CHIEF COMPLAINT: 

PRESENT ILLNESS: Briefly, the patient is a
52-year-old gentleman with a past medical history of alcohol
abuse who was diagnosed with alcoholic cirrhosis on this
admission.  He was admitted on [**10-3**] with eight episodes
of hematochezia and melena and one episode of hematemesis on
the day of admission.

MEDICAL HISTORY: 1.  Alcohol abuse.
2.  Question diabetes mellitus.

MEDICATION ON ADMISSION: 1.  Multivitamin.
2.  Vitamin A.
3.  Vitamin B.
4.  Vitamin C.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives with his partner.  [**Name (NI) **]
drinks a 6-pack of alcohol and half a pint of gin every
evening for the past several years.  He quit tobacco 10 years
ago.  He has no history of intravenous drug use or illicit
drug use.
Alcoholic cirrhosis of liver,Pneumonitis due to inhalation of food or vomitus,Severe sepsis,Esophageal varices in diseases classified elsewhere, with bleeding,Other and unspecified alcohol dependence, continuous,Acute posthemorrhagic anemia,Thrombocytopenia, unspecified,Septic shock
Alcohol cirrhosis liver,Food/vomit pneumonitis,Severe sepsis,Bleed esoph var oth dis,Alcoh dep NEC/NOS-contin,Ac posthemorrhag anemia,Thrombocytopenia NOS,Septic shock
Admission Date:  [**2138-10-3**]     Discharge Date: [**2138-10-14**]

Date of Birth:   [**2086-2-26**]     Sex:  M

Service:  Medicine

HISTORY OF PRESENT ILLNESS:  Briefly, the patient is a
52-year-old gentleman with a past medical history of alcohol
abuse who was diagnosed with alcoholic cirrhosis on this
admission.  He was admitted on [**10-3**] with eight episodes
of hematochezia and melena and one episode of hematemesis on
the day of admission.

The patient called the Emergency Medical Service.  His blood
pressure was found to be 80/palp with a heart rate in the
130s.  He was transferred to the Emergency Department.
Hemodynamically, the patient was stabilized.

In the Emergency Department, the patient's hematocrit was
found to be 16.9.  The patient was transfused 4 units of
packed red blood cells, 4 units of fresh frozen plasma, and
intravenous proton pump inhibitor.  He was started on an
octreotide drip and intravenous erythromycin.  The patient
had an nasogastric tube lavage which was positive for bright
red blood.  The Gastrointestinal Service was consulted for an
emergent esophagogastroduodenoscopy.

PAST MEDICAL HISTORY:
1.  Alcohol abuse.
2.  Question diabetes mellitus.

MEDICATIONS ON ADMISSION:
1.  Multivitamin.
2.  Vitamin A.
3.  Vitamin B.
4.  Vitamin C.

ALLERGIES:  The patient has no known drug allergies.

SOCIAL HISTORY:  The patient lives with his partner.  [**Name (NI) **]
drinks a 6-pack of alcohol and half a pint of gin every
evening for the past several years.  He quit tobacco 10 years
ago.  He has no history of intravenous drug use or illicit
drug use.

PHYSICAL EXAMINATION ON PRESENTATION:  Physical examination
on admission to the Medicine Service revealed the patient's
blood pressure was 131/78, his heart rate was 70, his
respiratory rate was 16, and his oxygen saturation was 96% on
room air.  In general, the patient was a pleasant
African-American gentleman in no apparent distress.  Head,
eyes, ears, nose, and throat examination revealed he did have
scleral icterus.  The oropharynx was clear.  The mucous
membranes were moist.  Cardiovascular examination revealed a
regular rate and rhythm.  Respiratory examination revealed
the patient's lungs were clear to auscultation bilaterally
with decreased breath sounds at the bases and crackles at the
left base.  The abdomen was soft, distended, and nontender.
He had tympanitic bowel sounds throughout.  There was no
hepatosplenomegaly.  Extremity examination revealed he had 1+
edema to the his knees.  His pulses were 2+.

PERTINENT LABORATORY VALUES ON PRESENTATION:   Laboratories
on admission to the Medicine Service revealed the patient's
hematocrit was 30.3.  His Chemistry-7 was within normal
limits.  His INR was 1.8.  His hepatology series was positive
for HBAB antibody.  At this point, all cultures were negative
to date.

BRIEF SUMMARY OF INTENSIVE CARE UNIT COURSE:  At this point,
the patient was intubated for airway protection.  The
esophagogastroduodenoscopy showed active bleeding from the
gastric varix.  The patient had 2+ bleeding varus in the
esophagus.  The bleeding site was injected with epinephrine
and morrhuate sodium to sclerose the varix; however, the
bleeding did not subside.  He was then treated with
intravenous vasopressin and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube was placed. The
[**Last Name (un) **] tube remained in place until [**10-4**].  He had no
more episodes of bleeding.  The Pitressin was discontinued;
however, the patient remained to be hypertensive.  A sepsis
workup ensued, and he was started on Levophed as his
hypertension did not respond to fluid boluses.

On [**10-5**], the patient had a right upper quadrant
ultrasound to see if there was enough ascites to tap.
Minimal fluid was tapped.  At this point, the patient became
febrile.  An echocardiogram was done which showed that he had
no vegetations, but there was possibly a left lower lobe
pneumonia.  Therefore, the patient was started intravenous
antibiotics.

On [**10-6**], the [**Last Name (un) **] tube was removed.  During his
Intensive Care Unit course, the patient was weaned off
pressors.  He was dependent on fresh frozen plasma during his
hospital course due to his coagulopathy secondary to his
liver disease.

On the evening of [**10-7**], the patient was extubated.  He
tolerated this well.  His vital signs were stable.  His
hematocrit had been stable in the 30s for over 24 hours, so
the patient was called out to the Medicine floor for further
treatment.

CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:

1.  GASTROINTESTINAL/VARICEAL BLEED ISSUES:  The patient was
followed by the Liver Service throughout his hospital course.
His hematocrit levels had remained stable.  He was maintained
on twice per day Protonix.

He had a repeat endoscopy on [**10-9**] which showed that he
had varices or cardia at the gastroesophageal junction and at
the lower one-third of the esophagus.  This varix was banded
successfully.  He also had an ulcer in the gastroesophageal
junction and cardia and blood in the body and antrum of his
stomach.

The patient was started on carafate 1 g four times per day.
He was continued on Protonix twice per day, and he was
started on nadolol and titrated up as tolerated.  However,
during his hospital course the nadolol had to be discontinued
given that he had worsening renal function.  In order to
maximize renal perfusion, the nadolol was discontinued.

Per the patient's computed tomography, it appeared that the
patient had chronic pancreatitis.  He did have significant
steatorrhea during his hospital stay; however, he was
asymptomatic.

2.  INFECTIOUS DISEASE ISSUES:  The patient had spiked a
fever on [**2138-10-6**] and was continued on ceftriaxone
and vancomycin in the Intensive Care Unit.  As his cultures
had been negative for any suspicious organisms, his
vancomycin was discontinued, and he was continued on
ceftriaxone during his hospital course.

He had a repeat paracentesis done on [**10-11**] which showed
no evidence of spontaneous bacterial peritonitis.  He
remained afebrile and was completing the course for his left
lower lobe pneumonia.

The patient had been on stress-dose steroids in the Intensive
Care Unit.  On [**10-10**], as it appeared that the patient
had not been septic and remained afebrile, his stress-dose
steroids were discontinued.

3.  PULMONARY ISSUES:  The patient was extubated on [**10-7**].  He had no respiratory issues during his Medicine Service
stay.

4.  ENDOCRINE ISSUES:  For the patient's diabetes mellitus ?
secondary to steroid use ? previous to his admission, he
remained on fingersticks four times per day and an insulin
sliding-scale as needed.

5.  RENAL ISSUES:  During the [**Hospital 228**] hospital course, he
had acute renal failure which started on [**10-9**].  His
creatinine increased to 1.1.  The source of his renal failure
was unclear.  Initially, this was thought to be an acute
tubular necrosis secondary to his hypotension while in the
Intensive Care Unit; however, it persisted so it was likely
secondary to hepatorenal syndrome.

The patient's diuretics were discontinued.  he was started on
intravenous albumin infusions daily.  He was continued on his
octreotide in order to maximize renal perfusion.

During his hospital course, upon until [**10-12**], the
patient's creatinine continued to rise.  Therefore, on
[**10-12**], the nadolol was discontinued and he was started
on Trental 400 mg by mouth three times per day and midodrine
75 mg by mouth three times per day.

6.  FLUIDS/ELECTROLYTES/NUTRITION ISSUES:  The patient
remained nothing by mouth during his hospital stay in the
Intensive Care Unit.  His diet was advanced on [**10-11**],
and the patient tolerated this well.

The Medicine Service tried to optimize his nutritional status
with additional Boost supplements and Mighty shakes.

7.  HEMATOLOGIC/COAGULOPATHY  ISSUES:  The patient was
admitted with an INR of 2.6, and it appeared that he was
dependent on fresh frozen plasma in order to reverse his
coagulopathy; however, during his hospital course an empiric
trial of vitamin K was started on  [**10-9**].

8.  CONSULTATION ISSUES:  The Addiction Service and Social
Work were consulted, and the patient will likely continue
with an outpatient detoxification treatment.

DISCHARGE DIAGNOSES:
 1.  Alcoholic cirrhosis.
 2.  Ascites.
 3.  Alcohol abuse; continuous.
 4.  Acute renal failure secondary to hepatorenal syndrome.
 5.  Coagulopathy.
 6.  Esophagitis.
 7.  Hypoalbuminemia.
 8.  Esophageal varices with bleed.
 9.  Hypophosphatemia; repleted.
10.  Hypokalemia; repleted.

NOTE:  The patient was to be discharged at a later date, and
someone else will complete the Discharge Summary at that
time.





                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 34978**], M.D. [**MD Number(1) 24755**]

Dictated By:[**Name8 (MD) 8736**]

MEDQUIST36

D:  [**2138-10-14**]  14:45
T:  [**2138-10-14**]  19:26
JOB#:  [**Job Number 34979**]


Admission Date:  [**2138-10-3**]     Discharge Date:  [**2138-10-17**]

Date of Birth:   [**2086-2-26**]     Sex:  M

Service:

CONTINUATION:  Previous discharge summary dictated by Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **].

HOSPITAL COURSE:  From [**2138-10-14**], to [**2138-10-17**].
1.  Gastrointestinal bleed - The patient remained stable in
terms of the gastrointestinal bleeding.  He had no further
bleeding episodes.  The patient was continued on Octreotide
and Midodrine until [**2138-10-15**].  The Midridogin and the
Octreotide were then discontinued.  The patient was continued
on Trental as well as Sucralfate and Protonix. The patient
was later started on Nadolol the day prior to discharge for
prophylaxis against further gastrointestinal bleeding
episodes from severe varices.  The patient tolerated the
Nadolol with blood pressure remaining around 100/60,
asymptomatic with changes of position.

2.  Infectious disease - The patient continued to have low
grade temperatures in the 99.0 to 100.0 range.  There was no
obvious source of infection.  The patient had blood cultures
and urine cultures which were negative for infection. The
patient had Clostridium difficile toxin assays done on his
stool which did not document any Clostridium difficile.  The
patient was continued on Ceftriaxone for a full ten day
course.

3.  Pulmonary - There were no active pulmonary issues during
the remainder of his hospital stay.  The patient did have
stable pleural effusions which should be followed up with
chest x-ray as an outpatient.

4.  Endocrine - The patient was noted to have high blood
sugar consistent with diabetes mellitus during his
hospitalization.  It was felt that the elevated blood sugar
may be related to acute illness.  The blood sugar did trend
down throughout the hospital stay.  Therefore, insulin was
discontinued on discharge.  The patient was discharged home,
however, with a glucometer to do fingerstick four times a day
with each meal and at bedtime.  The patient agreed to keep a
record of his blood sugar which he will bring to his primary
care physician appointment with Dr. [**Last Name (STitle) 818**] on Tuesday,
[**2138-10-21**].  It is felt that at that time he might consider
starting Glipizide at a low dose.  Given that he has
hepatorenal syndrome, we are hesitant upon starting an oral
hypoglycemic on discharge unless he definitely needed to be
started on an oral [**Doctor Last Name 360**].  The patient was advised that if
his blood sugar was over 300 that he should call the clinic
or present to the Emergency Department for therapy.

5.  Renal - The patient had renal failure consistent with
hepatorenal syndrome.  His creatinine remained stable at
around 1.4 for three days prior to discharge.  The patient
was maintaining good urine output throughout the remainder of
the hospitalization.  As stated previously by Dr. [**Last Name (STitle) **], the
patient's Nadolol was initially held secondary to what was
thought to be poor renal perfusion.  His creatinine did
improve somewhat and Nadolol was restarted prior to discharge
for prophylaxis of further vascular bleeding.

6.  Hematology - The patient had significant coagulopathies
related to his hepatic failure.  The patient's INR remained
in the 2.3 to 2.4 range despite treatment with Vitamin K and
therefore on discharge, the Vitamin K was not continued.  The
patient was told to monitor for signs of bleeding and, if he
needs follow-up with any further gastrointestinal bleeding,
especially blood in his vomit or his stool, he was instructed
to return to the Emergency Department immediately. The
patient will be followed up by hepatology in clinic.

7.  FEN - The patient was followed by nutrition for calorie
counts prior to discharge.  The patient did show improvement
in meeting his goals, however, he was below goal caloric
intake of greater than [**2134**].  On discharge, the patient was
encouraged to drink supplements which he agreed to do and he
was discharged home with a prescription for Nepro supplements
and instructed to drink them four times a day.  The patient
stated that he felt he would be eating better at home.

8.  Hepatic failure - As stated above, the patient had
significant coagulopathies from his hepatic failure.  The
patient's hepatic enzymes improved dramatically during
hospitalization.  His total bilirubin appeared to be
decreasing by discharge with a peak at 7.4.  The patient
likely had hepatitis secondary to alcohol with significant
sources given his variceal bleeding.  The patient was
continued on Ursodiol on discharge.  He was encouraged to
remain abstinent from alcohol.  The patient will follow-up
with AA after discharge.  The patient did have significant
ascites which he was asymptomatic from.  The patient was
informed that if he began having abdominal pain from tense
ascites that he should call his primary care physician or the
gastroenterology doctors that are following him for a
possible therapeutic tap.

DISCHARGE DIAGNOSES:
1.  Renal genitourinary failure.
2.  Ascites.
3.  Alcoholic cirrhosis.
4.  Esophagitis.
5.  Hepatopathy anemia.
6.  Esophageal varices with bleed.
7.  Alcohol abuse.

CONDITION ON DISCHARGE:  Stable.

DISCHARGE STATUS:  To home with services.

MEDICATIONS ON DISCHARGE:
1.  Thiamine 100 mg p.o. once daily.
2.  Folate 1 mg p.o. once daily.
3.  Multivitamin generic one capsule p.o. once daily.
4.  Pantoprazole 40 mg p.o. twice a day.
5.  Ursodiol 300 mg p.o. three times a day.
6.  Nadolol 10 mg p.o. once daily.
7.  Sucralfate one gram p.o. four times a day.
8.  Pentoxifylline 400 mg SR p.o. three times a day.
9.  Nepro Liquid one to two p.o. four times a day.
10. Glucometer - please check blood sugar with each meal and
at bedtime.
11. Test strips.
12. Lasix.

FOLLOW-UP:  The patient is to follow-up with gastroenterology
on Tuesday, [**2138-10-21**], for repeat endoscopy to further
evaluate varices and possible repeat banding.  The patient is
also advised to follow-up with a new primary care physician
which will be Dr. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 818**] on Tuesday, [**2138-10-21**], at
1:30 p.m.  The patient was encouraged to attend AA meetings
across the street.  The patient was advised that if he noted
any further blood in his vomit or in his stool or black tarry
stools that he was to return to the Emergency Department
immediately.  The patient was also encouraged to drink
nutritional supplements throughout the day.




                          [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 2506**]

Dictated By:[**Last Name (NamePattern1) **]

MEDQUIST36

D:  [**2138-10-17**]  16:34
T:  [**2138-10-18**]  11:34
JOB#:  [**Job Number 34980**]
{'Alcoholic cirrhosis of liver,Pneumonitis due to inhalation of food or vomitus,Severe sepsis,Esophageal varices in diseases classified elsewhere, with bleeding,Other and unspecified alcohol dependence, continuous,Acute posthemorrhagic anemia,Thrombocytopenia, unspecified,Septic shock'}


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: 

PRESENT ILLNESS: Briefly, the patient is a
52-year-old gentleman with a past medical history of alcohol
abuse who was diagnosed with alcoholic cirrhosis on this
admission.  He was admitted on [**10-3**] with eight episodes
of hematochezia and melena and one episode of hematemesis on
the day of admission.

MEDICAL HISTORY: 1.  Alcohol abuse.
2.  Question diabetes mellitus.

MEDICATION ON ADMISSION: 1.  Multivitamin.
2.  Vitamin A.
3.  Vitamin B.
4.  Vitamin C.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives with his partner.  [**Name (NI) **]
drinks a 6-pack of alcohol and half a pint of gin every
evening for the past several years.  He quit tobacco 10 years
ago.  He has no history of intravenous drug use or illicit
drug use. 

### Response:
{'Alcoholic cirrhosis of liver,Pneumonitis due to inhalation of food or vomitus,Severe sepsis,Esophageal varices in diseases classified elsewhere, with bleeding,Other and unspecified alcohol dependence, continuous,Acute posthemorrhagic anemia,Thrombocytopenia, unspecified,Septic shock'}
