CHIEF COMPLAINT: transfer from OSH for ? failed TIPS

PRESENT ILLNESS: Ms. [**Known lastname 19755**] is a 62 y/o female with alcoholic ESLD s/p TIPs
for variceal bleed 2y ago, h/o ascites who was admitted to
[**Hospital3 3583**] on [**12-15**] with 2 weeks of increasing left leg
edema, pain and erythema non-responsive to 5 days of Kelfex for
presumed cellulitis. (Pt was afebrile throughout her admission
at [**Hospital1 46**] and WBC max was 10.6 with 84% polys.) She also had
abdominal pain and increasing abd girth. She had no fever or
chills, and had decreased appetite but says this is her
baseline. Patient had also noticed increased abdominal girth.
Otherwise had no complaints. She was admitted to [**Hospital1 46**] for IV
abx and diuresis.
.
At [**Hospital3 3583**], she was treated with Iv Zosyn for LLE
cellulitis. LENI of the L leg was negative for DVT, and doppler
U/S of her abd showed a patent TIPS with high velocities,
causing concern for TIPS stenosis. She had a diagnostic and
therapeutic tap (3L removed) which showed no evidence of SBP.
she was transfused 1 unit pRBCs [**12-16**] at OSH. She was
transferred to [**Hospital1 18**] for further care and ? revision of TIPS.
Interestingly, her ammonia level was 19 at [**Hospital1 46**] compared to
her baseline there of 40-80. Blood cultures from [**12-15**] final
read is negative.
.
At present, pt reports she is tired and lightheaded with
decreased appetite. Continues to have abdominal and B leg pain
and states these are only slightly decreased from admission.
.
ROS: denies HA, CP, SOB, cough, N/V, dysuria, constipation.
Notes bilateral leg pain, abd pain, decreased appetite,
diarrhea.

MEDICAL HISTORY: 1. Parkinson's: ? new diagnosis. Off transplant list.
2. ESLD from EtOH cirrhosis: esophageal variceal bleed in [**10-2**],
Stage III varices s/p 4 bands with rebleeding requiring
intubation, [**Last Name (un) 10045**] placement and TIPS. h/o encephalopathy.
3. Type 2 DM on insulin therapy
4. HTN
4. GERD
5. h/o carpal tunnel surgery
6. Chronic Edema
7. h/o cellulitis
8. thrombocytopenia in setting of liver disease
9. [**Name (NI) **] (unclear site)

MEDICATION ON ADMISSION: Lasix 40mg po bid
protonix 40mg po qday
celexa 10mg po qday
lantus 50 units qhs
lactulose 2 tblspoons qid
ritalin 5mg po bid
MVI po qday
nadolol 10mg po qday
rifaximin 400mg po tid
thiamine 100mg po qday
zofran 4mg po q12h prn nausea
robitussin prn cough
benadryl 12.5mg po qhs prn itch
potassium 20meQ po qday
sinemet 25/100 3 half tabs po tid
aldactone 100mg po qday
percocet qday prn pain
novolog 5 units [**Hospital1 **]
insulin slide scale

ALLERGIES: Aspirin

PHYSICAL EXAM: PE: 98.2, 128/62, 88, 20, 100% RA, FS 139
Gen: NAD, lying in bed, answers questions appropriately
HEENT: scleral icterus, PERRL, NCAT, erythematous cheeks and
nose
Neck: no LAD, supple
Cor: RRR, s1s2, flow murmur
Pulm: decreasd B bases, otherwise CTAB
Abd: protuberant, decreased BS, tender to mild palpation, unalbe
to assess for HSM due to extreme discomfort
Skin: jaundiced, spider angiomata on face, chest, arms, palmar
erythema. BLE skin appears thickened, dry, scaly and
erythematous, although not definitely warm or cellulitic.
Ext: BLE pitting edema - on R leg edema up to knee, on L leg
edema at least halfway up thigh.
Neuro: oriented x 3, slow talking but alert, 4/5 strength B
grips/biceps/triceps/plantarflexion/dorsiflexion. + asterixis

FAMILY HISTORY: pt denies any illnesses in family.

SOCIAL HISTORY: currently living at [**Hospital 62931**]. Quit tobacco 20y ago,
quit EtOH 20y ago per pt, denies other drugs. Previously lived
at home with her son, daughter and [**Name2 (NI) 12496**].
Alcoholic cirrhosis of liver,Acute kidney failure, unspecified,Hepatic encephalopathy,Other ascites,Cyst and pseudocyst of pancreas,Defibrination syndrome,Unspecified septicemia,Severe sepsis,Septic shock,Acute vascular insufficiency of intestine,Thrombocytopenia, unspecified,Esophageal reflux,Unspecified essential hypertension,Paralysis agitans,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin
Alcohol cirrhosis liver,Acute kidney failure NOS,Hepatic encephalopathy,Ascites NEC,Pancreat cyst/pseudocyst,Defibrination syndrome,Septicemia NOS,Severe sepsis,Septic shock,Ac vasc insuff intestine,Thrombocytopenia NOS,Esophageal reflux,Hypertension NOS,Paralysis agitans,DMII wo cmp nt st uncntr,Long-term use of insulin
Admission Date:  [**2148-12-18**]              Discharge Date:   [**2148-12-25**]

Date of Birth:  [**2086-2-5**]             Sex:   F

Service: MEDICINE

Allergies:
Aspirin

Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
transfer from OSH for ? failed TIPS

Major Surgical or Invasive Procedure:
paracentesis

History of Present Illness:
Ms. [**Known lastname 19755**] is a 62 y/o female with alcoholic ESLD s/p TIPs
for variceal bleed 2y ago, h/o ascites who was admitted to
[**Hospital3 3583**] on [**12-15**] with 2 weeks of increasing left leg
edema, pain and erythema non-responsive to 5 days of Kelfex for
presumed cellulitis. (Pt was afebrile throughout her admission
at [**Hospital1 46**] and WBC max was 10.6 with 84% polys.) She also had
abdominal pain and increasing abd girth. She had no fever or
chills, and had decreased appetite but says this is her
baseline. Patient had also noticed increased abdominal girth.
Otherwise had no complaints. She was admitted to [**Hospital1 46**] for IV
abx and diuresis.
.
At [**Hospital3 3583**], she was treated with Iv Zosyn for LLE
cellulitis. LENI of the L leg was negative for DVT, and doppler
U/S of her abd showed a patent TIPS with high velocities,
causing concern for TIPS stenosis. She had a diagnostic and
therapeutic tap (3L removed) which showed no evidence of SBP.
she was transfused 1 unit pRBCs [**12-16**] at OSH. She was
transferred to [**Hospital1 18**] for further care and ? revision of TIPS.
Interestingly, her ammonia level was 19 at [**Hospital1 46**] compared to
her baseline there of 40-80. Blood cultures from [**12-15**] final
read is negative.
.
At present, pt reports she is tired and lightheaded with
decreased appetite. Continues to have abdominal and B leg pain
and states these are only slightly decreased from admission.
.
ROS: denies HA, CP, SOB, cough, N/V, dysuria, constipation.
Notes bilateral leg pain, abd pain, decreased appetite,
diarrhea.


Past Medical History:
1. Parkinson's: ? new diagnosis. Off transplant list.
2. ESLD from EtOH cirrhosis: esophageal variceal bleed in [**10-2**],
Stage III varices s/p 4 bands with rebleeding requiring
intubation, [**Last Name (un) 10045**] placement and TIPS. h/o encephalopathy.
3. Type 2 DM on insulin therapy
4. HTN
4. GERD
5. h/o carpal tunnel surgery
6. Chronic Edema
7. h/o cellulitis
8. thrombocytopenia in setting of liver disease
9. [**Name (NI) **] (unclear site)


Social History:
currently living at [**Hospital 62931**]. Quit tobacco 20y ago,
quit EtOH 20y ago per pt, denies other drugs. Previously lived
at home with her son, daughter and [**Name2 (NI) 12496**].

Family History:
pt denies any illnesses in family.

Physical Exam:
PE: 98.2, 128/62, 88, 20, 100% RA, FS 139
Gen: NAD, lying in bed, answers questions appropriately
HEENT: scleral icterus, PERRL, NCAT, erythematous cheeks and
nose
Neck: no LAD, supple
Cor: RRR, s1s2, flow murmur
Pulm: decreasd B bases, otherwise CTAB
Abd: protuberant, decreased BS, tender to mild palpation, unalbe
to assess for HSM due to extreme discomfort
Skin: jaundiced, spider angiomata on face, chest, arms, palmar
erythema. BLE skin appears thickened, dry, scaly and
erythematous, although not definitely warm or cellulitic.
Ext: BLE pitting edema - on R leg edema up to knee, on L leg
edema at least halfway up thigh.
Neuro: oriented x 3, slow talking but alert, 4/5 strength B
grips/biceps/triceps/plantarflexion/dorsiflexion. + asterixis


Pertinent Results:
ON ADMISSION:
[**2148-12-19**] 06:20AM BLOOD WBC-8.5# RBC-2.73* Hgb-9.2* Hct-28.3*
MCV-104* MCH-33.7* MCHC-32.5 RDW-17.3* Plt Ct-87*#
[**2148-12-19**] 06:20AM BLOOD Neuts-81.6* Lymphs-10.6* Monos-6.3
Eos-1.4 Baso-0.1
[**2148-12-19**] 06:20AM BLOOD PT-20.0* PTT-43.7* INR(PT)-1.9*
[**2148-12-19**] 06:20AM BLOOD Glucose-70 UreaN-20 Creat-1.2* Na-138
K-4.0 Cl-99 HCO3-33* AnGap-10
[**2148-12-19**] 06:20AM BLOOD ALT-5 AST-49* AlkPhos-162* TotBili-8.4*
[**2148-12-19**] 06:20AM BLOOD Albumin-2.2* Calcium-8.2* Phos-3.3 Mg-1.9
.
IRON STUDIES:
[**2148-12-20**] 05:15AM BLOOD calTIBC-94* VitB12-1336* Folate-7.8
Ferritn-570* TRF-72*
.
ON DISCHARGE
[**2148-12-22**] 07:10AM BLOOD WBC-6.5 RBC-2.42* Hgb-8.7* Hct-26.2*
MCV-108* MCH-35.9* MCHC-33.2 RDW-16.7* Plt Ct-75*
[**2148-12-22**] 07:10AM BLOOD PT-21.2* INR(PT)-2.0*
[**2148-12-22**] 07:10AM BLOOD Glucose-113* UreaN-16 Creat-1.1 Na-138
K-3.7 Cl-97 HCO3-33* AnGap-12
[**2148-12-22**] 07:10AM BLOOD TotBili-9.3*
[**2148-12-22**] 07:10AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.8
.
[**2148-12-19**] 11:05 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
      PERITONEAL FLUID.
   AEROBIC BOTTLE (Preliminary):    NO GROWTH.
   ANAEROBIC BOTTLE (Preliminary):    NO GROWTH.
WBC 215*
RBC 2874*
N 2* L 31* M 0 Meso 1* Macrophages 66*
TotPro 1
Glucose 108
Creat 1.1
Albumin LESS THAN 1.0
.
[**2148-12-21**] 03:00PM URINE RBC-2 WBC-12* Bacteri-RARE Yeast-NONE
Epi-5
[**2148-12-21**] 03:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM
[**2148-12-21**] 03:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2148-12-21**] 3:00 pm URINE      Source: CVS.
URINE CULTURE (Final [**2148-12-22**]):    <10,000 organisms/ml.
.
Blood Cultures 11/23 and [**12-21**] no growth at time of discharge
.
CT Abd/Pelvis W and W/O CONTRAST [**2148-12-19**]
IMPRESSION: 1. No evidence of pyelonephritis or diverticulitis.
2. Evidence of chronic liver disease with ascites and irregular
liver outline. Ascites has worsened from prior study. 3. Basal
pleural effusions and atelectasis worse than on previous
examination. 4. Lumbar spine degenerative change with spinal
canal stenosis at L2-3 and L4-5. 5. Non-specific pancreatic head
cystic abnormality--MRCP is recommended for further
characterization. These have not changed form previous study.
[**2148-10-23**] comparison.
.
DOPPLER ABDOMINAL [**Year (4 digits) **] [**2148-12-20**]: 1. Patent TIPS shunt with
appropriate velocities which appear to be unchanged from the
prior exam. 2. Slight increase in size of simple right liver
cyst. 3. Single gallstone. 4. Splenomegaly. 5. Ascites.


Brief Hospital Course:
Ms. [**Known lastname 19755**] is a 62yo woman with h/o EtOH cirrhosis s/p TIPS
after variceal bleed who is transferred from [**Hospital3 3583**]
after presenting there with increasing BLE (L>R) edema and
abdominal girth and found to have likely stenosed TIPS.
.
MEDICAL FLOOR HOSPITAL COURSE:
.
# Cirrhosis
Patient carries a history of ESLD s/p TIPS.  Given increased LE
swelling, there was a concern that the TIPS was stenosed.
Abdominal [**Hospital3 950**] showed no stenosis, however with increased
(albeit unchanged) velocities.  A venogram study was planned but
was unable to be performed given medical decompensation (below).

.
The patient underwent diagnostic paracentesis on hospital day 2
which did not show evidence of SBP.  On hospital day 6 the
patient's ascites had increased, her abdomen became distended,
and respirations were mildly impaired.  She underwent
therapeutic paracentesis, as is customarily performed on a
weekly basis given her proclivity to re-accumulate ascitic
fluid.  Paracentesis was attempted on the right lower abdomen,
where she normally undergoes drainage, but was unsuccessful.
Repeat attempt on the left lower abdomen several hours later was
successful in draining 5 L of serosanguinous fluid.  Fluid
evaluation was negative for SBP and cultures were negative 2
days later.
.
She was also continued on Nadolol 10mg po qday to prevent
variceal bleeding.  Lactulose 30mL po qid was also titrated to 3
bowel movements per day for encephalopathy.
.
# BLE edema and erythema
BLE edema was considered secondary to volume overload and not
infection, as wbc was wnl and she was afebrile.  Diuresis was
pursued w/ spironalactone / lasix.
.
# Parkinsons
Home dose sinemet was continued.
.
# DM
Controlled with home lantus 50 units qhs and sliding scale.
.
# Pancreatic Cyst
On CT scan patient was found to have a pancreatic head cyst
abnormality.  She would have followed up with an MRCP in [**3-3**]
weeks as an outpatient for further evaluation.
.
# Psych:
She was continued on citalopram and methylphenidate.
.
[**Hospital 12145**] HOSPITAL COURSE:
On [**12-23**], patient was noted to have spontaneous bleeding from
her mouth / gums and oozing from all her IV sites.  Coags were
checked and INR was elevated at 2.5.  Although her mental status
since admission was impaired (waxing/[**Doctor Last Name 688**] level of
consciousness and level of interaction), at approximately 5 pm
she was noted to have increased somnolence and difficulty to
arouse.  Furthermore, she was found to have several focal
neurologic signs worrisome for a CNS insult.  Given concern for
intracranial pathology and coagulopathy, she was sent for a
noncontrast CT of the head which was negative for ICH.
Subsequently she developed a fever; labs were sent to work up
DIC.  Lab data was consistent with DIC as well as ongoing blood
loss.  Differential on CBC showed stippled cells but no
schistocytes.  Neurology was consulted for altered mental status
of unclear etiology.  Of note, labs drawn amidst the
decompensation showed neutropenia w/ WBC of 600 (although this
was likely a lab error as repeat WBC was 5600).  She was written
for cefepime and vanco for neutropenic coverage, although no
doses were received.  At the time of Neurology evaluation,
patients temperature was noted to be 103 F and SBPS dropped into
the 90s. Repeat BP measurements then showed SBPs in 70s.  IVFs
were started and a CODE BLUE was called.
.
At the time of the CODE BLUE, patient was noted to be breathing
spontaneously without difficulty.  ABG checked at that time was
7.45/42/297 on NRB.  Patient had pulses but was unresponsive.
SBPs were 60s-70s.  IVF was hung in pressure bags through PIV
until L femoral CVL was placed. Dopamine gtt was also started
with improved SBPs to 110s w/ HRs to the 120s. She was then
transferred to the MICU for further management.  Code status was
discussed with her healthcare proxy and she was reported to be
DNR/DNI but pressors were okay to use.
.
In the MICU she was treated for presumed septic shock and DIC.
She was given cefepime, vanco, and flagyl and was volume
resuscitated with PRBCs, FFP, platelets, and cryogloblin.  She
required levophed and vasopressin to maintain MAPs >65. DIC labs
improved with blood products.  Blood cultures grew gram negative
rods. Overnight, repeating a CT of the abdomen was considered
but the patient was felt to be too unstable to transport. By the
following morning, pressors were weaned off and patient was more
alert but complaining of severe abdominal pain with some
rebounding. Also required BiPAP for respiratory distress
presumed secondary to volume overload in the setting of
oliguria.  Surgery was consulted for possible acute abdomen.
Upon review of CT abdomen/pelvis performed on the previous day,
there was concern for potential mesenteric ischemia.  This was
relayed to patient's son who was also her healthcare proxy.
Surgical options were discussed but it was decided to make the
patient CMO. She died the following day from cardiopulmonary
arrest at 0952 on [**12-25**].

Medications on Admission:
Lasix 40mg po bid
protonix 40mg po qday
celexa 10mg po qday
lantus 50 units qhs
lactulose 2 tblspoons qid
ritalin 5mg po bid
MVI po qday
nadolol 10mg po qday
rifaximin 400mg po tid
thiamine 100mg po qday
zofran 4mg po q12h prn nausea
robitussin prn cough
benadryl 12.5mg po qhs prn itch
potassium 20meQ po qday
sinemet 25/100 3 half tabs po tid
aldactone 100mg po qday
percocet qday prn pain
novolog 5 units [**Hospital1 **]
insulin slide scale

Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired
{'Alcoholic cirrhosis of liver,Acute kidney failure, unspecified,Hepatic encephalopathy,Other ascites,Cyst and pseudocyst of pancreas,Defibrination syndrome,Unspecified septicemia,Severe sepsis,Septic shock,Acute vascular insufficiency of intestine,Thrombocytopenia, unspecified,Esophageal reflux,Unspecified essential hypertension,Paralysis agitans,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin'}


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: transfer from OSH for ? failed TIPS

PRESENT ILLNESS: Ms. [**Known lastname 19755**] is a 62 y/o female with alcoholic ESLD s/p TIPs
for variceal bleed 2y ago, h/o ascites who was admitted to
[**Hospital3 3583**] on [**12-15**] with 2 weeks of increasing left leg
edema, pain and erythema non-responsive to 5 days of Kelfex for
presumed cellulitis. (Pt was afebrile throughout her admission
at [**Hospital1 46**] and WBC max was 10.6 with 84% polys.) She also had
abdominal pain and increasing abd girth. She had no fever or
chills, and had decreased appetite but says this is her
baseline. Patient had also noticed increased abdominal girth.
Otherwise had no complaints. She was admitted to [**Hospital1 46**] for IV
abx and diuresis.
.
At [**Hospital3 3583**], she was treated with Iv Zosyn for LLE
cellulitis. LENI of the L leg was negative for DVT, and doppler
U/S of her abd showed a patent TIPS with high velocities,
causing concern for TIPS stenosis. She had a diagnostic and
therapeutic tap (3L removed) which showed no evidence of SBP.
she was transfused 1 unit pRBCs [**12-16**] at OSH. She was
transferred to [**Hospital1 18**] for further care and ? revision of TIPS.
Interestingly, her ammonia level was 19 at [**Hospital1 46**] compared to
her baseline there of 40-80. Blood cultures from [**12-15**] final
read is negative.
.
At present, pt reports she is tired and lightheaded with
decreased appetite. Continues to have abdominal and B leg pain
and states these are only slightly decreased from admission.
.
ROS: denies HA, CP, SOB, cough, N/V, dysuria, constipation.
Notes bilateral leg pain, abd pain, decreased appetite,
diarrhea.

MEDICAL HISTORY: 1. Parkinson's: ? new diagnosis. Off transplant list.
2. ESLD from EtOH cirrhosis: esophageal variceal bleed in [**10-2**],
Stage III varices s/p 4 bands with rebleeding requiring
intubation, [**Last Name (un) 10045**] placement and TIPS. h/o encephalopathy.
3. Type 2 DM on insulin therapy
4. HTN
4. GERD
5. h/o carpal tunnel surgery
6. Chronic Edema
7. h/o cellulitis
8. thrombocytopenia in setting of liver disease
9. [**Name (NI) **] (unclear site)

MEDICATION ON ADMISSION: Lasix 40mg po bid
protonix 40mg po qday
celexa 10mg po qday
lantus 50 units qhs
lactulose 2 tblspoons qid
ritalin 5mg po bid
MVI po qday
nadolol 10mg po qday
rifaximin 400mg po tid
thiamine 100mg po qday
zofran 4mg po q12h prn nausea
robitussin prn cough
benadryl 12.5mg po qhs prn itch
potassium 20meQ po qday
sinemet 25/100 3 half tabs po tid
aldactone 100mg po qday
percocet qday prn pain
novolog 5 units [**Hospital1 **]
insulin slide scale

ALLERGIES: Aspirin

PHYSICAL EXAM: PE: 98.2, 128/62, 88, 20, 100% RA, FS 139
Gen: NAD, lying in bed, answers questions appropriately
HEENT: scleral icterus, PERRL, NCAT, erythematous cheeks and
nose
Neck: no LAD, supple
Cor: RRR, s1s2, flow murmur
Pulm: decreasd B bases, otherwise CTAB
Abd: protuberant, decreased BS, tender to mild palpation, unalbe
to assess for HSM due to extreme discomfort
Skin: jaundiced, spider angiomata on face, chest, arms, palmar
erythema. BLE skin appears thickened, dry, scaly and
erythematous, although not definitely warm or cellulitic.
Ext: BLE pitting edema - on R leg edema up to knee, on L leg
edema at least halfway up thigh.
Neuro: oriented x 3, slow talking but alert, 4/5 strength B
grips/biceps/triceps/plantarflexion/dorsiflexion. + asterixis

FAMILY HISTORY: pt denies any illnesses in family.

SOCIAL HISTORY: currently living at [**Hospital 62931**]. Quit tobacco 20y ago,
quit EtOH 20y ago per pt, denies other drugs. Previously lived
at home with her son, daughter and [**Name2 (NI) 12496**]. 

### Response:
{'Alcoholic cirrhosis of liver,Acute kidney failure, unspecified,Hepatic encephalopathy,Other ascites,Cyst and pseudocyst of pancreas,Defibrination syndrome,Unspecified septicemia,Severe sepsis,Septic shock,Acute vascular insufficiency of intestine,Thrombocytopenia, unspecified,Esophageal reflux,Unspecified essential hypertension,Paralysis agitans,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin'}
