CHIEF COMPLAINT: GI Bleed

PRESENT ILLNESS: Patient is a 21F with h/o bulemia, ETOH abuse, Cirrhosis
secondary to her eating disorder with known varices who presents
from [**Hospital6 3105**] with acute upper GI bleed.  HPI
is taken from records and mother as patient is intubated and
unable to provide history.

MEDICAL HISTORY: 1. Bulemia Nervosa
2. EtOH Abuse
3. Cirrhosis -> thought secondary to eating disorder.  Has had
liver biopsy on [**2167-10-22**]: macrovesicular steatosis with rare
hyalin. There is marked bridging fibrosis.  No feature of
autoimmune hepatitis.

MEDICATION ON ADMISSION: Eye drops (unknown)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 99.7, BP 97/60, HR 109, RR 18, 92% AC Fi02 100%, PEEP 10,
Tv500
Gen: Intubated, sedated, unresponsive
HEENT: Pupils fixed, minimally reactive to light, mild icteric
sclera
Neck: Supple, bounding carotid pulses
HEART: Tachy, regular, S1 S2 with S3, no m/r
LUNG: Coarse BS bilaterally, symmetric, no wheezing
ABDOMEN: Distended, soft, tympanic, could not appreciated liver
edge
EXT: Cool, 1+ edema bilat, 1+ DP pulses
SKIN: Mildly icteric
NEURO: Unresponsive, pupils pin point and minimally responsive,
flaccid throughout.

FAMILY HISTORY: Significant for multiple members with DM and HTN. No known
thyroid dz, autoimmune dz (Lupus, UC, crohn's etc), no liver dz
or other GI problems.

SOCIAL HISTORY: Lives at home with mother.  Recently drinking EtOH with friends
over the past few days, unknown quantities.  + toabacco, <1ppd.
Per mother, no h/o recreational drug use otherwise.
Other pulmonary insufficiency, not elsewhere classified,Esophageal varices in diseases classified elsewhere, with bleeding,Shock, unspecified,Pneumonia, organism unspecified,Acute systolic heart failure,Other primary cardiomyopathies,Cirrhosis of liver without mention of alcohol
Other pulmonary insuff,Bleed esoph var oth dis,Shock NOS,Pneumonia, organism NOS,Ac systolic hrt failure,Prim cardiomyopathy NEC,Cirrhosis of liver NOS
Admission Date:  [**2168-2-26**]              Discharge Date:   [**2168-3-10**]

Date of Birth:  [**2146-7-30**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
GI Bleed

Major Surgical or Invasive Procedure:
Intubation (from OSH)
Mechanical Ventilation
Central Venous Line Placement (from OSH)
Arterial Line Placement
Upper endoscopy x 2

History of Present Illness:
Patient is a 21F with h/o bulemia, ETOH abuse, Cirrhosis
secondary to her eating disorder with known varices who presents
from [**Hospital6 3105**] with acute upper GI bleed.  HPI
is taken from records and mother as patient is intubated and
unable to provide history.

The mother states that the patient was feeling unwell on the day
of admission.  Her friend had died a few nights before and she
was spending time with her friends consuming unknown quantities
of EtOH.  She denied any f/c, HA, abd pain during this time.
However, she was very fatigued and complained of shortness of
breath.  Her mother also noted her to be slightly yellow at this
time.  She spent most of the day in bed, but became nauseated
and vomitted black "clots."  As far as the mother knows there
was no bloody stool prior.  She was then taken to the ED at LGH.

At LGH, she nearly collapsed on arrival.  Her initial VS were T
99.8, BP 111/52, HR 130.  Labs notable for Hct 10.2, Plt 65, INR
1.5.  She also had EtOH 160, [**Doctor First Name **] 294 and AST/ALT 122/26.
Patient was transferred to the ICU and given 4 units PRBCs.  She
subsequently went into respiratory arrest with CXR showing
diffuse opacities.  She was intubated at 0215 on [**2-26**] and
sedated with propofol and versed.  She then underwent EGD
showing portal gastropathy, long grade III varix with red [**Last Name (un) 23199**]
sign -> banded x3.  There was also a grade II varix noted,
banded x1.  She was put on octreotide, PPI and volume
resuscitated.  Repeat Hct at 21.  Pt also underwent presumed TTE
with EF 15% (no documentation here).  In the afternoon of
transfer, ABG 7.45/32/68.  Fi02 increased to 80%.  Pt also
spiked temp to 103 given tylenol and cooling blanket.
Vancomycin was given prior to transfer.

On arrival, the patient is intubated and sedated with propofol
and versed.  She is on neosynephrine as well as levophed with
SBP 90s.

Past Medical History:
1. Bulemia Nervosa
2. EtOH Abuse
3. Cirrhosis -> thought secondary to eating disorder.  Has had
liver biopsy on [**2167-10-22**]: macrovesicular steatosis with rare
hyalin. There is marked bridging fibrosis.  No feature of
autoimmune hepatitis.

Social History:
Lives at home with mother.  Recently drinking EtOH with friends
over the past few days, unknown quantities.  + toabacco, <1ppd.
Per mother, no h/o recreational drug use otherwise.

Family History:
Significant for multiple members with DM and HTN. No known
thyroid dz, autoimmune dz (Lupus, UC, crohn's etc), no liver dz
or other GI problems.


Physical Exam:
VS: T 99.7, BP 97/60, HR 109, RR 18, 92% AC Fi02 100%, PEEP 10,
Tv500
Gen: Intubated, sedated, unresponsive
HEENT: Pupils fixed, minimally reactive to light, mild icteric
sclera
Neck: Supple, bounding carotid pulses
HEART: Tachy, regular, S1 S2 with S3, no m/r
LUNG: Coarse BS bilaterally, symmetric, no wheezing
ABDOMEN: Distended, soft, tympanic, could not appreciated liver
edge
EXT: Cool, 1+ edema bilat, 1+ DP pulses
SKIN: Mildly icteric
NEURO: Unresponsive, pupils pin point and minimally responsive,
flaccid throughout.


Pertinent Results:
LABS:
[**2-26**]
ABG 0623: 7.39/37/99
Na 138, K 3.3, CL 109, CO2 21, BUN 6, Cr 0.6, Gluc 120
BNP 940
.
[**2-25**]:
Ammonia: 118, WBC 3.9, Hct 8.6, Plt 65
Amylase 294, Lip 55, Na 135, K 3.3, Cl 102, C)2 22, BUN 6, Cr
0.6
Alb 2.2, Alk phos 107, Tbili 4.7, AST 122, ALT 26, Dbili 2.7
EtOH 167
U/A: Dark yellow, 5 hyaline casts
WBC 4.7, Hct 21.1, Plt 61, N91, L5B1.
PT 16, INR 1.6, PTT 35.1

IMAGING OSH:
CXR [**2-26**]: Diffuse interstitial and alveolar opacities, ETT 2cm
from carina, NG tube in place
.
RUQ U/S: Mild/mod ascites, GB with thickened wall, small
pericholecystic fluid, small layer of tiny stones, no CBD
dilatation.
.
EKG: Sinus tachy at 120s, nl axis and intervals, non-specific ST
changes in the setting of tachycardia.
.
CXR [**2-26**] on arrival: ETT ~3cm from carina, L subclavian projects
over SVC.  Cardiomegaly with bilateral alveolar opacities.
Sharp costophrenic angles, prominant stomach bubble, no
abdominal free air appreciated.
[**2-27**] TTE: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. There
is severe global left ventricular hypokinesis (LVEF = 25-30%),
without regionality to the wall motion abnormalities (consistent
with global process: infectious, toxic, metabolic, etc.)
Intrinsic left ventricular systolic function is likely more
depressed given the severity of mitral regurgitation. The right
ventricular cavity is normal with mild global free wall
hypokinesis. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. A
central jet of moderate to severe (3+) mitral regurgitation is
seen, likely stemming from mitral annular dilatation. Moderate
[2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a small
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.

IMPRESSION: Severe global left ventricular systolic dysfunction.
Mild global right ventricular systolic dysfunction.
Moderate-to-severe mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension. Small
pericardial effusion

   RADIOLOGY  Final Report
CT CHEST W/O CONTRAST  [**2168-2-28**] 9:10 AM
Reason: Evaluate for evidence of pneumonia, volume overload
Field of view: 36
[**Hospital 93**] MEDICAL CONDITION:
21 year old woman with cardiomyopathy and cirrhosis now with
likely sepsis and CXR with pneumonia vs. ARDS
REASON FOR THIS EXAMINATION:
Evaluate for evidence of pneumonia, volume overload
CONTRAINDICATIONS for IV CONTRAST: None.
CT CHEST WITHOUT INTRAVENOUS CONTRAST
INDICATION: 21-year-old woman with cardiomyopathy and cirrhosis
and ARDS. Evaluate for evidence of pneumonia, volume overload.
COMPARISON: Not available.
TECHNIQUE: MDCT axial images of the chest were obtained without
intravenous contrast. Coronal reformatted images were obtained.
FINDINGS: There are extensive consolidative and ground-glass
opacities, involving lung fields bilaterally, with sparing of
the periphery. The ground- glass opacities are predominantly
distributed in the nondependent portion and consolidated
opacities are in dependent portions of the perihilar regions.
There are small pleural effusions. The airways are patent. There
is a small pericardial effusion. There are no pathologically
enlarged mediastinal, hilar or axillary lymph nodes.
Non-contrast evaluation of the upper abdomen demonstrates small
amount of free intraperitoneal fluid. The liver is decreased in
attenuation, consistent with fatty infiltration.
BONE WINDOWS: There are no suspicious lytic or sclerotic
lesions.
IMPRESSION:
1. Confluent bilateral parenchymal opacities, most severe
dependently, in a pattern suggestive of ARDS. The possibility of
superimposed or pre-exisiting pneumonia is difficult to exclude
given the severity of the parenchymal findings.
2. Small bilateral pleural effusions.
3. Cardiomegaly.
4. Fatty liver infiltration.

   RADIOLOGY  Final Report

US ABD LIMIT, SINGLE ORGAN  [**2168-3-5**] 1:18 PM

US ABD LIMIT, SINGLE ORGAN

Reason: ELEVATED BILI EVALUATE FOR EVIDENCE OF BILIARY DISEASE

[**Hospital 93**] MEDICAL CONDITION:
21 year old woman with low grade temp, rising bili
REASON FOR THIS EXAMINATION:
Evaluate for evidence of biliary disease
CLINICAL HISTORY: 21-year-old female with low-grade temperature,
rising bilirubin. Evaluate for evidence of biliary disease.

COMPARISON: [**2168-2-27**].

FINDINGS. The liver is nodular, coarsened and echogenic
consistent with cirrhosis. No focal hepatic lesion is
identified. The umbilical vein is recanulized. The gallbladder
demonstrates wall thickening (5 mm) and edema, although remains
non- distended. Small stones are again identified within the
gallbladder. No intra- or extra- hepatic biliary dilatation is
appreciated. The common duct measures 2 mm. The right kidney
measures 10.6 cm and shows no hydronephrosis. The Portal vein is
patent with hepatopetal flow. A tiny amount of perihepatic
asictes is noted.

IMPRESSION:
1. Coarsened and nodular architecture of the liver consistent
with cirrhosis. No focal hepatic lesion is identified.

2. Cholelithiasis. The gallbladder demonstrates wall thickening
and edema, which is likely related to chronic liver disease.

TTE [**3-8**] Conclusions
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF 60%) 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 structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
After injection of agitated saline, a small number of air
bubbles appeared in the left atrium, but only after 5 cardiac
cycles had elapsed, consistent with transpulmonary passage of
contrast.

Compared with the findings of the prior study (images reviewed)
of [**2168-2-27**], the left ventricular ejection fraction is now
normal.

[**3-3**] EGD: Findings: Esophagus:
Other Recent banding was noted in the lower esophagus. There was
no futher varices seen and there was no bleeding
Stomach: Normal stomach.
Duodenum: Normal duodenum.

[**3-9**] EGD: Findings: Esophagus:
Protruding Lesions 2 cords of grade II varices were seen in the
lower third of the esophagus. There were superficial ulcers from
previous banding. 2 bands were successfully placed.
Stomach:
Mucosa: Granularity and mosaic appearance of the mucosa were
noted in the whole stomach. These findings are compatible with
portal hypertensive gastropathy.
Duodenum: Normal duodenum.
Impression: Varices at the lower third of the esophagus
(ligation)
Granularity and mosaic appearance in the whole stomach
compatible with portal hypertensive gastropathy
Otherwise normal EGD to third part of the duodenum
Recommendations:
1) Keep nil PO for 4 hours.
2) Sucralfate 1g QID for 2 weeks.
3) Repeat EGD and banding in 2 - 3 weeks.


Brief Hospital Course:
21 F with history of eating disorder and alcohol use transfered
intubated from OSH after massive UGIB, was s/p esophageal
variceal banding prior to transfer.

Hospital course by problem:

GI Bleed: HCT remained stable after transfer, at [**Hospital1 18**] pt ended
up requiring a total of 4 units PRBCs and 4 units FFP.  She had
follow up endoscopy on [**3-3**] which showed stable status of
varices s/p banding.  Repeat EGD on [**3-9**] showed persistent
varices with ulceration at site of prior banding. Varices were
rebanded.  Pt discharged on pantoprazole, a 2 week course of
sucralfate and nadolol. To follow up with Dr. [**Last Name (STitle) 497**] for repeat
EGD in 3 weeks.

Respiratory Distress: Patient went into respiratory distress at
the OSH in the setting of her acute bleed.  Appeared to have
worsened after blood transfusion.  She had impressive bilateral
infiltrates on exam as well as fevers in addition to a newly
depressed EF of 15% with 3+ MR and evidence for fluid overload.
The etiology for the patient's heart failure was unclear. She
was started on an ACEI and a beta blocker, initially diuresed on
a lasix gtt was off diuresis at time of transfer from the MICU
and was determined to be euvolumeic.  She was treated for
presumed ARDS and a possible aspiration pneumonia/pneumonitis,
received vancomycin, zosyn and IV ciprofloxacin.  Once
transfered to the floor the patient clinically improved with no
further oxygen requirement. A repeat TTE showed normalization of
cardiac function with improvement in mitral valve competency.
Her ACEI was discontinued and she was transitioned from
carvedilol to nadolol prior to discharge.

Cirrhosis: Followed by Dr. [**Last Name (STitle) 497**].  Recent biopsy with
macrovescicular steatosis with bridging fibrosis.  Thought to be
due to combination of eating disorder and ETOH use, there have
been several case reports of accelerated alcoholic cirrhosis in
patients with eating disorders.  Pt discharged on lactulose,
spironolactone, furosemide and nadolol.  Pt to follow up as
outpatient with Dr. [**Last Name (STitle) 497**] for consideration of transplant
evaluation. Patient extensively counseled about the need to
completely abstain from alcohol in the future.

Bulemia: Psychiatry was consulted for assistance in managing the
patient's eating disorder. She denied a recent history of
purging behavior but still endorsed restricting, has history of
laxative and diet pill abuse.  Was on a modified eating disorder
protocol on the floor, was consuming >2000Kcal per day.
Expressed an earnest interest in recovery and continuing
counseling once discharged.  Was discharged with social work
follow up.

EtOH Use: Unclear as to severity.  Had been drinking more
heavily lately given friends death. Was counseled extensively by
team regarding EtOH cessation. No positive CIWA scores while
hospitalized, no history of withdrawl.  Discharged on MVI,
folate, thiamine; with social work for ongoing counseling and
support.

Pt was seen by physical therapy who cleared her for discharge
home.  On day of discharge she was afebrile with stable vital
signs. Discharged home with family with outpatient social work,
hepatology and primary care follow up.


Medications on Admission:
Eye drops (unknown)

MEDICATIONS UPON TRANSFER:
Propofol
Versed
Levophed 0.08 mcg/kg/min
Neosynephrine 0.5 mcg/kg/min
Protonix IV
Octreotide 50mcg/hr IV
Vancomycin x1 dose

Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough for 1 weeks.
Disp:*200 ML(s)* Refills:*0*
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three
times a day: Titrate to a goal of [**2-9**] bowel movements a day.  .
Disp:*2700 ML(s)* Refills:*2*
7. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Upper GI bleed
Acute respiratory distress syndrome
Acute systolic congestive heart failure
Liver Cirrhosis
Alcoholic hepatitis
Eating disorder NOS


Discharge Condition:
Good.  Vital signs stable, tolerating oral intake, ambulating
independently.


Discharge Instructions:
You were admitted with a serious bleed in your esophagus.  You
were treated with blood transfusions and an endoscopy with
banding of the bleeding vessel.  You were also found to have
evidence of cardiac dysfunction which has resolved during your
hospitalization.  You were treated for a pneumonia that
developed while you were intubated.  You were found to have
evidence of worsening liver disease, likely related to a
combination of alcohol consumption and your eating disorder.
You have been started on some new medications, please take all
medications as prescribed.  You have been started on 2 diuretics
for your liver disease to help fluid retention.  Please discuss
when to stop these medications with Dr. [**Last Name (STitle) 497**] and Dr. [**Last Name (STitle) **].
Please attend all scheduled follow up both with your primary
care physician as well as your liver doctors.  It is imperative
that you continue to maintain a healthy diet and that you
completely abstain from alcohol in the future.

Followup Instructions:
You have the following appointment scheduled:

GI Procedures: EGD (upper endoscopy) [**2168-3-29**] at 7:30am with Dr.
[**Last Name (STitle) 497**].
Please call [**Telephone/Fax (1) 463**] if you need to reschedule

Liver transplant clinic
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2168-4-22**] 2:20

Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2168-4-16**] 9:15

You have an appointment scheduled with you primary care provider
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) **] on Friday, [**2168-3-11**] at 11:45am. Please call
[**Telephone/Fax (1) 34574**] if you need to reschedule.

Please call to schedule an outpatient social work appointment
with one of the counselors we discussed:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12982**], LICSW of [**Location (un) 7658**] [**Telephone/Fax (1) 64944**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of [**Location (un) **] [**Telephone/Fax (1) 64945**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Last Name (un) 3671**] in [**Hospital1 **] [**Telephone/Fax (1) 64946**]


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
{'Other pulmonary insufficiency, not elsewhere classified,Esophageal varices in diseases classified elsewhere, with bleeding,Shock, unspecified,Pneumonia, organism unspecified,Acute systolic heart failure,Other primary cardiomyopathies,Cirrhosis of liver without mention of alcohol'}


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: Patient is a 21F with h/o bulemia, ETOH abuse, Cirrhosis
secondary to her eating disorder with known varices who presents
from [**Hospital6 3105**] with acute upper GI bleed.  HPI
is taken from records and mother as patient is intubated and
unable to provide history.

MEDICAL HISTORY: 1. Bulemia Nervosa
2. EtOH Abuse
3. Cirrhosis -> thought secondary to eating disorder.  Has had
liver biopsy on [**2167-10-22**]: macrovesicular steatosis with rare
hyalin. There is marked bridging fibrosis.  No feature of
autoimmune hepatitis.

MEDICATION ON ADMISSION: Eye drops (unknown)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 99.7, BP 97/60, HR 109, RR 18, 92% AC Fi02 100%, PEEP 10,
Tv500
Gen: Intubated, sedated, unresponsive
HEENT: Pupils fixed, minimally reactive to light, mild icteric
sclera
Neck: Supple, bounding carotid pulses
HEART: Tachy, regular, S1 S2 with S3, no m/r
LUNG: Coarse BS bilaterally, symmetric, no wheezing
ABDOMEN: Distended, soft, tympanic, could not appreciated liver
edge
EXT: Cool, 1+ edema bilat, 1+ DP pulses
SKIN: Mildly icteric
NEURO: Unresponsive, pupils pin point and minimally responsive,
flaccid throughout.

FAMILY HISTORY: Significant for multiple members with DM and HTN. No known
thyroid dz, autoimmune dz (Lupus, UC, crohn's etc), no liver dz
or other GI problems.

SOCIAL HISTORY: Lives at home with mother.  Recently drinking EtOH with friends
over the past few days, unknown quantities.  + toabacco, <1ppd.
Per mother, no h/o recreational drug use otherwise. 

### Response:
{'Other pulmonary insufficiency, not elsewhere classified,Esophageal varices in diseases classified elsewhere, with bleeding,Shock, unspecified,Pneumonia, organism unspecified,Acute systolic heart failure,Other primary cardiomyopathies,Cirrhosis of liver without mention of alcohol'}
