CHIEF COMPLAINT: Hematemesis

PRESENT ILLNESS: 57 yoM w/ HepC cirrhosis w/ known varices EGD [**7-/2103**] presented
with one day of coffee-ground and then bright red emesis (<1L);
+ nausea; no melena/BRBPR. No prior episodes of GIB. Baseline
Hct in the low to mid-30's.
.
Pt. reports not taking medications, including insulin, home BG
of 411 last checked on day PTA. Pt. states that he has been
non-adherent w/ diabetic diet on [**3-5**] days PTA. Denies SOB, CP,
or worsening abdominal girth. States that this actually
improved. Recently had Spironolactone dose increased to 100mg qD
by PCP. [**Name10 (NameIs) 17613**] sadness, but no hopelessness, anhedonia or SI.
.
BP was 100/palp with EMS en route; was given 250 cc bolus with
improvement. In the ED he was HD stable with VS 118/68, 82, 16,
98% RA. He was given protonix and ocreotide.
.
Was admitted to ICU, where he underwent an EGD, showing grade I
and II non-bleeding ulcers and [**Doctor First Name **]-[**Doctor Last Name **] tear. Pt. received
2U PRBCs and 2U of FFPs. HCT stable.
.
ROS: Denies melena, BRBPR, previous hematemesis, CP, SOB,
encephalopathy hx.

MEDICAL HISTORY: #. Multiple gallbladder stones w/o cholecystitis
#. Hepatocellular Carcinoma
- two bx lesions c (+) path
- s/p RFA [**2103-8-29**]
#. Hospitalization x2 over last 2-4 months for severe
cellulitis of lower extremities
#. Hep C Genotype 1
- Pegylated interferon, ribavirin ([**2096**]): Viral relapse
- Liver bx ([**2099**]): Stage 3 fibrosis, grade 2 inflammation
- EGD ([**7-/2101**]): Esophagitis, varices
- AFP 9.8
#. Hypertension
#. DMII: c/b neuropathy
#. Psoriasis
#. Anxiety
#. GERD
#. Chronic anemia
#. s/p laminectomy ([**11/2095**])
#. Chronic pain [**2-4**] laminectomy managed by methadone
#. s/p right ankle surgery ([**2089**])

MEDICATION ON ADMISSION: VS 98.6F 140/90 94 18 100% RA
General: comfortable and well nurished appearing
HEENT: non-icteric sclera; MMM
Lungs: CTA b/l, nl movement
Cardio: RR, no m.r.g., no JVD
Abd: obese, + BS, soft, NT/ND, no shifting dullness.
Extremities: right leg external rotation > left at rest; flat
solar surfaces, onychomycosis, no ulceration. Trace edema b/l.
Skin: no rashes.
Neuro: A&OX3, intact repetition, strength 5/5 in UE, [**5-6**] in LE
proximally, [**4-6**] RLE at foot [**2-4**] pain.
? asterixis vs. intention tremor. No pronator drift, FTN intact.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS on arrival to the ED: 118/68, 82, 16, 98% RA
VS on arrival to the ICU: 80, 152/75, 13, 100% RA
General: comfortable and well nurished appearing
HEENT: non-icteric sclera; dry MM
Lungs: CTA b/l
Cardio: RRR, no m.r.g., no JVD
Abd: + BS, soft, NTND
Extremities: right leg external rotation > left at rest;
Skin: no rashes; WWP
Neuro: AA, OX3, no asterixis

FAMILY HISTORY: Both parents alive and in good health. Overweight/obesity, DM
and HTN in multiple family members. Denies hx Ca, CAD, Liver Px.

SOCIAL HISTORY: Lives at home alone in [**Location (un) **], has girlfriend. has no social
supports, most family lives far away and has no one to call in
case of emergency. Currently on disability (formerly employed in
communications/IT); no tobacco; no hx of recreational drug use;
very occasional EtOH
Gastroesophageal laceration-hemorrhage syndrome,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Acute kidney failure, unspecified,Hepatic encephalopathy,Malignant neoplasm of liver, primary,Other ascites,Urinary tract infection, site not specified,Other and unspecified coagulation defects,Polyneuropathy in diabetes,Long-term (current) use of insulin,Cirrhosis of liver without mention of alcohol,Esophageal varices without mention of bleeding,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Benign neoplasm of colon,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia of other chronic disease,Other chronic pain,Lumbago,Anxiety state, unspecified,Nonspecific abnormal findings in stool contents,Other psoriasis,Personal history of antineoplastic chemotherapy,Personal history of noncompliance with medical treatment, presenting hazards to health
Mallory-weiss syndrome,DMII ketoacd uncontrold,Acute kidney failure NOS,Hepatic encephalopathy,Mal neo liver, primary,Ascites NEC,Urin tract infection NOS,Coagulat defect NEC/NOS,Neuropathy in diabetes,Long-term use of insulin,Cirrhosis of liver NOS,Esoph varices w/o bleed,Enterococcus group d,Benign neoplasm lg bowel,Cholelithiasis NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Anemia-other chronic dis,Chronic pain NEC,Lumbago,Anxiety state NOS,Abn find-stool contents,Other psoriasis,Hx antineoplastic chemo,Hx of past noncompliance
Admission Date:  [**2104-1-6**]              Discharge Date:   [**2104-1-17**]

Date of Birth:  [**2046-10-17**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Male First Name (un) 5282**]
Chief Complaint:
Hematemesis

Major Surgical or Invasive Procedure:
EGD

History of Present Illness:
57 yoM w/ HepC cirrhosis w/ known varices EGD [**7-/2103**] presented
with one day of coffee-ground and then bright red emesis (<1L);
+ nausea; no melena/BRBPR. No prior episodes of GIB. Baseline
Hct in the low to mid-30's.
.
Pt. reports not taking medications, including insulin, home BG
of 411 last checked on day PTA. Pt. states that he has been
non-adherent w/ diabetic diet on [**3-5**] days PTA. Denies SOB, CP,
or worsening abdominal girth. States that this actually
improved. Recently had Spironolactone dose increased to 100mg qD
by PCP. [**Name10 (NameIs) 17613**] sadness, but no hopelessness, anhedonia or SI.
.
BP was 100/palp with EMS en route; was given 250 cc bolus with
improvement. In the ED he was HD stable with VS 118/68, 82, 16,
98% RA. He was given protonix and ocreotide.
.
Was admitted to ICU, where he underwent an EGD, showing grade I
and II non-bleeding ulcers and [**Doctor First Name **]-[**Doctor Last Name **] tear. Pt. received
2U PRBCs and 2U of FFPs. HCT stable.
.
ROS: Denies melena, BRBPR, previous hematemesis, CP, SOB,
encephalopathy hx.


Past Medical History:
#. Multiple gallbladder stones w/o cholecystitis
#. Hepatocellular Carcinoma
- two bx lesions c (+) path
- s/p RFA [**2103-8-29**]
#. Hospitalization x2 over last 2-4 months for severe
cellulitis of lower extremities
#. Hep C Genotype 1
- Pegylated interferon, ribavirin ([**2096**]): Viral relapse
- Liver bx ([**2099**]): Stage 3 fibrosis, grade 2 inflammation
- EGD ([**7-/2101**]): Esophagitis, varices
- AFP 9.8
#. Hypertension
#. DMII: c/b neuropathy
#. Psoriasis
#. Anxiety
#. GERD
#. Chronic anemia
#. s/p laminectomy ([**11/2095**])
#. Chronic pain [**2-4**] laminectomy managed by methadone
#. s/p right ankle surgery ([**2089**])

Social History:
Lives at home alone in [**Location (un) **], has girlfriend. has no social
supports, most family lives far away and has no one to call in
case of emergency. Currently on disability (formerly employed in
communications/IT); no tobacco; no hx of recreational drug use;
very occasional EtOH

Family History:
Both parents alive and in good health. Overweight/obesity, DM
and HTN in multiple family members. Denies hx Ca, CAD, Liver Px.

Physical Exam:
VS on arrival to the ED: 118/68, 82, 16, 98% RA
VS on arrival to the ICU: 80, 152/75, 13, 100% RA
General: comfortable and well nurished appearing
HEENT: non-icteric sclera; dry MM
Lungs: CTA b/l
Cardio: RRR, no m.r.g., no JVD
Abd: + BS, soft, NTND
Extremities: right leg external rotation > left at rest;
Skin: no rashes; WWP
Neuro: AA, OX3, no asterixis

By [**2104-1-7**] patient developed loss of attention and prominent
asterixis.


Pertinent Results:
Labs on admission:
[**2104-1-6**] 02:15AM BLOOD WBC-11.7* RBC-2.77* Hgb-8.9* Hct-26.5*
MCV-96 MCH-32.3* MCHC-33.8 RDW-14.5 Plt Ct-153
[**2104-1-6**] 11:19AM BLOOD WBC-10.5 RBC-2.61* Hgb-8.4* Hct-23.6*
MCV-90 MCH-32.1* MCHC-35.6* RDW-15.8* Plt Ct-117*
[**2104-1-7**] 02:54AM BLOOD WBC-13.2* RBC-3.11* Hgb-9.6* Hct-28.7*
MCV-92 MCH-31.0 MCHC-33.6 RDW-15.9* Plt Ct-127*
[**2104-1-6**] 02:56AM BLOOD PT-18.6* PTT-31.2 INR(PT)-1.7*
[**2104-1-7**] 02:54AM BLOOD PT-16.8* PTT-30.2 INR(PT)-1.5*
[**2104-1-6**] 02:15AM BLOOD Glucose-257* UreaN-70* Creat-4.3*#
Na-124* K-7.1* Cl-89* HCO3-20* AnGap-22*
[**2104-1-7**] 02:54AM BLOOD Glucose-61* UreaN-62* Creat-3.2* Na-131*
K-4.5 Cl-102 HCO3-22 AnGap-12
[**2104-1-6**] 02:15AM BLOOD ALT-63* AST-151* CK(CPK)-853*
AlkPhos-176* TotBili-1.6*
[**2104-1-7**] 02:54AM BLOOD ALT-59* AST-120* AlkPhos-147*
TotBili-2.2*
[**2104-1-6**] 11:19AM BLOOD Calcium-7.4* Phos-4.6*# Mg-1.6
[**2104-1-7**] 02:54AM BLOOD Albumin-2.7* Calcium-8.1* Phos-4.0 Mg-1.6
[**2104-1-7**] 04:59PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006
[**2104-1-7**] 04:59PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-TR
[**2104-1-6**] 02:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2104-1-6**] 02:56AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-5.0 Leuks-NEG
[**2104-1-6**] 02:56AM URINE RBC-[**6-11**]* WBC-[**3-6**] Bacteri-FEW Yeast-NONE
Epi-[**3-6**] RenalEp-[**3-6**]
.
.

Imaging/Studies:
.
CXR [**2104-1-6**] - PORTABLE UPRIGHT CHEST RADIOGRAPH: The heart size
and mediastinal contours
remain normal. The lungs are well inflated and remain clear. No
pneumothorax
or pleural effusion is seen. Degenerative changes of the
thoracic spine as
before.

IMPRESSION: No evidence of acute intrathoracic process seen.
.
EGD [**2104-1-6**]:  Summary: [**Doctor First Name **]-[**Doctor Last Name **] tear. Varices grade I/II at
the gastroesophageal junction and lower third of the esophagus.
Blood in the fundus
.
RUQ U/S: [**1-8**]
.
IMPRESSION:
1. Segment IV s/p RFA cystic and solid lesion with mural nodules
concerning
for tumor recurrence.
2. Segment III lesion also raises the possibility of recurrence.

3. Persistent ascites and gallstones.
4. Normal son[**Name (NI) 493**] exam of the portal venous system.
5. Mild left renal pelviectasis
.
Colonoscopy - see brief hospital course.
.
MRI of abdomen - Pending.
.
Microbiology:
.
URINE CULTURE (Final [**2104-1-11**]):
      ENTEROCOCCUS SP..    >100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------   <=2 S
NITROFURANTOIN--------  <=16 S
TETRACYCLINE----------  =>16 R
VANCOMYCIN------------   <=1 S
.
Peritoneal fluid, blood cultures negative.
.
Labs on discharge:
.
[**2104-1-17**] 05:35AM BLOOD WBC-8.9 RBC-2.92* Hgb-9.5* Hct-27.8*
MCV-95 MCH-32.4* MCHC-34.1 RDW-15.4 Plt Ct-126*
[**2104-1-17**] 05:35AM BLOOD PT-18.7* PTT-38.6* INR(PT)-1.7*
[**2104-1-17**] 05:35AM BLOOD Glucose-126* UreaN-27* Creat-1.8* Na-129*
K-4.0 Cl-99 HCO3-23 AnGap-11
[**2104-1-17**] 05:35AM BLOOD ALT-33 AST-73* LD(LDH)-232 AlkPhos-137*
TotBili-1.0
[**2104-1-17**] 05:35AM BLOOD Albumin-2.6* Calcium-7.8* Phos-3.6 Mg-1.6
[**2104-1-10**] 08:45AM BLOOD calTIBC-294 VitB12-1338* Folate-9.0
Ferritn-219 TRF-226

Brief Hospital Course:
57 year old man w/ history of HCV and HCC s/p RFA in [**8-/2103**], w/
Grade I/II varices, not on nadolol was admitted w/ episode of
hematemesis/UGIB [**2-4**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, diagnosed on emergent
endoscopy.  Patient received 2U of PRBCs and FFP and was
transfered from ICU to the floor for further care.
.
#) GIB and anemia.  Patient initially presented with a GIB due
to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear diagnosed via EGD.  Patient was also noted
to have grade I/II non-bleeding varices.  No banding was
performed. Patient was started on protonix 40 mg [**Hospital1 **] and Nadolol
20mg QD.  He received 2U of PRBCs and HCT nadired at 24, 26 on
admission and was 30 after transfusions.   No further frank
upper GI bleeding was noted.  Patient had intermittently guiac
positive stools with HCT dropping to 26 on HD#7.  This was felt
to be due to possible dilutional effect (Pt had received 50g of
albumin) vs. LGIB.  He underwent a colonoscopy which showed
three polyps, with one maximum size of 1cm.  No polypectomy was
performed due to agitation by the patient and INR of 1.6.  No
sites of bleeding were noted.  Patient received 2 additional
units of PRBCs.  HCT increased to 30 and remained stable until
discharge. He will require a repeat colonoscopy for polypectomy
and pathology evaluation.  He is currently scheduled for this
with Dr. [**Last Name (STitle) **].  Chronic anemia could not be further
characterized and patient had received transfusions.  He will
require outpatient evaluation including iron studies,
reticulocyte count and vitamin studies.  TSH was nl in [**2103**].
HCT on discharge was 28.
.
#) ESLD, HepC cirrhosis/HCC s/p RFA in [**8-9**].  Patient is
currently being worked up for liver transplantation (seen [**11-9**]
by Dr.[**Name (NI) 948**] office).  HCV tx by Ribavarin, interferon in
[**2096**], w/ relapse and VL of 465K [**11-9**].  His EGD showed Grade
I/II varices.  Prior to this admission, he had no hx of
encephalopathy.  Liver ultrasound showed coarsened liver
echotexture, segment IV s/p RFA cystic and solid lesion with
mural nodules concerning for tumor recurrence, segment III
lesion also raises the possibility of recurrence, persistent
small asictes, gallstones, normal portal venous system.  On
admission to the floor, patient was noted to have asterexis and
impaired attention and memory.  He was started on lactulose and
rifaximin.  WBC count was elevated and a diagnostic tap was
performed which failed to show SBP, 200 PMNs.  Other infectious
work up was negative including CXR, BCx, C.difficile antigen and
contaminated UA.  Due to persistent ecephalopathy and elevated
WBC, patient was started on ceftriaxone for possible SBP.  On
HD8 patient grew enterococcus in from urinary source.  He was
started on ampicillin IV on [**1-11**] and ceftriaxone was
discontinued.  With this treatment, encephalopathy improved
significantly, including improved attention (days of the week
and months of the year backwards, and nearly resolved
asterixis).  As part of liver [**Month/Day (4) **] work up, patient
underwent an echocardiogram, which showed normal PAP and LVEF of
70%.  Due to concern for recurrent bleeding, patient's nadolol
was increased to 40mg daily.  His lactulose was titrated to [**3-5**]
BMs per day and Rifaximin was continued at 400mg TID.
From social work perspective, patient has had difficulties
getting to appointments due to transportation and financial
issues.  The day of discharge, patient underwent an MRI of
abdomen to assess the recurrence of HCC.  This study will
require follow up by PCP and [**Hospital1 1388**] Dr. [**Last Name (STitle) 497**] and [**Doctor Last Name **].
.
#) ARF on CKD. Baseline Cr reported as 1.5 to 2.0, was 4.3 on
admission.  CKD was felt to be likely due to DM and HTN.  ARF on
admission was likely pre-renal in setting of N/V and hemorrhage.
Diuretics were held. Patient responded to IVF in ICU with Cr
improving to 3.2. However, improvement ceased as WBC began to
climb.  Urine lytes were intially consistent with intrinsic
disease, Na of 105, FeNA > 1%, however eventually showed
pre-renal state w/ Na 18, FeNA <1%. UA did not show casts,
eosinophils were negative.  Cr. improved after albmuin
administration and PRBC transfusions. Given this and lack of
hypotension, hepatorenal syndrome was felt unlikely and cause
was felt to be pre-renal.  Renal team was consulted who agreed
with above assessment.  At time of discharge Cr improved to 1.8.
 With this treatment, patient's LE edema re-accumulated,
approximately 1+ at time of discharge with 5kg wt gain over last
4 days of hospitalization.  Reported as baseline by patient.
Patient was restarted on Lasix 40 QD and Spironolactone of 50mg
qd at time of discharge.
.
#) Chronic RLE pain and back pain.  This was unchanged during
admission.  Pt. on methadone 40 mg QAM and 30 mg QPM as
outpatient.  These were continued.  Pain was reported as [**2105-2-5**].
 Patient was evaluated by physical therapy was deemed to require
rehabilitation for further gait and strength training.
.
#) Liver nodule.  see above for ultrasound results and further
work up performed with MRI on day of discharge.  This will
require follow up.
.
#) T2DM, Hyperglycmeia. Improved, still not consistently < 150.
Has had some hypoglycemia in AM, [**2-4**] NPO. Likely presented in
DKA w/ trace ketones in urine, and elevated BG at home and N/V.
A1C 5.9 in [**10-9**], thus relatively well controlled. Pt. on 85
lantus as OP.  This scale was restared with BG ranging between
110-220s, w/ occasional 60s during periods of NPO.  Pt. was
discharged w/ HISS and Lantus 85U QHS.
.
#) Hypertension. Blood pressures ranging 130-150 systolic
throughout hospital stay. he was restarted on home Diltiazem CR
at 120 QD on HD#5 and Spironolactone at discharge.  Goal SBP
130/80 or less.
0
#) PPX: PO protonix; pneumoboots
.
#) COMMUNICATION: with patient and Son [**Name (NI) 17614**] [**Name (NI) 805**] ([**Telephone/Fax (1) 17615**] OR [**Telephone/Fax (1) 17616**] OR [**Telephone/Fax (1) 17617**].  Multiple discussions
were held with family and it was felt that patient would benefit
from transient rehabilitation stay as well as recommeneded by
PT.
.
Patient was discharged in a hemodynamically stable condition,
afebrile.
.
Issues requiring follow up:
- Completion of ABx for UTI
- Titration of diuretics for optimal volume status
- Electrolyte monitoring with restarting of diuretics, 2d after
discharge
- Blood pressure regimen optimization
- HCT labs 2d after discharge
- MRI abdomen at [**Hospital1 18**] follow up
- PCP and Liver Clinic follow up as arranged.

Medications on Admission:
VS 98.6F 140/90 94 18 100% RA
General: comfortable and well nurished appearing
HEENT: non-icteric sclera; MMM
Lungs: CTA b/l, nl movement
Cardio: RR, no m.r.g., no JVD
Abd: obese, + BS, soft, NT/ND, no shifting dullness.
Extremities: right leg external rotation > left at rest; flat
solar surfaces, onychomycosis, no ulceration. Trace edema b/l.
Skin: no rashes.
Neuro: A&OX3, intact repetition, strength 5/5 in UE, [**5-6**] in LE
proximally, [**4-6**] RLE at foot [**2-4**] pain.
? asterixis vs. intention tremor. No pronator drift, FTN intact.



Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Eighty Five (85)
units Subcutaneous at bedtime.
2. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO QAM (once a day (in the morning)).
3. Methadone 10 mg Tablet Sig: Three (3) Tablet PO QPM (once a
day (in the evening)).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed.
7. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Hold for SBP < 90, HR < 60, page house officer if holding.
10. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO QMON
(every Monday): SBP prophylaxis
.
11. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous see sliding scale: see sliding scale.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Hold
for SBP < 90.
13. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day: Hold for SBP < 100.
14. Outpatient Lab Work
CBC, chem 10, PTT/PT, AST/ALT/Tbili/AP two days after discharged
and weekly there after.  Please fax results to PCP and Dr.
[**Last Name (STitle) **] at [**Hospital1 18**].
15. MRI follow up
Patient had undergone and MRI at [**Hospital1 18**] on day of discharge.
This will require follow up by PCP.
16. Nitrofurantoin Macrocrystal 100 mg Capsule Sig: One (1)
Capsule PO every six (6) hours for 2 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1186**] - [**Location (un) 538**]

Discharge Diagnosis:
Primary: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear with hemorrhage, acute kidney
injury, hepatic encephalopathy, urinary tract infection
Secondary: Hepatitis C and Hepatocellular Carcinoma, Cirrhosis,
Anemia of chronic disease, Esophageal Varices, Hypertension,
Diabetes.


Discharge Condition:
Hemodynamically stable, improved encephalopathy and afebrile.


Discharge Instructions:
You were admitted to [**Hospital1 18**] with nausea and bloody vomiting.  You
underwent an endoscopy that showed a tear in a part of your
esophagus as well as varices (blood vessel outpouchings in your
esophagus due to your liver disease).  You received blood
transfusions for this and your blood levels stabilized.  You
also underwent a colonoscopy that showed several polyps (see
below for follow up).
.
Because of the varices in your esophagus, you were started on a
medication called nadolol to prevent bleeding.
.
In addition, you were found to have developed encephalopathy (an
abnormality in the brain chemistry, due to liver disease or
infection) that to you felt like confusion.  Because of this you
were started on two medications: lactulose and rifaximin.  In
addition, you were found to have a urinary tract infection,
which was treated with intravenous antibiotic.
.
Finally, you stay was complicated by acute kidney failure on top
of your chronic kidney failure.  This was felt to be due to
blood loss and infection.  With blood transfusions and
intravenous fluids your kidney function recovered.  You were
restarted on your diuretics the day of discharge at lower doses,
50mg daily of Spironolactone and Lasix at 40mg daily.
.
Should you experience any further or worsening confusion,
fevers, chills, nausea, vomiting, bloody or black stools,
coughing up blood, worsening swelling in your legs or abdomen,
please call your primary care doctor or go to the nearest
emergency room.
.
Your medications were adjusted.  Please see list below and only
take medications you were prescribed.
.
While at the hospital your liver was imaged. A small lesion in
your liver was found concerning for recurrence of your cancer.
You will require an outpatient CT scan to evaluate this further.
 In addition, you will require a repeat colonoscopy to remove
the polyps in your colon.

Followup Instructions:
You have an appointment with your PCP, [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. #
[**Telephone/Fax (1) 7538**], on [**2-4**] at 6.15pm.

You also have an appointment on Saturday, [**1-19**] with your
PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], please call above number to confirm your
appointment.

Dr. [**Last Name (STitle) 497**], Liver center, [**2105-2-5**]:40 am, ([**Telephone/Fax (1) 1582**].

Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB)
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2104-1-23**] 9:00

Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 9394**] (ST-3) GI ROOMS Date/Time:[**2104-1-25**] 9:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2104-1-25**] 9:30.  For repeat colonoscopy and
polypectomy.



Completed by:[**2104-1-17**]
{'Gastroesophageal laceration-hemorrhage syndrome,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Acute kidney failure, unspecified,Hepatic encephalopathy,Malignant neoplasm of liver, primary,Other ascites,Urinary tract infection, site not specified,Other and unspecified coagulation defects,Polyneuropathy in diabetes,Long-term (current) use of insulin,Cirrhosis of liver without mention of alcohol,Esophageal varices without mention of bleeding,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Benign neoplasm of colon,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia of other chronic disease,Other chronic pain,Lumbago,Anxiety state, unspecified,Nonspecific abnormal findings in stool contents,Other psoriasis,Personal history of antineoplastic chemotherapy,Personal history of noncompliance with medical treatment, presenting hazards to health'}


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

PRESENT ILLNESS: 57 yoM w/ HepC cirrhosis w/ known varices EGD [**7-/2103**] presented
with one day of coffee-ground and then bright red emesis (<1L);
+ nausea; no melena/BRBPR. No prior episodes of GIB. Baseline
Hct in the low to mid-30's.
.
Pt. reports not taking medications, including insulin, home BG
of 411 last checked on day PTA. Pt. states that he has been
non-adherent w/ diabetic diet on [**3-5**] days PTA. Denies SOB, CP,
or worsening abdominal girth. States that this actually
improved. Recently had Spironolactone dose increased to 100mg qD
by PCP. [**Name10 (NameIs) 17613**] sadness, but no hopelessness, anhedonia or SI.
.
BP was 100/palp with EMS en route; was given 250 cc bolus with
improvement. In the ED he was HD stable with VS 118/68, 82, 16,
98% RA. He was given protonix and ocreotide.
.
Was admitted to ICU, where he underwent an EGD, showing grade I
and II non-bleeding ulcers and [**Doctor First Name **]-[**Doctor Last Name **] tear. Pt. received
2U PRBCs and 2U of FFPs. HCT stable.
.
ROS: Denies melena, BRBPR, previous hematemesis, CP, SOB,
encephalopathy hx.

MEDICAL HISTORY: #. Multiple gallbladder stones w/o cholecystitis
#. Hepatocellular Carcinoma
- two bx lesions c (+) path
- s/p RFA [**2103-8-29**]
#. Hospitalization x2 over last 2-4 months for severe
cellulitis of lower extremities
#. Hep C Genotype 1
- Pegylated interferon, ribavirin ([**2096**]): Viral relapse
- Liver bx ([**2099**]): Stage 3 fibrosis, grade 2 inflammation
- EGD ([**7-/2101**]): Esophagitis, varices
- AFP 9.8
#. Hypertension
#. DMII: c/b neuropathy
#. Psoriasis
#. Anxiety
#. GERD
#. Chronic anemia
#. s/p laminectomy ([**11/2095**])
#. Chronic pain [**2-4**] laminectomy managed by methadone
#. s/p right ankle surgery ([**2089**])

MEDICATION ON ADMISSION: VS 98.6F 140/90 94 18 100% RA
General: comfortable and well nurished appearing
HEENT: non-icteric sclera; MMM
Lungs: CTA b/l, nl movement
Cardio: RR, no m.r.g., no JVD
Abd: obese, + BS, soft, NT/ND, no shifting dullness.
Extremities: right leg external rotation > left at rest; flat
solar surfaces, onychomycosis, no ulceration. Trace edema b/l.
Skin: no rashes.
Neuro: A&OX3, intact repetition, strength 5/5 in UE, [**5-6**] in LE
proximally, [**4-6**] RLE at foot [**2-4**] pain.
? asterixis vs. intention tremor. No pronator drift, FTN intact.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS on arrival to the ED: 118/68, 82, 16, 98% RA
VS on arrival to the ICU: 80, 152/75, 13, 100% RA
General: comfortable and well nurished appearing
HEENT: non-icteric sclera; dry MM
Lungs: CTA b/l
Cardio: RRR, no m.r.g., no JVD
Abd: + BS, soft, NTND
Extremities: right leg external rotation > left at rest;
Skin: no rashes; WWP
Neuro: AA, OX3, no asterixis

FAMILY HISTORY: Both parents alive and in good health. Overweight/obesity, DM
and HTN in multiple family members. Denies hx Ca, CAD, Liver Px.

SOCIAL HISTORY: Lives at home alone in [**Location (un) **], has girlfriend. has no social
supports, most family lives far away and has no one to call in
case of emergency. Currently on disability (formerly employed in
communications/IT); no tobacco; no hx of recreational drug use;
very occasional EtOH 

### Response:
{'Gastroesophageal laceration-hemorrhage syndrome,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Acute kidney failure, unspecified,Hepatic encephalopathy,Malignant neoplasm of liver, primary,Other ascites,Urinary tract infection, site not specified,Other and unspecified coagulation defects,Polyneuropathy in diabetes,Long-term (current) use of insulin,Cirrhosis of liver without mention of alcohol,Esophageal varices without mention of bleeding,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Benign neoplasm of colon,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia of other chronic disease,Other chronic pain,Lumbago,Anxiety state, unspecified,Nonspecific abnormal findings in stool contents,Other psoriasis,Personal history of antineoplastic chemotherapy,Personal history of noncompliance with medical treatment, presenting hazards to health'}
