CHIEF COMPLAINT: Abdominal pain, LUE pain/swelling

PRESENT ILLNESS: 21 year old woman with eosinophilic esophagitis, chronic
pancreatitis, on TPN and now with end-stage liver disease,
cutaneous mastocytosis, Crohn's disease, GERD, legal blindness
s/p anoxic brain injury who presents with worsening abdominal
pain and LUE numbness/tingling, swelling.
.
The patient has chronic abdominal pain (daily, constant) but
states that over the last two days, the pain has worsened from
baseline [**2176-4-22**] to [**2176-7-25**]. The pain is sharp and has caused her
to be nauseated, no vomiting. The patient feels she has become
more jaundiced in the interim also. She has chronic loose stools
which has not worsened recently, denies dysuria, recent travel,
exotic foods, sick contacts. The patient felt her ascites and
lower extremity had worsened yesterday but resolved with her
normal spironolactone for diuresis. She states she has had
hematemesis in the past but not recently, known varices but no
variceal bleed, encephalopathy last year (admitted to [**Hospital1 2025**]) and
has never had SBP, paracentesis for ascites. She also denies
fevers/chills, shortness of breath, confusion, lethargy. The
patient underwent EGD on Tuesday with her pediatric GI doctor,
who stated there were varices, none actively bleeding or
requiring banding. The patient's mother is unsure of the grades
of these varices.
.
With regards to her left upper extremity, the patient noticed
"pins and needles" sensation for a week now. Per her mother, she
often gets this sensation when she needs a transfusion of
platelets. The patient had received 8 units platelets and 1 unit
pRBC prior to the EGD, however, given her known bleeding
diathesis. The patient state that her LUE became throbbing, with
intense pain and became more swollen around her wrist. This made
it difficult for her to grasp anything or grip tightly with that
hand. She has not tried anything for this pain, has two Fentanyl
patches for her abdominal pain. Of note, the patient had a IV
placed in the upper part of her left hand last week.
.
Of note, the etiology of the patient's liver disease remains
unclear although is felt possibly due to cholestasis from TPN.
She was evaluated at [**Hospital1 2025**] for liver transplant but denied
secondary to her low body mass index. Reportedly [**Hospital1 2025**] has also
declined transitioning her care from the pediatric GI to adult
GI/hepatology care. She was seen in Liver Clinic at [**Hospital1 18**] in
[**2177-3-18**] for a second opinion and full work-up revealed weakly
positive [**Last Name (un) 15412**] (1:20), elevated IgG >1900, normal ceruloplasmin,
elevated alpha-1 antitrypsin. Her first liver biopsy [**9-/2174**]
showed portal fibrosis, ceroid laden macrophages, ductular
reaction. Repeat biopsy [**5-/2176**] demonstrated cholestatic liver
with bridging fibrosis, ductular reaction and again ceroid laden
macrophages.
.
In the ED, initial VS were: pain [**9-27**], T99.2, HR140, BP130/76,
RR100% on RA. The patient has a TPN port in place. Labs were
notable for mildly elevated LFTs, TBili 12.3, INR 1.4, lipase
142 and mild leukocytosis to 12.8 without bands. Blood and urine
cultures were sent. CT head was normal. RUQ ultrasound with
doppler showed small amount of ascites (perihepatic, loculated)
and patent vasculature. Guaiac negative with ?small fissure near
gluteal cleft. She received Zofran X1 and Fentanyl X2.
.
On arrival to the MICU, VS were: T99.8, HR111, BP118/68, RR16,
O2sat 98% on RA. The patient was resting in bed, appearing
chronically ill and somewhat uncomfortable. Mother at bedside.
.
ROS: Ongoing symptoms of dysphagia, abdominal pain (constant,
especially with PO meds), fatigue. Also reports ongoing tendency
to bleed, especially of gums/lips, unclear precipitant recently.
Otherwise, denies fevers/chills, cough, wheeze, dysuria,

MEDICAL HISTORY: 1.  Eosinophilic esophagitis.
2.  Chronic pancreatitis diagnosed in [**2172**], with normal ERCP in
[**2172**].
3.  TPN dependence since [**77**]/[**2172**].
4.  Cutaneous mastocytosis.
5.  Crohn's disease, previously treated with 6-MP, methotrexate,
and Humira.
6.  GERD diagnosed on barium swallow.
7.  Pancytopenia status post bone marrow biopsy and FISH
demonstrating hypocellular marrow.
8.  Left-sided ovarian cyst.
9.  Chronic bleeding disorder of unknown etiology for which the
patient requires Amicar
10. Legally blind s/p anoxic brain injury from ?stroke, code
when anaphylaxis to Iron infusion ([**Hospital1 2025**])
.
Past Surgical History
1.  Cholecystectomy in [**2172**].
2.  Appendectomy in [**2172**].
3.  Splenectomy in [**10/2175**] for pancytopenia.
4.  Celiac sympathectomy in [**2173**].
5.  Side-to-side feeding jejunostomy in [**2175**].
6.  Left-sided ovarian cyst removal in [**2171**].
7.  ERCP x2 in [**2172**].

MEDICATION ON ADMISSION: * Nexium 40mg [**Hospital1 **]
* Zofran 8mg TID
* Fentanyl patch 100 mcg X2, changed daily, alternating days
* Pentasa 2500mg [**Hospital1 **]
* Singulair 20mg qHS
* Amicar 1000mg over 1 hour QID
* Zenpep DR 15,000 TID
* Spironolactone 100mg daily
* Carafate 1gm.10mL TID
* Symbicort 160mcg 1 puff daily
* Desmopressin 1.5mg/mL 1 spray PRN bleeding
* Albuterol 90 mcg PRN
* TPN over 14 hours, Pepcid 40mg, Vitamin K 10mg, vitamins,
Carnitine 1 gram included)

ALLERGIES: Meropenem / Vancomycin / morphine / Iron / Ursodiol / peanuts /
wheat / Gluten / Soy / dairy products / pregabalin / pork
products

PHYSICAL EXAM: Admission Exam:
VS: Temp: 99.8 BP: 127/76 HR: 140 -->120 RR: 18 O2sat 99% on RA

FAMILY HISTORY: No family history of liver disease or liver cancer. Family
history notable for coronary disease and breast, colon cancers.

SOCIAL HISTORY: Lives at home with her mother. Denies alcohol, tobacco or
illicit drugs. Resides in [**Location (un) 3320**], MA. Mother is primary means
of support. Aunt also supportive. The patient at baseline goes
out, shops, does yoga and has a fair appetite despite multiple
serious drug allergies.
Other tenosynovitis of hand and wrist,Biliary cirrhosis,Regional enteritis of unspecified site,Chronic pancreatitis,Eosinophilic esophagitis
Tenosynov hand/wrist NEC,Biliary cirrhosis,Regional enteritis NOS,Chronic pancreatitis,Eosinophilic esophagitis
Admission Date:  [**2177-6-13**]              Discharge Date:   [**2177-6-15**]

Date of Birth:  [**2155-10-30**]             Sex:   F

Service: MEDICINE

Allergies:
Meropenem / Vancomycin / morphine / Iron / Ursodiol / peanuts /
wheat / Gluten / Soy / dairy products / pregabalin / pork
products

Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Abdominal pain, LUE pain/swelling

Major Surgical or Invasive Procedure:
None

History of Present Illness:
21 year old woman with eosinophilic esophagitis, chronic
pancreatitis, on TPN and now with end-stage liver disease,
cutaneous mastocytosis, Crohn's disease, GERD, legal blindness
s/p anoxic brain injury who presents with worsening abdominal
pain and LUE numbness/tingling, swelling.
.
The patient has chronic abdominal pain (daily, constant) but
states that over the last two days, the pain has worsened from
baseline [**2176-4-22**] to [**2176-7-25**]. The pain is sharp and has caused her
to be nauseated, no vomiting. The patient feels she has become
more jaundiced in the interim also. She has chronic loose stools
which has not worsened recently, denies dysuria, recent travel,
exotic foods, sick contacts. The patient felt her ascites and
lower extremity had worsened yesterday but resolved with her
normal spironolactone for diuresis. She states she has had
hematemesis in the past but not recently, known varices but no
variceal bleed, encephalopathy last year (admitted to [**Hospital1 2025**]) and
has never had SBP, paracentesis for ascites. She also denies
fevers/chills, shortness of breath, confusion, lethargy. The
patient underwent EGD on Tuesday with her pediatric GI doctor,
who stated there were varices, none actively bleeding or
requiring banding. The patient's mother is unsure of the grades
of these varices.
.
With regards to her left upper extremity, the patient noticed
"pins and needles" sensation for a week now. Per her mother, she
often gets this sensation when she needs a transfusion of
platelets. The patient had received 8 units platelets and 1 unit
pRBC prior to the EGD, however, given her known bleeding
diathesis. The patient state that her LUE became throbbing, with
intense pain and became more swollen around her wrist. This made
it difficult for her to grasp anything or grip tightly with that
hand. She has not tried anything for this pain, has two Fentanyl
patches for her abdominal pain. Of note, the patient had a IV
placed in the upper part of her left hand last week.
.
Of note, the etiology of the patient's liver disease remains
unclear although is felt possibly due to cholestasis from TPN.
She was evaluated at [**Hospital1 2025**] for liver transplant but denied
secondary to her low body mass index. Reportedly [**Hospital1 2025**] has also
declined transitioning her care from the pediatric GI to adult
GI/hepatology care. She was seen in Liver Clinic at [**Hospital1 18**] in
[**2177-3-18**] for a second opinion and full work-up revealed weakly
positive [**Last Name (un) 15412**] (1:20), elevated IgG >1900, normal ceruloplasmin,
elevated alpha-1 antitrypsin. Her first liver biopsy [**9-/2174**]
showed portal fibrosis, ceroid laden macrophages, ductular
reaction. Repeat biopsy [**5-/2176**] demonstrated cholestatic liver
with bridging fibrosis, ductular reaction and again ceroid laden
macrophages.
.
In the ED, initial VS were: pain [**9-27**], T99.2, HR140, BP130/76,
RR100% on RA. The patient has a TPN port in place. Labs were
notable for mildly elevated LFTs, TBili 12.3, INR 1.4, lipase
142 and mild leukocytosis to 12.8 without bands. Blood and urine
cultures were sent. CT head was normal. RUQ ultrasound with
doppler showed small amount of ascites (perihepatic, loculated)
and patent vasculature. Guaiac negative with ?small fissure near
gluteal cleft. She received Zofran X1 and Fentanyl X2.
.
On arrival to the MICU, VS were: T99.8, HR111, BP118/68, RR16,
O2sat 98% on RA. The patient was resting in bed, appearing
chronically ill and somewhat uncomfortable. Mother at bedside.
.
ROS: Ongoing symptoms of dysphagia, abdominal pain (constant,
especially with PO meds), fatigue. Also reports ongoing tendency
to bleed, especially of gums/lips, unclear precipitant recently.
Otherwise, denies fevers/chills, cough, wheeze, dysuria,

Past Medical History:
1.  Eosinophilic esophagitis.
2.  Chronic pancreatitis diagnosed in [**2172**], with normal ERCP in
[**2172**].
3.  TPN dependence since [**77**]/[**2172**].
4.  Cutaneous mastocytosis.
5.  Crohn's disease, previously treated with 6-MP, methotrexate,
and Humira.
6.  GERD diagnosed on barium swallow.
7.  Pancytopenia status post bone marrow biopsy and FISH
demonstrating hypocellular marrow.
8.  Left-sided ovarian cyst.
9.  Chronic bleeding disorder of unknown etiology for which the
patient requires Amicar
10. Legally blind s/p anoxic brain injury from ?stroke, code
when anaphylaxis to Iron infusion ([**Hospital1 2025**])
.
Past Surgical History
1.  Cholecystectomy in [**2172**].
2.  Appendectomy in [**2172**].
3.  Splenectomy in [**10/2175**] for pancytopenia.
4.  Celiac sympathectomy in [**2173**].
5.  Side-to-side feeding jejunostomy in [**2175**].
6.  Left-sided ovarian cyst removal in [**2171**].
7.  ERCP x2 in [**2172**].


Social History:
Lives at home with her mother. Denies alcohol, tobacco or
illicit drugs. Resides in [**Location (un) 3320**], MA. Mother is primary means
of support. Aunt also supportive. The patient at baseline goes
out, shops, does yoga and has a fair appetite despite multiple
serious drug allergies.


Family History:
No family history of liver disease or liver cancer. Family
history notable for coronary disease and breast, colon cancers.



Physical Exam:
Admission Exam:
VS: Temp: 99.8 BP: 127/76 HR: 140 -->120 RR: 18 O2sat 99% on RA

GEN: Pleasant, mildly uncomfortable, NAD, chronically
ill-appearing, jaundiced
HEENT: PERRL, EOMI, icteric sclera, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy
RESP: CTA b/l with good air movement throughout, no
wheezing/rhonchi/rales
CV: Tachycardic, regular rhythm, S1 and S2 wnl, no
murmurs/gallops/rubs
ABD: Nondistended, surgical incision sites c/d/i - well healed,
soft, TTP in R/LUQ, no masses
EXT: No cyanosis/ecchymosis; palpable edema in dorsal region of
left wrist without skin changes/erythema, purulence, skin
breakdown - mild TTP. No palpable axillary cords.
SKIN: Jaundiced, no rashes/lesions, warm
NEURO: AAOx3. Cn II-XII intact. Strength and sensation grossly
intact throughout.
RECTAL: Reportedly guaiac neg from below (in ED), no
hemorrhoids, small palpable anal fissue (deep, 12 o'clock below
gluteal cleft)


Pertinent Results:
Admission Labs:
[**2177-6-13**] 06:15AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2177-6-13**] 06:15AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-0.2 PH-6.5 LEUK-TR
[**2177-6-13**] 06:15AM URINE  RBC-<1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
[**2177-6-13**] 06:10AM   LACTATE-0.7
[**2177-6-13**] 06:00AM   GLUCOSE-85 UREA N-8 CREAT-0.4 SODIUM-137
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-12
[**2177-6-13**] 06:00AM   ALT(SGPT)-135* AST(SGOT)-183* ALK PHOS-240*
TOT BILI-12.3*
[**2177-6-13**] 06:00AM   LIPASE-142*
[**2177-6-13**] 06:00AM   ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-3.4
MAGNESIUM-1.9
[**2177-6-13**] 06:00AM   WBC-12.8* RBC-3.34* HGB-9.1* HCT-29.9* MCV-90
MCH-27.2 MCHC-30.4* RDW-15.8*
[**2177-6-13**] 06:00AM   NEUTS-67 BANDS-0 LYMPHS-13* MONOS-9 EOS-9*
BASOS-1 ATYPS-1* METAS-0 MYELOS-0
.
Discharge Labs:
[**2177-6-14**] 06:11AM BLOOD WBC-11.6* RBC-3.17* Hgb-8.9* Hct-29.0*
MCV-91 MCH-28.1 MCHC-30.7* RDW-16.0* Plt Ct-417
[**2177-6-14**] 06:11AM BLOOD Neuts-44* Bands-0 Lymphs-34 Monos-13*
Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2177-6-14**] 06:11AM BLOOD PT-17.5* PTT-38.2* INR(PT)-1.6*
[**2177-6-14**] 06:11AM BLOOD Glucose-102* UreaN-11 Creat-0.4 Na-137
K-4.3 Cl-103 HCO3-27 AnGap-11
[**2177-6-14**] 06:11AM BLOOD ALT-125* AST-160* AlkPhos-218*
TotBili-11.0*
.
EKG: Sinus tachycardia, HR 134, normal axis, normal intervals,
QTc 419, no ST elevations or T wave inversions.
.
Imaging:
CT head without contrast:
No acute intracranial process. If there is continued concern for

embolic event, further evaluation with MRI is recommended.
.
RUQ ultrasound:
1. No intrahepatic biliary dilation. The common bile duct was
not seen. 2. Small amount of perihepatic ascites which
demonstrates a loculated appearance near the inferior tip of the
liver. Superimposed infection or hematoma cannot be excluded. 3.
Patent main portal vein.
.
L Wrist X-Ray:
There is no acute fracture. The alignment is maintained. There
is generalized demineralization. There is no aggressive bone
lesion or periostitis.
.
L UE ultrasound:
1. No DVT in the left arm.
2. No fluid collection is seen at the left wrist.
.
.

Brief Hospital Course:
The patient is a 21 year-old woman with eosinophilic
esophagitis, chronic pancreatitis, on TPN and now with end-stage
liver disease, cutaneous mastocytosis, Crohn's disease, GERD,
legal blindness s/p anoxic brain injury who presents with
worsening abdominal pain and LUE numbness/swelling.
.
# Left wrist/hand pain: Focal area of swelling on dorsum of the
wrist with limited range of motion secondary to pain. No history
of recent trauma, though she did have recent PIV placed in area
of swelling. X-ray negative for fracture, but demonstrated
generalized demineralization. LUE duplex without evidence of
DVT. Patient was evaluated by Plastic surgery service, who felt
that patient's symptoms were secondary to  extensor tendinitis
vs. arthritic process. Her wrist was placed in a splint, and she
was instructed to follow-up in Hand Clinic on [**2177-6-24**]. The
patient's pain was initially controlled with Fentanyl 25-50 mcg
PRN in the ICU. On the floor, the patient refused all narcotic
medications other than demerol. After explaining the risks of
this medication, she was given 15.5 mg X 2 with good control of
pain. Lidocaine patch was placed over wrist.
.
# Abdominal pain: Patient with baseline chronic abdominal pain
for which she uses fentanyl pathc. TBili stable from [**2177-5-27**]
in OMR, mildly elevated from [**2177-3-4**] OSH labs (TBili 10.3
then). RUQ ultrasound without new thrombi or worsening ascites.
The patient's pain was controlled with fentanyl in the ICU, and
later demerol on the floor (after speaking with pain service).
At discharge, he abdominal pain was well controlled.
.
# End-stage liver disease: Presumably from cholestasis of TPN,
although eosinophilic infiltration may be contributing. Has been
complicated by encephalopathy and varices in the past, no
variceal bleeding or significant ascites/SBP. MELD on admission
was 20. Long term goal involves weaning off TPN with transition
to full PO diet. Without this transition, patient is not a good
transplant candidate.
.
# Eosinophilic esophagitis: Stable. Continued TPN (with
Carnitine, Vitamin K, Pepcid).
.
# Chronic bleeding disorder: Etiology unclear. Continued Amikar
1000mg four times daily.
.
# Chronic pancreatitis: Diagnosed in [**2172**], normal ERCP then. On
chronic TPN for this, with associated liver complications.
Continued Zofran 8mg IV TID and Creon.
.
# Cutaneous mastocytosis: Stable. Continued Singulair 20mg qHS
and Advair (therapeutic exchange) for home Symbicort.
.
# Crohn's disease: Currently stable, although with chronically
loose stools. Continued Pentasa 2500mg [**Hospital1 **]
and Carafate 1 gram TID.
.
# GERD: Stable. Continued Nexium IV and Pepcid in TPN.
.

Medications on Admission:
* Nexium 40mg [**Hospital1 **]
* Zofran 8mg TID
* Fentanyl patch 100 mcg X2, changed daily, alternating days
* Pentasa 2500mg [**Hospital1 **]
* Singulair 20mg qHS
* Amicar 1000mg over 1 hour QID
* Zenpep DR 15,000 TID
* Spironolactone 100mg daily
* Carafate 1gm.10mL TID
* Symbicort 160mcg 1 puff daily
* Desmopressin 1.5mg/mL 1 spray PRN bleeding
* Albuterol 90 mcg PRN
* TPN over 14 hours, Pepcid 40mg, Vitamin K 10mg, vitamins,
Carnitine 1 gram included)


Discharge Medications:
1. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal EVERY OTHER DAY (Every Other Day): alternating days.

2. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal EVERY OTHER DAY (Every Other Day): alternating days.

3. Pentasa 500 mg Capsule, Extended Release Sig: Five (5)
Capsule, Extended Release PO twice a day.
4. Singulair 10 mg Tablet Sig: Two (2) Tablet PO at bedtime.
5. aminocaproic acid 250 mg/mL Solution Sig: 1000 (1000) mg
Intravenous QID (4 times a day) for ASDIR doses: Take as
directed by your hematologist.
6. Zenpep 15,000-51,000 -82,000 unit Capsule, Delayed
Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO
three times a day.
7. Nexium IV 40 mg Recon Soln Sig: One (1) infusion Intravenous
twice a day.
8. ondansetron HCl 2 mg/mL Solution Sig: Eight (8) mg
Intravenous every eight (8) hours as needed for nausea.
9. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day.
10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) puff Inhalation once a day.
12. desmopressin  Nasal
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for
sob/wheeze.
14. TPN
Per outpatient instructions
15. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for wrist pain.
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
Centrus Home Care

Discharge Diagnosis:
Primary Diagnosis:
- Extensor tendonitis, left wrist
- End-Stage Liver Disease
- Chronic Pancreatitis


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


Discharge Instructions:
Dear Ms. [**Known lastname 89962**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital with abdominal
pain and swelling in your wrist. The swelling in your wrist was
evaluated by the plastic surgeons. Thry believe your symptoms
are likely due to inflammation of some tendons in your wrist.
You will follow-up with them in a few weeks time.
.
MEDICATION CHANGES:
START: Lidocaine patch to wrist as needed for pain 12hrs on
12hrs off.
.
Please continue all your medications as they have been
prescribed. Should you experience any symptoms that concern you
after leaving the hospital, please call you doctor or return to
the emergency room.

Followup Instructions:
Please follow-up in Hand Clinic on Tuesday, [**6-24**]. Please call
([**Telephone/Fax (1) 32269**] after [**Hospital1 107**] Day to confirm your time.
.
Please arrange your follow-up appointment with Dr. [**Last Name (STitle) 497**] by
calling his office after [**Hospital1 107**] Day.
.
Department: TRANSPLANT SOCIAL WORK
When: WEDNESDAY [**2177-6-18**] at 11:00 AM
With: TRANSPLANT SOCIAL WORKER [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2177-7-16**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2177-7-23**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Other tenosynovitis of hand and wrist,Biliary cirrhosis,Regional enteritis of unspecified site,Chronic pancreatitis,Eosinophilic esophagitis'}


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: Abdominal pain, LUE pain/swelling

PRESENT ILLNESS: 21 year old woman with eosinophilic esophagitis, chronic
pancreatitis, on TPN and now with end-stage liver disease,
cutaneous mastocytosis, Crohn's disease, GERD, legal blindness
s/p anoxic brain injury who presents with worsening abdominal
pain and LUE numbness/tingling, swelling.
.
The patient has chronic abdominal pain (daily, constant) but
states that over the last two days, the pain has worsened from
baseline [**2176-4-22**] to [**2176-7-25**]. The pain is sharp and has caused her
to be nauseated, no vomiting. The patient feels she has become
more jaundiced in the interim also. She has chronic loose stools
which has not worsened recently, denies dysuria, recent travel,
exotic foods, sick contacts. The patient felt her ascites and
lower extremity had worsened yesterday but resolved with her
normal spironolactone for diuresis. She states she has had
hematemesis in the past but not recently, known varices but no
variceal bleed, encephalopathy last year (admitted to [**Hospital1 2025**]) and
has never had SBP, paracentesis for ascites. She also denies
fevers/chills, shortness of breath, confusion, lethargy. The
patient underwent EGD on Tuesday with her pediatric GI doctor,
who stated there were varices, none actively bleeding or
requiring banding. The patient's mother is unsure of the grades
of these varices.
.
With regards to her left upper extremity, the patient noticed
"pins and needles" sensation for a week now. Per her mother, she
often gets this sensation when she needs a transfusion of
platelets. The patient had received 8 units platelets and 1 unit
pRBC prior to the EGD, however, given her known bleeding
diathesis. The patient state that her LUE became throbbing, with
intense pain and became more swollen around her wrist. This made
it difficult for her to grasp anything or grip tightly with that
hand. She has not tried anything for this pain, has two Fentanyl
patches for her abdominal pain. Of note, the patient had a IV
placed in the upper part of her left hand last week.
.
Of note, the etiology of the patient's liver disease remains
unclear although is felt possibly due to cholestasis from TPN.
She was evaluated at [**Hospital1 2025**] for liver transplant but denied
secondary to her low body mass index. Reportedly [**Hospital1 2025**] has also
declined transitioning her care from the pediatric GI to adult
GI/hepatology care. She was seen in Liver Clinic at [**Hospital1 18**] in
[**2177-3-18**] for a second opinion and full work-up revealed weakly
positive [**Last Name (un) 15412**] (1:20), elevated IgG >1900, normal ceruloplasmin,
elevated alpha-1 antitrypsin. Her first liver biopsy [**9-/2174**]
showed portal fibrosis, ceroid laden macrophages, ductular
reaction. Repeat biopsy [**5-/2176**] demonstrated cholestatic liver
with bridging fibrosis, ductular reaction and again ceroid laden
macrophages.
.
In the ED, initial VS were: pain [**9-27**], T99.2, HR140, BP130/76,
RR100% on RA. The patient has a TPN port in place. Labs were
notable for mildly elevated LFTs, TBili 12.3, INR 1.4, lipase
142 and mild leukocytosis to 12.8 without bands. Blood and urine
cultures were sent. CT head was normal. RUQ ultrasound with
doppler showed small amount of ascites (perihepatic, loculated)
and patent vasculature. Guaiac negative with ?small fissure near
gluteal cleft. She received Zofran X1 and Fentanyl X2.
.
On arrival to the MICU, VS were: T99.8, HR111, BP118/68, RR16,
O2sat 98% on RA. The patient was resting in bed, appearing
chronically ill and somewhat uncomfortable. Mother at bedside.
.
ROS: Ongoing symptoms of dysphagia, abdominal pain (constant,
especially with PO meds), fatigue. Also reports ongoing tendency
to bleed, especially of gums/lips, unclear precipitant recently.
Otherwise, denies fevers/chills, cough, wheeze, dysuria,

MEDICAL HISTORY: 1.  Eosinophilic esophagitis.
2.  Chronic pancreatitis diagnosed in [**2172**], with normal ERCP in
[**2172**].
3.  TPN dependence since [**77**]/[**2172**].
4.  Cutaneous mastocytosis.
5.  Crohn's disease, previously treated with 6-MP, methotrexate,
and Humira.
6.  GERD diagnosed on barium swallow.
7.  Pancytopenia status post bone marrow biopsy and FISH
demonstrating hypocellular marrow.
8.  Left-sided ovarian cyst.
9.  Chronic bleeding disorder of unknown etiology for which the
patient requires Amicar
10. Legally blind s/p anoxic brain injury from ?stroke, code
when anaphylaxis to Iron infusion ([**Hospital1 2025**])
.
Past Surgical History
1.  Cholecystectomy in [**2172**].
2.  Appendectomy in [**2172**].
3.  Splenectomy in [**10/2175**] for pancytopenia.
4.  Celiac sympathectomy in [**2173**].
5.  Side-to-side feeding jejunostomy in [**2175**].
6.  Left-sided ovarian cyst removal in [**2171**].
7.  ERCP x2 in [**2172**].

MEDICATION ON ADMISSION: * Nexium 40mg [**Hospital1 **]
* Zofran 8mg TID
* Fentanyl patch 100 mcg X2, changed daily, alternating days
* Pentasa 2500mg [**Hospital1 **]
* Singulair 20mg qHS
* Amicar 1000mg over 1 hour QID
* Zenpep DR 15,000 TID
* Spironolactone 100mg daily
* Carafate 1gm.10mL TID
* Symbicort 160mcg 1 puff daily
* Desmopressin 1.5mg/mL 1 spray PRN bleeding
* Albuterol 90 mcg PRN
* TPN over 14 hours, Pepcid 40mg, Vitamin K 10mg, vitamins,
Carnitine 1 gram included)

ALLERGIES: Meropenem / Vancomycin / morphine / Iron / Ursodiol / peanuts /
wheat / Gluten / Soy / dairy products / pregabalin / pork
products

PHYSICAL EXAM: Admission Exam:
VS: Temp: 99.8 BP: 127/76 HR: 140 -->120 RR: 18 O2sat 99% on RA

FAMILY HISTORY: No family history of liver disease or liver cancer. Family
history notable for coronary disease and breast, colon cancers.

SOCIAL HISTORY: Lives at home with her mother. Denies alcohol, tobacco or
illicit drugs. Resides in [**Location (un) 3320**], MA. Mother is primary means
of support. Aunt also supportive. The patient at baseline goes
out, shops, does yoga and has a fair appetite despite multiple
serious drug allergies. 

### Response:
{'Other tenosynovitis of hand and wrist,Biliary cirrhosis,Regional enteritis of unspecified site,Chronic pancreatitis,Eosinophilic esophagitis'}
