CHIEF COMPLAINT: 

PRESENT ILLNESS: Mr. [**Known lastname 50010**] is an 80 year-old
male with a past medical history significant for alcoholic
cirrhosis, gastric and esophageal varices and recurrent
gastrointestinal bleed who presented to the [**Hospital 40262**] Hospital
with syncopal episodes after a gastrointestinal bleed.  His
son reports that he was in his usual state of health until
one week prior to admission when he complained of back pain,
decreased appetite, and decreased po intake and sleep.  Mr.
[**Known lastname 50010**] reports having brown stools and denies any tarry
black or malonic stools.  He does report vomiting times two
with bloody clots several days prior to transfer to [**Hospital1 1444**], and he states he passed out
while on the toilet after passing malonic stools.  This
episodes was not witnessed.  Mr. [**Known lastname 50010**] reports that he does
not remember the event.  He sustained trauma with a skin tear
at the left elbow and multiple rib fractures as seen on chest
CT on the left involving ribs 5 through 7 with disc
displacement in segments and pockets of air along the chest
wall consistent with subcutaneous air and a small left
pleural effusion.  There was no pneumothorax noted.  He
denied and had no evidence of head trauma.  His wife reported
that she heard the fall and brought him to the [**Hospital 40262**]
Hospital Emergency Department on [**10-16**].  At Falmuth vital
signs revealed a heart rate of 133 and a blood pressure of
84/41. He received 2 units of packed red blood cells and
hydration with normal saline.  He had an elevated white blood
cell count at that point at 18.4 and a hematocrit of 30 that
fell to 29.  His creatinine was 1.6 and fell to 1.3 after
hydration.  Esophagogastroduodenoscopy at [**Hospital 40262**] Hospital
showed blood in the stomach, but no active bleed and there
was a noted large varices in the gastric fundus and grade one
varix in the lower esophagus with no stigmata of recent
hemorrhage.  He was started on an Octreotide drip and
Protonix and transferred to [**Hospital1 188**] for evaluation of TIPS procedure.  At the time of
transfer his hematocrit was stable at 29.

MEDICAL HISTORY: 1.  Alcohol abuse.
2.  Alcoholic cirrhosis with known gastroesophageal varices.
3.  Hypertension.
4.  Depression.
5.  Gastroesophageal reflux disease.
6.  History of gastric ulcers secondary to non-steroidal
anti-inflammatory drugs and also being H-pylori positive.
7.  Chronic obstructive pulmonary disease.
8.  Anemia.

MEDICATION ON ADMISSION: 

ALLERGIES: He has an allergy to Penicillin and
Cephalosporins with unknown reactions.

PHYSICAL EXAM: 

FAMILY HISTORY: He has a sister with diabetes mellitus.
There is no history of gastrointestinal bleeding, heart
disease, or hypertension in the family.

SOCIAL HISTORY: Mr. [**Known lastname 50010**] is a retired Army cook.  He
lives with his wife and daughter in [**Name (NI) 50011**].  His son is
his health care proxy.  [**Name (NI) **] is full code.  He use to smoke,
but states he quit five years ago.  He has 120 to 180 pack
year history prior to that time.  He has a significant
alcohol history and states that his last drink was a Vodka
tonic one month ago.  He denies any intravenous drug use.
Hemorrhage of gastrointestinal tract, unspecified,Unspecified septicemia,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, continuous,Chronic airway obstruction, not elsewhere classified,Unspecified pleural effusion,Acute kidney failure, unspecified,Other complications due to other internal prosthetic device, implant, and graft,Urinary tract infection, site not specified
Gastrointest hemorr NOS,Septicemia NOS,Alcohol cirrhosis liver,Alcoh dep NEC/NOS-contin,Chr airway obstruct NEC,Pleural effusion NOS,Acute kidney failure NOS,Comp-int prost devic NEC,Urin tract infection NOS
Admission Date:  [**2164-10-17**]       Discharge Date:  [**2164-10-24**]

Date of Birth:                    Sex:  M

Service:  MICU

HISTORY OF PRESENT ILLNESS:  Mr. [**Known lastname 50010**] is an 80 year-old
male with a past medical history significant for alcoholic
cirrhosis, gastric and esophageal varices and recurrent
gastrointestinal bleed who presented to the [**Hospital 40262**] Hospital
with syncopal episodes after a gastrointestinal bleed.  His
son reports that he was in his usual state of health until
one week prior to admission when he complained of back pain,
decreased appetite, and decreased po intake and sleep.  Mr.
[**Known lastname 50010**] reports having brown stools and denies any tarry
black or malonic stools.  He does report vomiting times two
with bloody clots several days prior to transfer to [**Hospital1 1444**], and he states he passed out
while on the toilet after passing malonic stools.  This
episodes was not witnessed.  Mr. [**Known lastname 50010**] reports that he does
not remember the event.  He sustained trauma with a skin tear
at the left elbow and multiple rib fractures as seen on chest
CT on the left involving ribs 5 through 7 with disc
displacement in segments and pockets of air along the chest
wall consistent with subcutaneous air and a small left
pleural effusion.  There was no pneumothorax noted.  He
denied and had no evidence of head trauma.  His wife reported
that she heard the fall and brought him to the [**Hospital 40262**]
Hospital Emergency Department on [**10-16**].  At Falmuth vital
signs revealed a heart rate of 133 and a blood pressure of
84/41. He received 2 units of packed red blood cells and
hydration with normal saline.  He had an elevated white blood
cell count at that point at 18.4 and a hematocrit of 30 that
fell to 29.  His creatinine was 1.6 and fell to 1.3 after
hydration.  Esophagogastroduodenoscopy at [**Hospital 40262**] Hospital
showed blood in the stomach, but no active bleed and there
was a noted large varices in the gastric fundus and grade one
varix in the lower esophagus with no stigmata of recent
hemorrhage.  He was started on an Octreotide drip and
Protonix and transferred to [**Hospital1 188**] for evaluation of TIPS procedure.  At the time of
transfer his hematocrit was stable at 29.

Of note, he had a similar hospitalization at [**Hospital 40262**] Hospital
on [**2164-9-19**] for an episode of gastrointestinal bleed with
malonic stools after he self discontinued his Prevacid,
because of increased diarrhea.  He received 4 units of packed
red blood cells at this time and EG showed a submucosal
fundal mass with a differential diagnosis including stromal
tumor versus gastric fundal varix.
Esophagogastroduodenoscopy two weeks later at [**Hospital1 346**] revealed gastric fundal varices,
probable chronic pancreatitis and perigastric varices.  He
was treated with nonselected beta blockers at this time.

PAST MEDICAL HISTORY:
1.  Alcohol abuse.
2.  Alcoholic cirrhosis with known gastroesophageal varices.
3.  Hypertension.
4.  Depression.
5.  Gastroesophageal reflux disease.
6.  History of gastric ulcers secondary to non-steroidal
anti-inflammatory drugs and also being H-pylori positive.
7.  Chronic obstructive pulmonary disease.
8.  Anemia.

SOCIAL HISTORY:  Mr. [**Known lastname 50010**] is a retired Army cook.  He
lives with his wife and daughter in [**Name (NI) 50011**].  His son is
his health care proxy.  [**Name (NI) **] is full code.  He use to smoke,
but states he quit five years ago.  He has 120 to 180 pack
year history prior to that time.  He has a significant
alcohol history and states that his last drink was a Vodka
tonic one month ago.  He denies any intravenous drug use.

FAMILY HISTORY:  He has a sister with diabetes mellitus.
There is no history of gastrointestinal bleeding, heart
disease, or hypertension in the family.

ALLERGIES:  He has an allergy to Penicillin and
Cephalosporins with unknown reactions.

MEDICATIONS AT HOME:
1.  Nonselected beta blocker (the patient and family do not
know, which specific beta blocker).
2.  Norvasc 5 mg q.d.
3.  Quinine sulfate 325 q.h.s.
4.  Maxzide 50/25 q.d.
5.  Cardura 2 mg q.d.
6.  Prevacid 20 mg q.d.
7.  Zoloft 2 mg q.d.
8.  Imodium prn.

PHYSICAL EXAMINATION:  Vital signs on admission revealed a
temperature of 98.6, heart rate of 76, blood pressure 142/76,
respirations 18, and oxygen saturation of 100% on room air.
In general he was an overweight male appearing younger then
stated age lying in bed.  He was alert and oriented times two
and was using a morphine PCA with limited movement.  On HEENT
examination his sclera had evidence of slight icterus.  His
pupils were constricted, but were equally round and reactive
to light.  His extraocular movements intact.  He had rosacea
noted on his nose.  His oropharynx was clear with dry mucous
membranes.  His neck was supple without lymphadenopathy or
thyromegaly.  Examination of his chest revealed bruising over
the left axilla with tenderness to palpation.  He had
crackles two thirds of the way anteriorly on the left side by
auscultation.  He had crepitus at the left apex one third of
the way down on palpation.  His heart was regular, and there
was evidence of a 2 out of 6 systolic crescendo decrescendo
ejection murmur at the base radiating to the left carotids.
He also had 2 out of 6 holosystolic murmur at the apex with
radiation to the axilla.  His abdomen was firm and distended,
yet nontender to palpation.  He had good bowel sounds.  He
had no fluid wave or ascites.  He had no hepatosplenomegaly
to percussion.  Examination of his extremities revealed no
evidence of clubbing, cyanosis or edema.  Extremities were
warm and well perfuse.  He had 2+ dorsalis pedis pulses
bilaterally.  Examination of his skin revealed palmar
erythema bilaterally.  He had ecchymosis of his upper
extremities noted from his hand to his elbows bilaterally.
He had a left skin tear on his elbow on the left wrapped with
gauze.  He had telangiectasias noted on his face and
extremities.  There was also evidence of cherry angiomas on
the upper thorax.  On neurological examination he was alert
and oriented times three.  He knew he was in the hospital,
but not which hospital it was.  He had no asterixics noted in
his right hand and was not able to extend his left hand due
to pain.

LABORATORIES ON ADMISSION:  CBC revealed a white blood cell
count of 14, hematocrit 28.2, platelets 124.  He had a PT of
13.2, PTT of 25.6.  Chemistries revealed a sodium of 141,
potassium of 3.9, chloride 90, bicarb 25, BUN 46, creatinine
0.8 and glucose 145.  He had a calcium of 8.4, magnesium of
1.9 and phos of 3.0.  His albumin was 2.8.  Liver function
tests revealed an AST of 26, ALT of 20, T bili 1.0, amylase
29, LDH 225, alkaline phosphatase of 108.  He had an
electrocardiogram on admission, which showed a normal sinus
rhythm with a rate of 95.  He had a normal axis and normal
QRS intervals.  There was no evidence of ST or T wave
changes.

HOSPITAL COURSE:  1.  Upper gastrointestinal bleed:  Mr.
[**Known lastname 50010**] was transferred to [**Hospital1 188**] status post upper gastrointestinal bleed for
evaluation of TIPS for decompression of portal hypertension
and esophageal varix.  He was hemodynamically stable upon
admission.  His hematocrit and coags were followed.  He only
required 1 unit of packed red blood cells while admitted and
from that time his hematocrit remained in the 28 to 30 range.
He was started on Octreotide and Protonix drip.  He had an
abdominal ultrasound to evaluate his portal vein anatomy and
then underwent TIPS the following day.  The procedure was
uneventful, however, ultrasound after the procedure revealed
occlusion of the TIPS and questionable flow within the portal
vein.  Status post the TIPS procedure his liver function
tests began to rise and then slowly trended down over the
next several days.  On [**10-20**] he went for revision of his TIPS
with extension of the stent in both directions, and coiling
of several gastric varices by interventional radiology.  This
procedure was also uneventful and ultrasound after the TIPS
revision revealed patent flow within the portal vein and
TIPS.  His hematocrit, coags and platelets were monitored
closely.  As mentioned above he only required 1 unit of
packed red blood cells for a slight decrease in his
hematocrit.  He also received a total of 3 units of fresh
frozen platelets while in the Intensive Care Unit to maintain
his INR less then 1.5.  His platelets dipped down to 70, but
quickly rose back up to 160 and he required no transfusions
with platelets.  On the day prior to transfer to the floor it
was recommended by interventional radiology that he not be
transfused anymore fresh frozen platelets or platelets unless
he was actively bleeding in order to prevent TIPS
reocclusion.  On the day prior to transfer to the floor his
Octreotide drip was stopped and he was started on
Spironolactone 50 mg q.d. due to his protal hypertension and
ascites.

2.  Musculoskeletal:  On physical examination Mr. [**Known lastname 50010**]
suffered several rib fractures on the left with his syncopal
episode.  He was seen by Dr. [**Last Name (STitle) 952**] with the Department of
Thoracic Surgery and it was recommended that no intervention
be done at this time.  Due to his other acute issues, the
Thoracic Surgery Service will follow him once he has returned
to the floor, however, they feel that due to lack of evidence
of pneumothorax, no intervention was needed.  He was
initially started on a morphine PCA, which was then
subsequently transferred to Dilaudid PCA and then he was
changed to intravenous morphine.  Once he was transferred to
the floor he was started on po Oxycodone prn for pain.

3.  Infectious disease:  On the evening of [**10-19**], Mr. [**Known lastname 50010**]
went into respiratory failure requiring oxygenation by high
flow nebulized O2 mask.  At this point chest x-ray revealed
evidence of a right middle lobe and questionable right lower
lobe pneumonia felt possible secondary to aspiration.  He was
started on Levofloxacin and Flagyl empirically and subsequent
sputum cultures grew strep pneumo, H-flu.  At this point his
Flagyl was discontinued and he was continued on Levofloxacin
to complete a ten day course.  He never required intubation
and his respiratory status improved with chest physical
therapy, pulmonary toilet and on the day of discharge to the
floor he was on O2 by nasal cannula with O2 sats of 100%.  He
also had blood cultures with no growth to date fro [**10-19**] at
the time of transfer to the floor.  He also had a urine
culture on [**10-19**], which revealed greater then 100,000
colonies with Enterococcus susceptible to Vancomycin,
Ampicillin, Nitrofurantoin, however, resistant to
Levofloxacin.  His Foley was changed at this point and a
repeat urine culture was done, which revealed greater then
100,000 colonies of Enterococcus with the same sensitivities.
 At this point he was placed on Vancomycin due to his
Penicillin allergy.  His Foley catheter was discontinued
prior to transfer to the floor.

4.  Cardiovascular:  Mr. [**Known lastname 50010**] has a history of
hypertension, however, his antihypertensives were held on
admission due to his gastrointestinal bleed.  After the
initial TIPS procedure he became hypertensive with systolic
blood pressures in the 170s to 190s.  He was subsequently
placed on Nadolol 20 mg q.d. for maintenance of his blood
pressure as well as production versus esophageal varices.
This resulted in some improvement in his blood pressure,
however, he was also restarted on his Norvasc as prescribed
at home at 5 mg q.d..  _________________ his blood pressure
was noted two days after starting on that.  On the day of
transfer to the floor his blood pressures were 1 teens to
120s/40s to 50s.

5.  Renal:  It was noted on admission Mr. [**Known lastname 50010**] had an
elevated creatinine at the outside hospital of 1.3.  This
subsequently fell after hydration with intravenous fluids and
transfusion of 1 unit of red blood cells.  His creatinine
then remained stable throughout admission.

6.  Pulmonary:  As mentioned above Mr. [**Known lastname 50010**] had an episode
of respiratory distress on the evening of [**10-19**] with evidence
of a pneumonia on chest x-ray was started on Levofloxacin.
He also has a history of chronic obstructive pulmonary
disease and was maintained on Albuterol and Atrovent
nebulizers while admitted.  He experienced some _____________
on Nadolol, however, it was not felt significant and not
really clear whether or not it was related and he was
continued on a beta blocker without any problems or worsening
of his chronic obstructive pulmonary disease.

7.  Neurological:  On admission Mr. [**Known lastname 50012**] mental status
was noted to be a little bit cloudy and somewhat confused.
He was aware that he was in the hospital, but unclear to
which hospital he was in.  He was felt to be confabulating at
points and this was felt to be most likely to be secondary to
his alcoholism.  He was maintained on folate, thiamine, and
multivitamins.  His mental status did not change on admission
and he was also maintained on Lactulose titrated to two to
three bowel movements per day.

MEDICATIONS ON DISCHARGE FROM THE MICU:
1.  Vancomycin 1 gram q 12.
2.  Levofloxacin 500 mg q.d.
3.  Oxycodone 5 mg q 4 to 6 hours prn.
4.  Aldactone 50 mg q.d.
5.  Amlodipine 5 mg q.d.
6.  Nadolol 20 mg q.d.
7.  Lactulose 30 to 60 cc b.i.d.
8.  Multivitamin.
9.  Thiamine.
10.  Folate.
11.  Albuterol MDI.
12.  Tylenol prn.
13.  Protonix 40 mg b.i.d.
14.  Senna.
15.  Dulcolax.

This will be addended by the floor team on the day of
discharge.






                            DR.[**Last Name (STitle) **],[**Known firstname **] 12-735

Dictated By:[**Last Name (NamePattern1) 14268**]
MEDQUIST36

D:  [**2164-10-24**]  01:09
T:  [**2164-10-24**]  13:08
JOB#:  [**Job Number 50013**]


Name:  [**Known lastname 9245**], [**Known firstname **]                     Unit No:  [**Numeric Identifier 9246**]

Admission Date:  [**2164-10-17**]       Discharge Date:  [**2164-10-27**]

Date of Birth:   [**2084-2-5**]       Sex:  M

Service:  [**Hospital 633**] Medical Service

ADDENDUM:  Addendum to previous discharge summary with this
addendum covering the period from [**2164-10-25**] to
[**2164-10-27**].  Please see the previous discharge summary
for details of the patient's history.

HOSPITAL COURSE:  ([**10-25**] to [**2164-10-27**])  1.  Upper
gastrointestinal bleed - The patient's hematocrit remained
stable during the remainder of his hospitalization; it was
30.2 on [**2164-10-26**].

2.  Transjugular intrahepatic portacaval shunt - Because of a
slight rise in the patient's total bilirubin to 8.7 on
[**2164-10-25**], an abdominal ultrasound was performed to
assess for the patency of the patient's transjugular
intrahepatic portacaval shunt.  The final report came back
that the transjugular intrahepatic portacaval shunt had
normal flow and was patent.  The flow velocities ranged from
65 cm per second to 100 cm per second.  The main portal vein
was patent with hepatopetal flow at 40 cm/second.  The
anterior right portal vein demonstrates reversal flow as
would be expected in the transjugular intrahepatic portacaval
shunt.  The middle hepatic vein, right hepatic vein, right
hepatic artery and inferior vena cava were patent.  In
addition to the transjugular intrahepatic portacaval shunt
for the patient's portal hypertension he was continued on
Spironolactone 50 mg p.o. q.d. as well as Nadolol 20 mg p.o.
q.d.

3.  Intravenous access - The patient had challenging access
throughout his hospital course.  Upon transfer to the floor,
the patient had his right internal jugular central line in
place.  Due to the need for its removal prior to transfer to
a rehabilitation hospital a PICC catheter was placed on the
right side on [**2164-10-25**].  When it was observed,
however, that the patient's right upper extremity was more
edematous than his left upper extremity, a noninvasive study
of the right upper extremity was performed which demonstrated
a thrombosis of the right internal jugular vein with no color
flow present on doppler studies.  The subclavian vein was
patent demonstrating normal wall-to-wall flow.  The axillary,
brachial and cephalic veins were patent as well,
demonstrating normal doppler waveforms.  As a result, the
right internal jugular central line was promptly removed on
[**2164-10-25**] and the PICC line was removed as well.
After the final dose of Vancomycin was administered (see
below).  Vascular Surgery consultation was obtained on
[**2164-10-26**] which discussed the potential treatment
options for the patient's right internal jugular vein
thrombus.  In the setting of esophageal varices, history of
gastrointestinal bleed and liver disease, he is obviously not
a candidate for anticoagulation.  The possibility of an
superior vena cava filter was discussed but given the fact
that this is also not without risk and the patient has
several comorbidities they did not feel that the risk
out-weighed the benefits.  Thus, they recommended not
intervening on the right internal jugular thrombus at this
time.

4.  Urinary tract infection - As mentioned in the prior
discharge summary the patient had an Enterococcus urinary
tract infection sensitive to Vancomycin but resistant to
Levofloxacin and completed a seven day course of intravenous
Vancomycin on [**2164-10-26**].

5.  Thrombocytopenia - The patient's platelets remained
stable throughout this portion of the hospital course and on
[**2164-10-26**] were at 112 with no further transfusions of
fresh frozen plasma.

6.  Presumed aspiration pneumonia - The patient was continued
on 500 p.o. of Levaquin.

7.  Cardiovascular - The patient's blood pressures during
this interval remained stable in the 100s to 110s/60s to 70s
on Spironolactone, Nadolol and Norvasc.

8.  Pulmonary - Serial chest x-rays were obtained showing
interval improvement in the patient's previously described
bibasilar atelectasis.  He received b.i.d. Albuterol
nebulizer treatments as well as prn metered dose inhalers
with Albuterol.  As mentioned above he was continued on
Levofloxacin for aspiration pneumonia.  The patient's oxygen
requirement decreased throughout the duration of his hospital
course.  On [**2164-10-26**] he was saturating at 96% on 4
liters of nasal cannula.

9.  Pain - The patient's pain control was titrated down from
Morphine PCA in the Intensive Care Unit to Morphine
intravenously prn on the floor to Oxycodone p.o. with
adequate pain control.

10. Neurological - The patient had improvement in mental
status throughout his hospital course.  He did continue to
have poor eye contact when interacting but much of his change
in mental status was thought to be secondary to alcoholism.
The patient, of course, was maintained on Folate, Thiamine
and multivitamins.  He was also given Lactulose titrated to 2
to 3 bowel movements per day.

11.  Mobility - The patient worked extensively with both
physical therapy and occupational therapy throughout his
hospital course but was still quite limited in terms of
mobility, due to his prolonged stay in the Intensive Care
Unit and prior deconditioning.

DISCHARGE STATUS:  The patient will be discharged to a
rehabilitation hospital to be determined.

CONDITION ON DISCHARGE:  On [**2164-10-26**], the patient was
saturating at 96% on room air with blood pressures ranging
from the 100s to 110s/60s, breathing at 20 per minute with a
temperature of 97.0 with fluid intakes and outputs of 780 cc
in and 850 cc out over an eight hour period.  His mental
status was much improved compared to that of admission.

MEDICATIONS ON DISCHARGE:
Bisacodyl 10 mg p.o./p.r. q.d.
Senna one tablet p.o. b.i.d.
Acetaminophen 1 gm p.o. q.d. prn pain, maximum of 1 gm per
day
Albuterol 1 to 2 puffs inhaler q. 6 hours prn
Lactulose 36 ml p.o. b.i.d., titrate up to 2 bowel movements
per day
Nadolol 20 mg tablet p.o. q.d., hold for systolic blood
pressure less than 100, heartrate less than 60
Amlodipine 5 mg p.o. q.d.
Spironolactone 50 mg p.o. q.d.
Protonix 40 mg p.o. q.d.
Multivitamins 1 p.o. q.d.
Thiamine 100 mg p.o. q.d.
Folic acid 1 mg p.o. q.d.
Levofloxacin 500 mg p.o. q.d., please continue until [**2164-10-31**]
Oxycodone 5 mg p.o. t.i.d., standing dose, hold for
respirations less than 8 or sedation
Oxycodone 5 mg p.o. q. 6 hours prn, hold for respirations
less than 8 or sedation
Albuterol nebulizer solution, 1 inhaled b.i.d.

DISCHARGE INSTRUCTIONS:  Please continue check the patient's
liver function tests including total bilirubin, albumin as
well as INR at least once per week.

FOLLOW UP INSTRUCTIONS:  The patient is to follow up with his
primary medical doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, [**Telephone/Fax (1) 9247**],
within two weeks of leaving the hospital.  He should also
follow up with the Hepatology Service regarding his portal
hypertension.  The patient will need extensive physical
therapy and occupational therapy.  If there is ever a sudden
increase in total bilirubin or if the patient's clinical
course deteriorates, there would be a low threshold for
performing a repeat ultrasound to evaluate for the patency of
the transjugular intrahepatic portacaval shunt.




                            [**Known firstname **] [**Name6 (MD) 909**] [**Name8 (MD) **], M.D.  [**MD Number(1) 348**]

Dictated By:[**Last Name (NamePattern1) 9248**]
MEDQUIST36

D:  [**2164-10-26**]  14:18
T:  [**2164-10-26**]  14:46
JOB#:  [**Job Number 9249**]
{'Hemorrhage of gastrointestinal tract, unspecified,Unspecified septicemia,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, continuous,Chronic airway obstruction, not elsewhere classified,Unspecified pleural effusion,Acute kidney failure, unspecified,Other complications due to other internal prosthetic device, implant, and graft,Urinary tract infection, site not specified'}


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: Mr. [**Known lastname 50010**] is an 80 year-old
male with a past medical history significant for alcoholic
cirrhosis, gastric and esophageal varices and recurrent
gastrointestinal bleed who presented to the [**Hospital 40262**] Hospital
with syncopal episodes after a gastrointestinal bleed.  His
son reports that he was in his usual state of health until
one week prior to admission when he complained of back pain,
decreased appetite, and decreased po intake and sleep.  Mr.
[**Known lastname 50010**] reports having brown stools and denies any tarry
black or malonic stools.  He does report vomiting times two
with bloody clots several days prior to transfer to [**Hospital1 1444**], and he states he passed out
while on the toilet after passing malonic stools.  This
episodes was not witnessed.  Mr. [**Known lastname 50010**] reports that he does
not remember the event.  He sustained trauma with a skin tear
at the left elbow and multiple rib fractures as seen on chest
CT on the left involving ribs 5 through 7 with disc
displacement in segments and pockets of air along the chest
wall consistent with subcutaneous air and a small left
pleural effusion.  There was no pneumothorax noted.  He
denied and had no evidence of head trauma.  His wife reported
that she heard the fall and brought him to the [**Hospital 40262**]
Hospital Emergency Department on [**10-16**].  At Falmuth vital
signs revealed a heart rate of 133 and a blood pressure of
84/41. He received 2 units of packed red blood cells and
hydration with normal saline.  He had an elevated white blood
cell count at that point at 18.4 and a hematocrit of 30 that
fell to 29.  His creatinine was 1.6 and fell to 1.3 after
hydration.  Esophagogastroduodenoscopy at [**Hospital 40262**] Hospital
showed blood in the stomach, but no active bleed and there
was a noted large varices in the gastric fundus and grade one
varix in the lower esophagus with no stigmata of recent
hemorrhage.  He was started on an Octreotide drip and
Protonix and transferred to [**Hospital1 188**] for evaluation of TIPS procedure.  At the time of
transfer his hematocrit was stable at 29.

MEDICAL HISTORY: 1.  Alcohol abuse.
2.  Alcoholic cirrhosis with known gastroesophageal varices.
3.  Hypertension.
4.  Depression.
5.  Gastroesophageal reflux disease.
6.  History of gastric ulcers secondary to non-steroidal
anti-inflammatory drugs and also being H-pylori positive.
7.  Chronic obstructive pulmonary disease.
8.  Anemia.

MEDICATION ON ADMISSION: 

ALLERGIES: He has an allergy to Penicillin and
Cephalosporins with unknown reactions.

PHYSICAL EXAM: 

FAMILY HISTORY: He has a sister with diabetes mellitus.
There is no history of gastrointestinal bleeding, heart
disease, or hypertension in the family.

SOCIAL HISTORY: Mr. [**Known lastname 50010**] is a retired Army cook.  He
lives with his wife and daughter in [**Name (NI) 50011**].  His son is
his health care proxy.  [**Name (NI) **] is full code.  He use to smoke,
but states he quit five years ago.  He has 120 to 180 pack
year history prior to that time.  He has a significant
alcohol history and states that his last drink was a Vodka
tonic one month ago.  He denies any intravenous drug use. 

### Response:
{'Hemorrhage of gastrointestinal tract, unspecified,Unspecified septicemia,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, continuous,Chronic airway obstruction, not elsewhere classified,Unspecified pleural effusion,Acute kidney failure, unspecified,Other complications due to other internal prosthetic device, implant, and graft,Urinary tract infection, site not specified'}
