CHIEF COMPLAINT: GI bleed

PRESENT ILLNESS: The Pt is a 61y/o M with a PMH of primary sclerosing cholangitis
dx w/ cholangiocarcinoma [**8-28**] during routine change of stent
placed for recurrent biliary obstruction (CA19-9 at diagnosis
about 3). Cholangiocarcinoma found when CT scan [**9-27**]
demonstrated a 2.4 x 3.2 cm diameter low attenuation mass
surrounding the common duct, extending into the region of the
pancreatic head and through the retroperitoneum down to the
renal vein and encasing the proximal portal vein as well as the
hepatic artery. There was evidence also that the duodenum was
encroached upon by the tumor, although not circumferentially.
Based on the CT findings he was deemed unresectable. Received 6
cycles of Gemcitabine/oxaliplatin [**10-28**] to [**4-28**]. Pt found to
have progression of pulmonary disease and chemo regimen was
changed to second line of cisplatin/5FU [**4-28**]. Course complicated
by thrush and fatigue.
.
Pt presented to ED with hematochezia and hematemesis with BRB.
Hct 19 at OSH from 26 yesterday. Here hemodyamically stable. S/p
2U PRBC, 2LIVF at OSH in the setting of SBPs of 70s-->90s.

MEDICAL HISTORY: Onc history:
Dx [**8-28**] with cholangiocarcinoma
-- local extension including encasing the portal vein and
hepatic artery, extending into the head of the pancreas and
encircling the duodenum. (Not surgical candidate)
-- Chemotherapy: 6 cycles Gemcitabine/Oxaliplatin with
progression ([**Date range (1) 111295**]), 1 cycle 5FU and cisplatin (Currently
day 16 cycle 1)
Other PMHx:
-Primary sclerosing cholangitis (followed by Dr. [**Last Name (STitle) 497**]
-melanoma resection mid back approx 10 years ago with negative
sentinel node
-Cholecystectomy >20 years ago

MEDICATION ON ADMISSION: pancrease suppl qac
ursodiol 300mg tid
Dexamethasone
Compazine
Clotrimazole
Zofran

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: afebrile, HR 90s, BP 110s/60s, 100% RA
NAD- alert and talkative, jaundiced
lungs clear
RRR, soft SM
abdomen protuberant, liver edge palpable just below costal
margin, splenomegaly not detected
no peripheral edema

FAMILY HISTORY: Married x
30 years. 2 children. No smoking, no etoh

SOCIAL HISTORY: Physics teacher at [**Location (un) 5028**] High School.
Hemorrhage of gastrointestinal tract, unspecified,Portal vein thrombosis,Secondary malignant neoplasm of small intestine including duodenum,Malignant neoplasm of biliary tract, part unspecified site,Cholangitis,Bacteremia,Other ascites,Acute kidney failure, unspecified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Acute posthemorrhagic anemia,Portal hypertension,Leukocytopenia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Unspecified essential hypertension
Gastrointest hemorr NOS,Portal vein thrombosis,Sec malig neo sm bowel,Malig neo biliary NOS,Cholangitis,Bacteremia,Ascites NEC,Acute kidney failure NOS,Klebsiella pneumoniae,Thrombocytopenia NOS,Ac posthemorrhag anemia,Portal hypertension,Leukocytopenia NOS,Adv eff antineoplastic,Esoph varice oth dis NOS,Hypertension NOS
Admission Date:  [**2185-5-24**]              Discharge Date:   [**2185-6-10**]

Date of Birth:  [**2124-1-16**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
GI bleed

Major Surgical or Invasive Procedure:
Endoscopy s/p cauterization
Intubation x 2
Central line placement

History of Present Illness:
The Pt is a 61y/o M with a PMH of primary sclerosing cholangitis
dx w/ cholangiocarcinoma [**8-28**] during routine change of stent
placed for recurrent biliary obstruction (CA19-9 at diagnosis
about 3). Cholangiocarcinoma found when CT scan [**9-27**]
demonstrated a 2.4 x 3.2 cm diameter low attenuation mass
surrounding the common duct, extending into the region of the
pancreatic head and through the retroperitoneum down to the
renal vein and encasing the proximal portal vein as well as the
hepatic artery. There was evidence also that the duodenum was
encroached upon by the tumor, although not circumferentially.
Based on the CT findings he was deemed unresectable. Received 6
cycles of Gemcitabine/oxaliplatin [**10-28**] to [**4-28**]. Pt found to
have progression of pulmonary disease and chemo regimen was
changed to second line of cisplatin/5FU [**4-28**]. Course complicated
by thrush and fatigue.
.
Pt presented to ED with hematochezia and hematemesis with BRB.
Hct 19 at OSH from 26 yesterday. Here hemodyamically stable. S/p
2U PRBC, 2LIVF at OSH in the setting of SBPs of 70s-->90s.


Past Medical History:
Onc history:
Dx [**8-28**] with cholangiocarcinoma
-- local extension including encasing the portal vein and
hepatic artery, extending into the head of the pancreas and
encircling the duodenum. (Not surgical candidate)
-- Chemotherapy: 6 cycles Gemcitabine/Oxaliplatin with
progression ([**Date range (1) 111295**]), 1 cycle 5FU and cisplatin (Currently
day 16 cycle 1)
Other PMHx:
-Primary sclerosing cholangitis (followed by Dr. [**Last Name (STitle) 497**]
-melanoma resection mid back approx 10 years ago with negative
sentinel node
-Cholecystectomy >20 years ago


Social History:
Physics teacher at [**Location (un) 5028**] High School.

Family History:
Married x
30 years. 2 children. No smoking, no etoh


Physical Exam:
afebrile, HR 90s, BP 110s/60s, 100% RA
NAD- alert and talkative, jaundiced
lungs clear
RRR, soft SM
abdomen protuberant, liver edge palpable just below costal
margin, splenomegaly not detected
no peripheral edema


Pertinent Results:
[**2185-5-23**] 03:35PM BLOOD WBC-5.2 RBC-3.17* Hgb-8.8* Hct-26.2*
MCV-83 MCH-27.7 MCHC-33.6 RDW-18.3* Plt Ct-82*#
[**2185-5-24**] 03:20AM BLOOD WBC-4.5 RBC-2.57* Hgb-7.4* Hct-22.0*
MCV-86 MCH-29.0 MCHC-33.9 RDW-17.7* Plt Ct-74*
[**2185-5-24**] 07:41AM BLOOD WBC-3.7* RBC-2.78* Hgb-8.4* Hct-23.4*
MCV-84 MCH-30.1 MCHC-35.7* RDW-16.3* Plt Ct-80*
[**2185-5-24**] 10:25AM BLOOD WBC-3.9* RBC-3.14* Hgb-9.6* Hct-26.4*
MCV-84 MCH-30.6 MCHC-36.4* RDW-15.4 Plt Ct-72*
[**2185-5-24**] 09:50PM BLOOD Hct-30.7*
[**2185-5-27**] 05:39AM BLOOD WBC-2.4* RBC-3.31* Hgb-10.2* Hct-28.8*
MCV-87 MCH-30.8 MCHC-35.4* RDW-16.1* Plt Ct-245
[**2185-5-27**] 01:15PM BLOOD WBC-2.8* RBC-4.07* Hgb-12.1* Hct-34.7*
MCV-85 MCH-29.8 MCHC-35.0 RDW-15.6* Plt Ct-215
[**2185-5-23**] 03:35PM BLOOD Neuts-84* Bands-2 Lymphs-4* Monos-9 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2185-5-27**] 05:39AM BLOOD Neuts-67 Bands-0 Lymphs-18 Monos-9 Eos-4
Baso-0 Atyps-2* Metas-0 Myelos-0
[**2185-6-2**] 12:00AM BLOOD PT-12.9 PTT-25.4 INR(PT)-1.1
[**2185-5-24**] 03:20AM BLOOD PT-15.7* PTT-27.9 INR(PT)-1.4*
[**2185-5-24**] 03:20AM BLOOD Glucose-181* UreaN-22* Creat-0.9 Na-135
K-3.7 Cl-103 HCO3-24 AnGap-12
[**2185-5-27**] 09:55AM BLOOD Glucose-112* UreaN-33* Creat-0.9 Na-137
K-3.4 Cl-108 HCO3-21* AnGap-11
[**2185-5-27**] 05:39AM BLOOD ALT-39 AST-45* LD(LDH)-228 AlkPhos-442*
TotBili-1.9*
[**2185-5-24**] 03:20AM BLOOD ALT-64* AST-53* CK(CPK)-42 AlkPhos-322*
TotBili-1.0
[**2185-5-24**] 03:20AM BLOOD Lipase-15
[**2185-5-25**] 04:36AM BLOOD Lipase-7
[**2185-5-24**] 03:20AM BLOOD Albumin-2.5* Calcium-7.2* Phos-3.2 Mg-1.7
[**2185-5-27**] 09:55AM BLOOD Calcium-7.5* Phos-2.2* Mg-2.0
[**2185-5-27**] 04:11PM BLOOD Type-ART pO2-152* pCO2-40 pH-7.35
calTCO2-23 Base XS--3
[**2185-5-24**] 03:20AM BLOOD Glucose-166* Lactate-1.5 Na-132* K-3.6
Cl-103 calHCO3-24
[**2185-5-27**] 04:35PM BLOOD freeCa-1.06*
[**2185-5-24**] 01:57PM BLOOD freeCa-1.12

Angiogram #1
Selective arteriograms were performed within the celiac trunk
and SMA without signs of active bleeding.

Embolization of the gastroduodenal artery was performed with one
3-mm coil, four 4-mm coils and one 5-mm coil.

Delayed images demonstrated no opacification of the portal vein,
suggesting occlusion of this vessel.
Note: The patient has been stable with no further bleeding over
a 24 hour
period.

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


Angiogram # 2
IMPRESSION: Selective arteriograms were performed in the celiac,
SMA and [**Female First Name (un) 899**] without signs of active bleeding.

There is no flow within the GDA that was previously embolized
with coils.

The study and the report were reviewed by the staff radiologist

CT Abd/Pelvis:
1. Marked interval increase in intra-abdominal and intrapelvic
ascites with anasarca.
2. Bilateral pleural effusions, right greater than left.
3. Small bowel loops are dilated up to 4.2 cm with air seen
distally,
suggestive of an ileus. No evidence of free air.
4. Evaluation of vasculature could not be performed due to lack
of IV
contrast.
5. Sigmoid colonic wall thickening could be suggestive of
procto-sigmoiditis.

Abdominal Ultrasound [**6-2**]:
IMPRESSION: Large amount of ascites in all four abdominal
quadrants with
marking of right lower quadrant for paracentesis to be performed
by clinical staff.

Abdominal Ultrasound [**6-6**]:
Limited evaluation of the four abdominal quadrants was
performed. Small
pockets of ascites were identified in each quadrant with a
moderate-sized
pocket above the bladder. No site was large enough to mark for
paracentesis.

IMPRESSION: Moderate ascites without adequate spot for
paracentesis marking


Brief Hospital Course:
61M w/ primary sclerosing cholangitis diagnosed with
cholongiocarcinoma who presented hematemsis and BRBPR. This
stopped by the time he came to the ER. Endoscopy saw a clot in
the second portion of the duodenum, and during the procedure a
large amount of bleeding began apparently out of the second part
of the duodenum. The procedure was stopped and the patient was
transfused ~8-10U PRBC. An emergent angio did not find the
source of bleeding. The gastroduodenal artery was embolized as
the most likely source. 24 hours later the patient rebled and
was intubated for airway protection. ERCP found a bleeding
vessel in an ulcerated part of the tumor in the second part of
the duodenum. This was injected w/ epi and cauterized. A repeat
angio showed no clear target for embolization as the tumor was
well-vascularized, so given that the patient was likely to
rebleed and that the next bleed would be untreatable, the
decision was made to make the patient CMO. He was extubated and
actually did well. He remained hemodynamically stable and was
transferred to the floor.

On the floor, his only complaint was his abdominal distension
from his ascites. This was drained for palliative purposes on
[**6-2**] by paracentesis. This made him feel much better and allowed
him to eat. He had an abdominal port placed by interventional
radiology on [**6-9**] without incidence for repeat paracenteses.

Mr. [**Known lastname **] has a very high chance of the bleeding vessel
rebleeding and there is no medical intervention that can be done
to alleviate it at this time. In discussion with the family, the
patient, his primary oncologist, and the palliative care team,
the decision was made to focus on his comfort. His daily needs
are minimal but when his bleeding starts again, he will likely
need an NGT quickly for managment of bleeding as well as
possible associated nausea/hematemesis. He may also need a
flexiseal or other similar stool management system if he begins
having bright red blood per rectum.


Medications on Admission:
pancrease suppl qac
ursodiol 300mg tid
Dexamethasone
Compazine
Clotrimazole
Zofran


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
3. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
9. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
10. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
11. Morphine Sulfate 2-6 mg IV Q1H:PRN
12. Lorazepam 0.5-2 mg IV Q1H:PRN anxiety, tachypnea
13. Ondansetron 4 mg IV Q8H:PRN


Discharge Disposition:
Extended Care

Facility:
The [**Hospital1 656**] Family Hospice House

Discharge Diagnosis:
Upper gastrointestinal bleed
Cholangiocarcinoma
Primary Sclerosing Cholangitis


Discharge Condition:
All vital signs stable, comfortable.


Discharge Instructions:
You were admitted with a severe gastrointestinal bleed. It was
stabilized temporarily but will bleed again and at that time
there is no treatment available to stop it.

You also have acculmulations of fluid in your abdomen. You
underwent one drainage procedure and then had an abdominal port
placed to allow for easier drainage procedures in the future.

We have stopped all medications that do not contribute to your
comfort.


Followup Instructions:
None. Please call Dr. [**Last Name (STitle) **] (primary oncologist) at ([**Telephone/Fax (1) 83254**] with any questions.


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
{"Hemorrhage of gastrointestinal tract, unspecified,Portal vein thrombosis,Secondary malignant neoplasm of small intestine including duodenum,Malignant neoplasm of biliary tract, part unspecified site,Cholangitis,Bacteremia,Other ascites,Acute kidney failure, unspecified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Acute posthemorrhagic anemia,Portal hypertension,Leukocytopenia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Unspecified essential hypertension"}


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: GI bleed

PRESENT ILLNESS: The Pt is a 61y/o M with a PMH of primary sclerosing cholangitis
dx w/ cholangiocarcinoma [**8-28**] during routine change of stent
placed for recurrent biliary obstruction (CA19-9 at diagnosis
about 3). Cholangiocarcinoma found when CT scan [**9-27**]
demonstrated a 2.4 x 3.2 cm diameter low attenuation mass
surrounding the common duct, extending into the region of the
pancreatic head and through the retroperitoneum down to the
renal vein and encasing the proximal portal vein as well as the
hepatic artery. There was evidence also that the duodenum was
encroached upon by the tumor, although not circumferentially.
Based on the CT findings he was deemed unresectable. Received 6
cycles of Gemcitabine/oxaliplatin [**10-28**] to [**4-28**]. Pt found to
have progression of pulmonary disease and chemo regimen was
changed to second line of cisplatin/5FU [**4-28**]. Course complicated
by thrush and fatigue.
.
Pt presented to ED with hematochezia and hematemesis with BRB.
Hct 19 at OSH from 26 yesterday. Here hemodyamically stable. S/p
2U PRBC, 2LIVF at OSH in the setting of SBPs of 70s-->90s.

MEDICAL HISTORY: Onc history:
Dx [**8-28**] with cholangiocarcinoma
-- local extension including encasing the portal vein and
hepatic artery, extending into the head of the pancreas and
encircling the duodenum. (Not surgical candidate)
-- Chemotherapy: 6 cycles Gemcitabine/Oxaliplatin with
progression ([**Date range (1) 111295**]), 1 cycle 5FU and cisplatin (Currently
day 16 cycle 1)
Other PMHx:
-Primary sclerosing cholangitis (followed by Dr. [**Last Name (STitle) 497**]
-melanoma resection mid back approx 10 years ago with negative
sentinel node
-Cholecystectomy >20 years ago

MEDICATION ON ADMISSION: pancrease suppl qac
ursodiol 300mg tid
Dexamethasone
Compazine
Clotrimazole
Zofran

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: afebrile, HR 90s, BP 110s/60s, 100% RA
NAD- alert and talkative, jaundiced
lungs clear
RRR, soft SM
abdomen protuberant, liver edge palpable just below costal
margin, splenomegaly not detected
no peripheral edema

FAMILY HISTORY: Married x
30 years. 2 children. No smoking, no etoh

SOCIAL HISTORY: Physics teacher at [**Location (un) 5028**] High School. 

### Response:
{"Hemorrhage of gastrointestinal tract, unspecified,Portal vein thrombosis,Secondary malignant neoplasm of small intestine including duodenum,Malignant neoplasm of biliary tract, part unspecified site,Cholangitis,Bacteremia,Other ascites,Acute kidney failure, unspecified,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Acute posthemorrhagic anemia,Portal hypertension,Leukocytopenia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Unspecified essential hypertension"}
