CHIEF COMPLAINT: rectal bleeding

PRESENT ILLNESS: 75 yoM w/ h/o esophageal cancer s/p chemo and radiation, portal
hypertension/cirrhosis [**1-16**] EtOH w/ h/o variceal blead [**2177**],
recently dx HCC s/p chemoembolisation [**2199-3-5**] who presents s/p
syncope. Pt was on his way to outpt appointment when collapsed;
LOC ~ 1 min. No head trauma. No witnessed seizure activity. Pt
transported to ED where HR 80, sbp 70. He was noted to have a
melena/BRBPR in ED, and pt reported that he had noted several
episodes of melena for the last 5 days (unable to quantify exact
amount and frequency). He also reported significant NSAID use
(ibuprofen 2 tablets QID) In ED initial HCT 16.0; pt received 6
u PRBC, 3 u FFP, 2 L NS, protonix 40 mg IV X 1, octreotide gtt;
f/u HCT 14.2. Given persistent hypotension, he was started on a
dopamine gtt; received levofloxacin 500 mg IV X 1 and
metronidazole 500 mg IV X 1. Pt had EGD in ED which showed no
evidence of active bleeding; portal gastropathy, esophageal
varices, and small AVM in stomach were noted. Currently pt is
sedated following EGD, and further history is obtained from his
children. They report that he has had frequent loose BM
(~10/day) for the last 10 days and reported mild nausea
(although no significant vomiting) and bloating/abdominal
distension. No F/C/R. (+) decreased appetite/PO intake.

MEDICAL HISTORY: 1) Esophageal cancer dx [**4-17**]
- [**2198-5-3**] EGD: 3 cords grade II varices in lower 3rd of
esophagus; stricture @ 26 cm w/ contact bleeding; EUS c/w T3N1Mx

MEDICATION ON ADMISSION: 1) tylenol prn
2) Prilosec 20 mg PO daily
3) Atenolol 25 mg PO daily
4) Benadryl 25 mg PO QID prn
5) Advil [**12-16**] tab QID
6) FeSO4 325 mg PO daily
7) zantac 150 mg PO BId
8) Dilaudid 2 mg PO q6h prn
9) Aranesp (last dose 3/10)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals on admit to MICU: Tc 96.8, pc 80, bpc 119/42, resp 12,
100% NRB
Vitals on transfer to medicine floor: 63   138/67   14   100% on
2L
Gen: lying in reclining chair, A+Ox3, somnolent but arousable to
voice, following commands, NAD
HEENT: anicteric, pupils small and minimally responsive, EOM
slow to react, MMM, OP clear with no subungal jaundice, neck
supple, +JVD, +hepatojugular reflux, +flushed face
Chest: RSC portocath C/D/I; lungs with decreased BS at bases b/l
c/w small lung volumes, no wheezing, rhonchi or rales
Cardiac: RRR, no M/R/G
Abd: obese, markedly distended but soft; liver edge 3 cm below
RCM, NABS; no caput
Genitalia: +scrotal edema
Ext: No C/C/E, +trace LE edema b/l, 1+ DP bilaterally
Neuro: CN II-XII intact though pupils minimally reactive;
sensation to LT intact throughout, 5/5 strength in UE/LE b/l;
+asterixis; no tongue fasciculations; linear TP, somnolent but
pleasant affect

FAMILY HISTORY: Grandfather died of unknown cancer. Brother w/ "heart disease."
sister w/ breast CA

SOCIAL HISTORY: h/o heavy EtOH use; sober [**2176**]-[**2189**]; resumed EtOH; last drink
[**12-19**]. Quit tobacco 35 yrs ago ([**2-15**] ppd 30 yrs). Prior fishmarked
owner. Married and lives w/ wife
Esophageal varices with bleeding,Other shock without mention of trauma,Malignant neoplasm of liver, primary,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of bone and bone marrow,Acidosis,Acute kidney failure, unspecified,Stricture and stenosis of esophagus,Portal hypertension,Acute posthemorrhagic anemia,Personal history of malignant neoplasm of esophagus,Angiodysplasia of intestine (without mention of hemorrhage)
Esophag varices w bleed,Shock w/o trauma NEC,Mal neo liver, primary,Secondary malig neo lung,Secondary malig neo bone,Acidosis,Acute kidney failure NOS,Esophageal stricture,Portal hypertension,Ac posthemorrhag anemia,Hx-esophageal malignancy,Angio intes w/o hmrhg
Admission Date:  [**2199-3-14**]              Discharge Date:   [**2199-3-21**]

Date of Birth:  [**2123-7-5**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
rectal bleeding

Major Surgical or Invasive Procedure:
Upper endoscopy x 2
Colonoscopy


History of Present Illness:
75 yoM w/ h/o esophageal cancer s/p chemo and radiation, portal
hypertension/cirrhosis [**1-16**] EtOH w/ h/o variceal blead [**2177**],
recently dx HCC s/p chemoembolisation [**2199-3-5**] who presents s/p
syncope. Pt was on his way to outpt appointment when collapsed;
LOC ~ 1 min. No head trauma. No witnessed seizure activity. Pt
transported to ED where HR 80, sbp 70. He was noted to have a
melena/BRBPR in ED, and pt reported that he had noted several
episodes of melena for the last 5 days (unable to quantify exact
amount and frequency). He also reported significant NSAID use
(ibuprofen 2 tablets QID) In ED initial HCT 16.0; pt received 6
u PRBC, 3 u FFP, 2 L NS, protonix 40 mg IV X 1, octreotide gtt;
f/u HCT 14.2. Given persistent hypotension, he was started on a
dopamine gtt; received levofloxacin 500 mg IV X 1 and
metronidazole 500 mg IV X 1. Pt had EGD in ED which showed no
evidence of active bleeding; portal gastropathy, esophageal
varices, and small AVM in stomach were noted. Currently pt is
sedated following EGD, and further history is obtained from his
children. They report that he has had frequent loose BM
(~10/day) for the last 10 days and reported mild nausea
(although no significant vomiting) and bloating/abdominal
distension. No F/C/R. (+) decreased appetite/PO intake.

In MICU, pt received the last 3 units of his total 9 units
PRBCs, was a total of 12L positive so far over length of stay,
had colonscopy that did not reveal a bleeding source though was
notable for a diverticulum, polyps in the distal descending
colon, angioectasias in the ascending colon, transverse colon
and mid-descending colon (thermal therapy), grade 2 internal
hemorrhoids. Patient's hct remained stable after his initial
presentation, though he continues to have melanotic stools. Also
of note, patient's mental status has waxed and waned over
admission, worsened over the last night in the setting of
receiving Ativan and Ambien. Required 1:1 sitter while in MICU,
patient's family says he is somewhat of a "fighter" at baseline,
but that he worsened in the last 24h since the above meds were
given. Has had mild pain controlled with Tylenol, low dose given
hepatic dysfunction. INR has come down with Vit K, FFP.


Past Medical History:
1) Esophageal cancer dx [**4-17**]
- [**2198-5-3**] EGD: 3 cords grade II varices in lower 3rd of
esophagus; stricture @ 26 cm w/ contact bleeding; EUS c/w T3N1Mx

- [**2198-8-21**] EGD: - s/p cisplatin and 5FU w/ concurrent radiation
therapy completed [**7-18**]
- no evidence of residual disease by EGD [**2198-8-21**]
-> 2 cords grade II varices in lower third of esophagus with
esophageal stenosis at 23 cm
-> bx not c/w cancer; likely represents radiation changes
2) cirrhosis (attributed to EtOH) w/ h/o variceal bleed [**2177**] s/p
cautery
3) HCC dx [**1-19**]
- s/p chemoembolization
4) Arthritis
5) Seasonal allergies


Social History:
h/o heavy EtOH use; sober [**2176**]-[**2189**]; resumed EtOH; last drink
[**12-19**]. Quit tobacco 35 yrs ago ([**2-15**] ppd 30 yrs). Prior fishmarked
owner. Married and lives w/ wife

Family History:
Grandfather died of unknown cancer. Brother w/ "heart disease."
sister w/ breast CA

Physical Exam:
Vitals on admit to MICU: Tc 96.8, pc 80, bpc 119/42, resp 12,
100% NRB
Vitals on transfer to medicine floor: 63   138/67   14   100% on
2L
Gen: lying in reclining chair, A+Ox3, somnolent but arousable to
voice, following commands, NAD
HEENT: anicteric, pupils small and minimally responsive, EOM
slow to react, MMM, OP clear with no subungal jaundice, neck
supple, +JVD, +hepatojugular reflux, +flushed face
Chest: RSC portocath C/D/I; lungs with decreased BS at bases b/l
c/w small lung volumes, no wheezing, rhonchi or rales
Cardiac: RRR, no M/R/G
Abd: obese, markedly distended but soft; liver edge 3 cm below
RCM, NABS; no caput
Genitalia: +scrotal edema
Ext: No C/C/E, +trace LE edema b/l, 1+ DP bilaterally
Neuro: CN II-XII intact though pupils minimally reactive;
sensation to LT intact throughout, 5/5 strength in UE/LE b/l;
+asterixis; no tongue fasciculations; linear TP, somnolent but
pleasant affect

Pertinent Results:
Recent labs:
[**2199-3-21**] 05:41AM BLOOD WBC-4.6 RBC-3.03* Hgb-9.2* Hct-27.6*
MCV-91 MCH-30.5 MCHC-33.4 RDW-18.3* Plt Ct-151
[**2199-3-21**] 05:41AM BLOOD Plt Ct-151
[**2199-3-21**] 05:41AM BLOOD Glucose-123* UreaN-11 Creat-0.6 Na-135
K-3.4 Cl-98 HCO3-32* AnGap-8
[**2199-3-20**] 04:01AM BLOOD ALT-34 AST-70* LD(LDH)-286* AlkPhos-198*
TotBili-1.3
[**2199-3-21**] 05:41AM BLOOD Calcium-7.8* Phos-2.1*# Mg-1.4*
[**2199-3-20**] 04:01AM BLOOD Albumin-2.4* Calcium-7.4* Phos-3.7 Mg-1.6
[**2199-3-20**] 04:01AM BLOOD Ammonia-<6
[**2199-3-21**] 11:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2199-3-21**] 11:30AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2199-3-21**] 11:30AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2199-3-20**] 06:36PM ASCITES WBC-8* RBC-1381* Polys-27* Lymphs-46*
Monos-11* Mesothe-7* Macroph-9*
[**2199-3-20**] 06:36PM ASCITES Albumin-<1.0
[**2199-3-17**] 04:25AM BLOOD WBC-7.4 RBC-3.51* Hgb-10.3* Hct-30.8*
MCV-88 MCH-29.4 MCHC-33.5 RDW-18.6* Plt Ct-159
[**2199-3-17**] 04:25AM BLOOD PT-14.2* PTT-30.6 INR(PT)-1.3
[**2199-3-17**] 04:25AM BLOOD Glucose-120* UreaN-24* Creat-0.6 Na-136
K-3.5 Cl-105 HCO3-25 AnGap-10
[**2199-3-16**] 02:29AM BLOOD ALT-41* AST-52* AlkPhos-135* TotBili-3.4*
[**2199-3-15**] 01:06AM BLOOD ALT-51* AST-68* LD(LDH)-336* AlkPhos-144*
Amylase-49 TotBili-4.3* DirBili-1.9* IndBili-2.4
[**2199-3-15**] 01:06AM BLOOD Lipase-49
[**2199-3-17**] 04:25AM BLOOD Mg-1.6
[**2199-3-16**] 02:29AM BLOOD Calcium-7.5* Phos-2.4
[**2199-3-14**] 01:16PM BLOOD Albumin-2.2*
[**2199-3-15**] 01:06AM BLOOD Hapto-159
[**2199-3-14**] 12:30PM BLOOD TSH-6.0*
[**2199-3-14**] 12:30PM BLOOD T4-4.7
[**2199-3-14**] 12:30PM BLOOD AFP-1187*
[**2199-3-15**] 01:26AM BLOOD freeCa-1.07*
[**2199-3-14**] 09:38PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2199-3-14**] 09:38PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG
[**2199-3-14**] 09:38PM URINE RBC-[**2-16**]* WBC-0 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2199-3-14**] 09:38PM URINE Eos-NEGATIVE
[**2199-3-14**] 09:38PM URINE Hours-RANDOM Creat-67 Na-50

Micro:
[**2199-3-21**] URINE INPATIENT no growth
[**2199-3-18**] SPUTUM INPATIENT contamination
[**2199-3-15**] BLOOD CULTURE INPATIENT no growth
[**2199-3-14**] BLOOD CULTURE INPATIENT no growth
[**2199-3-14**] URINE INPATIENT no growth

Reports:
[**2199-3-21**]  CXR:
1) Interval resolution of the right upper lobe partial
atelectasis and/or infiltration.
2) Minimal degree of left lower lobe infiltration, unchanged. No
evidence of new infiltration or pulmonary congestion.

[**2199-3-20**]  Abd ultrasound:
FINDINGS: Four quadrant ultrasound of the abdomen demonstrates a
moderate amount of ascites. An appropriate spot within the right
lower quadrant of the abdomen was marked for the ordering
service, for the purpose of paracentesis.

[**2199-3-17**]  CHEST, SINGLE AP FILM:
History of GI bleed with wheezing. There are low lung volumes.
Right subclavian CV line has tip located in region of cavoatrial
junction. Allowing for technique, heart size is within normal
limits and there is no evidence for CHF. Lungs are grossly
clear.

[**2199-3-15**]  ECG:  Sinus rhythm. Compared to the previous tracing the
rate has slowed slightly.  T waves have normalized in the
inferior leads. ST-T wave abnormalities have normalized in leads
V4-V6. T wave inversions remain in leads V2-V3.

[**2199-3-15**]  CT abd/pelv:
IMPRESSION:
1. Interval development of a fair amount of fluid within the
abdomen and pelvis, which measures Hounsfield units consistent
with simple fluid or ascites. Clinical correlation is requested.
Low attenuation hemoperitoneum is rarely seen on CT, but there
is no sentinel clot sign as described above to indicate bleeding
from solid organs. Note that it is somewhat atypical for simple
ascitic fluid to collect in the right anterior pararenal space
and about the cecum and proximal ascending colon.
2. The appearance of the liver parenchyma is unchanged from
[**3-6**].
3. There is interval development of small bilateral pleural
effusions.

[**2199-3-14**]  GI Bleeding study
IMPRESSION: 1) No active bleeding within the bowel. 2) Findings
to suggest the possibility of a hematoma within the right upper
quadrant. This is possibly a nonspecific finding in light of
patient's recent chemo embolization. Clinical correlation is
requested.


Brief Hospital Course:
75 yoM with h/o esophgeal CA, variceal bleed, HCC s/p recent
chemoembolization presents s/p syncopal episode w/BRBPR and
melena.
.
GI bleed: felt to be most likely UGIB from esoph varices, though
EGD was not entirely clear as bleeding had stopped. DDx also
included PUD, gastric AVM, portal gastropathy, small bowel
neoplasm, diverticular bleed, colonic AVM, hematobilia (given
recent chemoembolization). Colonoscopy, bleeding scan, CT scan
of abdomen and EGD did not reveal bleeding lesion though EGD
showed varices that appeared to have bleed sometime recently.
Hct was fairly stable after receiving 9 units of PRBCs and 3
Units FFP, though the patient did get one more unit of PRBCs
after transfer to the medical floor for hct<28.  He was
continued on IV protonix [**Hospital1 **] and octreotide gtt initially, and
an attempt was made at banding his varices though this was not
successful secondary to an esoph stricture that limited passage
of the banding device.  He will follow up with Dr. [**First Name (STitle) 679**] on an
outpatient basis and will need his hct followed closely after
discharge.
.
Wheezing: developed while in the MICU after fluid resuscitation,
likely from lung compression by ascites + some element of
cardiac asthma. He responded well to lasix while in the unit,
and was continued on Lasix 40mg po qd while on the floor with a
goal -1L/day until he became volume contracted. Of note, he was
13L positive after agressive resuscitation in MICU. His wheezing
went away after diuresis and subsequent paracentesis.
.
ARF: Cr 5.1 on admit from baseline 0.7 [**2199-3-6**], felt to be
primarily prerenal with drop to 0.6 after volume resuscitation.
.
Hypotension: on admit, resolved with IVF, likely secondary to
volume depletion in setting of GI bleed.
.
Coagulopathy: may be secondary to Vit K deficiency (given poor
PO intake), decreased synthetic function given HCC and recent
chemoembolization, massive transfusion of PRBC. Cont Vit K 5 mg
SC X 3 days, gave FFP x 3 while in unit to correct INR to <1.4.
.
AG acidosis: on admit, likely secondary to increased lactate and
prerenal ARF from hypoperfusion, resolved with IVF.
.
Altered mental status: developed while in the unit in the
setting of Ativan, Ambien, Zyprexa given on one night. It was
felt unlikely to be from infection as his WBC count was normal,
he had no fever, his UA was negative, his CXR clear, blood cx
without growth. All sedating meds were held initially, his
mental status cleared, and then low dose (5mg) Ambien was used
as needed to help him sleep, at the patient's request.
.
h/o EtOH abuse: reportedly no EtOH since [**12-19**]. Gave thiamine and
folate. Monitored closely for evidence of withdrawal with Ativan
prn CIWA scale but no evid of withdrawal while in house.
.
Oncology: h/o esophageal cancer, hepatoma;  possible multiple
pulmonary mets, spinal mets, ileum mets on recent CT (although
atypical spread for both esophageal cancer and hepatoma). Will
need further w/u as outpatient once clinically stabilized.
.
Communication: Daughter [**Name (NI) 622**]
.
Code: Full code; confirmed w/ HCP [**Name (NI) 622**] [**Name (NI) 55451**]
([**Telephone/Fax (1) 55452**]). Discussed pt situation at length with daughter
[**Name (NI) 622**] on [**2199-3-17**]. Pt and family are aware of pt's guarded
prognosis. Per daughter pt has been a "fighter" and states that
he is "on his 7th out of 9 lives".  Also has stated that "every
day extra is a gift". He has also made it clear that he does not
want extreme measures to be taken if the cause of his demise is
irreversible. He is agreeable to intubation and cardioversion
only if there is a strong chance of recovery. If it is known
that his emobolization procedure is ineffective and there is
nothing else that can be done to save his liver the family is
comfortable with taking him home and making him comfortable.

Medications on Admission:
1) tylenol prn
2) Prilosec 20 mg PO daily
3) Atenolol 25 mg PO daily
4) Benadryl 25 mg PO QID prn
5) Advil [**12-16**] tab QID
6) FeSO4 325 mg PO daily
7) zantac 150 mg PO BId
8) Dilaudid 2 mg PO q6h prn
9) Aranesp (last dose 3/10)

Discharge Medications:
1. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 MDI* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*2*
9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Blood loss anemia
Hypovolemic shock
GI bleed, likely esophageal variceal bleed
Altered mental status
Respiratory distress
Acute renal failure
Coagulopathy
Acidosis, anion gap
h/o etoh abuse
Liver failure
Portal hypertension


Discharge Condition:
Hemodynamically stable, hct stable at ~30 after 10 units
resuscitation, no further melena or BRBPR

Discharge Instructions:
Please continue to take all medications as prescribed and to
follow up with your doctors. If you develop bleeding from your
mouth or rectum, dark stools, lightheadedness, dizziness, chest
pain, shortness of breath, or any other concerning symptoms, go
to the nearest Emergency Room for evaluation.

Followup Instructions:
Please keep the following appointments:

Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2199-4-11**] 12:00

Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**], Gastroenterology
([**Telephone/Fax (1) 16940**]  Tuesday [**2199-3-26**]  [**Last Name (NamePattern1) **].  [**Location (un) 858**],
[**Hospital Unit Name **]

You should also set up an appointment with your primary care
doctor in the next week to follow up on the medical issues
addressed during this hospitalization.


                             [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
{'Esophageal varices with bleeding,Other shock without mention of trauma,Malignant neoplasm of liver, primary,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of bone and bone marrow,Acidosis,Acute kidney failure, unspecified,Stricture and stenosis of esophagus,Portal hypertension,Acute posthemorrhagic anemia,Personal history of malignant neoplasm of esophagus,Angiodysplasia of intestine (without mention of hemorrhage)'}


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: rectal bleeding

PRESENT ILLNESS: 75 yoM w/ h/o esophageal cancer s/p chemo and radiation, portal
hypertension/cirrhosis [**1-16**] EtOH w/ h/o variceal blead [**2177**],
recently dx HCC s/p chemoembolisation [**2199-3-5**] who presents s/p
syncope. Pt was on his way to outpt appointment when collapsed;
LOC ~ 1 min. No head trauma. No witnessed seizure activity. Pt
transported to ED where HR 80, sbp 70. He was noted to have a
melena/BRBPR in ED, and pt reported that he had noted several
episodes of melena for the last 5 days (unable to quantify exact
amount and frequency). He also reported significant NSAID use
(ibuprofen 2 tablets QID) In ED initial HCT 16.0; pt received 6
u PRBC, 3 u FFP, 2 L NS, protonix 40 mg IV X 1, octreotide gtt;
f/u HCT 14.2. Given persistent hypotension, he was started on a
dopamine gtt; received levofloxacin 500 mg IV X 1 and
metronidazole 500 mg IV X 1. Pt had EGD in ED which showed no
evidence of active bleeding; portal gastropathy, esophageal
varices, and small AVM in stomach were noted. Currently pt is
sedated following EGD, and further history is obtained from his
children. They report that he has had frequent loose BM
(~10/day) for the last 10 days and reported mild nausea
(although no significant vomiting) and bloating/abdominal
distension. No F/C/R. (+) decreased appetite/PO intake.

MEDICAL HISTORY: 1) Esophageal cancer dx [**4-17**]
- [**2198-5-3**] EGD: 3 cords grade II varices in lower 3rd of
esophagus; stricture @ 26 cm w/ contact bleeding; EUS c/w T3N1Mx

MEDICATION ON ADMISSION: 1) tylenol prn
2) Prilosec 20 mg PO daily
3) Atenolol 25 mg PO daily
4) Benadryl 25 mg PO QID prn
5) Advil [**12-16**] tab QID
6) FeSO4 325 mg PO daily
7) zantac 150 mg PO BId
8) Dilaudid 2 mg PO q6h prn
9) Aranesp (last dose 3/10)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals on admit to MICU: Tc 96.8, pc 80, bpc 119/42, resp 12,
100% NRB
Vitals on transfer to medicine floor: 63   138/67   14   100% on
2L
Gen: lying in reclining chair, A+Ox3, somnolent but arousable to
voice, following commands, NAD
HEENT: anicteric, pupils small and minimally responsive, EOM
slow to react, MMM, OP clear with no subungal jaundice, neck
supple, +JVD, +hepatojugular reflux, +flushed face
Chest: RSC portocath C/D/I; lungs with decreased BS at bases b/l
c/w small lung volumes, no wheezing, rhonchi or rales
Cardiac: RRR, no M/R/G
Abd: obese, markedly distended but soft; liver edge 3 cm below
RCM, NABS; no caput
Genitalia: +scrotal edema
Ext: No C/C/E, +trace LE edema b/l, 1+ DP bilaterally
Neuro: CN II-XII intact though pupils minimally reactive;
sensation to LT intact throughout, 5/5 strength in UE/LE b/l;
+asterixis; no tongue fasciculations; linear TP, somnolent but
pleasant affect

FAMILY HISTORY: Grandfather died of unknown cancer. Brother w/ "heart disease."
sister w/ breast CA

SOCIAL HISTORY: h/o heavy EtOH use; sober [**2176**]-[**2189**]; resumed EtOH; last drink
[**12-19**]. Quit tobacco 35 yrs ago ([**2-15**] ppd 30 yrs). Prior fishmarked
owner. Married and lives w/ wife 

### Response:
{'Esophageal varices with bleeding,Other shock without mention of trauma,Malignant neoplasm of liver, primary,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of bone and bone marrow,Acidosis,Acute kidney failure, unspecified,Stricture and stenosis of esophagus,Portal hypertension,Acute posthemorrhagic anemia,Personal history of malignant neoplasm of esophagus,Angiodysplasia of intestine (without mention of hemorrhage)'}
