CHIEF COMPLAINT: Hematemesis

PRESENT ILLNESS: Ms. [**Name13 (STitle) 805**] is a 48-year-old F PMhx chronic HCV w Stage I
fibrosis, hypertension, Crohn's disease, rheumatoid arthritis,
and bipolar disorder who presented with with 3 days of
nausea/vomitting, and new onset hematemesis.  Patient reports 10
episodes of about a cup full of vomiting dark, coffee ground
emesis following a binge on 40 ounces of malt liquor and a half
a fifth of Captain [**Doctor Last Name **] original spiced rum.  Patient
reports that she often vomits after drinking (up to 3 times a
week).  She denies taking any cocaine during this time.  Patient
states that she has been having fevers (unmeasured) but no other
localizing symptoms.  She states that she has been drinking
water, but not taking any of her home medications and not eating
due to the vomiting.  She states that she may not have urinated
for the past 2 days and that she did pass a dark, oily stool
yesterday.   Patient denies recent travel, strange foods, or
sick contacts.  On the morning of admission, patient had 1
episode of hematemesis and called 911.

MEDICAL HISTORY: 1)  Cardiomyopathy most likely secondary to hypertensive heart
    disease and polysubstance abuse, LV systolic dysfunction,
    EF 35-40%, NYHA class I-II.
2)  Hypertension
3)  Polysubstance abuse (cocaine, etoh)
4.) Crohn's disease since [**2099**] vs. ulcerative colitis (Chronic
active colitis with ulceration seen on biopsy in [**8-18**] and [**2-/2114**])
5.) hx abnormal mammogram with L breast biopsy in [**10-19**] -
sclerosing adenosis, Pseudoangiomatous stromal hyperplasia.
6.) Bipolar/Schizophrenia (per patient)
7.) Depression (per patient)
8.) Fibromyalgia (per patient)
9.) Brain aneurysm s/p surgery at [**Hospital1 112**] (per patient)
10.) Nicotine abuse

MEDICATION ON ADMISSION: BENZTROPINE 1mg qAM, 2mg qPM
Lasix 20mg daily prn lower extremity edema
HCTZ - 25mg daily
COMBIVENT 2 puffs QID
LABETALOL 400mg [**Hospital1 **]
LISINOPRIL 40mg daily
PANTOPRAZOLE 40mg Tablet [**Hospital1 **]
PREDNISOLONE ACETATE 1%Drops QID to R eye
QUETIAPINE 700mg qHS
RANITIDINE 300mg [**Hospital1 **]
SULFASALAZINE 1000mg [**Hospital1 **]
TRAMADOL 50mg [**1-16**] Tablet qid prn
ZIPRASIDONE 80mg [**Hospital1 **]
ASPIRIN 81mg daily
NICOTINE patch

ALLERGIES: Aspirin

PHYSICAL EXAM: Admission:
Vitals: T:98.9 BP:75/43 P:111 R: 18 O2: 100%
General: Alert, oriented, moving around alot/ psychomotor
agitation.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP unable to see, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic flow
murmur over precordium not on carotids, not radiating to left
axilla.  No rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Non contributory

SOCIAL HISTORY: Patient lives on SSI/disability and lives alone in an apartment
above her 25 year old daughter.  + h/o cocaine and alcohol
abuse; + tobacco [**7-23**] cigarrettes a day since age 35
Acute esophagitis,Acute kidney failure with lesion of tubular necrosis,Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Chronic systolic heart failure,Acidosis,Acute posthemorrhagic anemia,Regional enteritis of unspecified site,Chronic hepatitis C without mention of hepatic coma,Chronic airway obstruction, not elsewhere classified,Chronic kidney disease, Stage III (moderate),Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Other specified cardiac dysrhythmias,Leukocytosis, unspecified,Rheumatoid arthritis,Bipolar disorder, unspecified,Cocaine abuse, unspecified,Myalgia and myositis, unspecified,Unspecified schizophrenia, unspecified
Acute esophagitis,Ac kidny fail, tubr necr,Hyp ht/kd NOS I-IV w hf,Chr systolic hrt failure,Acidosis,Ac posthemorrhag anemia,Regional enteritis NOS,Chrnc hpt C wo hpat coma,Chr airway obstruct NEC,Chr kidney dis stage III,Stomach ulcer NOS,Cardiac dysrhythmias NEC,Leukocytosis NOS,Rheumatoid arthritis,Bipolar disorder NOS,Cocaine abuse-unspec,Myalgia and myositis NOS,Schizophrenia NOS-unspec
Admission Date:  [**2130-3-1**]              Discharge Date:   [**2130-3-7**]

Date of Birth:  [**2081-7-16**]             Sex:   F

Service: MEDICINE

Allergies:
Aspirin

Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Hematemesis

Major Surgical or Invasive Procedure:
PICC line placement
Upper endoscopy [**2130-3-1**]

History of Present Illness:
Ms. [**Name13 (STitle) 805**] is a 48-year-old F PMhx chronic HCV w Stage I
fibrosis, hypertension, Crohn's disease, rheumatoid arthritis,
and bipolar disorder who presented with with 3 days of
nausea/vomitting, and new onset hematemesis.  Patient reports 10
episodes of about a cup full of vomiting dark, coffee ground
emesis following a binge on 40 ounces of malt liquor and a half
a fifth of Captain [**Doctor Last Name **] original spiced rum.  Patient
reports that she often vomits after drinking (up to 3 times a
week).  She denies taking any cocaine during this time.  Patient
states that she has been having fevers (unmeasured) but no other
localizing symptoms.  She states that she has been drinking
water, but not taking any of her home medications and not eating
due to the vomiting.  She states that she may not have urinated
for the past 2 days and that she did pass a dark, oily stool
yesterday.   Patient denies recent travel, strange foods, or
sick contacts.  On the morning of admission, patient had 1
episode of hematemesis and called 911.

On initial presentation to the ED vital signs were not checked.
Patient was sitting up in bed and able to discuss her history.
Exam was significant for good mentation, nontender abdomen.
Initial labs were significant for Hct 34 (previously 29-36), WBC
18 (N67), Cr 6.4 (normal 1.4-1.7), ALT/AST 33/43 (previously
27/26), lactate 5.8.  CXR demonstrated an elevated right
hemidiaphragm and no consolidation or pleural effusion seen on
the lateral view. She was bolused with IV NS (total 5L) with
blood pressure responsive and resolving to SBP 115-130s with HR
80bpm.  Had clear NG lavage.  Digital rectal exam showed dark
brown guaiac positive stool.  Repeat labs showed lactate 3.8,
Hct 29.  She received 1 dose zosyn and vancoymcin given concern
for infection, and 1 dose IV protonix given concern for GI
bleed. She was admitted to [**Hospital1 18**]

On arrival to the ICU patient had an initial blood pressure of
60s/20s, although this was in the context of her wiggling around
and not sitting still when the cuff was measuring.  I checked
the pressure myself and got 120/50 on a manual cuff.  Patient
did report some recent dizziness with standing, but denies frank
syncope.  Bladder scan was done with 750cc in the bladder.  A
foley was inserted.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies diarrhea, constipation, abdominal pain. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.

Past Medical History:
1)  Cardiomyopathy most likely secondary to hypertensive heart
    disease and polysubstance abuse, LV systolic dysfunction,
    EF 35-40%, NYHA class I-II.
2)  Hypertension
3)  Polysubstance abuse (cocaine, etoh)
4.) Crohn's disease since [**2099**] vs. ulcerative colitis (Chronic
active colitis with ulceration seen on biopsy in [**8-18**] and [**2-/2114**])
5.) hx abnormal mammogram with L breast biopsy in [**10-19**] -
sclerosing adenosis, Pseudoangiomatous stromal hyperplasia.
6.) Bipolar/Schizophrenia (per patient)
7.) Depression (per patient)
8.) Fibromyalgia (per patient)
9.) Brain aneurysm s/p surgery at [**Hospital1 112**] (per patient)
10.) Nicotine abuse


Social History:
Patient lives on SSI/disability and lives alone in an apartment
above her 25 year old daughter.  + h/o cocaine and alcohol
abuse; + tobacco [**7-23**] cigarrettes a day since age 35


Family History:
Non contributory


Physical Exam:
Admission:
Vitals: T:98.9 BP:75/43 P:111 R: 18 O2: 100%
General: Alert, oriented, moving around alot/ psychomotor
agitation.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP unable to see, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic flow
murmur over precordium not on carotids, not radiating to left
axilla.  No rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema


Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-18.6*# RBC-3.64* Hgb-10.5* Hct-31.6* MCV-87 RDW-13.9 Plt
Ct-427
---Neuts-67.5 Lymphs-26.1 Monos-5.1 Eos-0.7 Baso-0.6
Glucose-168* UreaN-72* Creat-6.4*# Na-136 K-3.4 Cl-86* HCO3-28
ALT-33 AST-43* AlkPhos-57 TotBili-0.6
Albumin-3.7 Calcium-9.2 Phos-6.1*# Mg-1.7
BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
Lactate-5.8*

UA: Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 Blood-SM  Nitrite-NEG
Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG
pH-5.5 Leuks-NEG
RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 UreaN-447 Creat-99
Na-74 K-26 Cl-48 TotProt-23 Prot/Cr-0.2 bnzodzp-NEG barbitr-NEG
opiates-NEG cocaine-POS amphetm-NEG mthdone-NEG

==============
OTHER STUDIES
==============
ECG [**2130-3-1**]:
Sinus tachycardia. It is difficult to determine the Q-T interval
secondary to underlying artifact and non-specific ST-T wave
changes. However, the Q-T interval may be slightly prolonged.
Compared to the previous tracing of [**2127-4-21**] artifact is not seen
on the current tracing and the Q-T interval may be prolonged.
Clinical correlation is suggested.
.
Chest Radiograph PA and Lateral [**2130-3-1**]:
IMPRESSION:
1. Elevated right hemidiaphragm.
2. Left base not well evaluated on the frontal view, although no
consolidation or pleural effusion seen on the lateral view.
.
EGD [**2130-3-1**]:
Impression: 	Severe esophagitis in the gastroesophageal junction
and lower third of the esophagus
Ulcer in the gastroesophageal junction
No blood was seen throughout the procedure
Otherwise normal EGD to third part of the duodenum
Recommendations: 	Continue PPI 40mg [**Hospital1 **].
Restart ranitidine when renal function improves, if possible.
Consider sucralfate slurry 1gram QID.
Alcohol cessation counselling.
Antireflux regimen: Avoid chocolate, peppermint, alcohol,
caffeine, onions, aspirin. Elevate the head of the bed 3 inches.
Go to bed with an empty stomach.
Repeat endoscopy in [**8-27**] weeks to evaluate esophageal ulcer and
esophagitis for healing.
.
Renal U/S [**2130-3-2**]:
IMPRESSION:
No obstructing stones, masses or hydronephrosis.
[**2130-3-7**] 05:48AM BLOOD WBC-8.5 RBC-3.69* Hgb-11.1* Hct-32.7*
MCV-89 MCH-30.1 MCHC-34.0 RDW-13.9 Plt Ct-291
[**2130-3-5**] 06:30AM BLOOD WBC-8.5 RBC-3.48* Hgb-10.1* Hct-30.4*
MCV-88 MCH-29.1 MCHC-33.3 RDW-14.6 Plt Ct-231
[**2130-3-4**] 06:00AM BLOOD WBC-7.1 RBC-3.34* Hgb-10.1* Hct-29.4*
MCV-88 MCH-30.4 MCHC-34.5 RDW-13.9 Plt Ct-224
[**2130-3-3**] 05:02AM BLOOD WBC-7.6 RBC-3.33* Hgb-10.3* Hct-29.1*
MCV-88 MCH-30.9 MCHC-35.4* RDW-14.0 Plt Ct-247
[**2130-3-2**] 09:49PM BLOOD WBC-7.5 RBC-3.25*# Hgb-9.4*# Hct-27.8*
MCV-86 MCH-29.1 MCHC-33.9 RDW-14.0 Plt Ct-231
[**2130-3-2**] 05:18AM BLOOD WBC-6.8 RBC-2.59* Hgb-7.4* Hct-22.8*
MCV-88 MCH-28.7 MCHC-32.6 RDW-13.7 Plt Ct-260
[**2130-3-1**] 01:20PM BLOOD WBC-13.2* RBC-2.86* Hgb-8.4* Hct-25.4*
MCV-89 MCH-29.5 MCHC-33.2 RDW-13.8 Plt Ct-322
[**2130-3-1**] 08:40AM BLOOD WBC-18.6*# RBC-3.64* Hgb-10.5* Hct-31.6*
MCV-87 MCH-28.9 MCHC-33.4 RDW-13.9 Plt Ct-427
[**2130-3-4**] 06:00AM BLOOD Neuts-46.4* Lymphs-39.9 Monos-8.5
Eos-4.8* Baso-0.4
[**2130-3-1**] 08:40AM BLOOD Neuts-67.5 Lymphs-26.1 Monos-5.1 Eos-0.7
Baso-0.6
[**2130-3-1**] 09:30AM BLOOD PT-12.2 PTT-23.3* INR(PT)-1.1
[**2130-3-7**] 12:47PM BLOOD Creat-1.7*
[**2130-3-7**] 05:48AM BLOOD Glucose-140* UreaN-21* Creat-1.8* Na-141
K-4.2 Cl-108 HCO3-26 AnGap-11
[**2130-3-6**] 06:30AM BLOOD Glucose-103* UreaN-15 Creat-1.6* Na-142
K-4.3 Cl-110* HCO3-29 AnGap-7*
[**2130-3-5**] 06:30AM BLOOD Glucose-152* UreaN-15 Creat-1.7* Na-141
K-3.9 Cl-108 HCO3-27 AnGap-10
[**2130-3-4**] 06:00AM BLOOD UreaN-18 Creat-1.8* Na-142 K-4.0 Cl-107
HCO3-29 AnGap-10
[**2130-3-3**] 05:02AM BLOOD Glucose-142* UreaN-18 Creat-1.9*# Na-142
K-3.9 Cl-106 HCO3-28 AnGap-12
[**2130-3-2**] 05:18AM BLOOD Glucose-94 UreaN-38* Creat-3.1*# Na-145
K-3.4 Cl-108 HCO3-31 AnGap-9
[**2130-3-1**] 01:20PM BLOOD Glucose-95 UreaN-55* Creat-4.7*# Na-139
K-3.7 Cl-104 HCO3-25 AnGap-14
[**2130-3-1**] 08:40AM BLOOD Glucose-168* UreaN-72* Creat-6.4*# Na-136
K-3.4 Cl-86* HCO3-28 AnGap-25*
[**2130-3-4**] 06:00AM BLOOD ALT-34 AST-36 LD(LDH)-239 AlkPhos-50
TotBili-0.2
[**2130-3-1**] 08:40AM BLOOD ALT-33 AST-43* AlkPhos-57 TotBili-0.6
[**2130-3-1**] 08:40AM BLOOD Lipase-21
[**2130-3-7**] 05:48AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.7
[**2130-3-4**] 06:00AM BLOOD Mg-2.2
[**2130-3-3**] 05:02AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.4
[**2130-3-2**] 05:18AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.7
[**2130-3-1**] 01:20PM BLOOD TotProt-5.8* Calcium-7.9* Phos-3.6#
Mg-1.7
[**2130-3-1**] 08:40AM BLOOD Albumin-3.7 Calcium-9.2 Phos-6.1*# Mg-1.7
[**2130-3-2**] 02:00PM BLOOD Cryoglb-NO CRYOGLO
[**2130-3-1**] 01:20PM BLOOD PEP-POLYCLONAL
[**2130-3-2**] 02:00PM BLOOD HIV Ab-NEGATIVE
[**2130-3-1**] 01:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2130-3-1**] 10:44AM BLOOD Lactate-3.8*
[**2130-3-1**] 08:53AM BLOOD Lactate-5.8*
.
Microbiology:
[**2130-3-1**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2130-3-1**] URINE URINE CULTURE-FINAL INPATIENT
[**2130-3-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2130-3-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]


Brief Hospital Course:
48-year-old F PMhx chronic HCV w Stage I fibrosis, hypertension,
Crohn's disease, rheumatoid arthritis, and bipolar disorder who
presented with several days of nausea/vomiting, and new onset
hematemesis.

#Severe esophagitis causing hematemesis and acute blood loss
anemia in the context of alcohol abuse and history of candidal
esophagitis.  Patient is on Protonix and ranitidine at home but
has questionable compliance.  EGD [**2130-3-2**] demonstrated severe
esophagitis as well as an ulcer at the GE junction.  We
initially started IV pantoprazole 40mg [**Hospital1 **], but switched to PO
after the first day.  We also started sucralfate slurry 1gram
QID and recommended/ encouraged alcohol cessation counseling.
Per GI we also instituted an antireflux regimen: Avoid
chocolate, peppermint, alcohol, caffeine, onions, aspirin.
Elevate the head of the bed 3 inches. Go to bed with an empty
stomach.  While in the ICU, we held patient's antihypertensive
regimen.  Patient's hematocrit also decreased the day after
admission down to 22.8 and patient was transfused 2 units of
PRBCs.  Hct was stable thereafter around 29.  Pt was discharged
on sucralfate, pantoprazole [**Hospital1 **], and ranitidine. HCT was 32.7
upon discharge. She was discharged with an appointment with GI
for repeat evaluation and discussion of repeat endoscopy to
ensure ulcer healing. Pt can retrial ASA therapy upon discharge
if clinically indicated.

#Acute renal failure with anion gap acidosis: Question prerenal
from hypotension/ poor PO intake versus toxic injury/ cocaine
(positive u tox).  Initial lactate 5.85, trended down to 3.8.
Also possible is retention as patient had 750cc in her bladder
when a foley was placed, perhaps from opioid use.  Anion gap
closed rapidly, possibly starvation/EtOH due to poor PO and
alcohol use.  Patient received 5L crystalloid in the ED.  FeNa
2.53 and FeUrea 39 consistent with intrinsic renal disease.
Nephrology was consulted but Cr began to dramatically fall prior
to completion of work up ( showed no obstruction).  HIV was
rechecked and was negative.  Once Cr back down to 1.7 (near
baseline of 1.3-1.5) ranitidine was restarted first. Attempted
to restart HCTZ and lisinopril and creatinine bumped to 1.8.
Thus these were stopped and pt was advised not to restart these
medications upon discharge until further evaluation and repeat
labs by PCP.  [**Name10 (NameIs) 17781**] negative. Pt's new baseline Cr may be
1.6-1.8. Follow up labs will help with determination. Creatinine
was 1.7 upon discharge.

#Leukocytosis: Unclear etiology: patient given vancomycin and
Zosyn in the ED but then stopped as no clear source.  All
cultures remained negative and trended down without other
intervention.  Likely leukemoid reaction due to vomiting and
acute GI bleeding.

#Tachycardia: Patient tachycardic during admission in the ICU.
Likely multifactorial including poor PO intake/ volume down
versus manic episode versus drug use.  Patient was given 2 units
of blood.  Tachycardia resolved by first night out of the ICU
and tele stopped.
.
#Chronic systolic CHF: Most recent TTE with marginally low EF of
50% (though previously as low as 35%). Pt appeared euvolemic
during admission and without lower extremity edema or pulmonary
edema. BB continued. Attempted to restart ACEI, however, pt had
a slight Cr bump and requested discharge. Lasix was also not
restarted given above.  Pt did not report any SOB and was not
hypoxic.

#Psychomotor agitation and recent alcohol abuse/cocaine use-
Patient reported binge drinking up 3 times a week.  Last drink
was 2/12 per report.  Question side effects from benzotropine as
well.  Cocaine + per urine. Patient was started on CIWA with
Ativan 1-2 mg PO q 2h CIWA>10 (initially IV).  She did not
require any Ativan on [**3-2**].  On regular medical floor patient
without clear psychomotor retardation and received no further
BZD without signs of withdrawal.

#Nicotine abuse:  Patient has been smoking up to a pack a day
for the past 10-20 years.  We counseled on quitting and
continued a NICOTINE patch.

#Hypertension: Initially all anti-hypertensives were held in
setting of GI bleed.  Labetalol was restarted prior to leaving
MICU as BPs trending high.  Attempted to restart Lisinopril and
HCTZ on [**3-6**], however, pt had a slight Cr bump on [**3-7**] and these
medications were discontinued. Labetalol was increased to 600mg
[**Hospital1 **]. SHE WAS STRONGLY URGED NOT TO USE LABETALOL WHILE USING
COCAINE. Lasix was not restarted given recent GI bleeding and
[**Last Name (un) **].

#Crohn's disease since [**2099**] vs. ulcerative colitis: Pt on
sulfasalazine at baseline but this was held given acute renal
failure. This was restarted upon discharge as [**Last Name (un) **] resolved.
.
#Fibromyalgia (per patient):  On chronic tramadol.  This was
restarted at discharge.
.
#Depression/ Bipolar/Schizophrenia (per patient)/social issues:
She was continued on her quetiapine and ziprasidone at home
doses with pleasant (if odd) somewhat hypomanic behavior.
Continued benzotropine as well. Psychiatry was consulted and did
not feel as though pt had any psychiatric contraindications to
discharge. Pt was offered resources by SW and psychiatry for
assistance with stopping ETOH and drug use. However, she
declined. She was advised to follow up with her psychiatrist
[**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], [**Location (un) 669**] Comprehensive (per old records: cell
[**Telephone/Fax (1) 93299**], office [**Telephone/Fax (2) 93300**]). Pt told the psychiatry
team prior to discharge that she woiuld call to make an
appointment. Per report, SW attempted to file a 51A given pt's
reports of possible abuse involving her boyfriend and her
grandson's-reported to social work [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7839**]. However, pt
would not give her daugther's/grandson's address-stated she did
not know it and therefore report, per report, was unable to be
filed. Pt did not report this information to her attending. She
reported this to SW who attempted to file a 51A unsuccessfully
as the address could not be reportedly found.
-WOULD STRONGLY CONSIDER NEUROPSYCHIATRIC TESTING TO HELP IN
DETERMINING IF UNDERLYING COGNITIVE VS. PSYCHIATRIC STATE
IMPAIRING DECISION MAKING. PT UNABLE TO RECEIVE VNA SERVICES FOR
HOME SAFETY EVALUATION AS SHE IS AMBULATORY.

#COPD w/o exacerbation: Pt continued on chronic bronchodilators

#Transitional:
-Repeat endoscopy in [**8-27**] weeks ([**2130-4-20**]) to evaluate esophageal
ulcer and esophagitis for healing. Appointment made with GI
-BP check to determine if labetalol dosing should be changed
-chemistry panel check to determine if lasix, lisinopril, HCTZ
can be/should be restarted
-neuropsychiatric testing.

Medications on Admission:
BENZTROPINE 1mg qAM, 2mg qPM
Lasix 20mg daily prn lower extremity edema
HCTZ - 25mg daily
COMBIVENT 2 puffs QID
LABETALOL 400mg [**Hospital1 **]
LISINOPRIL 40mg daily
PANTOPRAZOLE 40mg Tablet [**Hospital1 **]
PREDNISOLONE ACETATE 1%Drops QID to R eye
QUETIAPINE 700mg qHS
RANITIDINE 300mg [**Hospital1 **]
SULFASALAZINE 1000mg [**Hospital1 **]
TRAMADOL 50mg [**1-16**] Tablet qid prn
ZIPRASIDONE 80mg [**Hospital1 **]
ASPIRIN 81mg daily
NICOTINE patch

Discharge Medications:
1. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. quetiapine 400 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO QHS (once a day (at bedtime)):
700mg total.
4. quetiapine 300 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO at bedtime: 700mg total.
5. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
6. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO twice a
day.
13. tramadol 50 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
14. benztropine 1 mg Tablet Sig: 1-2 Tablets PO twice a day:
take 1mg (1 tablet) in the morning and 2mg (2 tablets) in the
evening.
15. labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*0*
16. pantoprazole 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:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 249**]

Discharge Diagnosis:
Primary Diagnosis:
Hematemesis due to esophagitis
gastro-esophageal ulcer
Acute renal failure

Secondary Diagnoses:
Chronic systolic CHF
Hypertension
Bipolar affective disorder/shizophrenia
Crohn's Disease


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


Discharge Instructions:
You were admitted due to bleeding from your gastrointestinal
tract including your stomach. You were initially admitted to the
ICU and underwent an endoscopy that showed an ulcer and severe
irritation in your esophagus (the tube connecting your mouth to
your stomach). You were started on some new medications for
this. You will need to follow up with a gastroenterologist after
discharge to ensure that your ulcer is healing.
.
Please avoid alcohol as this will worsen your ulcer and
esophagitis. You have been seen by social work to help provide
you with resources.
.
Please stop using cocaine. If you take labetalol (medication for
blood pressure) with cocaine you could suffer a significant
heart attack and die. Please use the resources that were
provided to you by social work to stop using cocaine. If you
continue to use cocaine, please do not take your labetalol.
.
Your medications have been changed
1.Sucralfate has been started to help heal your esophagus
2.omeprazole has been started to help with ulcer healing
3.Hydrochlorothiazide, lasix, and lisinopril have been stopped
at this time due to your kidney function.
4.your labetalol was increased because your other blood pressure
medications were changed.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
.
We strongly recommend you stop using alcohol to excess and other
drugs to help protect your health.

Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2130-3-10**] at 1:45 PM
With:DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] ( who works on Dr. [**Last Name (STitle) 93301**] team)
Phone:[**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**], south
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: DIV. OF GASTROENTEROLOGY
When: MONDAY [**2130-4-3**] at 4:30 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2163**], MD
Phone:[**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage
{'Acute esophagitis,Acute kidney failure with lesion of tubular necrosis,Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Chronic systolic heart failure,Acidosis,Acute posthemorrhagic anemia,Regional enteritis of unspecified site,Chronic hepatitis C without mention of hepatic coma,Chronic airway obstruction, not elsewhere classified,Chronic kidney disease, Stage III (moderate),Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Other specified cardiac dysrhythmias,Leukocytosis, unspecified,Rheumatoid arthritis,Bipolar disorder, unspecified,Cocaine abuse, unspecified,Myalgia and myositis, unspecified,Unspecified schizophrenia, 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: Hematemesis

PRESENT ILLNESS: Ms. [**Name13 (STitle) 805**] is a 48-year-old F PMhx chronic HCV w Stage I
fibrosis, hypertension, Crohn's disease, rheumatoid arthritis,
and bipolar disorder who presented with with 3 days of
nausea/vomitting, and new onset hematemesis.  Patient reports 10
episodes of about a cup full of vomiting dark, coffee ground
emesis following a binge on 40 ounces of malt liquor and a half
a fifth of Captain [**Doctor Last Name **] original spiced rum.  Patient
reports that she often vomits after drinking (up to 3 times a
week).  She denies taking any cocaine during this time.  Patient
states that she has been having fevers (unmeasured) but no other
localizing symptoms.  She states that she has been drinking
water, but not taking any of her home medications and not eating
due to the vomiting.  She states that she may not have urinated
for the past 2 days and that she did pass a dark, oily stool
yesterday.   Patient denies recent travel, strange foods, or
sick contacts.  On the morning of admission, patient had 1
episode of hematemesis and called 911.

MEDICAL HISTORY: 1)  Cardiomyopathy most likely secondary to hypertensive heart
    disease and polysubstance abuse, LV systolic dysfunction,
    EF 35-40%, NYHA class I-II.
2)  Hypertension
3)  Polysubstance abuse (cocaine, etoh)
4.) Crohn's disease since [**2099**] vs. ulcerative colitis (Chronic
active colitis with ulceration seen on biopsy in [**8-18**] and [**2-/2114**])
5.) hx abnormal mammogram with L breast biopsy in [**10-19**] -
sclerosing adenosis, Pseudoangiomatous stromal hyperplasia.
6.) Bipolar/Schizophrenia (per patient)
7.) Depression (per patient)
8.) Fibromyalgia (per patient)
9.) Brain aneurysm s/p surgery at [**Hospital1 112**] (per patient)
10.) Nicotine abuse

MEDICATION ON ADMISSION: BENZTROPINE 1mg qAM, 2mg qPM
Lasix 20mg daily prn lower extremity edema
HCTZ - 25mg daily
COMBIVENT 2 puffs QID
LABETALOL 400mg [**Hospital1 **]
LISINOPRIL 40mg daily
PANTOPRAZOLE 40mg Tablet [**Hospital1 **]
PREDNISOLONE ACETATE 1%Drops QID to R eye
QUETIAPINE 700mg qHS
RANITIDINE 300mg [**Hospital1 **]
SULFASALAZINE 1000mg [**Hospital1 **]
TRAMADOL 50mg [**1-16**] Tablet qid prn
ZIPRASIDONE 80mg [**Hospital1 **]
ASPIRIN 81mg daily
NICOTINE patch

ALLERGIES: Aspirin

PHYSICAL EXAM: Admission:
Vitals: T:98.9 BP:75/43 P:111 R: 18 O2: 100%
General: Alert, oriented, moving around alot/ psychomotor
agitation.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP unable to see, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic flow
murmur over precordium not on carotids, not radiating to left
axilla.  No rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Non contributory

SOCIAL HISTORY: Patient lives on SSI/disability and lives alone in an apartment
above her 25 year old daughter.  + h/o cocaine and alcohol
abuse; + tobacco [**7-23**] cigarrettes a day since age 35 

### Response:
{'Acute esophagitis,Acute kidney failure with lesion of tubular necrosis,Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Chronic systolic heart failure,Acidosis,Acute posthemorrhagic anemia,Regional enteritis of unspecified site,Chronic hepatitis C without mention of hepatic coma,Chronic airway obstruction, not elsewhere classified,Chronic kidney disease, Stage III (moderate),Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Other specified cardiac dysrhythmias,Leukocytosis, unspecified,Rheumatoid arthritis,Bipolar disorder, unspecified,Cocaine abuse, unspecified,Myalgia and myositis, unspecified,Unspecified schizophrenia, unspecified'}
