CHIEF COMPLAINT: HTN, Hematemesis

PRESENT ILLNESS: The patient is a 43 y/o M with no past history of GI bleeding,
who presented to the ED with an episode of hematemesis earlier
in the day. Per report, the patient had one episode of emesis
with possible blood in it earlier in the day and called his
PCP's office, who instructed him to present to the ED. While in
the ED, he had an episode of a large amount of bright red bloody
emesis.
.
On arrival to the ED, the patient's VS were 98.0 86 181/115 16
100. Hematocrit was 43. He was given 40 mg IV protonix and then
started on a protonix gtt at 8mg/hr. An 18G and a 16G IV were
placed for access. NG lavage was performed and did not clear. GI
was consulted with plans to see the patient in the ICU. In
addition, the patient was also given zofran for nausea. VS prior
to transfer were 85 151/107 22 97%.
.
On arrival to the ICU, the patient's VS were T: 98.3 BP: 174/116
P: 81 R: 21 O2: 99% on RA. He denied any current chest pain,
shortness of breath, abdominal pain, nausea, or lightheadedness.
He reported darker than usual stools for the past 2 weeks. He
did admit to significant alcohol use. He denied any other
complaints at this time.
.
.
Review of sytems:
(+) Per HPI
(-) Denies headache or visual changes. Denied cough, shortness
of breath. Denied chest pain or tightness, palpitations. Denied
diarrhea, constipation or abdominal pain. Denied arthralgias or
myalgias. Denies any focal numbness or weakness.

MEDICAL HISTORY: - CVA x [**2-12**] in the past
- Hypertension

MEDICATION ON ADMISSION: - Atenolol 100 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.3 BP: 174/116 P: 81 R: 21 O2: 99% on RA
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no JVD noted, no cervical LAD noted
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, hypoactive BS, no
rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses
Neuro: No gross neurologic deficits noted

FAMILY HISTORY: Mother had a stroke. Father has diabetes. Also has a brother
with diabetes.

SOCIAL HISTORY: Works in a chiropracter's office. Lives with his wife and 3
children. He reports alcohol intake of [**4-14**] beers and approx. 2
shots nightly. His last drink was 2 nights ago. He also reports
occasional marijuana and cocaine use.
Acute gastric ulcer with perforation, without mention of obstruction,Unspecified protein-calorie malnutrition,Alcohol withdrawal,Hypotension, unspecified,Other specified cardiac dysrhythmias,Helicobacter pylori [H. pylori],Leukocytosis, unspecified,Unspecified essential hypertension,Other and unspecified alcohol dependence, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Tobacco use disorder
Ac stomach ulcer w perf,Protein-cal malnutr NOS,Alcohol withdrawal,Hypotension NOS,Cardiac dysrhythmias NEC,Helicobacter pylori,Leukocytosis NOS,Hypertension NOS,Alcoh dep NEC/NOS-unspec,Hx TIA/stroke w/o resid,Tobacco use disorder
Admission Date:  [**2121-7-25**]              Discharge Date:   [**2121-8-3**]

Date of Birth:  [**2077-11-7**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
HTN, Hematemesis

Major Surgical or Invasive Procedure:
Exploratory Laparotomy, Anterior Gastrotomy


History of Present Illness:
The patient is a 43 y/o M with no past history of GI bleeding,
who presented to the ED with an episode of hematemesis earlier
in the day. Per report, the patient had one episode of emesis
with possible blood in it earlier in the day and called his
PCP's office, who instructed him to present to the ED. While in
the ED, he had an episode of a large amount of bright red bloody
emesis.
.
On arrival to the ED, the patient's VS were 98.0 86 181/115 16
100. Hematocrit was 43. He was given 40 mg IV protonix and then
started on a protonix gtt at 8mg/hr. An 18G and a 16G IV were
placed for access. NG lavage was performed and did not clear. GI
was consulted with plans to see the patient in the ICU. In
addition, the patient was also given zofran for nausea. VS prior
to transfer were 85 151/107 22 97%.
.
On arrival to the ICU, the patient's VS were T: 98.3 BP: 174/116
P: 81 R: 21 O2: 99% on RA. He denied any current chest pain,
shortness of breath, abdominal pain, nausea, or lightheadedness.
He reported darker than usual stools for the past 2 weeks. He
did admit to significant alcohol use. He denied any other
complaints at this time.
.
.
Review of sytems:
(+) Per HPI
(-) Denies headache or visual changes. Denied cough, shortness
of breath. Denied chest pain or tightness, palpitations. Denied
diarrhea, constipation or abdominal pain. Denied arthralgias or
myalgias. Denies any focal numbness or weakness.


Past Medical History:
- CVA x [**2-12**] in the past
- Hypertension


Social History:
Works in a chiropracter's office. Lives with his wife and 3
children. He reports alcohol intake of [**4-14**] beers and approx. 2
shots nightly. His last drink was 2 nights ago. He also reports
occasional marijuana and cocaine use.

Family History:
Mother had a stroke. Father has diabetes. Also has a brother
with diabetes.

Physical Exam:
Vitals: T: 98.3 BP: 174/116 P: 81 R: 21 O2: 99% on RA
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no JVD noted, no cervical LAD noted
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, hypoactive BS, no
rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses
Neuro: No gross neurologic deficits noted


Pertinent Results:
Admission Labs
[**2121-7-25**] 12:15AM BLOOD WBC-13.4* RBC-4.59* Hgb-14.3 Hct-43.1
MCV-94 MCH-31.1 MCHC-33.1 RDW-13.6 Plt Ct-344
[**2121-7-25**] 12:15AM BLOOD Neuts-81.8* Lymphs-13.3* Monos-3.1
Eos-1.5 Baso-0.4
[**2121-7-25**] 03:32AM BLOOD PT-12.9 PTT-21.4* INR(PT)-1.1
[**2121-7-26**] 03:30PM BLOOD Fibrino-153
[**2121-7-25**] 12:15AM BLOOD Glucose-121* UreaN-45* Creat-1.1 Na-138
K-4.9 Cl-105 HCO3-26 AnGap-12
[**2121-7-25**] 12:15AM BLOOD ALT-22 AST-20 AlkPhos-70 TotBili-0.4
[**2121-7-25**] 03:32AM BLOOD Calcium-8.8 Phos-1.3*# Mg-2.1

[**2121-8-2**] 07:10AM BLOOD WBC-12.2* RBC-3.59* Hgb-10.9* Hct-31.7*
MCV-88 MCH-30.5 MCHC-34.5 RDW-15.6* Plt Ct-668*
[**2121-8-2**] 07:10AM BLOOD Glucose-78 UreaN-17 Creat-0.9 Na-138
K-3.7 Cl-101 HCO3-28 AnGap-13

Brief Hospital Course:
BRIEF MICU COURSE:
The patient was placed on a PPI gtt in the ED and transferred to
the ICU. Once in the ICU, he underwent EGD by GI, during which
an ulcerated lesion was noted. Attempts to inject the lesion
with epinephrine resulted in significant bleeding. Ultimately
the bleeding was stopped and the EGD was halted. The patient was
given 2 units of blood at that time. CT scan was ordered, which
showed this known GI mass but no other masses. He continued to
have a falling hematocrit and was transfused additional units of
blood. On [**7-25**], he had episode of unresponsiveness and
hypotension. During this time, he was intubated and a CVL was
placed. GI scoped him and saw fresh blood and clot with nothing
to intervene upon. On [**7-26**], he vomited blood again and was thus
taken to the OR for operative exploration.

During the operation, no mass was palpable through the stomach
wall, a long gastrotomy was made and a bleeding ulcer noted
along the lesser curvature, which was then oversewn providing
hemostasis. An NG tube was left in the stomach and the patient
was brought to the SICU for further care.  Patient's
postoperative course in the ICU was uneventful.  His NGT
remained in place and serial HCT was monitored.  Patient was
deemed stable, extubated, and transferred to a regular nursing
floor on [**2121-8-1**].

BRIEF FLOOR COURSE:
Upon transfer to the floor, the patient remained stable and
continued to improve clinically.
Neuro: The patient received IV dilaudid as needed with good
effect and adequate pain control.  When tolerating oral intake,
the patient was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular standpoint
on metoprolol and lisonpril; vital signs were routinely
monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Diet continued to be advanced as appropriate, which
was well tolerated.  Patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection and required no
intervention while on the floor.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs.  The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.  The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.


Medications on Admission:
- Atenolol 100 mg daily

Discharge Medications:
1. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 12 days.
Disp:*96 Capsule(s)* Refills:*0*
2. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*48 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
12 days.
Disp:*24 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO four times a day
as needed for pain for 14 days.
Disp:*60 Tablet(s)* Refills:*0*
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
UGIB


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication.  Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.  Avoid lifting
weights greater than [**5-19**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water.  Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.


Followup Instructions:
Pls call your PCP [**Last Name (NamePattern4) **] ([**Telephone/Fax (1) 2535**] to follow-up management for
your high blood pressure.
*
Pls schedule an appointment with your Gastroenterologist for
outpatient EGD with possible biopsy of gastric ulcer. If you do
not have a gastroenterologist, please call [**Telephone/Fax (1) 463**] to set
up an appointment.
*
Pls schedule an appointment in [**Hospital 2536**] clinic to remove your staples
in [**1-11**] weeks. ([**Telephone/Fax (1) 2537**]



Completed by:[**2121-8-7**]
{'Acute gastric ulcer with perforation, without mention of obstruction,Unspecified protein-calorie malnutrition,Alcohol withdrawal,Hypotension, unspecified,Other specified cardiac dysrhythmias,Helicobacter pylori [H. pylori],Leukocytosis, unspecified,Unspecified essential hypertension,Other and unspecified alcohol dependence, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Tobacco use disorder'}


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: HTN, Hematemesis

PRESENT ILLNESS: The patient is a 43 y/o M with no past history of GI bleeding,
who presented to the ED with an episode of hematemesis earlier
in the day. Per report, the patient had one episode of emesis
with possible blood in it earlier in the day and called his
PCP's office, who instructed him to present to the ED. While in
the ED, he had an episode of a large amount of bright red bloody
emesis.
.
On arrival to the ED, the patient's VS were 98.0 86 181/115 16
100. Hematocrit was 43. He was given 40 mg IV protonix and then
started on a protonix gtt at 8mg/hr. An 18G and a 16G IV were
placed for access. NG lavage was performed and did not clear. GI
was consulted with plans to see the patient in the ICU. In
addition, the patient was also given zofran for nausea. VS prior
to transfer were 85 151/107 22 97%.
.
On arrival to the ICU, the patient's VS were T: 98.3 BP: 174/116
P: 81 R: 21 O2: 99% on RA. He denied any current chest pain,
shortness of breath, abdominal pain, nausea, or lightheadedness.
He reported darker than usual stools for the past 2 weeks. He
did admit to significant alcohol use. He denied any other
complaints at this time.
.
.
Review of sytems:
(+) Per HPI
(-) Denies headache or visual changes. Denied cough, shortness
of breath. Denied chest pain or tightness, palpitations. Denied
diarrhea, constipation or abdominal pain. Denied arthralgias or
myalgias. Denies any focal numbness or weakness.

MEDICAL HISTORY: - CVA x [**2-12**] in the past
- Hypertension

MEDICATION ON ADMISSION: - Atenolol 100 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.3 BP: 174/116 P: 81 R: 21 O2: 99% on RA
General: Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no JVD noted, no cervical LAD noted
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, hypoactive BS, no
rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses
Neuro: No gross neurologic deficits noted

FAMILY HISTORY: Mother had a stroke. Father has diabetes. Also has a brother
with diabetes.

SOCIAL HISTORY: Works in a chiropracter's office. Lives with his wife and 3
children. He reports alcohol intake of [**4-14**] beers and approx. 2
shots nightly. His last drink was 2 nights ago. He also reports
occasional marijuana and cocaine use. 

### Response:
{'Acute gastric ulcer with perforation, without mention of obstruction,Unspecified protein-calorie malnutrition,Alcohol withdrawal,Hypotension, unspecified,Other specified cardiac dysrhythmias,Helicobacter pylori [H. pylori],Leukocytosis, unspecified,Unspecified essential hypertension,Other and unspecified alcohol dependence, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Tobacco use disorder'}
