CHIEF COMPLAINT: Altered mental status

PRESENT ILLNESS: 59 yo F w/ PMH of alcohol and hepatitis C cirrhosis with history
of varices and upper GI bleed presents with loss of consciousnes
and was Guiac positive with a HCT drop from 44-->33 in the
setting of being intoxicated on alcohol who developed
hematemesis in the ED.

MEDICAL HISTORY: - Alcoholic cirrhosis- low grade varices- not banded, not
bleeding in past. Peripheral edema (on lasix 20mg daily). 1 pint
brandy per day for more than a year. She had tried detox once.
Denies withdrawal
seizures.
- Chronic Back pain
- Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown
how she got it, denies IVDU, transfusions. Never had liver bx.
- Hypertension
- Alcoholic cirrhosis- low grade varices- not banded, not
bleeding in past. Peripheral edema (on lasix 20mg daily). 1 pint
brandy per day for more than a year. She had tried detox once.
Denies withdrawal
seizures.
- Chronic Back pain
- Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown
how she got it, denies IVDU, transfusions. Never had liver bx.
- Hypertension

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Furosemide 20 mg PO DAILY
Hold for SBP<90
2. Spironolactone 50 mg PO DAILY
Hold for SBP<90
3. Nadolol 20 mg PO DAILY
Hold for SBP<90, HR<60
4. Acetaminophen-Caff-Butalbital [**2-8**] TAB PO Q8H:PRN headache
5. Citalopram 10 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Thiamine 100 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Exam on Admission:
General: sedateed and intubated, in NAD
HEENT: Sclera anicteric. Intubated with blood in the ETT ,
unable to assess JVP
CV: RRR, no MRG appreciated
Lungs: Rhonchrousou breath sounds bilaterally
Abdomen: soft, protuberant but nondistended. Hypoactive bowel
sounds.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated and inutbated

FAMILY HISTORY: Mother had MI
Sister with diabetes.
Many family members with alcohol abuse

SOCIAL HISTORY: Lives in [**Location 686**] with her 16yo son. [**Name (NI) **] history of alcohol
abuse, over 10 years. Current smoker. Denies other drug use. Has
been in alcohol detox once - relaped shortly thereafter. Drinks
[**2-8**] to 1 pint brandy per day though is actively trying to quit.
Gastroesophageal laceration-hemorrhage syndrome,Other shock without mention of trauma,Acute posthemorrhagic anemia,Portal hypertension,Altered mental status,Unspecified viral hepatitis C without hepatic coma,Alcoholic cirrhosis of liver,Esophageal varices without mention of bleeding,Other specified disorders of stomach and duodenum,Acute alcoholic intoxication in alcoholism, continuous,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Unspecified essential hypertension,Lumbago,Other chronic pain,Depressive disorder, not elsewhere classified,Tobacco use disorder,Hypopotassemia,Edema,Thrombocytopenia, unspecified
Mallory-weiss syndrome,Shock w/o trauma NEC,Ac posthemorrhag anemia,Portal hypertension,Altered mental status,Hpt C w/o hepat coma NOS,Alcohol cirrhosis liver,Esoph varices w/o bleed,Gastroduodenal dis NEC,Ac alcohol intox-contin,Migrne unsp wo ntrc mgrn,Hypertension NOS,Lumbago,Chronic pain NEC,Depressive disorder NEC,Tobacco use disorder,Hypopotassemia,Edema,Thrombocytopenia NOS
Admission Date:  [**2151-10-1**]              Discharge Date:   [**2151-10-5**]

Date of Birth:  [**2091-12-3**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
n/a


History of Present Illness:
59 yo F w/ PMH of alcohol and hepatitis C cirrhosis with history
of varices and upper GI bleed presents with loss of consciousnes
and was Guiac positive with a HCT drop from 44-->33 in the
setting of being intoxicated on alcohol who developed
hematemesis in the ED.

Per ED report, the patietn was alert and oriented x3 on
admission, intoxicated, and hypotensive to systolic of 70s. She
was given multiple listers of fluid and then developed
hematemesis with vomiting bright red blood and clots. She had an
NG tube placed and continued to vomit blood. She was started on
an octerotid and PPI drip with boluses, given a dose of
ceftriaxone and vancomycin and transffused 2u of PRBC. Her
pressures continued to be low and she received a 4th L of fluid
prior to transfer to the MICU.
On arrival to the MICU, she was intubated and sedated.

Review of systems:
unable to obatin as patient is sedated


Past Medical History:
- Alcoholic cirrhosis- low grade varices- not banded, not
bleeding in past. Peripheral edema (on lasix 20mg daily). 1 pint
brandy per day for more than a year. She had tried detox once.
Denies withdrawal
seizures.
- Chronic Back pain
- Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown
how she got it, denies IVDU, transfusions. Never had liver bx.
- Hypertension
- Alcoholic cirrhosis- low grade varices- not banded, not
bleeding in past. Peripheral edema (on lasix 20mg daily). 1 pint
brandy per day for more than a year. She had tried detox once.
Denies withdrawal
seizures.
- Chronic Back pain
- Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown
how she got it, denies IVDU, transfusions. Never had liver bx.
- Hypertension


Social History:
Lives in [**Location 686**] with her 16yo son. [**Name (NI) **] history of alcohol
abuse, over 10 years. Current smoker. Denies other drug use. Has
been in alcohol detox once - relaped shortly thereafter. Drinks
[**2-8**] to 1 pint brandy per day though is actively trying to quit.

Family History:
Mother had MI
Sister with diabetes.
Many family members with alcohol abuse

Physical Exam:
Exam on Admission:
General: sedateed and intubated, in NAD
HEENT: Sclera anicteric. Intubated with blood in the ETT ,
unable to assess JVP
CV: RRR, no MRG appreciated
Lungs: Rhonchrousou breath sounds bilaterally
Abdomen: soft, protuberant but nondistended. Hypoactive bowel
sounds.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated and inutbated

AT DISCHARGE:
O: AF 120s/70s  83-97  18  97%RA
Gen: NAD, sitting in chair comfortable
HEENT: MMM, hallitosis.
CV: RRR, normal S1/S2, no m/r/g.
Pulm: CTAB, no wheezes, rhonchi or rales.
Abd: Soft, non-tender, obese.
Neuro: AAO to person, place, time, president


Pertinent Results:
Labs on Admission:

[**2151-10-1**] 02:15AM BLOOD WBC-7.2# RBC-3.03* Hgb-11.1*# Hct-33.1*
MCV-109* MCH-36.7* MCHC-33.5 RDW-16.4* Plt Ct-78*
[**2151-10-1**] 02:15AM BLOOD Neuts-37.2* Lymphs-54.5* Monos-5.9
Eos-1.8 Baso-0.7
[**2151-10-1**] 09:03AM BLOOD PT-22.6* PTT-34.9 INR(PT)-2.2*
[**2151-10-1**] 02:15AM BLOOD Glucose-129* UreaN-18 Creat-1.0 Na-138
K-5.1 Cl-104 HCO3-22 AnGap-17
[**2151-10-1**] 07:40PM BLOOD ALT-28 AST-61* LD(LDH)-161 AlkPhos-97
TotBili-2.5*
[**2151-10-1**] 02:15AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.5*
[**2151-10-1**] 02:15AM BLOOD ASA-NEG Ethanol-292* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2151-10-1**] 09:13AM BLOOD Type-[**Last Name (un) **] pH-7.20*
[**2151-10-1**] 02:36AM BLOOD Lactate-4.8* K-4.6
[**2151-10-1**] 09:13AM BLOOD freeCa-0.86*

Labs on Discharge:
[**2151-10-5**] 05:01AM BLOOD WBC-4.5 RBC-2.56* Hgb-8.7* Hct-26.2*
MCV-102* MCH-34.0* MCHC-33.2 RDW-21.8* Plt Ct-57*
[**2151-10-5**] 05:01AM BLOOD Glucose-122* UreaN-4* Creat-0.4 Na-136
K-3.5 Cl-107 HCO3-27 AnGap-6*
[**2151-10-5**] 05:01AM BLOOD ALT-27 AST-55* AlkPhos-117* TotBili-1.9*
[**2151-10-5**] 05:01AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.9

Imaging:
EGD ([**2151-10-1**]): "Source of bleeding is identified as [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] tear at the GE junction, not bleeding at the time of the
endoscopy. No interventions were done.  Otherwise grade I
varices at the lower third of the esophagus with no stigmata of
bleeding. Moderate amount of old blood and clots in the stomach,
with no other sources of bleeding identified in the stomach;
Normal mucosa in the duodenum and otherwise normal EGD to third
part of the duodenum."

Portable Chest ([**2151-10-1**]): "Single frontal view of the chest was
obtained. Cardiac mediastinal and hilar contours are
unremarkable.  Both lungs are clear with no focal consolidation,
pleural effusion or pneumothorax."

Portable Abdomen ([**2151-10-1**]): "Gaseous distention of a loop of
small bowel in lower abdomen, with paucity of gas remaining
throughout the abdomen.  These findings are nonspecific, but
cannot exclude partial small-bowel obstruction.  No evidence of
free intraperitoneal air, though image quality limits
assessment. Nasogastric tube in place.  Right-sided pelvic
catheter consistent with a central venous access line."


Brief Hospital Course:
59 year old female with a history of of hepatitis C and
alcoholic cirrhosis and known Grade I varices who presented with
UGIB secondary to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear.

#UGIB- The patient has a history of esophageal varices and is
followed by Dr. [**Last Name (STitle) **] for her cirrhosis. She is on nadalal as
one of her home medications. She developed hematemesis in the
ED, where she received 3L crystalloid and 2 units of PRBC. She
was trasnferred to the MICU, and she had an EGD  performed by GI
which revealed [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tears of the esophagus. She was
monitored in the MICU and her HCT remained stable throughout her
MICU stay. She was started on sucralfate and received 48 hours
of a protonix drip. After transfer to the floor, she continued
to remain hemodynamically stable, although did continue to have
melanic stools. Her HCT continued to remain stable at discharge.
She was sent home with sucralfate and pantoprazole daily, along
with iron supplementation in the setting of acute blood loss.

#Hypovolemic shock- Patient presented with hypotension and
elevated lactate which resolved with fluid resusciation and
blood products.  Since her EGD, she remained hemodynamically
stable, her lactate trended down, and she required no additional
blood products.

#Altered mental status- Patient was found altered at home while
intoxicated. She had a positive flapping tremor and was started
on lactulose at time of transfer from MICU. The patient was
continued on a CIWA scale on the floor, and required minimal
diazepam for symptoms.

#Cirrhosis- Patient has alcoholic/HepC cirrhosis. SHe is
followed in the liver clinic by Dr. [**Last Name (STitle) **]. She is still actively
drinking per her postiive blood alcohol today in the ED.  Her
MELD score is 15. She has thormbocytopenia and known esophageal
varices. She has no history of ascites or hepatic
encephalopathy, however had a flapping tremor and was somnolent
at time of d/c from MICU, which was persistent on the floor. She
was treated with a 4d course of ceftriaxone in the setting of GI
Bleed.

#Alcohol abuse- Patient came to MICU intoxicated to >200 BAL.
Social work was consulted. The patient demonstrated interest in
attending AA after discharge.

#Hypertension- Patient was normotensive during MICU admission,
nadolol was restarted on transfer from MICU and continued on the
floor. Her home lasix and lisinopril were held in the setting of
GI bleeding, and she had no signs of fluid overload on the day
of discharge so these were not restarted.

#hypokalemia - K around 3.3-3.5. Unknown etiology. Was repleted
with PO K.

#Depression- Patient was restarted on citalopram once she was
able to tolerate PO

#Migraines- Fiorecet was held while in the hospital.

The patient was full code throughout admission.

TRANSITIONAL ISSUES:
Pt will need weekly labs to follow hypokalemia and hematocrit
for several weeks, has f/u appt with primary care [**10-14**]. Has
f/u appointment with GI and will need repeat EGD in roughly 3
weeks per GI recommendations.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Furosemide 20 mg PO DAILY
Hold for SBP<90
2. Spironolactone 50 mg PO DAILY
Hold for SBP<90
3. Nadolol 20 mg PO DAILY
Hold for SBP<90, HR<60
4. Acetaminophen-Caff-Butalbital [**2-8**] TAB PO Q8H:PRN headache
5. Citalopram 10 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Thiamine 100 mg PO DAILY


Discharge Medications:
1. Nadolol 20 mg PO DAILY
Hold for SBP<90, HR<60
2. Acetaminophen-Caff-Butalbital [**2-8**] TAB PO Q8H:PRN headache
3. Citalopram 10 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Thiamine 100 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*31
Tablet Refills:*3
8. Sucralfate 1 gm PO BID
RX *sucralfate 1 gram 1 tablet(s) by mouth twice a day Disp #*31
Tablet Refills:*4
9. Lactulose 30 mL PO TID
RX *lactulose [Constulose] 10 gram/15 mL 15-30 mL by mouth use
up to 4 times a day Disp #*1000 Milliliter Refills:*3
10. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
twice a day Disp #*62 Tablet Refills:*3


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary:
[**Doctor First Name **]-[**Doctor Last Name **] Tears
Alcoholic intoxication

Secondary:
Hepatitis C Virus
Cirrhosis
Migraines
Hypertension
Chronic low back pain
Lower extremity edema
Depression


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


Discharge Instructions:
Dear Ms. [**Known lastname **],

You were recently admitted to [**Hospital1 18**] after you were found to have
altered mental status. While you were here, you had an EGD after
some vomitting of blood which showed no change in your varices,
but there was evidence of tearing which most likely caused the
bleeding. There have been no changes to your home medications.
It is imperitive that you discontinue drinking, as this was the
most likely cause of your hospital admission. It was our
pleasure to take care of you while you were a patient here.
Please do not hesitate to contact us with any questions,
comments or concerns.

With Warm Regards,

Your Inpatient Medicine Team

Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2151-10-14**] at 2:10 PM
With: Dr. [**Last Name (STitle) **] [**Name (STitle) **]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your              regular primary
care doctor in follow up.

Department: LIVER CENTER
When: FRIDAY [**2151-10-22**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: RADIOLOGY
When: FRIDAY [**2151-10-22**] at 9:00 AM
With:  ULTRASOUND [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage
{'Gastroesophageal laceration-hemorrhage syndrome,Other shock without mention of trauma,Acute posthemorrhagic anemia,Portal hypertension,Altered mental status,Unspecified viral hepatitis C without hepatic coma,Alcoholic cirrhosis of liver,Esophageal varices without mention of bleeding,Other specified disorders of stomach and duodenum,Acute alcoholic intoxication in alcoholism, continuous,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Unspecified essential hypertension,Lumbago,Other chronic pain,Depressive disorder, not elsewhere classified,Tobacco use disorder,Hypopotassemia,Edema,Thrombocytopenia, unspecified'}


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: Altered mental status

PRESENT ILLNESS: 59 yo F w/ PMH of alcohol and hepatitis C cirrhosis with history
of varices and upper GI bleed presents with loss of consciousnes
and was Guiac positive with a HCT drop from 44-->33 in the
setting of being intoxicated on alcohol who developed
hematemesis in the ED.

MEDICAL HISTORY: - Alcoholic cirrhosis- low grade varices- not banded, not
bleeding in past. Peripheral edema (on lasix 20mg daily). 1 pint
brandy per day for more than a year. She had tried detox once.
Denies withdrawal
seizures.
- Chronic Back pain
- Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown
how she got it, denies IVDU, transfusions. Never had liver bx.
- Hypertension
- Alcoholic cirrhosis- low grade varices- not banded, not
bleeding in past. Peripheral edema (on lasix 20mg daily). 1 pint
brandy per day for more than a year. She had tried detox once.
Denies withdrawal
seizures.
- Chronic Back pain
- Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown
how she got it, denies IVDU, transfusions. Never had liver bx.
- Hypertension

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Furosemide 20 mg PO DAILY
Hold for SBP<90
2. Spironolactone 50 mg PO DAILY
Hold for SBP<90
3. Nadolol 20 mg PO DAILY
Hold for SBP<90, HR<60
4. Acetaminophen-Caff-Butalbital [**2-8**] TAB PO Q8H:PRN headache
5. Citalopram 10 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Thiamine 100 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Exam on Admission:
General: sedateed and intubated, in NAD
HEENT: Sclera anicteric. Intubated with blood in the ETT ,
unable to assess JVP
CV: RRR, no MRG appreciated
Lungs: Rhonchrousou breath sounds bilaterally
Abdomen: soft, protuberant but nondistended. Hypoactive bowel
sounds.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated and inutbated

FAMILY HISTORY: Mother had MI
Sister with diabetes.
Many family members with alcohol abuse

SOCIAL HISTORY: Lives in [**Location 686**] with her 16yo son. [**Name (NI) **] history of alcohol
abuse, over 10 years. Current smoker. Denies other drug use. Has
been in alcohol detox once - relaped shortly thereafter. Drinks
[**2-8**] to 1 pint brandy per day though is actively trying to quit. 

### Response:
{'Gastroesophageal laceration-hemorrhage syndrome,Other shock without mention of trauma,Acute posthemorrhagic anemia,Portal hypertension,Altered mental status,Unspecified viral hepatitis C without hepatic coma,Alcoholic cirrhosis of liver,Esophageal varices without mention of bleeding,Other specified disorders of stomach and duodenum,Acute alcoholic intoxication in alcoholism, continuous,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Unspecified essential hypertension,Lumbago,Other chronic pain,Depressive disorder, not elsewhere classified,Tobacco use disorder,Hypopotassemia,Edema,Thrombocytopenia, unspecified'}
