CHIEF COMPLAINT: Hematemesis

PRESENT ILLNESS: 69 year old male with a two-year history of cirrhosis secondary
to alcohol abuse. He presented to [**Hospital 1326**] Clinic at [**Hospital1 18**] on
the afternoon prior to admission, at which time he reported that
he had been feeling well. He has been sober for ~ 6 months and
is undergoing evaluation for liver transplant. Lab values at
this visit were hct 33.3, T.Bili 3.3, AST 70, ALT 21, INR 1.3.
.
Later on the same afternoon, he had an episode of unquantified
coffee ground emesis at home and was taken to [**Hospital3 10310**]
Hospital. At OSH, he was found to have a hematocrit of 27.8. NG
lavage was performed with dark red liquid aspirated. He had
another witnessed episode of hematemesis with report of ~300
cc's of bright red blood with clots. He received Octreotide gtt
at 50 mcg/hour, Zofran 4 mg IV x 1, 2 Liters NS, 2 PIV's, 2
units PRBC's and was transferred directly to the [**Hospital1 18**] MICU for
further care.

MEDICAL HISTORY: 1. ESLD with portal hypertension, ascites requiring bimonthly
paracentesis
2. h/o alcohol abuse
3. UGIB ([**2103**]) s/p variceal banding at [**Hospital1 2025**]
4. h/o hyponatremia as low as 119
5. Herniated discs between L3/L4
6. Tobacco abuse
7. colonoscopy performed in [**2173**] that showed two colonic
adenomas and one hyperplastic polyp

MEDICATION ON ADMISSION: 1. Prilosec
2. Lactulose
3. Lasix 40 mg per day
4. Aldactone 50 mg per day

ALLERGIES: Penicillins / Macrolide Antibiotics / Quinolones / Ursodiol

PHYSICAL EXAM: T 97.8, HR 101, BP 101/56, SpO2 100%
Gen - cachectic [**Male First Name (un) 4746**], agitated
HEENT - icteric sclera
CV - tachy, regular rhythm. [**2-15**] SM.
Chest - He has mild gynecomastia. Lungs CTA.
Abdomen - protuberant abdomen with an evert umbilicus. There is
no evidence of any palpable liver or spleen. He has evidence of
shifting dullness consistent with ascites.
Extrem - Extremities warm and well-perfused, no edema, 2+
peripheral pulses
Skin - Jaundiced to mid-torso. No cutaneous stigmata of chronic
liver disease.

FAMILY HISTORY: His father was an alcoholic. There is no family history of liver
disease that is known.

SOCIAL HISTORY: Significant history of alcohol use, drinking from the age of 25
until recently, stopping approximately six months ago. He has no
history of illicit drug use. He smoked half a pack of cigarettes
per day for 20 years, but has been off them for 20 years. He
never received a blood transfusion prior to [**2157**].
Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Acute respiratory failure,Acute posthemorrhagic anemia,Other and unspecified alcohol dependence, unspecified,Acquired coagulation factor deficiency,Hepatic encephalopathy,Thrombocytopenia, unspecified,Hyposmolality and/or hyponatremia
Alcohol cirrhosis liver,Bleed esoph var oth dis,Acute respiratry failure,Ac posthemorrhag anemia,Alcoh dep NEC/NOS-unspec,Acq coagul factor defic,Hepatic encephalopathy,Thrombocytopenia NOS,Hyposmolality
Admission Date:  [**2174-1-13**]              Discharge Date:   [**2174-1-21**]

Date of Birth:  [**2103-11-23**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Macrolide Antibiotics / Quinolones / Ursodiol

Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Hematemesis

Major Surgical or Invasive Procedure:
EGD
.
TIPS
.
Paracentesis

History of Present Illness:
69 year old male with a two-year history of cirrhosis secondary
to alcohol abuse. He presented to [**Hospital 1326**] Clinic at [**Hospital1 18**] on
the afternoon prior to admission, at which time he reported that
he had been feeling well. He has been sober for ~ 6 months and
is undergoing evaluation for liver transplant. Lab values at
this visit were hct 33.3, T.Bili 3.3, AST 70, ALT 21, INR 1.3.
.
Later on the same afternoon, he had an episode of unquantified
coffee ground emesis at home and was taken to [**Hospital3 10310**]
Hospital. At OSH, he was found to have a hematocrit of 27.8. NG
lavage was performed with dark red liquid aspirated. He had
another witnessed episode of hematemesis with report of ~300
cc's of bright red blood with clots. He received Octreotide gtt
at 50 mcg/hour, Zofran 4 mg IV x 1, 2 Liters NS, 2 PIV's, 2
units PRBC's and was transferred directly to the [**Hospital1 18**] MICU for
further care.


Past Medical History:
1. ESLD with portal hypertension, ascites requiring bimonthly
paracentesis
2. h/o alcohol abuse
3. UGIB ([**2103**]) s/p variceal banding at [**Hospital1 2025**]
4. h/o hyponatremia as low as 119
5. Herniated discs between L3/L4
6. Tobacco abuse
7. colonoscopy performed in [**2173**] that showed two colonic
adenomas and one hyperplastic polyp


Social History:
Significant history of alcohol use, drinking from the age of 25
until recently, stopping approximately six months ago. He has no
history of illicit drug use. He smoked half a pack of cigarettes
per day for 20 years, but has been off them for 20 years. He
never received a blood transfusion prior to [**2157**].

Family History:
His father was an alcoholic. There is no family history of liver
disease that is known.

Physical Exam:
T 97.8, HR 101, BP 101/56, SpO2 100%
Gen - cachectic [**Male First Name (un) 4746**], agitated
HEENT - icteric sclera
CV - tachy, regular rhythm. [**2-15**] SM.
Chest - He has mild gynecomastia. Lungs CTA.
Abdomen - protuberant abdomen with an evert umbilicus. There is
no evidence of any palpable liver or spleen. He has evidence of
shifting dullness consistent with ascites.
Extrem - Extremities warm and well-perfused, no edema, 2+
peripheral pulses
Skin - Jaundiced to mid-torso. No cutaneous stigmata of chronic
liver disease.


Pertinent Results:
[**2174-1-13**] 12:45PM   PT-14.8* INR(PT)-1.3*
[**2174-1-13**] 12:45PM   PLT COUNT-146*
[**2174-1-13**] 12:45PM   MACROCYT-1+
[**2174-1-13**] 12:45PM   NEUTS-64.7 LYMPHS-25.8 MONOS-7.6 EOS-1.5
BASOS-0.4
[**2174-1-13**] 12:45PM   WBC-5.7 RBC-3.39* HGB-11.0* HCT-33.3* MCV-98
MCH-32.5* MCHC-33.1 RDW-14.1
[**2174-1-13**] 12:45PM   HCV Ab-NEGATIVE
[**2174-1-13**] 12:45PM   HIV Ab-NEGATIVE
[**2174-1-13**] 12:45PM   CEA-5.7* PSA-0.3 AFP-3.3
[**2174-1-13**] 12:45PM   HBsAg-NEGATIVE HBc Ab-NEGATIVE HAV
Ab-NEGATIVE
[**2174-1-13**] 12:45PM   ALBUMIN-3.7 CALCIUM-9.2 PHOSPHATE-2.6*
MAGNESIUM-2.2
[**2174-1-13**] 12:45PM   ALT(SGPT)-21 AST(SGOT)-70* ALK PHOS-142* TOT
BILI-3.3*
[**2174-1-13**] 12:45PM   estGFR-Using this
[**2174-1-13**] 12:45PM   UREA N-12 CREAT-1.0 POTASSIUM-3.4
CHLORIDE-91* TOTAL CO2-30
[**2174-1-13**] 12:45PM   GLUCOSE-91
[**2174-1-13**] 11:38PM   PT-18.3* PTT-38.2* INR(PT)-1.7*
[**2174-1-13**] 11:38PM   PLT COUNT-116*
[**2174-1-13**] 11:38PM   WBC-7.4 RBC-2.64* HGB-8.5* HCT-24.6*# MCV-93
MCH-32.3* MCHC-34.7 RDW-15.8*
[**2174-1-13**] 11:38PM   ETHANOL-NEG
[**2174-1-13**] 11:38PM   ALBUMIN-2.4* CALCIUM-7.3* PHOSPHATE-3.6
MAGNESIUM-1.7
[**2174-1-13**] 11:38PM   CK-MB-NotDone cTropnT-<0.01
[**2174-1-13**] 11:38PM   LIPASE-34
[**2174-1-13**] 11:38PM   ALT(SGPT)-15 AST(SGOT)-41* LD(LDH)-142
CK(CPK)-43 ALK PHOS-79 AMYLASE-58 TOT BILI-3.6*
.
EGD [**2174-1-14**]
Blood in the esophagus
Varices at the lower third of the esophagus
Erythema, granularity and congestion in the whole stomach
compatible with portal hypertensive gastropathy
Blood in the stomach
Blood in the duodenal bulb and second part of the duodenum
No peptic or duodenal ulcers were noted.
Otherwise normal EGD to second part of the duodenum
.
RUQ U/S [**2174-1-17**]
1.  Limited examination secondary to patient cooperation.
Widely patent TIPS.  Repeat evaluation of the TIPS and hepatic
vasculature is recommended for a complete baseline examination
when the patient is more cooperative.
2.  Cirrhotic liver with moderate ascites.


Brief Hospital Course:
70 yo male with a known h/o ESLD with previously diagnosed
portal hypertension and varices who presented with hematemesis.
The following issues were investigated during this
hospitalization:
.
1) UGIB: Pt. presented with hematemesis x 2 in the setting of
known esophageal varices.  On admission, 4 units PRBC's were
transfused for a hct of 24.6 (down from 33.3 earlier on same
day) and two units of FFP for an INR of 1.7. An EGD revealed a
large active bleed, however an attempt at variceal banding was
unsuccessful. A  [**Last Name (un) **] tube was placed for emergent
tamponade of active bleeding.  On the following day a successful
TIPS was performed by IR, and patient the remained
hemodynamically stable s/p procedure. He was called out to the
general medicine floor where his Hct remained stable at 30 or
greater and his vitals signs were not indicative of bleeding. He
continued to receive a PPI [**Hospital1 **] and Levofloxacin was continued
for a total of 14 days, with 2 days remaining on discharge. A
discussion was initiated regarding the TIPS as his procedure was
complicated and interventional radiology felt that the stent was
at risk for thrombosing. Plavix was entertained as an option for
anticoagulation, given this concern, however, a literature
search revealed few convincing papers, particularly for this
particular patient who was more coagulopathic than patient
populations studied in those papers. The patient will need to
follow up with interventional radiology within one month for
evaluation of his stent for patency.
.
2) Cirrhosis:  Patient has h/o alcohol-induced cirrhosis, portal
hypertension, and known varices. Once stable from the variceal
bleeding, he was managed with Lactulose and Rifaximin for
encephalopathy, Levofloxacin prophylaxis as mentioned above and
one therapeutic paracentesis.
.
3) Thrombocytopenia: In the setting of liver disease. Pt was
monitored for signs of bleeding, and given no evidence of
bleeding, he was never transfused once he arrived to the floor.
His platelet count remained stable from day to day.
.
5) Hyponatremia: The patient was noted to have a serum sodium of
132 on the day prior to discharge. This was thought to be due to
a state of hypervolemic hyponatremia in the setting of liver
disease. Fluid restriction to 1.5 L/day was implemented.
Additionally, he had one therapeutic paracentesis. Given the
risk of ascites, the patient was restarted on a lower dose of
diuretics (at-home dose was held during most of this
hospitalization), which will need to be adjusted cautiously
given hyponatremia.


Medications on Admission:
1. Prilosec
2. Lactulose
3. Lasix 40 mg per day
4. Aldactone 50 mg per day


Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q2H (every
2 hours) as needed for stool output 1-2L/day.
2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for ascites.
6. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) as needed for ascites.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary
Upper GI Bleed from esophageal varices
.
Secondary
Cirrhosis c/b varices, encephalopathy and thrombocytopenia


Discharge Condition:
Vitals signs stable, able to tolerate PO


Discharge Instructions:
You were seen and evaluated for bleeding from esophageal varices
(veins in your food tube). You were initially admitted to the
ICU where you received intensive care while your blood count was
stabilized. You had a procedure performed - TIPS (transjugular
intrahepatic portosytemic shunt) to relieve the built up
pressure in your veins, which caused the bleeding. You were then
transferred to the general medicine floor where you continued to
improve, blood count and vital signs remained stable and now
you're being discharged to a rehabilitation facility for
continued therapy.

* Please take all of your medications as directed.

* Keep all of your follow-up appointments.

* Call your doctor or go to the ER for any of the following:
vomiting
  blood, blood in your stool or dark black, tarry stools,
  lightheadedness/dizziness, fainting, fevers/chills,
nausea/vomiting
  or any other concerning symptoms.

Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2174-2-2**] 10:20

You will need to be seen by the interventional radiologists who
performed your TIPS, in one month so that it can be evaluated.
Please discuss this with your hepatologist, Dr. [**Last Name (STitle) 497**] so that it
may be arranged.
{'Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Acute respiratory failure,Acute posthemorrhagic anemia,Other and unspecified alcohol dependence, unspecified,Acquired coagulation factor deficiency,Hepatic encephalopathy,Thrombocytopenia, unspecified,Hyposmolality and/or hyponatremia'}


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: 69 year old male with a two-year history of cirrhosis secondary
to alcohol abuse. He presented to [**Hospital 1326**] Clinic at [**Hospital1 18**] on
the afternoon prior to admission, at which time he reported that
he had been feeling well. He has been sober for ~ 6 months and
is undergoing evaluation for liver transplant. Lab values at
this visit were hct 33.3, T.Bili 3.3, AST 70, ALT 21, INR 1.3.
.
Later on the same afternoon, he had an episode of unquantified
coffee ground emesis at home and was taken to [**Hospital3 10310**]
Hospital. At OSH, he was found to have a hematocrit of 27.8. NG
lavage was performed with dark red liquid aspirated. He had
another witnessed episode of hematemesis with report of ~300
cc's of bright red blood with clots. He received Octreotide gtt
at 50 mcg/hour, Zofran 4 mg IV x 1, 2 Liters NS, 2 PIV's, 2
units PRBC's and was transferred directly to the [**Hospital1 18**] MICU for
further care.

MEDICAL HISTORY: 1. ESLD with portal hypertension, ascites requiring bimonthly
paracentesis
2. h/o alcohol abuse
3. UGIB ([**2103**]) s/p variceal banding at [**Hospital1 2025**]
4. h/o hyponatremia as low as 119
5. Herniated discs between L3/L4
6. Tobacco abuse
7. colonoscopy performed in [**2173**] that showed two colonic
adenomas and one hyperplastic polyp

MEDICATION ON ADMISSION: 1. Prilosec
2. Lactulose
3. Lasix 40 mg per day
4. Aldactone 50 mg per day

ALLERGIES: Penicillins / Macrolide Antibiotics / Quinolones / Ursodiol

PHYSICAL EXAM: T 97.8, HR 101, BP 101/56, SpO2 100%
Gen - cachectic [**Male First Name (un) 4746**], agitated
HEENT - icteric sclera
CV - tachy, regular rhythm. [**2-15**] SM.
Chest - He has mild gynecomastia. Lungs CTA.
Abdomen - protuberant abdomen with an evert umbilicus. There is
no evidence of any palpable liver or spleen. He has evidence of
shifting dullness consistent with ascites.
Extrem - Extremities warm and well-perfused, no edema, 2+
peripheral pulses
Skin - Jaundiced to mid-torso. No cutaneous stigmata of chronic
liver disease.

FAMILY HISTORY: His father was an alcoholic. There is no family history of liver
disease that is known.

SOCIAL HISTORY: Significant history of alcohol use, drinking from the age of 25
until recently, stopping approximately six months ago. He has no
history of illicit drug use. He smoked half a pack of cigarettes
per day for 20 years, but has been off them for 20 years. He
never received a blood transfusion prior to [**2157**]. 

### Response:
{'Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Acute respiratory failure,Acute posthemorrhagic anemia,Other and unspecified alcohol dependence, unspecified,Acquired coagulation factor deficiency,Hepatic encephalopathy,Thrombocytopenia, unspecified,Hyposmolality and/or hyponatremia'}
