CHIEF COMPLAINT: Abdominal pain.

PRESENT ILLNESS: This is a 53 year-old woman with
a history of alcoholic hepatitis and recent admission between
[**11-12**] and [**2177-11-17**] for alcoholic
intoxication/hepatitis/pancreatitis who now presents with one
month of worsening abdominal pain and increased abdominal
girth.  The patient states this has never occurred before.
She also complains of nausea and vomiting over the past week
with a decreased appetite.  She has had decreased bowel
movements over the past few weeks and increased abdominal
pain with meals and with alcohol consumption.  She continues
to drink about 1 pint of alcohol a day.  The last drink was
the morning of admission.  She also has had low grade
temperatures with chills as well as increased confusion for
the past week.  She denies any hematemesis, melena, bright
red blood per rectum, cough, chest pain, shortness of breath,
urinary frequency, dysuria, incontinence, recent loss of
consciousness, fall, head trauma.  She also denies any
previous episodes of ascites, spontaneous bacterial
peritonitis, encephalopathy or variceal bleeding.

MEDICAL HISTORY: Alcoholic hepatitis, alcoholic
pancreatitis, alcoholic ketoacidosis.  Depression with
suicidal ideation.  Right total hip replacement secondary to
AVN, breast cancer status post right mastectomy, status post
radiation therapy and chemotherapy in [**2171**], question of
hemachromatosis, status post cholecystectomy.

MEDICATION ON ADMISSION: Folate, thiamine, multivitamin,
Oxycodone, Effexor, Trazodone, BuSpar.

ALLERGIES: Terazol, Darvocet, Celebrex, Vioxx, Ampicillin
and Erythromycin.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives in an [**Hospital3 **]
facility.  She drinks approximately one pint of alcohol per
day and smokes approximately one pack of cigarettes per day.
Other staphylococcal septicemia,Other shock without mention of trauma,Acute pancreatitis,Acute respiratory failure,Alcoholic cirrhosis of liver,Alcohol abuse, unspecified
Staphylcocc septicem NEC,Shock w/o trauma NEC,Acute pancreatitis,Acute respiratry failure,Alcohol cirrhosis liver,Alcohol abuse-unspec
Admission Date:  [**2177-12-29**]     Discharge Date:  [**2178-1-1**]

Date of Birth:   [**2123-8-12**]     Sex:  F

Service:  MEDICAL ICU

CHIEF COMPLAINT:  Abdominal pain.

HISTORY OF PRESENT ILLNESS:  This is a 53 year-old woman with
a history of alcoholic hepatitis and recent admission between
[**11-12**] and [**2177-11-17**] for alcoholic
intoxication/hepatitis/pancreatitis who now presents with one
month of worsening abdominal pain and increased abdominal
girth.  The patient states this has never occurred before.
She also complains of nausea and vomiting over the past week
with a decreased appetite.  She has had decreased bowel
movements over the past few weeks and increased abdominal
pain with meals and with alcohol consumption.  She continues
to drink about 1 pint of alcohol a day.  The last drink was
the morning of admission.  She also has had low grade
temperatures with chills as well as increased confusion for
the past week.  She denies any hematemesis, melena, bright
red blood per rectum, cough, chest pain, shortness of breath,
urinary frequency, dysuria, incontinence, recent loss of
consciousness, fall, head trauma.  She also denies any
previous episodes of ascites, spontaneous bacterial
peritonitis, encephalopathy or variceal bleeding.

PAST MEDICAL HISTORY:  Alcoholic hepatitis, alcoholic
pancreatitis, alcoholic ketoacidosis.  Depression with
suicidal ideation.  Right total hip replacement secondary to
AVN, breast cancer status post right mastectomy, status post
radiation therapy and chemotherapy in [**2171**], question of
hemachromatosis, status post cholecystectomy.

MEDICATIONS ON ADMISSION:  Folate, thiamine, multivitamin,
Oxycodone, Effexor, Trazodone, BuSpar.

ALLERGIES:  Terazol, Darvocet, Celebrex, Vioxx, Ampicillin
and Erythromycin.

SOCIAL HISTORY:  The patient lives in an [**Hospital3 **]
facility.  She drinks approximately one pint of alcohol per
day and smokes approximately one pack of cigarettes per day.

PHYSICAL EXAMINATION ON ADMISSION:  Vital signs temperature
99.1, pulse 111, respiratory rate 18, blood pressure 100/54,
O2 sat 100% on room air.  In general, the patient is lying in
bed, lethargic, confused, but conversant.  HEENT pupils are
equal, round and reactive to light.  Scleral icterus.
Oropharynx clear.  Mucous membranes are slightly dry.
Sublingual icterus.  Neck full range of motion.  No
lymphadenopathy.  No bruits.  Chest decreased breath sounds
at right base.  Cardiovascular examination regular rate and
rhythm.  No murmurs.  Rectal dark brown OB positive stool.
Abdominal examination tense distended abdomen, decreased
bowel sounds, mild diffuse tenderness, positive shifting
dullness, positive fluid wave.  Extremities no edema.  Skin
with spider angiomata, positive umbilical veins, jaundice.
Neurological examination disoriented to time, positive
asterixics, good strength and sensation throughout.

LABORATORY DATA ON ADMISSION:  White blood cell count 12.3,
hematocrit 33.6, platelets 183, MCV 110, polys 86,
lymphocytes 6%, sodium 139, potassium 2.7, chloride 99,
bicarb 27, BUN 8, creatinine 1, glucose 74, calcium 8.5,
magnesium 1.4, phosphorus 4, INR 1.7, PTT 41.2.  ALT 20, AST
57, amylase 126, lipase 141, total bili 3.3, alcohol level
103, serum tox screen negative.  Ammonia level 79.  Head CT
negative.

IMPRESSION:  The patient is a 53 year-old woman with likely
alcoholic cirrhosis who presents with mental status changes,
alcoholic intoxication versus hepatic encephalopathy and
increased abdominal girth/pain times one month.

HOSPITAL COURSE:  1.  Gastrointestinal:  Alcoholic
cirrhosis/ascites/hepatic encephalopathy - the patient was
placed on Lactulose 30 cc q.i.d. to titrate to four to five
bowel movements per day.  She was also given vitamin K for
her elevated INR.  She was placed on clears for possible
alcoholic pancreatitis.  On the night of admission the
patient complained of increased nausea and was tachycardic to
the 120s.  She then vomited a small amount of bright red
blood and 300 to 350 cc of coffee grounds, which cleared
after nasogastric lavage with 500 cc of normal saline.  A
right femoral line was placed under sterile conditions and
the patient was given Ativan for her nausea and vomiting.
Intravenous fluids were started on GI fellow was contact[**Name (NI) **].
The MICU team was called to evaluate the patient for a
transfer to the MICU.  The patient underwent the paracentesis
in the Medical Intensive Care Unit.  Aspirate was not
consistent with spontaneous bacterial peritonitis, however,
she was continued on prophylactic antibiotics for SBP.  She
also underwent an esophagogastroduodenoscopy, which showed no
esophageal varices, so the Octreotide that she was placed on
was discontinued.  She was initially on a Protonix drip and
this was changed to b.i.d.  The paracentesis she had was also
therapeutic in that 5 liters were removed, however, it
quickly accumulated within one to two days and may have
contributed to her hypotension.  Abdominal CT was done and
was negative for ascites.  A repeat paracentesis was held off
for the time being.

She was maintained on NPO status and was hydrated
aggressively.  Her hematocrit remained stable and her
pancreatitis by laboratory data seemed to be resolving.

2.  Pulmonary:  On [**12-30**] the patient was intubated
secondary to worsening metabolic acidosis and compensatory
hyperventilation.  She had lactic acidosis on admission.  Her
metabolic acidosis was thought to be most likely secondary to
her alcoholic ketoacidosis.  It was difficult to control her
acid base status even on the ventilator.  As her respiratory
rate was very high in the 30s and 40s and she was also
developing hypoxia requiring increased FIO2.  On chest x-ray
she was seen to have pleural effusion right greater then
left. It was thought to be either secondary to fluid overload
versus pneumonia secondary to aspiration.  She is producing
increased secretions.  She was on Levofloxacin, Vancomycin
and Flagyl both for SBP prophylaxis and for possible
treatment for pneumonia.  In the end it was decided to
paralyze her and change the ventilator setting to AC to
decrease her work of breathing and therefore to hopefully
decrease her lactic acidosis.  She was sedated with Ativan
drip and her FIO2 was increased to 100%.  Her ETT aspirate
was sent for culture and showed 675 white blood cells, 30
polys, 5 bands consistent with infection, although the
appearance of it was similar to ascites.

3.  Cardiovascular:  The patient continued to be tachycardic
and hypotension and eventually was placed on neo-synephrine,
[**Last Name (un) **] and vaso drips.  The etiologies for her hypotension
included sepsis from her possible SBP or pancreatitis, blood
loss although esophagogastroduodenoscopy was negative for
active bleeding, adrenal insufficiency, although her
tachycardia could also be secondary to her alcohol withdraw.
Her blood cultures returned positive for gram positive
coxae.  She was already on Vancomycin as well as Levofloxacin
and Flagyl for SBP prophylaxis.  On [**12-30**] she received
2 units of packed red blood cells and her hematocrit remained
stable after that.  A right IJ was placed in while this was
done she was given fresh frozen platelets and after this was
successfully placed her right femoral line was removed.  She
continued to be hypotensive and none of her pressors were
able to be weaned.  She became bradycardic with runs of
ventricular tachycardia and her blood culture grew gram
positive coxae and gram positive rods with beta strep in her
urine culture.

4.  Infectious disease:  Blood culture with gram positive
rods, her sepsis may have contributed to her hypotension,
however, her white blood cell count decreased to 2.1
reflecting a very poor prognosis.  She was on Vancomycin,
Levofloxacin and Flagyl.  Her right femoral line was
discontinued and a right IJ was placed.  Beta strep grew in
her urine culture.

5.  Hematology:  She presented with an upper gastrointestinal
bleed and with laboratory data consistent with DIC.  She was
transfused 2 units of blood and after that her hematocrit
remained stable.  She was given vitamin K for her elevated
INR and fresh frozen platelets prior to every procedure.  Her
platelets decreased to 41 consistent with DIC.

6.  Renal:  Her renal function remained stable, but she
became oliguric likely secondary to her hypotension.  She was
hydrated aggressively while in the MICU.  Her electrolytes
were followed closely and repleted as necessary.

7.  Endocrine:  The patient had elevated blood glucose
secondary to her pancreatitis versus her sepsis versus the D5
she was being given for her alcoholic ketoacidosis.  She was
placed on an insulin drip to maintain her blood sugars below
200.

8.  Neurological:  The patient was somnolent and
unresponsive.  She was on both Ativan drip and morphine for
sedation.  She was paralyzed in order to ventilate her
passively.

9.  Prophylaxis:  Patient with Protonix and Pneumoboots.

10.  Code status:  The patient was a medical DNR.

11.  Communication:  The patient's aunt [**Name (NI) 2127**] [**Name (NI) 19236**] and
therapist Dr. [**Last Name (STitle) 19237**] were contact[**Name (NI) **] and informed of her poor
condition and poor prognosis.  They were aware of her medical
DNR status and agreed.  Her son [**Name (NI) **] was also spoken
with by the resident on the team and was aware of her
condition.  Her visited her prior to her death.

On [**1-1**] at 7:00 p.m. the patient passed away and
family agreed to withdraw life support.

CONDITION ON DISCHARGE:  Expired.

DISCHARGE STATUS:  Expired.

DISCHARGE DIAGNOSES:
1.  Alcoholic hepatitis.
2.  Alcoholic pancreatitis.
3.  Sepsis.
4.  Alcoholic ketoacidosis.
5.  Depression.
6.  Breast cancer.







                          DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761

Dictated By:[**Last Name (NamePattern1) 7069**]

MEDQUIST36

D:  [**2178-7-6**]  11:53
T:  [**2178-7-7**]  09:51
JOB#:  [**Job Number 19238**]
{'Other staphylococcal septicemia,Other shock without mention of trauma,Acute pancreatitis,Acute respiratory failure,Alcoholic cirrhosis of liver,Alcohol abuse, 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: Abdominal pain.

PRESENT ILLNESS: This is a 53 year-old woman with
a history of alcoholic hepatitis and recent admission between
[**11-12**] and [**2177-11-17**] for alcoholic
intoxication/hepatitis/pancreatitis who now presents with one
month of worsening abdominal pain and increased abdominal
girth.  The patient states this has never occurred before.
She also complains of nausea and vomiting over the past week
with a decreased appetite.  She has had decreased bowel
movements over the past few weeks and increased abdominal
pain with meals and with alcohol consumption.  She continues
to drink about 1 pint of alcohol a day.  The last drink was
the morning of admission.  She also has had low grade
temperatures with chills as well as increased confusion for
the past week.  She denies any hematemesis, melena, bright
red blood per rectum, cough, chest pain, shortness of breath,
urinary frequency, dysuria, incontinence, recent loss of
consciousness, fall, head trauma.  She also denies any
previous episodes of ascites, spontaneous bacterial
peritonitis, encephalopathy or variceal bleeding.

MEDICAL HISTORY: Alcoholic hepatitis, alcoholic
pancreatitis, alcoholic ketoacidosis.  Depression with
suicidal ideation.  Right total hip replacement secondary to
AVN, breast cancer status post right mastectomy, status post
radiation therapy and chemotherapy in [**2171**], question of
hemachromatosis, status post cholecystectomy.

MEDICATION ON ADMISSION: Folate, thiamine, multivitamin,
Oxycodone, Effexor, Trazodone, BuSpar.

ALLERGIES: Terazol, Darvocet, Celebrex, Vioxx, Ampicillin
and Erythromycin.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives in an [**Hospital3 **]
facility.  She drinks approximately one pint of alcohol per
day and smokes approximately one pack of cigarettes per day. 

### Response:
{'Other staphylococcal septicemia,Other shock without mention of trauma,Acute pancreatitis,Acute respiratory failure,Alcoholic cirrhosis of liver,Alcohol abuse, unspecified'}
