CHIEF COMPLAINT: Alcoholic hepatitis, mental status change, GIB

PRESENT ILLNESS: 42 yo M w/[**Hospital **] transferred from [**Hospital 48910**] Hospital on [**3-30**]. Pt's MS
was altered at presentation, so his medical history is unclear
and may include cirrhosis and hepatorenal syndrome, as well as
ETOH abuse. Per report, his brother was [**Name (NI) 653**] the first
night and stated that diarrhea was the pt's chief complaint and
[**First Name8 (NamePattern2) **] [**Last Name (un) 48910**] records the pt was noted to have liquid red stools.
At [**Last Name (un) 48910**] he was given 1 uPRBC and FFP, protonix and had a hct
24. He was transferred here b/c they had no ICU beds.
.
Per notes, in the [**Hospital1 **] ED, the patient was unable to give much
history due to MS changes. This was thought to be [**2-27**] to
encephalopathy and he was given PO lactulose. Initially his SBP
was 114 and then 92. An NGT was placed and bilious material was
lavaged. Per liver recs the patient was given 1 gm ceftriaxone,
and started on an octrotide gtt.

MEDICAL HISTORY: unknown

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: T 99.4 BP 108/68 HR 88 RR 24 o2 93/4L
General: jaundiced male, not oriented, in NAD
HEENT: COP, NG tube in place
Heart: tachycardic, no m/r/g/
Lungs: decreased BS at bases,
Abdomen: distended, nt, tympanic
Extremities: RUE 2+ edema, LE 1+ equal

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives with his mother, has one brother who was also a heavy
drinker and died during patients current hospitalization due to
his alcoholic liver disease. Patient has a 20 year history of
drinking.
Gastroesophageal laceration-hemorrhage syndrome,Hepatorenal syndrome,Acidosis,Other and unspecified coagulation defects,Acute kidney failure, unspecified,Pulmonary collapse,Alcohol withdrawal,Other ascites,Pneumonitis due to inhalation of food or vomitus,Paralytic ileus,Unspecified septicemia,Sepsis,Other specified disorders of stomach and duodenum,Acute duodenal ulcer with hemorrhage, without mention of obstruction,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, continuous,Chronic kidney disease, unspecified,Edema
Mallory-weiss syndrome,Hepatorenal syndrome,Acidosis,Coagulat defect NEC/NOS,Acute kidney failure NOS,Pulmonary collapse,Alcohol withdrawal,Ascites NEC,Food/vomit pneumonitis,Paralytic ileus,Septicemia NOS,Sepsis,Gastroduodenal dis NEC,Ac duodenal ulcer w hem,Alcohol cirrhosis liver,Alcoh dep NEC/NOS-contin,Chronic kidney dis NOS,Edema
Admission Date:  [**2179-3-30**]              Discharge Date:   [**2179-4-24**]

Date of Birth:  [**2136-6-25**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Alcoholic hepatitis, mental status change, GIB

Major Surgical or Invasive Procedure:
Intubation
EGD


History of Present Illness:
42 yo M w/[**Hospital **] transferred from [**Hospital 48910**] Hospital on [**3-30**]. Pt's MS
was altered at presentation, so his medical history is unclear
and may include cirrhosis and hepatorenal syndrome, as well as
ETOH abuse. Per report, his brother was [**Name (NI) 653**] the first
night and stated that diarrhea was the pt's chief complaint and
[**First Name8 (NamePattern2) **] [**Last Name (un) 48910**] records the pt was noted to have liquid red stools.
At [**Last Name (un) 48910**] he was given 1 uPRBC and FFP, protonix and had a hct
24. He was transferred here b/c they had no ICU beds.
.
Per notes, in the [**Hospital1 **] ED, the patient was unable to give much
history due to MS changes. This was thought to be [**2-27**] to
encephalopathy and he was given PO lactulose. Initially his SBP
was 114 and then 92. An NGT was placed and bilious material was
lavaged. Per liver recs the patient was given 1 gm ceftriaxone,
and started on an octrotide gtt.


Past Medical History:
unknown

Social History:
Lives with his mother, has one brother who was also a heavy
drinker and died during patients current hospitalization due to
his alcoholic liver disease. Patient has a 20 year history of
drinking.

Family History:
NC

Physical Exam:
PE: T 99.4 BP 108/68 HR 88 RR 24 o2 93/4L
General: jaundiced male, not oriented, in NAD
HEENT: COP, NG tube in place
Heart: tachycardic, no m/r/g/
Lungs: decreased BS at bases,
Abdomen: distended, nt, tympanic
Extremities: RUE 2+ edema, LE 1+ equal


Pertinent Results:
Pertinent lab results:

[**2179-3-30**] 10:09PM BLOOD WBC-11.3* RBC-2.48* Hgb-9.0* Hct-27.7*
MCV-112* MCH-36.3* MCHC-32.5 RDW-23.5* Plt Ct-117*
[**2179-4-23**] 05:20AM BLOOD WBC-6.3 RBC-2.52* Hgb-9.0* Hct-27.6*
MCV-110* MCH-35.8* MCHC-32.7 RDW-18.6* Plt Ct-405
[**2179-3-30**] 10:09PM BLOOD Neuts-71.3* Lymphs-23.0 Monos-4.3 Eos-1.2
Baso-0.2
[**2179-4-12**] 04:11AM BLOOD Neuts-71.5* Lymphs-17.5* Monos-7.1
Eos-3.4 Baso-0.5
[**2179-3-30**] 10:09PM BLOOD PT-18.9* PTT-38.9* INR(PT)-1.7*
[**2179-4-22**] 06:10AM BLOOD PT-15.2* PTT-33.3 INR(PT)-1.3*
[**2179-3-30**] 10:09PM BLOOD Glucose-92 UreaN-29* Creat-2.8* Na-131*
K-4.6 Cl-100 HCO3-18* AnGap-18
[**2179-4-23**] 05:20AM BLOOD Glucose-93 UreaN-3* Creat-0.6 Na-136
K-4.1 Cl-107 HCO3-21* AnGap-12
[**2179-3-30**] 10:09PM BLOOD ALT-137* AST-146* AlkPhos-264*
TotBili-7.5*
[**2179-4-22**] 06:10AM BLOOD ALT-57* AST-89* LD(LDH)-376* AlkPhos-118*
TotBili-2.1*
[**2179-4-1**] 03:19AM BLOOD Lipase-122*
[**2179-4-2**] 06:20AM BLOOD Lipase-80*
[**2179-4-10**] 06:27PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2179-3-30**] 10:09PM BLOOD Albumin-1.8* Calcium-7.4* Phos-4.7*
Mg-2.2
[**2179-4-23**] 05:20AM BLOOD Albumin-2.6* Calcium-8.6 Phos-2.8 Mg-1.7
[**2179-4-3**] 06:10AM BLOOD Hapto-42
[**2179-4-8**] 04:29AM BLOOD Triglyc-188*
[**2179-4-12**] 04:11AM BLOOD Triglyc-125
[**2179-3-31**] 04:14AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2179-3-30**] 10:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-12.6
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2179-3-31**] 04:14AM BLOOD HCV Ab-NEGATIVE
[**2179-4-2**] 10:14AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-Test Name
[**2179-4-2**] 10:14AM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test
[**2179-4-2**] 10:14AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Yhsv

Brief Hospital Course:
In the MICU, the patient had an NG lavage, which was clear. He
had an EGD on [**2179-3-31**] and was found to have 3 non-bleeding ulcers
in the first part of the duodenum (one of which was thought to
have recently bled and was clipped), [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] tear and
portal hypertensive gastropathy. His octreotide gtt was stopped
and he was continued on a protonix gtt. Diagnostic paracentesis
was negative. While in the ICU he received 2 units of PRBCs and
his hct has been stable for the last two days. He did receive
valium yesterday for alcohol withdrawal.
Then patient was transferred to the floor:

His course was unremarkable on the floor until the morning of
[**2179-4-7**] when he triggered for low urine output (143cc over 4
hours). The patient was noted to be tachypneic to the 40s and
had a new oxygen requirement 91% on 4L NC (whereas before he had
been 100% on RA). He received a bolus of 500cc of NS, followed
by another 250cc. UOP showed marginal improvement. He received
20mg IV lasix X 2. He also received nebulizers. CXR showed RML
and RLL collapse which was unchanged since [**4-5**]. However there
was left lower lobe collapse and left pleural effusion which was
new. By 6:30 AM UOP had improved to 175 cc/night. The patient
again triggered at 1:15pm. He was tachypneic to 24-30 and O2
sats were 94 - 95 % on NRB. His abdomen was noted to be
distended. He also had hypoactive bowel sounds. Abdominal
ultrasound showed bowel dilatation. An NGT was placed and the
patient felt better. A considerable amount of bilious material
was drained immediately. However he continues to be tachycardic
to the 110s. His O2 sat was 89% on RA, thus requiring the NRB.
Given the dilated loops of bowel, the patient was started on
empiric coverage with cipro and flagyll, and transferred to
MICU:
In the MICU he was intubated for respiratory distress and
treated with vanc/zosyn for presumed PNA although there was
never any growth from sputum culture other than oropharygngeal
flora.  The completed a 10 day course of zosyn.  He continued to
have an 02 requirement after transfered back to the floor.  He
underwent an uncomplicanted therapeutic paracentesis with
removal of 2L for ascites, his diuretics were also increased.
Both acted to decrease pulmonary edema and increase his baseline
low lunch volumes.  The patient was gradually weaned off 02
until he was able to ambulate independently in the [**Doctor Last Name **].
He was discharged home after being cleared by PT with liver
transplant follow up for ongoing monitoring.  He will have his
kidney funtion and electrolye followed there for now as he has
no insurance or PCP and he has been started in many new
medications, including diuretics.
On day of discharge pt was able to ambulate and complete ADLs
independently. He was pain free with stable vital signs, off
supplemental 02.  Hematocrit stable with no further evidence of
bleed.  He will complete a 2 week course for treatment of
presumed h. pylori infection in the setting of symptoms and
presence of duodenal ulcer without history of NSAID use.


Medications on Admission:
none

Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*2 inhalers* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours
for 14 days.
Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): hold for >4 bowel movements per day.
Disp:*2700 ML(s)* Refills:*2*
10. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
11. Amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
12. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: Once daily dosing
should be started after completing 2 weeks of twice a day
dosing.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Upper GI bleed, duodenal ulcer
Pneumonia
Cirrhosis


Discharge Condition:
Good, off 02, ambulating independently.


Discharge Instructions:
You were admitted with an upper GI bleed, you were found to have
an ulcer in your stomach. You should complete the 2 week course
of protonix and antibiotics you have been prescribed for
treatment of this. While you were hospitalized you developed
respiratory stress due to a pneumonia which was treated with a
course of antibiotics.
Because of your underlying severe liver disease it is very
important that you continue to get enough nutrition. Please
adhere to the prescribed diet to ensure you are taking in enough
protein and calories.
You have been started on several new medications for your reflux
disease/ulcer as well as for your liver disease.  You will need
to follow up closely either with a new PCP or your liver doctors
here at [**Name5 (PTitle) 18**] to have your labs monitored while on these new
medications.
Please take all medications as prescribed.  Please attend the
recommended follow up appointments.
Call your doctor or return to the emergency room if you
experience fevers or chills, worsening shortness of breath,
abdominal pain or confusion of for any other concerning
symptoms.
You will need to call Pharmacare (number on your prescriptions)
and give them your address and they can mail you refills of your
protonix and lactulose.

Followup Instructions:
You have an appointment with Dr. [**Name (NI) **] at the Liver Center
on [**2179-4-30**] at 10am.  Please call [**Telephone/Fax (1) 673**] with questions of
if you need to reschedule.

Please schedule a visit with a new primary care provider as soon
as possible, ideally within the next 2 weeks.
{'Gastroesophageal laceration-hemorrhage syndrome,Hepatorenal syndrome,Acidosis,Other and unspecified coagulation defects,Acute kidney failure, unspecified,Pulmonary collapse,Alcohol withdrawal,Other ascites,Pneumonitis due to inhalation of food or vomitus,Paralytic ileus,Unspecified septicemia,Sepsis,Other specified disorders of stomach and duodenum,Acute duodenal ulcer with hemorrhage, without mention of obstruction,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, continuous,Chronic kidney disease, unspecified,Edema'}


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: Alcoholic hepatitis, mental status change, GIB

PRESENT ILLNESS: 42 yo M w/[**Hospital **] transferred from [**Hospital 48910**] Hospital on [**3-30**]. Pt's MS
was altered at presentation, so his medical history is unclear
and may include cirrhosis and hepatorenal syndrome, as well as
ETOH abuse. Per report, his brother was [**Name (NI) 653**] the first
night and stated that diarrhea was the pt's chief complaint and
[**First Name8 (NamePattern2) **] [**Last Name (un) 48910**] records the pt was noted to have liquid red stools.
At [**Last Name (un) 48910**] he was given 1 uPRBC and FFP, protonix and had a hct
24. He was transferred here b/c they had no ICU beds.
.
Per notes, in the [**Hospital1 **] ED, the patient was unable to give much
history due to MS changes. This was thought to be [**2-27**] to
encephalopathy and he was given PO lactulose. Initially his SBP
was 114 and then 92. An NGT was placed and bilious material was
lavaged. Per liver recs the patient was given 1 gm ceftriaxone,
and started on an octrotide gtt.

MEDICAL HISTORY: unknown

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: T 99.4 BP 108/68 HR 88 RR 24 o2 93/4L
General: jaundiced male, not oriented, in NAD
HEENT: COP, NG tube in place
Heart: tachycardic, no m/r/g/
Lungs: decreased BS at bases,
Abdomen: distended, nt, tympanic
Extremities: RUE 2+ edema, LE 1+ equal

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives with his mother, has one brother who was also a heavy
drinker and died during patients current hospitalization due to
his alcoholic liver disease. Patient has a 20 year history of
drinking. 

### Response:
{'Gastroesophageal laceration-hemorrhage syndrome,Hepatorenal syndrome,Acidosis,Other and unspecified coagulation defects,Acute kidney failure, unspecified,Pulmonary collapse,Alcohol withdrawal,Other ascites,Pneumonitis due to inhalation of food or vomitus,Paralytic ileus,Unspecified septicemia,Sepsis,Other specified disorders of stomach and duodenum,Acute duodenal ulcer with hemorrhage, without mention of obstruction,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, continuous,Chronic kidney disease, unspecified,Edema'}
