CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: 43 year old woman with alcoholic cirrhosis complicated by
ascites/SBP, encephalopathy with grade 3 esophageal varices and
hepatorenal syndrome as well as alcoholic hepatitis, who
presented with dyspnea. She described being "unable to catch her
breath," and not related to worsening ascites as her abdomen is
soft. She reviously has not needed her albuterol more than ~
annually and she took 3-4 puffs, 3-4 times yesterday. The
patient denies dyspnea on exertion but endorses orthopnea
(baseline 6 pillows) and paroxymal nocturnal dyspnea.

MEDICAL HISTORY: -Alcohol cirrhosis - diagnosed 6 years ago, complicated by
esophageal varices (Grade 3 on EGD [**2129**] at [**Hospital6 28728**]
Center), ascites, SBP (treated at [**Hospital3 7362**] [**2129**]), recent
encephalopathy. Also with portal gastropathy and recent
hepatorenal syndrome
-GERD
-E. coli bacteremia/sepsis

MEDICATION ON ADMISSION: * Folic acid 1mg daily
* Multivitamin daily
* Ciprofloxacin 250mg daily
* Ferrous sulfate 325mg daily
* Thiamine 100mg daily
* Lactulose 30mL three times daily
* Nadolol 20mg daily
* Prednisone 40mg daily
* Omeprazole 20mg daily
* Albuterol sulfate 90mcg/actuation 1-2 puffs daily PRN sob,
wheeze

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission VS: T98.2, BP121/69, HR71, RR20, 100% on RA supine.
98% on
RA sitting. 95% on RA with ambulation.
Early AM VS: 97HR, 98/60, 96 RA
GENERAL: Chronically ill appearing, NAD, alert and oriented X3.
Jaundiced. Pleasant, cooperative, tearful.
HEENT: Sclera icteric. MMM. Normal oro/nasopharynx.
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly. No
HSM or tenderness appreciated.
EXTREMITIES: No edema, cyanosis, ecchymosis.

FAMILY HISTORY: Prostate cancer, myocardial infarction, diabetes. Sister has
depression, hypothyroidism. Aunt with scleroderma.

SOCIAL HISTORY: -Tobacco history: At least 25 years
-ETOH: Started drinking at 11 years old, by 18 years old was
taking [**1-18**] drinks daily X 15 years. Recently 1-2 drinks/week.
-Illicit drugs: Cocaine use from 18 years old until [**2130-6-17**].
No history of IVDU, tattoos or transfusions.
-Home: Married for 1.5 years, now divorced. Living with a
partner for 5 years.
Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Acute posthemorrhagic anemia,Other ascites,Acute kidney failure, unspecified,Other and unspecified alcohol dependence, unspecified,Thrombocytopenia, unspecified
Alcohol cirrhosis liver,Bleed esoph var oth dis,Ac posthemorrhag anemia,Ascites NEC,Acute kidney failure NOS,Alcoh dep NEC/NOS-unspec,Thrombocytopenia NOS
Admission Date:  [**2133-1-15**]              Discharge Date:   [**2133-1-23**]

Date of Birth:  [**2089-10-27**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
Right internal jugular insertion [**2133-1-16**]
EGD with banding [**2133-1-16**]
Paracentesis [**1-16**], [**1-19**], and [**1-22**]

History of Present Illness:
43 year old woman with alcoholic cirrhosis complicated by
ascites/SBP, encephalopathy with grade 3 esophageal varices and
hepatorenal syndrome as well as alcoholic hepatitis, who
presented with dyspnea. She described being "unable to catch her
breath," and not related to worsening ascites as her abdomen is
soft. She reviously has not needed her albuterol more than ~
annually and she took 3-4 puffs, 3-4 times yesterday. The
patient denies dyspnea on exertion but endorses orthopnea
(baseline 6 pillows) and paroxymal nocturnal dyspnea.

The patient had been recently admitted to [**Hospital1 18**] 2/14-27/[**2132**] for
alcoholic hepatitis with encephlopathy and hepatorenal syndrome.
Her Etoh hepatitis was addresss with steroids and NJT placement
(subsequently DC'd). The patient's diuretics had been stopped
due to HRS. She successfully weaned from octreotide and
midodrine.  Creatinine was 0.9 at the time of discharge. The
patient called the Liver Center today endorsing significant
dyspnea and some respiratory distress. Given concern for volume
overload vs. infection, she was brought in by EMS to [**Hospital1 18**] ED.
She denies chest pain, abdominal pain, fevers/chills,
lightheadedness, cough, rhinorrhea, lower extremity edema. She
continue to have nasal congestion from dry, bleeding mucosa. CXR
was not concerning for pneumonia or effusion. EKG showed normal
sinus rhythm with isolated T wave inversion in III. She did have
leukocytosis to WBC 18.1 (from [**9-29**]) with worsened left shift.
Hct 35.1, slightly increased from 30; INR 1.9, slightly improved
from 2.5; Na 131, stable from 128-131; TBili 17.2 from 22,
slightly improved.

She was treated for a URI and at 5am on [**2133-1-15**] she had ~ 1L of
hemetemesis during a BM. VSS. She tells me this has never
happened before.


Past Medical History:
-Alcohol cirrhosis - diagnosed 6 years ago, complicated by
esophageal varices (Grade 3 on EGD [**2129**] at [**Hospital6 28728**]
Center), ascites, SBP (treated at [**Hospital3 7362**] [**2129**]), recent
encephalopathy. Also with portal gastropathy and recent
hepatorenal syndrome
-GERD
-E. coli bacteremia/sepsis

Social History:
-Tobacco history: At least 25 years
-ETOH: Started drinking at 11 years old, by 18 years old was
taking [**1-18**] drinks daily X 15 years. Recently 1-2 drinks/week.
-Illicit drugs: Cocaine use from 18 years old until [**2130-6-17**].
No history of IVDU, tattoos or transfusions.
-Home: Married for 1.5 years, now divorced. Living with a
partner for 5 years.


Family History:
Prostate cancer, myocardial infarction, diabetes. Sister has
depression, hypothyroidism. Aunt with scleroderma.

Physical Exam:
Admission VS: T98.2, BP121/69, HR71, RR20, 100% on RA supine.
98% on
RA sitting. 95% on RA with ambulation.
Early AM VS: 97HR, 98/60, 96 RA
GENERAL: Chronically ill appearing, NAD, alert and oriented X3.
Jaundiced. Pleasant, cooperative, tearful.
HEENT: Sclera icteric. MMM. Normal oro/nasopharynx.
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly. No
HSM or tenderness appreciated.
EXTREMITIES: No edema, cyanosis, ecchymosis.


Pertinent Results:
Admission Labs:
[**2133-1-15**] 01:00PM BLOOD WBC-18.1* RBC-3.19* Hgb-12.2 Hct-35.1*
MCV-110* MCH-38.2* MCHC-34.8 RDW-17.6* Plt Ct-62*
[**2133-1-15**] 01:00PM BLOOD PT-19.7* PTT-27.8 INR(PT)-1.9*
[**2133-1-15**] 01:00PM BLOOD Glucose-206* UreaN-31* Creat-0.9 Na-131*
K-4.6 Cl-100 HCO3-21* AnGap-15
[**2133-1-15**] 01:00PM BLOOD ALT-85* AST-120* CK(CPK)-27* AlkPhos-302*
TotBili-17.2*
[**2133-1-15**] 01:00PM BLOOD Lipase-280*
[**2133-1-15**] 01:00PM BLOOD CK-MB-2 cTropnT-<0.01
[**2133-1-16**] 04:25AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.9
[**2133-1-16**] 06:09PM BLOOD Lactate-2.0

Discharge Labs:
[**2133-1-23**] 05:35AM BLOOD WBC-7.1 RBC-2.97* Hgb-10.6* Hct-30.0*
MCV-101* MCH-35.6* MCHC-35.2* RDW-20.0* Plt Ct-40*
[**2133-1-23**] 05:35AM BLOOD PT-25.0* PTT-39.3* INR(PT)-2.4*
[**2133-1-23**] 05:35AM BLOOD Glucose-112* UreaN-30* Creat-1.0 Na-132*
K-3.9 Cl-99 HCO3-23 AnGap-14
[**2133-1-23**] 05:35AM BLOOD ALT-44* AST-68* LD(LDH)-200 AlkPhos-200*
TotBili-13.5*
[**2133-1-23**] 05:35AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.8

Microbiology:

[**2133-1-16**] 5:30 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2133-1-17**]**

   URINE CULTURE (Final [**2133-1-17**]):    NO GROWTH.

[**2133-1-17**] 3:05 am STOOL     CONSISTENCY: SOFT      Source: Stool.


                            **FINAL REPORT [**2133-1-18**]**

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2133-1-18**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).

[**2133-1-16**] 6:24 pm PERITONEAL FLUID      PERITONEAL FLUID.

   GRAM STAIN (Final [**2133-1-16**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
      This is a concentrated smear made by cytospin method,
please refer to
      hematology for a quantitative white blood cell count..

   FLUID CULTURE (Preliminary):    NO GROWTH.

   ANAEROBIC CULTURE (Preliminary):    NO GROWTH.

CXR [**1-15**]:
IMPRESSION: No evidence of acute disease. Low lung volumes with
minor
basilar atelectasis. Non-specific air-fluid levels in the
epigastric region.

EGD [**2133-1-16**]:
Normal mucosa in the duodenum
Varices at the fundus
Erythema and mosaic appearance in the body and fundus compatible
with portal hypertensive gastropathy
Esophageal ring
Varices at the mid esophagus
Varices at the lower third of the esophagus (ligation)
Otherwise normal EGD to third part of the duodenum

Echo [**1-16**]:
Extremely limited image quality. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function appears
grossly normal (LVEF>55%). PA pressure could not be determined
due to extremely suboptimal image quality

Brief Hospital Course:
Primary Reason for Hospitalization:
43 year old woman with decompensated alcoholic
cirrhosis/hepatitis complicated by ascites, encephalopathy and a
history of SBP and HRS with known grade 3 esophageal varices on
subtherapeutic nadolol presenting with dyspnea, with course
complicated by esophageal variceal bleed.

Active Issues:

# Hemetemesis: Pt had a sentinel variceal bleed with 1L of
hematemesis while on the hepatobiliary service.  She was
transferred to the MICU where a central line was placed, PRBC's
were typed and screened and she was intubated for EGD.  On EGD
she was found to have 4 non-bleeding grade III esophageal
varices that were all successfully banded.  She was then
extubated and had no subsequent hematemesis or melena.  She
received a total of 5 units pRBCs.  She was transferred to the
floor with stable Hct.  She received 3 days of ocreotide and
pantoprazole gtt, and she was started on PO pantoprazole,
carafate, and ciprofloxacin for SBP ppx.  She was continued on
nadolol.  Her prednisone for acute alcoholic hepatitis was
discontinued.  She will need repeat EGD in 2 weeks.

# Dyspnea: Pt initially presented with dyspnea of unknown
etiology which resolved.  Thought likely [**12-18**] worsening ascites
since her breathing improved with large volume paracentesis.
Alternatively she may have underlying reactive airway disease
(is current smoker and uses albuterol inhalers at home).  She
received 3 large volume paracenteses during hospitalization, and
will likely require periodic taps as an outpatient to improve
her symptoms.

Chronic Issues:

# Alcoholic hepatitis: Recent episode and diagnosed last
admission. She had received approx 2 weeks of prednisone
therapy, however this was discontinued [**12-18**] variceal bleed.

# Alcoholic cirrhosis:  She was continued on lactulose.
Diuretics were held in setting of GI bleed and restarted after
her Hct remained stable. Her MELD score was 26 on discharge.

# # H/o EtOH - Last drink >2 ago. She had no signs of
withdrawal. She was continued on PO thiamine/folate.

# Non-occlusive portal vein thrombus: Seen on US during previous
admission, non-occlusive, no current indication for
anticoagulation.

# Anemia/thrombocytopenia: Stable, likely due to chronic liver
disease/splenic sequestration.

Transitional Issues:
-Medication changes: She was started on lasix 40mg daily,
spironolactone 100mg daily, pantoprazole 40mg daily, sucralfate
1g QID x14 days total.
-She is scheduled to follow up with Dr. [**Last Name (STitle) 7033**] in clinic on
[**2133-1-28**].
-She is scheduled for EGD on [**2133-2-6**] for repeat banding of
varices.
-She maintained full code status.

Medications on Admission:
* Folic acid 1mg daily
* Multivitamin daily
* Ciprofloxacin 250mg daily
* Ferrous sulfate 325mg daily
* Thiamine 100mg daily
* Lactulose 30mL three times daily
* Nadolol 20mg daily
* Prednisone 40mg daily
* Omeprazole 20mg daily
* Albuterol sulfate 90mcg/actuation 1-2 puffs daily PRN sob,
wheeze

Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day.
4. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Take at least once daily and titrate to [**1-19**] bowel
movements daily.
7. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
all care vna of greater [**Location (un) **]

Discharge Diagnosis:
Acute anemia due to GI bleed
Cirrhosis
Alcoholic hepatitis
Esophageal varices


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


Discharge Instructions:
Dear Ms. [**Known lastname 18732**],

You were admitted to [**Hospital1 18**] because you were having difficulty
breathing.  While you were here you had a bleed from your
esophageal varices.  You were transferred to the ICU and had an
endoscopy to band your varices and stop the bleeding.  You were
started on medications to control the bleeding, and your blood
counts remained stable.

Please note the following changes to your medications:
-START sucralfate 1g 4 times daily - take for 7 days
-CHANGE omeprazole to pantoprazole 40mg daily
-START lasix 40mg daily
-START spironolactone 100mg daily

We made no other changes to your medications.  Please continue
taking the rest of your medications as prescribed by your
outpatient providers.

You will need a repeat endoscopy as an outpatient for re-banding
of your varices.  We would also like you to follow up in the
liver clinic.  Please see below for your appointment times.

It has been a pleasure taking care of you at [**Hospital1 18**] and we wish
you a speedy recovery.

Followup Instructions:
It is recommended that you establish care with a Primary Care
Physician [**Name Initial (PRE) 176**] 2 weeks. If you need assistance finding a PCP
outside the [**Name9 (PRE) 86**] area, your local hospital or healthcare
center can be a resource.

Department: LIVER CENTER
When: WEDNESDAY [**2133-1-28**] at 9:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: GI-WEST PROCEDURAL CENTER
When: FRIDAY [**2133-2-6**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage
{'Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Acute posthemorrhagic anemia,Other ascites,Acute kidney failure, unspecified,Other and unspecified alcohol dependence, unspecified,Thrombocytopenia, 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: Dyspnea

PRESENT ILLNESS: 43 year old woman with alcoholic cirrhosis complicated by
ascites/SBP, encephalopathy with grade 3 esophageal varices and
hepatorenal syndrome as well as alcoholic hepatitis, who
presented with dyspnea. She described being "unable to catch her
breath," and not related to worsening ascites as her abdomen is
soft. She reviously has not needed her albuterol more than ~
annually and she took 3-4 puffs, 3-4 times yesterday. The
patient denies dyspnea on exertion but endorses orthopnea
(baseline 6 pillows) and paroxymal nocturnal dyspnea.

MEDICAL HISTORY: -Alcohol cirrhosis - diagnosed 6 years ago, complicated by
esophageal varices (Grade 3 on EGD [**2129**] at [**Hospital6 28728**]
Center), ascites, SBP (treated at [**Hospital3 7362**] [**2129**]), recent
encephalopathy. Also with portal gastropathy and recent
hepatorenal syndrome
-GERD
-E. coli bacteremia/sepsis

MEDICATION ON ADMISSION: * Folic acid 1mg daily
* Multivitamin daily
* Ciprofloxacin 250mg daily
* Ferrous sulfate 325mg daily
* Thiamine 100mg daily
* Lactulose 30mL three times daily
* Nadolol 20mg daily
* Prednisone 40mg daily
* Omeprazole 20mg daily
* Albuterol sulfate 90mcg/actuation 1-2 puffs daily PRN sob,
wheeze

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission VS: T98.2, BP121/69, HR71, RR20, 100% on RA supine.
98% on
RA sitting. 95% on RA with ambulation.
Early AM VS: 97HR, 98/60, 96 RA
GENERAL: Chronically ill appearing, NAD, alert and oriented X3.
Jaundiced. Pleasant, cooperative, tearful.
HEENT: Sclera icteric. MMM. Normal oro/nasopharynx.
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly. No
HSM or tenderness appreciated.
EXTREMITIES: No edema, cyanosis, ecchymosis.

FAMILY HISTORY: Prostate cancer, myocardial infarction, diabetes. Sister has
depression, hypothyroidism. Aunt with scleroderma.

SOCIAL HISTORY: -Tobacco history: At least 25 years
-ETOH: Started drinking at 11 years old, by 18 years old was
taking [**1-18**] drinks daily X 15 years. Recently 1-2 drinks/week.
-Illicit drugs: Cocaine use from 18 years old until [**2130-6-17**].
No history of IVDU, tattoos or transfusions.
-Home: Married for 1.5 years, now divorced. Living with a
partner for 5 years. 

### Response:
{'Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Acute posthemorrhagic anemia,Other ascites,Acute kidney failure, unspecified,Other and unspecified alcohol dependence, unspecified,Thrombocytopenia, unspecified'}
