CHIEF COMPLAINT: Hematemesis and "dark" stool

PRESENT ILLNESS: The patient is a 38yo male with known who Cirrhosis presents
after coughing about a half a cup of blood on Friday night
followed by "dark" and tarry looking stool on Saturday morning.
On friday night ([**2175-12-8**]) he did not feel well after vomiting,
but the remainder of the evening was uneventful. Initially he
did not have headaches, dizziness or lightheadedness but on
Saturday morning after having a large episode of melena he
admits to feeling "dizzy" followed by a brief syncopal episode
witnessed by his girlfriend. [**Name (NI) **] denies any associated head
injuries or hitting his head or other extremities. He was
brought to the ED by his girlfriend shortly thereafter. He
reported malaise and general weakness over the week prior to
this presentation.
.
On additional ROS he had a dry cough last week and 2-3 episodes
of diarrhea. He also reports a subjective fever and night
sweats. He denies any nausea, heartburn symptoms or additional
episodes of emesis. He initially had some mild, diffuse pain is
his lower abdomen upon waking Saturday morning but denies any
additional abdominal pain, nausea or vomiting since his
admission. He denies any sick contacts. [**Name (NI) **] state that his most
recent alcohol consumption was 6 days ago, when he consumed [**7-16**]
beers at a football game. On arrival to the [**Hospital1 18**] ED his
temperature was 98.4F, HR 85, BP 132/71, RR 18, SpO2 100% on
room air. Tmax 99.5 (oral)in ED. He received Octreotide bolus,
IV Pantoprazole, Ciprofloxacin and 3L normal saline IVFs along
with 1 unit PRBC blood transfusion.
.
He states he had previously been a "very heavy" drinker and was
diagnosed with cirrhosis in the [**Country 13622**] Republic in [**2170**] after
an acute presentation for a perforated duodenal ulcer which
required surgery. Per patient, he had a liver biopsy at that
time but efforts to obtain official records have been
unsuccessful to date. He was initially admitted to the MICU for
stabilization where he received an additional unit of blood and
he underwent an EGD which was unremarkable. The patient had some
additional melena in the MICU but no abdominal pain, nausea,
vomiting or chest pain/palpitations. He had two PIVs (18 gauge)
set up for access and Ciprofloxacin was continued in the setting
of his GI bleed. He had a climbing Hct to the 26-27 range, up
from nadir of 24.6 on presentation. He was hemodynamically
stable upon admission to the general medical service. Of note,
the patient's cocaine screen returned as positive soon after
transfer from the MICU.

MEDICAL HISTORY: Cirrhosis
Gastric varices
h/o alcohol abuse
Duodenal ulcer, status post Billroth I performed in DR [**Last Name (STitle) **] [**2170**]

MEDICATION ON ADMISSION: Nadolol 20 mg daily
Multivitamin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tc 98.3, Tm 99.3, RR 16-18, HR60-70s, BP 110/80 , 100%RA
GENERAL: No acute distress. Oriented to person, place and time,
affect appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No active
bleeding.
NECK: Supple with JVP of [**5-13**] cm. No lymphadenopathy noted. No
thyromegaly.
CARDIAC: RRR, S1/S2 appreciated, no murmurs/rubs/gallops. No
S3/S4.
LUNGS: No chest wall deformities. CTA bilaterally. No crackles,
wheezes or rhonchi.
ABDOMEN: large vertical scar at midline (10") and ventral
herniation noted, Soft, NT/ND, liver edge palpable at costal
margin. No abdominial bruits. No splenomegaly.
EXTREMITIES: 1+ peripheral LE edema, 2+ pedal pulses bilaterally
SKIN: No rashes, telangiectasias, stasis dermatitis, ulcers or
lesions
NEURO: CNs [**3-21**] grossly intact, no focal sensory or motor
deficits, gait assessment deferred
.

FAMILY HISTORY: Noncontributory. Denies any known ETOH-ism in other siblings or
close family members. [**Name (NI) **] known liver or GI diseases in family
per patient.

SOCIAL HISTORY: Lives with girlfriend. [**Name (NI) 1403**] as a stone [**Doctor Last Name 3456**]. He has a prior
history of heavy ETOH use, usually beer, stopped briefly after
duodenal ulcer/surgery in [**Country 13622**] Republic in [**2170**] but
continued to struggle with ETOH-ism. Currently, he reports
occasional beer ([**4-11**] /week) or wine with dinner, but consumed 8
beers at a football game the week prior to admission. No history
of DTs, hallucinations or seizures. Attended AA for a period of
but last meeting about 6 months ago. Patient admits to
intermittent intranasal cocaine use. Denies IVDU. He has never
used tobacco.
Blood in stool,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Acute posthemorrhagic anemia,Other and unspecified alcohol dependence, continuous,Syncope and collapse,Acquired absence of organ, stomach,Hypovolemia
Blood in stool,Esoph varice oth dis NOS,Ac posthemorrhag anemia,Alcoh dep NEC/NOS-contin,Syncope and collapse,Acq absence of stomach,Hypovolemia
Admission Date:  [**2175-12-9**]              Discharge Date:   [**2175-12-12**]

Date of Birth:  [**2137-10-30**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Hematemesis and "dark" stool

Major Surgical or Invasive Procedure:
1.EGD (Esophagogastroduodenoscopy)
2.Colonoscopy
3.Pass through capsule endoscopy study

History of Present Illness:
The patient is a 38yo male with known who Cirrhosis presents
after coughing about a half a cup of blood on Friday night
followed by "dark" and tarry looking stool on Saturday morning.
On friday night ([**2175-12-8**]) he did not feel well after vomiting,
but the remainder of the evening was uneventful. Initially he
did not have headaches, dizziness or lightheadedness but on
Saturday morning after having a large episode of melena he
admits to feeling "dizzy" followed by a brief syncopal episode
witnessed by his girlfriend. [**Name (NI) **] denies any associated head
injuries or hitting his head or other extremities. He was
brought to the ED by his girlfriend shortly thereafter. He
reported malaise and general weakness over the week prior to
this presentation.
.
On additional ROS he had a dry cough last week and 2-3 episodes
of diarrhea. He also reports a subjective fever and night
sweats. He denies any nausea, heartburn symptoms or additional
episodes of emesis. He initially had some mild, diffuse pain is
his lower abdomen upon waking Saturday morning but denies any
additional abdominal pain, nausea or vomiting since his
admission. He denies any sick contacts. [**Name (NI) **] state that his most
recent alcohol consumption was 6 days ago, when he consumed [**7-16**]
beers at a football game. On arrival to the [**Hospital1 18**] ED his
temperature was 98.4F, HR 85, BP 132/71, RR 18, SpO2 100% on
room air. Tmax 99.5 (oral)in ED. He received Octreotide bolus,
IV Pantoprazole, Ciprofloxacin and 3L normal saline IVFs along
with 1 unit PRBC blood transfusion.
.
He states he had previously been a "very heavy" drinker and was
diagnosed with cirrhosis in the [**Country 13622**] Republic in [**2170**] after
an acute presentation for a perforated duodenal ulcer which
required surgery. Per patient, he had a liver biopsy at that
time but efforts to obtain official records have been
unsuccessful to date. He was initially admitted to the MICU for
stabilization where he received an additional unit of blood and
he underwent an EGD which was unremarkable. The patient had some
additional melena in the MICU but no abdominal pain, nausea,
vomiting or chest pain/palpitations. He had two PIVs (18 gauge)
set up for access and Ciprofloxacin was continued in the setting
of his GI bleed. He had a climbing Hct to the 26-27 range, up
from nadir of 24.6 on presentation. He was hemodynamically
stable upon admission to the general medical service. Of note,
the patient's cocaine screen returned as positive soon after
transfer from the MICU.

Past Medical History:
Cirrhosis
Gastric varices
h/o alcohol abuse
Duodenal ulcer, status post Billroth I performed in DR [**Last Name (STitle) **] [**2170**]

Social History:
Lives with girlfriend. [**Name (NI) 1403**] as a stone [**Doctor Last Name 3456**]. He has a prior
history of heavy ETOH use, usually beer, stopped briefly after
duodenal ulcer/surgery in [**Country 13622**] Republic in [**2170**] but
continued to struggle with ETOH-ism. Currently, he reports
occasional beer ([**4-11**] /week) or wine with dinner, but consumed 8
beers at a football game the week prior to admission. No history
of DTs, hallucinations or seizures. Attended AA for a period of
but last meeting about 6 months ago. Patient admits to
intermittent intranasal cocaine use. Denies IVDU. He has never
used tobacco.

Family History:
 Noncontributory. Denies any known ETOH-ism in other siblings or
close family members. [**Name (NI) **] known liver or GI diseases in family
per patient.

Physical Exam:
Tc 98.3, Tm 99.3, RR 16-18, HR60-70s, BP 110/80 , 100%RA
GENERAL: No acute distress. Oriented to person, place and time,
affect appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No active
bleeding.
NECK: Supple with JVP of [**5-13**] cm. No lymphadenopathy noted. No
thyromegaly.
CARDIAC: RRR, S1/S2 appreciated, no murmurs/rubs/gallops. No
S3/S4.
LUNGS: No chest wall deformities. CTA bilaterally. No crackles,
wheezes or rhonchi.
ABDOMEN: large vertical scar at midline (10") and ventral
herniation noted, Soft, NT/ND, liver edge palpable at costal
margin. No abdominial bruits. No splenomegaly.
EXTREMITIES: 1+ peripheral LE edema, 2+ pedal pulses bilaterally
SKIN: No rashes, telangiectasias, stasis dermatitis, ulcers or
lesions
NEURO: CNs [**3-21**] grossly intact, no focal sensory or motor
deficits, gait assessment deferred
.

Pertinent Results:
MICROBIOLOGY:
[**2175-12-9**] Blood Cultures x 2 - Negative/No growth
.
OTHER STUDIES/IMAGING:
.
CXR [**2175-12-9**]: The lungs are clear without consolidation or edema.
The
mediastinum is unremarkable. The cardiac silhouette is within
normal limits
for size. No effusion or pneumothorax is noted. The visualized
osseous
structures are unremarkable.
.
EKG [**2175-12-9**] : Rate 80s, NSR, occasional T wave
flattening,compared to the previous tracing [**2174-6-23**] there is a
decrease in voltage in the inferior leads.
.
RIGHT FOOT XRAY [**2175-12-9**]: No significant underlying degenerative
joint disease is noted. No fracture is seen throughout the foot.
The regional soft tissues are unremarkable.
.
EGD: No clear source of bleeding found
.
COLONOSCOPY:Colonoscopy revealed some diverticulitis of the
sigmoid colon, but no source of bleeding
.
CAPSULE ENDOSCOPY: The capsule remained in the stomach for 2h 39
min -
suggestive of gastroparesis 2. No definitive site of gi bleeding
or cause of anemia was identified

.
EGD of [**2175-7-13**]: Normal mucosa in the esophagus 3 cords of
non-bleeding varices at the fundus Granularity, friability,
congestion and erythema in the whole stomach compatible with
portal hypertensive gastropathy Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum Ultrasound of
liver and abdomen of [**2175-7-13**]: Cirrhosis, no ascites,
splenomegaly (constant) of 14.9 cm. Otherwise normal.
.
OTHER ADMISSION LABS:
.
[**2175-12-9**] 04:43PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
[**2175-12-9**] 04:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG
[**2175-12-11**] 12:20PM BLOOD Hct-27.7*
[**2175-12-9**] 02:45PM BLOOD Glucose-117* UreaN-14 Creat-0.8 Na-137
K-4.0 Cl-102 HCO3-24 AnGap-15
[**2175-12-9**] 02:45PM BLOOD ALT-46* AST-69* LD(LDH)-173 AlkPhos-106
TotBili-0.7
[**2175-12-11**] 12:20PM BLOOD Hct-27.7*
[**2175-12-10**] 03:42AM BLOOD WBC-4.3 RBC-2.85* Hgb-8.0* Hct-24.6*
MCV-86 MCH-28.0 MCHC-32.4 RDW-14.9 Plt Ct-125*
[**2175-12-9**] 08:05PM BLOOD Hct-26.4*
.
DISCHARGE LABS:
[**2175-12-12**] 07:00AM BLOOD WBC-3.8* RBC-3.06* Hgb-8.5* Hct-26.3*
MCV-86 MCH-27.9 MCHC-32.5 RDW-15.4 Plt Ct-136*
[**2175-12-12**] 07:00AM BLOOD Plt Ct-136*
[**2175-12-12**] 07:00AM BLOOD Glucose-108* UreaN-9 Creat-0.8 Na-135
K-4.0 Cl-102 HCO3-25 AnGap-12
[**2175-12-11**] 06:55AM BLOOD Albumin-3.7 Mg-2.2

Brief Hospital Course:
In summary, Mr. [**Known lastname 77244**] is a 38 yo male with alcoholic
cirrhosis who presented after an episode of hematemasis followed
by melena and then a brief witnessed syncopal episode at home.
He presented to the [**Hospital1 18**] ED and he was immediately admitted to
the medical ICU for close monitoring. On admission, he had a
marked hematocrit drop from the low 30s down to 24 and he
required 2 Units of transfused blood. Fortunately, he appeared
to stabilize thereafter. Additional details outlined below:

.
GI bleed: Mr. [**Known lastname 77244**] has a previous history of bleeding
from a ruptured duodenal ulcer and a history of gastric varices
noted on prior EGD, but emergent EGD on this admission revealed
no bleeding source all the way to the jejunum. Therefore his
initial octreotide was discontinued. The team decided to
continue with his daily Protonix for GI protection and was
started on a 1 week regimen of Ciprofloxacin 500mg [**Hospital1 **] for
infection prophylaxis. Serial Hcts were monitored and his diet
was advanced very slowly from NPO to clears and then regular. On
[**2175-12-11**] after he stabilized further he underwent a colonoscopy
which revealed some diverticulitis of the sigmoid colon, but no
obvious source of bleeding. Thus, it was recommended per the
[**Hospital1 18**] GI team that he proceed to a capsule endoscopy. The
capsule study showed that the capsule remained in the stomach
for about 2 hours and 39 minutes which was suggestive of
gastroparesis, otherwise there were no definitive sites of GI
bleeding identified to explain the cause of Mr. [**Known lastname 95046**]
anemia. Ultimately, a specific source was not identified despite
three thorough GI scoping methods (EGD, colonoscopy and capsule
study). Fortunately, he had no additional bouts of concerning
active bleeding during his hospital stay, with the exception of
a small amount of melena on hospital day #1 in the MICU, and his
hematocrit continued to stabilize while he recovered. At time of
discharge his Hct was in the 26 range and repeat labs done
[**2175-12-13**] showed Hct 27.6. He will plan to follow-up in the
GI/Liver Clinic soon after discharge with weekly Hct checks,
additional studies and management for his cirrhosis.

 .
Substance Abuse: Mr. [**Known lastname 77244**] had a prior history of alcohol
abuse which dates back to his twenties and early thirties. He
admits to prior binge drinking and having as many as 15 drinks a
day. Now, he states that he has cut back and drinks 3-4
drinks/week, though he recently had 8 beers one week ago at a
[**Company **] Game.  From this history it was felt that ETOH
withdrawal was unlikely but he was nonetheless monitored closely
and placed on a CIWA scale with PRN Valium ordered. He also
admitted to intermittent cocaine use after his urine toxicology
screen tested positive. He was reminded that cocaine use can
also be very addictive any can have serious health consequences
such as acute heart attacks and strokes. He was seen by a social
worker/addictions counselor during his hospital stay. Mr.
[**Known lastname 77244**] expressed some interest in attending AA meetings to
use them for a "crutch" in helping him decrease his drinking. He
explained that he has several sober friends who have offered to
take him to meetings and he is aware of where/when they are (and
plans to look at schedule on line at home).  He declined any
offers for professional addictions support or formal therapy. At
time of discharge he appeared to be coping well and he was
reminded to utilize the resources which were discussed to help
him cut back on his drinking and avoid cocaine use. He was asked
to take a daily multivitamin, thiamine, & folate supplements.
.
Syncope: The patient's syncope event was attributed to
orthostasis in the setting of acute acute blood loss. Blood loss
was fairly substantial as it dropped his Hct close to 10 points
from the low 30s to 24 range. The patient's girlfriend witnessed
the syncope and confirmed no head injuries or other injuries.
Throughout his hospital stay orthostatics were assessed and he
had stable supine and standing blood pressures by time of
discharge and he denied palpitations, dizziness, lightheadedness
or nausea.
.
Cirrhosis: Although there is no logged biopsy or tissue evidence
to date the patient reports that he had a liver biopsy done in
[**2170**] in the [**Country 13622**] Republic and was told that he had
cirrhosis at that time. Given his history, this is likely
alcohol related. Per reports, previous work-up has included
normal hepatitis A, B and C serologies. HIV ab, AMA, [**Doctor First Name **], SMA,
IgG level, alpha-1 antitrypsin and ceruloplasmin have also all
been normal. During this hospital stay he had evidence of mild
dysfunction with elevated INR 1.3, high PT levels, and elevated
LFTs (ALT 85, AST 157). Otherwise, no prominent HSM, jaundice or
other stigmata of alcoholic cirrhosis was noted. The patient
will continue his Nadolol and will plan to follow-up at [**Hospital1 18**]
Liver Center with Dr. [**Last Name (STitle) **].
.
Foot/Ankle Pain:  The patient complained of right sided foot and
ankle pain and swelling for the past 1 1/2-2 weeks. He denied
any injury to the area during his recent fall with his syncopal
event. A set of plain films were performed and revealed no
fractures or abnormalities. He was given additional pillows, ice
packs and offered a small amount of Tylenol PRN for his joint
pain. He will plan to follow-up on this complaint more
thoroughly on an outpatient basis.
.
Fluids, Electrolytes, Nutrition: The patient was switched from
NPO to clears and then to a regular diet which he tolerated very
well with no evidence of nausea, vomiting or additional UGI/LGI
bleeding. As noted, thiamine and folate were supplemented and
his electrolytes were monitored daily and repleted as needed.
.
Prophylaxis: He was encouraged to ambulate and get up and out of
bed for DVT prophylaxis and Pneumatic boots were also ordered.
Protonix was given for ongoing GI protection.
.
The patient was maintained as a full code status for the
entirety of his hospital stay and communication occurred
directly with the patient on a daily basis regarding his health
care plans and status.


Medications on Admission:
Nadolol 20 mg daily
Multivitamin

Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days: take every 12 hours and complete on
[**2175-12-15**] .
Disp:*6 Tablet(s)* Refills:*0*
5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Outpatient Lab Work
Please have weekly blood lab checks (Hematocrit)faxed to Dr.
[**Last Name (STitle) **] at the Liver Center at [**Hospital1 18**] up until your appointment
with him on [**1-17**].
(Fax #[**Telephone/Fax (1) 4400**]).  You can go to the [**Company 191**] Atrium Suite between
8:30am and 4pm (phone [**Telephone/Fax (1) 250**]) Monday through Friday to
have labs drawn.


Discharge Disposition:
Home

Discharge Diagnosis:
Cirrhosis
Acute Gastrointestinal Bleed
Alcoholism


Discharge Condition:
Stable. At the time of discharge the patient had stable vital
signs and he appeared to be in no distress. He had no abdominal
pain or complaints of nausea, vomiting or bloody bowel
movements. The patient's hematocrit had greatly improved and
remained stable.


Discharge Instructions:
It was a pleasure taking care of you during your stay here at
[**Hospital1 69**].

You were admitted to the hospital after complaints of bloody
vomit, bloody stool, and an episode of syncope/fainting. You
were initially treated in the intensive care unit and received a
blood transfusion and IV fluids to help stabilize you and then
you were transferred to the regular medical floor.
Gastroenterology (GI) specialists were consulted and you
underwent an EGD or upper GI endoscopy, a colonoscopy and
lastly, a capsule endoscopy study. The results of these tests
will be reviewed further at your follow-up visit to the [**Hospital1 18**]
Liver Center.

Your upper gastrointestinal bleeding and lower gastrointestinal
bleeding are likely related to your alcoholic liver disease. You
should avoid alcohol use as it may worsen your liver disease and
increase your risks for serious, harmful bleeding.
.
Medication instructions:
Please take your daily Nadolol as previously prescribed for
blood pressure control and to help prevent variceal/GI bleeding.
Please continue your daily multivitamins.

Begin taking the following new medications :
Daily thiamine and folic acid supplements as prescribed. Please
complete your antibiotic course with Ciprofloxacin for a total
of 7 days for prevention of bacterial infections which can
spread from your gastrointestinal tract to your bloodstream. You
have already completed the first 4 days of Ciprofloxacin
therapy, so please finish the remainder as instructed until
[**2175-12-15**].
Also, you can continue taking Protonix for anti-acid protection
after discharge.

Additional instruction: You will need to have weekly blood lab
checks (Hematocrit)faxed to Dr. [**Last Name (STitle) **] at the Liver Center at
[**Hospital1 18**] up until your appointment with him on [**1-17**]. (Fax
#[**Telephone/Fax (1) 4400**])
.
Call your primary care doctor or go to them emergency room if
you have any additional bloody vomit, lightheadedness,
dizziness, shortness of breath, fainting, bloody stools,
worsening abdominal pain, fevers, chills or any other concerning
symptoms.




Followup Instructions:
1. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Wednesday [**12-13**] at 9:50am in the Atrium Suite on the [**Location (un) 448**] of the
[**Hospital Ward Name 23**] Building/[**Hospital Ward Name 516**] [**Hospital1 18**] (phone #[**Telephone/Fax (1) 250**]). You
will still keep your new primary care appointment with Dr. [**Last Name (STitle) **]
on [**2-14**]. [**2176**].
.
2.Please follow-up with the [**Hospital1 18**] Liver Center with Dr. [**Last Name (STitle) **]
in the [**Hospital Unit Name **], [**Location (un) **]. On [**1-17**] at 3:30pm .
Phone #[**Telephone/Fax (1) 2422**]
.
3.You will need to have weekly blood lab checks
(Hematocrit)faxed to Dr. [**Last Name (STitle) **] at the Liver Center at [**Hospital1 18**]
up until your appointment with him on [**1-17**]. (Fax
#[**Telephone/Fax (1) 4400**]). Please go to the Atrium Suite blood lab on the
[**Location (un) 448**] of the [**Hospital Ward Name 23**] Building/[**Hospital Ward Name 516**] [**Hospital1 18**] (phone
#[**Telephone/Fax (1) 250**]between 8:30am and 4:00pm.
.
4.Please call your health insurance company/provider to let them
know of the above appointments prior to your visit.
.
5. Please consider follow up with Alcoholics Anonymous
([**URL 95047**])
.

                             [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]

Completed by:[**2175-12-17**]
{'Blood in stool,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Acute posthemorrhagic anemia,Other and unspecified alcohol dependence, continuous,Syncope and collapse,Acquired absence of organ, stomach,Hypovolemia'}


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: Hematemesis and "dark" stool

PRESENT ILLNESS: The patient is a 38yo male with known who Cirrhosis presents
after coughing about a half a cup of blood on Friday night
followed by "dark" and tarry looking stool on Saturday morning.
On friday night ([**2175-12-8**]) he did not feel well after vomiting,
but the remainder of the evening was uneventful. Initially he
did not have headaches, dizziness or lightheadedness but on
Saturday morning after having a large episode of melena he
admits to feeling "dizzy" followed by a brief syncopal episode
witnessed by his girlfriend. [**Name (NI) **] denies any associated head
injuries or hitting his head or other extremities. He was
brought to the ED by his girlfriend shortly thereafter. He
reported malaise and general weakness over the week prior to
this presentation.
.
On additional ROS he had a dry cough last week and 2-3 episodes
of diarrhea. He also reports a subjective fever and night
sweats. He denies any nausea, heartburn symptoms or additional
episodes of emesis. He initially had some mild, diffuse pain is
his lower abdomen upon waking Saturday morning but denies any
additional abdominal pain, nausea or vomiting since his
admission. He denies any sick contacts. [**Name (NI) **] state that his most
recent alcohol consumption was 6 days ago, when he consumed [**7-16**]
beers at a football game. On arrival to the [**Hospital1 18**] ED his
temperature was 98.4F, HR 85, BP 132/71, RR 18, SpO2 100% on
room air. Tmax 99.5 (oral)in ED. He received Octreotide bolus,
IV Pantoprazole, Ciprofloxacin and 3L normal saline IVFs along
with 1 unit PRBC blood transfusion.
.
He states he had previously been a "very heavy" drinker and was
diagnosed with cirrhosis in the [**Country 13622**] Republic in [**2170**] after
an acute presentation for a perforated duodenal ulcer which
required surgery. Per patient, he had a liver biopsy at that
time but efforts to obtain official records have been
unsuccessful to date. He was initially admitted to the MICU for
stabilization where he received an additional unit of blood and
he underwent an EGD which was unremarkable. The patient had some
additional melena in the MICU but no abdominal pain, nausea,
vomiting or chest pain/palpitations. He had two PIVs (18 gauge)
set up for access and Ciprofloxacin was continued in the setting
of his GI bleed. He had a climbing Hct to the 26-27 range, up
from nadir of 24.6 on presentation. He was hemodynamically
stable upon admission to the general medical service. Of note,
the patient's cocaine screen returned as positive soon after
transfer from the MICU.

MEDICAL HISTORY: Cirrhosis
Gastric varices
h/o alcohol abuse
Duodenal ulcer, status post Billroth I performed in DR [**Last Name (STitle) **] [**2170**]

MEDICATION ON ADMISSION: Nadolol 20 mg daily
Multivitamin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tc 98.3, Tm 99.3, RR 16-18, HR60-70s, BP 110/80 , 100%RA
GENERAL: No acute distress. Oriented to person, place and time,
affect appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No active
bleeding.
NECK: Supple with JVP of [**5-13**] cm. No lymphadenopathy noted. No
thyromegaly.
CARDIAC: RRR, S1/S2 appreciated, no murmurs/rubs/gallops. No
S3/S4.
LUNGS: No chest wall deformities. CTA bilaterally. No crackles,
wheezes or rhonchi.
ABDOMEN: large vertical scar at midline (10") and ventral
herniation noted, Soft, NT/ND, liver edge palpable at costal
margin. No abdominial bruits. No splenomegaly.
EXTREMITIES: 1+ peripheral LE edema, 2+ pedal pulses bilaterally
SKIN: No rashes, telangiectasias, stasis dermatitis, ulcers or
lesions
NEURO: CNs [**3-21**] grossly intact, no focal sensory or motor
deficits, gait assessment deferred
.

FAMILY HISTORY: Noncontributory. Denies any known ETOH-ism in other siblings or
close family members. [**Name (NI) **] known liver or GI diseases in family
per patient.

SOCIAL HISTORY: Lives with girlfriend. [**Name (NI) 1403**] as a stone [**Doctor Last Name 3456**]. He has a prior
history of heavy ETOH use, usually beer, stopped briefly after
duodenal ulcer/surgery in [**Country 13622**] Republic in [**2170**] but
continued to struggle with ETOH-ism. Currently, he reports
occasional beer ([**4-11**] /week) or wine with dinner, but consumed 8
beers at a football game the week prior to admission. No history
of DTs, hallucinations or seizures. Attended AA for a period of
but last meeting about 6 months ago. Patient admits to
intermittent intranasal cocaine use. Denies IVDU. He has never
used tobacco. 

### Response:
{'Blood in stool,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Acute posthemorrhagic anemia,Other and unspecified alcohol dependence, continuous,Syncope and collapse,Acquired absence of organ, stomach,Hypovolemia'}
