CHIEF COMPLAINT: CC:[**CC Contact Info 77154**]
Major Surgical or Invasive Procedure:
EGD.  Push enteroscopy.  Endotracheal intubation.

PRESENT ILLNESS: 51yoM with h/o heavy Etoh use and [**2199**] craniotomy for left
subdural due to fall +/- seizure in the setting of drunkeness,
transfered from [**Location (un) **] for GIB and anemia. History is pieced
together from records, pt not good historian. He was reportedly
found down today at home (unwitnessed, unclear how long down).
Brought to [**Location (un) **] with Hct 13.8, ETOH 460, INR of 2.2, ammonia
of 100. He may have had guiaic positive yellow/brown stool there
per the ED dash.  CT head with 3mm hyperdensity L
fontal/parietal, ? new blood vs changes from old SDH at same
site.  Placed 20G IV there. BPs were stable en route to [**Hospital1 **] with
SBP 100, HR 90.
.
Upon arrival, SBPs 80-90. Cordis placed in right IJ. Patient
states that he had been in a fight earlier in the week -- his
daughter's boyfriend may have punched him in the eye, unclear.
[**Name2 (NI) **] was noted to be jaundiced with severe anasarca. He was guiaic
negative with no stool in the vault on signout.
.
In ED, initial VS 97.4, 103, 98/44, 16, 100/2L.
Labs in ED showed:
WBC 13.2, N 79.9, Hct 14.2, Platelets 168. INR 1.7, PTT 39.5.
UA with few bact, 5 WBC, elevated glucose, protein, ketone.
Trop 0.01, creatinine 0.9.
ALT 40, AP 226, TB 8.6, DB 6.7, Alb 2.3, Lipase 88.
.
Multiple images showed chronic fractures per ED. CT chest with
contrast with sternal mid body fracture without hematoma new
since [**2198**], right 11th posterior rib deformity likely subacute
with more chronic rib deformities in right 8.9 ribs, trace b/l
pleural effusions vs subpleural fat, anasarca, ascites. CT
C-spine without acute fracture. CT head with b/l subdural
hematomas measuring 3mm in max diameter without shift. CT abd
and pelvis with small b/l pleural effusions and adjacent
atelectasis, free fluid without hemoperitoneum, mild anasarca,
subacute Right post 11th rib fracture.  CXR with chronic sternal
fracture and rib fractures.
.
Peritoneal fluid with 12 WBC, 246 RBC, 12 poly, protein 0.9, Glu
171. Cultures were sent of the peritoneal fluid.
.
Most concerning, was a L parietal/temporal hemorrhage which is
not apparently new. Seen by neurosurgery but nothing to do. GI
wants NG lavage but ED team feels hesitant doing it down in ED.
.
He received Octreotide 0.6mg, Zofran, Vitamin K 10mg IV X 1,
Morphine 4mg, Lactulose 45 mg PO x1, Neomycin 3gm PO x1, 1g IV
Ceftriaxone. On Octreotide and Protonix gtts now. He was
transfused 4u PRBC's, 2u FFP, 2u platelets, and 2.5 L NS.
.
VS on tranfer were, 85, 98/44 -> 106/85, 16, on NC.  He was
getting either his third or fourth U of PRBC. Twin brother will
be in on Saturday.
.
ROS: He states he's had 6 months of BRBPR (last episode a long
time ago) and melena (last episode 1 mo ago) and no other blood
loss otherwise. Increased abdominal distention for the past [**1-6**]
months. Endorses PND and orthopnea, SOB. Negative for f/c/ns,
CP, abd pain, dizziness/LH. He has been drinking everyday, pints
of vodka. States last episode of hematemesis was 8 months ago at
which point he was "operated on" and [**Location (un) **] and had to have his
stomach pumped -- again poor history.

MEDICAL HISTORY: - History of heavy etoh use (1 quart vodka daily)
- S/p craniotomy in [**2199**] for L SDH with shift, at that time
noted chronic bilateral subdurals as well
- GERD
- depression

MEDICATION ON ADMISSION: none. States was previously on Paxil, Wellbutrin, denies ever
being on Spironolactone, Lasix, Nadolol, other liver meds.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: 97   p94 - 105  108/50 (105-124)   15  94% 4LNC
Very large and obviously jaundiced and distended M in no
distress, smells of EtOH. Conversant but slow speech, not
slurred.
Bilateral eyes with purulent crust in eyes, scleral edema, and
scleral icterus
Mouth dry but no obvious lesions, did not open mouth very wide,
unable to assess OP
CTAB anteriorly without w/c/r/r
Low grade tachycardia but regular, no m/g
Abd grossly distended and slightly tight, +caput medusae
Gross anasarca along abdominal wall, BUE's and BLE's
CN 2-12 grossly intact, no focal neuro deficit noted

FAMILY HISTORY: M - EtOH
F - deceased at 87yo

SOCIAL HISTORY: Smoked from 8 yrs old until [**5-13**] yrs ago; heavy ETOH use - 1
quart vodka/daily, lives with wife [**Telephone/Fax (1) 77153**] ([**Doctor Last Name 1356**]). Has 22
yo daughter, no IVDU or drug use now.
Blood in stool,Hepatorenal syndrome,Acute kidney failure with lesion of tubular necrosis,Alcoholic cirrhosis of liver,Acute respiratory failure,Septic shock,Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Pneumonia, organism unspecified,Unspecified septicemia,Severe sepsis,Acute posthemorrhagic anemia,Other ascites,Body Mass Index 50.0-59.9, adult,Acidosis,Unspecified protein-calorie malnutrition,Rhabdomyolysis,Cellulitis and abscess of trunk,Other postoperative infection,Paralytic ileus,Thrombocytopenia, unspecified,Other and unspecified alcohol dependence, continuous,Morbid obesity,Other diseases of pharynx, not elsewhere classified,Venous (peripheral) insufficiency, unspecified,Leukocytosis, unspecified,Unarmed fight or brawl,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Blood in stool,Hepatorenal syndrome,Ac kidny fail, tubr necr,Alcohol cirrhosis liver,Acute respiratry failure,Septic shock,Subdural hem w/o coma,Pneumonia, organism NOS,Septicemia NOS,Severe sepsis,Ac posthemorrhag anemia,Ascites NEC,BMI 50.0-59.9, adult,Acidosis,Protein-cal malnutr NOS,Rhabdomyolysis,Cellulitis of trunk,Other postop infection,Paralytic ileus,Thrombocytopenia NOS,Alcoh dep NEC/NOS-contin,Morbid obesity,Disease of pharynx NEC,Venous insufficiency NOS,Leukocytosis NOS,Unarmed fight or brawl,Abn react-procedure NEC
Admission Date:  [**2203-5-20**]              Discharge Date:   [**2203-5-30**]

Date of Birth:  [**2151-6-29**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
CC:[**CC Contact Info 77154**]
Major Surgical or Invasive Procedure:
EGD.  Push enteroscopy.  Endotracheal intubation.

History of Present Illness:
51yoM with h/o heavy Etoh use and [**2199**] craniotomy for left
subdural due to fall +/- seizure in the setting of drunkeness,
transfered from [**Location (un) **] for GIB and anemia. History is pieced
together from records, pt not good historian. He was reportedly
found down today at home (unwitnessed, unclear how long down).
Brought to [**Location (un) **] with Hct 13.8, ETOH 460, INR of 2.2, ammonia
of 100. He may have had guiaic positive yellow/brown stool there
per the ED dash.  CT head with 3mm hyperdensity L
fontal/parietal, ? new blood vs changes from old SDH at same
site.  Placed 20G IV there. BPs were stable en route to [**Hospital1 **] with
SBP 100, HR 90.
.
Upon arrival, SBPs 80-90. Cordis placed in right IJ. Patient
states that he had been in a fight earlier in the week -- his
daughter's boyfriend may have punched him in the eye, unclear.
[**Name2 (NI) **] was noted to be jaundiced with severe anasarca. He was guiaic
negative with no stool in the vault on signout.
.
In ED, initial VS 97.4, 103, 98/44, 16, 100/2L.
Labs in ED showed:
WBC 13.2, N 79.9, Hct 14.2, Platelets 168. INR 1.7, PTT 39.5.
UA with few bact, 5 WBC, elevated glucose, protein, ketone.
Trop 0.01, creatinine 0.9.
ALT 40, AP 226, TB 8.6, DB 6.7, Alb 2.3, Lipase 88.
.
Multiple images showed chronic fractures per ED. CT chest with
contrast with sternal mid body fracture without hematoma new
since [**2198**], right 11th posterior rib deformity likely subacute
with more chronic rib deformities in right 8.9 ribs, trace b/l
pleural effusions vs subpleural fat, anasarca, ascites. CT
C-spine without acute fracture. CT head with b/l subdural
hematomas measuring 3mm in max diameter without shift. CT abd
and pelvis with small b/l pleural effusions and adjacent
atelectasis, free fluid without hemoperitoneum, mild anasarca,
subacute Right post 11th rib fracture.  CXR with chronic sternal
fracture and rib fractures.
.
Peritoneal fluid with 12 WBC, 246 RBC, 12 poly, protein 0.9, Glu
171. Cultures were sent of the peritoneal fluid.
.
Most concerning, was a L parietal/temporal hemorrhage which is
not apparently new. Seen by neurosurgery but nothing to do. GI
wants NG lavage but ED team feels hesitant doing it down in ED.
.
He received Octreotide 0.6mg, Zofran, Vitamin K 10mg IV X 1,
Morphine 4mg, Lactulose 45 mg PO x1, Neomycin 3gm PO x1, 1g IV
Ceftriaxone. On Octreotide and Protonix gtts now. He was
transfused 4u PRBC's, 2u FFP, 2u platelets, and 2.5 L NS.
.
VS on tranfer were, 85, 98/44 -> 106/85, 16, on NC.  He was
getting either his third or fourth U of PRBC. Twin brother will
be in on Saturday.
.
ROS: He states he's had 6 months of BRBPR (last episode a long
time ago) and melena (last episode 1 mo ago) and no other blood
loss otherwise. Increased abdominal distention for the past [**1-6**]
months. Endorses PND and orthopnea, SOB. Negative for f/c/ns,
CP, abd pain, dizziness/LH. He has been drinking everyday, pints
of vodka. States last episode of hematemesis was 8 months ago at
which point he was "operated on" and [**Location (un) **] and had to have his
stomach pumped -- again poor history.

Past Medical History:
- History of heavy etoh use (1 quart vodka daily)
- S/p craniotomy in [**2199**] for L SDH with shift, at that time
noted chronic bilateral subdurals as well
- GERD
- depression

Social History:
Smoked from 8 yrs old until [**5-13**] yrs ago; heavy ETOH use - 1
quart vodka/daily, lives with wife [**Telephone/Fax (1) 77153**] ([**Doctor Last Name 1356**]). Has 22
yo daughter, no IVDU or drug use now.

Family History:
M - EtOH
F - deceased at 87yo


Physical Exam:
97   p94 - 105  108/50 (105-124)   15  94% 4LNC
Very large and obviously jaundiced and distended M in no
distress, smells of EtOH. Conversant but slow speech, not
slurred.
Bilateral eyes with purulent crust in eyes, scleral edema, and
scleral icterus
Mouth dry but no obvious lesions, did not open mouth very wide,
unable to assess OP
CTAB anteriorly without w/c/r/r
Low grade tachycardia but regular, no m/g
Abd grossly distended and slightly tight, +caput medusae
Gross anasarca along abdominal wall, BUE's and BLE's
CN 2-12 grossly intact, no focal neuro deficit noted


Pertinent Results:
OSH labs: WBC 16.5, Hct 13.8, Plts 176
Ammonia 102, BUN/Cr 18/0.8, Tbili 9.1, AST 151, ALT 36, Lipase
79, AlkP 218, CK 278, MB 4.3, INR 2.2, Tylenol negative, EtOH
468
.
EKG: NSR at 101, normal QRS axis, normal P waves, sub 1-mm STD's
in V4-6, diffusely smaller complexes in comparison to prior EKG.


CT Abd/Pelvis:  [**2203-5-19**]
IMPRESSION:
1. Bilateral trace pleural effusions versus pleural fat with
adjacent
compressive atelectasis.
2. Simple free fluid (ascites) noted within the abdomen with no
hemoperitoneum.

CT Head [**5-19**]:
IMPRESSION:
1. Bilateral subacute to chronic subdural hematomas.
2. Enlarged right parotid gland; correlate with clinical
examination and
history. There is suggestion on prior exams, this may be
chronic.

CT C-spine [**5-19**]:
IMPRESSION:
1. No acute fracture identified.
2. There appears to be obliteration of much of the [**Last Name (un) **] and
oropharynx upto
the level of the epiglottis which may reflect external
compression versus
material within the pharynx (3;11). Beyond the epiglottis the
airway is
patent.
Recommend clinical correlation and examination. Findings
discussed with Dr.
[**Last Name (STitle) **] at 3;40am on [**2203-5-19**] via telephone.

CT Chest [**5-19**]:
IMPRESSION:
1. Eleventh posterior right rib deformity consistent with
subacute fracture.
Additional more chronic-appearing fractures are noted along the
right eighth
and ninth ribs.
2. Lucency through the sternal body with no significant
surrounding hematoma
may represent a sternal fracture of indeterminate chronicity,
correlate
clinically.
3. Bilateral trace pleural effusions versus pleural fat with
adjacent
compressive atelectasis.

RUQ/Abdominal US [**5-20**]:
IMPRESSION: Moderate amount of ascites seen within the abdomen.
Very
echogenic liver consistent with fatty infiltration. The degree
of
echogenicity severely limits the ability to visualize the liver.
Patent left
portal vein. The remainder of the exam is virtually
nondiagnostic as
ultrasound is unable to visualize the patient's anatomy due to
the body
habitus.

TTE [**5-26**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF 65%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. There is mild posterior leaflet mitral valve
prolapse. An eccentric, anteriorly directed jet of Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.

RUQ US ([**5-28**]):
IMPRESSION:
1. Cirrhosis of the liver. Hepatofugal flow in the main and left
portal vein
(through periumbilical vein) suggests portal hypertension.
Stable mild
splenomegaly.

2. Mildly distended gallbladder, without evidence of
cholelithiasis or
son[**Name (NI) 493**] signs specific for cholecystitis.

3. Moderate amount of ascites. The above findings were discussed
with Dr.
[**Last Name (STitle) 3419**] at 12:50 p.m. on [**2203-5-28**].

CT chest/abdomen/pelvis [**5-28**]
IMPRESSION:
1. Left upper lobe consolidation. While the imaging appearance
is most
consistent with atelectasis, the location is somewhat unusual,
and the airways
appear patent. Thus, it is difficult to definitively exclude
pneumonia.
Lungs are otherwise clear with no further evidence of infectious
process in
the chest.

2. Enlargement of the pulmonary artery measuring up to 4 cm,
suggesting
underlying pulmonary hypertension.

3. Engorgement of the upper lobe pulmonary vessels without frank
pulmonary
edema.

4. Hepatosteatosis. No focal liver lesions.

5. Cholelithiasis without CT evidence of cholecystitis.

6. Mild splenomegaly.

7. Small-moderate simple ascites. No loculated collection to
suggest abscess
formation. No other evidence of intraabdominal infection.

8. Multiple thoracic vertebral bodies segmentation anomalies, as
previously
detailed on chest CT [**2203-5-19**].

[**2203-5-20**] 08:56PM   WBC-13.3* RBC-2.45* HGB-7.4* HCT-22.2* MCV-91
MCH-30.1 MCHC-33.2 RDW-20.3*
[**2203-5-20**] 08:56PM   PLT COUNT-179
[**2203-5-20**] 08:56PM   PT-16.8* PTT-36.2* INR(PT)-1.5*
[**2203-5-20**] 08:56PM   FIBRINOGE-264
[**2203-5-20**] 04:47PM   WBC-15.5* RBC-2.77* HGB-8.0* HCT-25.1* MCV-91
MCH-28.9 MCHC-31.9 RDW-20.2*
[**2203-5-20**] 04:47PM   PLT COUNT-192
[**2203-5-20**] 04:47PM   PT-16.6* PTT-36.1* INR(PT)-1.5*
[**2203-5-20**] 04:47PM   FIBRINOGE-320
[**2203-5-20**] 04:34PM ASCITES  TOT PROT-0.9 GLUCOSE-180 CREAT-1.0
LD(LDH)-69 ALBUMIN-<1
[**2203-5-20**] 04:34PM ASCITES  WBC-75* RBC-1800* POLYS-7* LYMPHS-1*
MONOS-0 MESOTHELI-8* MACROPHAG-84*
[**2203-5-20**] 01:23PM   TYPE-CENTRAL VE PO2-63* PCO2-49* PH-7.28*
TOTAL CO2-24 BASE XS--3
[**2203-5-20**] 01:23PM   LACTATE-1.5
[**2203-5-20**] 01:23PM   freeCa-1.07*
[**2203-5-20**] 01:16PM   WBC-17.3* RBC-2.60* HGB-7.4* HCT-23.5* MCV-91
MCH-28.6 MCHC-31.6 RDW-20.5*
[**2203-5-20**] 01:16PM   PLT COUNT-230
[**2203-5-20**] 01:16PM   PT-16.6* PTT-36.1* INR(PT)-1.5*
[**2203-5-20**] 01:16PM   FIBRINOGE-317
[**2203-5-20**] 01:12PM   GLUCOSE-163* UREA N-21* CREAT-1.0 SODIUM-138
POTASSIUM-5.2* CHLORIDE-107 TOTAL CO2-22 ANION GAP-14
[**2203-5-20**] 01:12PM   CALCIUM-7.7* PHOSPHATE-4.8* MAGNESIUM-2.2
[**2203-5-20**] 08:22AM   LACTATE-1.7
[**2203-5-20**] 08:13AM   GLUCOSE-165* UREA N-21* CREAT-1.1 SODIUM-137
POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-21* ANION GAP-14
[**2203-5-20**] 08:13AM   ALT(SGPT)-43* AST(SGOT)-191* LD(LDH)-313*
CK(CPK)-155 ALK PHOS-213* TOT BILI-10.6*
[**2203-5-20**] 08:13AM   CK-MB-5 cTropnT-<0.01
[**2203-5-20**] 08:13AM   WBC-15.1* RBC-2.27* HGB-6.5* HCT-20.6* MCV-91
MCH-28.8 MCHC-31.6 RDW-21.0*
[**2203-5-20**] 08:13AM   PLT COUNT-206
[**2203-5-20**] 08:13AM   PT-16.8* PTT-36.8* INR(PT)-1.5*
[**2203-5-20**] 08:13AM   FIBRINOGE-296
[**2203-5-20**] 08:13AM   WBC-15.1* RBC-2.27* HGB-6.5* HCT-20.6* MCV-91
MCH-28.8 MCHC-31.6 RDW-21.0*
[**2203-5-20**] 08:13AM   PLT COUNT-206
[**2203-5-20**] 08:13AM   PT-16.8* PTT-36.8* INR(PT)-1.5*
[**2203-5-20**] 08:13AM   FIBRINOGE-296
[**2203-5-20**] 02:53AM   GLUCOSE-153* UREA N-19 CREAT-1.0 SODIUM-136
POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-19* ANION GAP-17
[**2203-5-20**] 02:53AM   ALT(SGPT)-41* AST(SGOT)-198* LD(LDH)-346* ALK
PHOS-233* TOT BILI-9.7*
[**2203-5-20**] 02:53AM   CALCIUM-7.7* PHOSPHATE-4.5 MAGNESIUM-2.2
[**2203-5-20**] 02:53AM   WBC-14.6* RBC-2.44*# HGB-7.0*# HCT-22.1*#
MCV-91 MCH-28.8 MCHC-31.7 RDW-20.9*
[**2203-5-20**] 02:53AM   PLT COUNT-216
[**2203-5-20**] 02:53AM   PT-17.5* PTT-37.6* INR(PT)-1.6*
[**2203-5-19**] 10:15PM ASCITES  TOT PROT-0.9 GLUCOSE-171 ALBUMIN-0.5
[**2203-5-19**] 10:15PM ASCITES  WBC-12* RBC-246* POLYS-12* LYMPHS-4*
MONOS-0 MESOTHELI-20* MACROPHAG-64*
[**2203-5-19**] 10:00PM   GLUCOSE-125* UREA N-18 CREAT-0.9 SODIUM-136
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15
[**2203-5-19**] 10:00PM   estGFR-Using this
[**2203-5-19**] 10:00PM   ALT(SGPT)-40 AST(SGOT)-163* CK(CPK)-219 ALK
PHOS-226* TOT BILI-8.6* DIR BILI-6.7* INDIR BIL-1.9
[**2203-5-19**] 10:00PM   LIPASE-88*
[**2203-5-19**] 10:00PM   cTropnT-<0.01
[**2203-5-19**] 10:00PM   ALBUMIN-2.3* CALCIUM-7.6* PHOSPHATE-3.2
MAGNESIUM-2.2 IRON-21*
[**2203-5-19**] 10:00PM   calTIBC-213* FERRITIN-43 TRF-164*
[**2203-5-19**] 10:00PM   ACETMNPHN-NEG
[**2203-5-19**] 10:00PM   WBC-13.2* RBC-1.51*# HGB-4.1*# HCT-14.2*#
MCV-94 MCH-27.2# MCHC-29.0*# RDW-23.5*
[**2203-5-19**] 10:00PM   NEUTS-79.9* LYMPHS-14.1* MONOS-4.9 EOS-0.5
BASOS-0.7
[**2203-5-19**] 10:00PM   PLT COUNT-168#
[**2203-5-19**] 10:00PM URINE  COLOR-DkAmb APPEAR-SlHazy SP [**Last Name (un) 155**]-1.015
[**2203-5-19**] 10:00PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-15 BILIRUBIN-LG UROBILNGN-4* PH-5.0 LEUK-NEG
[**2203-5-19**] 10:00PM URINE  RBC-1 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-6
[**2203-5-19**] 10:00PM URINE  HYALINE-42*
[**2203-5-19**] 10:00PM URINE  MUCOUS-OCC
[**2203-5-19**] 09:03PM   PT-18.5* PTT-39.5* INR(PT)-1.7*

Brief Hospital Course:
The patient had presented with a GI bleed on [**2203-5-20**].  He had
two EGDs and a small bowel enteroscopy performed during this
hospitalization which showed varices which were not actively
bleeding and were too small to intervene upon.  His source of GI
bleed was believed to be secondary to portal hypertensive
gastropathy as well as abnormal mucosa in the duodenum with
evidence of active diffuse oozing which was not intervenable.  A
raised lesion was also noted in the stomach body which did not
show evidence of active bleed, but 2 endoclips were placed on
[**5-29**] at the time of the enteroscopy.  A family meeting was held
at which time it was decided that further escalation of care
would be medically futile, and the patient was made DNR/DNI,
with no further escalation of care.  It was decided not to check
daily labs, not to transfuse further blood products, and not to
increase pressor doses.  The patient had continued to have
active rectal bleeding with dark red blood in his stool until
the time of death.  The patient became hypotensive for 2 hours
prior to time of death with progressively decreasing blood
pressures, likely secondary to his GI bleed which was due to his
end stage liver disease.  He then became progressively
bradycardic until his rhythm became asystolic, and the time of
death was pronounced as 20:55 on [**2203-5-30**], with chief cause of
death recorded as gastrointestinal bleed, immediate cause of
death cardiac arrest, and antecedent cause of death hypotension.
 His family, including his daughter, [**Name (NI) 53239**] [**Name (NI) 14840**], who was
his health care proxy, his twin brother [**Name (NI) **] [**Name (NI) 14840**], and
his sister [**Name (NI) **] were notified of his death.  The family refused
an autopsy.  The primary care physician, [**Name10 (NameIs) 17029**], [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] was attempted to be contact[**Name (NI) **] but his covering physician
did not return the page to inform him of the patient??????s death.
The MICU team will attempt to contact his PCP again in the
morning.


Medications on Admission:
none. States was previously on Paxil, Wellbutrin, denies ever
being on Spironolactone, Lasix, Nadolol, other liver meds.


Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
n/a

Discharge Condition:
n/a

Discharge Instructions:
n/a

Followup Instructions:
n/a

                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
{'Blood in stool,Hepatorenal syndrome,Acute kidney failure with lesion of tubular necrosis,Alcoholic cirrhosis of liver,Acute respiratory failure,Septic shock,Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Pneumonia, organism unspecified,Unspecified septicemia,Severe sepsis,Acute posthemorrhagic anemia,Other ascites,Body Mass Index 50.0-59.9, adult,Acidosis,Unspecified protein-calorie malnutrition,Rhabdomyolysis,Cellulitis and abscess of trunk,Other postoperative infection,Paralytic ileus,Thrombocytopenia, unspecified,Other and unspecified alcohol dependence, continuous,Morbid obesity,Other diseases of pharynx, not elsewhere classified,Venous (peripheral) insufficiency, unspecified,Leukocytosis, unspecified,Unarmed fight or brawl,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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 77154**]
Major Surgical or Invasive Procedure:
EGD.  Push enteroscopy.  Endotracheal intubation.

PRESENT ILLNESS: 51yoM with h/o heavy Etoh use and [**2199**] craniotomy for left
subdural due to fall +/- seizure in the setting of drunkeness,
transfered from [**Location (un) **] for GIB and anemia. History is pieced
together from records, pt not good historian. He was reportedly
found down today at home (unwitnessed, unclear how long down).
Brought to [**Location (un) **] with Hct 13.8, ETOH 460, INR of 2.2, ammonia
of 100. He may have had guiaic positive yellow/brown stool there
per the ED dash.  CT head with 3mm hyperdensity L
fontal/parietal, ? new blood vs changes from old SDH at same
site.  Placed 20G IV there. BPs were stable en route to [**Hospital1 **] with
SBP 100, HR 90.
.
Upon arrival, SBPs 80-90. Cordis placed in right IJ. Patient
states that he had been in a fight earlier in the week -- his
daughter's boyfriend may have punched him in the eye, unclear.
[**Name2 (NI) **] was noted to be jaundiced with severe anasarca. He was guiaic
negative with no stool in the vault on signout.
.
In ED, initial VS 97.4, 103, 98/44, 16, 100/2L.
Labs in ED showed:
WBC 13.2, N 79.9, Hct 14.2, Platelets 168. INR 1.7, PTT 39.5.
UA with few bact, 5 WBC, elevated glucose, protein, ketone.
Trop 0.01, creatinine 0.9.
ALT 40, AP 226, TB 8.6, DB 6.7, Alb 2.3, Lipase 88.
.
Multiple images showed chronic fractures per ED. CT chest with
contrast with sternal mid body fracture without hematoma new
since [**2198**], right 11th posterior rib deformity likely subacute
with more chronic rib deformities in right 8.9 ribs, trace b/l
pleural effusions vs subpleural fat, anasarca, ascites. CT
C-spine without acute fracture. CT head with b/l subdural
hematomas measuring 3mm in max diameter without shift. CT abd
and pelvis with small b/l pleural effusions and adjacent
atelectasis, free fluid without hemoperitoneum, mild anasarca,
subacute Right post 11th rib fracture.  CXR with chronic sternal
fracture and rib fractures.
.
Peritoneal fluid with 12 WBC, 246 RBC, 12 poly, protein 0.9, Glu
171. Cultures were sent of the peritoneal fluid.
.
Most concerning, was a L parietal/temporal hemorrhage which is
not apparently new. Seen by neurosurgery but nothing to do. GI
wants NG lavage but ED team feels hesitant doing it down in ED.
.
He received Octreotide 0.6mg, Zofran, Vitamin K 10mg IV X 1,
Morphine 4mg, Lactulose 45 mg PO x1, Neomycin 3gm PO x1, 1g IV
Ceftriaxone. On Octreotide and Protonix gtts now. He was
transfused 4u PRBC's, 2u FFP, 2u platelets, and 2.5 L NS.
.
VS on tranfer were, 85, 98/44 -> 106/85, 16, on NC.  He was
getting either his third or fourth U of PRBC. Twin brother will
be in on Saturday.
.
ROS: He states he's had 6 months of BRBPR (last episode a long
time ago) and melena (last episode 1 mo ago) and no other blood
loss otherwise. Increased abdominal distention for the past [**1-6**]
months. Endorses PND and orthopnea, SOB. Negative for f/c/ns,
CP, abd pain, dizziness/LH. He has been drinking everyday, pints
of vodka. States last episode of hematemesis was 8 months ago at
which point he was "operated on" and [**Location (un) **] and had to have his
stomach pumped -- again poor history.

MEDICAL HISTORY: - History of heavy etoh use (1 quart vodka daily)
- S/p craniotomy in [**2199**] for L SDH with shift, at that time
noted chronic bilateral subdurals as well
- GERD
- depression

MEDICATION ON ADMISSION: none. States was previously on Paxil, Wellbutrin, denies ever
being on Spironolactone, Lasix, Nadolol, other liver meds.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: 97   p94 - 105  108/50 (105-124)   15  94% 4LNC
Very large and obviously jaundiced and distended M in no
distress, smells of EtOH. Conversant but slow speech, not
slurred.
Bilateral eyes with purulent crust in eyes, scleral edema, and
scleral icterus
Mouth dry but no obvious lesions, did not open mouth very wide,
unable to assess OP
CTAB anteriorly without w/c/r/r
Low grade tachycardia but regular, no m/g
Abd grossly distended and slightly tight, +caput medusae
Gross anasarca along abdominal wall, BUE's and BLE's
CN 2-12 grossly intact, no focal neuro deficit noted

FAMILY HISTORY: M - EtOH
F - deceased at 87yo

SOCIAL HISTORY: Smoked from 8 yrs old until [**5-13**] yrs ago; heavy ETOH use - 1
quart vodka/daily, lives with wife [**Telephone/Fax (1) 77153**] ([**Doctor Last Name 1356**]). Has 22
yo daughter, no IVDU or drug use now. 

### Response:
{'Blood in stool,Hepatorenal syndrome,Acute kidney failure with lesion of tubular necrosis,Alcoholic cirrhosis of liver,Acute respiratory failure,Septic shock,Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Pneumonia, organism unspecified,Unspecified septicemia,Severe sepsis,Acute posthemorrhagic anemia,Other ascites,Body Mass Index 50.0-59.9, adult,Acidosis,Unspecified protein-calorie malnutrition,Rhabdomyolysis,Cellulitis and abscess of trunk,Other postoperative infection,Paralytic ileus,Thrombocytopenia, unspecified,Other and unspecified alcohol dependence, continuous,Morbid obesity,Other diseases of pharynx, not elsewhere classified,Venous (peripheral) insufficiency, unspecified,Leukocytosis, unspecified,Unarmed fight or brawl,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
