CHIEF COMPLAINT: Hematemesis, abdominal pain, pancytopenia

PRESENT ILLNESS: 42M w/anemia and abdominal pain, referred by Dr. [**Last Name (STitle) **] from
clinic in [**Hospital1 **]. Pt complains of frequent hematemasis,
abdominal pain, and weakness.

MEDICAL HISTORY: EtOH abuse
Chronic abdominal pain
? Ascites
? s/p bone marrow bipsy
? Diabetes
? Hypertension
? Hypercholesterolemia

MEDICATION ON ADMISSION: B12 1000 mcg daily
folic acid 1 mg daily
thiamine 100 mg daily
iron tablet daily
omeprazole cap 40 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
Poor dentition
Neck: Supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2. Systolic ejection
murmur loudest at right upper sternal border
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Mildly distended but soft. Tender to palpation in RLQ,
otherwise nontender. Bowel sounds present. No hepatomegaly
appreciated. Spleen tip ~2 cm below costal margin. No shifting
dullness. No r/g.
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No axillary or inguinal lymphadenopathy. Mild ecchymosis
bilaterally shins.
Neuro: CNII-XII intact, strength/sensation grossly intact, gait
deferred.

FAMILY HISTORY: Diabetes - Mother, Father
Liver disease - Brother (deceased)
No cancer hx

SOCIAL HISTORY: Works on and off as landscaper.
Lives with friends.
Denies tobacco use.
Drinks 2 24 ounce Natural Ice beer per day after work. Denies
admissions for EtOH withdrawal or withdrawal seizures. Last
drink this morning.
Distant hx of cocaine use.
Other pancytopenia,Hematemesis,Hemoptysis, unspecified,Alcohol withdrawal,Pure hypercholesterolemia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified alcohol dependence, continuous,Alcoholic fatty liver,Splenomegaly,Iron deficiency anemia secondary to blood loss (chronic)
Other pancytopenia,Hematemesis,Hemoptysis NOS,Alcohol withdrawal,Pure hypercholesterolem,Hypertension NOS,DMII wo cmp nt st uncntr,Alcoh dep NEC/NOS-contin,Alcoholic fatty liver,Splenomegaly,Chr blood loss anemia
Admission Date:  [**2200-7-10**]              Discharge Date:   [**2200-7-13**]

Date of Birth:  [**2157-7-27**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hematemesis, abdominal pain, pancytopenia

Major Surgical or Invasive Procedure:
None


History of Present Illness:
42M w/anemia and abdominal pain, referred by Dr. [**Last Name (STitle) **] from
clinic in [**Hospital1 **]. Pt complains of frequent hematemasis,
abdominal pain, and weakness.

Patient is poor historian, but relays 1 month history of small
amounts of bright red hemoptysis and hematemesis, x 2 times
daily. Frequently wakes up with blood around mouth, neck. Today
he had 3 such episodes. Per ED, he had < 1 cup hematemesis, but
per patient, may have been hemoptysis. Accompanied by abdominal
pain that is pressure-like but occasionally has sharp epigastric
pain.

Has also been feeling weak, and found to be pancytopenic over
last few months. Has been following up care at [**Hospital3 33953**]
Community Health Center because of "blood" labs and hematemesis.
Was following with him, but was sent here by taxi today because
of ongoing hematemesis.

Was admitted either in [**Month (only) 205**] or last year to [**Hospital3 **]
where he had CT scan, bone marrow biopsy, and potentially
paracentesis as well. Uncertain of results. He may have also had
both EGD and colonoscopy during that time that was positive for
some finding, but uncertain what.

In the ED, initial VS were:
98.1 77 122/79 18 99% RA

Two 18 g attained, 1+ liter NS, protonix 80 mg given, zofran 2mg
x2, vitamin K (phytonadione) 10mg given.

1 cup hematemesis in ED.
Guaiac negative.
GI consulted, voiced concern re. question of variceal bleed.
Hemonc also consulted, recommended 1 bag platelets.
NG lavage was deferred b/c of clinical stability and
thrombocytopenia

Labs notable for platelets of 29*, WBC 2.6* (N:53.5 L:38.1 M:6.2
E:1.4 Bas:0.9), AST 160*, ALT 37, AP 105, Tbili 1.3, Alb 4.3,
Lip 53.  Slightly elevated coags at PT: 13.2  PTT: 43.7  INR:
1.2.  EKG performed, NSR.

On transfer, VS were:
99.2 85 122/68 16 99% RA

On arrival to the MICU, patient's VS.
99 89 143/71 22 97% RA

Here, patient feeling better. Currently with some tremulousness,
anxiety. Relates history of chronic abdominal pain that is in a
different location depending on the day, black stool x few days
(on iron), red urine in the morning, gum bleeding, ecchymoses of
legs/abdomen, some dyspnea on exertion although not currently,
low energy for several years, equivocal f/c/ns, and weight los
of 240 lbs (5 yrs ago) to 170-180 lbs now.


Past Medical History:
EtOH abuse
Chronic abdominal pain
? Ascites
? s/p bone marrow bipsy
? Diabetes
? Hypertension
? Hypercholesterolemia


Social History:
Works on and off as landscaper.
Lives with friends.
Denies tobacco use.
Drinks 2 24 ounce Natural Ice beer per day after work. Denies
admissions for EtOH withdrawal or withdrawal seizures. Last
drink this morning.
Distant hx of cocaine use.

Family History:
Diabetes - Mother, Father
Liver disease - Brother (deceased)
No cancer hx


Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
Poor dentition
Neck: Supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2. Systolic ejection
murmur loudest at right upper sternal border
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Mildly distended but soft. Tender to palpation in RLQ,
otherwise nontender. Bowel sounds present. No hepatomegaly
appreciated. Spleen tip ~2 cm below costal margin. No shifting
dullness. No r/g.
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No axillary or inguinal lymphadenopathy. Mild ecchymosis
bilaterally shins.
Neuro: CNII-XII intact, strength/sensation grossly intact, gait
deferred.

Exam on discharge remained unchanged compared to admission.


Pertinent Results:
[**2200-7-10**] 05:45PM BLOOD WBC-2.6* RBC-4.24* Hgb-8.5* Hct-30.2*
MCV-71* MCH-20.0* MCHC-28.1* RDW-21.1* Plt Ct-29*
[**2200-7-11**] 01:28AM BLOOD Ret Man-3.3*
[**2200-7-10**] 05:45PM BLOOD Glucose-112* UreaN-6 Creat-0.5 Na-140
K-3.8 Cl-107 HCO3-25 AnGap-12
[**2200-7-10**] 05:45PM BLOOD ALT-37 AST-160* LD(LDH)-265* AlkPhos-105
TotBili-1.3
[**2200-7-10**] 05:45PM BLOOD Albumin-4.3 Calcium-8.2* Phos-4.0 Mg-2.3
[**2200-7-11**] 01:28AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2200-7-11**] 04:49AM BLOOD HIV Ab-NEGATIVE
[**2200-7-11**] 01:28AM BLOOD ASA-NEG Ethanol-165* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2200-7-11**] 01:28AM BLOOD HCV Ab-NEGATIVE

CXR [**2200-7-10**]
Final Report

COMPARISON:  No relevant comparisons available.

TWO VIEWS OF THE CHEST:

The lungs are well expanded and clear.  The cardiomediastinal
silhouette,
hilar contours and pleural surfaces are normal.  No pleural
effusion or
pneumothorax is present.

IMPRESSION:

No acute intrathoracic process.

Brief Hospital Course:
MICU COURSE

# HEMATEMESIS/HEMOPTYSIS: Patient was started on protonix,
octreotide, ceftriaxone for GI bleed in ?cirrhotic (later when
outside records were received, he had fatty liver on imaging)
with concern for potential variceal involvement. In addition, 2
bags of platelets were given. Hematocrit was closely followed
which was 25.2 upon discharge from ICU, as compared to 30.2 upon
admission but stable for the course of the admission (attributed
to hemodilution). Active type and cross was maintained with a
goal to tranfuse patient to goal of crit > 21. EGD from OSH did
not show evidence of varices, so protonix gtt, octreotide, and
ceftriaxone were discontinued. Because of history of hemoptysis
and constitutional symptoms, TB rule-out workup was also
initiated. PPD was placed on [**2200-7-11**] and AFB sputums were
ordered, all of which were negative. OMFS was consulted because
of bleeding gums, and they recommended outpatient followup at
[**Hospital1 2177**]. Patient's hematemesis and "hempotysis" largely resolved
over course of admission, and remained hemodynamically stable
throughout.

# PANCYTOPENIA: Patient demonstrated pancytopenia on labs with
evidence of bone marrow suppression with suppressed retic count
as well as all cell lines down.  HIV testing was conducted,
which was negative. Outside hospital records from [**Hospital 10287**] were obtained which showed that patient's pancytopenia
were consistent with alcohol abuse and resulting bone marrow
suppression (consistent with his bone marrow biopsy report at
outside hospital). Therefore, hem/onc was not consulted.

# ABDOMINAL PAIN: Because of chronic abdominal pain in context
of extensive alcohol use history and likely cirrhosis, abdominal
ultrasound was performed, which was unrevealing. HBV and HCV
serologies were sent as well, which were negative.  Patient's
abdominal pain was improved upon discharge from MICU.

# ALCOHOL USE/WITHDRAWAL: Patient with history of sustained
drinking and at risk, esp. with tremulousness, anxiety. Patient
was put on ciwa scale and received thiamine, folate, MVI
repletion. Patient improved throughout admission and was no
longer requiring diazepam by discharge.

Transitional issues:
- alcohol cessation is important

Medications on Admission:
B12 1000 mcg daily
folic acid 1 mg daily
thiamine 100 mg daily
iron tablet daily
omeprazole cap 40 mg daily


Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Multivitamins 1 TAB PO DAILY
RX *Chewable Multi Vitamin   1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
4. Ferrous Sulfate 325 mg PO DAILY
RX *Feosol 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
5. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*3


Discharge Disposition:
Home

Discharge Diagnosis:
Primary diagnoses:
Hemoptysis
Hematemesis
Pancytopenia
splenomegaly
fatty liver
alcohol use


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Mr [**Known lastname 7086**],

It was a great pleasure taking care of you. As you know you were
admitted for coughing up blood and vomiting small amounts of
blood.

During your stay, your blood level remained stable but your
blood alcohol level was high. From your outside hospital
records, you had imaging study taht was consistent with fat
deposition on your liver secondary to alcohol. You had an upper
scope there which did not show a lesion to explain vomiting
blood. We did not repeat the scope since this was done very
recently for the same reason. Your symptoms are most likely
secondary to your low platelets.

Stopping the alcohol drinking will be very important to prevent
developing liver cirrhosis.

We did not make changes in your medication list. Please continue
taking them the way you were taking at home prior to admission.

We have obtained three sputums of which the initial report was
negative for Tuberculosis.

Please follow with your appointments as illustrated below.

Followup Instructions:
Please call [**Telephone/Fax (1) 34194**] to schedule a follow up appointment
with your primary care physician Dr [**Last Name (STitle) **],[**Name9 (PRE) **].

Please call the free dental care clinic at [**Hospital6 **]
to have a check up on your gums to evaluate for the cause of gum
bleeding.

Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2200-8-6**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Other pancytopenia,Hematemesis,Hemoptysis, unspecified,Alcohol withdrawal,Pure hypercholesterolemia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified alcohol dependence, continuous,Alcoholic fatty liver,Splenomegaly,Iron deficiency anemia secondary to blood loss (chronic)'}


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, abdominal pain, pancytopenia

PRESENT ILLNESS: 42M w/anemia and abdominal pain, referred by Dr. [**Last Name (STitle) **] from
clinic in [**Hospital1 **]. Pt complains of frequent hematemasis,
abdominal pain, and weakness.

MEDICAL HISTORY: EtOH abuse
Chronic abdominal pain
? Ascites
? s/p bone marrow bipsy
? Diabetes
? Hypertension
? Hypercholesterolemia

MEDICATION ON ADMISSION: B12 1000 mcg daily
folic acid 1 mg daily
thiamine 100 mg daily
iron tablet daily
omeprazole cap 40 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
Poor dentition
Neck: Supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2. Systolic ejection
murmur loudest at right upper sternal border
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Mildly distended but soft. Tender to palpation in RLQ,
otherwise nontender. Bowel sounds present. No hepatomegaly
appreciated. Spleen tip ~2 cm below costal margin. No shifting
dullness. No r/g.
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No axillary or inguinal lymphadenopathy. Mild ecchymosis
bilaterally shins.
Neuro: CNII-XII intact, strength/sensation grossly intact, gait
deferred.

FAMILY HISTORY: Diabetes - Mother, Father
Liver disease - Brother (deceased)
No cancer hx

SOCIAL HISTORY: Works on and off as landscaper.
Lives with friends.
Denies tobacco use.
Drinks 2 24 ounce Natural Ice beer per day after work. Denies
admissions for EtOH withdrawal or withdrawal seizures. Last
drink this morning.
Distant hx of cocaine use. 

### Response:
{'Other pancytopenia,Hematemesis,Hemoptysis, unspecified,Alcohol withdrawal,Pure hypercholesterolemia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified alcohol dependence, continuous,Alcoholic fatty liver,Splenomegaly,Iron deficiency anemia secondary to blood loss (chronic)'}
