CHIEF COMPLAINT: variceal bleeding

PRESENT ILLNESS: Mr [**Known lastname 25699**] is a pleasant 85 yo gentleman with history of
esophageal varices s/p banding, Hep B, alcoholic cirrhosis who
admitted to [**Hospital3 **] hospital on [**2143-3-13**] for acute
variceal bleeding. Pt states that he was at home when he first
noticed bleeding from his nose. This was followed by bloody
emesis and bright red blood in his stools. At the OSH, he
received 4 U PRBCs on the 9th, 1 on the 10th, 1 on the 11th, and
crit was subsequently stable in low 30s since the 12th. Repeat
endoscopy was performed today with additional banding. He was
treated with protonix, octreotide and vasopressin. He was also
treated with nadolol, which could not be uptitrated due to
bradycardia. During the hospitalization he underwent
paracentesis and was negative for SBP. He was transferred to [**Hospital1 **]
for TIPS procedure given recurrent bleeding with banding. He was
transferred directly to the MICU.

MEDICAL HISTORY: - Hepatitis B-diagnosed [**2140**], + varices, ? EtOH related, childs
B/C cirrhosis
- Recent hospitalization [**2143-2-28**] for varices, recieved 4 u PRBCs
at that time
- Hypertension
- Pancytopenia
- Bradycardia while sleeping

MEDICATION ON ADMISSION: 1. ASA 81 mg daily
2. Lisinopril 5 MG daily
3. Omeprazole 20 mg [**Hospital1 **]
4. Spironolactone 25 mg [**Hospital1 **]
5. Nadolol 40 mg daily
6. Metoprolol ER 25 mg daily

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T:97 BP:144/65 P:56 R: 18 O2: 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, dull to percussion
laterally, bowel sounds present, no rebound tenderness or
guarding,
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: aao x3, CNs [**2-16**] intact, motor function grossly normal
.
DISCHARGE EXAM:
BP 97/52-110/64  HR 58-64
94% on RA

FAMILY HISTORY: Unknown, non-contributory

SOCIAL HISTORY: Social History: Works at shaws, lives alone but gets assistance
from his daughter
- [**Name (NI) 1139**]: none recently, history of [**1-6**] ppd since teenager
- Alcohol: denies, last drink 5 yrs ago
- Illicits: none
Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Esophageal varices in diseases classified elsewhere, with bleeding,Portal hypertension,Other ascites,Cirrhosis of liver without mention of alcohol,Unspecified essential hypertension,Thrombocytopenia, unspecified,Myelodysplastic syndrome, unspecified
Hpt B chrn wo cm wo dlta,Bleed esoph var oth dis,Portal hypertension,Ascites NEC,Cirrhosis of liver NOS,Hypertension NOS,Thrombocytopenia NOS,Myelodysplastic synd NOS
Admission Date:  [**2143-3-18**]              Discharge Date:   [**2143-3-23**]

Date of Birth:  [**2057-6-18**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
variceal bleeding

Major Surgical or Invasive Procedure:
Endoscopy with variceal banding


History of Present Illness:
Mr [**Known lastname 25699**] is a pleasant 85 yo gentleman with history of
esophageal varices s/p banding, Hep B, alcoholic cirrhosis who
admitted to [**Hospital3 **] hospital on [**2143-3-13**] for acute
variceal bleeding. Pt states that he was at home when he first
noticed bleeding from his nose. This was followed by bloody
emesis and bright red blood in his stools. At the OSH, he
received 4 U PRBCs on the 9th, 1 on the 10th, 1 on the 11th, and
crit was subsequently stable in low 30s since the 12th. Repeat
endoscopy was performed today with additional banding. He was
treated with protonix, octreotide and vasopressin. He was also
treated with nadolol, which could not be uptitrated due to
bradycardia. During the hospitalization he underwent
paracentesis and was negative for SBP. He was transferred to [**Hospital1 **]
for TIPS procedure given recurrent bleeding with banding. He was
transferred directly to the MICU.

Past Medical History:
- Hepatitis B-diagnosed [**2140**], + varices, ? EtOH related, childs
B/C cirrhosis
- Recent hospitalization [**2143-2-28**] for varices, recieved 4 u PRBCs
at that time
- Hypertension
- Pancytopenia
- Bradycardia while sleeping


Social History:
Social History: Works at shaws, lives alone but gets assistance
from his daughter
- [**Name (NI) 1139**]: none recently, history of [**1-6**] ppd since teenager
- Alcohol: denies, last drink 5 yrs ago
- Illicits: none


Family History:
Unknown, non-contributory

Physical Exam:
ADMISSION EXAM:
Vitals: T:97 BP:144/65 P:56 R: 18 O2: 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, dull to percussion
laterally, bowel sounds present, no rebound tenderness or
guarding,
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: aao x3, CNs [**2-16**] intact, motor function grossly normal
.
DISCHARGE EXAM:
BP 97/52-110/64  HR 58-64
94% on RA

Pertinent Results:
ADMISSION LABS:
[**2143-3-18**] 10:02PM GLUCOSE-114* UREA N-17 CREAT-0.8 SODIUM-135
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-27 ANION GAP-8
[**2143-3-18**] 10:02PM estGFR-Using this
[**2143-3-18**] 10:02PM ALT(SGPT)-42* AST(SGOT)-68* ALK PHOS-174* TOT
BILI-2.7*
[**2143-3-18**] 10:02PM ALBUMIN-2.4* CALCIUM-7.5* PHOSPHATE-2.3*
MAGNESIUM-1.8
[**2143-3-18**] 10:02PM WBC-7.9 RBC-3.63* HGB-11.6* HCT-33.6* MCV-93
MCH-31.9 MCHC-34.5 RDW-19.8*
[**2143-3-18**] 10:02PM NEUTS-89* BANDS-0 LYMPHS-2* MONOS-5 EOS-3
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2143-3-18**] 10:02PM HYPOCHROM-NORMAL ANISOCYT-2+
POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+
OVALOCYT-OCCASIONAL ACANTHOCY-OCCASIONAL
[**2143-3-18**] 10:02PM PLT SMR-VERY LOW PLT COUNT-72*
[**2143-3-18**] 10:02PM PT-15.6* PTT-30.4 INR(PT)-1.4*
.
EKG: [**2143-3-12**]-atrial bigeminy with occasional PVCs, inferior q
waves, no ST changes, tw flattening in V4-V6.
.
MICROBIOLOGY:
[**2143-3-19**] HBV Viral Load: <40
HepBe Ag Neg, HepBe Ab Reactive
.
Echo:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal inferior dyskinesis. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is borderline pulmonary artery systolic hypertension. There is
no pericardial effusion.
.
Abd U/S:
IMPRESSION:

1. Cirrhotic liver without focal lesion identified.
2. Moderate abdominal ascites.
3. Cholelithiasis.
4. Patency of the hepatic vasculature as described.
.
Discharge labs:
[**2143-3-23**] 05:15AM BLOOD WBC-6.4 RBC-3.18* Hgb-10.7* Hct-30.5*
MCV-96 MCH-33.6* MCHC-35.0 RDW-20.0* Plt Ct-71*
[**2143-3-23**] 05:15AM BLOOD PT-16.6* PTT-32.1 INR(PT)-1.5*
[**2143-3-23**] 05:15AM BLOOD Glucose-151* UreaN-25* Creat-0.8 Na-136
K-4.2 Cl-103 HCO3-28 AnGap-9
[**2143-3-23**] 05:15AM BLOOD ALT-29 AST-48* AlkPhos-166* TotBili-1.2

Brief Hospital Course:
ASSESSMENT AND PLAN:
85yoM with h/o Hepatitis B/EtOH Cirrhosis (c/b portal
hypertension w/ bleeding esophageal varices s/p banding and
ascites), HTN, ?[**Hospital 90129**] transferred from [**Hospital3 1443**] Hospital
on [**3-18**] for GI bleeding despite banding, s/p endoscopy on [**3-22**]
with banding.
.
#. Variceal Bleed: Patient had received 4U of blood at the
outside hospital prior to transfer. He had also had endoscopies
performed on [**3-13**] and [**3-18**], both with banding of varices. He was
transferred for consideration of TIPS procedure, however, this
was not performed out of concern for the risks of hepatic
decompensation, encephalopathy, and other complications related
to patient's advanced age. The patient remained stable after
overnight observation in the ICU and was called out to the floor
on the following day. Hct remained stable on the floor ~ 30. The
patient was monitored on telemetry and showed no hemodynamic
instability. He did not require blood transfusion. There were no
further signs of bleeding. Nadolol 20 mg [**Hospital1 **] was started. The
patient was initially on an octreotide and pantoprazole drip.
These were stopped as bleeding resolved. The patient completed 5
days of ceftriaxone for SBP prophylaxis after bleed. He was
discharged on pantoprazole 40 mg per day x 4 weeks and
sucralfate 1 mg QID x 2 weeks. Repeat endoscopy was performed on
[**3-22**], which showed band ulcers, and 1 grade II varix, which was
banded. The patient was scheduled for repeat endoscopy at [**Hospital1 18**]
on [**5-14**] with Dr. [**Last Name (STitle) **] and with follow-up in Dr.[**Name (NI) 37751**] clinic.
Aspirin was stopped - this medication should be discussed with
the [**Name6 (MD) 228**] primary MD.
.
#. Hepatitis B/alcoholic cirrhosis c/b variceal bleeding. MELD
11. Inactive carrier of HepB. HepB VL returned at less than 40.
HepBe Ag negative and Ab postive. The patient was encouraged to
continue his abstinence from alcohol. Nadolol was started as
above. Spironolactone was increased to 100 mg per day and lasix
was started at 40 mg per day. The patient will need weekly chem7
to check potassium and creatinine while on diuretics until
values are stable.
.
# MDS: Listed on outside hospital records. Thrombocytopenia
likely due to cirrhosis from splenic sequestration. The patient
will need outpatient f/u for this issue.
.
#. VRE rectal swab ordered
.
# DVT prophylaxis was with pneumoboots.
# Communication: daughter [**Name (NI) **]: [**Telephone/Fax (1) 90130**], [**Telephone/Fax (1) 90131**]
.
Transitional Issues:
- continue protonix x 4 weeks, sucralfate x 2 weeks
- repeat endoscopy on [**5-14**], f/u in Dr.[**Name (NI) 37751**] clinic
- discussion re: aspirin
- dicussion of diuretics

Medications on Admission:
1. ASA 81 mg daily
2. Lisinopril 5 MG daily
3. Omeprazole 20 mg [**Hospital1 **]
4. Spironolactone 25 mg [**Hospital1 **]
5. Nadolol 40 mg daily
6. Metoprolol ER 25 mg daily


Discharge Medications:
1. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months: Last day is [**2143-4-17**].
5. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 2 weeks: Last day is [**4-5**].
6. Outpatient Lab Work
Repeat Chem7 in 1 week on [**3-28**] to check potassium.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 3137**] Care Center - [**Location (un) 1468**]

Discharge Diagnosis:
Primary:
Esophageal variceal bleed
Hepatitis B/ Alcoholic cirrhosis
.
Secondary:
Possible MDS
Hypertension


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for an esophageal variceal
bleed. You were observed briefly in the intensive care unit
where your blood count and blood pressure were stable. You had
no further episodes of bleeding. You received a blood
transfusion at the outside hospital but not at [**Hospital1 18**]. We
performed an endoscopy, which showed an additional enlarged vein
in your esophagus - a band was placed. The enlarged veins are
due to your liver disease - it is extremely important that you
not drink alcohol because this can worsen your liver disease.
.
We started new medicines to help prevent another bleed in the
future. You will need to have a repeat endoscopy - information
for this is listed below. You should also follow-up with Dr.
[**Last Name (STitle) **] as an outpatient.
.
We made the following changes to your medications:
We STOPPED Aspirin - you should restart this medication at the
discretion of your primary MD
We STOPPED Lisinopril
We STOPPED Omeprazole
We STARTED Nadolol 20 mg twice per day (to prevent bleeding)
We STARTED Pantoprazole 40 mg once per day for the next month
We STARTED Sucralfate - 4 times per day for the next 2 weeks
.
Your follow-up information is listed below.

Followup Instructions:
Department: LIVER CENTER
When: WEDNESDAY [**2143-5-29**] at 1:20 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
.
We are also working to schedule you for a repeat endoscopy. This
is planned tentatively for [**2143-5-14**]. You will receive a
phone call about this appointment. If you do not hear about this
appointment in the next week, you should call Dr.[**Name (NI) 37751**] office
at [**Telephone/Fax (1) 2422**] to make sure the repeat endoscopy is scheduled.


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
{'Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Esophageal varices in diseases classified elsewhere, with bleeding,Portal hypertension,Other ascites,Cirrhosis of liver without mention of alcohol,Unspecified essential hypertension,Thrombocytopenia, unspecified,Myelodysplastic syndrome, unspecified'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: variceal bleeding

PRESENT ILLNESS: Mr [**Known lastname 25699**] is a pleasant 85 yo gentleman with history of
esophageal varices s/p banding, Hep B, alcoholic cirrhosis who
admitted to [**Hospital3 **] hospital on [**2143-3-13**] for acute
variceal bleeding. Pt states that he was at home when he first
noticed bleeding from his nose. This was followed by bloody
emesis and bright red blood in his stools. At the OSH, he
received 4 U PRBCs on the 9th, 1 on the 10th, 1 on the 11th, and
crit was subsequently stable in low 30s since the 12th. Repeat
endoscopy was performed today with additional banding. He was
treated with protonix, octreotide and vasopressin. He was also
treated with nadolol, which could not be uptitrated due to
bradycardia. During the hospitalization he underwent
paracentesis and was negative for SBP. He was transferred to [**Hospital1 **]
for TIPS procedure given recurrent bleeding with banding. He was
transferred directly to the MICU.

MEDICAL HISTORY: - Hepatitis B-diagnosed [**2140**], + varices, ? EtOH related, childs
B/C cirrhosis
- Recent hospitalization [**2143-2-28**] for varices, recieved 4 u PRBCs
at that time
- Hypertension
- Pancytopenia
- Bradycardia while sleeping

MEDICATION ON ADMISSION: 1. ASA 81 mg daily
2. Lisinopril 5 MG daily
3. Omeprazole 20 mg [**Hospital1 **]
4. Spironolactone 25 mg [**Hospital1 **]
5. Nadolol 40 mg daily
6. Metoprolol ER 25 mg daily

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T:97 BP:144/65 P:56 R: 18 O2: 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, dull to percussion
laterally, bowel sounds present, no rebound tenderness or
guarding,
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: aao x3, CNs [**2-16**] intact, motor function grossly normal
.
DISCHARGE EXAM:
BP 97/52-110/64  HR 58-64
94% on RA

FAMILY HISTORY: Unknown, non-contributory

SOCIAL HISTORY: Social History: Works at shaws, lives alone but gets assistance
from his daughter
- [**Name (NI) 1139**]: none recently, history of [**1-6**] ppd since teenager
- Alcohol: denies, last drink 5 yrs ago
- Illicits: none 

### Response:
{'Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Esophageal varices in diseases classified elsewhere, with bleeding,Portal hypertension,Other ascites,Cirrhosis of liver without mention of alcohol,Unspecified essential hypertension,Thrombocytopenia, unspecified,Myelodysplastic syndrome, unspecified'}
