CHIEF COMPLAINT: Variceal bleeding

PRESENT ILLNESS: 65 year old male with alcoholic cirrhosis (Childs class A),
esophageal varices, and prior episodes of variceal bleeding s/p
sclerotherapy and banding.  He was recently admitted from [**2120-5-3**]
to [**2120-5-5**] for BRBPR thought due to variceal bleeding, and
received a total of 5 units PRBCs.  EGD was performed on [**2120-5-4**],
showing four cords of grade 2 varices which were again treated
with banding.  He presented today for a scheduled outpatient EGD
for followup of his varices and additional banding.  During the
procedure, he was found to have active bleeding with
approximately 100 ml observed blood loss and a fall in his BP to
the 60s systolic.  Variceal bands were successfully placed with
apparent control of his bleeding.  He was transferred to the
[**Hospital Unit Name 153**] from the GI suite for further management.
.
On arrival, he was alert and mentating normally.  He reported
some continued lightheadedness and fatigue.  He notes having
several episodes of hematemesis over the preceeding two days,
with some mild lightheadedness around the time of the episodes.
He also noticed a small amount of blood in his recent stools.
Despite the bleeding, he continued to take his home BP meds
including Nadolol and Valsartan.  He otherwise feels close to
his baseline.  He reports drinking several beers and shots a few
weekends ago, but none since then or for several months prior.
His wife reports heavier drinking.

MEDICAL HISTORY: # Alcoholic Cirrhosis
-- decompensated with varices
-- variceal bleed [**3-12**] s/p banding
-- admission [**2120-5-3**] to [**2120-5-5**] for BRBPR
# Hypertension

MEDICATION ON ADMISSION: Nadolol 20 mg PO daily
Valsartan 160 mg PO daily
Omeprazole 40 mg PO BID
Thiamine HCl 100 mg PO daily
Folic acid 1 mg PO daily
Ferrous sulfate 325 mg PO TID

ALLERGIES: Amoxicillin

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T 97.6, BP 116/60 -> 80/44, HR 59, RR 14, SpO2 99% on RA
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm. Normal S1, S2.  Systolic murmur
heard best at LLSB without radiation.
Abdomen: Bowel sounds present.  Soft, non-tender, mildly
distended, possible slight ascites.  No rebound tenderness or
guarding.  Liver enlarged, spleen not palpable.
GU: no foley currently
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema.
Neuro: No asterixis.
.
Discharge Physical Exam:
afebrile, 118/73, 78, 18 99RA
General: well appearing man in NAD comfortable, appropriate
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no thyromegaly, no JVD, no LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: Regular rate and rhythm. Normal S1, S2.
Abdomen: Bowel sounds present.  Soft, non-tender.  No rebound
tenderness or guarding.  Liver enlarged, spleen not palpable.
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema.
Neuro: No asterixis.

FAMILY HISTORY: no known

SOCIAL HISTORY: Lives with wife, [**Name (NI) **].  [**Name2 (NI) **] drink sometime between [**Date range (1) 66379**]
per wife.  She is not aware of how much he drinks daily.
Occasional tobacco use.  Wife reports no history of drug use.
Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Portal hypertension,Acute kidney failure, unspecified,Other and unspecified coagulation defects,Unspecified essential hypertension,Other and unspecified alcohol dependence, unspecified,Other specified disorders of stomach and duodenum,Thrombocytopenia, unspecified,Anemia, unspecified,Other specified cardiac dysrhythmias
Alcohol cirrhosis liver,Bleed esoph var oth dis,Portal hypertension,Acute kidney failure NOS,Coagulat defect NEC/NOS,Hypertension NOS,Alcoh dep NEC/NOS-unspec,Gastroduodenal dis NEC,Thrombocytopenia NOS,Anemia NOS,Cardiac dysrhythmias NEC
Admission Date:  [**2120-9-6**]              Discharge Date:   [**2120-9-9**]

Date of Birth:  [**2055-1-28**]             Sex:   M

Service: MEDICINE

Allergies:
Amoxicillin

Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Variceal bleeding


Major Surgical or Invasive Procedure:
EGD (outpatient clinic):  [**2120-9-6**]
PICC placement: [**2120-9-6**]

History of Present Illness:
65 year old male with alcoholic cirrhosis (Childs class A),
esophageal varices, and prior episodes of variceal bleeding s/p
sclerotherapy and banding.  He was recently admitted from [**2120-5-3**]
to [**2120-5-5**] for BRBPR thought due to variceal bleeding, and
received a total of 5 units PRBCs.  EGD was performed on [**2120-5-4**],
showing four cords of grade 2 varices which were again treated
with banding.  He presented today for a scheduled outpatient EGD
for followup of his varices and additional banding.  During the
procedure, he was found to have active bleeding with
approximately 100 ml observed blood loss and a fall in his BP to
the 60s systolic.  Variceal bands were successfully placed with
apparent control of his bleeding.  He was transferred to the
[**Hospital Unit Name 153**] from the GI suite for further management.
.
On arrival, he was alert and mentating normally.  He reported
some continued lightheadedness and fatigue.  He notes having
several episodes of hematemesis over the preceeding two days,
with some mild lightheadedness around the time of the episodes.
He also noticed a small amount of blood in his recent stools.
Despite the bleeding, he continued to take his home BP meds
including Nadolol and Valsartan.  He otherwise feels close to
his baseline.  He reports drinking several beers and shots a few
weekends ago, but none since then or for several months prior.
His wife reports heavier drinking.


Past Medical History:
# Alcoholic Cirrhosis
-- decompensated with varices
-- variceal bleed [**3-12**] s/p banding
-- admission [**2120-5-3**] to [**2120-5-5**] for BRBPR
# Hypertension


Social History:
Lives with wife, [**Name (NI) **].  [**Name2 (NI) **] drink sometime between [**Date range (1) 66379**]
per wife.  She is not aware of how much he drinks daily.
Occasional tobacco use.  Wife reports no history of drug use.


Family History:
no known


Physical Exam:
Admission Physical Exam:
Vitals: T 97.6, BP 116/60 -> 80/44, HR 59, RR 14, SpO2 99% on RA
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm. Normal S1, S2.  Systolic murmur
heard best at LLSB without radiation.
Abdomen: Bowel sounds present.  Soft, non-tender, mildly
distended, possible slight ascites.  No rebound tenderness or
guarding.  Liver enlarged, spleen not palpable.
GU: no foley currently
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema.
Neuro: No asterixis.
.
Discharge Physical Exam:
afebrile, 118/73, 78, 18 99RA
General: well appearing man in NAD comfortable, appropriate
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no thyromegaly, no JVD, no LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: Regular rate and rhythm. Normal S1, S2.
Abdomen: Bowel sounds present.  Soft, non-tender.  No rebound
tenderness or guarding.  Liver enlarged, spleen not palpable.
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema.
Neuro: No asterixis.

Pertinent Results:
Admission Labs:
[**2120-9-6**] 10:49AM   WBC-10.4# RBC-2.39*# HGB-7.0* HCT-22.2*
MCV-93# MCH-29.4# MCHC-31.7 RDW-16.8*
[**2120-9-6**] 10:49AM   NEUTS-72.1* LYMPHS-16.0* MONOS-9.6 EOS-1.8
BASOS-0.4
[**2120-9-6**] 10:49AM   PT-19.0* PTT-27.7 INR(PT)-1.7*
[**2120-9-6**] 10:49AM   ALT(SGPT)-49* AST(SGOT)-120* LD(LDH)-179 ALK
PHOS-83 TOT BILI-1.2
[**2120-9-6**] 10:49AM   ALBUMIN-3.5 CALCIUM-8.8 PHOSPHATE-3.1
MAGNESIUM-2.1
[**2120-9-6**] 10:49AM   GLUCOSE-119* UREA N-58* CREAT-2.7*#
SODIUM-133 POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-21* ANION GAP-14
[**2120-9-6**] 01:09PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2120-9-6**] 01:09PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2120-9-6**] 01:09PM URINE  HOURS-RANDOM UREA N-544 CREAT-216
SODIUM-37 POTASSIUM-54 CHLORIDE-22 URIC ACID-11.5
[**2120-9-6**] 01:09PM URINE  OSMOLAL-397
[**2120-9-6**] 03:22PM   AFP-2.5
.
Microbiology: none
.
Imaging:
EGD ([**9-6**]):
Findings: Esophagus:  Protruding Lesions 4 cords of grade III
varices were seen in the lower third of the esophagus. The
varices were actively oozing with bright red blood in the
esophageal lumen and stomach. 4 bands were successfully placed.

Stomach:  There was blood in the stomach. There were no evidence
of gastric varices.
Impression: Varices at the lower third of the esophagus
(ligation) There was blood in the stomach. There were no
evidence of gastric varices. Otherwise normal EGD to third part
of the duodenum
Recommendations: Admit to Hospital. PPI, cefriaxone prophylaxis,
serial hcts. Patient will need to follow up for repeat banding
in [**4-5**] weeks.
.
RUQ u/s ([**9-6**]):
IMPRESSION: 1. Hepatofugal flow in all portal veins and reversal
of flow within the splenic vein. This is new from [**2118-3-6**]
examination.
2. Cirrhosis with sequelae of portal hypertension. There is no
ascites.
3. Relaxed gallbladder with stable mild gallbladder wall
thickening and
cholelithiasis.
.
CXR ([**9-6**])
Right PICC ends at the upper cavoatrial junction. There is no
evidence of
pneumothorax. Lungs are clear. Mediastinal silhouette is normal.

.
Discharge Labs:

[**2120-9-9**] 01:51PM BLOOD Hct-26.6*
[**2120-9-9**] 05:01AM BLOOD WBC-6.5 RBC-2.66* Hgb-8.0* Hct-24.2*
MCV-91 MCH-30.1 MCHC-33.1 RDW-18.2* Plt Ct-115*
[**2120-9-9**] 05:01AM BLOOD Glucose-98 UreaN-17 Creat-1.2 Na-136
K-4.0 Cl-105 HCO3-22 AnGap-13
[**2120-9-9**] 05:01AM BLOOD ALT-63* AST-125* AlkPhos-73 TotBili-0.9
[**2120-9-9**] 05:01AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.8

Brief Hospital Course:
65 year old male with alcoholic cirrhosis (Childs class A),
esophageal varices, and prior episodes of variceal bleeding s/p
sclerotherapy and banding who was admitted to the [**Hospital Unit Name 153**] after
having active variceal bleeding and hypotension during a planned
outpatient EGD for followup of his varices.

Active Diagnoses:
# Variceal Bleeding / Hypotension: Patient presented with active
variceal bleeding and hypotension (SBP 60s) during an outpatient
EGD.  Bands were placed with apparent control of the bleeding.
His BP stabilized initially without urgent transfusion, but
later dropped to the 80s.  On admission, the patient admitted to
several episodes of hematemesis over the few days prior to the
EGD.  He apparently took his Nadolol for the two days prior to
admission despite hematemesis.  His Hct was 22.2 on arrival to
the ICU.  He was treated with IV octreotide and IV Protonix for
a planned 3 day course.  He was transfused a total of 3 units
PRBCs.  In addition, he was given ceftriaxone as an empiric
therapy for possible biliary/GI infection.  With this treatment,
his Hct stabilized, as did his vital signs.  He was kept NPO for
two days to ensure recovery.
.
He was planned for transfer to the floor on the 2nd day of his
admission, however was found to be bradycardic to the 50s.  This
was attributed to octreotide, and resolved on d/c of that
medication.  On the 3rd day of his hospitalization, with
resolution of the bradycardia, he was transferred to the floor.
His medications were changed to PO at this time, including
switching IV ceftriaxone to PO Cipro.  In addition, sucralfate
was added.  On the floor pt stabilized and at time of discharge
his hct was 26.6.
.
# Acute Kidney Injury: The patient's creatinine was 2.7 on
arrival to the ICU, up from a baseline of around 1.0 from his
recent admission.  This was likely prerenal related to recent
blood loss and hypotension.  By the time of transfer, the
creatinine had dropped to 1.4.  At the time of discharge, it was
1.2.  During this period of elevation, all medications were
adjusted for renal function as appropriate.  The patient had
good urine output throughout this admission.  At time of
discharge he was had been restarted on home meds, with the
exception of valsartan as pt's pressures were normotensive.
.
# Alcoholic Cirrhosis: The patient has a long history of
cirrhosis with complications from variceal bleeding, but
otherwise fairly stable.  His LFTs were slightly elevated from
his baseline on admission to the ICU with ALT 49, AST 120, and
TBili 1.2. These were followed throughout his stay.  A RUQ u/s
was performed to check for portal vein thrombosis; this was
negative.  At time of discharge he still had a transaminitis
consistent with alcoholic disease, T bili had come down to 0.9.

.
# Alcohol Abuse: The patient reports no alcohol consumption in
several weeks, but his wife reports that he drinks more heavily.
 He was monitored for withdrawal symptoms; none were seen.  Pt
was encouraged to seek EtOH counseling at time of discharge.


Medications on Admission:
Nadolol 20 mg PO daily
Valsartan 160 mg PO daily
Omeprazole 40 mg PO BID
Thiamine HCl 100 mg PO daily
Folic acid 1 mg PO daily
Ferrous sulfate 325 mg PO TID


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

2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
6. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 doses.
Disp:*7 Tablet(s)* Refills:*0*
8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO three times a day.


Discharge Disposition:
Home

Discharge Diagnosis:
esophageal variceal bleed
alcoholic liver cirrhosis


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


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

It was a pleasure taking care of you.  You were admitted to the
hospital because you had a gastrointestinal bleed secondary to
your liver cirrhosis.  We transfused you with blood and stopped
the bleeding source.  Your blood counts are still low but you
are not actively bleeding.  You are still at risk for
gastrointestinal bleeds and it is imperative that you stop
drinking.  Please discuss this issue with your family and your
doctor.  As we discussed, you would likely benefit from a
support group such as AA.

Please call or return to the hospital if you develop blood in
the stool, blood in your vomit, dark tarry stools,
lightheadedness, dizziness, or any other symptom that concerns
you.
Please START the following medications:
-Ciprofloxacin 500mg take 1 tablet every 12h for 7 doses (3.5
days)
-Sucralfate take 1g every 6h
.
Please STOP the following medications:
- Please hold your valsartan until you follow up with your PCP
to ensure that your blood pressure is stable enough.
.
Please do not take your Iron tablets for 4 days until you've
completed taking ciprofloxacin

Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2120-9-16**] at 3:50 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Someone from the Liver Center will call you with an earlier
appointment. Please call if you have not heard from them in 3
days.

Department: LIVER CENTER
When: TUESDAY [**2120-11-12**] at 8:45 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Portal hypertension,Acute kidney failure, unspecified,Other and unspecified coagulation defects,Unspecified essential hypertension,Other and unspecified alcohol dependence, unspecified,Other specified disorders of stomach and duodenum,Thrombocytopenia, unspecified,Anemia, unspecified,Other specified cardiac dysrhythmias'}


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: Variceal bleeding

PRESENT ILLNESS: 65 year old male with alcoholic cirrhosis (Childs class A),
esophageal varices, and prior episodes of variceal bleeding s/p
sclerotherapy and banding.  He was recently admitted from [**2120-5-3**]
to [**2120-5-5**] for BRBPR thought due to variceal bleeding, and
received a total of 5 units PRBCs.  EGD was performed on [**2120-5-4**],
showing four cords of grade 2 varices which were again treated
with banding.  He presented today for a scheduled outpatient EGD
for followup of his varices and additional banding.  During the
procedure, he was found to have active bleeding with
approximately 100 ml observed blood loss and a fall in his BP to
the 60s systolic.  Variceal bands were successfully placed with
apparent control of his bleeding.  He was transferred to the
[**Hospital Unit Name 153**] from the GI suite for further management.
.
On arrival, he was alert and mentating normally.  He reported
some continued lightheadedness and fatigue.  He notes having
several episodes of hematemesis over the preceeding two days,
with some mild lightheadedness around the time of the episodes.
He also noticed a small amount of blood in his recent stools.
Despite the bleeding, he continued to take his home BP meds
including Nadolol and Valsartan.  He otherwise feels close to
his baseline.  He reports drinking several beers and shots a few
weekends ago, but none since then or for several months prior.
His wife reports heavier drinking.

MEDICAL HISTORY: # Alcoholic Cirrhosis
-- decompensated with varices
-- variceal bleed [**3-12**] s/p banding
-- admission [**2120-5-3**] to [**2120-5-5**] for BRBPR
# Hypertension

MEDICATION ON ADMISSION: Nadolol 20 mg PO daily
Valsartan 160 mg PO daily
Omeprazole 40 mg PO BID
Thiamine HCl 100 mg PO daily
Folic acid 1 mg PO daily
Ferrous sulfate 325 mg PO TID

ALLERGIES: Amoxicillin

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T 97.6, BP 116/60 -> 80/44, HR 59, RR 14, SpO2 99% on RA
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm. Normal S1, S2.  Systolic murmur
heard best at LLSB without radiation.
Abdomen: Bowel sounds present.  Soft, non-tender, mildly
distended, possible slight ascites.  No rebound tenderness or
guarding.  Liver enlarged, spleen not palpable.
GU: no foley currently
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema.
Neuro: No asterixis.
.
Discharge Physical Exam:
afebrile, 118/73, 78, 18 99RA
General: well appearing man in NAD comfortable, appropriate
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no thyromegaly, no JVD, no LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: Regular rate and rhythm. Normal S1, S2.
Abdomen: Bowel sounds present.  Soft, non-tender.  No rebound
tenderness or guarding.  Liver enlarged, spleen not palpable.
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema.
Neuro: No asterixis.

FAMILY HISTORY: no known

SOCIAL HISTORY: Lives with wife, [**Name (NI) **].  [**Name2 (NI) **] drink sometime between [**Date range (1) 66379**]
per wife.  She is not aware of how much he drinks daily.
Occasional tobacco use.  Wife reports no history of drug use. 

### Response:
{'Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Portal hypertension,Acute kidney failure, unspecified,Other and unspecified coagulation defects,Unspecified essential hypertension,Other and unspecified alcohol dependence, unspecified,Other specified disorders of stomach and duodenum,Thrombocytopenia, unspecified,Anemia, unspecified,Other specified cardiac dysrhythmias'}
