CHIEF COMPLAINT: Altered Mental Status, Jaundice, Abdominal Pain and Swelling

PRESENT ILLNESS: Mr. [**Known lastname 15582**] is a 27 year old man with history of alcohol abuse
(18beers per day for 12 years), ETOH withdrawal seizures
requiring 2 MICU admissions in past, presented to [**Hospital1 5109**] with increasing jaundice, abdominal distension,
encephalopathy, found to have ETOH level of 325, tylenol level
of 13, transferred to [**Hospital1 18**] MICU for further management.

MEDICAL HISTORY: Hx of ETOH abuse
- hx of withdrawal seizures x6 requiring 2 MICU stays in the
past
No other medical history

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T:98.7 BP:139/97 P:100 R: 18 O2: 96% RA
General: Lethargic, slow to respond but arousable and oriented
to person, place and time. Diffusely jaundiced, bilateral
gynecomastia and diffuse spider angiomata across chest and UE
bilaterally.
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, S1/S2 clear and of good quality,
2-3/6 systolic murmur heard throughout precordium, no rubs,
gallops
Abdomen: Distended, tense, tender to palpation over epigastrium
and RUQ without a [**Doctor Last Name **] sign. Caput present, tympanic to
percussion anteriorly with dullness to percussion over dependent
regions. No fluid wave appreciated.
GU: Foley in place draining dark urine.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Slow mentation, slow to respond but appropriate answers.
Significant Asterixis in UE bilaterally but mild tongue
fasciculations. Arousable but oriented to person, place and
time. No focal neurologic deficits otherwise

FAMILY HISTORY: NC
No family history of liver disease

SOCIAL HISTORY: Occupation: Commercial Fisherman
Drugs: None
Tobacco: 14 pack-yr history
Alcohol: 18 beers/day x12 years, most recently 4 beers/day
Acute pancreatitis,Hepatic encephalopathy,Acute and subacute necrosis of liver,Unspecified septicemia,Sepsis,Other ascites,Other and unspecified coagulation defects,Hyposmolality and/or hyponatremia,Alcohol withdrawal delirium,Urinary tract infection, site not specified,Acute alcoholic hepatitis,Other and unspecified alcohol dependence, continuous,Tobacco use disorder,Disorders of phosphorus metabolism,Pain in joint, forearm,Pressure ulcer, other site,Unspecified deficiency anemia,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Thrombocytopenia, unspecified,Diarrhea,Do not resuscitate status
Acute pancreatitis,Hepatic encephalopathy,Acute necrosis of liver,Septicemia NOS,Sepsis,Ascites NEC,Coagulat defect NEC/NOS,Hyposmolality,Delirium tremens,Urin tract infection NOS,Ac alcoholic hepatitis,Alcoh dep NEC/NOS-contin,Tobacco use disorder,Dis phosphorus metabol,Joint pain-forearm,Pressure ulcer, site NEC,Deficiency anemia NOS,Cholelithiasis NOS,Thrombocytopenia NOS,Diarrhea,Do not resusctate status
Admission Date:  [**2185-7-28**]              Discharge Date:   [**2185-8-13**]

Date of Birth:  [**2158-5-6**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Altered Mental Status, Jaundice, Abdominal Pain and Swelling

Major Surgical or Invasive Procedure:
Paracentesis

History of Present Illness:
Mr. [**Known lastname 15582**] is a 27 year old man with history of alcohol abuse
(18beers per day for 12 years), ETOH withdrawal seizures
requiring 2 MICU admissions in past, presented to [**Hospital1 5109**] with increasing jaundice, abdominal distension,
encephalopathy, found to have ETOH level of 325, tylenol level
of 13, transferred to [**Hospital1 18**] MICU for further management.

Patient was visiting his sister from [**Name (NI) 1727**], complaining of
increasing diffuse abdominal pain for the last week.  He noticed
that his abdomen has become increasingly distended, and his
family noticed that his eyes were becoming increasingly yellow.
He presented initially to urgent care for abdominal pain and
distension and was admitted to [**Hospital3 **].  He was
easily arousable and oriented, with mild asterixis.  Abdominal
ultrasound (without dopplers) was unremarkable. RUQ ultrasound
was significant for cholelithiasis without cystitis or bile duct
dilation and hyperecogenic liver consistent with
hepatosteatosis.  Labs were remarkable for TBili of 18 with
Dbili of 8, AST of 350, INR 2.1, lipase 1100, Na 116.  ETOH
level was noted to be 220, and APAP level of 13. He had 3 beers
night before [**Hospital1 2436**] admission but family reports he has not
taken any Tylenol.  Patient was given a dose of
N-acetylcysteine, 5600mg IV x1.  Diagnostic paracentesis was
negative for SBP with WBC 100 and negative gram stain, culture
pending.  Patient was started on ceftaz empirically.  He was
given 40mg IV solumedrol for potential alcoholic hepatitis. He
was also given 2mg IV lorazepam out of concern for potential
ETOH withdrawal.  He also received  Rifaximin x1, Pentoxyfilline
and Potassium 10mEq.  Vitals at OSH prior to transfer were as
follows: 97.6  92  122/74  18  92%RA.  He denies fevers, chills,
lower extremity swelling. He does report nausea and vomiting and
lethargy. Family reports mental slowing. No diarrhea or
constipation, cough, SOB or chest pain.



Past Medical History:
Hx of ETOH abuse
- hx of withdrawal seizures x6 requiring 2 MICU stays in the
past
No other medical history


Social History:
Occupation: Commercial Fisherman
Drugs: None
Tobacco: 14 pack-yr history
Alcohol: 18 beers/day x12 years, most recently 4 beers/day


Family History:
NC
No family history of liver disease

Physical Exam:
Admission Physical Exam:
Vitals: T:98.7 BP:139/97 P:100 R: 18 O2: 96% RA
General: Lethargic, slow to respond but arousable and oriented
to person, place and time. Diffusely jaundiced, bilateral
gynecomastia and diffuse spider angiomata across chest and UE
bilaterally.
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, S1/S2 clear and of good quality,
2-3/6 systolic murmur heard throughout precordium, no rubs,
gallops
Abdomen: Distended, tense, tender to palpation over epigastrium
and RUQ without a [**Doctor Last Name **] sign. Caput present, tympanic to
percussion anteriorly with dullness to percussion over dependent
regions. No fluid wave appreciated.
GU: Foley in place draining dark urine.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Slow mentation, slow to respond but appropriate answers.
Significant Asterixis in UE bilaterally but mild tongue
fasciculations. Arousable but oriented to person, place and
time. No focal neurologic deficits otherwise


Pertinent Results:
Admission Labs:
[**2185-7-28**] 11:49PM BLOOD WBC-11.4* RBC-3.60* Hgb-11.2* Hct-32.1*
MCV-89 MCH-31.0 MCHC-34.8 RDW-18.5* Plt Ct-92*
[**2185-7-28**] 11:49PM BLOOD Neuts-89.6* Bands-0 Lymphs-7.6*
Monos-1.8* Eos-0.6 Baso-0.4
[**2185-7-28**] 11:49PM BLOOD PT-24.7* PTT-52.5* INR(PT)-2.3*
[**2185-7-28**] 11:49PM BLOOD Glucose-157* UreaN-3* Creat-0.5 Na-121*
K-3.1* Cl-86* HCO3-21* AnGap-17
[**2185-7-28**] 11:49PM BLOOD ALT-40 AST-230* LD(LDH)-348* AlkPhos-196*
TotBili-17.8*

Pancreatitis Trend:
[**2185-7-28**] 11:49PM BLOOD Lipase-809*
[**2185-7-28**] 11:49PM BLOOD Albumin-3.1* Calcium-8.1* Phos-1.5*
Mg-2.1 Iron-140
[**2185-7-28**] 11:49PM BLOOD Lipase-809*
[**2185-7-30**] 05:50AM BLOOD Lipase-638*
[**2185-8-1**] 04:00AM BLOOD Lipase-151*

Hepatitis Trend:
[**2185-7-28**] 11:49PM BLOOD ALT-40 AST-230* LD(LDH)-348* AlkPhos-196*
TotBili-17.8*
[**2185-7-30**] 05:50AM BLOOD ALT-37 AST-188* AlkPhos-186* Amylase-288*
TotBili-18.8* DirBili-12.2* IndBili-6.6
[**2185-7-31**] 04:00AM BLOOD ALT-35 AST-168* AlkPhos-188*
TotBili-20.7*
[**2185-8-1**] 04:00AM BLOOD ALT-34 AST-143* LD(LDH)-356* AlkPhos-182*
TotBili-19.4*
[**2185-8-2**] 01:30AM BLOOD ALT-34 AST-135* LD(LDH)-414* AlkPhos-173*
TotBili-17.9*
[**2185-8-3**] 05:22AM BLOOD ALT-23 AST-82* TotBili-14.6*
[**2185-8-4**] 01:06AM BLOOD ALT-23 AST-74* TotBili-13.8*

INR Trend:
[**2185-7-28**] 11:49PM BLOOD PT-24.7* PTT-52.5* INR(PT)-2.3*
[**2185-8-1**] 04:00AM BLOOD PT-22.9* PTT-62.0* INR(PT)-2.1*
[**2185-8-3**] 05:22AM BLOOD PT-23.4* PTT-79.6* INR(PT)-2.2*
[**2185-8-4**] 01:06AM BLOOD PT-21.7* PTT-62.8* INR(PT)-2.0*

Hereditary Liver Disease Labs:
[**2185-7-28**] 11:49PM BLOOD HCV Ab-NEGATIVE
[**2185-7-29**] 06:30PM BLOOD HCV Ab-NEGATIVE
[**2185-7-28**] 11:49PM BLOOD tTG-IgA-13
[**2185-7-28**] 11:49PM BLOOD Ethanol-72*
[**2185-7-28**] 11:49PM BLOOD IgG-[**2082**]* IgA-1025*
[**2185-7-29**] 12:03AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2185-7-28**] 11:50PM BLOOD Smooth-POSITIVE *
[**2185-7-28**] 11:49PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2185-8-3**] 04:20PM BLOOD IgM HAV-NEGATIVE
[**2185-7-30**] 05:50AM BLOOD Ammonia-37
[**2185-7-28**] 11:49PM BLOOD Triglyc-161*
[**2185-7-28**] 11:49PM BLOOD calTIBC-183* Ferritn-235 TRF-141*
[**2185-8-2**] 04:35PM BLOOD Cryoglb-NO CRYOGLO

Transitional Issues:
Pending Labs include:
- BLOOD CERULOPLASMIN
- BLOOD OXYCODONE
- HEREDITARY HEMOCHROMATOSIS MUTATION ANALYSIS
- EBV
- CMV
- Blood cultures Pending


Reports:
[**7-29**] CXR: Negative

[**7-29**] Abd US:IMPRESSION:
1. Diffusely echogenic liver compatible with fatty infiltration;
however, more advanced forms of liver disease such as cirrhosis
or fibrosis cannot be excluded.
2. Limited Doppler evaluation of the liver given the patient's
inability to
cooperate. However, absence of flow in the expected location of
the main
portal vein is concerning for portal vein thrombosis. Normal
flow in the left portal vein. CTA of the abdomen should be
considered for further evaluation if clinically indicated.
3. Large ascites.
4. Gallbladder wall edema, likely secondary to ascites.
Gallbladder sludge.

[**7-29**] CT Abd:
IMPRESSION:
1. Enlarged fatty liver.
2. Patent portal venous system without evidence of thrombus.
3. Moderate ascites.
4. Cholelithiasis without cholecystitis.

Wrist X-Ray: Negative


Brief Hospital Course:
27M with hx of ETOH abuse, multiple alcohol withdrawal seizures
including to MICU admissions in past, presenting with
progressive abdominal pain and distension with encephalopathy,
transfered from OSH for further management.
.
Pt was diagnosed with alcoholic hepatitis with DF = 57 and
initially treated at OSH with solumedrol and NAC as tylenol
ingestion had not yet been ruled out at that time.  At [**Hospital1 18**]
MICU, pt was found to have pancreatitis and alcoholic hepatitis
and was treated with pentoxyphylline.  Paracentesis ruled out
SBP, and no other evidence of infection.  Pt's course was
complicated by persistent AMS, which was determined to be
secondary to hepatic encephalopathy and benzodiazepine
administration for EtOH withdrawal.  Pt was stabilized in the
MICU and transferred to [**Doctor Last Name **] [**Doctor Last Name **] for several days.  While on
ET, pt was continually somnolent.  Other etiologies of AMS were
ruled out, but  due to worsening somnolence and concern for
airway protection, patient bounced back to MICU.  At this point,
SBP was ruled out, he was taken off benzos and CT abdomen was
completed which did not show worsening of Liver/Pancreatic
pathologies. He was found to have a UTI which was treated with
Cipro.  Pt was stabilized and returned to ET.  On [**8-12**], pt
spiked a low grade temperature, but leukocytosis had been
improving and pt was otherwise asymptomatic.  Blood and urine
cultures were drawn and sent.  Several hours later, pt began
spiking more significant temperatures and he began requiring an
increased oxygen demand.  Pt was started on broad spectrum
antibiotics, and given non-rebreather.  His family (HCP) were
contact[**Name (NI) **] and they came to the hospital immediately.  They
confirmed his code status as a DNR/DNI and they refused ICU care
and Bipap.  At this point, pt's oxygen requirement could not be
met with NRB and family decided to make pt [**Name (NI) 3225**] and pt expired.



Medications on Admission:
None

Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
alcoholic hepatitis
pancreatitis
UTI


Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired
{'Acute pancreatitis,Hepatic encephalopathy,Acute and subacute necrosis of liver,Unspecified septicemia,Sepsis,Other ascites,Other and unspecified coagulation defects,Hyposmolality and/or hyponatremia,Alcohol withdrawal delirium,Urinary tract infection, site not specified,Acute alcoholic hepatitis,Other and unspecified alcohol dependence, continuous,Tobacco use disorder,Disorders of phosphorus metabolism,Pain in joint, forearm,Pressure ulcer, other site,Unspecified deficiency anemia,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Thrombocytopenia, unspecified,Diarrhea,Do not resuscitate status'}


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, Jaundice, Abdominal Pain and Swelling

PRESENT ILLNESS: Mr. [**Known lastname 15582**] is a 27 year old man with history of alcohol abuse
(18beers per day for 12 years), ETOH withdrawal seizures
requiring 2 MICU admissions in past, presented to [**Hospital1 5109**] with increasing jaundice, abdominal distension,
encephalopathy, found to have ETOH level of 325, tylenol level
of 13, transferred to [**Hospital1 18**] MICU for further management.

MEDICAL HISTORY: Hx of ETOH abuse
- hx of withdrawal seizures x6 requiring 2 MICU stays in the
past
No other medical history

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T:98.7 BP:139/97 P:100 R: 18 O2: 96% RA
General: Lethargic, slow to respond but arousable and oriented
to person, place and time. Diffusely jaundiced, bilateral
gynecomastia and diffuse spider angiomata across chest and UE
bilaterally.
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, S1/S2 clear and of good quality,
2-3/6 systolic murmur heard throughout precordium, no rubs,
gallops
Abdomen: Distended, tense, tender to palpation over epigastrium
and RUQ without a [**Doctor Last Name **] sign. Caput present, tympanic to
percussion anteriorly with dullness to percussion over dependent
regions. No fluid wave appreciated.
GU: Foley in place draining dark urine.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Slow mentation, slow to respond but appropriate answers.
Significant Asterixis in UE bilaterally but mild tongue
fasciculations. Arousable but oriented to person, place and
time. No focal neurologic deficits otherwise

FAMILY HISTORY: NC
No family history of liver disease

SOCIAL HISTORY: Occupation: Commercial Fisherman
Drugs: None
Tobacco: 14 pack-yr history
Alcohol: 18 beers/day x12 years, most recently 4 beers/day 

### Response:
{'Acute pancreatitis,Hepatic encephalopathy,Acute and subacute necrosis of liver,Unspecified septicemia,Sepsis,Other ascites,Other and unspecified coagulation defects,Hyposmolality and/or hyponatremia,Alcohol withdrawal delirium,Urinary tract infection, site not specified,Acute alcoholic hepatitis,Other and unspecified alcohol dependence, continuous,Tobacco use disorder,Disorders of phosphorus metabolism,Pain in joint, forearm,Pressure ulcer, other site,Unspecified deficiency anemia,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Thrombocytopenia, unspecified,Diarrhea,Do not resuscitate status'}
