CHIEF COMPLAINT: Hematemesis

PRESENT ILLNESS: 51 y/o F w/alcoholic cirrhosis, s/p banding of varices in last
year, who presented to [**Hospital 1562**] Hospital today after vomiting
bright red blood. While there, she vomited initially 700 cc BRB
and then 1500 cc during EGD. BP dropped as low as 80s but
responded with volume (received 500 NS, 1500 Hespan, 3 U PRBCs).
She was intubated for airway protection and a femoral line was
placed for access. She was placed on octreotide gtt and given
levofloxacin for prophylaxis. EGD demonstrated massive GI bleed
near GEJ likely from grade IV esohpageal varices, large amt of
fresh blood and clots. one column of varix had whitish spot.
Placed five bands at distal esophagus. She was transferred here
for ? TIPS.
.
Per her fiance, she was hospitalized one week ago for abdominal
pain and swelling. She was told she had an infection and was on
antibiotics, but never had a paracentesis. She had also been
taking vitamin K. She has "coughed up" blood in the past and has
had bands placed once in the past.

MEDICAL HISTORY: 1. Cirrhosis, diagnosed in last year per fiance. Initially there
was a question of Hep C, per him tests were first positive and
subsequently negative
2. Hx of VRE per chart
3. Hx "nonspecific colitis"
4. Hx C Diff
5. ? pancreatic mass

MEDICATION ON ADMISSION: Antibiotic - unknown which one
Vitamin K

ALLERGIES: Penicillins / Aspirin / Acetaminophen

PHYSICAL EXAM: VS - T 98.4, BP 130s/60s, HR 90s-100s, RR 16, sats 97% on RA
Gen: Jaundiced, middle aged female, lying in bed. Minimally
interactive. AAOx3, but ? confabulating answers to some
questions.
HEENT: Sclera hemorrhagic. PERRL. ? strabismus.
Neck: No JVD. Central line on L.
CV: Tachy, reg, normal S1, S2. No m/r/g.
Lungs: CTA anteriorly, but decreased BS at bases.
Abd: Soft, mildly distended, nontender. + BS. No masses
appreciated. No rebound or guarding.
Ext: Mild edema bilaterally in LE. Appears volume overloaded on
exam, but not pitting edema. Feet very cool, 2+ DP/PT pulses
bilaterally. No clubbing or cyanosis.
Neuro: CN appear grossly intact, though able to fully assess.
Grip strong and symmetric. L sided weakness - LUE 4-/5 on
flexion/extension, vs 4+/5 on RUE. "too tired" to assess LE. Can
wiggle toes. Babinski equivocal bilaterally.
Skin: Profoundly jaundiced. No rashes

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at home in [**Location (un) **] with fiance and four children (ages
17, 15, 14, and 12). Works as a deli clerk at local Stop & Shop.
Hx tobacco, 1 ppd but quit 3 years ago. Long alcohol hx, last
drink in [**Month (only) 404**] per fiance.
Acute and subacute necrosis of liver,Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Acute kidney failure with lesion of tubular necrosis,Autoimmune hemolytic anemias,Urinary tract infection, site not specified,Methicillin susceptible pneumonia due to Staphylococcus aureus,Spontaneous bacterial peritonitis,Congestive heart failure, unspecified,End stage renal disease,Infection and inflammatory reaction due to other vascular device, implant, and graft,Pulmonary collapse,Acute posthemorrhagic anemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obstruction of bile duct,Portal hypertension,Other and unspecified alcohol dependence, in remission,Other drugs and medicinal substances causing adverse effects in therapeutic use,Mixed hyperlipidemia,Infection with microorganisms resistant to penicillins
Acute necrosis of liver,Alcohol cirrhosis liver,Bleed esoph var oth dis,Ac kidny fail, tubr necr,Autoimmun hemolytic anem,Urin tract infection NOS,Meth sus pneum d/t Staph,Spontan bact peritonitis,CHF NOS,End stage renal disease,React-oth vasc dev/graft,Pulmonary collapse,Ac posthemorrhag anemia,Hyp kid NOS w cr kid V,DMII wo cmp nt st uncntr,Obstruction of bile duct,Portal hypertension,Alcoh dep NEC/NOS-remiss,Adv eff medicinal NEC,Mixed hyperlipidemia,Inf mcrg rstn pncllins
Admission Date:  [**2157-5-12**]              Discharge Date:   [**2157-6-17**]

Date of Birth:  [**2105-11-6**]             Sex:   F

Service: SURGERY

Allergies:
Penicillins / Aspirin / Acetaminophen

Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Hematemesis

Major Surgical or Invasive Procedure:
1. Orthotopic liver and renal transplant [**2157-6-6**]
2. ERCP, common bile duct stent [**2157-6-12**]
3. EGD [**2157-5-15**]
4. TIPS
5. Central line placement
6. Paracentesis
7. tunneled hemodialysis line placement
8. Colonoscopy [**2157-6-3**]
9. Hemodialysis


History of Present Illness:
51 y/o F w/alcoholic cirrhosis, s/p banding of varices in last
year, who presented to [**Hospital 1562**] Hospital today after vomiting
bright red blood. While there, she vomited initially 700 cc BRB
and then 1500 cc during EGD. BP dropped as low as 80s but
responded with volume (received 500 NS, 1500 Hespan, 3 U PRBCs).
She was intubated for airway protection and a femoral line was
placed for access. She was placed on octreotide gtt and given
levofloxacin for prophylaxis. EGD demonstrated massive GI bleed
near GEJ likely from grade IV esohpageal varices, large amt of
fresh blood and clots. one column of varix had whitish spot.
Placed five bands at distal esophagus. She was transferred here
for ? TIPS.
.
Per her fiance, she was hospitalized one week ago for abdominal
pain and swelling. She was told she had an infection and was on
antibiotics, but never had a paracentesis. She had also been
taking vitamin K. She has "coughed up" blood in the past and has
had bands placed once in the past.


Past Medical History:
1. Cirrhosis, diagnosed in last year per fiance. Initially there
was a question of Hep C, per him tests were first positive and
subsequently negative
2. Hx of VRE per chart
3. Hx "nonspecific colitis"
4. Hx C Diff
5. ? pancreatic mass


Social History:
Lives at home in [**Location (un) **] with fiance and four children (ages
17, 15, 14, and 12). Works as a deli clerk at local Stop & Shop.
Hx tobacco, 1 ppd but quit 3 years ago. Long alcohol hx, last
drink in [**Month (only) 404**] per fiance.

Family History:
NC

Physical Exam:
VS - T 98.4, BP 130s/60s, HR 90s-100s, RR 16, sats 97% on RA
Gen: Jaundiced, middle aged female, lying in bed. Minimally
interactive. AAOx3, but ? confabulating answers to some
questions.
HEENT: Sclera hemorrhagic. PERRL. ? strabismus.
Neck: No JVD. Central line on L.
CV: Tachy, reg, normal S1, S2. No m/r/g.
Lungs: CTA anteriorly, but decreased BS at bases.
Abd: Soft, mildly distended, nontender. + BS. No masses
appreciated. No rebound or guarding.
Ext: Mild edema bilaterally in LE. Appears volume overloaded on
exam, but not pitting edema. Feet very cool, 2+ DP/PT pulses
bilaterally. No clubbing or cyanosis.
Neuro: CN appear grossly intact, though able to fully assess.
Grip strong and symmetric. L sided weakness - LUE 4-/5 on
flexion/extension, vs 4+/5 on RUE. "too tired" to assess LE. Can
wiggle toes. Babinski equivocal bilaterally.
Skin: Profoundly jaundiced. No rashes


Pertinent Results:
LABS on admission:
WBC 2.6, Hct 26.3, MCV 91, Plt 104*
(DIFF: Neuts-68.5 Lymphs-21.5 Monos-3.9 Eos-5.9* Baso-0.2)
PT 20.1, PTT 35.9, INR 1.9
Na 136, K 5.7, Cl 110, HCO3 22, BUN 22, Cr 0.6, Glu 117
ALT 22, AST 76, LDH 146, AlkPhos 252, TBili 3.4
Albumin 1.7, Calcium 6.6, Phos 3.8, Mg 1.4
ABG: 7.39/41/100 on AC, 40% FiO2, Tv 550, PEEP 5, RR 15
Lactate 1.2
UA: Clear, LtAmb, USG 1.025, Blood TR, Nit NEG, Prot TR, Glu
NEG, Ket NEG, Bili NEG, Urobil NEG, pH 5.0, Leuks NEG, RBC 2,
WBC 0, Bact NONE, Epi 0, CastHy 2*
.
LABS during hospitalization:
[**2157-5-23**] 01:10PM BLOOD Vanco-53.6*
[**2157-5-28**] 06:15AM BLOOD Vanco-13.8*
.
[**2157-5-26**] T cell subset: WBC-3.9* Lymph-9.3* Abs [**Last Name (un) **]-363 CD3%-97
Abs CD3-352* CD4%-58 Abs CD4-209* CD8%-21 Abs CD8-77*
CD4/CD8-2.7
.
[**2157-5-13**] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE
[**2157-5-13**] HCV Ab-POSITIVE
[**2157-5-19**] HAV Ab-POSITIVE
[**2157-5-19**] HERPES SIMPLEX (HSV) 2, IGG-
[**2157-5-19**] HERPES SIMPLEX (HSV) 1, IGG-Test
[**2157-5-19**] AFP 1.0
[**2157-5-25**] CEA 2.8
[**2157-5-25**] CA [**70**]-9 -Test
[**2157-5-26**] VBG: 7.47/36/35/27
[**2157-5-26**] HEPATITIS Be ANTIBODY-PND
[**2157-5-26**] STRONGYLOIDES ANTIBODY,IGG-PND
[**2157-5-26**] HERPES 8 IgG ANTIBODY-PND
[**2157-5-26**] HEPATITIS Be ANTIGEN-PND
[**2157-5-27**] Serum Osmolality 317*
[**2157-5-28**] Iron 141, calTIBC 148, Ferritin 871, TRF 114, Hapto <20
[**2157-5-29**] TSH PND
[**2157-5-29**] Free T4 PND
.
Urine studies:
[**2157-5-23**] URINE Osmolal-335
[**2157-5-23**] URINE Creat 36, Na 83, K 22, Cl 82
[**2157-5-27**] 11:22PM URINE HISTOPLASMA ANTIGEN-PND
.
Ascites fluid:
[**2157-5-19**] WBC 125, RBC [**Numeric Identifier 24869**]
(DIFF: Polys 23, Lymphs 35, Monos 10, Eos 3, Mesothe 1,
Macrophages 28)
TotProt 1.0, Glucose 154, LDH 54, Albumin LESS THAN ASSAY
.
.
IMAGING:
[**2157-5-13**] ABD U/S: Four-quadrant ultrasound shows a trace of fluid
only, the largest pocket been identified in the right lower
quadrant. This is not suitable for planned paracentesis and no
spot was marked. Limited views of the liver show somewhat
nodular outline consistent with cirrhosis.
.
[**2157-5-13**] LIVER U/S: Pulsatile flow is demonstrated in the IVC and
major hepatic veins. The portal vein and hepatic arteries are
patent. The liver is shrunken and nodular, and ascites is
present. The common bile duct is not dilated, a stone is present
within the neck of the gallbladder. A 3.2-cm cyst is present in
the right lobe, unchanged.
IMPRESSION: Cirrhotic liver with ascites. Patent portal and
hepatic vessels
.
[**2157-5-17**] ABD U/S: Patent TIPS shunts with velocities ranging from
52-221 cm/sec. The hepatic venous velocities are rather high and
consequently a short-term followup study is recommended to
reevaluate and exclude the possibility of stenosis at the
hepatic venous stent.
.
[**2157-5-19**] RUE U/S: Right cephalic and brachial vein thrombosis.
.
[**2157-5-19**] ECHO:
1. The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%).
2. There is mild pulmonary artery systolic hypertension.
.
[**2157-5-21**] CXR: Endotracheal tube is approximately 3 cm above
carina. NG tube is in body of stomach. Left jugular CV line is
in mid SVC. No pneumothorax. Right lateral chest is not included
on the film. Persistent opacity consistent with atelectasis in
the left lower lobe is again demonstrated, slightly improved
since prior film of same date.
.
[**2157-5-22**] CT a/p:
1. Cirrhotic liver with portal hypertension.
2. Peripheral wedge-shaped hypoenhancing areas within the
spleen, likely infarcts.
3. There are no focal enhancing liver lesions.
4. Cholelithiasis.
5. TIPS in place.
6. Multiple enlarged portosystemic varices in the upper abdomen.

7. Replaced right hepatic artery arising from the SMA.
8. Enlarged lymph nodes as described much larger than we
typically see in patients with cirrhosis, does the patient has
any other underlying liver disease?
9. Hepatic cyst.
10. NG tube in place.
.
[**2157-5-24**] renal U/S: Normal-sized kidneys with no hydronephrosis.
.
[**2157-5-30**] CXR:
1. Worsening left retrocardiac opacity. Although possibly due to
a
combination of atelectasis and effusion, pneumonia should be
considered in the appropriate clinical setting.
2. Minimal hazy opacity in right upper lobe, for which an early
focus of pneumonia is not excluded.
.
[**2157-5-31**] PFTs: performed, report pending
.
[**2157-5-31**] LIVER U/S: There has been resolution/reabsorption of
nearly all of the ascites and there is insufficient amount for
ultrasound-guided paracentesis.
.
[**2157-6-3**] CXR:
1. Persistent left pleural effusion and left retrocardiac
opacity. Although this may represent a combination of
atelectasis and effusion, pneumonia should be considered in the
appropriate clinical setting.
2. Mild pulmonary interstitial edema.
3. No pneumothorax.
.
[**2157-6-3**] MANDIBLE XR/PANOREX: Limited study. No evidence of
fractures or gross bony abscess. Further characterization of the
dentition could be performed with a Panorex view if clinically
warranted.
.
[**2157-6-3**] COLONOSCOPY: Grade 1 external hemorrhoids, xanthomas in
sigmoid (which were biopsied), other normal colonoscopy to
cecum.


Brief Hospital Course:
51yo F w/ EtOH cirrhosis, s/p upper GIB from esophageal varices.
Underwent banding and TIPS procedure. MICU course complicated by
hemolytic anemia due to incorrect blood type during transfusion,
MRSA ventilator associated pneumonia, Klebsiella SBP, and now
acute renal failure likely due to CIN.
.
# RESP: Ms. [**Known lastname 67131**] was originally intubated for airway
protection at the OSH. After transfer here, while still
intubated, she developed fevers and infiltrates on CXR.
Endotracheal specimen revealed MRSA. A bronchoscopy was
performed and cultures revealed GPC and yeast. She was treated
with vancomycin and was able to be extubated on [**2157-5-23**].
Post-extubation, her respiratory status was stable. She had
albuterol inhalers prn, but did not need them. She was able to
use an incentive spirometer to help with her atelectasis. CXR
showed a persistent retrocardiac opacity but she was afebrile
and had no cough or sputum production, so antibiotics were never
restarted. Post-colonoscopy, she had decreased O2 sats but her
CXR showed only mild volume overload, so it was felt to be most
likely due to atelectasis/sedation from the procedure.
.
# CV: Ms. [**Known lastname 67131**] has no known cardiac history. EKG showed sinus
tach, with TWI in VI, TW flattening in III, aVF, but no ST
changes. Her ECHO shows hyperdynamic walls, with EF 75%, but no
WMA.
.
# ID: Ms. [**Known lastname 67131**] was febrile while in the MICU and the source
was not known. Urine grew VRE as well as yeast. Yeast cultures
were unable to be speciated. While in the MICU, she had a PICC
line for access, but it appeared infected with presumed septic
thrombi in superficial veins. Blood cultures were negative. The
PICC line was removed and a left IJ was placed instead.
Respiratory sources were considered, and she was treated with
vancomycin for a MRSA ventilator-associated pneumonia.
Vancomycin was used from [**5-15**] -> [**5-24**], and was discontinued once
she developed persistent renal failure. Her Cr became elevated
to such an extent that her vancomycin was able to be dosed by
level. Other sources were felt to be possible SBP given that a
peritoneal culture grew Klebsiella. For that, she was treated
with cefepime for 14 days ([**5-17**] -> [**5-31**]). Repeat paracentesis was
considered, but follow-up ultrasound showed that there was no
ascites. Once she completed the course of cefepime, she was
started on cipro per the liver team for SBP ppx. Both pneumovax
and dT were given on [**6-3**] as her immunization status was unable
to be obtained. She continued to have a retrocardiac opacity on
CXR, but no signs or symptoms of pneumonia. Stool cultures were
negative for Cdiff.
.
# RENAL: Ms. [**Known lastname 67131**] went into acute renal failure on [**2157-5-23**],
after undergoing a CT with contrast. Renal consulted on the
patient and felt that the most likely etiology to her acute
renal failure was contrast induced nephropathy. Hepatorenal
syndrome was considered, but was less likely given that her
urine lytes showed that she was not sodium avid. Octreotide and
midodrine were tried empirically, in case there was an element
of hepatorenal syndrome, but there was no improvement in renal
function with these medications so both were discontinued. A
tunnelled HD line was placed on [**6-3**] and hemodialysis was
started on [**6-4**].  On [**2157-6-5**] she underwent a combined
liver/renal transplant. Her renal graft began functioning soon
after implantation. Her creatinine trended down over time.
.
# HEME: On one transfusion, Ms. [**Known lastname 67131**] was given incorrectly
typed blood and developed hemolysis which likely decreased her
Hct and may have contributed to her jaundice. Her Hct reached a
nadir of 23 on [**6-1**] so she was given 1u pRBC which increased her
Hct appropriately to 27. However, it continued to slowly trend
down. She was given epogen at dialysis, but it appeared that she
was not responding to epogen.  During the course of her
transplant she recieved 3 L of cell [**Doctor Last Name 10105**], 18 units of FFP, 10
units of cells, 5 platelets, and 5 cryo. She was also transfused
on POD 1 with 4 PRBCs, 2 FPP, and 4 platelets for her acute
blood loss anemia.
.
#. Pancytopenia: This was felt to be due to a combination of
marrow suppression from alcohol abuse and cirrhosis. Her anemia
was also likely due to her massive GI bleed, hemolytic anemia,
and possibly renal failure. Her thrombocytopenia was monitored
daily and platelets were only transfused for bleeding or around
times of procedures.   On discharge her hematocrit, WBC, and
platelet counts were stable and appropriate.
.
# GI: Ms. [**Known lastname 67131**] had a severe variceal bleed at the OSH,
requiring 5u pRBC and 2u FFP. She underwent EGD and banding at
OSH with repeat EGD here (5 bands placed) as well as a TIPS
procedure. She was followed by the liver team here and was
placed on the transplant list. Her MELD score was 40 and she was
given supportive care while waiting for a transplant. Attempts
were made to complete all testing prior to transplant. A dental
evaluation was attempted on [**6-3**], but the patient was uanble to
fully cooperate. A mammogram was scheduled for [**6-6**]. Equipment
was needed in order to do a PAP, but was unable to be obtained
prior to her transplant. A PAP from several years ago was
negative. A colonoscopy was performed and was essentially
normal. Xanthomas were biopsied and removed, but the results
were pending upon transfer to the surgery service.
A liver/renal transplant became available to her on [**2157-6-5**].
Please see the operative note for further details. The patient
was taken intubed to the SICU from the OR. She was extubated on
POD 2. Over time her LFT's trended down and her encephalopathy
cleared. On POD6 her T Bili was acutely elevated and again rose
to 20.8 on POD 7. An ERCP was performed which demonstrated a
stricture at the common bile duct anasotomosis. A stent was
placed during this procedure. The following day her T Bili was
significantly decreased to 9.1 On dicharge her transaminases and
T Bili had normalized.
.
# NEURO: After being extubated and having her sedation weaned,
her mental status continued to be waxing and [**Doctor Last Name 688**]. It was
unclear if this was related to uremia and/or encephalopathy
(though she had no asterixis). She was continued on rifaximin
and lactulose for prevention of encephalopathy. Any medications
which could be altering her mental status were discontinued.
In the post-op period her encephalopathy cleared has her liver
function improved. On discharge she was alert, oriented,
understood why she had been hospitalized, and was able to take
an active role in her care. She continued to learn about her
medications and long-term needs.
.
# ENDOCRINE: Her hyperglycemia was likely due to her severe
illness. Her fingersticks were controlled with an insulin
sliding scale. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Diabetes center consult was obtained
post-opertively. Intermittantly she was on an insulin drip. On
dishcarge her blood glucose was controlled with glargine and
ISS.
.
# FEN: In the MICU, while intubated, she was given nutrition via
tube feeds in OG/NG tube. Once she was extubated, she was able
to take clears and her diet was advanced to solids upon transfer
to the floor. She was given [**First Name8 (NamePattern2) **] [**Doctor First Name **], renal diet with supplements.
She was not given IVF on the floor as her kidney function was
worsening and she was total body volume overloaded. Her
electrolytes were monitored daily and were repleted as needed to
keep her K >4 and Mg >2.
Post-operatively she was started on TPN on POD 1; however due to
access issues as well as her ability to take PO's this was
discontinued on POD 4. On discharge she was tolerating a regular
diet with good PO intake.
.
# ACCESS: She had a PICC line originally in MICU, but it was
removed due to concerns about infection. A left IJ was placed
[**5-19**] in the MICU. A tunneled HD catheter was placed [**6-2**].  The
LIJ was removed in the SICU once it stopped functioning. She was
maintained with peripheral access for the remainder of her
hospitalization.
.
# PPX: She was given pneumoboots for DVT prophylaxis (no heparin
given her low platelets). She was also given a PPI q12. No bowel
regimen was needed as she had profuse diarrhea.
.
# CODE: FULL
.
# DISPO: To rehab.
.


Medications on Admission:
Antibiotic - unknown which one
Vitamin K


Discharge Medications:
1. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours).
Disp:*15 Tablet(s)* Refills:*2*
2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): single strength.
Disp:*30 Tablet(s)* Refills:*2*
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 units
Injection [**Hospital1 **] (2 times a day): until ambulating.
Disp:*qs * Refills:*2*
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  QID
(4 times a day) as needed.
Disp:*qs * Refills:*0*
8. Ursodiol 300 mg Capsule Sig: 300 mg Capsules PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*2*
10. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
11. Insulin SS
please see attached sliding scale
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Outpatient Lab Work
please draw labs every monday and thursday.
needs ast,alt,ap,TB,cbc,chem10, tacro level


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
End-stage liver disease and end-stage renal disease.


Discharge Condition:
good


Discharge Instructions:
Take all medications as instructed.  Regular diet.  You may
resume activity as tolerated.

You may shower, then pat-dry incision.  Do not rub incision. No
tub baths or swimming for 3-4 weeks.
You may leave the incision uncovered or use a light dressing for
comfort.

* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to eat or drink
* Inability to pass gas or stool
* Redness/swelling/drainage from incisions
* Decreased urine output
* Other symptoms concerning to you

Followup Instructions:

[**Hospital **] clinic  [**Telephone/Fax (1) 673**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2157-6-23**] 1:40
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2157-6-30**] 2:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2157-7-7**] 1:00



Completed by:[**2157-6-17**]
{'Acute and subacute necrosis of liver,Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Acute kidney failure with lesion of tubular necrosis,Autoimmune hemolytic anemias,Urinary tract infection, site not specified,Methicillin susceptible pneumonia due to Staphylococcus aureus,Spontaneous bacterial peritonitis,Congestive heart failure, unspecified,End stage renal disease,Infection and inflammatory reaction due to other vascular device, implant, and graft,Pulmonary collapse,Acute posthemorrhagic anemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obstruction of bile duct,Portal hypertension,Other and unspecified alcohol dependence, in remission,Other drugs and medicinal substances causing adverse effects in therapeutic use,Mixed hyperlipidemia,Infection with microorganisms resistant to penicillins'}


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: 51 y/o F w/alcoholic cirrhosis, s/p banding of varices in last
year, who presented to [**Hospital 1562**] Hospital today after vomiting
bright red blood. While there, she vomited initially 700 cc BRB
and then 1500 cc during EGD. BP dropped as low as 80s but
responded with volume (received 500 NS, 1500 Hespan, 3 U PRBCs).
She was intubated for airway protection and a femoral line was
placed for access. She was placed on octreotide gtt and given
levofloxacin for prophylaxis. EGD demonstrated massive GI bleed
near GEJ likely from grade IV esohpageal varices, large amt of
fresh blood and clots. one column of varix had whitish spot.
Placed five bands at distal esophagus. She was transferred here
for ? TIPS.
.
Per her fiance, she was hospitalized one week ago for abdominal
pain and swelling. She was told she had an infection and was on
antibiotics, but never had a paracentesis. She had also been
taking vitamin K. She has "coughed up" blood in the past and has
had bands placed once in the past.

MEDICAL HISTORY: 1. Cirrhosis, diagnosed in last year per fiance. Initially there
was a question of Hep C, per him tests were first positive and
subsequently negative
2. Hx of VRE per chart
3. Hx "nonspecific colitis"
4. Hx C Diff
5. ? pancreatic mass

MEDICATION ON ADMISSION: Antibiotic - unknown which one
Vitamin K

ALLERGIES: Penicillins / Aspirin / Acetaminophen

PHYSICAL EXAM: VS - T 98.4, BP 130s/60s, HR 90s-100s, RR 16, sats 97% on RA
Gen: Jaundiced, middle aged female, lying in bed. Minimally
interactive. AAOx3, but ? confabulating answers to some
questions.
HEENT: Sclera hemorrhagic. PERRL. ? strabismus.
Neck: No JVD. Central line on L.
CV: Tachy, reg, normal S1, S2. No m/r/g.
Lungs: CTA anteriorly, but decreased BS at bases.
Abd: Soft, mildly distended, nontender. + BS. No masses
appreciated. No rebound or guarding.
Ext: Mild edema bilaterally in LE. Appears volume overloaded on
exam, but not pitting edema. Feet very cool, 2+ DP/PT pulses
bilaterally. No clubbing or cyanosis.
Neuro: CN appear grossly intact, though able to fully assess.
Grip strong and symmetric. L sided weakness - LUE 4-/5 on
flexion/extension, vs 4+/5 on RUE. "too tired" to assess LE. Can
wiggle toes. Babinski equivocal bilaterally.
Skin: Profoundly jaundiced. No rashes

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at home in [**Location (un) **] with fiance and four children (ages
17, 15, 14, and 12). Works as a deli clerk at local Stop & Shop.
Hx tobacco, 1 ppd but quit 3 years ago. Long alcohol hx, last
drink in [**Month (only) 404**] per fiance. 

### Response:
{'Acute and subacute necrosis of liver,Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Acute kidney failure with lesion of tubular necrosis,Autoimmune hemolytic anemias,Urinary tract infection, site not specified,Methicillin susceptible pneumonia due to Staphylococcus aureus,Spontaneous bacterial peritonitis,Congestive heart failure, unspecified,End stage renal disease,Infection and inflammatory reaction due to other vascular device, implant, and graft,Pulmonary collapse,Acute posthemorrhagic anemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obstruction of bile duct,Portal hypertension,Other and unspecified alcohol dependence, in remission,Other drugs and medicinal substances causing adverse effects in therapeutic use,Mixed hyperlipidemia,Infection with microorganisms resistant to penicillins'}
