10:55PM   ALBUMIN-3.2*
[**2126-10-24**] 10:55PM   WBC-8.0 RBC-2.00*# HGB-7.7* HCT-21.2*
MCV-106*# MCH-38.7*# MCHC-36.4* RDW-22.1*
[**2126-10-24**] 10:55PM   WBC-8.0 RBC-2.00*# HGB-7.7* HCT-21.2*
MCV-106*# MCH-38.7*# MCHC-36.4* RDW-22.1*
[**2126-10-24**] 10:55PM   NEUTS-70.6* LYMPHS-21.7 MONOS-5.0 EOS-1.8
BASOS-0.8
[**2126-10-24**] 10:55PM   ANISOCYT-3+ POIKILOCY-1+ MACROCYT-3+
[**2126-10-24**] 10:55PM   PLT COUNT-69*
[**2126-10-24**] 10:55PM   PT-19.5* PTT-37.1* INR(PT)-1.9*
.
CT Abd/Pelv [**10-25**]:
Very large acute retroperitoneal hemorrhage 23 x 10 x 10 cm.
There may be active bleeding vs acute blood products.  Very
distended gallbladder without signs of cholecystitis.
.
CT Abd/Pelv [**10-28**]:
IMPRESSION:
1. Slight decrease in size in retroperitoneal hematoma. No new
hematoma identified.
2. Worsening diffuse anasarca. Worsening bilateral effusions and
findings consistent with congestive heart failure.
3. Multifocal patchy areas of ground glass opacity in both
lungs, most likely representing infection. Differential
diagnosis includes asymmetric pulmonary edema.
4. Bilateral lower lobe atelectasis or consolidation.
.
CT Head [**10-25**]:
No evidence for hemorrhage or fracture.
.
CT C spine [**10-25**]:
No evidence for cervical spine fracture or malalignment. A 2-mm
right upper lobe lung nodule. A dedicated chest CT is
recommended to evaluate for other nodules.
.
CXR [**10-27**]:
Bibasilar atelectasis


Brief Hospital Course:
Pt was admitted to the MICU for care.

RP Bleed: A repeat CTA was peformed and continuing bleed was
identified.  The patient went to angiography with IR and had two
lumbar arteries (L1, L3) embolized.  Her hematocrits stablized
after embolization. Received a total of 10 U pRBC and 6 bags of
platelets during hospital course. Repeat CT of abdomen showed
stable size of RP hematoma. Hct remained stable and pt
transferred to medical floor where Hct continued to remain
stable, not requiring additional transfusions of pRBCs. The pt
did have fevers during this time and underwent infectious
work-up which was negative (see below). It was thought that the
fevers were secondary to the resolving large RP hematoma. Placed
on prn oxycodone for pain around site of hematoma with good
effect.

Fevers: During the hospitalization, the patient had intermittent
fevers.  She was started on vancomycin and flagyl for presumed
aspiration pneumonia in the MICU.  Cultures for sputum were sent
and grew MRSA.  The patient was treated for MRSA in sputum with
7 day course of vancomycin. However, CXR was negative for
pneumonic process. The flagyl was discontinued and was placed on
levaquin for SBP prophylaxis. Upon transfer to the floor, the pt
continued to have intermittent fevers. CT abdomen did not reveal
enough ascites to be tappable. Urine and blood cultures were all
negative. Did not suspect meningitis given lack of other
clinical symptoms that would suggest meningitis. On review of
pt's most recent discharge summary, it was noted that the
patient had intermittent fevers upon her most recent
hospitalization in which a source was never identified. There
was a question of drug fever on the prior admission. The pt
continued to have occasional low grade fevers by the time of
discharge, however her fever curve had trended down. It was
thought that the major contributor to the fevers was likely the
result of her large resolving retroperitoneal hematoma.

Hyponatremia: During the MICU course, the patient's sodium fell
from normal limits to a nadar of 123.  Free water fluids were
held and urine lytes were sent.  Spironolactone and other
diuretics were also held.  Urine lytes were consistent with a
cirrhotic cause to her hypervolumic hypernatremia. On transfer
to the medical floor, diuretics were continued to be held and
patient was placed on a 1L free water restriction with
improvement in sodium. The pt never exihibited any neurologic
compromise [**1-3**] hyponatremia.
.
ETOH cirrhosis: Child's Class C, MELD score 24. History of
esophageal varices, portal gastropathy, portal HTN with ascites,
s/p TIPS [**8-6**].  Is not a liver transplant candidate because of
continued ETOH use.
- Ascites:  Held lasix and spirinolactone given hyponatremia.
- Esophageal varices:  Propranolol 20 TID.
- Encephalopathy:  Lactulose 30 [**Hospital1 **]
- Nutrition:  Folate, Thiamine, Iron. Performed nutrition
calorie counts which showed intake of approximately 1000 kcal
per day that were recorded. As suspected that pt's total intake
was not accurately recorded, was not initiated on tube feeds.
Continued to encourage po intake during hospitalization.
- Withdrawal: Placed on CIWA scale without any development of
withdrawal seizures or DTs.
.
Thrombocytopenia: Chronic, likely etiology is splenomegaly from
liver disease and subsequent thrombocytopenia.  While in the
MICU, the patient had downward trending platlet counts despite
aggressive therapy with platelet transfusions. Hematology was
consulted and recommended Winrho.  Pt received one dose.
Platlet count was stable at 25 prior to leaving the MICU. During
stay on medical floor, did not require further platelet
transfusions and platelet count recovered to pt's prior
baseline.
.
Depression: Followed by psychiatry service. Per psych, pt does
not have a history of bipolar disorder despite prior notes
documenting this. Celexa was switched to remeron 7.5 mg qhs and
risperdal 0.5 mg [**Hospital1 **] was continued.  The pt did have one episode
of visual hallucinations during hospital course that was not
felt to be related to alcohol withdrawal as pt was already more
than 10 days out from her last drink at this point. Per pt, has
had auditory hallucinations in the past as well off of
risperdal. Risperdal was continued and pt did not have further
episodes of visual or auditory hallucinations.
.
Of note, during the hospital course, the patient attempted to
signout AMA while she was still deemed medically unstable (Hct
had not stabilized, having intermittent fevers). Seen by
psychiatry who deemed pt not competant to make this decision
given her lack of insight and judgement.
.
The patient was followed closely by the SW and CM services while
on the medical floor. The pt does have an outside CM through
Mass Health. Due to insurance reasons, the patient was unable to
qualify for an inpatient alcohol recovery program. The patient
was advised to participate in an intensive outpatient 30 day
alcohol program; however refused to go directly from
hospitalization to the program. Was reevaluated by psychiatry
who felt that patient was compentent to make this decision. The
patient subsequently signed out AMA. She did express a desire to
participate in an outpatient alcohol recovery program that would
be arranged in the future with her CM through Mass Health.

Medications on Admission:
lasix 20mg po qday
spironolactone 50mg po qday
risperdal 5mg po bid
magnesium oxide 900mg po bid
celexa 20mg po qday
trazodone 150mg po qhs
propranolol 20 mg po qday
omeprazole 20mg po qday
lactulose [**Hospital1 **] (pt holdinf for diarrhea)
piroxicam tid
levofloxacin (from d/c summary, but pt not taking daily -->
completed levoflox treatment for PNA last week, though)


Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*1800 ML(s)* Refills:*2*
2. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. 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:*2*
8. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*15 Tablet(s)* Refills:*2*
9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for R flank pain.
Disp:*15 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Retroperitopneal bleed s/p embolization of lumbar artery
Alcoholic Intoxication
Alcoholic Cirrhosis
.
Secondary Diagnosis:
Depression
Thrombocytopenia
Coagulopathy
Gastric ulcer
PTSD


Discharge Condition:
Stable. Eating regular diet. Breathing well on room air.


Discharge Instructions:
You were admitted with alcohol intoxication and a very low blood
count secondary to a large retroperitoneal bleed. You had 2
arteries in your back embolized. You also were detoxed from
alcohol.

You were discharged from the hospital against medical advice.

You will need to follow closely with your Mass Health case
manager to make arrangements for placement in a alcoholic day
program.

Please take all of your medications as prescribed.

It is very important that you continue to abstain from alcohol
to prevent further damage to your liver and other organs. If you
do not do this, the risks include further liver damage, liver
failure, and possibly death.

Please call your doctor or return to the emergency room if you
experience any of the following: fever > 101, chills, night
sweats, increased abdominal pain, lightheadedness.

Followup Instructions:
Please follow-up with your primary care doctor within 1 week of
discharge.

Please follow-up with your MassHealth case manager within [**1-4**]
days of discharge.

It is very important that you participate in AA mtgs and an
outpatient alcoholic day program.


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

Completed by:[**2126-11-6**]
{'Injury to other intra-abdominal organs without mention of open wound into cavity, retroperitoneum,Fall from other slipping, tripping, or stumbling,Acute alcoholic intoxication in alcoholism, continuous,Alcoholic cirrhosis of liver,Hyposmolality and/or hyponatremia,Hepatic encephalopathy,Alcohol withdrawal,Pneumonitis due to inhalation of food or vomitus,Tachycardia, unspecified,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Depressive disorder, not elsewhere classified,Other specified disorders of stomach and duodenum,Posttraumatic stress disorder,Infection with microorganisms resistant to penicillins'}


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: RP Bleed

PRESENT ILLNESS: 39 F w/ ETOH cirrhosis, Child's C w/ recent admission ([**Date range (1) **])
from a massive UGI bleed sp TIPS [**8-6**] and epi injection of a
bleeding gastric ulcer, known esophageal varices, portal
gastropathy, portal hypertension with ascites,
splenomegaly/thrombocytopenia trasnferred from OSH with several
falls, abd pain and Hct 20.  Has been drinking since admission
and fell down 7 steps 2 days prior to admission without seeking
medical attention.  On Thursday she was intoxicated and standing
up in kitchen and slipped and fell on water, she remembers
little else although has had abdominal pain since.  She denies
fevers but tachycardic, lactate 3.5 and has a history of recent
pneumonia at [**Hospital1 **] and h/o MRSA PNA in [**8-7**] so was given
Vanc/levo/flagyl in ED.  Blood pressure stable 130's in ED.  She
is coagulopathic from intrinsic liver disease.
.
Surgery was consulted in the ED for RP bleed seen on CT and
possible active bleeding but given extent of liver disease and
area of bleed felt that she was an undesirable candidate and
that she should be monitored in the MICU with possible need for
serial scans.  In the ED she received 1 unit pRBCs at OSH, 4
units FFP, and Vit K 10 sc x 1 at [**Hospital1 18**] ED.  Hepatology aware of
patient.

MEDICAL HISTORY: ETOH cirrhosis, Child's class B to C
esophageal varices/portal hypertension
portal gastropathy
ascites
splenomegaly/thrombocytopenia
Esophagitis
Bipolar Disorder
PTSD
PUD
Chronic Diarrhea

MEDICATION ON ADMISSION: lasix 20mg po qday
spironolactone 50mg po qday
risperdal 5mg po bid
magnesium oxide 900mg po bid
celexa 20mg po qday
trazodone 150mg po qhs
propranolol 20 mg po qday
omeprazole 20mg po qday
lactulose [**Hospital1 **] (pt holdinf for diarrhea)
piroxicam tid
levofloxacin (from d/c summary, but pt not taking daily -->
completed levoflox treatment for PNA last week, though)

ALLERGIES: Dilantin

PHYSICAL EXAM: Vitals: HR 166 BP 121/53  RR 18  95%/2L n.c.
Gen: awake, oriented, tremulous, mild discomfort
HEENT: Pupils equal, round, dilated, reactive, icteric sclera,
OP clear, MM dry
Neck: prominent carotid pulse, JVP ?8cm
CV: Regular, tachycardic, systolic murmur
Pulm: bibasilar crackles L>R
Abd: Normoactive bowel sounds, firm area on right side of
abdomen otherwise soft, distended, palpable spleen tip,
voluntary guarding right sided, no rebound
Ext: WWP, no edema
skin: mult spider angiomas on chest, no caput medusa
guaiac: negative in ED

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

SOCIAL HISTORY: Lives with a friend, divorced, [**Name2 (NI) 69144**] mother of two.  2 L
Vodka/day, occasional tobacco. 

### Response:
{'Injury to other intra-abdominal organs without mention of open wound into cavity, retroperitoneum,Fall from other slipping, tripping, or stumbling,Acute alcoholic intoxication in alcoholism, continuous,Alcoholic cirrhosis of liver,Hyposmolality and/or hyponatremia,Hepatic encephalopathy,Alcohol withdrawal,Pneumonitis due to inhalation of food or vomitus,Tachycardia, unspecified,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Depressive disorder, not elsewhere classified,Other specified disorders of stomach and duodenum,Posttraumatic stress disorder,Infection with microorganisms resistant to penicillins'}
