CHIEF COMPLAINT: Variceal bleeding

PRESENT ILLNESS: 58 year old male with past medical history of alcoholic
cirrhosis complicated by gastric varices and recurrent GI
bleeding, myelodysplastic syndrome, radiation proctitis after
XRT for prastate cancer and JRA presented to [**Location (un) 2274**] today for
screening endoscopy and colonoscopy. Colonoscopey was not done
but endoscopy showed hypertensive gastropathy and villous
mucosa/?Barrett's at GE junction. A biopsy was taken but
complicated by profuse bleeding which was not amenable to
epinephrine injection or clipping due to poor visualization.
.
He was subsequently transferred to [**Hospital1 18**] ED for further
management. In the ED, he was intubated for airway protection.
Initial vitals were 177/72 87 100% on FiO2 100% PEEP of 5 RR: 14
and Vt: 500. OG tube suction showed dark blood. He was given
octreotid bolus.
Intubated. Pulse: 87. RR:14. FiO2100% BP:177/72. Bolused
octreotide and started on 2 units of O negative blood
transfusion. He was subsequently transferred to MICU.
.
In the MICU he received 2 units of pRBC, 1 unit of platelets and
1 unit of FFP. Right IJ trauma line was placed without any
complications. EGD showed clotted of bleed at GE junction which
could be variceal or arterial.

MEDICAL HISTORY: Alcoholic cirrhosis complicated by gastric varices and
encephalopathy
Myelodysplastic syndrome
Radiation proctitis
Total hip replacement
Juvenile rheumatoid arthritis
Seizures

MEDICATION ON ADMISSION: Tramadol 50 mg po QID
Lasix 40 mg po qdaily
Spironolactone 100 mg po qdaily
Propranolol 20 mg po BID
Folic acid 1 mg po qdaily
MVA

ALLERGIES: Dilantin

PHYSICAL EXAM: ADMISSION EXAM:
Tmax: 38.1 ??????C (100.6 ??????F)
Tcurrent: 38.1 ??????C (100.6 ??????F)
HR: 78 (62 - 78) bpm
BP: 151/64(86) {96/47(61) - 158/68(90)} mmHg
RR: 16 (13 - 29) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 76.7 kg (admission): 76.7 kg

FAMILY HISTORY: Not obtained as he was intubated/sedated

SOCIAL HISTORY: Unable to obtain as he was intubated.  Per Atrius records never
smoked.
Hematoma complicating a procedure,Hepatic encephalopathy,Pneumonia due to other gram-negative bacteria,Esophageal varices in diseases classified elsewhere, with bleeding,Iatrogenic cerebrovascular infarction or hemorrhage,Alcohol withdrawal,Alcoholic cirrhosis of liver,Other convulsions,Polyarticular juvenile rheumatoid arthritis, chronic or unspecified,Precipitous drop in hematocrit,Acute and subacute iridocyclitis, unspecified,Hemiplegia, unspecified, affecting unspecified side,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other and unspecified alcohol dependence, continuous,Nonspecific low blood pressure reading,Myelodysplastic syndrome, unspecified,Personal history of malignant neoplasm of prostate,Other specified disorders of rectum and anus,Other specified disorders of stomach and duodenum,Barrett's esophagus,Hypocalcemia,Spasm of muscle,Dysphagia, oropharyngeal phase,Facial weakness
Hematoma complic proc,Hepatic encephalopathy,Pneumo oth grm-neg bact,Bleed esoph var oth dis,Iatrogen CV infarc/hmrhg,Alcohol withdrawal,Alcohol cirrhosis liver,Convulsions NEC,Juv rheum arthritis NOS,Drop, hematocrit, precip,Acute iridocyclitis NOS,Unsp hemiplga unspf side,Abn react-procedure NEC,Alcoh dep NEC/NOS-contin,Low blood press reading,Myelodysplastic synd NOS,Hx-prostatic malignancy,Rectal & anal dis NEC,Gastroduodenal dis NEC,Barrett's esophagus,Hypocalcemia,Spasm of muscle,Dysphagia, oropharyngeal,Facial weakness
Admission Date:  [**2141-10-20**]              Discharge Date:   [**2141-10-30**]

Date of Birth:  [**2083-5-4**]             Sex:   M

Service: NEUROLOGY

Allergies:
Dilantin

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Variceal bleeding

Major Surgical or Invasive Procedure:
EGD

History of Present Illness:
58 year old male with past medical history of alcoholic
cirrhosis complicated by gastric varices and recurrent GI
bleeding, myelodysplastic syndrome, radiation proctitis after
XRT for prastate cancer and JRA presented to [**Location (un) 2274**] today for
screening endoscopy and colonoscopy. Colonoscopey was not done
but endoscopy showed hypertensive gastropathy and villous
mucosa/?Barrett's at GE junction. A biopsy was taken but
complicated by profuse bleeding which was not amenable to
epinephrine injection or clipping due to poor visualization.
.
He was subsequently transferred to [**Hospital1 18**] ED for further
management. In the ED, he was intubated for airway protection.
Initial vitals were 177/72 87 100% on FiO2 100% PEEP of 5 RR: 14
and Vt: 500. OG tube suction showed dark blood. He was given
octreotid bolus.
Intubated. Pulse: 87. RR:14. FiO2100% BP:177/72. Bolused
octreotide and started on 2 units of O negative blood
transfusion. He was subsequently transferred to MICU.
.
In the MICU he received 2 units of pRBC, 1 unit of platelets and
1 unit of FFP. Right IJ trauma line was placed without any
complications. EGD showed clotted of bleed at GE junction which
could be variceal or arterial.


Past Medical History:
Alcoholic cirrhosis complicated by gastric varices and
encephalopathy
Myelodysplastic syndrome
Radiation proctitis
Total hip replacement
Juvenile rheumatoid arthritis
Seizures


Social History:
Unable to obtain as he was intubated.  Per Atrius records never
smoked.

Family History:
Not obtained as he was intubated/sedated


Physical Exam:
ADMISSION EXAM:
Tmax: 38.1 ??????C (100.6 ??????F)
Tcurrent: 38.1 ??????C (100.6 ??????F)
HR: 78 (62 - 78) bpm
BP: 151/64(86) {96/47(61) - 158/68(90)} mmHg
RR: 16 (13 - 29) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 76.7 kg (admission): 76.7 kg

General: Intubated. Sedated.  Anicteric sclera.  PERRLA. EOMI.
Neck: JVP not elevated.  Trauma line in place at RIJ
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neurologic: Tone: less rigid and less hypertonic.  Still Upgoing
babiski bilaterally.  Not following commands, withdraws to pain
on L>R

DISCHARGE PHYSICAL EXAM:
VS: 96.9, 130/60, 60, 16, 98%RA
GEN: mildly paranoid, but interactive, somewhat cooperative
HEENT: OP clear, MM mildly dry
CV: RRR
PULM: CTA-B
ABD: soft, NT, ND
EXT: no edema

NEURO EXAM:
MS - didn't know his location, the month or date, but knew the
year.
CN - mild L facial droop, EOMI but needs lots of encouragement
to look past the midline to the L
MOTOR - antigravity in all 4 extremities, will not cooperate
with a more formal exam
SENSORY - intact to LT throughout, but mildldy diminished on
L-side
REFLEXES - upgoing toe bilaterally
COODRINATION - able to reach for examiners hand accurately
bilaterally
GAIT - deferred

Pertinent Results:
ADMISSION LABS [**2141-10-20**]:
CBC: WBC-3.7* RBC-2.39* Hgb-7.2* Hct-23.0* MCV-96 MCH-30.4
MCHC-31.5 RDW-13.7 Plt Ct-63*
Diff: Neuts-80.4* Lymphs-12.7* Monos-5.8 Eos-0.8 Baso-0.3
Coags: PT-14.6* PTT-28.6 INR(PT)-1.4*
Chemistries: Glucose-119* UreaN-13 Creat-0.6 Na-145 K-2.3*
Cl-115* HCO3-16* AnGap-16 Calcium-5.8* Phos-2.4* Mg-1.1*

DISCHARGE LABS:

[**2141-10-30**] 04:45AM BLOOD WBC-3.8* RBC-2.95* Hgb-8.6* Hct-26.9*
MCV-91 MCH-29.3 MCHC-32.1 RDW-15.3 Plt Ct-87*
[**2141-10-27**] 08:35AM BLOOD Neuts-82* Bands-0 Lymphs-9* Monos-5 Eos-4
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2141-10-30**] 04:45AM BLOOD Glucose-99 UreaN-17 Creat-0.9 Na-141
K-3.4 Cl-111* HCO3-23 AnGap-10
[**2141-10-30**] 04:45AM BLOOD ALT-34 AST-50* LD(LDH)-261* AlkPhos-75
TotBili-0.8
[**2141-10-24**] 12:18AM BLOOD Lipase-442*
[**2141-10-30**] 04:45AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.8 Mg-1.5*
[**2141-10-26**] 04:30AM BLOOD %HbA1c-5.0 eAG-97
[**2141-10-26**] 04:30AM BLOOD Triglyc-60 HDL-59 CHOL/HD-2.2 LDLcalc-60

CXR:
Low lung volumes accentuate prominence of the pulmonary
vasculature. Endotracheal tube in appropriate location.

CT Head:
No CT evidence for acute intracranial hemorrhage.

CT C-spine:
Degenerative changes of the cervical spine without evidence for
for fracture, normal alignment.

RUQ U/S:
1. Markedly dilated, but patent portal vein with biphhasic,
helical flow.
2. Patent paraumbilical vein and varices due to portal
hypertension.
3. Patent hepatic veins.
4. Gallstone, but no acute cholecystitis.
5. 4.6 x 4.3 cm anechoic cystic lesion at the porta hepatis,
likely represents a liver cyst off the caudate lobe.
.
[**10-23**] MRI:  IMPRESSION:
1. Early subacute infarcts in bilateral frontal, parietal, right
posterior
temporal and occipital lobes, right thalamus and right superior
cerebellar
vermis. These are of different chronicity and likely
thromboembolic in
etiology.
2. Generalized cerebral atrophy with extensive changes of
chronic small
vessel ischemic disease.
3. The right temporalis muscle is slightly enlarged in size and
appears
hyperintense on FLAIR images, this may represent edema or
myositis.

EEG [**2141-10-24**]: IMPRESSION: This EEG continues to show an
exceptionally active paroxysmal epileptiform abnormality in the
right occipital pole in the context of a continuous focal delta
disturbance suggestive of a large
structural lesion in that region. There are superimposed fairly
frequent electrographic seizures that are now spreading to the
left
homolygous hemipsheric regions but with no obvious clinical
accompaniment.

EEG [**2141-10-25**]: IMPRESSION: This is an abnormal continuous ICU
video EEG study due to paroxysmal at times periodic epileptiform
discharges in the right occipital pole in the context of a
continuous focal delta activity
suggestive of a large structural lesion in that region. There
are
superimposed intermittent electrographic seizures that
occasionally
spread to the left homologous hemispheric regions but with no
obvious
clinical accompaniment. The seizures decreased in frequency and
amplitude towards the end of the recording. Background was
asymmetric
with delta slowing and suppression on the right and [**6-27**] Hz
posterior
dominant rhythm on the left.

EEG [**2141-10-26**]: IMPRESSION: This is an abnormal continuous ICU
video EEG study due to paroxysmal and, at times, periodic
epileptiform discharges in the right occipital pole in the
context of a continuous focal delta activity suggestive of a
large structural lesion in that region. There are
superimposed intermittent electrographic seizures but with no
obvious
clinical accompaniment. The seizures stopped after 17:52.
Background
was asymmetric with delta slowing and suppression on the right
and [**6-27**]
Hz posterior dominant rhythm on the left.

MR HEAD [**2141-10-26**]: IMPRESSION:
Limited study due to motion artefacts.
1. Multiple areas of restricted diffusion with associated FLAIR
and T2
hyperintensity in bilateral frontal, parietal, right posterior
temporal and occipital lobes, right thalamus and right superior
cerebellar vermis. The distribution of the lesions make the
possibility of these being infarcts more likely than being due
to seizures. These have not significantly changed since the
prior study. No evidence of hemorrhagic transformation of the
infarcts.
2. Generalized cerebral atrophy with extensive changes of
chronic small
vessel ischemic disease.

CTA HEAD AND NECK [**2141-10-27**]: IMPRESSION: Moderate atherosclerotic
calcifications of the cervical carotid bifurcations with no
evidence of critical stenosis.
There is no evidence of critical stenosis or aneurysms in the
circle of
[**Location (un) 431**]. Evolution of the bilateral parietal infarction, with
associated
vasogenic edema, producing effacement of the sulci on the right
parietal lobe as described above, there is no evidence of
hemorrhagic transformation.


Brief Hospital Course:
Mr. [**Known lastname 4027**] is a 58 year old male with past medical history of
alcoholic cirrhosis complicated by gastric varices,
encephalopathy and recurrent GI bleeding admitted for concern
for variceal bleeding after biopsy of mass at the
gastroesophageal (GE)junction, found to have R MCA and PCA
territoty infarcts once awakened from sedation.
.
ACTIVE ISSUES BY PROBLEM:
# GE junction bleed: Endoscopy by hepatology showed clotted off
lesion which could be hematoma at the site of arterial bleed or
variceal bleed.  No intervention was made during the endoscopy.
The patient had a trauma line placed, and serial HCTs were
monitored.  While in the MICU, his HCTs remained stable and he
was hemodynamically stable.  The patient was initially on
pantoprazole and octreotide drips.  After the endoscopy, the
octreotide drip was discontinued, and the patient was switched
to IV PPI [**Hospital1 **].  He was also started on ceftriaxone for
spontaneous bacterial peritonitis (SBP) prophylaxis.  The
patient's HCTs were checked q8h, with goal HCT maintained
between 25 and 30.  Hepatology followed the patient and on [**10-27**]
felt that ASA 81mg was ok to give, which was started for
secondary stroke prevention (see below)
.
# New right hemispheric stroke: As sedation was weaned, it
became apparent that the patient had left hemiparesis and loss
of leftward gaze.  Additionally, he continued to have focal
occipital seizures even after increasing antiepileptics.  The
patient also had evidence of upper motor neuron signs, with
upgoing Babinski, hyperreflexia, and rigid tone on the left
side.  CT head/neck without contrast was negative for acute
process.  EEG showed abnormal epileptiform discharges (the
patient has a history of seizures).  MRI showed early subacute
infarcts in bilateral frontal, parietal, right posterior
temporal and occipital lobes, right thalamus and right superior
cerebellar vermis; there are of different chronicity and likely
thromboembolic in etiology.  TTE showed aortic regurgitation and
aortic stenosis and bubble study was done showing no PFO.
However, saline was only injected at rest, as patient could not
perform any maneuvers. Social work, PT/OT, and speech and
swallow were all consulted.  Neurology was consulted, and then
patient was transferred to the neurology service once he was
stable enough to leave the ICU.  We started him on ASA 81mg QD
on [**10-27**].  He received a CTA to see if his blood vessels were
patent, which they were.  Therefore the asymmetrical appearance
of his infarcts is unlikely to be caused by hypotension, as this
would be more symmetrical in appearance.
.
# Seizures:  The patient has a history of alcohol withdrawal and
post-op seizures.  EEG showed abnormal epileptiform discharges;
hundreds of briefly sustained electrographic seizures from the
right occipital area with occasional spread to the left occiput.
 He was started on IV Keppra 2 grams [**Hospital1 **]. His EEG improved to
show less frequent seizures, but they were still occurring.  He
was then started on lacosamide, and his seizures further
decreased.  However, he continued to have no clinical correlate
and was awake and interactive during his sublclinical seizures.
We stopped his lacosamide, and his EEG did not become more
active, so we slowly tapered down the keppra to 1000mg [**Hospital1 **].
This can be further tapered down in the future as long as his
exam doesn't worsen with each subsequent decrease.
.
# Fevers:  The patient started spiking fevers while in the MICU.
  No infectious source was found, but there was a possible RLL
infiltrate on CXR and the patient was empirically started on
cefepime.  His sputum cultures were also growing out Gram
negative rods.  The patient was never ill-appearing, however,
and it was thought that his fevers could be medication related
or neurogenic fevers, given his new onset stroke.  However,
given his recent intubation, he will complete a 15 day course
for presumed VAP.
.
#. Alcoholic cirrhosis complicated by cirrhosis and
encephalopathy: Hepatology was following the patient, and he was
continued on PPI [**Hospital1 **], and was started on ceftriaxone for SBP
prophylaxis.  Social work was consulted.  The patient was also
initiated on CIWA protocol.  On transfer from the unit, the
patient was not requiring any ativan for withdrawal.  The
patient's home lasix, spironolactone, propranolol were in the
setting of the UGIB, but eventually were restarted with no
issues.
.
# Hypernatremia:  The patient was hypernatremic and we increased
free water flushes through the patient's NGT.

PENDING RESULTS:
Final EEG read [**10-27**], [**10-28**] and [**10-29**]

TRANSTIONAL CARE ISSUES
Patient is Rh neg and received RH + plt.  If a candidate for
liver transplant, he needs to get WinRho (Rh immunoglobulin).
His LFTs will need to be monitored frequently as he was just
started on simvastatin on [**2141-10-30**].  In addition, his platelets
will need to be monitored while he is on aspirin to ensure that
they do not drop below 50.

Medications on Admission:
Tramadol 50 mg po QID
Lasix 40 mg po qdaily
Spironolactone 100 mg po qdaily
Propranolol 20 mg po BID
Folic acid 1 mg po qdaily
MVA


Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): Do not exceed 2 grams of tylenol in 24 hours.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours) as needed for agitation.
12. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. cefepime in D5W 2 gram/50 mL Piggyback Sig: Two (2) grams
Intravenous every eight (8) hours for 10 days: Last day = [**11-8**]
to finish a 15 day course.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
15. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Right sided MCA and PCA territory infarcts


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.

NEURO EXAM: rambling, mildly paranoid speech, L arm > L leg
weakness, extinction to DSS on L


Discharge Instructions:
Dear Mr. [**Known lastname 4027**],
You were seen in the hospital because you need an EGD, but
during this procedure you had some bleeding, that led to you
needing to be intubated.  Once you woke up, it was found that
you had had a stroke that caused you difficulty moving your left
side.

We made the following changes to you medications:
1) We STOPPED your TRAMADOL.
2) We STARTED you on SUBCUTANEOUS HEPARIN 5,000 units three
times a day to prevent DVTs while you are at rehab.
3) We STARTED you on TYLENOL 500mg every 6 hours.  You are not
to exceed more than 2 grams of tylenol in a given 24 hour period
as this can cause liver damage.
4) We STARTED you on OXYCODONE 5mg every 6 hours as needed for
pain.
5) We STARTED you on ASPIRIN 81mg once a day.
6) We STARTED you on SEROQUEL 12.5mg every 12 hours as needed
for agitation.
7) We STARTED you on SIMVASTATIN 10mg once a day.  Your liver
function tests will need to be monitored while you are on this
medication.
8) We STARTED you on CEFEPIME 2 grams every 8 hours.  You will
continue this antibiotic until [**2141-11-8**].
9) We STARTED you on PANTOPRAZOLE 40mg every 12 hours.
10) We STARTED  you on KEPPRA 1,000mg twice a day.

Please continue to take yout other medications as previously
prescribed.

If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.

It was a pleasure taking care of you on this hospitalization.

Followup Instructions:
You have a follow-up appointment with Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 3614**] on [**11-27**] at 8:30am.  His office is located at 26 City [**Doctor Last Name **] Mall in
[**Location (un) 1468**], MA.  If you have any questions about thia appointment
you can call his office on [**Telephone/Fax (1) 97983**]

Department: NEUROLOGY
When: TUESDAY [**2141-12-5**] at 3:00 PM
With: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD [**Telephone/Fax (1) 657**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
{"Hematoma complicating a procedure,Hepatic encephalopathy,Pneumonia due to other gram-negative bacteria,Esophageal varices in diseases classified elsewhere, with bleeding,Iatrogenic cerebrovascular infarction or hemorrhage,Alcohol withdrawal,Alcoholic cirrhosis of liver,Other convulsions,Polyarticular juvenile rheumatoid arthritis, chronic or unspecified,Precipitous drop in hematocrit,Acute and subacute iridocyclitis, unspecified,Hemiplegia, unspecified, affecting unspecified side,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other and unspecified alcohol dependence, continuous,Nonspecific low blood pressure reading,Myelodysplastic syndrome, unspecified,Personal history of malignant neoplasm of prostate,Other specified disorders of rectum and anus,Other specified disorders of stomach and duodenum,Barrett's esophagus,Hypocalcemia,Spasm of muscle,Dysphagia, oropharyngeal phase,Facial weakness"}


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 bleeding

PRESENT ILLNESS: 58 year old male with past medical history of alcoholic
cirrhosis complicated by gastric varices and recurrent GI
bleeding, myelodysplastic syndrome, radiation proctitis after
XRT for prastate cancer and JRA presented to [**Location (un) 2274**] today for
screening endoscopy and colonoscopy. Colonoscopey was not done
but endoscopy showed hypertensive gastropathy and villous
mucosa/?Barrett's at GE junction. A biopsy was taken but
complicated by profuse bleeding which was not amenable to
epinephrine injection or clipping due to poor visualization.
.
He was subsequently transferred to [**Hospital1 18**] ED for further
management. In the ED, he was intubated for airway protection.
Initial vitals were 177/72 87 100% on FiO2 100% PEEP of 5 RR: 14
and Vt: 500. OG tube suction showed dark blood. He was given
octreotid bolus.
Intubated. Pulse: 87. RR:14. FiO2100% BP:177/72. Bolused
octreotide and started on 2 units of O negative blood
transfusion. He was subsequently transferred to MICU.
.
In the MICU he received 2 units of pRBC, 1 unit of platelets and
1 unit of FFP. Right IJ trauma line was placed without any
complications. EGD showed clotted of bleed at GE junction which
could be variceal or arterial.

MEDICAL HISTORY: Alcoholic cirrhosis complicated by gastric varices and
encephalopathy
Myelodysplastic syndrome
Radiation proctitis
Total hip replacement
Juvenile rheumatoid arthritis
Seizures

MEDICATION ON ADMISSION: Tramadol 50 mg po QID
Lasix 40 mg po qdaily
Spironolactone 100 mg po qdaily
Propranolol 20 mg po BID
Folic acid 1 mg po qdaily
MVA

ALLERGIES: Dilantin

PHYSICAL EXAM: ADMISSION EXAM:
Tmax: 38.1 ??????C (100.6 ??????F)
Tcurrent: 38.1 ??????C (100.6 ??????F)
HR: 78 (62 - 78) bpm
BP: 151/64(86) {96/47(61) - 158/68(90)} mmHg
RR: 16 (13 - 29) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 76.7 kg (admission): 76.7 kg

FAMILY HISTORY: Not obtained as he was intubated/sedated

SOCIAL HISTORY: Unable to obtain as he was intubated.  Per Atrius records never
smoked. 

### Response:
{"Hematoma complicating a procedure,Hepatic encephalopathy,Pneumonia due to other gram-negative bacteria,Esophageal varices in diseases classified elsewhere, with bleeding,Iatrogenic cerebrovascular infarction or hemorrhage,Alcohol withdrawal,Alcoholic cirrhosis of liver,Other convulsions,Polyarticular juvenile rheumatoid arthritis, chronic or unspecified,Precipitous drop in hematocrit,Acute and subacute iridocyclitis, unspecified,Hemiplegia, unspecified, affecting unspecified side,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other and unspecified alcohol dependence, continuous,Nonspecific low blood pressure reading,Myelodysplastic syndrome, unspecified,Personal history of malignant neoplasm of prostate,Other specified disorders of rectum and anus,Other specified disorders of stomach and duodenum,Barrett's esophagus,Hypocalcemia,Spasm of muscle,Dysphagia, oropharyngeal phase,Facial weakness"}
