CHIEF COMPLAINT: upper GI bleed

PRESENT ILLNESS: This was a 58F with history of seizure disorder, BPAD, frontal
and cerebellar atrophy but no prior history of liver disease or
GIB who presented to the ED by ambulance after a syncopal
episode at home. She reported having taken zolpidem and then
walked to the kitchen.  Unclear actual mechanism of fall as
patient unable to remember but noted to have blood on her face,
which was attributed to striking her face on the sink as she
fell.  EMS reported observing two possible focal seizures with
fixed gaze and arm posturing with incontinence.  She has a
history of seizures with tramadol in the past but had not taken
this in some time.

MEDICAL HISTORY: - Type II DM (not on meds)
- HTN
- HL
- Insomnia
- Chronic Gait instability with falls
- Cerebellar atrophy
- Frontal atrophy
- Bipolar disorder
- Seizure disorder (not on meds)
- Osteoarthritis
- Cervical Spondylosis

MEDICATION ON ADMISSION: Medications:
- lisinopril 5mg daily
- atenolol 25mg daily
- niacin 500mg daily
- aspirin 81mg daily
- ambien 10-20mg QHS
- Calcium-Vit D
- Mobic 15mg daily
- Fish Oil 1000mg caps daily
.
Allergies:
Lidocaine
Lorazepam
Ultram

ALLERGIES: Lorazepam / Ultram

PHYSICAL EXAM: At admission:
VS: T 96.9 ??????F, HR 65, BP 107/62, RR 23, O2 Sat 100% on RA
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: Nl S1 and S2, RRR, no M/R/G, peripheral pulses
at radials and DP's present and normal
Respiratory / Chest: Clear to auscultation bilaterally with
equal chest expansion bilaterally
Abdominal: Soft, Non-tender, normoactive bowel sounds, mild
tenderness with deep palpation of the epigastrum and RUQ
Extremities: Warm and well perfused with no lower extremity
edema appreciated
Skin:  Warm
Neurologic: Alert and oriented *3.  Responding to questions
appropriately.
Child-like affect.

FAMILY HISTORY: Father with diabetes

SOCIAL HISTORY: Retired. Lives separately from husband [**Name (NI) 4468**].  History of
smoking.  She denied any EtOH or drug use.
Chronic or unspecified gastric ulcer with perforation, without mention of obstruction,Pneumonitis due to inhalation of food or vomitus,Acute posthemorrhagic anemia,Hematemesis,Cardiac arrest,Other shock without mention of trauma,Unspecified analgesic and antipyretic causing adverse effects in therapeutic use,Vomiting alone,Nonspecific low blood pressure reading,Syncope and collapse,Open wound of nasal cavity, without mention of complication,Epistaxis,Fall from other slipping, tripping, or stumbling,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Abnormality of gait,Cerebral degeneration, unspecified,Bipolar disorder, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Cervical spondylosis without myelopathy
Chr stomach ulcer w perf,Food/vomit pneumonitis,Ac posthemorrhag anemia,Hematemesis,Cardiac arrest,Shock w/o trauma NEC,Adv eff analgesic NOS,Vomiting alone,Low blood press reading,Syncope and collapse,Open wound nasal cavity,Epistaxis,Fall from slipping NEC,DMII wo cmp nt st uncntr,Hypertension NOS,Hyperlipidemia NEC/NOS,Abnormality of gait,Cereb degeneration NOS,Bipolar disorder NOS,Epilep NOS w/o intr epil,Osteoarthros NOS-unspec,Cervical spondylosis
Admission Date:  [**2141-7-29**]              Discharge Date:   [**2141-7-30**]

Date of Birth:  [**2083-5-14**]             Sex:   F

Service: MEDICINE

Allergies:
Lorazepam / Ultram

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
upper GI bleed

Major Surgical or Invasive Procedure:
endoscopy [**2141-7-30**]
Placement of left femoral central venous catheter [**2141-7-30**]

History of Present Illness:
This was a 58F with history of seizure disorder, BPAD, frontal
and cerebellar atrophy but no prior history of liver disease or
GIB who presented to the ED by ambulance after a syncopal
episode at home. She reported having taken zolpidem and then
walked to the kitchen.  Unclear actual mechanism of fall as
patient unable to remember but noted to have blood on her face,
which was attributed to striking her face on the sink as she
fell.  EMS reported observing two possible focal seizures with
fixed gaze and arm posturing with incontinence.  She has a
history of seizures with tramadol in the past but had not taken
this in some time.

In the ED she had a SBP in the 50s in triage while awake and
mentating. 18g IV placed and she received 4L NS with improvement
of SBP to 80-90s.  She had an episode of stool incontinence with
a melena.  NG lavage with 1L fluid showed copious coffee grounds
that cleared followed by bright red blood.  At that point lavage
was stopped.  Labs notable for Hct 31.7 from a distant baseline
of 38 in [**2135**] and a Cr 1.7 from baseline of 1.1.  Head CT was
without acute change.  She received 1 unit pRBCs in the ED and
was started on pantoprazole drip after an 80 mg bolus.  A second
unit of pRBC's was started just prior to transfer to the ICU.  .

After arrival to the ICU the patient when asked more about her
history noted decreased appetite with early satiety x1 month as
well as epigastric pain, which she attributed to her diabetes
and reportedly improved with sugar.  Her husband endorsed at
least one episode of emesis a day, but he was not sure if this
was bloody.  She endorsed occasional falls, which were a
longstanding issue.  Of note, patient did endorse taking
meloxicam daily for arthritis pain.  She denied any abdominal
pain at time of arrival to the ICU and denied any heartburn,
chest pain, F/C, dizziness, or dysuria.


Past Medical History:
- Type II DM (not on meds)
- HTN
- HL
- Insomnia
- Chronic Gait instability with falls
- Cerebellar atrophy
- Frontal atrophy
- Bipolar disorder
- Seizure disorder (not on meds)
- Osteoarthritis
- Cervical Spondylosis


Social History:
Retired. Lives separately from husband [**Name (NI) 4468**].  History of
smoking.  She denied any EtOH or drug use.


Family History:
Father with diabetes


Physical Exam:
At admission:
VS: T 96.9 ??????F, HR 65, BP 107/62, RR 23, O2 Sat 100% on RA
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: Nl S1 and S2, RRR, no M/R/G, peripheral pulses
at radials and DP's present and normal
Respiratory / Chest: Clear to auscultation bilaterally with
equal chest expansion bilaterally
Abdominal: Soft, Non-tender, normoactive bowel sounds, mild
tenderness with deep palpation of the epigastrum and RUQ
Extremities: Warm and well perfused with no lower extremity
edema appreciated
Skin:  Warm
Neurologic: Alert and oriented *3.  Responding to questions
appropriately.
Child-like affect.


Pertinent Results:
===================
LABORATORY RESULTS
===================
At Admission:
WBC-13.4* Hgb-10.9* Hct-31.7* MCV-91 RDW-12.9 Plt Ct-349#
----Neuts-60.4 Lymphs-31.9 Monos-4.7 Eos-2.3 Baso-0.7
Glucose-167* UreaN-37* Creat-1.7* Na-137 K-4.6 Cl-97 HCO3-23
PT-12.7 PTT-19.8* INR(PT)-1.1 Lipase-70*
Calcium-10.3 Phos-4.8*# Mg-2.4
Lactate-2.6*

Prior to demise:
WBC-9.7 RBC-1.28*# Hgb-4.1*# Hct-12.1*# MCV-94 RDW-14.3 Plt
Ct-86*
---PT-28.1* PTT-150* INR(PT)-2.7*
Glucose-105* UreaN-13 Creat-0.5 Na-147* K-3.2* Cl-129* HCO3-8*
Calcium-3.5* Mg-1.2*

ABG: Temp-35.6 pO2-79* pCO2-49* pH-6.98* calTCO2-12*
Lactate-7.1*

Hct Trend:
[**2141-7-29**] 02:30AM Hgb-10.9* Hct-31.7*
[**2141-7-29**] 10:30AM Hgb-10.9* Hct-31.9*
[**2141-7-29**] 03:30PM           Hct-30.2*
[**2141-7-29**] 09:50PM           Hct-26.9*
[**2141-7-30**] 02:30AM           Hct-25.9*
[**2141-7-30**] 03:44AM Hgb-4.1*# Hct-12.1*#

============================
RADIOLOGY AND OTHER RESULTS
============================
EKG [**7-29**]:
NSR at 60bpm. LAD, poor R wave progression. TWI in V1, TWF in
V2-V3. No prior for comparison.

CT head [**7-29**]
FINDINGS: There is no evidence of acute intracranial hemorrhage,
discrete
masses, mass effect or shift of normally midline structures. The
ventricles
and sulci are prominent which is not typical for the patient's
age, however it is unchanged since [**2134-5-3**]. There is
pronounced cerebellar atrophy
bilaterally. No acute fractures are identified. Bilateral
mastoid and
paranasal sinuses are clear.

IMPRESSION: No acute intracranial pathology.

CXR [**7-29**]
PORTABLE AP CHEST RADIOGRAPH: Prominence of the right hilum and
upper
mediastinum may represent technique and rotated position. Both
lungs are
clear with no focal consolidation, pleural effusion or
pneumothorax.
Recommend a repeat PA and lateral chest radiograph for further
evaluation.

The study and the report were reviewed by the staff radiologist.


Upper Endoscopy [**2141-7-30**]:
Impression:  Immediately upon entering the esophagus there was a
large amount of active bleeding obscuring the view. At approx
45cm there was an area without any blood, ?if this was
peritoneum, reflecting a massive perforation. Procedure aborted,
surgical team at the bedside.
Otherwise normal EGD to unknown


Brief Hospital Course:
58F with history of seizures and bipolar disorder presenting
with syncope, hypotension, melena and coffee grounds on lavage.
Patient was admitted to the medical ICU for concern of
hematemasis.  She was started on a pantoprazole drip and NSAIDs
were held.  2 large PIV were placed.  As Hct's were initially
stable and hemodynamics were stable, endoscopy was initially
defered until [**7-31**].

At approximately 2:30am on [**7-30**], patient became
unresponsiveness, hypotensive, with hematemesis.  Palpable
pulse, anesthesia called for intubation and then Code Blue
called.  ETT and OGT and oropharynx with copious blood.  PEA
arrest.  2 rounds epi, chest compressions, L groin cordis placed
by surgery, NS wide open and PRBC running.  Regained pulse after
~10-15 minutes down time with MAPs >60.

Massive transfusion protocol activated, GI, surgery, IR
consulted.   R groin Aline placed by MICU attending.  Liters of
blood continuing pour from OGT and oropharynx.  Hypoxemia
requiring FiO2 1.0 and PEEP 10 for sats > 90, CXR with ETT in
place, no PTX, no obvious free air.  acidosis pH 6.85 Ca <
assay, PTT>150, INR 5,  Progressive massive abdominal
distention.  Received 22 U PRBC 6 FFP 4 Plt.

GI arrived for endoscopy, concerning for perforation; surgery /
anesthesia planned to take pt to the OR.  While preparing
patient for transfer, Aline tracing dampened, pulse initially
not palpable ?????? then thready.  Repeat episode of massive
hemoptysis around yankauer / OGT, decorticate posturing.
Decision made at bedside to not initiate CPR and cease further
resuscitative efforts; discussed with surgery, nursing, medical
housestaff.  Communicated with her husband the severe nature of
her illness and that further resuscitation would not be
performed.  PRBC/pressors/Vent D/c??????d and patient died shortly
thereafter.


Medications on Admission:
Medications:
- lisinopril 5mg daily
- atenolol 25mg daily
- niacin 500mg daily
- aspirin 81mg daily
- ambien 10-20mg QHS
- Calcium-Vit D
- Mobic 15mg daily
- Fish Oil 1000mg caps daily
.
Allergies:
Lidocaine
Lorazepam
Ultram


Discharge Medications:
n/a

Discharge Disposition:
Expired

Discharge Diagnosis:
deceased

Discharge Condition:
deceased

Discharge Instructions:
deceased

Followup Instructions:
deceased
{'Chronic or unspecified gastric ulcer with perforation, without mention of obstruction,Pneumonitis due to inhalation of food or vomitus,Acute posthemorrhagic anemia,Hematemesis,Cardiac arrest,Other shock without mention of trauma,Unspecified analgesic and antipyretic causing adverse effects in therapeutic use,Vomiting alone,Nonspecific low blood pressure reading,Syncope and collapse,Open wound of nasal cavity, without mention of complication,Epistaxis,Fall from other slipping, tripping, or stumbling,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Abnormality of gait,Cerebral degeneration, unspecified,Bipolar disorder, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Cervical spondylosis without myelopathy'}


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: upper GI bleed

PRESENT ILLNESS: This was a 58F with history of seizure disorder, BPAD, frontal
and cerebellar atrophy but no prior history of liver disease or
GIB who presented to the ED by ambulance after a syncopal
episode at home. She reported having taken zolpidem and then
walked to the kitchen.  Unclear actual mechanism of fall as
patient unable to remember but noted to have blood on her face,
which was attributed to striking her face on the sink as she
fell.  EMS reported observing two possible focal seizures with
fixed gaze and arm posturing with incontinence.  She has a
history of seizures with tramadol in the past but had not taken
this in some time.

MEDICAL HISTORY: - Type II DM (not on meds)
- HTN
- HL
- Insomnia
- Chronic Gait instability with falls
- Cerebellar atrophy
- Frontal atrophy
- Bipolar disorder
- Seizure disorder (not on meds)
- Osteoarthritis
- Cervical Spondylosis

MEDICATION ON ADMISSION: Medications:
- lisinopril 5mg daily
- atenolol 25mg daily
- niacin 500mg daily
- aspirin 81mg daily
- ambien 10-20mg QHS
- Calcium-Vit D
- Mobic 15mg daily
- Fish Oil 1000mg caps daily
.
Allergies:
Lidocaine
Lorazepam
Ultram

ALLERGIES: Lorazepam / Ultram

PHYSICAL EXAM: At admission:
VS: T 96.9 ??????F, HR 65, BP 107/62, RR 23, O2 Sat 100% on RA
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: Nl S1 and S2, RRR, no M/R/G, peripheral pulses
at radials and DP's present and normal
Respiratory / Chest: Clear to auscultation bilaterally with
equal chest expansion bilaterally
Abdominal: Soft, Non-tender, normoactive bowel sounds, mild
tenderness with deep palpation of the epigastrum and RUQ
Extremities: Warm and well perfused with no lower extremity
edema appreciated
Skin:  Warm
Neurologic: Alert and oriented *3.  Responding to questions
appropriately.
Child-like affect.

FAMILY HISTORY: Father with diabetes

SOCIAL HISTORY: Retired. Lives separately from husband [**Name (NI) 4468**].  History of
smoking.  She denied any EtOH or drug use. 

### Response:
{'Chronic or unspecified gastric ulcer with perforation, without mention of obstruction,Pneumonitis due to inhalation of food or vomitus,Acute posthemorrhagic anemia,Hematemesis,Cardiac arrest,Other shock without mention of trauma,Unspecified analgesic and antipyretic causing adverse effects in therapeutic use,Vomiting alone,Nonspecific low blood pressure reading,Syncope and collapse,Open wound of nasal cavity, without mention of complication,Epistaxis,Fall from other slipping, tripping, or stumbling,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Abnormality of gait,Cerebral degeneration, unspecified,Bipolar disorder, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Cervical spondylosis without myelopathy'}
