CHIEF COMPLAINT: Transfer for management of recurrent variceal bleeding

PRESENT ILLNESS: The patient is a 60 year old female with a history of hepatitis
C cirrhosis, type II diabetes, and alcohol abuse who is
transferred from [**Hospital **] hospital for management of recurrent
variceal bleeding. The patient was admitted to [**Hospital1 **] from
[**2187-11-9**] to [**2187-11-21**] when she presented with altered mental
status, seizure activity and hematemasis. Per records she was
found unresponsive with concern for seizure activity. She was
admitted for a similar presentation on [**2187-10-23**]. She as intubated
on arrival to the emergency room for airway proteection. She
underwent emergent upper endoscopy which showed active
esophageal varceal bleeding and she received 2 bands and
sclerotherapy and ethanolamine. She underwent repeat upper
endoscopy on [**2187-11-13**] at which time five additional bands were
placed. Her course was complicated by prolonged respiratory
failure which was thought to be secondary to ARDS in the setting
of aspiration of blood. She required high PEEP and FiO2 to
maintain adequate oxygenation. On [**2187-11-20**] she was scheduled for
tracheostomy for prolonged respiratory failure. During the
initial bronchoscopy she was noted to have blood coming out her
nose and her mouth. Gastroenterology was called emergently to
the operating room who performed upper endoscopy on [**2187-11-20**].
She was noted to have fresh blood in the esophagus but no active
bleeding from her varices. She was noted to have evidence of
ulcers and it was felt that these might be the source of the
bleeding. No bands were located. She was restarted on an
octreotide drip and protonix drip. The following morning she was
again found to have significant hemoptysis. Repeat endoscopy was
performed which showed active variceal bleeding. Intervention
was unable to be performed so she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10045**] tube placed
with pressure of 35 mmHg in the esophagus. She was transferred
to this hospital for consideration of TIPS procedure for
recurrent variceal bleeding.
.
On arrival to this hospital she is intubated and sedated and
unresponsive to sternal rub. No further history can be obtained.
She was stabilized in the MICU and taken emergently for TIPS
procedure. In interventional radiology she had a paracentesis
performed with removal of 7 liters of clear fluid. TIPS
procedure was performed successfully. Her baseline right atrial
pressures were 12, portal pressures vein 32, portosystemic
gradient 20. Post TIPS pressures were right atrial 19, portal
vein 28, portosystemic gradient 9. She underwent embolization of
prominent esophageal varices. She had a 12 F triple lumen
central line left in place post-procedure. She was
hemodynamically stable during the procedure.

MEDICAL HISTORY: Hepatitis C Cirrhosis
History of esophageal variceal bleeding
History of hepatic encephalopathy
Hypertension
History of alcohol abuse
Insulin depedent diabetes
Chronic Anemia

MEDICATION ON ADMISSION: Home Medications:
Neurontin 100 mg TID
Haldol 0.5 mg [**Hospital1 **]
Haldol 0.5 mg QHS
Oxycodone 5 mg [**Hospital1 **]
Dilaudid 2 mg Q4H:PRN
Maalox 30 mL PO PRN
Lactulose 30 mL [**Hospital1 **]
Ambien 20 mg QHS
Vitamin C 500 mg [**Hospital1 **]
Effexor 75 mg daily
Lantus 40 mg QHS
Humalog sliding scale
.
Medications on arrival from OSH
Propofol 30 mcg/kg/min
Insulin drip 8units/hr
Octreotide 50 mcg IV/hr
VAncomycin 1 gram IV Q12H
Ceftazidime 2 grams IV BID
Lactulose 30 cc Q6H
TPN

ALLERGIES: Lisinopril

PHYSICAL EXAM: Vitals: T: 100.3 BP: 129/51 P: 112 R: 14 O2: 92% (AC 450 x 14,
PEEP 15, FiO2 100%)
General: Intubated, sedated, no response to sternal rub
HEENT: PERRL, Sclera mildly icteric, dry, [**Last Name (un) 10045**] tube in left
nostril, ET tube in place, dried blood on the face and in the
oropharynx
Neck: supple, right large bore central line in right IJ, left
subclavian in place
Lungs: Decreased lung volumes, crackles at the bases
bilaterally, no rales or ronchi
CV: hyperdynamic, tachycardic, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, distended, soft, bowel sounds hypoactive, unable
to appreciate organmegaly secondary to body habitus
GU: foley with dark urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2+
edema to knees.
Back: Stage II sacral decubitus ulcer
.
Transfer Vitals: 127/50 74 98%
(AC 450 x 14, PEEP 15, FiO2 100%)

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Known history of alcohol abuse. Otherwise unknown
Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Acute kidney failure, unspecified,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Other and unspecified alcohol dependence, unspecified,Chronic hepatitis C without mention of hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Alcohol cirrhosis liver,Bleed esoph var oth dis,Acute kidney failure NOS,Acute respiratry failure,Hyperosmolality,Alcoh dep NEC/NOS-unspec,Chrnc hpt C wo hpat coma,DMII wo cmp nt st uncntr
Admission Date:  [**2187-11-21**]              Discharge Date:   [**2187-11-26**]

Date of Birth:  [**2127-8-27**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transfer for management of recurrent variceal bleeding

Major Surgical or Invasive Procedure:
Placement of arterial line, central line, TIPS. Pt was already
intubated on arrival.

History of Present Illness:
The patient is a 60 year old female with a history of hepatitis
C cirrhosis, type II diabetes, and alcohol abuse who is
transferred from [**Hospital **] hospital for management of recurrent
variceal bleeding. The patient was admitted to [**Hospital1 **] from
[**2187-11-9**] to [**2187-11-21**] when she presented with altered mental
status, seizure activity and hematemasis. Per records she was
found unresponsive with concern for seizure activity. She was
admitted for a similar presentation on [**2187-10-23**]. She as intubated
on arrival to the emergency room for airway proteection. She
underwent emergent upper endoscopy which showed active
esophageal varceal bleeding and she received 2 bands and
sclerotherapy and ethanolamine. She underwent repeat upper
endoscopy on [**2187-11-13**] at which time five additional bands were
placed. Her course was complicated by prolonged respiratory
failure which was thought to be secondary to ARDS in the setting
of aspiration of blood. She required high PEEP and FiO2 to
maintain adequate oxygenation. On [**2187-11-20**] she was scheduled for
tracheostomy for prolonged respiratory failure. During the
initial bronchoscopy she was noted to have blood coming out her
nose and her mouth. Gastroenterology was called emergently to
the operating room who performed upper endoscopy on [**2187-11-20**].
She was noted to have fresh blood in the esophagus but no active
bleeding from her varices. She was noted to have evidence of
ulcers and it was felt that these might be the source of the
bleeding. No bands were located. She was restarted on an
octreotide drip and protonix drip. The following morning she was
again found to have significant hemoptysis. Repeat endoscopy was
performed which showed active variceal bleeding. Intervention
was unable to be performed so she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10045**] tube placed
with pressure of 35 mmHg in the esophagus. She was transferred
to this hospital for consideration of TIPS procedure for
recurrent variceal bleeding.
.
On arrival to this hospital she is intubated and sedated and
unresponsive to sternal rub. No further history can be obtained.
She was stabilized in the MICU and taken emergently for TIPS
procedure. In interventional radiology she had a paracentesis
performed with removal of 7 liters of clear fluid. TIPS
procedure was performed successfully. Her baseline right atrial
pressures were 12, portal pressures vein 32, portosystemic
gradient 20. Post TIPS pressures were right atrial 19, portal
vein 28, portosystemic gradient 9. She underwent embolization of
prominent esophageal varices. She had a 12 F triple lumen
central line left in place post-procedure. She was
hemodynamically stable during the procedure.


Past Medical History:
Hepatitis C Cirrhosis
History of esophageal variceal bleeding
History of hepatic encephalopathy
Hypertension
History of alcohol abuse
Insulin depedent diabetes
Chronic Anemia


Social History:
Known history of alcohol abuse. Otherwise unknown

Family History:
Unknown

Physical Exam:
Vitals: T: 100.3 BP: 129/51 P: 112 R: 14 O2: 92% (AC 450 x 14,
PEEP 15, FiO2 100%)
General: Intubated, sedated, no response to sternal rub
HEENT: PERRL, Sclera mildly icteric, dry, [**Last Name (un) 10045**] tube in left
nostril, ET tube in place, dried blood on the face and in the
oropharynx
Neck: supple, right large bore central line in right IJ, left
subclavian in place
Lungs: Decreased lung volumes, crackles at the bases
bilaterally, no rales or ronchi
CV: hyperdynamic, tachycardic, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, distended, soft, bowel sounds hypoactive, unable
to appreciate organmegaly secondary to body habitus
GU: foley with dark urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2+
edema to knees.
Back: Stage II sacral decubitus ulcer
.
Transfer Vitals: 127/50 74 98%
(AC 450 x 14, PEEP 15, FiO2 100%)


Pertinent Results:
Admission labs:
WBC 10.6
Hct 37.3
Plts 139
PT 17.7  PTT 29.0  INR 1.6
Fibrino 320
Retic 3.5

137     107    57    Gluc 229
--------------------
5.9     25     1.5

ALT/AST  28/74
LDH 417
CK 50
ALkP 119
Tbili 4.2
Trigly 143
Ammonia 57
7.32/52/85/28
lactate 1.6

Discharge labs:
WBC: 4.6  Hct 28.9
Plts 110
PT 16.9  PTT 26.5  INR 1.5

147    114    47   Gluc 272
3.9    25    1.1

AST/ALT  46/78
AlkP 225
Tbili 2.8
Cardiac enzymes negative x2
7.41/41/128/27
lactate 2.3

Micro:  from OSH
Blood culture [**2187-11-9**] - negative
Clostridium difficle [**2187-11-18**] - negative
Sputum [**2187-11-13**] - contaminated, positive for stenotrophomonas
VRE positive swab [**2187-11-16**]
.
[**2187-11-21**] BCx
Coag negative Staph
with 3 subsequent negative BCx's

2 catheter tip Cx's negative
HCV VL 12,500
Cdiff negative x1
[**2187-11-22**] Sputum with commensurate resp flora
[**2187-11-25**] Sputum with 3+ GNR's

Images:  from OSH
CXR [**2187-11-20**]: Lines in appropriate position. No pneumothorax.
Left basilar infiltrate with probably small pleural effusion.
Right mid lung atelectasis.
.
Bronchoscopy [**2187-11-20**] - Durign the bronchoscopy it was noted
that she was bleeding from the nose and the throat.
.
Endoscopy [**2187-11-13**] - Grade 3 to 4 esophageal varices with a red
[**Last Name (un) 23199**] sign on one of the lateral varices. one band was placed in
the lower esophagus and some fibrosis was seen from previous
sclerotherapy. There was extensive portal hypertensive
gastropathy in the antrum. No active bleeding. Five bands were
placed.
.
Endoscopy [**2187-11-9**] - Large coil-shaped varices occupying more
than [**1-20**] of the esophagus were noted (grade F3). There was
active bleeding from a large varix chain. Banding was performed
at the bleeding site x 2. Sclerotherapy was performed.
.
EKG [**2187-11-9**]: normal sinus rhythm, normal axis, normal
intervals, non-diagnostic q waves in II, III, avF with t-wave
flattening in III, avF. Unchanged from prior dated [**2187-11-6**].

IMAGES from [**Hospital1 18**]:
[**2187-11-21**] initial CXR
FINDINGS: The trachea is slightly deviated to the right, the tip
of the
endotracheal tube projects approximately 3.5 cm above the
carina. Senkstaaken
device is in place. Visualization of a left-sided central venous
access line
inserted over the subclavian vein, the tip projects over the
upper SVC.

Both costophrenic sinuses are not included in the image.
Moderate
cardiomegaly, atelectasis along the right minor fissure, in the
retrocardiac
area and at the left lung base. Moderate cardiomegaly without
evidence of
frank pulmonary edema.

[**2187-11-21**] CT abd pelvis
CT ABDOMEN WITHOUT AND WITH CONTRAST: There is bibasilar
atelectasis/consolidtion, right greater than left. The
nasogastric/
Sangstaken tube courses through the air distended distal
esophagus and
terminates in the stomach; the balloon is inflated within the
proximal
stomach, close to the GE junction. There is no focal dilation of
small bowel
or colon. No active extravasation is identified. There is a
moderate amount
of ascites in the abdomen and pelvis, which measures simple
fluid in
attenuation. No sentinel clot is identified.

The liver has a nodular contour consistent with cirrhosis. The
gallbladder is
distended. The spleen is markedly enlarged, measuring 23 cm in
craniocaudal
dimension. The pancreas and right adrenal gland are
unremarkable. Tiny
atrophic / hypoplastic left kidney. There are extensive varices
within the
abdomen. Abdominal lymph nodes do not meet size criteria for
pathologic
enlargement.

CT PELVIS WITH IV CONTRAST: Ascites extends into the pelvis, and
measures
simple fluid in attenuation. There is a Foley catheter within
the urinary
bladder, which is decompressed. There are coarse calcifications
in the uterus
consistent with degenerated fibroids. There is fluid within the
rectum. There
is diffuse body wall edema.

There are bone lesions suspicious for malignancy.

IMPRESSION:
1. Moderate amount of ascites which measures simple fluid in
attenuation.
Active extravasation is not identified.
2. Findings of cirrhosis and portal hypertension.
3. Bilat lower lobe atelctases / consolidation.
3. Shrunken left kidney.

[**2187-11-22**] EKG
Baseline artifact. Borderline resting sinus tachycardia. Low
voltage
diffusely. Non-specific ST-T wave changes. Non-diagnostic Q
waves in
lead III. No previous tracing available for comparison. Clinical
correlation
is suggested.

[**2187-11-22**] Echo
LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.

LEFT VENTRICLE: Normal LV wall thickness. LV cavity normal for
BSA. Normal regional LV systolic function. Overall normal LVEF
(>55%). Estimated cardiac index is high (>4.0L/min/m2). No
resting LVOT gradient.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
valvular AS. The increased transaortic velocity is related to
high cardiac output. No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild thickening of mitral valve
chordae. Trivial MR.

TRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.

PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal for the patient's body size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The estimated cardiac index is
high (>4.0L/min/m2). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.

IMPRESSION: Normal biventricular systolic function. Mild
estimated pulmonary artery systolic hypertension.

[**2187-11-25**] final CXR
FINDINGS: As compared to the previous radiograph, today's image
shows
multiple respiratory motion artifacts. The endotracheal tube and
nasogastric
tube are in unchanged position. Also unchanged is the
right-sided central
venous access line. Unchanged size of the cardiac silhouette
with
retrocardiac atelectasis, no evidence of newly occurred
parenchymal opacities
in addition to the pre-existing widespread, left more than right
opacities.
No evidence of right-sided pleural effusion, the left
costophrenic sinus is
not included on the image.


Brief Hospital Course:
MICU Course:

60 year old female with a history of hepatitis C cirrhosis, type
II diabetes, and alcohol abuse who is transferred from [**Hospital **]
hospital for management of recurrent variceal bleeding.

Variceal Bleeding: Pt had upper endoscopy on [**2187-11-9**] at OSH
with multiple cords of grade 3 varices and significant portal
hypertensive gastropathy. Endoscopy [**2187-11-21**] showed active
variceal bleeding and intervention was unsucessful. [**Last Name (un) **]
tube was placed at OSH. Pt was admitted already intubated for
respiratory failure, [**Last Name (un) **] tube was in place, had already
received 5U PRBC's from OSH, was hemodynamicallys stable with
Hct 37.3. Liver was consulted on arrival, massive bleeding
protocol was started and 6U PRBC's were crossmatched. She went
emergently for CT scan abdomen pelvis and then to IR for TIPS
procedure and 7L paracentesis early in the am of [**2187-11-21**] and 50g
albumin was given. Para fluid was unfortunately not sent for
fluid analysis. IR also placed large bore trauma line in R IJ.
Octreotide and PPI drips were started. Vanc and Ceftazadime,
which were started at OSH, were continued for SBP
prophy/coverage. The [**Last Name (un) **] tube was pulled. Through
admission, Hct trended down but no obvious bleeding sources and
was not transfused any more blood through admission. Octreotide
gtt was stopped by time of dc.

Cirrhosis/End Stage Liver Disease:  Secondary to hepatitis C and
alcohol abuse.  She is off of sedation and remains significantly
altered likely from encephalopathy.  NGT placed and started on
PO lactulose and rifaximin.  Current MELD score is 21. Ammonia
level 57.  She has recurrent variceal bleeding although she did
not have any further bleeding through admission. Through
admission, MICU team had discovered that pt had been followed by
Hepatology at [**Hospital1 498**] and they were willing to accept the pt for
further management.

Respiratory Failure: Has been intubated since [**2187-11-9**] with
difficulty weaning secondary to high PEEP and FiO2 requirements,
initially felt to be secondary to ARDS in the setting of
aspirating large volumes of blood. Pt also had large ascites and
small lung volumes. On day of transfer from OSH, pt had planned
to be trach'ed but experienced massive bleeding. She was
continued on AC ventilation and respiratory status improved with
7L paracentesis and continued ventilation. Acidosis and
oxygenation improved with PEEP of 18, gas 7.40/43/93. Pt had
some pulm edema with some frothy sputum suctioned from ETT which
resolved with Lasix diuresis. Through admission pt continued to
be weaned and on day of dc was on AC 450/20, PEEP 8, and FiO2
80. Pt has weaned well but if continues to be vent dependent,
may need trach.

Fevers: Reportedly febrile to 101 at OSH and 100.3 on admission,
WBC count 10.6 on admission and trended down. Ordered for
vancomycin and ceftazidime but did not receive prior to
transfer, was started on upon admission. Cx's from OSH with
sputum positive for stenotrophomonas, rectal swab positive for
VRE, and [**3-21**] positive BCx's for Staph Epidermidis sensitive only
to Vancomycin. Here, BCx's upon admission at [**Hospital1 18**] [**2-19**] positive
for GPC's in pairs and clusters. OSH PICC and L subclavian lines
were pulled and new central access placed, both catheter tips
were negative. Pt was switched from ceftazadime to ceftriaxone
per Hepatology recs for SBP. 3 subsequent blood cultures have
been negative to date. Just before discharge to [**Name (NI) 498**], pt's
sputum Cx was 3+ positive for GNR's with identification and
sensitivity pending, pt was continued on Ceftriaxone and
Vancomycin and sputum Cx should be monitored at followup.

Acute Renal Failure:  Creatinine at 1.5 from baseline of 1.1
prior to this hospitalization.  FENa consistent with prerenal
etiology and pt received IVF's with Cr trending down slowly to
normal value of 1.0. Urine output has been good.

Type II Diabetes:  Had been on an insulin gtt at the outside
hospital.  Converted to fixed dose and sliding scale and was on
Glargine 50U qhs and Humalog sliding scale 4U starting at
151-200, 6U for 201-250, 12U 251-300, 16U 301-350, and 20
351-400.

Elevated troponin: Mild elevatation in Trop's 0.09 to 0.10 with
negative MB's and CK's x3. EKG's showing non-specific ST-T
changes, echo showing no wall motion abnormalities, normal
ventricular function and mild pulm HTN. Unlikely to represent
acute coronary syndrome given normal CKs.  EKG did not show
signs of ischemia.

Hyperkalemia: In the setting of renal failure and also received
multiple blood products. Held on Kayexalate and trended down to
normal values on its own. No worrisome EKG changes.

Hypernatremia: Through admission pt began to have elevated
sodium and was receiving free water flushes through Dobhoff
tube, and will likely need to have this continued and
electrolytes monitored.

Current access: RIJ, R art line, Dobhoff, ETT
Full code, discussed with HCP
Communication with brother [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 84246**] or [**Telephone/Fax (3) 84247**]? who wished current aggressive treatment.

Medications on Admission:
Home Medications:
Neurontin 100 mg TID
Haldol 0.5 mg [**Hospital1 **]
Haldol 0.5 mg QHS
Oxycodone 5 mg [**Hospital1 **]
Dilaudid 2 mg Q4H:PRN
Maalox 30 mL PO PRN
Lactulose 30 mL [**Hospital1 **]
Ambien 20 mg QHS
Vitamin C 500 mg [**Hospital1 **]
Effexor 75 mg daily
Lantus 40 mg QHS
Humalog sliding scale
.
Medications on arrival from OSH
Propofol 30 mcg/kg/min
Insulin drip 8units/hr
Octreotide 50 mcg IV/hr
VAncomycin 1 gram IV Q12H
Ceftazidime 2 grams IV BID
Lactulose 30 cc Q6H
TPN


Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
2. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime: 50U Glargine at bedtime and SSI per
discharge summary.
4. CeftriaXONE 1 gm IV Q24H (Started on [**2187-11-23**])
5. Vancomycin 1000 mg IV Q 12H Started in  [**2187-11-21**]
6. Pantoprazole 40 mg IV Q12H


Discharge Disposition:
Extended Care

Discharge Diagnosis:
1. Hepatitis C
2. Cirrhosis
3. DM2
4. EtOH abuse


Discharge Condition:
Pt was opening eyes, minimally following commands, intubated.


Discharge Instructions:
You were admitted to [**Hospital1 18**] with variceal bleeding and for
evaluation of your liver disease. While you were here, you
received a TIPS procedure, you were kept intubated and
mechanically ventilated, and your blood levels were closely
monitored.

Followup Instructions:
You are being transferred to [**Hospital1 498**] for further work up of your
liver disease


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Completed by:[**2187-12-20**]
{'Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Acute kidney failure, unspecified,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Other and unspecified alcohol dependence, unspecified,Chronic hepatitis C without mention of hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: Transfer for management of recurrent variceal bleeding

PRESENT ILLNESS: The patient is a 60 year old female with a history of hepatitis
C cirrhosis, type II diabetes, and alcohol abuse who is
transferred from [**Hospital **] hospital for management of recurrent
variceal bleeding. The patient was admitted to [**Hospital1 **] from
[**2187-11-9**] to [**2187-11-21**] when she presented with altered mental
status, seizure activity and hematemasis. Per records she was
found unresponsive with concern for seizure activity. She was
admitted for a similar presentation on [**2187-10-23**]. She as intubated
on arrival to the emergency room for airway proteection. She
underwent emergent upper endoscopy which showed active
esophageal varceal bleeding and she received 2 bands and
sclerotherapy and ethanolamine. She underwent repeat upper
endoscopy on [**2187-11-13**] at which time five additional bands were
placed. Her course was complicated by prolonged respiratory
failure which was thought to be secondary to ARDS in the setting
of aspiration of blood. She required high PEEP and FiO2 to
maintain adequate oxygenation. On [**2187-11-20**] she was scheduled for
tracheostomy for prolonged respiratory failure. During the
initial bronchoscopy she was noted to have blood coming out her
nose and her mouth. Gastroenterology was called emergently to
the operating room who performed upper endoscopy on [**2187-11-20**].
She was noted to have fresh blood in the esophagus but no active
bleeding from her varices. She was noted to have evidence of
ulcers and it was felt that these might be the source of the
bleeding. No bands were located. She was restarted on an
octreotide drip and protonix drip. The following morning she was
again found to have significant hemoptysis. Repeat endoscopy was
performed which showed active variceal bleeding. Intervention
was unable to be performed so she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10045**] tube placed
with pressure of 35 mmHg in the esophagus. She was transferred
to this hospital for consideration of TIPS procedure for
recurrent variceal bleeding.
.
On arrival to this hospital she is intubated and sedated and
unresponsive to sternal rub. No further history can be obtained.
She was stabilized in the MICU and taken emergently for TIPS
procedure. In interventional radiology she had a paracentesis
performed with removal of 7 liters of clear fluid. TIPS
procedure was performed successfully. Her baseline right atrial
pressures were 12, portal pressures vein 32, portosystemic
gradient 20. Post TIPS pressures were right atrial 19, portal
vein 28, portosystemic gradient 9. She underwent embolization of
prominent esophageal varices. She had a 12 F triple lumen
central line left in place post-procedure. She was
hemodynamically stable during the procedure.

MEDICAL HISTORY: Hepatitis C Cirrhosis
History of esophageal variceal bleeding
History of hepatic encephalopathy
Hypertension
History of alcohol abuse
Insulin depedent diabetes
Chronic Anemia

MEDICATION ON ADMISSION: Home Medications:
Neurontin 100 mg TID
Haldol 0.5 mg [**Hospital1 **]
Haldol 0.5 mg QHS
Oxycodone 5 mg [**Hospital1 **]
Dilaudid 2 mg Q4H:PRN
Maalox 30 mL PO PRN
Lactulose 30 mL [**Hospital1 **]
Ambien 20 mg QHS
Vitamin C 500 mg [**Hospital1 **]
Effexor 75 mg daily
Lantus 40 mg QHS
Humalog sliding scale
.
Medications on arrival from OSH
Propofol 30 mcg/kg/min
Insulin drip 8units/hr
Octreotide 50 mcg IV/hr
VAncomycin 1 gram IV Q12H
Ceftazidime 2 grams IV BID
Lactulose 30 cc Q6H
TPN

ALLERGIES: Lisinopril

PHYSICAL EXAM: Vitals: T: 100.3 BP: 129/51 P: 112 R: 14 O2: 92% (AC 450 x 14,
PEEP 15, FiO2 100%)
General: Intubated, sedated, no response to sternal rub
HEENT: PERRL, Sclera mildly icteric, dry, [**Last Name (un) 10045**] tube in left
nostril, ET tube in place, dried blood on the face and in the
oropharynx
Neck: supple, right large bore central line in right IJ, left
subclavian in place
Lungs: Decreased lung volumes, crackles at the bases
bilaterally, no rales or ronchi
CV: hyperdynamic, tachycardic, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, distended, soft, bowel sounds hypoactive, unable
to appreciate organmegaly secondary to body habitus
GU: foley with dark urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 2+
edema to knees.
Back: Stage II sacral decubitus ulcer
.
Transfer Vitals: 127/50 74 98%
(AC 450 x 14, PEEP 15, FiO2 100%)

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Known history of alcohol abuse. Otherwise unknown 

### Response:
{'Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Acute kidney failure, unspecified,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Other and unspecified alcohol dependence, unspecified,Chronic hepatitis C without mention of hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
