CHIEF COMPLAINT: hematemesis

PRESENT ILLNESS: 60y/o F with alcoholic cirrhosis presented on [**2146-9-9**] with
hematemesis and melena x1 day.  Pt underwent EGD at that time,
where varices were cauterized.  Pt was discharged on [**9-20**].  She
came back for followup EGD on [**9-26**] to assess for possible
sclerotherapy.  She was found to have grade [**4-1**] varices, more
numerous than a few years prior.  No active bleeding, bright red
blood noted in stomach.  No intervention performed at that time.
 Pt then rec'd 1.5L paracentesis as outpatient on [**9-27**].
.
Afterwards, at home, she developed nausea and had another
episode of hematemesis, which she describes as clumpy and dark
red.  Felt lightheaded, but no chest pressure or SOB.  + dark
stools.  No other episodes of hematemesis.  Pt was admitted to
OSH, and she was started on octreotide and transfused with 3
units PRBCs - Hct from [**9-27**] was 20.  Last Hct prior to transfer
was 24.  She was then transferred to [**Hospital1 18**] for evaluation for
TIPS.
.
Here, pt denies chest pain/pressure, SOB, or dizziness.  Feels
thirsty.  No further episodes of hematemesis.  Still with +
dark, watery BMs, but no BRBPR.  Pt had 6 BM yesterday, none
thus far today.

MEDICAL HISTORY: 1.  alcoholic cirrhosis
2.  h/o variceal bleed
3.  Type 2 DM
4.  GERD
5.  h/o carpal tunnel surgery

MEDICATION ON ADMISSION: metformin 500mg po daily
protonix 40mg po daily
levofloxacin 500mg po daily
spironolactone 50mg po bid
lasix 40mg po daily
inderal 10mg po bid

ALLERGIES: Aspirin

PHYSICAL EXAM: VS:  96.8    93/24   64   15   100% RA
I/O: 400/650
Gen: somewhat pale-appearing, obese, NAD
Neuro: no asterixis, A&O x3, appropriate
HEENT:  PERRL, EOMI, MM dry, OP clear
Neck: no cervical LAD, flat neck veins
CV:  RRR, nl S1/S2, no murmurs appreciated
Pulm: CTAB, good air movement
Abd: soft, distended, nontender, liver edge not palpable, no
masses
Ext: [**1-30**]+ pretibial edema, somewhat cool, 2+ DP pulses
Skin: no rashes, no caput medusae, no spider angiomata
visualized

FAMILY HISTORY: no liver disease
no GI bleeding

SOCIAL HISTORY: Lives with youngest son, daughter-in-law, and grandson.  [**Name (NI) **]
tobacco, no IVDU.  H/o EtOH x10 years - 1 bottle hard liquor per
week, quit 7 years ago.  Works as a home health aide.
Alcoholic cirrhosis of liver,Hepatic encephalopathy,Hematemesis,Esophageal varices with bleeding,Acute respiratory failure,Acidosis,Acute posthemorrhagic anemia,Thrombocytopenia, unspecified,Urinary tract infection, site not specified,Other and unspecified coagulation defects,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Iron deficiency anemia, unspecified,Hypotension, unspecified,Unspecified essential hypertension,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Esophageal reflux
Alcohol cirrhosis liver,Hepatic encephalopathy,Hematemesis,Esophag varices w bleed,Acute respiratry failure,Acidosis,Ac posthemorrhag anemia,Thrombocytopenia NOS,Urin tract infection NOS,Coagulat defect NEC/NOS,DMII wo cmp nt st uncntr,Iron defic anemia NOS,Hypotension NOS,Hypertension NOS,Enterococcus group d,Esophageal reflux
Admission Date:  [**2146-9-28**]              Discharge Date:   [**2146-10-15**]

Date of Birth:  [**2086-2-5**]             Sex:   F

Service: MEDICINE

Allergies:
Aspirin

Attending:[**First Name3 (LF) 1491**]
Chief Complaint:
hematemesis

Major Surgical or Invasive Procedure:
TIPS procedure.
[**Last Name (un) **] tube.


History of Present Illness:
60y/o F with alcoholic cirrhosis presented on [**2146-9-9**] with
hematemesis and melena x1 day.  Pt underwent EGD at that time,
where varices were cauterized.  Pt was discharged on [**9-20**].  She
came back for followup EGD on [**9-26**] to assess for possible
sclerotherapy.  She was found to have grade [**4-1**] varices, more
numerous than a few years prior.  No active bleeding, bright red
blood noted in stomach.  No intervention performed at that time.
 Pt then rec'd 1.5L paracentesis as outpatient on [**9-27**].
.
Afterwards, at home, she developed nausea and had another
episode of hematemesis, which she describes as clumpy and dark
red.  Felt lightheaded, but no chest pressure or SOB.  + dark
stools.  No other episodes of hematemesis.  Pt was admitted to
OSH, and she was started on octreotide and transfused with 3
units PRBCs - Hct from [**9-27**] was 20.  Last Hct prior to transfer
was 24.  She was then transferred to [**Hospital1 18**] for evaluation for
TIPS.
.
Here, pt denies chest pain/pressure, SOB, or dizziness.  Feels
thirsty.  No further episodes of hematemesis.  Still with +
dark, watery BMs, but no BRBPR.  Pt had 6 BM yesterday, none
thus far today.

Past Medical History:
1.  alcoholic cirrhosis
2.  h/o variceal bleed
3.  Type 2 DM
4.  GERD
5.  h/o carpal tunnel surgery


Social History:
Lives with youngest son, daughter-in-law, and grandson.  [**Name (NI) **]
tobacco, no IVDU.  H/o EtOH x10 years - 1 bottle hard liquor per
week, quit 7 years ago.  Works as a home health aide.

Family History:
no liver disease
no GI bleeding

Physical Exam:
VS:  96.8    93/24   64   15   100% RA
I/O: 400/650
Gen: somewhat pale-appearing, obese, NAD
Neuro: no asterixis, A&O x3, appropriate
HEENT:  PERRL, EOMI, MM dry, OP clear
Neck: no cervical LAD, flat neck veins
CV:  RRR, nl S1/S2, no murmurs appreciated
Pulm: CTAB, good air movement
Abd: soft, distended, nontender, liver edge not palpable, no
masses
Ext: [**1-30**]+ pretibial edema, somewhat cool, 2+ DP pulses
Skin: no rashes, no caput medusae, no spider angiomata
visualized

Pertinent Results:
OSH:
WBC 7.4, Hct 24, plt 94
Na 135, K 4.2, Cl 101, HCO3 27, BUN 32, Cr 0.9, glc 116, Ca 7.7,
alb 2.0
t bili 2.8, direct 0.4, AST 45, ALT 33, LDH 479, alk phose 103,
PT 33.5  INR 1.46
CK < 20, trop < 0.038

Admission labs:

CBC: WBC-2.7* RBC-3.13* HGB-10.1* HCT-30.1* MCV-96 MCH-32.4*
MCHC-33.8 RDW-18.3*   NEUTS-62.7 BANDS-0 LYMPHS-26.9 MONOS-8.5
EOS-1.6 BASOS-0.3
PLT COUNT-44*

electrolytes:
GLUCOSE-128* UREA N-24* CREAT-1.0 SODIUM-139 POTASSIUM-3.9
CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
ALBUMIN-2.3* CALCIUM-8.0* PHOSPHATE-2.8 MAGNESIUM-1.5*

LFTs: ALT(SGPT)-21 AST(SGOT)-65* LD(LDH)-173 CK(CPK)-31 ALK
PHOS-89 TOT BILI-5.4*

LACTATE-2.2*

coags: PT-15.0* PTT-34.0 INR(PT)-1.5

enzymes:
CK 31  CK-MB-NotDone cTropnT-<0.01

EKG: NSR 61bpm, nl intervals, nl axis, early R wave progression,
no ST/T wave changes suggestive of ischemia
.......
Floor:

[**2146-10-15**] 06:10AM BLOOD WBC-7.6 RBC-3.02* Hgb-9.9* Hct-30.3*
MCV-100* MCH-32.7* MCHC-32.7 RDW-21.3* Plt Ct-37*
[**2146-10-15**] 06:10AM BLOOD Plt Ct-37*
[**2146-10-15**] 06:10AM BLOOD Glucose-182* UreaN-23* Creat-0.5 Na-144
K-4.1 Cl-102 HCO3-37* AnGap-9
[**2146-10-14**] 12:39PM BLOOD ALT-26 AST-41* AlkPhos-137* TotBili-4.8*
[**2146-10-15**] 06:10AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0

Brief Hospital Course:
Patient is 60 y/o F with alcoholic cirrhosis s/p variceal
hemorrhage who presents for evaluation for TIPS.

1.  Upper GI bleed - Initially patient did not appear to be
actively bleeding, with no hematemesis.  Plan was to have EGD in
ICU and then transfer to floor.  EGD performed and Grade III
varices were noted starting at 24 cm from GE junction and
extending to GE junction.  An active variceal bleed was found
which was banded x 1 and 3 other varices were banded in the
process.  Approximately one hour s/p EGD and banding, patient
developed large volume hemetemesis requiring intubation for
airway protection and placement of [**Last Name (un) **] to tamponade
bleeding.  The following day patient went for successful TIPS
procedure in IR (only time patient was exposed to heparin).
Bleeding slowed and [**Last Name (un) 10045**] left in place with gastric balloon
inflated for ~2 days.  Once the risk of rebleed was low, the
[**Last Name (un) 10045**] was removed.  No further episodes of hemetemesis.
Continued melena.  Hct was checked frequently and patient
initially transfused for <30, but once no active bleed, was
transfused <25.  Octreotide gtt was started on admission and
continued until [**Last Name (un) 10045**] tube was removed.  Levofloxacin given
for 6 days for GI prophylaxis against sepsis but was stopped on
[**10-4**] d/t worry that it was contributing to thrombocytopenia.
Patient's BetaBlocker held initially but added propranolol then
nadolol when BP stabilized.
Pt transferred to the floor, did well. She was generally weak,
though without focal findings. She tolerated NG tube feedings
though could not take adequate PO due to sore throat and large
caliber NG tube she reported. The NG was d/c'd. She did not take
adequate PO after that, and a Dobhoff feeding tube was placed
post pyloric by fluoro. She restarted her tube feeds and was
transferred to acute rehab with follow up. The pt was maintained
on rifamixin and lactulose during her hospital course and
afterwards.
.
2. Respiratory failure - Initially intubated for airway
protection and placement of [**Last Name (un) 10045**] during bleed.  Once
bleeding resolved, extubated without complications.  GPC in
pairs and clusters, but c/w oropharyngeal flora, no fever, no
white count, unlikely PNA.  Was treated with Vanc initially but
this was stopped after 3 days when suspicion of PNA was low and
thought was it was contributing to thrombocytopenia.  HOB >40
degrees.
Pt had good o2 sats on the floor with minimal o2 by nasal
cannula (1-2L).
.
3. Thrombocytopenia - Potential meds d/c'd and hematology
consulted. A platelet autoantibody was discovered. The pt was
transfused a few times with platelets and prednisone was started
at 1mg/kg per hepatology. A tapering dose was given at/after
acute rehab.
.
4. Coagulopathy - In setting of liver disease patient is
coagulopathic with poor production of factors and low plts d/t
splenic sequestration and medication effect
INR maintained <1.5, plts >20, fibrinogen >120 - check Q12. Pt
did well and had stable INR.
.
5. Cirrhosis/Liver Transpant - Cause most likely alcoholic
cirrhosis. No evidence for autoimmune hepatitis,
hemochromatosis, viral etiologies, SPEP normal, AFP elevated. Pt
had a mild encephalopathy during her stay on the floor. She was
logical and sequential in her thinking and understood what was
going on though she would occasionally have difficulty recalling
the name of the hospital. She always knew her name and the
season and month.  Paracentesis from OSH showed no growth of
cultures.  Lasix and spironolactone initially held in setting of
hypotension, but restarted when more stable and tolerated well.
Lactulose was continued to prevent encephalopathy. F/U Liver
transplant workup labs: large work up started to be followed as
outpt (cscope, mammography, etc).
.
6. Anemia - Due to variceal bleed, but also was on iron therapy
as outpatient, indicating an underlying iron deficiency.  Iron
studies normal but may be confounded by multiple transfusions.
Pt transfused on occasion for low hct, though stable toward the
end of admission.
.
7. Diabetes mellitus - Metformin held.  Start metformin once
taking adequate.  QID fingersticks, RISS. Pt had increasing
blood glucose levels with the beginning of steroids. The pt was
started on NPH 20 qam and 10 qpm which she tolerated well.
.
8. FEN/GI - NPO while intubated, TF's while bridging patient to
full diet. The pt was not able to have enough PO intake and a
dobhoff was restarted and pt was d/c'd to acute rehab with tube
feeds per nutrition.

Medications on Admission:
metformin 500mg po daily
protonix 40mg po daily
levofloxacin 500mg po daily
spironolactone 50mg po bid
lasix 40mg po daily
inderal 10mg po bid


Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for ENCEPHALOPATHY.
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for systolic bp<100 or heart rate <55.
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for systolic bp <100.
5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 13 days: for UTI.
7. Sodium Chloride 0.9 % Parenteral Solution Sig: 1-2 MLs
Intravenous  DAILY (Daily) as needed: for picc line flush.
8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous  Daily and PRN as needed: flush picc line to
ensure patency.
9. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous  Q12H (every 12 hours).
10. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous  Q8H:PRN as needed.
11. Prednisone 10 mg Tablet Sig: See below mg PO once a day for
18 days: 70 mg on [**10-16**] and [**10-17**]; then 60 mg from [**Date range (1) 62923**];
then 50 mg from [**Date range (1) 62924**]; then 40 mg from [**Date range (1) 62925**]; then
30 from [**Date range (1) 62926**]; then 20 mg from [**Date range (1) 62927**]; then 10 mg
from [**Date range (1) 62928**]; then off.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous QAM.
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous QPM with dinner.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Cape & Islands

Discharge Diagnosis:
Esophageal varices.
Alcoholic cirrhosis.


Discharge Condition:
Stable (plt ct >40, hct >30, generalized weakness w/o focal
findings, with mild encephalopathy).


Discharge Instructions:
Monitor daily platelets and contact primary physician if
platelets <20.
.
Monitor hematocrit daily and contact physician [**Last Name (NamePattern4) **] < 25 or
symptomatic.
.
Continue steroids until tapering dose is finished.
.
Take Rifaximin as indicated in ongoing fashion (the hepatologist
want you on this medication).
.
Change from tube feeds to po feeds as tolerated. The Dobhoff
feeding tube may be removed once adequate PO intake is achieved
(>75% of a normal diet).

Followup Instructions:
You have many appointments. Please see below for the list.
.
Call Dr. [**First Name (STitle) 10733**] at [**Telephone/Fax (1) 13266**] for a follow up appointment
within 1 month.
.
Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2146-10-18**] 4:30
.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9
Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2146-10-18**] 4:30
.
The hepatologists will call you with your liver ultrasounds
follow up appointment, which will be just before your
appointment with Dr. [**Last Name (STitle) 497**] on [**11-7**] (see below).
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2146-11-7**] 9:00
.
You will also have an appointment on [**2146-11-7**] with Dr. [**First Name (STitle) **]
of the transplant surgery service. The schedulers did not have
an exact time before the weekend, so please call them at
[**Telephone/Fax (1) 673**] to confirm the time, date, and location of your
appointment.
{'Alcoholic cirrhosis of liver,Hepatic encephalopathy,Hematemesis,Esophageal varices with bleeding,Acute respiratory failure,Acidosis,Acute posthemorrhagic anemia,Thrombocytopenia, unspecified,Urinary tract infection, site not specified,Other and unspecified coagulation defects,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Iron deficiency anemia, unspecified,Hypotension, unspecified,Unspecified essential hypertension,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Esophageal reflux'}


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: hematemesis

PRESENT ILLNESS: 60y/o F with alcoholic cirrhosis presented on [**2146-9-9**] with
hematemesis and melena x1 day.  Pt underwent EGD at that time,
where varices were cauterized.  Pt was discharged on [**9-20**].  She
came back for followup EGD on [**9-26**] to assess for possible
sclerotherapy.  She was found to have grade [**4-1**] varices, more
numerous than a few years prior.  No active bleeding, bright red
blood noted in stomach.  No intervention performed at that time.
 Pt then rec'd 1.5L paracentesis as outpatient on [**9-27**].
.
Afterwards, at home, she developed nausea and had another
episode of hematemesis, which she describes as clumpy and dark
red.  Felt lightheaded, but no chest pressure or SOB.  + dark
stools.  No other episodes of hematemesis.  Pt was admitted to
OSH, and she was started on octreotide and transfused with 3
units PRBCs - Hct from [**9-27**] was 20.  Last Hct prior to transfer
was 24.  She was then transferred to [**Hospital1 18**] for evaluation for
TIPS.
.
Here, pt denies chest pain/pressure, SOB, or dizziness.  Feels
thirsty.  No further episodes of hematemesis.  Still with +
dark, watery BMs, but no BRBPR.  Pt had 6 BM yesterday, none
thus far today.

MEDICAL HISTORY: 1.  alcoholic cirrhosis
2.  h/o variceal bleed
3.  Type 2 DM
4.  GERD
5.  h/o carpal tunnel surgery

MEDICATION ON ADMISSION: metformin 500mg po daily
protonix 40mg po daily
levofloxacin 500mg po daily
spironolactone 50mg po bid
lasix 40mg po daily
inderal 10mg po bid

ALLERGIES: Aspirin

PHYSICAL EXAM: VS:  96.8    93/24   64   15   100% RA
I/O: 400/650
Gen: somewhat pale-appearing, obese, NAD
Neuro: no asterixis, A&O x3, appropriate
HEENT:  PERRL, EOMI, MM dry, OP clear
Neck: no cervical LAD, flat neck veins
CV:  RRR, nl S1/S2, no murmurs appreciated
Pulm: CTAB, good air movement
Abd: soft, distended, nontender, liver edge not palpable, no
masses
Ext: [**1-30**]+ pretibial edema, somewhat cool, 2+ DP pulses
Skin: no rashes, no caput medusae, no spider angiomata
visualized

FAMILY HISTORY: no liver disease
no GI bleeding

SOCIAL HISTORY: Lives with youngest son, daughter-in-law, and grandson.  [**Name (NI) **]
tobacco, no IVDU.  H/o EtOH x10 years - 1 bottle hard liquor per
week, quit 7 years ago.  Works as a home health aide. 

### Response:
{'Alcoholic cirrhosis of liver,Hepatic encephalopathy,Hematemesis,Esophageal varices with bleeding,Acute respiratory failure,Acidosis,Acute posthemorrhagic anemia,Thrombocytopenia, unspecified,Urinary tract infection, site not specified,Other and unspecified coagulation defects,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Iron deficiency anemia, unspecified,Hypotension, unspecified,Unspecified essential hypertension,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Esophageal reflux'}
