CHIEF COMPLAINT: hematemesis

PRESENT ILLNESS: 59 year old woman with no PMH presents with 5 days of abdominal
pain and nausea, and one day of nausea/hematemesis.
.
5 days ago patient experienced [**12-31**] loose non bloody bowel
movements per day, assocaiated with mild intermittent lower
abdominal pain.  Three days ago, she noted shaking and felt hot
and sweaty, thought she hd a temperature, but did not have a
thermometer.  This evening around 7:00 pm she became acutely
nauseous and vomiting with BRB.  With her second emesis, she
vomited > 1 cup BRB. She then had 4 more episodes of
hematemesis, < 1 cup.
.
Denies dizziness, lightheadedness, syncope, chest pain.  No
recent travel or food experiementation.  She does note a tick
bite to her right thigh about 1 week ago.  She removed it
promptly, and did not have any rash.
.
On arrival to the ED VS were 97.1 98 102/59 15 99% RA.  NGT was
placed, removed mild BRB and coffee grounds, cleared after 500cc
lavage. Guaiac negative brown stool.  Hct 40.  Called GI,
thought likely [**Doctor First Name 329**] [**Doctor Last Name **] tear, would consider endoscopy in
am.  Started on pantoprazole bolus + drip, 2 18g PIVs placed.
Given 2L NS.  Admitted to ICU for UGIB.
.
On arrival to the MICU, she feels shaky, but nausea is improved
since arrival.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: Sulfa(Sulfonamide Antibiotics) / Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
VS: 98.0, 100-110/60-76, 73-86, 18, 95% on 4L
Gen: Well-appearing, alert, and communicative
HEENT: MMM
Lungs: Minimal crackles anteriorly R>L.
Heart: RRR, no murmuirs, no rubs
Abd: Soft, nontender, nondistended
Ext: Trace pedal edema, edema of right hand, clubbing of
fingers. No further rashon legs

FAMILY HISTORY: Father with type II DM and bladder cancer, mother with lung
cancer.

SOCIAL HISTORY: Works at a law firm. Smokes 8 cigarettes/day. Drinks 2
beers/day.
Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Intestinal infection due to other organism, not elsewhere classified,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Unspecified septicemia,Severe sepsis,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Esophagitis, unspecified,Hypoxemia,Other and unspecified Escherichia coli [E. coli],Diaphragmatic hernia without mention of obstruction or gangrene,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Leukocytosis, unspecified,Alcohol abuse, unspecified,Salicylates causing adverse effects in therapeutic use
Chr stomach ulc w hem,Viral enteritis NOS,Food/vomit pneumonitis,Acute respiratry failure,Septicemia NOS,Severe sepsis,Urin tract infection NOS,Hyposmolality,Chr duoden ulcer w hem,Esophagitis, unspecified,Hypoxemia,E.coli infection NEC/NOS,Diaphragmatic hernia,Elev transaminase/ldh,Leukocytosis NOS,Alcohol abuse-unspec,Adv eff salicylates
Admission Date:  [**2152-4-30**]              Discharge Date:   [**2152-5-6**]

Date of Birth:  [**2092-8-3**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa(Sulfonamide Antibiotics) / Sulfa(Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 633**]
Chief Complaint:
hematemesis

Major Surgical or Invasive Procedure:
EGD

History of Present Illness:
59 year old woman with no PMH presents with 5 days of abdominal
pain and nausea, and one day of nausea/hematemesis.
.
5 days ago patient experienced [**12-31**] loose non bloody bowel
movements per day, assocaiated with mild intermittent lower
abdominal pain.  Three days ago, she noted shaking and felt hot
and sweaty, thought she hd a temperature, but did not have a
thermometer.  This evening around 7:00 pm she became acutely
nauseous and vomiting with BRB.  With her second emesis, she
vomited > 1 cup BRB. She then had 4 more episodes of
hematemesis, < 1 cup.
.
Denies dizziness, lightheadedness, syncope, chest pain.  No
recent travel or food experiementation.  She does note a tick
bite to her right thigh about 1 week ago.  She removed it
promptly, and did not have any rash.
.
On arrival to the ED VS were 97.1 98 102/59 15 99% RA.  NGT was
placed, removed mild BRB and coffee grounds, cleared after 500cc
lavage. Guaiac negative brown stool.  Hct 40.  Called GI,
thought likely [**Doctor First Name 329**] [**Doctor Last Name **] tear, would consider endoscopy in
am.  Started on pantoprazole bolus + drip, 2 18g PIVs placed.
Given 2L NS.  Admitted to ICU for UGIB.
.
On arrival to the MICU, she feels shaky, but nausea is improved
since arrival.

Past Medical History:
None

Social History:
Works at a law firm. Smokes 8 cigarettes/day. Drinks 2
beers/day.


Family History:
Father with type II DM and bladder cancer, mother with lung
cancer.

Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
VS: 98.0, 100-110/60-76, 73-86, 18, 95% on 4L
Gen: Well-appearing, alert, and communicative
HEENT: MMM
Lungs: Minimal crackles anteriorly R>L.
Heart: RRR, no murmuirs, no rubs
Abd: Soft, nontender, nondistended
Ext: Trace pedal edema, edema of right hand, clubbing of
fingers. No further rashon legs

Pertinent Results:
ADMISSION LABS:
[**2152-4-30**] 09:30PM BLOOD WBC-15.6* RBC-4.54 Hgb-13.8 Hct-40.6
MCV-89 MCH-30.3 MCHC-33.9 RDW-11.8 Plt Ct-189
[**2152-4-30**] 09:30PM BLOOD Neuts-87.7* Lymphs-6.1* Monos-5.6 Eos-0.4
Baso-0.2
[**2152-4-30**] 09:30PM BLOOD PT-12.4 PTT-29.8 INR(PT)-1.1
[**2152-4-30**] 09:30PM BLOOD Glucose-126* UreaN-17 Creat-0.9 Na-128*
K-3.6 Cl-89* HCO3-25 AnGap-18
[**2152-4-30**] 09:30PM BLOOD ALT-59* AST-51* AlkPhos-68 TotBili-0.6
.
DISCHARGE LABS:
[**2152-5-6**] 01:30PM BLOOD WBC-8.3 RBC-4.09* Hgb-12.1 Hct-38.0
MCV-93 MCH-29.6 MCHC-31.9 RDW-12.9 Plt Ct-359#
[**2152-5-5**] 06:15AM BLOOD Neuts-79.3* Lymphs-15.4* Monos-4.7
Eos-0.1 Baso-0.5
[**2152-5-1**] 04:25AM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL
Polychr-OCCASIONAL
[**2152-5-1**] 05:15PM BLOOD Parst S-NEGATIVE
[**2152-5-6**] 01:30PM BLOOD Glucose-94 UreaN-10 Creat-0.6 Na-138
K-4.5 Cl-103 HCO3-27 AnGap-13
[**2152-5-5**] 06:15AM BLOOD ALT-49* AST-59* AlkPhos-63 TotBili-0.4
.
MICROBIOLOGY:
[**2152-5-1**] Urine culture: mixed flora
[**2152-5-1**] Blood culture: no growth to date
[**2152-5-1**] Influenza A/B nasopharyngeal swab: negative
[**2152-5-1**] Lyme serology: pending
[**2152-5-1**] H. pylori Ab: negative
[**2152-5-1**] Urine Legionella Ag: negative
[**2152-5-2**] Blood culture: no growth to date
[**2152-5-3**] Blood culture: no growth to date
[**2152-5-3**] Blood culture (mycolytic): no growth to date
[**2152-5-3**] Stool culture/C. diff: pending
.
IMAGING:
[**2152-4-30**] CXR: The lung apices are not depicted. NG tube ends in
the gastric antrum in appropriate position. The lungs are clear,
the cardiomediastinal silhouette and hila are normal. There is
no pleural effusion and no pneumothorax. Partially visualized
abdomen shows normal bowel gas pattern.

EGD [**2152-5-1**]:
Esophagitis in the lower third of the esophagus
Small hiatal hernia
Friability and erythema in the antrum and stomach body
compatible with gastritis
Ulcer in the pylorus
Ulcers in the duodenal bulb
Otherwise normal EGD to third part of the duodenum
Recommendations: Prilosec 40mg [**Hospital1 **]
Advance diet as tolerated. Avoid NSAIDs. Serial hcts. Active
type and cross. GI bleeding is unlikely the cause of the
patient's current hypotensive episodes and warrents further
investigation for a possible infectious cause. Given the clear
history of NSAID use, follow up egd is not required but would
check a h pylori serology and treat if positive. Would need a
test of cure 4 weeks post h pylori serology as well.

.
[**2152-5-1**] CTA chest:
1. No PE.
2. Mild pulmonary edema.
3. Upper lobe peribronchovascular airspace filling could be
edema or a manifestation of more severe airspace abnormality in
the lower lungs, mostly consolidation, partially atelectasis,
due to aspiration, multifocal
pneumonia, or less likely hemorrhage. In the setting of a recent
transfusions, transfusion reaction may be contributory.
4. Esophageal wall thickening, with diffuse infiltration of the
mediastinal fat which may reflect inflammatory change or
confluent lymphadenopathy, though the progression from normal
mediastinal contours on [**4-30**] favors a rapidly evolving
inflammatory process. There is no finding to suggest esophageal
perforation.
.
[**2152-5-2**] CXR: As compared to the previous radiograph, there is a
massive increase in extent and severity of multifocal pneumonia.
The resulting very widespread parenchymal opacities are more
extensive on the right than on the left and show multiple air
bronchograms. In addition, retrocardiac atelectasis has newly
appeared, and there is a small right pleural effusion. The
opacities are better displayed on the CTA examination, performed
yesterday at 9:41 p.m. Moderate cardiomegaly.


Brief Hospital Course:
59 year old woman with no known medical history who presented
with subjective fevers, abdominal pain, and hematemesis and
developed hypoxic respiratory failure. Clinical picture likely
consistent with an initial gastroenteritis with emesis likely
leading to aspiration pneumonia and hematemesis.

# Hematemesis: EGD revealed mild esophagitis, a non-bleeding 7mm
ulcer in the pylorus, and several superficial non-bleeding
ulcers ranging in size from 3mm to 5mm in the duodenal bulb.
This was likely due to aspirin use and recurrent emesis. H.
pylori antibody is negative. Her HCT continued to rise and she
was transitioned from a pantoprazole gtt to pantoprazole 40mg PO
Q12h.

# Hypoxemic Respiratory Failure: Patient developed fevers and
new hypoxia on [**5-1**]. She was empirically treated for pneumonia
with ceftriaxone. CT chest showed likely multifocal pneumonia
which was possible due to aspiration. Given these findings,
antibiotics were broadened to vanc/levo/flagyl and ID was
consulted. The vanc was discontinued on [**5-3**] and the patient was
discharged with PO levo and flagyl for likely aspiration
pneumonia. Her pulmonary status improved significantly during
hosptialization and she was satting 100% on RA at discharge.

# Volume overload: the patient received over 12L of IV fluids in
the ICU in the setting of hypotension (BP 80/40s with fever,
mottled legs, likely sepsis with pulmonary source). After pt
stabalized, she was gently diuresed.

# Diarrhea/Abdominal Pain: Likely viral gastroenteritis as this
resolved during the hospitalization. Stool cultures, including C
diff, were negative.

# Tick Bite: Recent tick bite removed quickly. Lyme serologies
were negative and smear was negative for babesiosis although
ANAPLASMA PHAGOCYTOPHILUM was negative.
.
# Transaminitis: Very mild transaminitis (50s). No RUQ pain, no
hyperbilirubinemia. Likely related to viral
gastroenteritis/acute infectious process.

Transitional issues/INcidental radiographic findings.
-Pt will require primary care follow up: has not seen a PCP [**Last Name (NamePattern4) **]
10 years. Would follow LFT's as well.
-Pt has recently decided to stop smoking. Outpatient support
should be provided to support this goal.
-Pt still mildly volume overload at discharge. She was
mobilizing and self-diuresing effectively and will follow up
with PCP closely to see if she would benefit from lasix.
-PT WAS NOTED TO HAVE ESOPHAGEAL WALL THICKENING ON CT WITH
CONFLUENT LYMPHADENOPATHY THAT FAVORED AN INFLAMMATORY PROCESS.
This will likely require further work up

Medications on Admission:
None

Discharge Medications:
1. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 6 Days
RX *metronidazole 500 mg Every 8 hours Disp #*18 Tablet
Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg twice a day Disp #*60 Tablet Refills:*2
3. Levofloxacin 750 mg PO DAILY
RX *Levaquin 750 mg daily Disp #*6 Tablet Refills:*0


Discharge Disposition:
Home

Discharge Diagnosis:
Pneumonia- multifocal
Ulcers of the stomach and duodenum (upper small intestine).
Diarrhea
Gastroenteritis
Pulmonary Edema


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


Discharge Instructions:
You were treated in the hospital for pneumonia and vomitting up
of blood clots that likely developed because of vomitting,
diarrhea, and fevers (possibly due to a stomach flu) as well as
high doses of aspirin that worsened your stomach and small
intestine ulcers.

It is important that you complete the course of antibiotics for
treatment of your pneumonia. Please take Levofloxacin 750 mg by
mouth daily and metronidazole 500 mg by mouth every 8 hours for
six more days.

As you know, you were given many liters of fluids through your
veins while you were in the intensive care unit because you were
so sick. You will continue to urinate out this fluid within the
next several days.

Because you vomitted blood, we took a look at your esophagus,
stomach, and upper small intestines with a camera. We saw that
you have an ulcer in your stomach and several ulcers of your
upper small intestine. To help treat your ulcers, it is
important that you start to take Prilosec (omeprazole) 40mg
twice a day. It is also important that you avoid all
non-steroidal anti-inflammatory drugs, including ibuprofen,
alleve, and aspirin. You may take tylenol.

You developed new diarrhea in the hospital. This is most likely
likely due to antibiotics and should resolve as your gut flora
return. You can take yogurt or lactobacillus supplements to
accelerate this process. If your diarrhea gets worse or you
develop any fevers, please see your doctor.

Finally, it is important that you begin to see a primary care
doctor regularly. Please follow-up regarding this
hospitalization with [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **] NP (see appointment below). At
that time, you will also be set up with a primary care doctor.

We have made the following changes to your medications:
START Levofloxacin 750 mg by mouth daily and metronidazole 500
mg by mouth every 8 hours for six more days.
START Pantoprazole 40mg by mouth twice a day


Followup Instructions:
Name: NP [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **]
Location: [**Hospital **] Medical Group
Address: [**Month (only) 66695**], [**Hospital1 **],[**Numeric Identifier 66696**]
Phone: [**Telephone/Fax (1) 66697**]
Appointment: Monday [**2152-5-8**] 10:40am
*This is a follow up appointment for your hospitalization. You
will be reconnected with your primary care provider after this
visit.
{'Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Intestinal infection due to other organism, not elsewhere classified,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Unspecified septicemia,Severe sepsis,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Esophagitis, unspecified,Hypoxemia,Other and unspecified Escherichia coli [E. coli],Diaphragmatic hernia without mention of obstruction or gangrene,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Leukocytosis, unspecified,Alcohol abuse, unspecified,Salicylates causing adverse effects in therapeutic use'}


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: hematemesis

PRESENT ILLNESS: 59 year old woman with no PMH presents with 5 days of abdominal
pain and nausea, and one day of nausea/hematemesis.
.
5 days ago patient experienced [**12-31**] loose non bloody bowel
movements per day, assocaiated with mild intermittent lower
abdominal pain.  Three days ago, she noted shaking and felt hot
and sweaty, thought she hd a temperature, but did not have a
thermometer.  This evening around 7:00 pm she became acutely
nauseous and vomiting with BRB.  With her second emesis, she
vomited > 1 cup BRB. She then had 4 more episodes of
hematemesis, < 1 cup.
.
Denies dizziness, lightheadedness, syncope, chest pain.  No
recent travel or food experiementation.  She does note a tick
bite to her right thigh about 1 week ago.  She removed it
promptly, and did not have any rash.
.
On arrival to the ED VS were 97.1 98 102/59 15 99% RA.  NGT was
placed, removed mild BRB and coffee grounds, cleared after 500cc
lavage. Guaiac negative brown stool.  Hct 40.  Called GI,
thought likely [**Doctor First Name 329**] [**Doctor Last Name **] tear, would consider endoscopy in
am.  Started on pantoprazole bolus + drip, 2 18g PIVs placed.
Given 2L NS.  Admitted to ICU for UGIB.
.
On arrival to the MICU, she feels shaky, but nausea is improved
since arrival.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: Sulfa(Sulfonamide Antibiotics) / Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
VS: 98.0, 100-110/60-76, 73-86, 18, 95% on 4L
Gen: Well-appearing, alert, and communicative
HEENT: MMM
Lungs: Minimal crackles anteriorly R>L.
Heart: RRR, no murmuirs, no rubs
Abd: Soft, nontender, nondistended
Ext: Trace pedal edema, edema of right hand, clubbing of
fingers. No further rashon legs

FAMILY HISTORY: Father with type II DM and bladder cancer, mother with lung
cancer.

SOCIAL HISTORY: Works at a law firm. Smokes 8 cigarettes/day. Drinks 2
beers/day. 

### Response:
{'Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Intestinal infection due to other organism, not elsewhere classified,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Unspecified septicemia,Severe sepsis,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Esophagitis, unspecified,Hypoxemia,Other and unspecified Escherichia coli [E. coli],Diaphragmatic hernia without mention of obstruction or gangrene,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Leukocytosis, unspecified,Alcohol abuse, unspecified,Salicylates causing adverse effects in therapeutic use'}
