CHIEF COMPLAINT: Altered mental status, rectal bleeding

PRESENT ILLNESS: 51 yo w h/p cirrhosis [**1-8**] ETOH, ascites, hemorrhoids, and anemia
p/w rectal bleeding for 4-5 days and MS changes per family to
[**Hospital1 **] MC on [**2134-5-1**]. Pt received 4U? of blood. She underwent
paracentesis without evidence of SBP on [**2134-5-2**]. A CT abdomen
was negative for hepatoma. Pt also presented with ARF on
admission with creatinine 2.2, improved with fluids initially.
However, subsequently her renal function was worsening to a
creatinine of 3.1. A component of HRS was suspected and
midodrine and octreotide was started. Albumin was given as well.
She was treated with Levofloxacin and initially also with FLagyl
presumptively for SBP, then FLagyl was discontinued and
Levofloxacin was continued for SBP prophylaxis and ? treatment
of UTI.
Currently the pt c/o intermittent pain in her lower abdomen that
has started with placement of foley catheter. The pain has been
stable for the last few days and she has received po and iv
narcotics for it. It is a crampy pain that last several seconds
and then resolves by itself. The pt also reports pain in her R
arm however she has trouble to describe it any furhter. Over the
last days she had several BM a day. She denies N, V. She reports
being confused and her husband confirms this. However the
husband reports that the MS improved initially and has been
stable for the last few days. She denies any furhterHer weakness
has improved initially at rehab but has worsened over her
hospitalization predominantly on her R.
In terms of her ETOH abuse the pt reports being sober for the
last 12months, per records from OSH 6months.
.
ROS: negative for CP, SOB, diarrhea, constipation, f/c/ns,
weight loss.

MEDICAL HISTORY: Recent admission at [**Hospital1 **] for myopathy thought to be due to
viral infection in [**2134-3-7**]
Recent admission for hypotension thought to be due to blood loss
anemia from rectal bleeding in [**2134-4-6**]
ESLD, [**1-8**] ETOH with cirrhosis > previous workup for transplant
at [**Hospital1 2025**], not listed due to ongoing ETOH abuse, also the pt wanted
less aggressive measures
Portal hypertension with ascites, no evidence of SBP
Per intern admission note negative endoscopy and colonscopy
during recent admission
Rectal bleeding from medium size hemorrhoids, s/p banding [**2134-4-13**]

MEDICATION ON ADMISSION: Octreotide and midodrine since [**5-8**]
Levofloxacin 500 QD
Ferrous sulfate
KCL
Lasix
Protonix
Prozac
Nadolol
Lidoderm patch
Lactulose
Aldactone
K-phos

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 98.2 BP 102/60 HR 94 RR 18 O2Sat 96RA FS 123
Gen: NAD, AAOx1
HEENT: NC/AT, PERRLA, mmm, sclerae icteric
NECK: no LAD, no JVD, no carotid bruit
COR: S1S2, regular rhythm, no m/r/g
PULM: decreased breathsounds in the bases, otherwise CTA b/l, no
wheezing or rhonchi
ABD: + bowel sounds, soft, tympanic, tense distension, no pain
on palpation
Skin: warm extremities, anasarca R>L, ecchymosis, spider
angiomata, erythema in R armpit, tender to palpation, ROMI
EXT: 2+ DP, no edema/c/c, no CVA tenderness
Neuro: 4/5 strength in R arm, due to pain?, handgrip [**4-10**] b/l,
4/5 strength in hip/knee flexor and hip/knee extensor, [**4-10**] in
foot extensor and flexor, following commands, PERRLA, reflexes
2+ b/l, positive asterixis, recall immediate intact, delayed [**12-9**]

FAMILY HISTORY: No liver disease

SOCIAL HISTORY: ETOH: heavy in the past, several glasses of red wine a day, no
hard drinks, last 12months ago
Tobacco: none
Living situation: married, from [**Country 532**], immigrated 20yrs ago
Alcoholic cirrhosis of liver,Hepatic encephalopathy,Cellulitis and abscess of upper arm and forearm,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Acute respiratory failure,Congestive heart failure, unspecified,Anemia, unspecified,Other specified disorders resulting from impaired renal function,Other and unspecified coagulation defects,Encounter for palliative care,Personal history of alcoholism
Alcohol cirrhosis liver,Hepatic encephalopathy,Cellulitis of arm,Urin tract infection NOS,Protein-cal malnutr NOS,Acute respiratry failure,CHF NOS,Anemia NOS,Impair ren funct dis NEC,Coagulat defect NEC/NOS,Encountr palliative care,Hx of alcoholism
Admission Date:  [**2134-5-10**]              Discharge Date:   [**2134-5-19**]

Date of Birth:  [**2083-4-1**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Altered mental status, rectal bleeding

Major Surgical or Invasive Procedure:
Endotracheal intubation, paracentesis, central venous lines

History of Present Illness:
51 yo w h/p cirrhosis [**1-8**] ETOH, ascites, hemorrhoids, and anemia
p/w rectal bleeding for 4-5 days and MS changes per family to
[**Hospital1 **] MC on [**2134-5-1**]. Pt received 4U? of blood. She underwent
paracentesis without evidence of SBP on [**2134-5-2**]. A CT abdomen
was negative for hepatoma. Pt also presented with ARF on
admission with creatinine 2.2, improved with fluids initially.
However, subsequently her renal function was worsening to a
creatinine of 3.1. A component of HRS was suspected and
midodrine and octreotide was started. Albumin was given as well.
She was treated with Levofloxacin and initially also with FLagyl
presumptively for SBP, then FLagyl was discontinued and
Levofloxacin was continued for SBP prophylaxis and ? treatment
of UTI.
Currently the pt c/o intermittent pain in her lower abdomen that
has started with placement of foley catheter. The pain has been
stable for the last few days and she has received po and iv
narcotics for it. It is a crampy pain that last several seconds
and then resolves by itself. The pt also reports pain in her R
arm however she has trouble to describe it any furhter. Over the
last days she had several BM a day. She denies N, V. She reports
being confused and her husband confirms this. However the
husband reports that the MS improved initially and has been
stable for the last few days. She denies any furhterHer weakness
has improved initially at rehab but has worsened over her
hospitalization predominantly on her R.
In terms of her ETOH abuse the pt reports being sober for the
last 12months, per records from OSH 6months.
.
ROS: negative for CP, SOB, diarrhea, constipation, f/c/ns,
weight loss.

Past Medical History:
Recent admission at [**Hospital1 **] for myopathy thought to be due to
viral infection in [**2134-3-7**]
Recent admission for hypotension thought to be due to blood loss
anemia from rectal bleeding in [**2134-4-6**]
ESLD, [**1-8**] ETOH with cirrhosis > previous workup for transplant
at [**Hospital1 2025**], not listed due to ongoing ETOH abuse, also the pt wanted
less aggressive measures
Portal hypertension with ascites, no evidence of SBP
Per intern admission note negative endoscopy and colonscopy
during recent admission
Rectal bleeding from medium size hemorrhoids, s/p banding [**2134-4-13**]

Pt and husband denies heart, lung disease


Social History:
ETOH: heavy in the past, several glasses of red wine a day, no
hard drinks, last 12months ago
Tobacco: none
Living situation: married, from [**Country 532**], immigrated 20yrs ago

Family History:
No liver disease

Physical Exam:
VS T 98.2 BP 102/60 HR 94 RR 18 O2Sat 96RA FS 123
Gen: NAD, AAOx1
HEENT: NC/AT, PERRLA, mmm, sclerae icteric
NECK: no LAD, no JVD, no carotid bruit
COR: S1S2, regular rhythm, no m/r/g
PULM: decreased breathsounds in the bases, otherwise CTA b/l, no
wheezing or rhonchi
ABD: + bowel sounds, soft, tympanic, tense distension, no pain
on palpation
Skin: warm extremities, anasarca R>L, ecchymosis, spider
angiomata, erythema in R armpit, tender to palpation, ROMI
EXT: 2+ DP, no edema/c/c, no CVA tenderness
Neuro: 4/5 strength in R arm, due to pain?, handgrip [**4-10**] b/l,
4/5 strength in hip/knee flexor and hip/knee extensor, [**4-10**] in
foot extensor and flexor, following commands, PERRLA, reflexes
2+ b/l, positive asterixis, recall immediate intact, delayed [**12-9**]


Pertinent Results:
.
Labs on [**2134-5-10**] from OSH:
......10.2
9.7>-----< 52
......29.5
75N, 10L, 14M
.
INR: 2.4, aPTT: 49.6
.
134/105/49
----------<109
4.4/19/3.1
.
Calc 9.1, Phos: 5.5, Mg 1.9
.
Bilirubin 6.9 on [**2134-5-8**], Alb 2.4, AST 68, ALT 25
.
UA [**5-9**]: 1.017, 150prot, small bili, large blood, negative
nitrate
Used [**5-9**]: >100WBC, > 100 RBC, may bact
UCx: MRSA 10-50,000 organisms
.
EKG: [**2134-5-1**] from OSH: SR, HR 70, NA,QT mild prolonged at 455,
early RW progression, no ST or TW changes
.
CT abdomen [**2134-5-3**]
Large ascites, thickened irregular appearing colon, more
pronounced in ascending colon, cholelithiasis, nodular contour
of the liver, mild splenomegaly
.

Brief Hospital Course:
51 yo with end-stage ETOH cirrhosis who presented from an
outside hospital with rectal bleeding, MS changes, and renal
failure.  The pt was transferred for further treatment and
evaluation for possible liver transplant.  She was treated
aggressively for medical issues (as outlined below); however, as
she developed progressive multi-organ failure including probable
pneumonia the family decided to make her comfort measures only.
She died shortly thereafter.
.
# End-stage liver disease: Pt developed liver disease due to
years of ETOH abuse. She was abstinent for 12 months prior to
admission.  Her disease had been progressing rapidly with MELD
score was around 34.  She was cared for by the liver service as
well as the transplant team during her stay.  She was unable to
be listed for transplant due to probable pneumonia and overall
deteriorating condition.  She was transferred to the MICU, where
she was intubated electively for further MRI, however,
eventually developed respiratory failure due to volume overload
and pneumonia.
.
# Abdominal pain: due to tense ascites.  She had multiple
therapeutic paracentesis and was treated symptomatically wtih
pain medication.
.
# Anemia: Pt has history of esophageal varices which have bled
in the past.  She is s/p rectal banding in early [**2134-4-6**].
.
# ARF: baseline crt 0.5.  However, over a period of months her
renal function declined.  Prior to admission crt was
approximately 2.  Etiology thought to be hepatorenal syndrome.
During her hospital stay, her renal function continued to
decline (crt 3.4).
.
# Encephalopathy: due to ESLD.  Treated symptomatically.
.
# Congestive heart failure: pt developed volume overload while
being resuscitated for episodes of hypotension.  Diuresis with
lasix drip was given with incomplete response.
.
# Pneumonia: pt with hypoxia & CXR findings suspicious for PNA,
thus she was treated with antibiotics for hospital acquired
infection.

Medications on Admission:
Octreotide and midodrine since [**5-8**]
Levofloxacin 500 QD
Ferrous sulfate
KCL
Lasix
Protonix
Prozac
Nadolol
Lidoderm patch
Lactulose
Aldactone
K-phos

Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
Primary:
End-stage liver disease from alcholic cirrhosis
Renal failure
Respiratory failure
Congestive heart failure
Encephalopathy


Discharge Condition:
Deceased

Discharge Instructions:
none

Followup Instructions:
none
{'Alcoholic cirrhosis of liver,Hepatic encephalopathy,Cellulitis and abscess of upper arm and forearm,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Acute respiratory failure,Congestive heart failure, unspecified,Anemia, unspecified,Other specified disorders resulting from impaired renal function,Other and unspecified coagulation defects,Encounter for palliative care,Personal history of alcoholism'}


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: Altered mental status, rectal bleeding

PRESENT ILLNESS: 51 yo w h/p cirrhosis [**1-8**] ETOH, ascites, hemorrhoids, and anemia
p/w rectal bleeding for 4-5 days and MS changes per family to
[**Hospital1 **] MC on [**2134-5-1**]. Pt received 4U? of blood. She underwent
paracentesis without evidence of SBP on [**2134-5-2**]. A CT abdomen
was negative for hepatoma. Pt also presented with ARF on
admission with creatinine 2.2, improved with fluids initially.
However, subsequently her renal function was worsening to a
creatinine of 3.1. A component of HRS was suspected and
midodrine and octreotide was started. Albumin was given as well.
She was treated with Levofloxacin and initially also with FLagyl
presumptively for SBP, then FLagyl was discontinued and
Levofloxacin was continued for SBP prophylaxis and ? treatment
of UTI.
Currently the pt c/o intermittent pain in her lower abdomen that
has started with placement of foley catheter. The pain has been
stable for the last few days and she has received po and iv
narcotics for it. It is a crampy pain that last several seconds
and then resolves by itself. The pt also reports pain in her R
arm however she has trouble to describe it any furhter. Over the
last days she had several BM a day. She denies N, V. She reports
being confused and her husband confirms this. However the
husband reports that the MS improved initially and has been
stable for the last few days. She denies any furhterHer weakness
has improved initially at rehab but has worsened over her
hospitalization predominantly on her R.
In terms of her ETOH abuse the pt reports being sober for the
last 12months, per records from OSH 6months.
.
ROS: negative for CP, SOB, diarrhea, constipation, f/c/ns,
weight loss.

MEDICAL HISTORY: Recent admission at [**Hospital1 **] for myopathy thought to be due to
viral infection in [**2134-3-7**]
Recent admission for hypotension thought to be due to blood loss
anemia from rectal bleeding in [**2134-4-6**]
ESLD, [**1-8**] ETOH with cirrhosis > previous workup for transplant
at [**Hospital1 2025**], not listed due to ongoing ETOH abuse, also the pt wanted
less aggressive measures
Portal hypertension with ascites, no evidence of SBP
Per intern admission note negative endoscopy and colonscopy
during recent admission
Rectal bleeding from medium size hemorrhoids, s/p banding [**2134-4-13**]

MEDICATION ON ADMISSION: Octreotide and midodrine since [**5-8**]
Levofloxacin 500 QD
Ferrous sulfate
KCL
Lasix
Protonix
Prozac
Nadolol
Lidoderm patch
Lactulose
Aldactone
K-phos

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 98.2 BP 102/60 HR 94 RR 18 O2Sat 96RA FS 123
Gen: NAD, AAOx1
HEENT: NC/AT, PERRLA, mmm, sclerae icteric
NECK: no LAD, no JVD, no carotid bruit
COR: S1S2, regular rhythm, no m/r/g
PULM: decreased breathsounds in the bases, otherwise CTA b/l, no
wheezing or rhonchi
ABD: + bowel sounds, soft, tympanic, tense distension, no pain
on palpation
Skin: warm extremities, anasarca R>L, ecchymosis, spider
angiomata, erythema in R armpit, tender to palpation, ROMI
EXT: 2+ DP, no edema/c/c, no CVA tenderness
Neuro: 4/5 strength in R arm, due to pain?, handgrip [**4-10**] b/l,
4/5 strength in hip/knee flexor and hip/knee extensor, [**4-10**] in
foot extensor and flexor, following commands, PERRLA, reflexes
2+ b/l, positive asterixis, recall immediate intact, delayed [**12-9**]

FAMILY HISTORY: No liver disease

SOCIAL HISTORY: ETOH: heavy in the past, several glasses of red wine a day, no
hard drinks, last 12months ago
Tobacco: none
Living situation: married, from [**Country 532**], immigrated 20yrs ago 

### Response:
{'Alcoholic cirrhosis of liver,Hepatic encephalopathy,Cellulitis and abscess of upper arm and forearm,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Acute respiratory failure,Congestive heart failure, unspecified,Anemia, unspecified,Other specified disorders resulting from impaired renal function,Other and unspecified coagulation defects,Encounter for palliative care,Personal history of alcoholism'}
