CHIEF COMPLAINT: Hematemesis

PRESENT ILLNESS: Mr. [**Known lastname 52**] is a 60 y/o man with cryptogenic cirrhosis and known
gastric fundal varices transferred from [**Hospital6 33**]
with hematemesis. Patient felt nauseated on day of admission and
spit up small amt of blood at home. Initial BP on EMS arrival
was in the 80s with HR in the 110s. At that time, he was taken
to [**Hospital1 34**] where he received 4 U PRBCs and 2 U FFP and platelets. He
was treated with IV protonix and octreotide gtt. No endoscopy
was performed as his bleeding had stopped and no ultrasound was
done of his liver/TIPS. He was transferred to [**Hospital1 18**] after 1 day
for further care.

MEDICAL HISTORY: 1) Cryptogenic cirrhosis c/b ascites, gastric varices, hepatic
encephalopathy s/p TIPS in [**2147**]
2) h/o nephrolithiasis

MEDICATION ON ADMISSION: Lactulose 30 mL daily to twice daily
Spironolactone 50 mg [**Hospital1 **]
Lasix 40 mg daily
Protonix 40 mg daily
Rifaximin 200mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.2 BP 143/74 HR 124 RR 22 O2 96% on room air
GEN: somnolent but arousable to voice, does not answer questions
reliably (consistently answers "yes")
HEENT: pupils large but reactive bilaterally, sclerae anicteric,
MM slightly dry, op clear
RESP: grossly clear without wheezes or rhonchi
CV: RRR, normal S1, S2
ABD: distended but soft, nontender to palpation throughout, +
fluid wave, hypoactive bowel sounds
EXT: dp pulses 2+ bilaterally, no edema
SKIN: no rash
NEURO: alert, not oriented, not reliably answering questions,
face symmetric, PERRL, tongue midline, moving lower extremities
in hip flexion, bilateral hand grip intact, no hyperreflexia, no
clonus, no appreciable asterixis on exam

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives with wife. [**Name (NI) **] alcohol, prior smoker (quit > 30 years ago).
Hemorrhage of gastrointestinal tract, unspecified,Acute respiratory failure,Cirrhosis of liver without mention of alcohol,Portal hypertension,Iron deficiency anemia secondary to blood loss (chronic),Varices of other sites
Gastrointest hemorr NOS,Acute respiratry failure,Cirrhosis of liver NOS,Portal hypertension,Chr blood loss anemia,Varices of other sites
Admission Date:  [**2149-10-10**]              Discharge Date:   [**2149-10-14**]

Date of Birth:  [**2089-7-14**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Hematemesis

Major Surgical or Invasive Procedure:
Dermabond injection of gastric varix
TIPS revision


History of Present Illness:
Mr. [**Known lastname 52**] is a 60 y/o man with cryptogenic cirrhosis and known
gastric fundal varices transferred from [**Hospital6 33**]
with hematemesis. Patient felt nauseated on day of admission and
spit up small amt of blood at home. Initial BP on EMS arrival
was in the 80s with HR in the 110s. At that time, he was taken
to [**Hospital1 34**] where he received 4 U PRBCs and 2 U FFP and platelets. He
was treated with IV protonix and octreotide gtt. No endoscopy
was performed as his bleeding had stopped and no ultrasound was
done of his liver/TIPS. He was transferred to [**Hospital1 18**] after 1 day
for further care.

Of note, per wife, the patient has had 3 other admissions to
[**Hospital6 33**] in the past month for hematemesis. [**9-17**]:
endoscopy showed possible [**Doctor First Name **]-[**Doctor Last Name **] tear. [**9-27**]: had
hematemesis requiring 6 units RBCs. EGD showed no active
bleeding, but cautery was performed. [**10-3**]: self-limited
bleeding, no endoscopy performed.

On arrival to the ICU, the patient is somnolent but arousable to
voice. Not answering questions. Accompanied by wife who reports
he was more somnolent today and was given PR lactulose X 1 prior
to transfer. She reports that he becomes encephalopathic when he
misses his lactulose.

Past Medical History:
1) Cryptogenic cirrhosis c/b ascites, gastric varices, hepatic
encephalopathy s/p TIPS in [**2147**]
2) h/o nephrolithiasis

Social History:
Lives with wife. [**Name (NI) **] alcohol, prior smoker (quit > 30 years ago).

Family History:
NC

Physical Exam:
VS: T 97.2 BP 143/74 HR 124 RR 22 O2 96% on room air
GEN: somnolent but arousable to voice, does not answer questions
reliably (consistently answers "yes")
HEENT: pupils large but reactive bilaterally, sclerae anicteric,
MM slightly dry, op clear
RESP: grossly clear without wheezes or rhonchi
CV: RRR, normal S1, S2
ABD: distended but soft, nontender to palpation throughout, +
fluid wave, hypoactive bowel sounds
EXT: dp pulses 2+ bilaterally, no edema
SKIN: no rash
NEURO: alert, not oriented, not reliably answering questions,
face symmetric, PERRL, tongue midline, moving lower extremities
in hip flexion, bilateral hand grip intact, no hyperreflexia, no
clonus, no appreciable asterixis on exam

Pertinent Results:
[**2149-10-10**] 09:04PM BLOOD WBC-4.2 RBC-3.72* Hgb-11.4* Hct-32.6*
MCV-88# MCH-30.7 MCHC-35.1* RDW-18.7* Plt Ct-109*
[**2149-10-12**] 09:21AM BLOOD WBC-5.8 RBC-3.55* Hgb-10.7* Hct-30.7*
MCV-86 MCH-30.2 MCHC-35.0 RDW-17.3* Plt Ct-63*
[**2149-10-14**] 06:40AM BLOOD WBC-4.4 RBC-3.40* Hgb-10.6* Hct-29.2*
MCV-86 MCH-31.1 MCHC-36.1* RDW-18.2* Plt Ct-78*
[**2149-10-10**] 09:04PM BLOOD PT-17.5* PTT-31.1 INR(PT)-1.6*
[**2149-10-14**] 06:40AM BLOOD PT-17.6* PTT-37.6* INR(PT)-1.6*
[**2149-10-10**] 09:04PM BLOOD Glucose-170* UreaN-17 Creat-1.3* Na-146*
K-3.9 Cl-114* HCO3-16* AnGap-20
[**2149-10-14**] 06:40AM BLOOD Glucose-93 UreaN-10 Creat-0.9 Na-139
K-3.4 Cl-109* HCO3-26 AnGap-7*
[**2149-10-10**] 09:04PM BLOOD ALT-22 AST-34 LD(LDH)-235 AlkPhos-79
TotBili-4.0*
[**2149-10-14**] 06:40AM BLOOD ALT-19 AST-31 LD(LDH)-216 AlkPhos-69
TotBili-3.9*
[**2149-10-11**] 12:12PM BLOOD Lactate-2.5*
[**2149-10-12**] 03:46PM BLOOD Lactate-1.9

Abd Doppler U/S ([**10-11**]):
IMPRESSION:
1. Patent TIPS with decreased velocities within the TIPS
compared to prior
study with low to no flow demonstrated in the left portal vein.
2. Cirrhosis, cholelithiasis and persistent significant ascites.

Abd Doppler U/S ([**10-12**]):
The main portal vein velocity measures approximately 51 cm/s and
demonstrates wall-to-wall flow. Wall-to-wall flow is
demonstrated within the TIPS stent with velocities ranging from
78 cm/s in the proximal, 137 cm/s in the mid, and 121 cm/s in
the distal portions of the TIPS shunt. These have increased when
compared to prior exam.

Brief Hospital Course:
Upon arrival to [**Hospital1 18**] on [**10-10**], he was noted to be developing
encephalopathy. Late that night, he had an episode of brisk
hematemesis, requiring 6 units RBCs and 2 units FFP. He was
intubated for airway protection. EGD was performed and showed
gastric fundal varices with an area of ulceration, injected with
5 ml dermabond, but no active bleeding. A 7 day course of cipro
was started for infection prophylaxis. The following day, his
TIPS was found to have poor flow on U/S, so he underwent TIPS
revision, with resultant improvement in flows. His hematocrit
stabilized after the transfusion, and he was extubated, then
transferred out of the ICU. His octreotide drip was stopped at
that time, after an approximately 3 day course. His mental
status gradually improved to becoming alert and oriented x3.
Prior to discharge, he had been restarted on his home lactulose,
rifaximin (dose increased), lasix, and spironolactone. He was
also started on metoprolol, later switched to nadolol 20mg
daily, for variceal bleeding prophylaxis. He may need this dose
increased, but was started low due to asymptomatic SBPs in the
90s. He had no recurrence of GI bleeding after the episode on
[**10-10**].

Medications on Admission:
Lactulose 30 mL daily to twice daily
Spironolactone 50 mg [**Hospital1 **]
Lasix 40 mg daily
Protonix 40 mg daily
Rifaximin 200mg daily

Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three
times a day: Please adjust as needed to achieve [**3-25**] loose stools
daily.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary: Gastric variceal bleeding

Secondary: Cryptogenic cirrhosis


Discharge Condition:
Hemodynamically stable


Discharge Instructions:
You were admitted to [**Hospital1 18**] with bleeding from an enlarged vein
in your stomach. This was treated with a glue injection, and you
also required blood products due to your bleeding. Your TIPS was
opened wider to help prevent future bleeding, but this increases
the risk of developing confusion. You blood counts have been
stable over the past 3 days, so we will discharge you home.

Please take all medications as prescribed and go to all follow
up appointments. We have made the following medication changes:
- Increased your rifaximin dose.
- Started ciprofloxacin, which prevents infections in the
setting of a GI bleed. You will need to take this for 2 more
days.
- Started nadolol, a beta-blocker that helps prevent recurrence
of variceal bleeding.

If you develop any nausea, vomiting, bleeding, bloody stools,
dizziness, confusion, or any other concerning symptoms, please
seek medical attention or come to the ER immediately.

Followup Instructions:
Please call [**Hospital1 18**] radiology at ([**Telephone/Fax (1) 6713**] to schedule an
ultrasound of your TIPS in 2 months.

Please call the [**Hospital1 18**] liver clinic at ([**Telephone/Fax (1) 1582**] to schedule
an appointment for 2 months.

Please call your primary care doctor, [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **], at
[**Telephone/Fax (1) 36012**] to arrange a follow up appointment.



Completed by:[**2149-10-14**]
{'Hemorrhage of gastrointestinal tract, unspecified,Acute respiratory failure,Cirrhosis of liver without mention of alcohol,Portal hypertension,Iron deficiency anemia secondary to blood loss (chronic),Varices of other sites'}


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: Mr. [**Known lastname 52**] is a 60 y/o man with cryptogenic cirrhosis and known
gastric fundal varices transferred from [**Hospital6 33**]
with hematemesis. Patient felt nauseated on day of admission and
spit up small amt of blood at home. Initial BP on EMS arrival
was in the 80s with HR in the 110s. At that time, he was taken
to [**Hospital1 34**] where he received 4 U PRBCs and 2 U FFP and platelets. He
was treated with IV protonix and octreotide gtt. No endoscopy
was performed as his bleeding had stopped and no ultrasound was
done of his liver/TIPS. He was transferred to [**Hospital1 18**] after 1 day
for further care.

MEDICAL HISTORY: 1) Cryptogenic cirrhosis c/b ascites, gastric varices, hepatic
encephalopathy s/p TIPS in [**2147**]
2) h/o nephrolithiasis

MEDICATION ON ADMISSION: Lactulose 30 mL daily to twice daily
Spironolactone 50 mg [**Hospital1 **]
Lasix 40 mg daily
Protonix 40 mg daily
Rifaximin 200mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.2 BP 143/74 HR 124 RR 22 O2 96% on room air
GEN: somnolent but arousable to voice, does not answer questions
reliably (consistently answers "yes")
HEENT: pupils large but reactive bilaterally, sclerae anicteric,
MM slightly dry, op clear
RESP: grossly clear without wheezes or rhonchi
CV: RRR, normal S1, S2
ABD: distended but soft, nontender to palpation throughout, +
fluid wave, hypoactive bowel sounds
EXT: dp pulses 2+ bilaterally, no edema
SKIN: no rash
NEURO: alert, not oriented, not reliably answering questions,
face symmetric, PERRL, tongue midline, moving lower extremities
in hip flexion, bilateral hand grip intact, no hyperreflexia, no
clonus, no appreciable asterixis on exam

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives with wife. [**Name (NI) **] alcohol, prior smoker (quit > 30 years ago). 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Acute respiratory failure,Cirrhosis of liver without mention of alcohol,Portal hypertension,Iron deficiency anemia secondary to blood loss (chronic),Varices of other sites'}
