CHIEF COMPLAINT: Abdominal Pain
Anasarca
Transplant evaluation

PRESENT ILLNESS: 52-year-old female with history of alcoholic and hepatitis B
cirrhosis, who was recently discharged from [**Hospital 1474**] hospital on
[**12-15**] folling treatment for spontaneous bacterial
peritonitis. She was seen in clinic today and was found with
large ascites, profoundly distended, and notably jaundiced and
in pain. She was admitted for a diagnostic and therapeutic
paracentesis and further work up.
.
Recently she has had slightly worsening abdominal pain,
increased [**Location (un) **] and some nausea and 1 episode of non-bloody
emesis. Reports with weight gain 15 lbs.

MEDICAL HISTORY: # Alcoholic liver cirrhosis diagnosed in [**2134**] with ascites and
esophageal varices.
# Hepatitis B cirrhosis, which the patient states she
contracted from her husband. Does not appear to have been
completely treated in the past. The patient does report being
enrolled in an interferon clinical trial at [**Hospital1 2025**] many years ago
but was deemed to not be a "non-responder."
# COPD.
# Hypothyroidism.
# Depression.
# Status post cholecystectomy.
# Sciatica status post back surgery x2

MEDICATION ON ADMISSION: Lasix 40 mg daily
spironolactone 100 mg daily
midodrine 10 mg t.i.d.
nadolol 20 mg daily
lactulose t.i.d.
folic acid 1 mg daily
ferrous sulfate 300mg po BID
Multivitamin
Thiamine 100mg daily
Magnesium Oxide 400mg po TID with meals
levothyroxine 25 mcg daily
combivent 2 puffs every four hours
oxycodone 5 mg Q4 p.r.n.
ciproflox 250mg PO Daily

ALLERGIES: Talwin Nx

PHYSICAL EXAM: 98.6 112/69 72 20 94%RA
GEN: illappearing, tearfull, obese
HEENT: icteric sclera, jaundiced skin
CV: rrr s1, s2, no M/g/R
RESP: diffuse wheezing bilaterally
ABD: tender to palpation, obese, +bs, site of paracentesis is
still draining fluid
EXT: tense pitting edema bilaterally
Neuro: AAOx3, 5/5 strength, sensation intact, no flap.

FAMILY HISTORY: The patient reports alcoholism in both sides of
her family. Mother deceased from bladder cancer at the age of
51. Father with heart disease and angina, but no history of
myocardial infarction or coronary artery bypass grafts. The
patient has three children with two girls at the ages of 23 and

SOCIAL HISTORY: The patient has currently quit smoking for 2 weeks. She was
previously smoking one pack per day for a total of 40 years.
The patient is a former drinker with her last drink being on
[**2155-3-29**]. She was drinking approximately four to six packs of
beer per week along with binge-drinking with 40 beers on the
weekends. She was drinking for a total of 30 years. Her last
cocaine use was last year. Last marijuana use two years
ago. She denies a history of IV drug abuse. She is not
currently in substance abuse counseling or support, but states
that she has not had any temptation to use illicits again.
Alcoholic cirrhosis of liver,Acute kidney failure, unspecified,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Hepatorenal syndrome,Urinary tract infection, site not specified,Other ascites,Hyposmolality and/or hyponatremia,Unspecified pleural effusion,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Anemia, unspecified,Chronic airway obstruction, not elsewhere classified,Unspecified acquired hypothyroidism
Alcohol cirrhosis liver,Acute kidney failure NOS,Hpt B chrn wo cm wo dlta,Hepatorenal syndrome,Urin tract infection NOS,Ascites NEC,Hyposmolality,Pleural effusion NOS,Mth sus Stph aur els/NOS,Thrombocytopenia NOS,Anemia NOS,Chr airway obstruct NEC,Hypothyroidism NOS
Admission Date:  [**2156-12-28**]              Discharge Date:   [**2157-2-4**]

Date of Birth:  [**2104-10-25**]             Sex:   F

Service: MEDICINE

Allergies:
Talwin Nx

Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
Abdominal Pain
Anasarca
Transplant evaluation

Major Surgical or Invasive Procedure:
Ultrasound guided paracentesis [**2156-12-29**]
Central Line Dialysis Catheter Placement


History of Present Illness:
52-year-old female with history of alcoholic and hepatitis B
cirrhosis, who was recently discharged from [**Hospital 1474**] hospital on
[**12-15**] folling treatment for spontaneous bacterial
peritonitis. She was seen in clinic today and was found with
large ascites, profoundly distended, and notably jaundiced and
in pain. She was admitted for a diagnostic and therapeutic
paracentesis and further work up.
.
Recently she has had slightly worsening abdominal pain,
increased [**Location (un) **] and some nausea and 1 episode of non-bloody
emesis. Reports with weight gain 15 lbs.


Past Medical History:
# Alcoholic liver cirrhosis diagnosed in [**2134**] with ascites and
esophageal varices.
# Hepatitis B cirrhosis, which the patient states she
contracted from her husband. Does not appear to have been
completely treated in the past. The patient does report being
enrolled in an interferon clinical trial at [**Hospital1 2025**] many years ago
but was deemed to not be a "non-responder."
# COPD.
# Hypothyroidism.
# Depression.
# Status post cholecystectomy.
# Sciatica status post back surgery x2


Social History:
The patient has currently quit smoking for 2 weeks. She was
previously smoking one pack per day for a total of 40 years.
The patient is a former drinker with her last drink being on
[**2155-3-29**]. She was drinking approximately four to six packs of
beer per week along with binge-drinking with 40 beers on the
weekends. She was drinking for a total of 30 years. Her last
cocaine use was last year. Last marijuana use two years
ago. She denies a history of IV drug abuse. She is not
currently in substance abuse counseling or support, but states
that she has not had any temptation to use illicits again.


Family History:
The patient reports alcoholism in both sides of
her family. Mother deceased from bladder cancer at the age of
51. Father with heart disease and angina, but no history of
myocardial infarction or coronary artery bypass grafts. The
patient has three children with two girls at the ages of 23 and

21 with hepatitis B. the oldest son does not have hepatitis B


Physical Exam:
98.6 112/69 72 20 94%RA
GEN: illappearing, tearfull, obese
HEENT: icteric sclera, jaundiced skin
CV: rrr s1, s2, no M/g/R
RESP: diffuse wheezing bilaterally
ABD: tender to palpation, obese, +bs, site of paracentesis is
still draining fluid
EXT: tense pitting edema bilaterally
Neuro: AAOx3, 5/5 strength, sensation intact, no flap.


Pertinent Results:
PARACENTESIS DIAG. OR THERAPEUTIC  [**2156-12-29**] 4:45 PM

PARACENTESIS DIAG. OR THERAPEU

Reason: DIAGNOSTIC AND THERAPEUTIC paracentesis please send cell
cou

[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with hep B/ETOH cirrhosis
REASON FOR THIS EXAMINATION:
DIAGNOSTIC AND THERAPEUTIC paracentesis please send cell count
and differential, fluid for culture
PARACENTESIS ON [**12-29**]

CLINICAL HISTORY: ETOH cirrhosis. Diagnostic tap requested.

PROCEDURE AND FINDINGS: A full discussion of pertinent risks,
benefits, and alternatives to the procedure was performed,
informed consent was obtained. Preprocedure timeout documents
proper patient, site, and procedure.

Using aseptic technique and ultrasound guidance, a 5 French [**Last Name (un) 11097**]
centesis catheter was passed through anesthetized tissues in the
left flank, to the peritoneal cavity from which approximately 1
liter of clear, straw-colored fluid was removed and sent for the
requested labs.

Hemostasis was then obtained, patient tolerated the procedure
well without any immediate post-procedure complications.

Dr. [**Last Name (STitle) 4401**] performed the procedure.

IMPRESSION: Successful ultrasound-guided paracentesis.
.
CT ABDOMEN W/CONTRAST  [**2157-1-1**] 5:41 PM

CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST

Reason: assess for loculation

[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with cirrhosis with large ascites, tap with
only 1L removed, assess for loculation
REASON FOR THIS EXAMINATION:
assess for loculation
CONTRAINDICATIONS for IV CONTRAST: not needed

INDICATION: 52-year-old female with cirrhosis and large ascites
with recent 1 liter of fluid removed via paracentesis. Assess
for loculation.

COMPARISON: [**2156-11-3**].

TECHNIQUE: MDCT acquired axial images of the abdomen and pelvis
were obtained with IV contrast. Multiplanar reformations were
performed.

CT ABDOMEN WITH IV CONTRAST: There is a moderate right pleural
effusion with associated atelectasis. There is airspace opacity
within the left lung base, likely atelectasis.

The liver is small and nodular consistent with cirrhosis.
Metallic clips are present within the gallbladder fossa,
consistent with prior cholecystectomy. The previously seen early
enhancing lesions within the liver are not well demonstrated,
given the lack of arterial phase timing. The pancreas and
adrenal glands are unremarkable. The spleen is bulky, measuring
13 cm. The small bowel is filled with oral contrast with no
evidence of obstruction. The large bowel is unremarkable. The
rectum and sigmoid colon are stool filled.
There is moderate amount of ascites located primarily along the
pericolic gutters and extending down into the deep pelvis. There
are no obvious septations or collection surrounded by soft
tissue to suggest loculation.

This examination is limited due to artifact created from the
patient's body habitus, particularly on the right of the abdomen
and pelvis.

There is diffuse anasarca throughout the subcutaneous tissues of
the abdomen and pelvis.

CT PELVIS WITH IV CONTRAST: The uterus and adnexa are
unremarkable. The urinary bladder is collapsed and contains a
Foley catheter.

There is no appreciable lymphadenopathy in the abdomen and
pelvis.

BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.

IMPRESSION:
1. No loculation. Majority of fluid within the pericolic gutters
and extending down into the deep pelvis.

2. Moderate right pleural effusion.

3. Cirrhotic liver and splenomegaly.
.
Echo: The left atrium is mildly dilated. The estimated right
atrial pressure is 0-5 mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%) Transmitral Doppler and tissue velocity imaging are
consistent with normal LV diastolic function. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. An eccentric, posteriorly
directed jet of Mild to moderate ([**12-15**]+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
The pulmonic valve leaflets are thickened. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.

IMPRESSION: Normal left ventricular function. Normal right
ventricular function. Moderately elevated estimated pulmonary
pressures.
Compared with the prior study (images reviewed) of [**2156-11-3**],
the estimated pulmonary pressures are moderately elevated and
the severity of mitral regurgitation has increased.
.
US ABD LIMIT, SINGLE ORGAN  [**2157-1-7**] 9:16 AM

US ABD LIMIT, SINGLE ORGAN

Reason: EVAL FOR ASCITES AND MARK THE SPOT FOR PARACENTESIS

[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with EtOH, Hep B cirrhosis, refractory
ascites.
REASON FOR THIS EXAMINATION:
Please assess for degree of ascites. Anasarca vs. ascites.
LIMITED ABDOMEN ULTRASOUND

COMPARISON: None.

HISTORY: Ascites.

FINDINGS: Limited [**Doctor Last Name 352**]-scale imaging of the abdomen was
performed to assess for underlying ascites. Minimal amounts of
fluid are seen in all four quadrants and midline pelvic view.
Subsequently, no spot was marked due to limited quantity of free
fluid.

IMPRESSION: Minimal amount of abdominal ascites, unable to mark
spot for paracentesis.
.
These findings were discussed with Dr. [**Last Name (STitle) 656**] at the time of
review.


Brief Hospital Course:
# Cirrhosis: The patient reported recent onset of jaundice and
acute exacerbation of peripheral edema and abdominal ascites. An
ultrasound guided paracentesis was performed but could only
drain 1L. CT abdomen showed ascites fluid in difficult to reach
locations, along paracolic gutters and in pelvis. In addition,
it showed much of the fluid was in her subcutaneous tissues.
Hepatitis B was thought to be a precipitating factor. A viral
load was checked and came back at 6700 copies. She was thus
started on entecavir. On initial presentaiton her sodium was low
at 123 and her creatinine was elevated to 1.3. She was placed on
a fluid restriction and her diuretics were held.  Her creatinine
improved but her urine output and peripheral edema remained
unchanged. In an effort to mobilize her fluid, she was
adminstered 50g of albumin daily followed by IV lasix.  Her
creatinine, sodium, and urine output remained unchanged.
.
She was titrated up to albumin 25g [**Hospital1 **] followed by lasix 80mg
[**Hospital1 **] 30 minutes after giving albumin, and she began to respond
with increased urine output, increased sodium, and decreased
creatinine.  The patient also reported feeling less edematous.
Her nadolol, lactulose, and midodrine were continued. Her cipro
was continued for SBP prophylaxis.
.
The team attempted to aggressively diurese her with albumin
cover, and was successful; unfortunately she then went into
renal failure, and was oliguric. HD (ultrafiltration) was
attempted in order to take off more fluid but her blood
pressures did not tolerate much fluid loss. Eventually after
much discussion with the team, the patient, and the patient's
family, we decided to send the patient to the MICU where she
could get CVVH and potentially be able to tolerate a greater
degree of fluid removal over 24 hour fluid removal cycles.  She
did not tolerate the CVVH secondary to hypotension and after
further family meetings she was made comfort measures only and
transferred back to the medical floor for placement in an
inpatient hospice setting. In terms of pain and discomfort,
morphine solution was given with good effect.
.
#Dyspnea:Patient reporting increased dyspnea when changing
position from lying down to sitting up. Reporting mild
exertional dyspnea as well. CXR showed vascular congestion. She
also had a mild O2 desaturation 97 to 95 with sitting up. Her
history and presentation was suggestive of hepatopulmonary
syndrome.  She reported improvement with increased diuresis. She
had stable oxygenation on room air.
.
#Hyperkalemia: Earlier in admission, in setting of hyponatremia.
She did not have a history of DM, not on NSAIDS, ACEI, or
spironolactone. A morning cortisol was measured and was found to
be normal. Her ekg did not show changes consistent with
hyperkalemia.  She was given kayexalate to keep her potassium
under 5.0; this was not an issue later in the admission.  Once
she was made comfort measures only her labs were no longer
obtained.
.
# Transplant workup: To be finished during hospitalization. Much
of her workup was completed at outside hospitals.  She recived a
transplant workup and psychiatry consult during this
hospitalization.  A colonoscopy is being considered. The
ultimate problem are two issues, as above: pulmonary function,
and BMI. Thus because the fluid issues above influenced both, we
saw diuresis and then CVVH as one way to bring the patient
towards the possibility of going onto the transplant list. Given
she did not tolerate CVVH she was made comfort measures and was
comfortable on time of discharge.
.
#:Anemia: Patient reported chronic BRBPR since her hemmorrhoid
surgery 1 month ago, and she ocntinued with brbpr here. No
vomiting, no hematemesis, no melena. She received 1 unit prbcs
he day of admission, and received 2 units of prbc's a week
later. Through most of her admission, despite ongoing BRBPR, she
had stable Hcts. The source of the BRBPR was not clear, since
she sometimes also had maroon stool; the possibility existed
that some food dye or medicine could have been responsible for
some of the color; however, a colonoscopy and workup for GI
bleeding was secondary to trying to see if the patient might
become eligible for a liver. Her hematocrit was stable at last
check before suspending lab draws.
.
# Goals of care: the patient became more discouraged during this
lengthy admission, and frustrated by the experience of waiting
for an uncertain and potentially grim outcome. She decided to
change her code status and a family meeting affirmed her
decision to be DNR/DNI in the presence of her children,
ex-husband and current partner. She eventually decided to give
CVVH a try as one last strategy to attempt to advance towards
transplant, but with the understanding that if this did not work
she might be more interested in trying to move to the goal of
comfort care. Given the ineffect of CVVH she was made CMO and
transferred to inpatient hospice.


Medications on Admission:
Lasix 40 mg daily
spironolactone 100 mg daily
midodrine 10 mg t.i.d.
nadolol 20 mg daily
lactulose t.i.d.
folic acid 1 mg daily
ferrous sulfate 300mg po BID
Multivitamin
Thiamine 100mg daily
Magnesium Oxide 400mg po TID with meals
levothyroxine 25 mcg daily
combivent 2 puffs every four hours
oxycodone 5 mg Q4 p.r.n.
ciproflox 250mg PO Daily


Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed.
3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1)  Inhalation Q4H (every 4 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
7. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
9. Morphine Concentrate 20 mg/mL Solution Sig: 5-20mg  PO Q2H
(every 2 hours) as needed for pain.
10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 169**] Center Wedgemere

Discharge Diagnosis:
Liver Failure
Cirrhosis
End Stage Renal Disease
Depression


Discharge Condition:
Fair, Hemodynamically Stable


Discharge Instructions:
You were admitted for your liver failure.  Medical therapies
were initiated and you also had hemodialysis which was
ineffective.

You are being discharged to a hospice center.

If you experience increased pain, shortness of breath, nausea,
vomitting or any other concerning symptom please contact your
primary care doctor

Followup Instructions:
{'Alcoholic cirrhosis of liver,Acute kidney failure, unspecified,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Hepatorenal syndrome,Urinary tract infection, site not specified,Other ascites,Hyposmolality and/or hyponatremia,Unspecified pleural effusion,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Anemia, unspecified,Chronic airway obstruction, not elsewhere classified,Unspecified acquired hypothyroidism'}


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
Anasarca
Transplant evaluation

PRESENT ILLNESS: 52-year-old female with history of alcoholic and hepatitis B
cirrhosis, who was recently discharged from [**Hospital 1474**] hospital on
[**12-15**] folling treatment for spontaneous bacterial
peritonitis. She was seen in clinic today and was found with
large ascites, profoundly distended, and notably jaundiced and
in pain. She was admitted for a diagnostic and therapeutic
paracentesis and further work up.
.
Recently she has had slightly worsening abdominal pain,
increased [**Location (un) **] and some nausea and 1 episode of non-bloody
emesis. Reports with weight gain 15 lbs.

MEDICAL HISTORY: # Alcoholic liver cirrhosis diagnosed in [**2134**] with ascites and
esophageal varices.
# Hepatitis B cirrhosis, which the patient states she
contracted from her husband. Does not appear to have been
completely treated in the past. The patient does report being
enrolled in an interferon clinical trial at [**Hospital1 2025**] many years ago
but was deemed to not be a "non-responder."
# COPD.
# Hypothyroidism.
# Depression.
# Status post cholecystectomy.
# Sciatica status post back surgery x2

MEDICATION ON ADMISSION: Lasix 40 mg daily
spironolactone 100 mg daily
midodrine 10 mg t.i.d.
nadolol 20 mg daily
lactulose t.i.d.
folic acid 1 mg daily
ferrous sulfate 300mg po BID
Multivitamin
Thiamine 100mg daily
Magnesium Oxide 400mg po TID with meals
levothyroxine 25 mcg daily
combivent 2 puffs every four hours
oxycodone 5 mg Q4 p.r.n.
ciproflox 250mg PO Daily

ALLERGIES: Talwin Nx

PHYSICAL EXAM: 98.6 112/69 72 20 94%RA
GEN: illappearing, tearfull, obese
HEENT: icteric sclera, jaundiced skin
CV: rrr s1, s2, no M/g/R
RESP: diffuse wheezing bilaterally
ABD: tender to palpation, obese, +bs, site of paracentesis is
still draining fluid
EXT: tense pitting edema bilaterally
Neuro: AAOx3, 5/5 strength, sensation intact, no flap.

FAMILY HISTORY: The patient reports alcoholism in both sides of
her family. Mother deceased from bladder cancer at the age of
51. Father with heart disease and angina, but no history of
myocardial infarction or coronary artery bypass grafts. The
patient has three children with two girls at the ages of 23 and

SOCIAL HISTORY: The patient has currently quit smoking for 2 weeks. She was
previously smoking one pack per day for a total of 40 years.
The patient is a former drinker with her last drink being on
[**2155-3-29**]. She was drinking approximately four to six packs of
beer per week along with binge-drinking with 40 beers on the
weekends. She was drinking for a total of 30 years. Her last
cocaine use was last year. Last marijuana use two years
ago. She denies a history of IV drug abuse. She is not
currently in substance abuse counseling or support, but states
that she has not had any temptation to use illicits again. 

### Response:
{'Alcoholic cirrhosis of liver,Acute kidney failure, unspecified,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Hepatorenal syndrome,Urinary tract infection, site not specified,Other ascites,Hyposmolality and/or hyponatremia,Unspecified pleural effusion,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified,Anemia, unspecified,Chronic airway obstruction, not elsewhere classified,Unspecified acquired hypothyroidism'}
