CHIEF COMPLAINT: Upper GI bleed

PRESENT ILLNESS: This is an 85-year-old gentleman with a pmhx. significant for
Hepatitis B cirrhosis (grade II varices, + UGI bleed, +ascites,
no known hepatic encephalopathy), ?ETOH cirrhosis, hypertension,
and ?MDS who is admitted from an extended care facility for
hematemesis.
.
Mr. [**Known lastname 25699**] was discharged on [**3-23**] (morning of this admission
date) from the liver service at [**Hospital1 18**] after being treated for
variceal bleeding.  His story starts on [**3-13**] when he was admitted
to [**Hospital3 1443**] Hospital for acute variceal bleeding.  He
had 2 EGDs at [**Hospital1 487**], and had multiple varices banded.
However, despite these interventions, Mr. [**Known lastname 25699**] continued to
bleed, and he was transferred to [**Hospital1 18**] for evaluation for TIPS.
The patient's hematocrit remained stable in MICU at [**Hospital1 18**] and
due to patient's age and higher risk of hepatic encephalopathy,
TIPS was deferred.  Mr. [**Known lastname 25699**] was treated supportively; he went
for repeat EGD on [**3-22**], which showed band ulcers, and 1 grade II
varix, which was banded.  Patient was also treated with 5 days
of ceftriaxone for SBP prophylaxis.  He was started on nadolol
for bleeding prophylaxis.  On [**3-23**], Mr. [**Known lastname 25699**] was discharged to
[**Hospital 3137**] Care Center in [**Location (un) 1468**] in stable condition.
.
Patient states that he felt well at extended care facility and
ate a few meals.  In the afternoon he felt "hot," burped, felt a
band dislodge, and then noticed blood coming out of his nose.
He then proceeded to vomit bright red blood.  He is concerned
that his grand-daughter witnessed this episode and became upset.
.
In the ED, initial vitals were: 96.9 72 112/59 12 96% on RA.  He
vomited 200cc of bright red blood in the ED.  Patient was
started on protonix and octreotide gtt and given 1 L of fluid.
Liver service was consulted who recommended transfer to MICU
with urgent scope.  On admission, vitals were: 78 102/55 18 100@
on 2L.
.
In ICU, GI came by for urgent scope.  Copious blood noted from
previously banded varix.  Anesthesia was called to intubate for
airway protection.  Massive transfusion protocol was initiated
and patient received 7 units prbcs, 1 units of plts, and 2 of
FFP.  Sengstaken-[**Last Name (un) **] tube was placed and triple lumen
inserted in RIJ.  Family was informed of change in status.
Patient was transferred to IR for emergent TIPS.

MEDICAL HISTORY: - Hepatitis B-diagnosed [**2140**], + varices, ? EtOH related, childs
B/C cirrhosis
- Recent hospitalization [**2143-2-28**] for varices, recieved 4 u PRBCs
at that time
- Hypertension
- Pancytopenia
- Bradycardia while sleeping

MEDICATION ON ADMISSION: 1. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months: Last day is [**2143-4-17**].
5. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 2 weeks: Last day is [**4-5**].

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: hr 70, BP 95/51, RR 14 sp02 99% ON 2L
GENERAL: Intubated, sedated, [**Last Name (un) **] tube in place
HEENT:  Blood oozing from nose and mouth
CHEST:  Symmetric lung expansions bilaterally
CARDIAC:  RRR, no murmurs, rubs, or gallops
ABDOMEN: +BS, markedly distended, tense
EXTREMITIES:  No edema bilaterally
NEURO:  Sedated, unresponsive
SKIN:  Warm and dry
.
On discharge:
96% on RA
decreased breath sounds throughout bilateral lung fields
1+ edema in bil. LE
A&Ox3, able to state days of the week backwards
hard-of-hearing

FAMILY HISTORY: Unknown, non-contributory

SOCIAL HISTORY: Social History: Works at shaws, lives alone but gets assistance
from his daughter
- [**Name (NI) 1139**]: none recently, history of [**1-6**] ppd since teenager
- Alcohol: denies, last drink 5 yrs ago
- Illicits: none
Alcoholic cirrhosis of liver,Chronic viral hepatitis B with hepatic coma without hepatitis delta,Esophageal varices in diseases classified elsewhere, with bleeding,Pneumonitis due to inhalation of food or vomitus,Other shock without mention of trauma,Portal hypertension,Other ascites,Paroxysmal ventricular tachycardia,Hyperosmolality and/or hypernatremia,Pulmonary congestion and hypostasis,Other and unspecified alcohol dependence, in remission,Unspecified essential hypertension,Other specified disorders of stomach and duodenum
Alcohol cirrhosis liver,Hpt B chrn coma wo dlta,Bleed esoph var oth dis,Food/vomit pneumonitis,Shock w/o trauma NEC,Portal hypertension,Ascites NEC,Parox ventric tachycard,Hyperosmolality,Pulm congest/hypostasis,Alcoh dep NEC/NOS-remiss,Hypertension NOS,Gastroduodenal dis NEC
Admission Date:  [**2143-3-23**]              Discharge Date:   [**2143-4-1**]

Date of Birth:  [**2057-6-18**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Upper GI bleed


Major Surgical or Invasive Procedure:
[**2143-3-23**] - TIPS
[**2143-3-23**] - Upper endoscopy
[**2143-3-23**] - CVL Placement and intubation
[**Last Name (un) **] tube placement
Blood transfusions

History of Present Illness:
This is an 85-year-old gentleman with a pmhx. significant for
Hepatitis B cirrhosis (grade II varices, + UGI bleed, +ascites,
no known hepatic encephalopathy), ?ETOH cirrhosis, hypertension,
and ?MDS who is admitted from an extended care facility for
hematemesis.
.
Mr. [**Known lastname 25699**] was discharged on [**3-23**] (morning of this admission
date) from the liver service at [**Hospital1 18**] after being treated for
variceal bleeding.  His story starts on [**3-13**] when he was admitted
to [**Hospital3 1443**] Hospital for acute variceal bleeding.  He
had 2 EGDs at [**Hospital1 487**], and had multiple varices banded.
However, despite these interventions, Mr. [**Known lastname 25699**] continued to
bleed, and he was transferred to [**Hospital1 18**] for evaluation for TIPS.
The patient's hematocrit remained stable in MICU at [**Hospital1 18**] and
due to patient's age and higher risk of hepatic encephalopathy,
TIPS was deferred.  Mr. [**Known lastname 25699**] was treated supportively; he went
for repeat EGD on [**3-22**], which showed band ulcers, and 1 grade II
varix, which was banded.  Patient was also treated with 5 days
of ceftriaxone for SBP prophylaxis.  He was started on nadolol
for bleeding prophylaxis.  On [**3-23**], Mr. [**Known lastname 25699**] was discharged to
[**Hospital 3137**] Care Center in [**Location (un) 1468**] in stable condition.
.
Patient states that he felt well at extended care facility and
ate a few meals.  In the afternoon he felt "hot," burped, felt a
band dislodge, and then noticed blood coming out of his nose.
He then proceeded to vomit bright red blood.  He is concerned
that his grand-daughter witnessed this episode and became upset.
.
In the ED, initial vitals were: 96.9 72 112/59 12 96% on RA.  He
vomited 200cc of bright red blood in the ED.  Patient was
started on protonix and octreotide gtt and given 1 L of fluid.
Liver service was consulted who recommended transfer to MICU
with urgent scope.  On admission, vitals were: 78 102/55 18 100@
on 2L.
.
In ICU, GI came by for urgent scope.  Copious blood noted from
previously banded varix.  Anesthesia was called to intubate for
airway protection.  Massive transfusion protocol was initiated
and patient received 7 units prbcs, 1 units of plts, and 2 of
FFP.  Sengstaken-[**Last Name (un) **] tube was placed and triple lumen
inserted in RIJ.  Family was informed of change in status.
Patient was transferred to IR for emergent TIPS.


Past Medical History:
- Hepatitis B-diagnosed [**2140**], + varices, ? EtOH related, childs
B/C cirrhosis
- Recent hospitalization [**2143-2-28**] for varices, recieved 4 u PRBCs
at that time
- Hypertension
- Pancytopenia
- Bradycardia while sleeping


Social History:
Social History: Works at shaws, lives alone but gets assistance
from his daughter
- [**Name (NI) 1139**]: none recently, history of [**1-6**] ppd since teenager
- Alcohol: denies, last drink 5 yrs ago
- Illicits: none


Family History:
Unknown, non-contributory

Physical Exam:
VS: hr 70, BP 95/51, RR 14 sp02 99% ON 2L
GENERAL: Intubated, sedated, [**Last Name (un) **] tube in place
HEENT:  Blood oozing from nose and mouth
CHEST:  Symmetric lung expansions bilaterally
CARDIAC:  RRR, no murmurs, rubs, or gallops
ABDOMEN: +BS, markedly distended, tense
EXTREMITIES:  No edema bilaterally
NEURO:  Sedated, unresponsive
SKIN:  Warm and dry
.
On discharge:
96% on RA
decreased breath sounds throughout bilateral lung fields
1+ edema in bil. LE
A&Ox3, able to state days of the week backwards
hard-of-hearing

Pertinent Results:
[**2143-3-23**] 11:17PM   TYPE-ART PO2-242* PCO2-42 PH-7.30* TOTAL
CO2-21 BASE XS--5
[**2143-3-23**] 11:17PM   LACTATE-4.0*
[**2143-3-23**] 11:17PM   HGB-5.9* calcHCT-18 O2 SAT-98
[**2143-3-23**] 11:17PM   freeCa-0.89*
[**2143-3-23**] 07:40PM   GLUCOSE-178* UREA N-28* CREAT-0.9 SODIUM-135
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-27 ANION GAP-8
[**2143-3-23**] 07:40PM   HGB-9.5* calcHCT-29
[**2143-3-23**] 07:40PM   WBC-11.0# RBC-2.65* HGB-9.1* HCT-25.6* MCV-97
MCH-34.4* MCHC-35.5* RDW-20.4*
[**2143-3-23**] 07:40PM   NEUTS-80* BANDS-1 LYMPHS-10* MONOS-5 EOS-4
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2143-3-23**] 07:40PM   HYPOCHROM-1+ ANISOCYT-3+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-OCCASIONAL
OVALOCYT-2+ SCHISTOCY-1+ BURR-1+
[**2143-3-23**] 07:40PM   PLT COUNT-116*#
[**2143-3-23**] 07:40PM   PT-16.2* PTT-32.7 INR(PT)-1.4*
[**2143-3-23**] 05:15AM   GLUCOSE-151* UREA N-25* CREAT-0.8 SODIUM-136
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-28 ANION GAP-9
[**2143-3-23**] 05:15AM   ALT(SGPT)-29 AST(SGOT)-48* ALK PHOS-166* TOT
BILI-1.2
[**2143-3-23**] 05:15AM   CALCIUM-7.3* PHOSPHATE-1.7* MAGNESIUM-2.1
[**2143-3-23**] 05:15AM   WBC-6.4 RBC-3.18* HGB-10.7* HCT-30.5* MCV-96
MCH-33.6* MCHC-35.0 RDW-20.0*
[**2143-3-23**] 05:15AM   PLT COUNT-71*
[**2143-3-23**] 05:15AM   PT-16.6* PTT-32.1 INR(PT)-1.5*
[**2143-3-22**] 06:10AM   GLUCOSE-133* UREA N-25* CREAT-0.8 SODIUM-136
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-27 ANION GAP-8
[**2143-3-22**] 06:10AM   ALT(SGPT)-33 AST(SGOT)-50* ALK PHOS-172* TOT
BILI-1.9*
[**2143-3-22**] 06:10AM   CALCIUM-7.8* PHOSPHATE-1.9* MAGNESIUM-1.8
[**2143-3-22**] 06:10AM   WBC-6.9 RBC-3.18* HGB-10.8* HCT-30.1* MCV-95
MCH-33.9* MCHC-35.8* RDW-20.4*
[**2143-3-22**] 06:10AM   PLT COUNT-67*
[**2143-3-22**] 06:10AM   PT-17.3* PTT-32.5 INR(PT)-1.5*
.
[**2143-3-26**]:  In comparison with the study of [**3-25**], there is
continued and
possibly increasing pulmonary edema with continued mild
enlargement of the
cardiac silhouette and stable mediastinal venous engorgement.
Probable
bilateral pleural effusions, more prominent on the left.
Monitoring and
support devices remain in place.
.
TIPS:
FINDINGS:
1. Large amount of ascites. Ultrasound-guided catheter
paracentesis was
performed, and 6 liters of fluid was removed. The initial fluid
was clear and
straw colored. During the middle of the procedure, the fluid was
pink tinged,
however this returned to clear straw-colored fluid at the end of
the
procedure.
2. Initial x-ray image demonstrates that the [**Last Name (un) **] tube is
positioned
with the balloon in the proximal to mid esophagus rather than
the distal
esophagus. Prior to the procedure, it was noted this had been
withdrawn
during patient movement, and after discussion with the referring
hepatology
team, a decision was made not to manipulate this any further.
3. Pre TIPS portosystemic gradient measured 30 mmHg.
4. Successful placement of a TIPS (Viatorr 6 cm x 2 cm x 10 mm)
dilated 10
mm, afterwards portosystemic gradient measured 6 mmHg.
5. Given that post-TIPS venography demonstrated persistent
filling of two
prominent varices to the distal esophagus, both of these were
sclerosed/embolized using a mixture of Gelfoam, contrast, and
dehydrated
alcohol to successful stasis.
6. Successful repositioning of the triple-lumen central venous
line, with the
tip in the SVC. The line is ready for use.

IMPRESSION:
1. Ultrasound-guided paracentesis.
2. Successful TIPS placement as described above.
3. Successful embolization/sclerosis of two prominent varices in
the distal
esophagus, as described above.
4. Repositioning of the triple-lumen, with the tip at the high
SVC, and the
line is now ready to use
.
On discharge:
[**2143-4-1**]:
WBC 5.2 Hgb 10.3 Hct 30.4 Plt 55 PT 16.9 PTT 34.8 INR 1.5
Na 135 K 3.9 Cl 101 HCO3 31 BUN 12 Cr 0.6 Glc 118
ALT 72 AST 84 ALP 309 Totbili 2.3 GGT 83
Ca 7.6 Ph 2.3 Mg 2.2

Microbiology
[**2143-3-24**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL INPATIENT
[**2143-3-20**] SWAB R/O VANCOMYCIN RESISTANT
ENTEROCOCCUS-FINAL {ENTEROCOCCUS SP.} INPATIENT
[**2143-3-19**] IMMUNOLOGY HBV Viral Load-FINAL INPATIENT
[**2143-3-18**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT

### Pending studies: Hepatitis B surface antigen


Brief Hospital Course:
85-year-old gentleman with a history of EtOH/Hepatitis B
cirrhosis and grade II varices who is admitted for recurrent
upper GI bleed.

# Variceal bleed: Patient with history of variceal bleed
transferred to the MICU for UGIB now s/p emergent intubation
with [**Last Name (un) **] tube insertion and urgent TIPS. Patient received
8 units PRBCs, 4 units FFP, 1 pack platelets, and 1
cryoprecipitate.  Hemostasis was achieved and blood counts were
stable post-procedure. Patient was initially treated with
octreotide and PPI gtt, which were discontinued after hemostasis
achieved. Patient was transferred to the floor where he remained
hemodynamically stable without evidence of bleeding for several
days. Nadolol and spironolactone were stopped after TIPS
procedure. Patient was continued on protonix x 3 weeks (last
dose on [**2143-4-17**]) and sucralfate x 2 weeks (last dose on [**2143-4-10**]).
The patient does not need further surveillance endoscopies. He
was discharged to a rehabilitation facility.

He will follow-up with the liver center in [**1-6**] weeks.
Appointment is being scheduled at discharge, and patient should
call liver center within next few days to confirm appointment.

# Hypoxia: The patient was +6L in the ICU after the transfusion
of multiple blood products as above. He was diuresed
aggressively with lasix in the ICU and on the floor with weaning
of oxygen. He required no oxygen on the day of discharge. He was
ambulating in the halls with physical therapy with the
assistance of a walker.

He was started on lasix 40 mg PO qD and aldactone 50 mg PO qD
for continuing diuresis. Patient should have standing weights
daily with titration of PO lasix as needed for goal net negative
500 mL/day. He should have a chemistry panel checked in a week
to assess stability of creatinine, K, Ph, Mg with results faxed
to Dr. [**Last Name (STitle) **] at [**Hospital1 18**] Liver Center (phone: [**Telephone/Fax (1) 2422**] fax:
[**Telephone/Fax (1) 4400**]).

# Hypertension: Nadolol was stopped on admission. Lisinopril was
started at 5 mg per day.

# Hepatitis B/EtOH Cirrhosis: LFTs were stable to downtrending
on discharge with MELD of 14.

# Code status is DNR/ ok to intubate per patient's daughter:
daughter [**Name (NI) **]: [**Telephone/Fax (1) 90130**], [**Telephone/Fax (1) 90131**]

# Contact precautions: [**Name2 (NI) **]

#Transitional Issues:
- blood pressure monitoring
- monitoring for decompensation of cirrhosis or encephalopathy
- rehabilitation to improve pulmonary status
- daily weights, continuing diuresis as above with lasix
- chemistry panel within one week of discharge


Medications on Admission:
1. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months: Last day is [**2143-4-17**].
5. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 2 weeks: Last day is [**4-5**].

Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation every six (6)
hours as needed for shortness of breath or wheezing.
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 2 weeks: Last day is [**2143-4-10**].
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
3 weeks: Last day is [**2143-4-17**].
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Not to exceed 2g per day.
7. trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO HS (at bedtime)
as needed for insomnia.
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:  .

9. Aldactone 50 mg Tablet Sig: One (1) Tablet PO once a day.
10. Outpatient Lab Work
Check chem 10 within 1 week of discharge. Please fax results to:
Name: [**Last Name (LF) **], [**Name8 (MD) **] MD
Location: [**Hospital1 18**]-DIVISION OF GASTROENTEROLOGY/LIVER CENTER
Address: [**Known firstname **], STE 8E, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2422**]
Fax: [**Telephone/Fax (1) 4400**]


Discharge Disposition:
Extended Care

Facility:
[**Hospital 3137**] Care Center - [**Location (un) 1468**]

Discharge Diagnosis:
Primary:
Variceal bleed
Alcoholic/Hepatitis B Cirrhosis
Hypertension


Discharge Condition:
Mental Status: Clear and coherent; very hard-of-hearing but able
to state the days of the week backwards
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for bleeding from an
esophageal varix despite recent maximum medical and conservative
management. An urgent TIPS (transjugular intrahepatic
portosystemic shunt) procedure was completed and the bleeding
was controlled. You were briefly intubated with a special tube
inflated in your esophagus to help control the bleeding. You had
many units of blood transfused. After you were transferred to
the regular floor, you remained stable and we worked to diurese
fluids from your lungs and body. You will work to improve your
strength at the rehabilitation facility.
.
We made the following changes to your medications:
We STOPPED Spironolactone
We STOPPED Nadolol
We STARTED Albuterol nebulizer to be used only as needed for
shortness of breath
We STARTED lactulose to help prevent confusion
We STARTED lisinopril for high blood pressure
We CONTINUED pantoprazole and sucralfate for GI bleeding
We started both lasix and aldactone to remove fluid off your
body.

Your follow-up information is listed below. You will not need a
repeat endoscopy because the TIPS procedure was performed so
that appointment can be cancelled.

Followup Instructions:
Please follow-up with your primary care doctor
([**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 84026**]) after you are discharged
from rehab.

The liver center is working on getting you a follow-up
appointment in the next 1-2 weeks after your hospitalization.
Please call [**Telephone/Fax (1) 2422**] in the next few days to ask about your
hospital follow-up appointment.

Department: LIVER CENTER
When: WEDNESDAY [**2143-5-29**] at 1:20 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Alcoholic cirrhosis of liver,Chronic viral hepatitis B with hepatic coma without hepatitis delta,Esophageal varices in diseases classified elsewhere, with bleeding,Pneumonitis due to inhalation of food or vomitus,Other shock without mention of trauma,Portal hypertension,Other ascites,Paroxysmal ventricular tachycardia,Hyperosmolality and/or hypernatremia,Pulmonary congestion and hypostasis,Other and unspecified alcohol dependence, in remission,Unspecified essential hypertension,Other specified disorders of stomach and duodenum'}


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: Upper GI bleed

PRESENT ILLNESS: This is an 85-year-old gentleman with a pmhx. significant for
Hepatitis B cirrhosis (grade II varices, + UGI bleed, +ascites,
no known hepatic encephalopathy), ?ETOH cirrhosis, hypertension,
and ?MDS who is admitted from an extended care facility for
hematemesis.
.
Mr. [**Known lastname 25699**] was discharged on [**3-23**] (morning of this admission
date) from the liver service at [**Hospital1 18**] after being treated for
variceal bleeding.  His story starts on [**3-13**] when he was admitted
to [**Hospital3 1443**] Hospital for acute variceal bleeding.  He
had 2 EGDs at [**Hospital1 487**], and had multiple varices banded.
However, despite these interventions, Mr. [**Known lastname 25699**] continued to
bleed, and he was transferred to [**Hospital1 18**] for evaluation for TIPS.
The patient's hematocrit remained stable in MICU at [**Hospital1 18**] and
due to patient's age and higher risk of hepatic encephalopathy,
TIPS was deferred.  Mr. [**Known lastname 25699**] was treated supportively; he went
for repeat EGD on [**3-22**], which showed band ulcers, and 1 grade II
varix, which was banded.  Patient was also treated with 5 days
of ceftriaxone for SBP prophylaxis.  He was started on nadolol
for bleeding prophylaxis.  On [**3-23**], Mr. [**Known lastname 25699**] was discharged to
[**Hospital 3137**] Care Center in [**Location (un) 1468**] in stable condition.
.
Patient states that he felt well at extended care facility and
ate a few meals.  In the afternoon he felt "hot," burped, felt a
band dislodge, and then noticed blood coming out of his nose.
He then proceeded to vomit bright red blood.  He is concerned
that his grand-daughter witnessed this episode and became upset.
.
In the ED, initial vitals were: 96.9 72 112/59 12 96% on RA.  He
vomited 200cc of bright red blood in the ED.  Patient was
started on protonix and octreotide gtt and given 1 L of fluid.
Liver service was consulted who recommended transfer to MICU
with urgent scope.  On admission, vitals were: 78 102/55 18 100@
on 2L.
.
In ICU, GI came by for urgent scope.  Copious blood noted from
previously banded varix.  Anesthesia was called to intubate for
airway protection.  Massive transfusion protocol was initiated
and patient received 7 units prbcs, 1 units of plts, and 2 of
FFP.  Sengstaken-[**Last Name (un) **] tube was placed and triple lumen
inserted in RIJ.  Family was informed of change in status.
Patient was transferred to IR for emergent TIPS.

MEDICAL HISTORY: - Hepatitis B-diagnosed [**2140**], + varices, ? EtOH related, childs
B/C cirrhosis
- Recent hospitalization [**2143-2-28**] for varices, recieved 4 u PRBCs
at that time
- Hypertension
- Pancytopenia
- Bradycardia while sleeping

MEDICATION ON ADMISSION: 1. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
2. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months: Last day is [**2143-4-17**].
5. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 2 weeks: Last day is [**4-5**].

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: hr 70, BP 95/51, RR 14 sp02 99% ON 2L
GENERAL: Intubated, sedated, [**Last Name (un) **] tube in place
HEENT:  Blood oozing from nose and mouth
CHEST:  Symmetric lung expansions bilaterally
CARDIAC:  RRR, no murmurs, rubs, or gallops
ABDOMEN: +BS, markedly distended, tense
EXTREMITIES:  No edema bilaterally
NEURO:  Sedated, unresponsive
SKIN:  Warm and dry
.
On discharge:
96% on RA
decreased breath sounds throughout bilateral lung fields
1+ edema in bil. LE
A&Ox3, able to state days of the week backwards
hard-of-hearing

FAMILY HISTORY: Unknown, non-contributory

SOCIAL HISTORY: Social History: Works at shaws, lives alone but gets assistance
from his daughter
- [**Name (NI) 1139**]: none recently, history of [**1-6**] ppd since teenager
- Alcohol: denies, last drink 5 yrs ago
- Illicits: none 

### Response:
{'Alcoholic cirrhosis of liver,Chronic viral hepatitis B with hepatic coma without hepatitis delta,Esophageal varices in diseases classified elsewhere, with bleeding,Pneumonitis due to inhalation of food or vomitus,Other shock without mention of trauma,Portal hypertension,Other ascites,Paroxysmal ventricular tachycardia,Hyperosmolality and/or hypernatremia,Pulmonary congestion and hypostasis,Other and unspecified alcohol dependence, in remission,Unspecified essential hypertension,Other specified disorders of stomach and duodenum'}
