CHIEF COMPLAINT: Severe nausea and vomiting

PRESENT ILLNESS: 19yo female admitted on [**2116-10-3**] w/ severe nausea and vomiting.
The patient was seen in ED on [**2116-9-29**] with bloody diarrhea and
crampy abdominal pain.  Stool cultures sent were negative,
including E coli.  CT showed colitis.  She was admitted
overnight & sent home with po flagyl/cipro.
.
Following discharge she felt progressively better & diarrhea
decreased in volume.  However, 2days prior to admission, she
developed severe nausea and retching. When she presented on
[**2116-10-4**], she was found to have thrombocytopenia, hemolytic
anemia (with schitocytes on smear), and renal failure.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: Ciprofloxacin
Flagyl

ALLERGIES: Ciprofloxacin Hcl

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
Temperature 97.9, blood pressure 134/72, pulse 96, respiratory
rate 16, oxygen saturation 100% on room air.
Gen- pleasant though somewhat anxious young woman lying in bed
HEENT- PERRL, anicteric, EOMI, dry mucus membrane, oropharynx is
clear, however, palatal petechia noted. no cervical
lymphadenopathy,
CV- regular rhythm and rate, no rubs/mmurmur/gallop
RESP- lungs clear bilaterally
ABDOMEN- Active bowel sounds.  Non-distended.  Mild
periumbilical tenderness.  No guarding; no hepato- nor
splenomegaly.
EXT- [**1-13**]+ pedal edema, pedal pulses 2+ and equal bilaterally.
NERUO- Alert and oriented x3, CNII-XII intact, moving all limbs
spontanesouly, sensation grossly intact
SKIN- no rashes, no bruises (except at sites of blood draws)

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: She is a freshman at [**First Name4 (NamePattern1) 1663**] [**Last Name (NamePattern1) 1688**]. Her aunts and grandmother
live in the area; however, her parents are in [**State 622**]. The
patient is a nonsmoker. She does not drink significant amount of
alcohol.
Thrombotic microangiopathy,Hemolytic-uremic syndrome,Acute kidney failure, unspecified,Bacterial pneumonia, unspecified,Other pulmonary insufficiency, not elsewhere classified,Acidosis,Other specified hypotension,Other and unspecified noninfectious gastroenteritis and colitis,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Irritable bowel syndrome,Nausea alone,Headache,Hypocalcemia,Tachycardia, unspecified
Thrombot microangiopathy,Hemolytic uremic synd,Acute kidney failure NOS,Bacterial pneumonia NOS,Other pulmonary insuff,Acidosis,Hypotension NEC,Noninf gastroenterit NEC,Abn react-procedure NEC,Irritable bowel syndrome,Nausea alone,Headache,Hypocalcemia,Tachycardia NOS
Admission Date:  [**2116-10-3**]              Discharge Date:   [**2116-10-14**]

Date of Birth:  [**2097-9-3**]             Sex:   F

Service: MEDICINE

Allergies:
Ciprofloxacin Hcl

Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Severe nausea and vomiting

Major Surgical or Invasive Procedure:
-Plasmapheresis
-Intubation
-Right internal jugular venous catheter (removed [**2116-10-14**])


History of Present Illness:
19yo female admitted on [**2116-10-3**] w/ severe nausea and vomiting.
The patient was seen in ED on [**2116-9-29**] with bloody diarrhea and
crampy abdominal pain.  Stool cultures sent were negative,
including E coli.  CT showed colitis.  She was admitted
overnight & sent home with po flagyl/cipro.
.
Following discharge she felt progressively better & diarrhea
decreased in volume.  However, 2days prior to admission, she
developed severe nausea and retching. When she presented on
[**2116-10-4**], she was found to have thrombocytopenia, hemolytic
anemia (with schitocytes on smear), and renal failure.

Past Medical History:
None

Social History:
She is a freshman at [**First Name4 (NamePattern1) 1663**] [**Last Name (NamePattern1) 1688**]. Her aunts and grandmother
live in the area; however, her parents are in [**State 622**]. The
patient is a nonsmoker. She does not drink significant amount of
alcohol.

Family History:
Non-contributory

Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Temperature 97.9, blood pressure 134/72, pulse 96, respiratory
rate 16, oxygen saturation 100% on room air.
Gen- pleasant though somewhat anxious young woman lying in bed
HEENT- PERRL, anicteric, EOMI, dry mucus membrane, oropharynx is
clear, however, palatal petechia noted. no cervical
lymphadenopathy,
CV- regular rhythm and rate, no rubs/mmurmur/gallop
RESP- lungs clear bilaterally
ABDOMEN- Active bowel sounds.  Non-distended.  Mild
periumbilical tenderness.  No guarding; no hepato- nor
splenomegaly.
EXT- [**1-13**]+ pedal edema, pedal pulses 2+ and equal bilaterally.
NERUO- Alert and oriented x3, CNII-XII intact, moving all limbs
spontanesouly, sensation grossly intact
SKIN- no rashes, no bruises (except at sites of blood draws)


Pertinent Results:
[**2116-10-3**] 09:40PM BLOOD Glucose-95 UreaN-30* Creat-1.2* Na-135
K-3.6 Cl-102 HCO3-23 AnGap-14
[**2116-10-3**] 09:40PM BLOOD WBC-6.3 RBC-3.50* Hgb-10.8* Hct-29.3*
MCV-84 MCH-30.7 MCHC-36.7* RDW-13.9 Plt Ct-15*#
[**2116-10-3**] 10:40PM BLOOD LD(LDH)-877*
[**2116-10-3**] 10:40PM BLOOD calTIBC-226* Hapto-<20* Ferritn-735*
TRF-174*
.
[**2116-10-4**] 08:15AM BLOOD ADAMTS13 ACTIVITY 49%
.
[**2116-10-12**] 04:58AM BLOOD WBC-5.6 RBC-2.67* Hgb-8.4* Hct-23.8*
MCV-89 MCH-31.5 MCHC-35.3* RDW-14.3 Plt Ct-274
[**2116-10-13**] 05:23AM BLOOD WBC-6.1 RBC-2.66* Hgb-8.0* Hct-24.1*
MCV-91 MCH-30.2 MCHC-33.4 RDW-14.5 Plt Ct-373
[**2116-10-14**] 06:00AM BLOOD WBC-6.2 RBC-2.62* Hgb-8.1* Hct-23.8*
MCV-91 MCH-31.0 MCHC-34.2 RDW-14.7 Plt Ct-408
.
[**2116-10-12**] 04:58AM BLOOD Glucose-97 UreaN-9 Creat-0.8 Na-141 K-3.7
Cl-104 HCO3-29 AnGap-12
[**2116-10-13**] 05:23AM BLOOD Glucose-89 UreaN-11 Creat-1.0 Na-139
K-3.8 Cl-106 HCO3-26 AnGap-11
[**2116-10-14**] 06:00AM BLOOD Glucose-100 UreaN-10 Creat-0.8 Na-142
K-3.9 Cl-109* HCO3-25 AnGap-12
.
[**2116-10-12**] 04:58AM BLOOD LD(LDH)-262*
[**2116-10-13**] 05:23AM BLOOD LD(LDH)-283*
[**2116-10-14**] 06:00AM BLOOD LD(LDH)-315*
.
[**2116-10-13**] 05:23AM BLOOD Hapto-<20*
[**2116-10-14**] 06:00AM BLOOD Hapto-22*

.
[**2116-10-13**] 05:23AM BLOOD Albumin-3.2* Calcium-8.2* Phos-3.8 Mg-1.9
.
[**2116-10-9**]
COMPARISON: CT abdomen and pelvis with contrast [**2116-9-28**].
CT OF THE ABDOMEN WITH CONTRAST: Since the prior examination,
there has been interval development of bilateral lower lung lobe
air space consolidation primarily along the bronchovascular
bundles, most prominently at the right lower lung. There is
moderate-sized bilateral pleural effusions with associated
subsegmental atelectasis. The heart is normal in size. The liver
is unremarkable. There are no focal liver lesions or biliary
ductal dilatation identified. The gallbladder, pancreas, spleen,
and adrenal glands are normal in appearance. The kidneys enhance
symmetrically and excrete contrast normally. There is no
evidence of hydronephrosis or hydroureter. The stomach and
intra-abdominal loops of small and large bowel are normal in
appearance and caliber. There is no pathologically enlarged
mesenteric or retroperitoneal lymphadenopathy. The visualized
aorta is normal in caliber.

CT OF THE PELVIS WITH CONTRAST: Since the prior examination,
there has been interval improvement in the diffuse bowel wall
thickening throughout the colon. A segment of thickened bowel
remains which most likely is within the terminal ileum. However,
the bowel wall thickening within the large bowel has resolved.
There has been interval increase in the amount of intrapelvic
free fluid, although no focal fluid collections or abscess is
identified. A Foley is seen within an otherwise collapsed
bladder. The uterus and adnexa are unremarkable. There is
diffuse subcutaneous fat stranding consistent with anasarca.
There is no pathologically enlarged inguinal or pelvic
lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. Interval resolution in the degree of colonic and sigmoid
colon wall thickening has resolved, however a small segment of
what looks to be terminal ileum is now thickened. There is
interval increase in the amount of intrapelvic free fluid but no
focal fluid collections or abscesses.
2. Bilateral lower lung lobe pneumonia, right greater than left.
Moderate- sized bilateral pleural effusions.
.
CHEST (PORTABLE AP)  [**2116-10-11**]
A single AP view of the chest is obtained [**2116-10-11**] at 11:53 and
is compared with a prior radiograph of [**2116-10-8**]. Cardiac size
remains unchanged. Mediastinal contour is also unremarkable.
Right-sided pulmonary infiltrates appear to have increased,
particularly in the right base. There also is an increase in the
left base with a left pleural effusion. Ill-defined infiltrate
is developing in the left upper lobe. The patient has been
extubated. A right-sided IJ line is in unchanged position.
IMPRESSION:
Persistent multifocal airspace disease, which appears more
widespread with extension to the left upper lobe. Left pleural
effusion increasing since prior examination.

Brief Hospital Course:
#TTP-HUS: Upon admission, the pt was diagnosed w/ TTP-HUS given
her thrombocytopenia, hemolytic anemia (with schitocytes), and
renal failure.  She was admitted to the [**Hospital Unit Name 153**].  The hematology
and transfusion medicine services were consulted and started on
plasmapheresis ([**10-4**]).  She underwent a total of 8 sessions of
plasmapheresis (the last on [**2116-10-12**]) with good therapeutic
response.  Her platelet count returned to [**Location 213**] levels and
eventually her hematocrit stabilized as well, though she still
anemic (23.8) and with evidence of hemolysis on the day of
discharge (LDH 381 and haptoglobin 22).  The pt's renal failure
resolved with the therapy (peak creatinine 1.4 and discharge
creatinine 0.8).  She never had mental status changes during
hospitalization.  The etiology of the TTP-HUS was not determined
during her stay.  It may have resulted from E. coli
0157:H7-associated TTP (Shiga toxin was negative).  It could
have been due to Idiopathic-TTP, though ADAMTS13 activity was
only mildly depressed.  She identifies no precipitant foods,
specifically denies eating raw spinach, undercooked meat, or
drinking tonic (quinine) water.
.
#Respiratory Distress: on the second day of plasmapheresis the
pt developed respiratory distress, requiring intubation.  The
cause of her respiratory distress was thought to be due to
volume overload or acute lung injury from the plasmapheresis.
Imaging was consistent with both of these possible diagnoses.
As well, the pt began spiking temperatures with the
plasmapheresis therapy.  These fevers were thought to be the
result of transfusion reactions; however, because of her tenuous
state and chest imaging suggestive of pneumonia she was started
on a course of levofloxacin empirically (subsequently changed to
azithromycin given rash).  Infectious workup (blood, sputum,
stool, and urine cultures) were unrevealing.  The pt was
extubated successfully three days following intubation, and
transferred to the floor.  She was weaned off oxygen and by the
time of discharge was ambulating without dyspnea.
.
#Colitis/Terminal Ileitis:  The patient did have some abdominal
pain during admission; particularly in the right lower quadrant.
 She had no further bouts of bloody diarrhea, though she did
have some intermittent loose stool.  CT of the abdomen showed
wall thickening of the terminal ileum.  The patient's infectious
workup was negative. There was question of new onset IBD;
however, this was not worked up in the acute setting.  Given the
TTP-HUS diagnosis, the cipro and flagyl (started for the bloody
diarrhea she had had days prior to admission) were discontinued.
The pt's abdominal pain resolved during her hospitalization.  It
was recommended that she undergo an outpatient colonoscopy to
evaluate for possible underlying intestinal pathology such as
IBD.
.
#Headache:  The patient noted mild, focal left temporal
headaches throughout stay, associated with no focal neurological
changes, nor any aura.  They spread over her head and were
associated with pain to palpation over the affected areas.  The
HA's were responsive to tylenol.  They were thought to be
tension headaches.
.
#Rash: While receiving empiric levofloxacin (for possible
pneumonia) the patient developed, a small, pruritic rash on the
right arm (on day four of treatment).  Because of concern for
allergic reaction to the antibiotic, the levofloxacine was
discontinued and azithromycin was started.  The patient will
complete a total of 7 days of empiric anti-pneumonia therapy.


Medications on Admission:
Ciprofloxacin
Flagyl

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: Do not take more than 4grams of tylenol
(ie, acetaminophen) daily.
2. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 2 days.
3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-13**] Sprays Nasal
PRN (as needed) as needed for nasal dryness.
4. Outpatient Lab Work
Obtain serial CBC blood work as per Dr. [**Last Name (STitle) **]
5. Outpatient study
Obtain outpatient colonoscopy as per Dr. [**Last Name (STitle) **]


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
-Thrombotic Thrombocytopenia Purpura-Hemolytic Uremic Syndrome
-Acute Renal Failure
-Pneumonia vs. Transfusion Associated Acute Lung Injury


Discharge Condition:
Good


Discharge Instructions:
Watch for bruising, rashes, shortness of breath/difficulty
breathing, return of bloody diarrhea, non-bloody diarrhea
lasting >3 days, or general worsening of symptoms.  If any of
these occur, you should call your primary care doctor [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9643**] ([**Telephone/Fax (1) 250**])  immediately or go to the emergency room.

-You should have your blood drawn two to three times a week to
check your blood tests.

Followup Instructions:
A follow-up appointment has been arranged with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] (Internal Medicine) on Thursday [**10-15**] @ 8:20AM in the
Atrium Sweet on the [**Location (un) 453**] of the [**Hospital Ward Name 23**] Clinical Center of
the [**Hospital1 18**] [**Hospital Ward Name 516**].  The office phone number is([**Telephone/Fax (1) 6301**].

                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
{'Thrombotic microangiopathy,Hemolytic-uremic syndrome,Acute kidney failure, unspecified,Bacterial pneumonia, unspecified,Other pulmonary insufficiency, not elsewhere classified,Acidosis,Other specified hypotension,Other and unspecified noninfectious gastroenteritis and colitis,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Irritable bowel syndrome,Nausea alone,Headache,Hypocalcemia,Tachycardia, 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: Severe nausea and vomiting

PRESENT ILLNESS: 19yo female admitted on [**2116-10-3**] w/ severe nausea and vomiting.
The patient was seen in ED on [**2116-9-29**] with bloody diarrhea and
crampy abdominal pain.  Stool cultures sent were negative,
including E coli.  CT showed colitis.  She was admitted
overnight & sent home with po flagyl/cipro.
.
Following discharge she felt progressively better & diarrhea
decreased in volume.  However, 2days prior to admission, she
developed severe nausea and retching. When she presented on
[**2116-10-4**], she was found to have thrombocytopenia, hemolytic
anemia (with schitocytes on smear), and renal failure.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: Ciprofloxacin
Flagyl

ALLERGIES: Ciprofloxacin Hcl

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
Temperature 97.9, blood pressure 134/72, pulse 96, respiratory
rate 16, oxygen saturation 100% on room air.
Gen- pleasant though somewhat anxious young woman lying in bed
HEENT- PERRL, anicteric, EOMI, dry mucus membrane, oropharynx is
clear, however, palatal petechia noted. no cervical
lymphadenopathy,
CV- regular rhythm and rate, no rubs/mmurmur/gallop
RESP- lungs clear bilaterally
ABDOMEN- Active bowel sounds.  Non-distended.  Mild
periumbilical tenderness.  No guarding; no hepato- nor
splenomegaly.
EXT- [**1-13**]+ pedal edema, pedal pulses 2+ and equal bilaterally.
NERUO- Alert and oriented x3, CNII-XII intact, moving all limbs
spontanesouly, sensation grossly intact
SKIN- no rashes, no bruises (except at sites of blood draws)

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: She is a freshman at [**First Name4 (NamePattern1) 1663**] [**Last Name (NamePattern1) 1688**]. Her aunts and grandmother
live in the area; however, her parents are in [**State 622**]. The
patient is a nonsmoker. She does not drink significant amount of
alcohol. 

### Response:
{'Thrombotic microangiopathy,Hemolytic-uremic syndrome,Acute kidney failure, unspecified,Bacterial pneumonia, unspecified,Other pulmonary insufficiency, not elsewhere classified,Acidosis,Other specified hypotension,Other and unspecified noninfectious gastroenteritis and colitis,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Irritable bowel syndrome,Nausea alone,Headache,Hypocalcemia,Tachycardia, unspecified'}
