CHIEF COMPLAINT: Massive hematemesis

PRESENT ILLNESS: 50 yo male with hx of Hep C and alcohol cirrhosis/ESLD on liver
transplant list s/p recent admission during which pt underwent
TIPS without complications.  Patient returned to [**Hospital1 18**] on [**2187-8-15**]
noted to have worsening pedal edema despite TIPS and diuretics.
He underwent TIPS dilation on [**2187-8-17**] without complication.
Patient also underwent colonoscopy without any significant
findings.  Patient presented to OSH on [**2187-8-23**] with massive
hematemesis and hypotension.  Initial Hct was 19, INR at OSH
4.4.  Patient transiently placed on octreoltide drip and IV
protonix.  EGD revealed increased bledding at ampula.  Patient
was injected with epinephrine without any effect.  Patient was
then transfered emergently to [**Hospital1 18**].  On arrival, patient was
intubated for airway protection, OGT placed with 400 cc of blood
return.  Patient then had BRBPR.  Pt was hypotensive  post
intubation in the SBP of 90's.

MEDICAL HISTORY: CAD with stent
Anemia
ETOH abuse
Hepatitis C
Liver cirrhosis/End stage liver disease
History of abdominal wall bleeding w/ paracentesis

MEDICATION ON ADMISSION: Spironolactone, Lasix, oxycodone, lactulose, protonix

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T99.2 BP 115/66 P 89 RR 14 99% on 4L NC
Gen: Awake, alert and oriented x3, slightly confused but able to
converse without any difficulty
HEENT: nc/at, +icteric sclera bilaterally, small conjunctival
injection of left sclera, normal oropharynx, mucous membrane
moist.  neck supple, +R IJ
Cor: RRR, nl S1, S2, no M/R/G, no JVD
Lungs: CTA bilaterally no crackles, no wheezes, no rhonchi
Abd: markedly distended, tympanic to percussion periumbilically
and dullness at bilateraly lower quadrants, +fluid wave, ~13 cm
umbilical hernia with distension and tense skin, no woozing of
fluid.
GU: bilateral scrotal edema with +transillumination, no mass
palpable.
Ext: 3+ pitting edema bilaterally, 1+ DP palpable bilaterally
Neuro: alert and oriented x3, CNIII-XII intact, stregths gross
intact at all major muscles groups.  Sensory not tested.  no
asterixis or tremor.  No nystagmus seen.  Gait and coordination
deferred.

FAMILY HISTORY: Mother 47yo Breast cancer
Father CVA

SOCIAL HISTORY: Currently unemployed. Lives with wife, a healthcare proxy.
Lives in [**Location 21318**].  Has not used drugs x 15 years.  No
ETOH since [**6-14**]. [**1-12**] pack of cigarrettes/day x 30 years.
Other complications due to other vascular device, implant, and graft,Hematemesis,Alcoholic cirrhosis of liver,Chronic hepatitis C without mention of hepatic coma,Alcohol abuse, unspecified,Acute respiratory failure,Hepatic encephalopathy
Comp-oth vasc dev/graft,Hematemesis,Alcohol cirrhosis liver,Chrnc hpt C wo hpat coma,Alcohol abuse-unspec,Acute respiratry failure,Hepatic encephalopathy
Admission Date:  [**2187-8-23**]              Discharge Date:   [**2187-9-2**]

Date of Birth:  [**2137-3-14**]             Sex:   M

Service: MED

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Massive hematemesis

Major Surgical or Invasive Procedure:
Hepatic artery embolization by internventional radiology
Paracentesis

History of Present Illness:
50 yo male with hx of Hep C and alcohol cirrhosis/ESLD on liver
transplant list s/p recent admission during which pt underwent
TIPS without complications.  Patient returned to [**Hospital1 18**] on [**2187-8-15**]
noted to have worsening pedal edema despite TIPS and diuretics.
He underwent TIPS dilation on [**2187-8-17**] without complication.
Patient also underwent colonoscopy without any significant
findings.  Patient presented to OSH on [**2187-8-23**] with massive
hematemesis and hypotension.  Initial Hct was 19, INR at OSH
4.4.  Patient transiently placed on octreoltide drip and IV
protonix.  EGD revealed increased bledding at ampula.  Patient
was injected with epinephrine without any effect.  Patient was
then transfered emergently to [**Hospital1 18**].  On arrival, patient was
intubated for airway protection, OGT placed with 400 cc of blood
return.  Patient then had BRBPR.  Pt was hypotensive  post
intubation in the SBP of 90's.

Past Medical History:
CAD with stent
Anemia
ETOH abuse
Hepatitis C
Liver cirrhosis/End stage liver disease
History of abdominal wall bleeding w/ paracentesis


Social History:
Currently unemployed. Lives with wife, a healthcare proxy.
Lives in [**Location 21318**].  Has not used drugs x 15 years.  No
ETOH since [**6-14**]. [**1-12**] pack of cigarrettes/day x 30 years.

Family History:
Mother 47yo Breast cancer
Father CVA

Physical Exam:
VS: T99.2 BP 115/66 P 89 RR 14 99% on 4L NC
Gen: Awake, alert and oriented x3, slightly confused but able to
converse without any difficulty
HEENT: nc/at, +icteric sclera bilaterally, small conjunctival
injection of left sclera, normal oropharynx, mucous membrane
moist.  neck supple, +R IJ
Cor: RRR, nl S1, S2, no M/R/G, no JVD
Lungs: CTA bilaterally no crackles, no wheezes, no rhonchi
Abd: markedly distended, tympanic to percussion periumbilically
and dullness at bilateraly lower quadrants, +fluid wave, ~13 cm
umbilical hernia with distension and tense skin, no woozing of
fluid.
GU: bilateral scrotal edema with +transillumination, no mass
palpable.
Ext: 3+ pitting edema bilaterally, 1+ DP palpable bilaterally
Neuro: alert and oriented x3, CNIII-XII intact, stregths gross
intact at all major muscles groups.  Sensory not tested.  no
asterixis or tremor.  No nystagmus seen.  Gait and coordination
deferred.

Pertinent Results:
[**2187-8-28**] 04:00AM BLOOD WBC-9.9 RBC-4.02* Hgb-12.5* Hct-36.6*
MCV-91 MCH-31.2 MCHC-34.3 RDW-18.0* Plt Ct-49*
[**2187-8-28**] 04:00AM BLOOD Plt Ct-49*
[**2187-8-28**] 04:00AM BLOOD Glucose-153* UreaN-19 Creat-0.3* Na-140
K-3.1* Cl-107 HCO3-24 AnGap-12
[**2187-8-28**] 04:00AM BLOOD ALT-19 AST-39 LD(LDH)-152 AlkPhos-49
Amylase-32 TotBili-22.9*

[**2187-8-24**] 7:33 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES

                            **FINAL REPORT [**2187-8-28**]**

   AEROBIC BOTTLE (Final [**2187-8-28**]):
      REPORTED BY PHONE TO CARNIVAL,[**Doctor First Name **] @2307 ON [**2187-8-25**].
      VIRIDANS STREPTOCOCCI.

   ANAEROBIC BOTTLE (Final [**2187-8-28**]):
      VIRIDANS STREPTOCOCCI.

CT ABDOMEN WITH CONTRAST: Lung bases are grossly clear except
for minimal dependent changes. There is extensive ascites as on
the prior examination. The liver contour is nodular and
shrunken, consistent with cirrhosis. New metallic coils are seen
wihtin the right lobe of the liver, presumbly from the patient's
hepatic artery embolization. Additionally, a new TIPS shunt has
been placed. The previously identified area of hypervascularity
within the medial caudate lobe is not well-visualized on the
current examination due to lack of arterial phase of imaging.
The portal vein and hepatic veins are patent.

The gallbladder contains multiple stones and sludge within the
gallbladder neck. The spleen is slightly enlarged. The adrenals
and kidneys are within normal limits. The pancreas and stomach
are unremarkable. Multiple loops of small bowel appear dilated
and thickened, probably a result of the patient's cirrhotic
state. Mild small bowel loop dilatation is noted.

CT PELVIS WITH CONTRAST: The colon, appendix, urinary bladder
and rectum are unremarkable. There is extensive ascites within
the pelvis. Note is made of bilateral opening inguinal rings,
with a small amount of fluid in the hernias. A subcutaneous
anterior abdominal wall fluid collection is noted as on the
prior examination, measuring approximately 8.2 cm transverse x
3.2 cm AP.

BONE WINDOWS: No suspicious bony lesions. Degenerative changes
are seen within the lower lumbar spine.

IMPRESSION: No significant change from the prior examination,
with changes of portal hypertension and cirrhosis. No evidence
of loculated fluid collection or abscess formation.


Brief Hospital Course:
1) GI bleed: On admission, pt underwent emergent EGD which
showed no bleeding from gastric or esophageal varices but did
have bleeding from peri-ampullary region.  The area was injected
with epinephrine but still had active oozing of blood.  Per
report, pt had 1-2 L of hematemesis during the procedure.
Patient got triple phase CT scan which did not see any active
bleed.  Patient was then brought to Interventional Radiology to
identify the source of the bleed.  Pseudoaneurysm of arterial
[**Last Name (un) **] of right hepatic artery found and subsequently embolized
on [**8-22**].  The hepatic artery pseudoaneurysm was believed to be
secondary to eroded TIPS.  Patient's Hct was contininued to drop
acutely on admission and received multiple transfusion till the
embolization.  Patient was given total of 12 units of PRBC, 6
units of FFP, one bag of platelets since presentation to OSH.
Patient remained in MICU till [**8-28**] where Hct, platelets, and
coags were checked frequently.  NG lavage from [**8-23**] showed clots
and later clearing on [**8-24**]/  Patient was initially on octreotide
drip but was discontinued on [**2187-8-25**].  Patient initially
remained hemodynamically stable after the embolization
procedure.  However on [**8-24**], Hct dropped from 32 to 27 and got 4
units of PRBC.  On [**8-26**], his Hct continued to drop requiring
another 4 units of PRBC and wa brought back to the
interventional radiology for repeat intervention.  Patient has
been hemodynamically stable since then.  Patient was then
transferred to the medicine floor where he remained slightly
hypotensive with SBP of 100's but hemodynamically stable.  He
required several more therapeutic paracentesis which were all
negative for SBP, and his blood pressure tolerated well and his
hematocrit remained stable until [**9-2**].  When Hct dropped from
333 to 24 and then to 21 acutely.  In the early morning of [**9-2**],
he was found to be hypotensive in the 80's systolic but
eventually came back up to 100's.  Around 7am, he was found to
be tachypnic appearing ill.  The day before, he got another
paracentesis without any complication and any evidence of
peritoneal bleed seen in the peritoneal fluid.  In the morning
of [**9-2**], his abdomen appeared distended but tympanic in nature
with less fluid.  It was concerning for perforated bowel, so KUB
and upright Chest film were ordered which were negative for free
air.  His initial vital signs were within his usual baseline and
within the normal limits, oxygenating well on room air.   He was
noted to have low grade temp of 100 for the past 1 week with
negative workup.  He then suddenly became hypotensive with a
lactate of 14.5, ABG of 7.40/22/86/14 on RA.  MICU was called
and pt was resuscitated with IVF and transferred to the ICU.
Hct at that time was noted to be 21.  He was intubated, and
given PRBC but became hypotensive.  Repeat ABG showed 6.79/65/66
and eventually deceased.  He had multiple ecchymosis and bleed
from the all of the line sites which were consistent with the
DIC picture.  His high lactate, hypotensive state, and
underlying metabolic acidosis picture was consistent with the
sepsis picture rather than pure GI bleed.  Autopsy permission
was obtained by his wife.

2)SBP: Patient was initially started on IV Cipro for SBP
prophylaxis but was changed to levofloxacin and flagyl for
empiric SBP prophylasix.  Patient then got ultrasound guided
diagnostic/therapeutic paracentesis on [**8-24**] due to high bladder
pressure in which 3.5 L of fluid was removed and the peritoneal
fluid studies were consistent with SBP (500 WBC 79%PMN's).
Patient was started on Zosyn on [**8-24**] after acute rise in WBC
from 12 to 24.  The peritoneal fluid culture grew strep viridan,
so vancomycin was added to zosyn.  Patient got another
paracentesis on [**8-28**].  Patient got albumin and FFP during the
procedure.  Patient had a persistent low grade temp of 100's for
almost a week with a negative workup including peritoneal fluid
culture, blood culture, urine culture, chest x-ray, and CT
Abdomen for abscess.  It is possible that he had a nidus of
infection at his hepatic artery coil that was emolized which
eventually caused another bleed on [**9-2**] which led to his demise.

3)Hepatic encephalopathy:  After extubation, patient was not
oriented and was arguing with the staff that he wanted to leave
AMA.  After discussing with his wife and the team, he was felt
incapacitated to make that decision under worsening of
encephalopathy.  He has been on lactulose for encephalopathy.
On [**8-28**] when transferred to the floor, patient was alert and
oriented x3 and more cooperative.  Patient was having good
response to lactulose and showing improvent in his mental
status.

4)Cirrhosis/ascites:  As noted above, patient required 2
therapeutic paracentesis to releave abdominal distension.  He
also has remarkable umbilical hernia that was very tense as his
peritoneal fluid reaccumulated.  Patient was initially on
spironolactone 25 mg po qd and lasix 20 mg IV qd which was
changed to spironolactone 50 mg po qd and lasix 40 mg po qd.
Prior to this admission, he was not responding well to diuretics
as his ascites and pedal edema worsened despite TIPS and
diuretics.

5)Renal: Creatinine on admission was 0.6 and has been stable
since [**8-25**] when creatinine level went up to 1.2 which was
attributed to high contrast/dye load during CTA and angiogram.
Patient got mucomyst and aggressive hydration after the CTA and
angiogram.  The creatinine shortly came down to 0.7 then 0.3 and
have been stable since.

6)Respiratory:  Patient was initially intubated to protect his
airway from massive hematemesis.  He remained intubated in the
MICU till [**2187-8-27**].  Post-extubation course without any
complication.

7)Pneumonia: Chest X-ray from [**2187-6-27**] showing possible new left
lobe infiltrate which was thought as new bacterial.  Patient was
already covered with Vanc and Zosyn for SBP treatment which also
should cover for common bacterial pathogens. The repeat Chest
X-ray did not appear to consistent with pneumonia.

8)Thrombocytopenia: Patient noted to have thrombocytopenia
secondary to liver failure.  Patient received one bag of
platelets initially.  It remained low in 40-70's but has been
stable without significant drop in the platelet count.  The goal
was to transfuse for active bleed or platelet count <10.

9)FEN: Pt was initially on tube feed.  After extubaton,
speech/swallow service evaluated the patient, and he was
tolerating thick liquid since.  Patient remained on low sodium
low protein diet for his liver disease.  In addition, dob hob
was placed and tube feeding was started overnight to supplement
his nutrition since he was at a catabolic state as it was
evident by the low creatinine.


Medications on Admission:
Spironolactone, Lasix, oxycodone, lactulose, protonix

Discharge Disposition:
Home

Facility:
Patient deceased

Discharge Diagnosis:
1. GI bleed
2. Sepsis
3. Hepatic artery pseudoaneurysm/rupture s/p coiling
4. SBP
5. End stage liver disease
6. Cirrhosis

Discharge Condition:
Patient deceased.


Completed by:[**2187-9-10**]
{'Other complications due to other vascular device, implant, and graft,Hematemesis,Alcoholic cirrhosis of liver,Chronic hepatitis C without mention of hepatic coma,Alcohol abuse, unspecified,Acute respiratory failure,Hepatic encephalopathy'}


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: Massive hematemesis

PRESENT ILLNESS: 50 yo male with hx of Hep C and alcohol cirrhosis/ESLD on liver
transplant list s/p recent admission during which pt underwent
TIPS without complications.  Patient returned to [**Hospital1 18**] on [**2187-8-15**]
noted to have worsening pedal edema despite TIPS and diuretics.
He underwent TIPS dilation on [**2187-8-17**] without complication.
Patient also underwent colonoscopy without any significant
findings.  Patient presented to OSH on [**2187-8-23**] with massive
hematemesis and hypotension.  Initial Hct was 19, INR at OSH
4.4.  Patient transiently placed on octreoltide drip and IV
protonix.  EGD revealed increased bledding at ampula.  Patient
was injected with epinephrine without any effect.  Patient was
then transfered emergently to [**Hospital1 18**].  On arrival, patient was
intubated for airway protection, OGT placed with 400 cc of blood
return.  Patient then had BRBPR.  Pt was hypotensive  post
intubation in the SBP of 90's.

MEDICAL HISTORY: CAD with stent
Anemia
ETOH abuse
Hepatitis C
Liver cirrhosis/End stage liver disease
History of abdominal wall bleeding w/ paracentesis

MEDICATION ON ADMISSION: Spironolactone, Lasix, oxycodone, lactulose, protonix

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T99.2 BP 115/66 P 89 RR 14 99% on 4L NC
Gen: Awake, alert and oriented x3, slightly confused but able to
converse without any difficulty
HEENT: nc/at, +icteric sclera bilaterally, small conjunctival
injection of left sclera, normal oropharynx, mucous membrane
moist.  neck supple, +R IJ
Cor: RRR, nl S1, S2, no M/R/G, no JVD
Lungs: CTA bilaterally no crackles, no wheezes, no rhonchi
Abd: markedly distended, tympanic to percussion periumbilically
and dullness at bilateraly lower quadrants, +fluid wave, ~13 cm
umbilical hernia with distension and tense skin, no woozing of
fluid.
GU: bilateral scrotal edema with +transillumination, no mass
palpable.
Ext: 3+ pitting edema bilaterally, 1+ DP palpable bilaterally
Neuro: alert and oriented x3, CNIII-XII intact, stregths gross
intact at all major muscles groups.  Sensory not tested.  no
asterixis or tremor.  No nystagmus seen.  Gait and coordination
deferred.

FAMILY HISTORY: Mother 47yo Breast cancer
Father CVA

SOCIAL HISTORY: Currently unemployed. Lives with wife, a healthcare proxy.
Lives in [**Location 21318**].  Has not used drugs x 15 years.  No
ETOH since [**6-14**]. [**1-12**] pack of cigarrettes/day x 30 years. 

### Response:
{'Other complications due to other vascular device, implant, and graft,Hematemesis,Alcoholic cirrhosis of liver,Chronic hepatitis C without mention of hepatic coma,Alcohol abuse, unspecified,Acute respiratory failure,Hepatic encephalopathy'}
