CHIEF COMPLAINT: CC:[**CC Contact Info 73413**]

PRESENT ILLNESS: HPI: 44F h/o HCV c/b cirrhosis and varices, morbid obesity s/p
gastric bypass surgery with prior anastomotic ulcer transferred
from OSH for management of GI bleeding. According to her
husband, she began to feel ill approximately 1 week prior with
confusion and lethargy and progressive abdominal pain. Began to
have black diarrhea 5 days ago. The morning of admission went to
the bathroom and vomited dark brown-black material. The husband
became worried and called EMS given her history of GI bleeding
and multiple prior admissions (last [**4-26**]).
.
At OSH, she was alert but restless and diaphoretic; tachy to
100s. Became hypotensive to low of 76/50 and received 2L normal
saline plus 4 units pRBC with SBP 100-110s. Did not require
pressors. Given PPI and santostatin 50mcg bolus. Hct 27.
Intubated. Also hyperkalemic to 6.3 without ECG changesand given
kayex/insulin/D50. Transferred to [**Hospital1 18**] for evaluation.

MEDICAL HISTORY: 1. HCV (genotype IIb) with cirrhosis and varices (grade I/II on
[**11-27**] EGD)
2. obesity s/p gastric bypass surgery ([**2181**])
3. h/o GI bleeding from gastric bypass anastamotic ulcer ([**2189**])
4. DM2
5. Polysubstance abuse (cocaine, benzos, opiates)
6. h/o rectal abscess
7. h/o bowel obstruction ([**2189**])
8. chronic low back pain
9. s/p appy and c-section

MEDICATION ON ADMISSION: 1. Nadolol
2. Xanax
3. lactulose

ALLERGIES: Nsaids / Aspirin

PHYSICAL EXAM: On presentation to Medicine floor:
99, 110/68, 61, 20, 98% RA
Gen: morbidly obese middle aged female
HEENT: NCAT PERRLA EOMI Anicteric MMM OP clear
CV: nml S1 S2 RRR no M/r/g
Chest: CTA Bil, no m/r/g
ABD: Morbidly obese, +bs, TTP in epigastrium, no rebound or
guarding
EXT: no c/c/e
Neuro: nonfocal, no asterisix

FAMILY HISTORY: NC

SOCIAL HISTORY: Social History: Unmarried but lives long-term with significant
other. 1ppd tobacco (40 pack-years). Social EtOH. Former cocaine
and opiate user, sober >6 months.
Portal hypertension,Cirrhosis of liver without mention of alcohol,Esophageal varices in diseases classified elsewhere, with bleeding,Chronic hepatitis C without mention of hepatic coma,Pneumonia, organism unspecified,Hyposmolality and/or hyponatremia,Acute respiratory failure,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Intestinal bypass or anastomosis status
Portal hypertension,Cirrhosis of liver NOS,Bleed esoph var oth dis,Chrnc hpt C wo hpat coma,Pneumonia, organism NOS,Hyposmolality,Acute respiratry failure,Thrombocytopenia NOS,DMII wo cmp nt st uncntr,Intestinal bypass status
Admission Date:  [**2192-6-2**]              Discharge Date:   [**2192-6-9**]

Date of Birth:  [**2148-1-13**]             Sex:   F

Service: MEDICINE

Allergies:
Nsaids / Aspirin

Attending:[**First Name3 (LF) 1580**]
Chief Complaint:
CC:[**CC Contact Info 73413**]

Major Surgical or Invasive Procedure:
EGD
Central venous catheter placement.

History of Present Illness:
HPI: 44F h/o HCV c/b cirrhosis and varices, morbid obesity s/p
gastric bypass surgery with prior anastomotic ulcer transferred
from OSH for management of GI bleeding. According to her
husband, she began to feel ill approximately 1 week prior with
confusion and lethargy and progressive abdominal pain. Began to
have black diarrhea 5 days ago. The morning of admission went to
the bathroom and vomited dark brown-black material. The husband
became worried and called EMS given her history of GI bleeding
and multiple prior admissions (last [**4-26**]).
.
At OSH, she was alert but restless and diaphoretic; tachy to
100s. Became hypotensive to low of 76/50 and received 2L normal
saline plus 4 units pRBC with SBP 100-110s. Did not require
pressors. Given PPI and santostatin 50mcg bolus. Hct 27.
Intubated. Also hyperkalemic to 6.3 without ECG changesand given
kayex/insulin/D50. Transferred to [**Hospital1 18**] for evaluation.


Past Medical History:
1. HCV (genotype IIb) with cirrhosis and varices (grade I/II on
[**11-27**] EGD)
2. obesity s/p gastric bypass surgery ([**2181**])
3. h/o GI bleeding from gastric bypass anastamotic ulcer ([**2189**])
4. DM2
5. Polysubstance abuse (cocaine, benzos, opiates)
6. h/o rectal abscess
7. h/o bowel obstruction ([**2189**])
8. chronic low back pain
9. s/p appy and c-section

Social History:
Social History: Unmarried but lives long-term with significant
other. 1ppd tobacco (40 pack-years). Social EtOH. Former cocaine
and opiate user, sober >6 months.


Family History:
NC


Physical Exam:
On presentation to Medicine floor:
99, 110/68, 61, 20, 98% RA
Gen: morbidly obese middle aged female
HEENT: NCAT PERRLA EOMI Anicteric MMM OP clear
CV: nml S1 S2 RRR no M/r/g
Chest: CTA Bil, no m/r/g
ABD: Morbidly obese, +bs, TTP in epigastrium, no rebound or
guarding
EXT: no c/c/e
Neuro: nonfocal, no asterisix

Pertinent Results:
[**2192-6-2**] 10:55PM   TYPE-ART PO2-68* PCO2-49* PH-7.39 TOTAL
CO2-31* BASE XS-3
[**2192-6-2**] 10:55PM   K+-4.2
[**2192-6-2**] 10:55PM   HGB-11.8* calcHCT-35
[**2192-6-2**] 10:55PM   HCT-34.4*
[**2192-6-2**] 06:51PM   GLUCOSE-163* UREA N-22* CREAT-0.8 SODIUM-143
POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-29 ANION GAP-8
[**2192-6-2**] 06:51PM   estGFR-Using this
[**2192-6-2**] 06:51PM   ALT(SGPT)-24 AST(SGOT)-86* LD(LDH)-287* ALK
PHOS-142* AMYLASE-49 TOT BILI-1.3
[**2192-6-2**] 06:51PM   LIPASE-58
[**2192-6-2**] 06:51PM   ALBUMIN-2.5* CALCIUM-6.5* PHOSPHATE-2.2*
MAGNESIUM-1.6
[**2192-6-2**] 06:51PM   AMMONIA-30
[**2192-6-2**] 06:51PM   WBC-9.9 RBC-3.80* HGB-11.5* HCT-34.3* MCV-90
MCH-30.3 MCHC-33.7 RDW-17.0*
[**2192-6-2**] 06:51PM   PLT COUNT-82*
[**2192-6-2**] 06:51PM   PT-17.0* PTT-30.8 INR(PT)-1.6*
[**2192-6-2**] 06:51PM   FIBRINOGE-252
Reports:
EGD:
 Normal duodenum.
Impression: Grade 2 esophageal varices
Portal Hypertensive Gastropathy
Post Gastric bypass with gastro-jejunostomy
Otherwise normal EGD to second part of the duodenum
Recommendations: Plan:
1) Intravenous PPI
2) NPO for 48 hours as severe gastritis
3) Wean off sedation - when conscious for carafate 1gram qid
4) Start Nadolol 20mg [**Hospital1 **] if not contra-indicated
5) Repeat EGD and for banding in 2 weeks.


Brief Hospital Course:
44F h/o HCV c/b cirrhosis and varices, morbid obesity s/p
gastric bypass surgery with prior anastomotic ulcer presenting
with hematemesis was transferred to [**Hospital1 18**] MICU from an outside
hospital with upper GI bleed.  Upper endoscopy was peformed and
showed macerated polyp near anastomotic site and grade II
nonbleeding varices. surgery c/s to evaluate if issue with
gastric bypass surgical site, but no clear evidence that this
was the source.  She was started on octreotide gtt, nadolol,
carafate, ppi, and levo for ppx.  Pt found to have a falling hct
to 25, requiring transfusion of 1 units PRBC, and given vitamin
K 1mg IV.  Abdominal US was performed and showed coarse
echotexture, patent vessels, and normal ducts.  RUL opacity was
seen on CXR and vancomycin and flagy were added to levo.  She
was intabated for airway protection in the setting of
hematemesis.  CT chest subsequently showed complete colapse of
the RUL.  Bronchoscopy was performed because of concern about
obstruction causing collapse but no mass was found and collapse
attributed to mucous plugging, though secretion were suggestive
of CAP.  Vanc and flagyl where discontinued based on sputum
results and and levo was continued.  She was then transfered out
of the intensive care unit and brought to the medicine floor. On
the medicine floor you were found to have a falling hematocrit
to 25 and was guaiac positive.  She was transfused an additional
2 units PRBCs with recovery of hct to 33. Repeat upper endoscopy
was was performed and no bleeding was found during this
endoscopy, but gastritis and esophageal varices were seen. Three
esophageal varices were banded and she was continued on protonix
and sucralfate for treatment of gastritis. On the day of
discharge hematocrit was stable and pt was guaiac negative.  She
was discharge with a perscription for levofloxacin to complete a
14 day course.
.
Of Note: While the pt was intbated the MICU team sought the pt's
next of [**Doctor First Name **] to give consent for EGD, at which time it was found
that the pt's son had died.  After EGD pt was extubated and
transferred to the floor where she was told of the death of her
son.  She was evaluated by psychiatry and social work who
ensured that pt had adequate follow up with her therapist and
recommended continuation of Xanax with addition of remeron.

Medications on Admission:
1. Nadolol
2. Xanax
3. lactulose


Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO three times a
day: with meals.
Disp:*90 Tablet(s)* Refills:*2*
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
Disp:*21 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*35 Tablet(s)* Refills:*0*
5. 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*
6. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 8 doses.
Disp:*24 Tablet(s)* Refills:*0*
7. Lactulose 10 g/15 mL Syrup Sig: Twenty (20) ML PO BID (2
times a day).
Disp:*1200 ML(s)* Refills:*2*
8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*qs 1 week* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary diagnosis: Upper GI Bleed from gastric bypass
anastomotic site
.
Secondary diagnoses:
1. HCV (genotype IIb) with cirrhosis and varices (grade I/II on
[**11-27**] EGD)
2. obesity s/p gastric bypass surgery ([**2181**])
3. h/o GI bleeding from gastric bypass anastamotic ulcer ([**2189**])

4. DM2
5. Polysubstance abuse (cocaine, benzos, opiates)
6. h/o rectal abscess
7. h/o bowel obstruction ([**2189**])
8. chronic low back pain
9. s/p appy and c-section


Discharge Condition:
afebrile, ambulating without difficulty, improved abdominal
pain, vital signs stable.


Discharge Instructions:
You were transferred to [**Hospital1 18**] from an outside hospital when you
were found to be bleeding from your gastrointestinal tract
requiring multiple blood transfusions.  You were admitted to the
intensive care unit.  Upper endoscopy showed that you were
bleeding from the sutures of your gastric bypass surgery.  You
were intubated and subsequently extubated, but developed an area
of consolidation within your lung that was evaluated by chest
xray, CT scan of the chest, and bronchoscopy and was felt could
possibly be pneumona.  You were treated with antibiotics and the
area of consolidation has resolved.  You were transfered out of
the intensive care unit and brought to the medicine floor.  On
the medicine floor you were found to have a falling hematocrit
and blood in your stool so you recieved a blood transfusion.
Repeat upper endoscopy was schedulued the next day to evaluate
for possible continued bleeding.  No bleeding was found during
this endoscopy, but gastritis and esophageal varices were seen.
 Three esophageal varices were banded and you were continued on
protonix and sucralfate for treatment of gastritis.  On the day
of discharge your hematocrit was stable and bleeding had
resolved.
.
Please keep all you appointments as listed below.
.
Please take all your medications as they are perscribed below.
.
If you have any symptoms of vommiting blood, vommiting dark
material, blood in your stools, severe abdominal pain, chest
pain, shortness of breath, fever, chills or any other concerning
symptoms please go to the emergency room.

Followup Instructions:
You are to Follow up in two weeks with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2422**]).
Her office will call your home on Monday to schedule the
appointment.  If they do not call you you should call them to
make the appointment yourself.
.
Please make an appointment in the bariatric surgery center
([**Telephone/Fax (1) 2723**]) within the next 2-3 weeks.
.
Please follow up with your therapist, Dr. [**First Name (STitle) **] in the next week.
.
Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
([**Telephone/Fax (1) 73414**]) in the next 7-10 days.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1583**] MD, MSC, MPH[**MD Number(3) 1584**]
{'Portal hypertension,Cirrhosis of liver without mention of alcohol,Esophageal varices in diseases classified elsewhere, with bleeding,Chronic hepatitis C without mention of hepatic coma,Pneumonia, organism unspecified,Hyposmolality and/or hyponatremia,Acute respiratory failure,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Intestinal bypass or anastomosis status'}


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: CC:[**CC Contact Info 73413**]

PRESENT ILLNESS: HPI: 44F h/o HCV c/b cirrhosis and varices, morbid obesity s/p
gastric bypass surgery with prior anastomotic ulcer transferred
from OSH for management of GI bleeding. According to her
husband, she began to feel ill approximately 1 week prior with
confusion and lethargy and progressive abdominal pain. Began to
have black diarrhea 5 days ago. The morning of admission went to
the bathroom and vomited dark brown-black material. The husband
became worried and called EMS given her history of GI bleeding
and multiple prior admissions (last [**4-26**]).
.
At OSH, she was alert but restless and diaphoretic; tachy to
100s. Became hypotensive to low of 76/50 and received 2L normal
saline plus 4 units pRBC with SBP 100-110s. Did not require
pressors. Given PPI and santostatin 50mcg bolus. Hct 27.
Intubated. Also hyperkalemic to 6.3 without ECG changesand given
kayex/insulin/D50. Transferred to [**Hospital1 18**] for evaluation.

MEDICAL HISTORY: 1. HCV (genotype IIb) with cirrhosis and varices (grade I/II on
[**11-27**] EGD)
2. obesity s/p gastric bypass surgery ([**2181**])
3. h/o GI bleeding from gastric bypass anastamotic ulcer ([**2189**])
4. DM2
5. Polysubstance abuse (cocaine, benzos, opiates)
6. h/o rectal abscess
7. h/o bowel obstruction ([**2189**])
8. chronic low back pain
9. s/p appy and c-section

MEDICATION ON ADMISSION: 1. Nadolol
2. Xanax
3. lactulose

ALLERGIES: Nsaids / Aspirin

PHYSICAL EXAM: On presentation to Medicine floor:
99, 110/68, 61, 20, 98% RA
Gen: morbidly obese middle aged female
HEENT: NCAT PERRLA EOMI Anicteric MMM OP clear
CV: nml S1 S2 RRR no M/r/g
Chest: CTA Bil, no m/r/g
ABD: Morbidly obese, +bs, TTP in epigastrium, no rebound or
guarding
EXT: no c/c/e
Neuro: nonfocal, no asterisix

FAMILY HISTORY: NC

SOCIAL HISTORY: Social History: Unmarried but lives long-term with significant
other. 1ppd tobacco (40 pack-years). Social EtOH. Former cocaine
and opiate user, sober >6 months. 

### Response:
{'Portal hypertension,Cirrhosis of liver without mention of alcohol,Esophageal varices in diseases classified elsewhere, with bleeding,Chronic hepatitis C without mention of hepatic coma,Pneumonia, organism unspecified,Hyposmolality and/or hyponatremia,Acute respiratory failure,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Intestinal bypass or anastomosis status'}
