CHIEF COMPLAINT: Nausea, hematemesis

PRESENT ILLNESS: 52 yo male with h/o Hep C Cirrhosis, ETOH abuse (recent detox)
found by family on the bathroom floor, vomiting coffee ground
emesis. Per the family, the patient has had protracted medical
course which began about 1 month ago when he was brought into
[**Hospital1 18**] for etoh withdrawal and MS changes; he was then brought to
Arborway for ETOH detox. The family reports he had been heavily
drinking and also had been "different on Ribavarin/IFN" (thus
was taken off it at that time). He was then transfered from
detox to [**Hospital1 336**] for abdominal pain and treated for pancreatitis.
He was discharged home on percocet. He subsequently continued to
feel poorly with abdominal pain. Last Monday [**7-28**] he had been
vomiting some bloody material and was brought to [**Hospital3 **]
where an NG lavage was negative, guiac negative and tx with
carafate and PPI and sent home. Per his sister, his mental
status was okay at that time. He persisted to vomit bloody
material all week and this morning his wife brought him here for
furhter managmeent.
.
Per the family, pt has had ongoing abdominal pain since etoh
detox. They are unsure if he is drinking etoh but the patient
denies it. he has been taking librium and valium (pt admits to
using this). Per family he has been sleeping a lot and had
garbled speech for many days.
.
He was brought to [**Hospital3 **] today; had INR 2.0, Hct 25;
NGT showed coffee ground emesis; gave 1 u prbcs, 2700cc of NS
and transferred here + 40mg IV protonix.
.
In ED, vitals on arrival 98.4, 86 108/53 18 98%RA. Pt was
lethargic and smelled of ETOH. Repeat hct 26.9, Plts 49 and he
received 1 bag of platelets. Vitals remained stable SBP
90s-110s. HR 80s. Pt had slurred speech but A&Ox2. NGT lavage
negative.
.
During his ED course the patient fell out of bed unwitnessed but
sustained abrasion to left flank.. no trauma to head but given
his coagulpathic state a CT head/Abd were ordered.
.

MEDICAL HISTORY: Hep C-acquired in military '[**53**], liver biopsy '[**70**] showed
cirrhosis, tx with Ribavarin and IFN '[**73**]-00 and again '[**81**]-'[**82**]
stopped 1 month ago; HCV RNA negative
GERD
HTN
Diverticulosis on c-scope'[**80**]
Internal Hemorrhoids
Depression with SI
ETOH and Opiate dependence; s/p detox x2; recent admission [**7-18**]
for SI
h/o head trauma w/skull fracture
Anxiety; started on Buspar 3 weeks ago
h/o orthopedic surgeries
Chronic Thrombocytopenia
.

MEDICATION ON ADMISSION: Buspar 10mg [**Hospital1 **]
Atenolol 100mg daily
Protonix 40mg daily
Valium, Librium and [**Name (NI) 41919**] unclear dose

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GEN:somnolent but arousable, able to converse with constant
re-orientation.
HEENT:NC/AT, EOMI, PERRL, purulent material on R. eye
Neck:Supple, JVP flat, no lymphadenopathy
SKIN: Slight ecchymotic area on R. flank, non-tender
CV:RRR, no murmurs/rubs
PULM: Coarse bs throughout
ABD: Soft, non-tender, ND, +BS, no rebound/guarding
EXT:No LE edema
NEURO:No asterixis. A&Ox3, knows president, knows wife's name.
CN 2-12 grossly intact, sensation intact throughout, strength
[**4-5**] b/l in UE/LE

FAMILY HISTORY: Father, sister and brother with diverticulitis, no h/o colon
cancer

SOCIAL HISTORY: The patient was born and raised in [**Location (un) 86**]. He has served in the
marines for 8 years (submarine) during which he describes
periods of depression. No hx of combat (cold war). The patient
was employed as a lineman unti 1.5 years ago when he went on
disability (work related injury in [**2170**]). He is currently
married and has two daughters 17, 19. H/O ETOh abuse; per wife
last drink 1 month ago and has been getting Librium/valium for
detox at home. No current smoking but previously smoked <1ppd
and quit 30 years ago. HIV negative per OSH report.
Acute esophagitis,Pneumonitis due to inhalation of food or vomitus,Acute pancreatitis,Acute cholecystitis,Acute posthemorrhagic anemia,Other specified disorders of stomach and duodenum,Chronic hepatitis C without mention of hepatic coma,Unspecified essential hypertension,Dysthymic disorder,Thrombocytopenia, unspecified,Acute conjunctivitis, unspecified,Other dysphagia,Other and unspecified alcohol dependence, unspecified
Acute esophagitis,Food/vomit pneumonitis,Acute pancreatitis,Acute cholecystitis,Ac posthemorrhag anemia,Gastroduodenal dis NEC,Chrnc hpt C wo hpat coma,Hypertension NOS,Dysthymic disorder,Thrombocytopenia NOS,Acute conjunctivitis NOS,Dysphagia NEC,Alcoh dep NEC/NOS-unspec
Admission Date:  [**2183-8-3**]              Discharge Date:   [**2183-8-14**]

Date of Birth:  [**2131-5-25**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Nausea, hematemesis

Major Surgical or Invasive Procedure:
[**2183-8-5**] EGD

History of Present Illness:
52 yo male with h/o Hep C Cirrhosis, ETOH abuse (recent detox)
found by family on the bathroom floor, vomiting coffee ground
emesis. Per the family, the patient has had protracted medical
course which began about 1 month ago when he was brought into
[**Hospital1 18**] for etoh withdrawal and MS changes; he was then brought to
Arborway for ETOH detox. The family reports he had been heavily
drinking and also had been "different on Ribavarin/IFN" (thus
was taken off it at that time). He was then transfered from
detox to [**Hospital1 336**] for abdominal pain and treated for pancreatitis.
He was discharged home on percocet. He subsequently continued to
feel poorly with abdominal pain. Last Monday [**7-28**] he had been
vomiting some bloody material and was brought to [**Hospital3 **]
where an NG lavage was negative, guiac negative and tx with
carafate and PPI and sent home. Per his sister, his mental
status was okay at that time. He persisted to vomit bloody
material all week and this morning his wife brought him here for
furhter managmeent.
.
Per the family, pt has had ongoing abdominal pain since etoh
detox. They are unsure if he is drinking etoh but the patient
denies it. he has been taking librium and valium (pt admits to
using this). Per family he has been sleeping a lot and had
garbled speech for many days.
.
He was brought to [**Hospital3 **] today; had INR 2.0, Hct 25;
NGT showed coffee ground emesis; gave 1 u prbcs, 2700cc of NS
and transferred here + 40mg IV protonix.
.
In ED, vitals on arrival 98.4, 86 108/53 18 98%RA. Pt was
lethargic and smelled of ETOH. Repeat hct 26.9, Plts 49 and he
received 1 bag of platelets. Vitals remained stable SBP
90s-110s. HR 80s. Pt had slurred speech but A&Ox2. NGT lavage
negative.
.
During his ED course the patient fell out of bed unwitnessed but
sustained abrasion to left flank.. no trauma to head but given
his coagulpathic state a CT head/Abd were ordered.
.


Past Medical History:
Hep C-acquired in military '[**53**], liver biopsy '[**70**] showed
cirrhosis, tx with Ribavarin and IFN '[**73**]-00 and again '[**81**]-'[**82**]
stopped 1 month ago; HCV RNA negative
GERD
HTN
Diverticulosis on c-scope'[**80**]
Internal Hemorrhoids
Depression with SI
ETOH and Opiate dependence; s/p detox x2; recent admission [**7-18**]
for SI
h/o head trauma w/skull fracture
Anxiety; started on Buspar 3 weeks ago
h/o orthopedic surgeries
Chronic Thrombocytopenia
.


Social History:
 The patient was born and raised in [**Location (un) 86**]. He has served in the
marines for 8 years (submarine) during which he describes
periods of depression. No hx of combat (cold war). The patient
was employed as a lineman unti 1.5 years ago when he went on
disability (work related injury in [**2170**]). He is currently
married and has two daughters 17, 19. H/O ETOh abuse; per wife
last drink 1 month ago and has been getting Librium/valium for
detox at home. No current smoking but previously smoked <1ppd
and quit 30 years ago. HIV negative per OSH report.

Family History:
Father, sister and brother with diverticulitis, no h/o colon
cancer

Physical Exam:
GEN:somnolent but arousable, able to converse with constant
re-orientation.
HEENT:NC/AT, EOMI, PERRL, purulent material on R. eye
Neck:Supple, JVP flat, no lymphadenopathy
SKIN: Slight ecchymotic area on R. flank, non-tender
CV:RRR, no murmurs/rubs
PULM: Coarse bs throughout
ABD: Soft, non-tender, ND, +BS, no rebound/guarding
EXT:No LE edema
NEURO:No asterixis. A&Ox3, knows president, knows wife's name.
CN 2-12 grossly intact, sensation intact throughout, strength
[**4-5**] b/l in UE/LE


Pertinent Results:
[**2183-8-5**] ECHO:
The left atrium is dilated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
No vegetations seen (cannot definitively exclude).
.
[**2183-8-6**] CT ABDOMEN
IMPRESSION:
1. No retroperitoneal hematoma.
2. Nodular ground-glass peribronchial opacities in the right
middle lobe
riases concern for infection. Left lower lobe opacity more has
the appearance of a small area of aspiration or atelectasis.
3. Nonobstructing 4 mm renal stone, lower pole of the left
kidney with
other punctate left and right renal calculi.
4. Colonic diverticulosis, without evidence of diverticulitis.

5. Cholelithiasis.
.
[**2183-8-5**] EGD: No varices
Grade 2 esophagitis in the gastroesophageal junction and lower
third of the esophagus compatible with esophagitis
Mild portal hypertensive gastropathy changes in the fundus
Erosions in the antrum compatible with N G trauma
Otherwise normal EGD to second part of the duodenum
.
[**2183-8-5**] CXR: In comparison with the study of [**8-4**], there is again
patchy
opacification at the left base. Again, although this could
represent
atelectatic change, the possibility of pneumonia should be
seriously
considered. A lateral view would be helpful for further
evaluation if the
patient's condition permits.
.
[**2183-8-8**] CXR: Resolution of right infrahilar opacity. Improvement
in left
lower lobe opacity now strongly suggestive of atelectasis.
.
[**2183-8-8**] Abdominal US: Son[**Name (NI) 493**] findings are consistent with
cholecystitis given the distended gallbladder with wall edema.
However, there is no son[**Name (NI) 493**] [**Name2 (NI) 515**] sign and appearance is
little changed over two days since prior CT. Would recommend a
HIDA scan to further evaluate gallbladder function. The
gallbladder wall edema could also be due to the patient's
underlying liver disease. Coarse echogenic liver consistent with
patient's known prior liver disease.


Brief Hospital Course:
GI BLEED: Pt had several days of coffee ground emesis before
admission. Endoscopy on [**2183-8-5**] showed grade II esophagitis
(thought to be the bleeding source) and portal hypertensive
gastropathy.  He required 3 units PRBCs during course with
stable hematocrit following this.  Patient was started on PPI
[**Hospital1 **] and his hematocrit was closely monitored throughout his
hospitalization.

FEVER: Pt had fever of 101 F soon after admission.  Initially
broadly covered with vanco and zosyn.  Based on chest xray
source thought to be an aspiration pneumonia (right middle lobe
in setting of vomiting and altered mental status).  Sputum
cultures repeatedly too contaminated for evaluation.  Regimen
trimmed down to levofloxacin and flagyl.  With increased
right-sided abdominal pain and nausea more imaging was
performed. CT abdomen and abdominal ultrasound suggested acute
cholecystitis. Surgery was notified and felt that surgery was
not indicated at this time.  Pt will be considered for surgery
when he is not acutely ill. Once pt completed levofloxacin
course for pneumonia pt was switched to cipro and continued on
flagyl.  Pt will complete a two week course of antibiotics for
acute cholecystitis.  At time of discharge respiratory and GI
symptoms had largely resolved with some residual RUQ tenderness.
 Repeat chest x-ray showed resolution of consolidation.  Pt will
follow up with Dr. [**First Name (STitle) 679**] in two weeks to be reevaluated. Pt did
not complain of any coughing, SOB, or pleuritic pain upon
discharge. Pt did continue to have RUQ pain [**6-10**] at baseline,
and 7.5/10 with meals. Dr. [**First Name (STitle) 679**] will follow up with pt in clinic
and refer to surgery if appropriate.

WEAKNESS: Pt said he felt weak s/p ICU. Pt did not have any
steriods in the ICU and critical care myopathy was very unlikely
considering the pt had [**5-5**] motor strength, and not in the ICU
that long. Pt's neuro exam on cordination was fine - with normal
FNF and HTS, but unsteady in his gait. Pt was not able to
perform tandem gait. Neuro was consulted and found that this was
not an acute process but actually subacute to chronic. They
believed this was [**2-1**] alcohol use, and likely anterior vermis
syndrome. PT did not feel that [**Hospital 3782**] rehab would have helped
with this, and neuro recommended to continue current regimen of
meds including thiamine, folate, and MVI.

AMS: Pt has been on multiple benzos per wife for withdrawal; MS
changes occuring over past week; likely related to withdrawal vs
acute intoxication. Did not appear overtly encephalopathic &
ammonia level 24. CT head negative. This improved significantly
over his course with return to baseline.  Likely benzo related.

ANEMIA: With GI bleed as above.  Also concern that having non-GI
losses based on dropping hematocrit in abscence of obvious GI
bleeding.  CT abdomen negative for RP bleed or bleeding
associated with fall in the ED.

S/P FALL: Pt fell while in ED and given low platelets and
elevated INR; CT Head and Abdomen done; CT head negative and no
RP bleed.

ETOH ABUSE: Pt recently admitted for detox and currently denies
ETOh use over past few weeks; however given strong h/o abuse
will cover for possible withdrawal.  CIWA scale was done without
need for benzos.  MVI and folate and thiamine given.

CONJUNCTIVITIS: red eye with purulent discharge, started on
eythromycin opthalmic solution. Course was completed prior to
discharge.

HEPATITIS C: Followed by Dr [**First Name (STitle) 679**]; recently completed course of
Ribavarin in IFN. Pt does not appear encephalopathic.
Considered Lactulose but MS improved.


Medications on Admission:
Buspar 10mg [**Hospital1 **]
Atenolol 100mg daily
Protonix 40mg daily
Valium, Librium and [**Name (NI) 41919**] unclear dose


Discharge Medications:
1. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
3. 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:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days: last dose on [**8-21**].
Disp:*21 Tablet(s)* Refills:*0*
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days: last dose on [**8-21**].
Disp:*14 Tablet(s)* Refills:*0*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*qs ML(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
10. Outpatient Physical Therapy
treatment as per physical therapy
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
UGIB- esophagitis and portal hypertensive gastropathy per EGD
Pneumonia
Acute cholecystitis

Secondary:
Hep C cirrhosis
h/o EtOH and opiate abuse
HTN
Depression/Anxiety
Chronic thrombocytopenia


Discharge Condition:
Stable; pt does not require supplemental oxygen; tolerates po
diet and meds


Discharge Instructions:
You were admitted to the hospital after experiencing several
episodes of coffee ground emesis suggesting an upper GI bleed.
You were admitted to the ICU.  In the ICU you were found to have
low blood counts so you were given a transfusion. You also
underwent an upper GI scope to look for causes of the bleeding.
The endoscopy showed inflammation of your esophagus and
gastropathy in your stomach.  On chest x-ray you were found to
have a pneumonia.  A CT scan was performed to get a better look
at the pneumonia.  It showed pneumonia as well as acute
cholecystitis (inflammation of your gall bladder).  You were
started on the appropriate antibiotics.  Because you had stopped
vomiting and were without fever you were transferred to the
floor where you were further managed and monitored for your
infections and GI bleeding.
.
The Surgery team was notified of your acute cholecystitis.  They
did not feel that surgery was indicated at this time but will
likely consider surgery when the inflammation has resolved to
prevent future episodes of cholecystitis.  Dr. [**First Name (STitle) 679**] will notify
them of your status after you follow up in his clinic.
.
Because you were very weak during your admission Physical
Therapy was consulted.  They felt that you would greatly benefit
from continued physical therapy as an outpatient.

The following changes were made to your medications:
--You were started on Ciprofloxacin and Metronidazole to treat
your acute cholecystitis.  You will continue these medications
until [**2183-8-21**].
--You should take a multivitamin, thiamine, and folate
supplements daily
-- Your protonix was increased from 40mg once a day to 40mg
twice a day.
-- your atenolol was decreased to 50mg once a day
-- your Buspar was changed to celexa 20mg once a day
.
Please notify your physician or return to the ED if your
abdominal pains or respiratory symptoms progress or if your
vomiting and fever return.

Followup Instructions:
An appointment has been scheduled for you with Dr. [**First Name (STitle) 679**] on
Monday [**8-25**] at 1pm. Telephone number [**Telephone/Fax (1) 682**].


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

Completed by:[**2183-8-24**]
{'Acute esophagitis,Pneumonitis due to inhalation of food or vomitus,Acute pancreatitis,Acute cholecystitis,Acute posthemorrhagic anemia,Other specified disorders of stomach and duodenum,Chronic hepatitis C without mention of hepatic coma,Unspecified essential hypertension,Dysthymic disorder,Thrombocytopenia, unspecified,Acute conjunctivitis, unspecified,Other dysphagia,Other and unspecified alcohol dependence, 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: Nausea, hematemesis

PRESENT ILLNESS: 52 yo male with h/o Hep C Cirrhosis, ETOH abuse (recent detox)
found by family on the bathroom floor, vomiting coffee ground
emesis. Per the family, the patient has had protracted medical
course which began about 1 month ago when he was brought into
[**Hospital1 18**] for etoh withdrawal and MS changes; he was then brought to
Arborway for ETOH detox. The family reports he had been heavily
drinking and also had been "different on Ribavarin/IFN" (thus
was taken off it at that time). He was then transfered from
detox to [**Hospital1 336**] for abdominal pain and treated for pancreatitis.
He was discharged home on percocet. He subsequently continued to
feel poorly with abdominal pain. Last Monday [**7-28**] he had been
vomiting some bloody material and was brought to [**Hospital3 **]
where an NG lavage was negative, guiac negative and tx with
carafate and PPI and sent home. Per his sister, his mental
status was okay at that time. He persisted to vomit bloody
material all week and this morning his wife brought him here for
furhter managmeent.
.
Per the family, pt has had ongoing abdominal pain since etoh
detox. They are unsure if he is drinking etoh but the patient
denies it. he has been taking librium and valium (pt admits to
using this). Per family he has been sleeping a lot and had
garbled speech for many days.
.
He was brought to [**Hospital3 **] today; had INR 2.0, Hct 25;
NGT showed coffee ground emesis; gave 1 u prbcs, 2700cc of NS
and transferred here + 40mg IV protonix.
.
In ED, vitals on arrival 98.4, 86 108/53 18 98%RA. Pt was
lethargic and smelled of ETOH. Repeat hct 26.9, Plts 49 and he
received 1 bag of platelets. Vitals remained stable SBP
90s-110s. HR 80s. Pt had slurred speech but A&Ox2. NGT lavage
negative.
.
During his ED course the patient fell out of bed unwitnessed but
sustained abrasion to left flank.. no trauma to head but given
his coagulpathic state a CT head/Abd were ordered.
.

MEDICAL HISTORY: Hep C-acquired in military '[**53**], liver biopsy '[**70**] showed
cirrhosis, tx with Ribavarin and IFN '[**73**]-00 and again '[**81**]-'[**82**]
stopped 1 month ago; HCV RNA negative
GERD
HTN
Diverticulosis on c-scope'[**80**]
Internal Hemorrhoids
Depression with SI
ETOH and Opiate dependence; s/p detox x2; recent admission [**7-18**]
for SI
h/o head trauma w/skull fracture
Anxiety; started on Buspar 3 weeks ago
h/o orthopedic surgeries
Chronic Thrombocytopenia
.

MEDICATION ON ADMISSION: Buspar 10mg [**Hospital1 **]
Atenolol 100mg daily
Protonix 40mg daily
Valium, Librium and [**Name (NI) 41919**] unclear dose

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GEN:somnolent but arousable, able to converse with constant
re-orientation.
HEENT:NC/AT, EOMI, PERRL, purulent material on R. eye
Neck:Supple, JVP flat, no lymphadenopathy
SKIN: Slight ecchymotic area on R. flank, non-tender
CV:RRR, no murmurs/rubs
PULM: Coarse bs throughout
ABD: Soft, non-tender, ND, +BS, no rebound/guarding
EXT:No LE edema
NEURO:No asterixis. A&Ox3, knows president, knows wife's name.
CN 2-12 grossly intact, sensation intact throughout, strength
[**4-5**] b/l in UE/LE

FAMILY HISTORY: Father, sister and brother with diverticulitis, no h/o colon
cancer

SOCIAL HISTORY: The patient was born and raised in [**Location (un) 86**]. He has served in the
marines for 8 years (submarine) during which he describes
periods of depression. No hx of combat (cold war). The patient
was employed as a lineman unti 1.5 years ago when he went on
disability (work related injury in [**2170**]). He is currently
married and has two daughters 17, 19. H/O ETOh abuse; per wife
last drink 1 month ago and has been getting Librium/valium for
detox at home. No current smoking but previously smoked <1ppd
and quit 30 years ago. HIV negative per OSH report. 

### Response:
{'Acute esophagitis,Pneumonitis due to inhalation of food or vomitus,Acute pancreatitis,Acute cholecystitis,Acute posthemorrhagic anemia,Other specified disorders of stomach and duodenum,Chronic hepatitis C without mention of hepatic coma,Unspecified essential hypertension,Dysthymic disorder,Thrombocytopenia, unspecified,Acute conjunctivitis, unspecified,Other dysphagia,Other and unspecified alcohol dependence, unspecified'}
