CHIEF COMPLAINT: variceal bleed

PRESENT ILLNESS: 62M w/ EtOH cirrhosis decompensated with varices, HTN, who
presented to the [**Hospital3 **] ED with hematemesis on [**5-10**].
The patient is unable to answer questions.  History is from OSH
d/c summary.  Exam was notable for hypotension and tachycardia,
and labs were notable for a Hct 12.4 and INR 2.6 on
presentation.  He received 4U PRBC in the ED and was admitted to
the ICU.  He was seen by GI and had an EGD which showed multiple
cords of grade 2 esophageal varices with stigmata of recent
bleeding.  They did not band the varices.  His Hct after
transfusion was 27.  He was started on IV Protonix and
octreotide gtt.  On the evening of [**5-11**], he had large volume
hematemesis, hypotension to SBP 60s.  He was intubated for
airway protection and started on neosyncephrine and levophed.
GI repeated EGD and found an actively bleeding varix which they
sclerosed.  He received a total of 9U PRBC and 4U FFP.  Levophed
and neosynephrine were weaned on [**5-12**].  He was subsequently
hypertensive 160s-180s.  On [**5-12**]/3 bottles of his admission
blood cultures grew gram positive cocci, later speciated to
Viridans Strep, suspected enteric source with variceal bleed.
No prior history of indwelling lines, endocarditis, or IV drug
use.  He was started on vancomycin and Zosyn before culture
speciation returned.  Surveillance blood cultures on [**5-12**] from
femoral line grew [**2-3**] coag negative Staph.  Admission urine
culture grew 10-50K E. coli, but UA was not suspicious for UTI.
The patient developed loose stools and distended abdomen on [**5-13**]
in the setting of rising WBC, so stool was sent for C. diff
(results not available) and patient was started on empiric
metronidazole.  Octreotide gtt was d/c'd [**5-14**].  He was extubated
the morning of [**5-14**].  Post-extubation, he was noted to be
confused and lethargic.  His altered mental status was felt to
be secondary to poorly metabolized Versed.  His ammonia level
was 43, so hepatic encephalopathy was felt to be lower on the
differential.  He was transferred to [**Hospital1 18**] for consideration of
non-emergent TIPS.
.
On arrival to the [**Hospital1 18**] MICU, he was afebrile with HR 80s, BP
151/97, afebrile, 100% on RA.  He was moving all extremities but
not responding to name or following commands.  He rarely
spontaneously opened his eyes.

MEDICAL HISTORY: 1. EtOH cirrhosis: decompensated with varices, h/o variceal
bleed [**3-12**] s/p banding
2. Hypertension

MEDICATION ON ADMISSION: OUTPATIENT MEDS:
Protonix 40mg daily
Nadolol 20mg daily (?noncompliant)
MVI
Folic acid 1mg daily
Thiamine 100mg daily
.
MEDS ON TRANSFER:
Protonix 40mg IV BID
Vancomycin 1g Q12H
Piperacillin-Tazobactam 3.375g IV Q6H
Metronidazole 500mg IV Q8H
Albuterol nebs Q6H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals- 98.0, 88, 151/97, 20, 98% RA
Gen- mildly agitated, not responsive to name, not following
commands, rarely spontaneously opens eyes
HEENT- icteric sclerae, pupils 1-2mm, NGT in place
Neck- supple, no JVD appreciated
Pulm- CTAB but patient not cooperative with exam
CV- RR, no murmurs auscultated
Abd- distended but fairly soft, tympanitic, no bulging flanks or
appreciable dullness to percussion, no fluid wave, patient did
not grimace to deep palpation
Extrem- L femoral TLC, trace ankle edema b/l, pneumoboots in
place, DP/PT pulses full b/l
Neuro- occasionally spontaneously opened eyes during exam,
moving all 4 extremities, did not cooperate with/resisted neuro
exam

FAMILY HISTORY: Unable to obtain.

SOCIAL HISTORY: Lives with wife, [**Name (NI) **].  [**Name2 (NI) **] drink sometime between [**Date range (1) 66379**]
per wife.  She is not aware of how much he drinks daily.
Occasional tobacco use.  Wife reports no history of drug use.
Alcoholic cirrhosis of liver,Bacteremia,Esophageal varices in diseases classified elsewhere, with bleeding,Other ascites,Unspecified essential hypertension,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus
Alcohol cirrhosis liver,Bacteremia,Bleed esoph var oth dis,Ascites NEC,Hypertension NOS,Other streptococcus
Admission Date:  [**2117-5-14**]              Discharge Date:   [**2117-5-18**]

Date of Birth:  [**2055-1-28**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 943**]
Chief Complaint:
variceal bleed

Major Surgical or Invasive Procedure:
endoscopic banding


History of Present Illness:
62M w/ EtOH cirrhosis decompensated with varices, HTN, who
presented to the [**Hospital3 **] ED with hematemesis on [**5-10**].
The patient is unable to answer questions.  History is from OSH
d/c summary.  Exam was notable for hypotension and tachycardia,
and labs were notable for a Hct 12.4 and INR 2.6 on
presentation.  He received 4U PRBC in the ED and was admitted to
the ICU.  He was seen by GI and had an EGD which showed multiple
cords of grade 2 esophageal varices with stigmata of recent
bleeding.  They did not band the varices.  His Hct after
transfusion was 27.  He was started on IV Protonix and
octreotide gtt.  On the evening of [**5-11**], he had large volume
hematemesis, hypotension to SBP 60s.  He was intubated for
airway protection and started on neosyncephrine and levophed.
GI repeated EGD and found an actively bleeding varix which they
sclerosed.  He received a total of 9U PRBC and 4U FFP.  Levophed
and neosynephrine were weaned on [**5-12**].  He was subsequently
hypertensive 160s-180s.  On [**5-12**]/3 bottles of his admission
blood cultures grew gram positive cocci, later speciated to
Viridans Strep, suspected enteric source with variceal bleed.
No prior history of indwelling lines, endocarditis, or IV drug
use.  He was started on vancomycin and Zosyn before culture
speciation returned.  Surveillance blood cultures on [**5-12**] from
femoral line grew [**2-3**] coag negative Staph.  Admission urine
culture grew 10-50K E. coli, but UA was not suspicious for UTI.
The patient developed loose stools and distended abdomen on [**5-13**]
in the setting of rising WBC, so stool was sent for C. diff
(results not available) and patient was started on empiric
metronidazole.  Octreotide gtt was d/c'd [**5-14**].  He was extubated
the morning of [**5-14**].  Post-extubation, he was noted to be
confused and lethargic.  His altered mental status was felt to
be secondary to poorly metabolized Versed.  His ammonia level
was 43, so hepatic encephalopathy was felt to be lower on the
differential.  He was transferred to [**Hospital1 18**] for consideration of
non-emergent TIPS.
.
On arrival to the [**Hospital1 18**] MICU, he was afebrile with HR 80s, BP
151/97, afebrile, 100% on RA.  He was moving all extremities but
not responding to name or following commands.  He rarely
spontaneously opened his eyes.

Past Medical History:
1. EtOH cirrhosis: decompensated with varices, h/o variceal
bleed [**3-12**] s/p banding
2. Hypertension

Social History:
Lives with wife, [**Name (NI) **].  [**Name2 (NI) **] drink sometime between [**Date range (1) 66379**]
per wife.  She is not aware of how much he drinks daily.
Occasional tobacco use.  Wife reports no history of drug use.


Family History:
Unable to obtain.

Physical Exam:
Vitals- 98.0, 88, 151/97, 20, 98% RA
Gen- mildly agitated, not responsive to name, not following
commands, rarely spontaneously opens eyes
HEENT- icteric sclerae, pupils 1-2mm, NGT in place
Neck- supple, no JVD appreciated
Pulm- CTAB but patient not cooperative with exam
CV- RR, no murmurs auscultated
Abd- distended but fairly soft, tympanitic, no bulging flanks or
appreciable dullness to percussion, no fluid wave, patient did
not grimace to deep palpation
Extrem- L femoral TLC, trace ankle edema b/l, pneumoboots in
place, DP/PT pulses full b/l
Neuro- occasionally spontaneously opened eyes during exam,
moving all 4 extremities, did not cooperate with/resisted neuro
exam


Pertinent Results:
WBC-18.2* RBC-3.74* HGB-11.1* HCT-31.5* MCV-84 MCH-29.8
MCHC-35.3* RDW-15.7*  PLT COUNT-103*
  -   NEUTS-82.3* LYMPHS-11.3* MONOS-5.0 EOS-1.2 BASOS-0.3
PT-16.5* PTT-34.7 INR(PT)-1.5*
GLUCOSE-91 UREA N-11 CREAT-1.1 SODIUM-141 POTASSIUM-3.9
CHLORIDE-114* TOTAL CO2-20*
CALCIUM-7.7* PHOSPHATE-2.4* MAGNESIUM-1.8
ALT(SGPT)-401* AST(SGOT)-390* ALK PHOS-74 TOT BILI-2.7*

Hep B and C studies pending

[**5-15**] urine cx, blood cx, catheter tip cx NGTD as of [**5-16**]
[**5-15**] C diff toxin negative

[**5-15**] abdominal ultrasound: 1. Small amount of right upper
quadrant ascites. 2. Patent portal vein. 3. Decompressed
gallbladder with stones and sludge within its lumen. Gallbladder
wall edema. This could represent third spacing due to low
albumin. No albumin results are available on OMR for this
patient, and therefore correlation with laboratory values is
recommended. If clinical concern exists for acute cholecystitis,
consider a HIDA scan.

[**5-15**] single view CXR: An NG tube is present, tip beneath
diaphragm. There are low inspiratory volumes. Heart is probably
not enlarged. There is no CHF. There is bibasilar atelectasis.
No gross effusion. Slight prominence of the cardiomediastinal
silhouette is likely accentuated by low lung volumes and
lordotic positioning, probably also with unfolded aorta.

[**5-15**] TTE: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%) The estimated cardiac index is
normal (>=2.5L/min/m2). Transmitral Doppler and tissue velocity
imaging are consistent with normal LV diastolic function. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. Mild (1+) mitral regurgitation is seen. There
is a trivial/physiologic pericardial effusion.

[**5-18**] EGD: 3 cords of grade II esophageal varices. Evidence of
sclerotherapy of one varix in the lower third of the esophagus.
3 bands were placed successfully on the varices.
Friability, erythema, congestion, nodularity and mosaic
appearance in the fundus compatible with portal gastropathy
Varices at the lower third of the esophagus and gastroesophageal
junction (ligation)
Otherwise normal EGD to second part of the duodenum

Brief Hospital Course:
1. Variceal bleed:  Patient transferred 15U variceal bleed, s/p
sclerosis of actively bleeding varix.  Patient's hematocrit
subsequently stabilized and he remained hemodynamically stable.
The liver service performed an EGD that demonstrated 3 cords of
grade II esophageal varices with evidence of sclerotherapy of
one varix in the lower third of the esophagus. 3 bands were
placed successfully on the varices.  The patient will need
repeat EGD in [**3-7**] weeks for repeat evaluation and possible
further banding. He will continue on pantoprazole 40mg QD and
nadolol.

2. Bacteremia:  Viridans Strep from [**5-12**] blood cultures at [**Hospital1 **], presumed enteric source in setting of variceal bleed,
initially on Vancomycin at OSH, but changed to ceftriaxone.
Pip-Tazo was stopped given absence of gram negative aetiology
for sepsis.  Was initially on metronidazole for empiric C.
difficile treatment given diarrhea and marked leukocytosis, but
C. difficile toxin was negative so this was discontinued.
Written for 2 week course of ceftriaxone from [**2117-5-12**] to
[**2117-5-26**].  He was initially on vancomycin for coagulase
negative Staph but per OSH culture data appears to be
contaminant, so Vancomycin discontinued.  Echocardiogram was
done to assess for endocarditis and transthoracic Echo was
negative.  Per ID the patient will need a transesophageal
echocardiogram as an outpatient prior to completion of two week
courses of ceftriaxone to determine whether he had endocarditis
and will need a longer course of therapy.  Dr. [**Last Name (STitle) 44890**], his
primary care physician has been [**Name (NI) 653**] and will coordinate
the TEE.  He should have CBC, electrolytes, and LFTs remeasured
as an outpatient while he is on the ceftriaxone to monitor renal
and liver function.

3. Alcoholic cirrhosis:  Decompensated with variceal bleed.
Wife denies history of encephalopathy, ascites, and SBP.  Liver
enzymes elevated here, only mildly elevated AST on admission.
Management of variceal bleed as above.  He was restarted on
nadolol prophylaxis as above.

4. FULL CODE

Medications on Admission:
OUTPATIENT MEDS:
Protonix 40mg daily
Nadolol 20mg daily (?noncompliant)
MVI
Folic acid 1mg daily
Thiamine 100mg daily
.
MEDS ON TRANSFER:
Protonix 40mg IV BID
Vancomycin 1g Q12H
Piperacillin-Tazobactam 3.375g IV Q6H
Metronidazole 500mg IV Q8H
Albuterol nebs Q6H

Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.

2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 8 days.
Disp:*7 gram* Refills:*0*
4. PICC Line Care
PICC line care per NEHT protocol.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 511**] Home Therapy

Discharge Diagnosis:
variceal bleed
ETOH Cirrhosis
Hypertension


Discharge Condition:
hemodynamically stable


Discharge Instructions:
You were admitted to the hospital with bleeding from veins in
your esophagus.  You required many blood transfusions to replace
blood you lost from bleeding.  Endoscopic procedures at [**Hospital1 **]
and here treated the varices with application of bands and with
injection of solutions to prevent bleeding.  You will need a
repeat endoscopy in three weeks to reassess your bleed.

In addition you were found to have an infection in your blood.
You will need antibiotics for a total of two weeks through your
IV.  There is a chance that this infection may be affecting your
heart.  Dr. [**Last Name (STitle) 44890**] will help you set up an appointment for a scan
of your heart to determine whether you have this infection; if
you do you will need to be treated for a longer period of time
with antibiotics.

Please continue to take your medications as prescribed.  Please
follow appropriate care for your PICC line.  If you develop
bleeding, fevers, chills, confusion, or any other concerning
symptoms please contact a physician [**Name Initial (PRE) 2227**].

Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 44890**] on
Thursday [**5-20**]. You can call him at ([**Telephone/Fax (1) 68965**].

Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2117-6-3**] 1:30
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2117-6-3**] 1:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2117-7-27**] 11:45



Completed by:[**2117-5-21**]
{'Alcoholic cirrhosis of liver,Bacteremia,Esophageal varices in diseases classified elsewhere, with bleeding,Other ascites,Unspecified essential hypertension,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus'}


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: 62M w/ EtOH cirrhosis decompensated with varices, HTN, who
presented to the [**Hospital3 **] ED with hematemesis on [**5-10**].
The patient is unable to answer questions.  History is from OSH
d/c summary.  Exam was notable for hypotension and tachycardia,
and labs were notable for a Hct 12.4 and INR 2.6 on
presentation.  He received 4U PRBC in the ED and was admitted to
the ICU.  He was seen by GI and had an EGD which showed multiple
cords of grade 2 esophageal varices with stigmata of recent
bleeding.  They did not band the varices.  His Hct after
transfusion was 27.  He was started on IV Protonix and
octreotide gtt.  On the evening of [**5-11**], he had large volume
hematemesis, hypotension to SBP 60s.  He was intubated for
airway protection and started on neosyncephrine and levophed.
GI repeated EGD and found an actively bleeding varix which they
sclerosed.  He received a total of 9U PRBC and 4U FFP.  Levophed
and neosynephrine were weaned on [**5-12**].  He was subsequently
hypertensive 160s-180s.  On [**5-12**]/3 bottles of his admission
blood cultures grew gram positive cocci, later speciated to
Viridans Strep, suspected enteric source with variceal bleed.
No prior history of indwelling lines, endocarditis, or IV drug
use.  He was started on vancomycin and Zosyn before culture
speciation returned.  Surveillance blood cultures on [**5-12**] from
femoral line grew [**2-3**] coag negative Staph.  Admission urine
culture grew 10-50K E. coli, but UA was not suspicious for UTI.
The patient developed loose stools and distended abdomen on [**5-13**]
in the setting of rising WBC, so stool was sent for C. diff
(results not available) and patient was started on empiric
metronidazole.  Octreotide gtt was d/c'd [**5-14**].  He was extubated
the morning of [**5-14**].  Post-extubation, he was noted to be
confused and lethargic.  His altered mental status was felt to
be secondary to poorly metabolized Versed.  His ammonia level
was 43, so hepatic encephalopathy was felt to be lower on the
differential.  He was transferred to [**Hospital1 18**] for consideration of
non-emergent TIPS.
.
On arrival to the [**Hospital1 18**] MICU, he was afebrile with HR 80s, BP
151/97, afebrile, 100% on RA.  He was moving all extremities but
not responding to name or following commands.  He rarely
spontaneously opened his eyes.

MEDICAL HISTORY: 1. EtOH cirrhosis: decompensated with varices, h/o variceal
bleed [**3-12**] s/p banding
2. Hypertension

MEDICATION ON ADMISSION: OUTPATIENT MEDS:
Protonix 40mg daily
Nadolol 20mg daily (?noncompliant)
MVI
Folic acid 1mg daily
Thiamine 100mg daily
.
MEDS ON TRANSFER:
Protonix 40mg IV BID
Vancomycin 1g Q12H
Piperacillin-Tazobactam 3.375g IV Q6H
Metronidazole 500mg IV Q8H
Albuterol nebs Q6H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals- 98.0, 88, 151/97, 20, 98% RA
Gen- mildly agitated, not responsive to name, not following
commands, rarely spontaneously opens eyes
HEENT- icteric sclerae, pupils 1-2mm, NGT in place
Neck- supple, no JVD appreciated
Pulm- CTAB but patient not cooperative with exam
CV- RR, no murmurs auscultated
Abd- distended but fairly soft, tympanitic, no bulging flanks or
appreciable dullness to percussion, no fluid wave, patient did
not grimace to deep palpation
Extrem- L femoral TLC, trace ankle edema b/l, pneumoboots in
place, DP/PT pulses full b/l
Neuro- occasionally spontaneously opened eyes during exam,
moving all 4 extremities, did not cooperate with/resisted neuro
exam

FAMILY HISTORY: Unable to obtain.

SOCIAL HISTORY: Lives with wife, [**Name (NI) **].  [**Name2 (NI) **] drink sometime between [**Date range (1) 66379**]
per wife.  She is not aware of how much he drinks daily.
Occasional tobacco use.  Wife reports no history of drug use. 

### Response:
{'Alcoholic cirrhosis of liver,Bacteremia,Esophageal varices in diseases classified elsewhere, with bleeding,Other ascites,Unspecified essential hypertension,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus'}
