CHIEF COMPLAINT: melena

PRESENT ILLNESS: HPI: 51F with h/o upper GI bleed from duodenal ulcer 5y ago
presented to OSH with 3d of melena (4-6x/d) and coffee ground
emesis. She states she has had lower abdominal pain and
epigastric pain since the melena started. Yesterday morning, she
developed lightheadedness and presyncope (no LOC, no head
trauma). She denies associated chest pain, palpitations. Her
prior UGIB was in the setting of NSAID use, and she has
continued to use ibuprofen 3x/wk + recent Naproxen use for back
pain s/p mechanical fall. She reports occasional low grade fever
over the past couple of days with Tmax 99.8. She denies sick
contacts and recent travel. Reports social EtOH use, no known
h/o liver disease. VS on presentation to OSH ED included HR 98
and BP 89/51. Hct at OSH was 37, troponinI elevated at 0.59 but
CK flat, and WBC 35.0. NG lavage was performed with coffee
grounds, no bright red blood that did not clear with 250cc;
guaiac positive stool on DRE. She received morphine 4mg IV,
Pepcid 20mg IV, Protonix 40mg IV, and 2L NS. She was transferred
to the [**Hospital1 18**] ED for further management.
.
In the ED, VS were T 99.2, HR 106, BP 101/44, RR 20, O2sat
100%RA. She was given morphine 4mg IV, ceftriaxone 1g IV, and 1L
NS. GI was consulted. She was transferred to the MICU for
management of UGIB.
.
Currently, she states she feels a little better. She c/o thirst
and lower abdominal pain. Her lightheadedness has resolved and
her nausea has improved. Last BM was yesterday evening.

MEDICAL HISTORY: 1. Depression/adjustment d/o- surrounding daughter's death in
[**2158**]
2. Asthma
3. HTN
4. UGIB- 5y ago in FL, [**3-14**] duodenal ulcer assoc. w/NSAID use,
per pt EGD without apparent source--> ex lap, duodenal source
found and repaired with "fatty tissue", c/b SBO.
5. Goiter s/p thyroidectomy

MEDICATION ON ADMISSION: Prozac 20mg/40mg qod
Vasotec 20mg qd
Vicodin ES 7.5-750mg q6h prn
Ativan 1mg tid prn anxiety
MVI

ALLERGIES: Morphine

PHYSICAL EXAM: Vitals- T 96.9, HR 106, BP 115/59, RR 14, O2sat 100% 2LNC
General- somnolent but easily arousable, lying flat in bed with
NAD
HEENT- NCAT, sclerae anicteric, dry mucous membranes, NGT
draining scant amounts pink-tinged fluid
Neck- supple, no JVD
Pulm- CTAB, good air movement
CV- RRR, nl S1/S2, no m/r/g
Abd- +BS throughout, nondistended, soft, no epigastric TTP, +
RLQ/LLQ tenderness to moderate palpation with no
rebound/guarding, no palpable hepatosplenomegaly
Extrem- no LE edema, DP pulses 2+ b/l
Skin- no jaundice or scleral icterus, no spider angiomata, no
caput medusae, ?palmar erythema

FAMILY HISTORY: Father with h/o liver disease presumed [**3-14**] EtOH and upper GI
bleed. Brother with h/o liver disease presumed [**3-14**] EtOH.

SOCIAL HISTORY: Lives in [**Location 3146**], Mass. with boyfriend and 26yo daughter. [**Name (NI) 1403**]
as nurse [**First Name (Titles) **] [**Last Name (Titles) **] NH. + tobacco, 1/2ppd x 40y. + occ. EtOH
([**3-15**] drinks, 1x/wk). Denies IVDU.
Acute gastric ulcer with hemorrhage, without mention of obstruction,Subendocardial infarction, initial episode of care,Unspecified gastritis and gastroduodenitis, with hemorrhage,Acute posthemorrhagic anemia,Other esophagitis,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Postsurgical hypothyroidism
Ac stomach ulcer w hem,Subendo infarct, initial,Gstr/ddnts NOS w hmrhg,Ac posthemorrhag anemia,Other esophagitis,Asthma NOS,Hypertension NOS,Postsurgical hypothyroid
Admission Date:  [**2160-4-19**]              Discharge Date:   [**2160-4-22**]

Date of Birth:  [**2108-10-11**]             Sex:   F

Service: MEDICINE

Allergies:
Morphine

Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
melena

Major Surgical or Invasive Procedure:
EGD


History of Present Illness:
HPI: 51F with h/o upper GI bleed from duodenal ulcer 5y ago
presented to OSH with 3d of melena (4-6x/d) and coffee ground
emesis. She states she has had lower abdominal pain and
epigastric pain since the melena started. Yesterday morning, she
developed lightheadedness and presyncope (no LOC, no head
trauma). She denies associated chest pain, palpitations. Her
prior UGIB was in the setting of NSAID use, and she has
continued to use ibuprofen 3x/wk + recent Naproxen use for back
pain s/p mechanical fall. She reports occasional low grade fever
over the past couple of days with Tmax 99.8. She denies sick
contacts and recent travel. Reports social EtOH use, no known
h/o liver disease. VS on presentation to OSH ED included HR 98
and BP 89/51. Hct at OSH was 37, troponinI elevated at 0.59 but
CK flat, and WBC 35.0. NG lavage was performed with coffee
grounds, no bright red blood that did not clear with 250cc;
guaiac positive stool on DRE. She received morphine 4mg IV,
Pepcid 20mg IV, Protonix 40mg IV, and 2L NS. She was transferred
to the [**Hospital1 18**] ED for further management.
.
In the ED, VS were T 99.2, HR 106, BP 101/44, RR 20, O2sat
100%RA. She was given morphine 4mg IV, ceftriaxone 1g IV, and 1L
NS. GI was consulted. She was transferred to the MICU for
management of UGIB.
.
Currently, she states she feels a little better. She c/o thirst
and lower abdominal pain. Her lightheadedness has resolved and
her nausea has improved. Last BM was yesterday evening.


Past Medical History:
1. Depression/adjustment d/o- surrounding daughter's death in
[**2158**]
2. Asthma
3. HTN
4. UGIB- 5y ago in FL, [**3-14**] duodenal ulcer assoc. w/NSAID use,
per pt EGD without apparent source--> ex lap, duodenal source
found and repaired with "fatty tissue", c/b SBO.
5. Goiter s/p thyroidectomy


Social History:
Lives in [**Location 3146**], Mass. with boyfriend and 26yo daughter. [**Name (NI) 1403**]
as nurse [**First Name (Titles) **] [**Last Name (Titles) **] NH. + tobacco, 1/2ppd x 40y. + occ. EtOH
([**3-15**] drinks, 1x/wk). Denies IVDU.

Family History:
Father with h/o liver disease presumed [**3-14**] EtOH and upper GI
bleed. Brother with h/o liver disease presumed [**3-14**] EtOH.

Physical Exam:
Vitals- T 96.9, HR 106, BP 115/59, RR 14, O2sat 100% 2LNC
General- somnolent but easily arousable, lying flat in bed with
NAD
HEENT- NCAT, sclerae anicteric, dry mucous membranes, NGT
draining scant amounts pink-tinged fluid
Neck- supple, no JVD
Pulm- CTAB, good air movement
CV- RRR, nl S1/S2, no m/r/g
Abd- +BS throughout, nondistended, soft, no epigastric TTP, +
RLQ/LLQ tenderness to moderate palpation with no
rebound/guarding, no palpable hepatosplenomegaly
Extrem- no LE edema, DP pulses 2+ b/l
Skin- no jaundice or scleral icterus, no spider angiomata, no
caput medusae, ?palmar erythema


Pertinent Results:
[**2160-4-19**] 09:10AM   ALT(SGPT)-12 AST(SGOT)-21 LD(LDH)-244
CK(CPK)-34 ALK PHOS-73 TOT BILI-0.2
[**2160-4-19**] 09:10AM   CK-MB-NotDone cTropnT-0.15*
[**2160-4-19**] 09:37PM   CK(CPK)-36
[**2160-4-19**] 09:37PM   CK-MB-NotDone cTropnT-0.15*
[**2160-4-19**] 09:37PM   HCT-30.8*
[**2160-4-19**] 12:51PM   HCT-35.2*
[**2160-4-19**] 09:10AM   ALBUMIN-2.9*
[**2160-4-19**] 09:10AM   WBC-28.6* RBC-3.93* HGB-10.9* HCT-31.7*
MCV-81* MCH-27.6 MCHC-34.3 RDW-16.8*
[**2160-4-19**] 09:10AM   PLT COUNT-344
[**2160-4-19**] 05:35AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2160-4-19**] 05:35AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2160-4-19**] 03:59AM URINE  HOURS-RANDOM
[**2160-4-19**] 03:59AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2160-4-19**] 03:59AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2160-4-19**] 01:51AM   HGB-12.2 calcHCT-37
[**2160-4-19**] 01:00AM   GLUCOSE-137* UREA N-26* CREAT-0.8 SODIUM-136
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-24 ANION GAP-17
[**2160-4-19**] 01:00AM   estGFR-Using this
[**2160-4-19**] 01:00AM   CK(CPK)-31
[**2160-4-19**] 01:00AM   cTropnT-0.13*
[**2160-4-19**] 01:00AM   CK-MB-NotDone
[**2160-4-19**] 01:00AM   WBC-32.2* RBC-4.24 HGB-11.6* HCT-34.4*
MCV-81* MCH-27.3 MCHC-33.6 RDW-16.8*
[**2160-4-19**] 01:00AM   NEUTS-88* BANDS-5 LYMPHS-4* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2160-4-19**] 01:00AM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2160-4-19**] 01:00AM   PT-11.5 PTT-20.9* INR(PT)-1.0

CXR:
IMPRESSION:
1. No evidence of aspiration or pneumonia.
2. Probable healing right rib fractures.

TTE:
Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or  color Doppler. Left ventricular wall thicknesses
and cavity size are normal.
Overall left ventricular systolic function is mildly to
moderately depressed  (40-50%) with basal inferior, lateral and
apical hypokinesis. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened.
Tricuspid regurgitation is present but cannot be quantified.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.

EGD:
Esophagus:
 Mucosa: Diffuse continuous erythema and ulcerations of the
mucosa with no bleeding were noted in the lower third of the
esophagus and middle third of the esophagus. These findings are
compatible with esophagitis. Localized erythema and erosions of
the mucosa with no bleeding were noted in the gastroesophageal
junction. These findings are compatible with NGT trauma.
Stomach:
 Contents: Food was found in the stomach body.
 Mucosa: Localized erythema and erosion with multiple
ulcerations of the mucosa with no bleeding were noted in the
pylorus.  Normal mucosa was noted in the antrum. Cold forceps
biopsies were performed for histology at the stomach antrum.
Duodenum: Normal duodenum.
Other
findings: The anatomy of the pylorus was distorted secondary to
hypertrophic gastric folds and multiple ulcerations.
Impression: Erythema and ulcerations in the lower third of the
esophagus and middle third of the esophagus compatible with
esophagitis
Food in the stomach body
Erythema and erosion and multiple ulcerations in the pylorus
The anatomy of the pylorus was distorted secondary to
hypertrophic gastric folds and multiple ulcerations.
Normal mucosa in the antrum (biopsy)
Erythema and erosions in the gastroesophageal junction
compatible with NGT trauma

Pathology Examination
Name 	Birthdate   	Age    	Sex	Pathology #    	[**Hospital1 18**] [**Known lastname 71980**],[**Known firstname **]       	[**2108-10-11**]   	51	Female
	[**Numeric Identifier 71981**]	[**Numeric Identifier 71982**]
Report to:  	DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by:  	DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] GOODELL/mtd



SPECIMEN SUBMITTED: Gastric Biopsy

Procedure date    	Tissue received    	Report Date   	Diagnosed
by
[**2160-4-19**]	[**2160-4-19**]	[**2160-4-23**]	DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/nbh

DIAGNOSIS:



Stomach, antrum, mucosal biopsy:



Antral mucosa with no diagnostic abnormalities recognized.

[**2160-4-22**] 05:25AM BLOOD WBC-14.1* RBC-3.68* Hgb-10.0* Hct-30.1*
MCV-82 MCH-27.1 MCHC-33.2 RDW-16.6* Plt Ct-338
[**2160-4-22**] 05:25AM BLOOD Plt Ct-338
[**2160-4-22**] 05:25AM BLOOD Glucose-99 UreaN-5* Creat-0.6 Na-141
K-3.5 Cl-106 HCO3-24 AnGap-15
[**2160-4-20**] 03:07AM BLOOD CK(CPK)-36
[**2160-4-20**] 03:07AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2160-4-19**] 09:37PM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2160-4-19**] 09:10AM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2160-4-19**] 01:00AM BLOOD cTropnT-0.13*
[**2160-4-22**] 05:25AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0 Cholest-117
[**2160-4-22**] 05:25AM BLOOD Triglyc-93 HDL-58 CHOL/HD-2.0 LDLcalc-40

Brief Hospital Course:
In the ED, VS were T 99.2, HR 106, BP 101/44, RR 20, O2sat
100%RA. Her hct was 34 on admit. She was given morphine 4mg IV,
ceftriaxone 1g IV, and 1L NS, and admitted to MICU for
management of UGIB. She had EGD which showed multiple mucosal
ulcerations and erosions throughout esophagus, pylorus. They
recommended ppi [**Hospital1 **] and carafate, repeat EGD in 3 weeks with Dr.
[**Last Name (STitle) 9746**]. Hct was stable o/n, so pt. was transferred to floor.

# UGIB: likely NSAID-induced gastritis/duodenitis. large, severe
ulcerations bring up possibility of obstructive picture.  Diet
was advanced without difficulty and hct remained stable with
clearing of blood in stools at discharge.  Discharged on 1 month
of ppi [**Hospital1 **] and carafate until f/u EGD with Dr. [**Last Name (STitle) 9746**] in three
weeks.  She was also given strict orders to not use NSAIDs or
alcohol.  Given severe ulceration and high risk for rebleeding,
pt. had cardiac catheterization postponed as below.
.
# Leukocytosis: WBC count markedly elevated to 32 on admit,
trended down slowly to 14 upon discharge.  She should have CBC
done as outpt. to confirm resolution.  Otherwise, she may need
workup for myeloproliferative diseases.
.
# Elevated troponin: No symptoms suggestive of ischemia.
Troponin I elevated at OSH at 0.59 (upper limit 0.5) with flat
CK. Troponin T mildly elevated here at 0.13. no elevation of
CKs. No e/o renal dz. Cards consulted and believe she had NSTEMI
given
 ECHO with moderately depressed EF. Started baby aspirin and
[**Name (NI) 71983**], with plans to start ACE-I as outpatient as BP can
tolerate.  Given recent bleed and likelyihood of needing to
place stents requiring anticoagulation, decision was made not to
proceed with catheterizaiton.  Pt. was discharged with plans for
outpt. cath evaluatino as outpt. after follow EGD performed in 3
weeks.  Until that time, pt. was told to take off work and to
limit activity severely so as [**Last Name (un) **] to stress heart.  She will
follow up with Drs. [**Last Name (STitle) 10302**] and [**Name5 (PTitle) 171**] as outpt.
.

Medications on Admission:
Prozac 20mg/40mg qod
Vasotec 20mg qd
Vicodin ES 7.5-750mg q6h prn
Ativan 1mg tid prn anxiety
MVI


Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q DAY () as needed for
pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed: not to exceed 4g tylenol
in one 24 hour period.
Disp:*45 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as directed: take 1 tab sublingually should you
develop[ chest pain.  If chest pain does not resolve, can take
another tab each 5 minutes for a total of 3 tabs total.
Disp:*30 0* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
NSTEMI
Upper GI bleed
Blood Loss Anemia
Gastritis
Esophagitis
HTN
_____________
Depression
Asthma


Discharge Condition:
good, tolerating foods, satting well on room air, chest pain
free,


Discharge Instructions:
You have had a GI bleed and heart attack.  You were evaluated by
GI and cardiology and are at high risk for having another heart
attack, however given your GI bleed, we are holding off on
coronary catheterization.  Given your high risk of bleeding and
heart attack, you should take all medications as prescribed,
follow up as below and adhere to the following discharge
instructions.

Please seek medical attention immediately should you develop
chest pain, shortness of breath, dizziness, nausea,
palpitations.  Also, seek medical attention should you develop
any symptoms of GI bleeding such as dizziness, lightheadedness,
black stools, bright red blood with stools, or palpitations.

You should avoid even moderate exertion and limit lifting to 5
pounds or less.  You should limit your walking to 1 block at a
time for now, and take off work until cleared by your PCP or
cardiologist.

Take all medications exactly as prescribed.  You should adhere
to a low salt, low cholesterol diet with a maximum of 2g sodium
a day.  Weigh yourself every day and call your PCP should you
gain more than 3 pounds.

You should attend your follow-up apointments as outlined below.



Followup Instructions:
You should follow up [**Last Name (un) 5767**] Dr. [**Name (NI) **] at the following
appointment: Provider: [**Last Name (LF) 5302**],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT
MEDICINE (SB) Date/Time:[**2160-4-29**] 12:00

You have a GI appt. for EGD with Drs. [**Last Name (STitle) 6880**] and [**Name5 (PTitle) 9746**]
which you must attend.  Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5085**], MD
Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2160-5-6**] 8:00
Provider: [**Name10 (NameIs) **] WEST,ROOM TWO GI ROOMS Date/Time:[**2160-5-6**] 8:00

You have a cardiology appointment with Drs. [**Last Name (STitle) 171**] and [**Name5 (PTitle) 10302**]
on [**5-21**] at 3PM.  Call ([**Telephone/Fax (1) 1987**] to get directions and
location or appointment or to reschedule.

You also have the following appointment which you should attend:
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 9045**] Date/Time:[**2160-5-21**] 9:00
{'Acute gastric ulcer with hemorrhage, without mention of obstruction,Subendocardial infarction, initial episode of care,Unspecified gastritis and gastroduodenitis, with hemorrhage,Acute posthemorrhagic anemia,Other esophagitis,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Postsurgical hypothyroidism'}


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: melena

PRESENT ILLNESS: HPI: 51F with h/o upper GI bleed from duodenal ulcer 5y ago
presented to OSH with 3d of melena (4-6x/d) and coffee ground
emesis. She states she has had lower abdominal pain and
epigastric pain since the melena started. Yesterday morning, she
developed lightheadedness and presyncope (no LOC, no head
trauma). She denies associated chest pain, palpitations. Her
prior UGIB was in the setting of NSAID use, and she has
continued to use ibuprofen 3x/wk + recent Naproxen use for back
pain s/p mechanical fall. She reports occasional low grade fever
over the past couple of days with Tmax 99.8. She denies sick
contacts and recent travel. Reports social EtOH use, no known
h/o liver disease. VS on presentation to OSH ED included HR 98
and BP 89/51. Hct at OSH was 37, troponinI elevated at 0.59 but
CK flat, and WBC 35.0. NG lavage was performed with coffee
grounds, no bright red blood that did not clear with 250cc;
guaiac positive stool on DRE. She received morphine 4mg IV,
Pepcid 20mg IV, Protonix 40mg IV, and 2L NS. She was transferred
to the [**Hospital1 18**] ED for further management.
.
In the ED, VS were T 99.2, HR 106, BP 101/44, RR 20, O2sat
100%RA. She was given morphine 4mg IV, ceftriaxone 1g IV, and 1L
NS. GI was consulted. She was transferred to the MICU for
management of UGIB.
.
Currently, she states she feels a little better. She c/o thirst
and lower abdominal pain. Her lightheadedness has resolved and
her nausea has improved. Last BM was yesterday evening.

MEDICAL HISTORY: 1. Depression/adjustment d/o- surrounding daughter's death in
[**2158**]
2. Asthma
3. HTN
4. UGIB- 5y ago in FL, [**3-14**] duodenal ulcer assoc. w/NSAID use,
per pt EGD without apparent source--> ex lap, duodenal source
found and repaired with "fatty tissue", c/b SBO.
5. Goiter s/p thyroidectomy

MEDICATION ON ADMISSION: Prozac 20mg/40mg qod
Vasotec 20mg qd
Vicodin ES 7.5-750mg q6h prn
Ativan 1mg tid prn anxiety
MVI

ALLERGIES: Morphine

PHYSICAL EXAM: Vitals- T 96.9, HR 106, BP 115/59, RR 14, O2sat 100% 2LNC
General- somnolent but easily arousable, lying flat in bed with
NAD
HEENT- NCAT, sclerae anicteric, dry mucous membranes, NGT
draining scant amounts pink-tinged fluid
Neck- supple, no JVD
Pulm- CTAB, good air movement
CV- RRR, nl S1/S2, no m/r/g
Abd- +BS throughout, nondistended, soft, no epigastric TTP, +
RLQ/LLQ tenderness to moderate palpation with no
rebound/guarding, no palpable hepatosplenomegaly
Extrem- no LE edema, DP pulses 2+ b/l
Skin- no jaundice or scleral icterus, no spider angiomata, no
caput medusae, ?palmar erythema

FAMILY HISTORY: Father with h/o liver disease presumed [**3-14**] EtOH and upper GI
bleed. Brother with h/o liver disease presumed [**3-14**] EtOH.

SOCIAL HISTORY: Lives in [**Location 3146**], Mass. with boyfriend and 26yo daughter. [**Name (NI) 1403**]
as nurse [**First Name (Titles) **] [**Last Name (Titles) **] NH. + tobacco, 1/2ppd x 40y. + occ. EtOH
([**3-15**] drinks, 1x/wk). Denies IVDU. 

### Response:
{'Acute gastric ulcer with hemorrhage, without mention of obstruction,Subendocardial infarction, initial episode of care,Unspecified gastritis and gastroduodenitis, with hemorrhage,Acute posthemorrhagic anemia,Other esophagitis,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Postsurgical hypothyroidism'}
