CHIEF COMPLAINT: confusion, chillc

PRESENT ILLNESS: 25M with a history of alcohol abuse who was admitted to the SICU
with acute hepatic failure in setting of acetaminophen
toxicity/EtOH abuse.
.
According to SICU notes, the patient had been self-medicating
for ongoing tooth pain with 20-30 tylenol tablets daily and
unquantified doses ibuprofen X 8 days. Additionally, he had been
binge drinking, with consumption of approximately 1L whiskey and
12-15 beers daily. On [**2165-1-27**], the patient reported abdominal
pain with accompanying  nausea and non-bloody emesis. His
symptoms progressed to include diffuse myalgias, confusion,
chills and diaphoresis. He was brought to an OSH, where the
patient was noted to have transaminases in [**2152**], INR ~5,
lactate 14. He was resuscitated and NAC gtt was initiated. He
was subsequently transferred to [**Hospital1 18**] SICU.
.
While in the SICU, he was continued on NAC gtt, and the
patient's LFTs trended to peaks of ALT 6880, AST 8562 on [**1-29**] and
subsequently trended downward. INR peaked at 14.3 on [**1-29**], and
was given total 4 units FFP and 1 cryo, and since downtrended to
3.6. Hepatitis serologies have all returned negative. RUQ U/S
revealed patent vessels, no ascites, varices or acute liver
lesions. He was seen by psych, who felt that he had EtOH
dependence, but no acute psychiatric issues. Dental eval
revealed poor dentition, panorex with 2 necrotic teeth, but no
acute signs of infection.
.
On the floor, the patient reports no current symptoms. He feels
tired, but denies confusion, abdominal pain, N/V/D.

MEDICAL HISTORY: - dental caries
- tonsillectomy

MEDICATION ON ADMISSION: none

ALLERGIES: Heparin Agents

PHYSICAL EXAM: ADMISSION EXAM
VS: 98.8  94  104/57  24  96%RA
GENERAL: Well appearing M. Comfortable, appropriate.
HEENT: Sclera mildly icteric.
CARDIAC: RRR, S1, S2, clear and of good quality without m/r/g
LUNGS: Resp were unlabored, moving air well and symmetrically.
CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender to palpation. No HSM.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
[**Location (un) **] bilaterally to knees.
.
DISCHARGE EXAM
VS: 98.1 131/52 67 18 100%RA
GENERAL: Well appearing M. Comfortable, appropriate.
HEENT: Sclera mildly icteric.
CARDIAC: RRR, S1, S2, clear and of good quality without m/r/g
LUNGS: Resp were unlabored, moving air well and symmetrically.
CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, no TTP. No HSM.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
Skin- papular erythematous rash over arms and chest, improved
from previous

FAMILY HISTORY: No significant family hx GI cancers or liver disease.

SOCIAL HISTORY: Lives with mother/step-father.  [**Name (NI) 1403**] at [**Company 92075**].  No tobacco
use. Alcohol habits include binge drinking a "few days/week" as
much as 1L whiskey, 12 beers/day. No recretional drugs.
Poisoning by aromatic analgesics, not elsewhere classified,Defibrination syndrome,Acute and subacute necrosis of liver,Encephalopathy, unspecified,Toxic effect of unspecified alcohol,Accidental poisoning by unspecified alcohol,Accidental poisoning by aromatic analgesics, not elsewhere classified,Other and unspecified alcohol dependence, unspecified,Cannabis dependence, unspecified,Disorders of phosphorus metabolism,Other dental caries,Dermatitis due to drugs and medicines taken internally,Expectorants causing adverse effects in therapeutic use
Pois-arom analgesics NEC,Defibrination syndrome,Acute necrosis of liver,Encephalopathy NOS,Toxic effect alcohol NOS,Acc poison-alcohol NOS,Acc poison-arom analgesc,Alcoh dep NEC/NOS-unspec,Cannabis depend-unspec,Dis phosphorus metabol,Dental caries NEC,Drug dermatitis NOS,Adv eff expectorants
Admission Date:  [**2165-1-28**]              Discharge Date:   [**2165-2-8**]

Date of Birth:  [**2139-5-25**]             Sex:   M

Service: MEDICINE

Allergies:
Heparin Agents

Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
confusion, chillc

Major Surgical or Invasive Procedure:
None


History of Present Illness:
25M with a history of alcohol abuse who was admitted to the SICU
with acute hepatic failure in setting of acetaminophen
toxicity/EtOH abuse.
.
According to SICU notes, the patient had been self-medicating
for ongoing tooth pain with 20-30 tylenol tablets daily and
unquantified doses ibuprofen X 8 days. Additionally, he had been
binge drinking, with consumption of approximately 1L whiskey and
12-15 beers daily. On [**2165-1-27**], the patient reported abdominal
pain with accompanying  nausea and non-bloody emesis. His
symptoms progressed to include diffuse myalgias, confusion,
chills and diaphoresis. He was brought to an OSH, where the
patient was noted to have transaminases in [**2152**], INR ~5,
lactate 14. He was resuscitated and NAC gtt was initiated. He
was subsequently transferred to [**Hospital1 18**] SICU.
.
While in the SICU, he was continued on NAC gtt, and the
patient's LFTs trended to peaks of ALT 6880, AST 8562 on [**1-29**] and
subsequently trended downward. INR peaked at 14.3 on [**1-29**], and
was given total 4 units FFP and 1 cryo, and since downtrended to
3.6. Hepatitis serologies have all returned negative. RUQ U/S
revealed patent vessels, no ascites, varices or acute liver
lesions. He was seen by psych, who felt that he had EtOH
dependence, but no acute psychiatric issues. Dental eval
revealed poor dentition, panorex with 2 necrotic teeth, but no
acute signs of infection.
.
On the floor, the patient reports no current symptoms. He feels
tired, but denies confusion, abdominal pain, N/V/D.

Past Medical History:
- dental caries
- tonsillectomy

Social History:
Lives with mother/step-father.  [**Name (NI) 1403**] at [**Company 92075**].  No tobacco
use. Alcohol habits include binge drinking a "few days/week" as
much as 1L whiskey, 12 beers/day. No recretional drugs.

Family History:
No significant family hx GI cancers or liver disease.

Physical Exam:
ADMISSION EXAM
VS: 98.8  94  104/57  24  96%RA
GENERAL: Well appearing M. Comfortable, appropriate.
HEENT: Sclera mildly icteric.
CARDIAC: RRR, S1, S2, clear and of good quality without m/r/g
LUNGS: Resp were unlabored, moving air well and symmetrically.
CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender to palpation. No HSM.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
[**Location (un) **] bilaterally to knees.
.
DISCHARGE EXAM
VS: 98.1 131/52 67 18 100%RA
GENERAL: Well appearing M. Comfortable, appropriate.
HEENT: Sclera mildly icteric.
CARDIAC: RRR, S1, S2, clear and of good quality without m/r/g
LUNGS: Resp were unlabored, moving air well and symmetrically.
CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, no TTP. No HSM.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
Skin- papular erythematous rash over arms and chest, improved
from previous

Pertinent Results:
LABORATORY DATA
CBC
[**2165-1-28**] 07:57PM BLOOD WBC-19.7* RBC-4.61 Hgb-14.1 Hct-42.4
MCV-92 MCH-30.6 MCHC-33.2 RDW-14.6 Plt Ct-163
[**2165-1-28**] 07:57PM BLOOD Neuts-96.9* Lymphs-2.5* Monos-0.3*
Eos-0.2 Baso-0.1
[**2165-2-8**] 05:40AM BLOOD WBC-6.8 RBC-3.59* Hgb-11.0* Hct-33.3*
MCV-93 MCH-30.6 MCHC-33.0 RDW-19.1* Plt Ct-72*
.
INR
[**2165-1-28**] 07:57PM BLOOD PT-62.7* PTT-36.8* INR(PT)-6.3*
[**2165-1-29**] 06:30AM BLOOD PT-84.5* PTT-41.6* INR(PT)-8.6*
[**2165-1-29**] 11:13AM BLOOD PT-100* PTT-42.3* INR(PT)-14.3*
[**2165-1-29**] 05:30PM BLOOD PT-55.3* PTT-35.3 INR(PT)-5.5*
[**2165-1-30**] 06:12AM BLOOD PT-85.0* PTT-37.8* INR(PT)-8.6*
[**2165-1-30**] 01:43PM BLOOD PT-37.9* PTT-31.4 INR(PT)-3.7*
[**2165-2-8**] 05:40AM BLOOD PT-21.8* PTT-41.3* INR(PT)-2.1*
.
Fibrinogen
[**2165-1-29**] 12:16AM BLOOD Fibrino-86*
[**2165-1-29**] 05:30PM BLOOD Fibrino-67*
[**2165-1-30**] 01:43PM BLOOD Fibrino-134*#
[**2165-2-1**] 01:56AM BLOOD Fibrino-66*
[**2165-2-7**] 06:20AM BLOOD Fibrino-167*#
.
Chemistry
[**2165-1-28**] 07:57PM BLOOD Glucose-167* UreaN-16 Creat-1.2 Na-135
K-5.3* Cl-101 HCO3-15* AnGap-24*
[**2165-2-8**] 05:40AM BLOOD Glucose-85 UreaN-7 Creat-0.9 Na-136 K-3.9
Cl-104 HCO3-23 AnGap-13
.
LFTS
[**2165-1-28**] 07:57PM BLOOD ALT-3237* AST-3970* AlkPhos-82
TotBili-6.7*
[**2165-1-30**] 06:12AM BLOOD ALT-6346* AST-6129* AlkPhos-123
TotBili-6.2*
[**2165-2-7**] 06:20AM BLOOD ALT-271* AST-39 LD(LDH)-220 AlkPhos-105
TotBili-15.8*
[**2165-2-8**] 05:40AM BLOOD ALT-196* AST-42* LD(LDH)-269* AlkPhos-94
TotBili-15.3*
.
MISC
[**2165-1-29**] 12:16AM BLOOD %HbA1c-5.1 eAG-100
[**2165-1-29**] 12:16AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE HAV
Ab-NEGATIVE
[**2165-1-29**] 12:16AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2165-1-29**] 12:16AM BLOOD CEA-3.6 PSA-0.5 AFP-1.3
[**2165-1-29**] 12:16AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2165-1-30**] 01:43PM BLOOD AFP-1.8
[**2165-1-29**] 12:16AM BLOOD IgG-859 IgA-216 IgM-28*
[**2165-1-28**] 07:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-27
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2165-1-30**] 01:43PM BLOOD Acetmnp-NEG
[**2165-1-29**] 12:16AM BLOOD [**Year/Month/Day **] Ab-NEGATIVE
[**2165-1-28**] 09:27PM BLOOD Lactate-5.6*
[**2165-1-31**] 07:55AM BLOOD Lactate-2.1*
.
Test                          Result              Reference
Range/Units
CA [**71**]-9                       37  H               <37 U/mL
CERULOPLASMIN                 15  L               18-36 mg/dL
COPPER                        42  L               70-175 mcg/dL
.
URINE STUDIES
[**2165-1-28**] 08:50PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.024
[**2165-1-28**] 08:50PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-70 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2165-1-28**] 08:50PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
.
MICROBIOLOGY
.
 [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2165-1-31**]):    POSITIVE BY
EIA.

   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2165-1-31**]):    POSITIVE
BY EIA.

   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2165-1-31**]):
      NEGATIVE <1:10 BY IFA.
.
 CMV Viral Load (Final [**2165-1-31**]):
      CMV DNA not detected.
.
HBV, [**Year/Month/Day **] Viral load pending
.
STUDIES
Chest xray [**2165-1-28**]
Semi-erect radiograph. Normal size of the cardiac silhouette. No
pleural effusions. No pulmonary edema. No pneumothorax. No areas
of atelectasis. Borderline diameter of the azygos vein might
indicate increased circulating blood volume.
.
Liver US
1. No focal liver lesions, varices or ascites.
2. Liver Doppler shows full patency of the portal and hepatic
veins with
normally directed flow.


Brief Hospital Course:
PRIMARY REASON FOR ADMISSION
The patient is a 25M with a history of alcohol abuse who was
admitted with acute hepatic failure in setting of excessive
acetaminophen use/EtOH abuse.
.
# Acute Liver Failure: Patient was initially presented to an OSH
with abdominal pain and confusion.  He was found to have a
transaminitis with ALT/AST of 3237/3970 respectively. This was
felt to most likely represent acetaminophen toxicity in the
setting of extensive alcohol use.  Patient was started on a NAC
gtt and transferred to [**Hospital1 18**] for evaluation for transplant.
Work-up of other possible etiologies included negative hepatitis
serologies (HBV/[**Hospital1 **] viral loads pending), normal copper and
ceruloplasmin, negative AMA and anti-smooth muscle, normal IgG
level, and negative HIV.  Liver US showed patent liver
vasculature. ALT/AST trended upward to maximum values of 6880/
8562.  INR trended upward to 14.  Patient was continued on the
NAC gtt.  LFTs trended downward, acetaminophen levels normalized
and the patient was transferred to the floor. He was given
vitamin K 5 mg x 3 days.  INR trended down to 2.1 and NAC gtt
was discontinued and INR remained stable. Bilirubin continued to
trend upward to a max of 15.8.  At the time of discharge labs
were notable for ALT/AST of 196/ 42, INR of 2.1 and total
bilirubin of 15.3. Patient remained pain free without signs of
hepatic encephalopathy. The patient was discharged home with
instructions to follow-up with the liver center. He was given
instructions to avoid both alcohol and tylenol.
.
# Alcohol Abuse: Patient has a history of alcohol abuse of many
years duration. He was evaluated by psychiatry who felt
presentation was consistent with alcohol and cannabis
dependence.  He was continued on thiamine and folate. He
exhibited no signs of withdrawal. Per the patient he intends to
quit using both alcohol and cannabis.
.
# Necrotic teeth: Patient was seen by dental who noted necrotic
teeth on panorex. They recommended extraction when INR
normalized. The patient will follow-up with dental as an
outpatient regarding extraction.
.
# Rash- Patient developed an erythematous papular rash while on
the floor. This was felt to most likely represent a drug rash
possibly due to NAC.  All unnecessary medications were
discontinued.  Rash was improving at the time of discharge.
.
# thrombocytopenia- Patient's platelet count was noted to trend
down from 163 on admission to a nadir of 63. The etiology of
this drop was not known.  HIT antibody was positive but with a
low optical density. Given the clinical scenario it was felt
that HIT was unlikely.  EBV studies demonstrated previous
exposure but no current infection.  Ultimately it was felt
presentation might be representative of low grade DIC which was
slow to improve given poor liver function. Platelet count
trended upward to 72 on discharge. He was without signs of
bleeding.
.
TRANSITIONAL ISSUES
- Patient will follow-up with the liver center and a new [**Company 191**] PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] and HBV viral loads were pending at the time of discharge
- Patient was full code throughout this hospitalization


Medications on Admission:
none

Discharge Medications:
none

Discharge Disposition:
Home

Discharge Diagnosis:
Tylenol/alcohol hepatotoxicity.


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


Discharge Instructions:
It was a pleasure to care for at [**Hospital1 **].
.
You were admitted with liver injury due to tylenol and alcohol.
After treatment and supportive care your liver recovered. It was
noted during the admission your platelet count was low. Please
follow up with your primary care physician and liver specialist
as an outpatient in regards to your pletelet count and liver
disease.
.
You will have to wait a couple of weeks to have dental work done
as your blood is thin and you are prone to bleeding. Please
follow up with your new primary care physician regarding this.
You can make a dental appointment at ([**Telephone/Fax (1) 92076**] when the
time is appropiate.
Please follow up with the outpatient appointments below:

Followup Instructions:
Department: LIVER CENTER
When: TUESDAY [**2165-2-12**] at 4:20 PM
With: [**Name6 (MD) **] [**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

Department: [**Hospital3 249**]
When: FRIDAY [**2165-2-15**] at 2:35 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] North [**Hospital **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
**Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] is your new physician at [**Name9 (PRE) 191**].  He works
closely with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in your
care.**
{'Poisoning by aromatic analgesics, not elsewhere classified,Defibrination syndrome,Acute and subacute necrosis of liver,Encephalopathy, unspecified,Toxic effect of unspecified alcohol,Accidental poisoning by unspecified alcohol,Accidental poisoning by aromatic analgesics, not elsewhere classified,Other and unspecified alcohol dependence, unspecified,Cannabis dependence, unspecified,Disorders of phosphorus metabolism,Other dental caries,Dermatitis due to drugs and medicines taken internally,Expectorants causing adverse effects in therapeutic use'}


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: confusion, chillc

PRESENT ILLNESS: 25M with a history of alcohol abuse who was admitted to the SICU
with acute hepatic failure in setting of acetaminophen
toxicity/EtOH abuse.
.
According to SICU notes, the patient had been self-medicating
for ongoing tooth pain with 20-30 tylenol tablets daily and
unquantified doses ibuprofen X 8 days. Additionally, he had been
binge drinking, with consumption of approximately 1L whiskey and
12-15 beers daily. On [**2165-1-27**], the patient reported abdominal
pain with accompanying  nausea and non-bloody emesis. His
symptoms progressed to include diffuse myalgias, confusion,
chills and diaphoresis. He was brought to an OSH, where the
patient was noted to have transaminases in [**2152**], INR ~5,
lactate 14. He was resuscitated and NAC gtt was initiated. He
was subsequently transferred to [**Hospital1 18**] SICU.
.
While in the SICU, he was continued on NAC gtt, and the
patient's LFTs trended to peaks of ALT 6880, AST 8562 on [**1-29**] and
subsequently trended downward. INR peaked at 14.3 on [**1-29**], and
was given total 4 units FFP and 1 cryo, and since downtrended to
3.6. Hepatitis serologies have all returned negative. RUQ U/S
revealed patent vessels, no ascites, varices or acute liver
lesions. He was seen by psych, who felt that he had EtOH
dependence, but no acute psychiatric issues. Dental eval
revealed poor dentition, panorex with 2 necrotic teeth, but no
acute signs of infection.
.
On the floor, the patient reports no current symptoms. He feels
tired, but denies confusion, abdominal pain, N/V/D.

MEDICAL HISTORY: - dental caries
- tonsillectomy

MEDICATION ON ADMISSION: none

ALLERGIES: Heparin Agents

PHYSICAL EXAM: ADMISSION EXAM
VS: 98.8  94  104/57  24  96%RA
GENERAL: Well appearing M. Comfortable, appropriate.
HEENT: Sclera mildly icteric.
CARDIAC: RRR, S1, S2, clear and of good quality without m/r/g
LUNGS: Resp were unlabored, moving air well and symmetrically.
CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender to palpation. No HSM.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
[**Location (un) **] bilaterally to knees.
.
DISCHARGE EXAM
VS: 98.1 131/52 67 18 100%RA
GENERAL: Well appearing M. Comfortable, appropriate.
HEENT: Sclera mildly icteric.
CARDIAC: RRR, S1, S2, clear and of good quality without m/r/g
LUNGS: Resp were unlabored, moving air well and symmetrically.
CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, no TTP. No HSM.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
Skin- papular erythematous rash over arms and chest, improved
from previous

FAMILY HISTORY: No significant family hx GI cancers or liver disease.

SOCIAL HISTORY: Lives with mother/step-father.  [**Name (NI) 1403**] at [**Company 92075**].  No tobacco
use. Alcohol habits include binge drinking a "few days/week" as
much as 1L whiskey, 12 beers/day. No recretional drugs. 

### Response:
{'Poisoning by aromatic analgesics, not elsewhere classified,Defibrination syndrome,Acute and subacute necrosis of liver,Encephalopathy, unspecified,Toxic effect of unspecified alcohol,Accidental poisoning by unspecified alcohol,Accidental poisoning by aromatic analgesics, not elsewhere classified,Other and unspecified alcohol dependence, unspecified,Cannabis dependence, unspecified,Disorders of phosphorus metabolism,Other dental caries,Dermatitis due to drugs and medicines taken internally,Expectorants causing adverse effects in therapeutic use'}
