CHIEF COMPLAINT: abdominal pain, bacteremia, fevers; concern for possible hepatic
abscess and/or cholangitis

PRESENT ILLNESS: 50 yo female with hx of gastric bypass ([**2125**]), spinal fusion,
anxiety, GERD, presents in transfer from [**Hospital3 **] Hospital for
concern of possible hepatic abscess.
3 days ago, pt began to develop abdominal discomfort, for which
she took Gas-x, as she has a hx of gas pains s/p gastric bypass,
although the nature of the pain seemed different.  Pain was
located in RUQ and radiated around R side to R back.  Pain
progressively worsened to [**10-23**], and began to develop fevers
which started off mild, but progressed to 104+.  She was noted
to have mild elevation of LFT's with AST to 103, ALT 106, alk
phos 75.  Bili 0.8.  WBC on [**1-25**] showed WBC 7.7 and bandemia
40%.  Pt was treated with IV Unasyn, and Ertapenem was later
added last night.  Pt feels that she has continued to clinically
worsen with increased pain, fevers, rigors, worst at night.
.
She had multiple imaging studies, which revealed 4.4 cm mass in
lateral segment of of L lobe of the liver, and a 2.7 cm lesion
in medial segment of L lobe of liver.  MRCP was performed to
further evaluate, however the report is currently pending
(awaiting fax).
Pt had blood cultures drawn, and micro showed e.coli, with some
resistances.

MEDICAL HISTORY: Migraines
GERD
Anxiety
Chronic back pain
Hx hysterectomy, [**2119**]
Hx gastric bypass surgery, [**2125**]. No complications.
Hx spinal fusion, [**2116**]

MEDICATION ON ADMISSION: Transfer Medications:
tylenol 650 mg po q 4hr prn
dilaudid 0.5 mg IV q 2 hr prn
dilaudid 2 mg IM q 4hr prn
serax 10 mg po qHS prn insomnia (did not receive)
nexium 40 mg IV q day
trazodone 50 mg po q hs
propranolol 60 mg po q hs
paroxetine 40 mg po q hs
fentanyl 25 mcg/hr patch q 3 days (placed 9 am [**1-25**])
docusate 100 mg po BID prn
.
Ampicillin/Sulbactam 3gm IV q 6hr (last dose 1/13 8am)
Ertapenem (dose?) IV q 24 hrs (las dose 11pm [**1-25**])
.
D5 1/2 NS +KCl @ 125 cc/hr

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 99.3  103/61  63  20  96RA
GEN: AAOx3. non-toxic.
HEENT: eomi, perrl, MMM.
Neck:  No LAD. JVP WNL. No cervial or supraclavicular LAD.
RESP:  CTA B. No WRR.
CV:  RRR. No mrg.
ABD:  +BS. Soft, ND.  Mildly uncomfortable on palp of RUQ.
Ext:  No CEE.
Neuro:  CN 2-12 grossly intact.

FAMILY HISTORY: Family hx of colon cancer.
DM
Father: lung cancer, smoker

SOCIAL HISTORY: Lives in [**Location **], MA.  On disability d/t back pain.  Married,
children.
Tobacco: quit [**2129-1-14**]; previously 1 pack/wk x 1yr
ETOH: occasional
Drugs: denies
Septicemia due to escherichia coli [E. coli],Abscess of liver,Acute edema of lung, unspecified,Acute kidney failure with lesion of tubular necrosis,Esophageal reflux,Backache, unspecified,Other chronic pain,Anxiety state, unspecified,Bariatric surgery status,Arthrodesis status,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Severe sepsis,Other specified disorders of liver
E coli septicemia,Abscess of liver,Acute lung edema NOS,Ac kidny fail, tubr necr,Esophageal reflux,Backache NOS,Chronic pain NEC,Anxiety state NOS,Bariatric surgery status,Arthrodesis status,Migrne unsp wo ntrc mgrn,Severe sepsis,Liver disorders NEC
Admission Date:  [**2129-1-26**]              Discharge Date:   [**2129-1-31**]

Date of Birth:  [**2078-7-4**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
abdominal pain, bacteremia, fevers; concern for possible hepatic
abscess and/or cholangitis

Major Surgical or Invasive Procedure:
Drainage of liver abscess [**2129-1-28**]

History of Present Illness:
50 yo female with hx of gastric bypass ([**2125**]), spinal fusion,
anxiety, GERD, presents in transfer from [**Hospital3 **] Hospital for
concern of possible hepatic abscess.
3 days ago, pt began to develop abdominal discomfort, for which
she took Gas-x, as she has a hx of gas pains s/p gastric bypass,
although the nature of the pain seemed different.  Pain was
located in RUQ and radiated around R side to R back.  Pain
progressively worsened to [**10-23**], and began to develop fevers
which started off mild, but progressed to 104+.  She was noted
to have mild elevation of LFT's with AST to 103, ALT 106, alk
phos 75.  Bili 0.8.  WBC on [**1-25**] showed WBC 7.7 and bandemia
40%.  Pt was treated with IV Unasyn, and Ertapenem was later
added last night.  Pt feels that she has continued to clinically
worsen with increased pain, fevers, rigors, worst at night.
.
She had multiple imaging studies, which revealed 4.4 cm mass in
lateral segment of of L lobe of the liver, and a 2.7 cm lesion
in medial segment of L lobe of liver.  MRCP was performed to
further evaluate, however the report is currently pending
(awaiting fax).
Pt had blood cultures drawn, and micro showed e.coli, with some
resistances.

Pt was subsequently transferred for furhter evaluation and
treatment with concern of possible liver abscess and/or
cholangitis.
.
.
ROS:
+: as per HPI, plus: fevers, chills, rigors, night sweats,
nausea, vomiting (x1), abdominal distention (subjective),
constipation.
.
Denies:
10 point ROS otherwise negative.

Past Medical History:
Migraines
GERD
Anxiety
Chronic back pain
Hx hysterectomy, [**2119**]
Hx gastric bypass surgery, [**2125**]. No complications.
Hx spinal fusion, [**2116**]


Social History:
Lives in [**Location **], MA.  On disability d/t back pain.  Married,
children.
Tobacco: quit [**2129-1-14**]; previously 1 pack/wk x 1yr
ETOH: occasional
Drugs: denies

Family History:
Family hx of colon cancer.
DM
Father: lung cancer, smoker


Physical Exam:
VS: 99.3  103/61  63  20  96RA
GEN: AAOx3. non-toxic.
HEENT: eomi, perrl, MMM.
Neck:  No LAD. JVP WNL. No cervial or supraclavicular LAD.
RESP:  CTA B. No WRR.
CV:  RRR. No mrg.
ABD:  +BS. Soft, ND.  Mildly uncomfortable on palp of RUQ.
Ext:  No CEE.
Neuro:  CN 2-12 grossly intact.

on discharge
98.0 112/72 61 20 100RA
well appearing
exam as above

Pertinent Results:
[**2129-1-26**] 06:10PM   GLUCOSE-105* UREA N-7 CREAT-0.4 SODIUM-139
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-29 ANION GAP-10
[**2129-1-26**] 06:10PM   estGFR-Using this
[**2129-1-26**] 06:10PM   ALT(SGPT)-136* AST(SGOT)-66* LD(LDH)-172 ALK
PHOS-104 TOT BILI-0.6
[**2129-1-26**] 06:10PM   LIPASE-20
[**2129-1-26**] 06:10PM   CALCIUM-8.3* PHOSPHATE-1.8* MAGNESIUM-1.8
[**2129-1-26**] 06:10PM   WBC-5.2 RBC-3.21* HGB-9.8* HCT-28.7* MCV-89
MCH-30.5 MCHC-34.2 RDW-12.4
[**2129-1-26**] 06:10PM   NEUTS-79.2* BANDS-0 LYMPHS-13.2* MONOS-6.9
EOS-0.6 BASOS-0.2
[**2129-1-26**] 06:10PM   PLT COUNT-176
[**2129-1-26**] 06:10PM   PT-12.2 PTT-23.7 INR(PT)-1.0
Peak Cr: 3.0 ([**1-29**])
Discharge Cr is 2.6 ([**1-31**])

Blood culture
Blood Culture, Routine (Preliminary):
      ESCHERICHIA COLI.    FINAL SENSITIVITIES.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------  =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----     8 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

MRCP: [**2129-1-27**]
IMPRESSION:
1. 4.2 x 2.7 cm rim-enhancing hepatic lesion containing fluid
and debris
concerning for abscess. This has increased in size from recent
outside
hospital CT [**2129-1-23**].
2. Periportal edema, small amount of pericholecystic and
retroperitoneal
fluid, and small bilateral pleural effusions probably related to
third
spacing.
3. Dependent atelectasis of the right lower lobe overlying the
hepatic dome.
4. Convex contour abnormality of the left hepatic lobe has
similar imaging
characteristics to normal hepatic parenchyma and is not
concerning. This may
be related to prior trauma or could be congenital.


Brief Hospital Course:
50 yo female with hx of gastric bypass [**2125**], hysterectomy [**2119**],
lumbar fusion [**2116**], presents in transfer from OSH with e.coli
bacteremia, high fevers, RUQ pain, and concern for liver abscess
and/or cholangitis.
.
Primary Diagnosis: 790.7 BACTEREMIA
Secondary Diagnosis: 572.0 ABSCESS, LIVER
Patient had high fevers and RUQ pain in setting of E. coli
bacteremia at OSH. OSH MRCP had showed probable liver abscess.
ERCP and ID team was consulted. Patient was covered with vanco
initially, Zosyn and cipro. Vanco was D/Ced after blood cx grew
GNR. Given persistant bacteremia and probable liver abscess,
patient underwent U/S guided drainage of liver lesion on
[**2129-1-28**]. 8cc was aspirated and sent for culture, no drain was
left in place. Hepatology believes that the patient had a
hepatic cyst that became secondarily infected. She was
discharged on cipro and flagyl and will remain on these
medications until directed to stop by the ID team.  ID followup
was arranged [**2129-2-23**]; she will require repeat abd imaging (CT or
MRI, pending renal status) prior to her ID appt.  She will
follow up with hepatology (Dr [**Last Name (STitle) 696**] within a week of
discharge.
.
.
# Hypoxemic respiratory distress- Patient developed respiratory
distress and hypoxemia in setting of fevers to 104. A-a gradient
of 136.  Corrected with oxygen.  Suspect V/Q mismatch as
etiology, likely pulmonary edema.  TTE showed mild to moderate
MR and normal LVEF. Trop reflected demand, and trended down. TTE
and trop leak suggested component of flash pulmonary edema in
setting of fever, tachypnea, and transient bacteremia.  Hypoxia
resolved quickly and she thereafter remained stable on room air
following this initial decompensation.
.
Secondary Diagnosis: 584.9 ACUTE RENAL FAILURE
FENA high, BUN low. no cast in UA. renal u/s wnl. Likely from
combination of sepsis and contrast nephropathy. Cr peaked at 3.0
[**1-29**] and improved to [**2-19**] on [**1-31**].  Renal was consulted (Dr
[**Last Name (STitle) 118**], and agreed with diagnosis. She is to have her Cr
checked as outpatient; expect normalization within 2 weeks per
renal.  She will not need renal f/u unless Creatinine fails to
rapidly improve.
.
Secondary Diagnosis: 724.2 PAIN, BACK LUMBAR
Stable, continued on home narcotic regimen
.
# Anxiety: continue home paroxetine
.
# GERD: continued PPI
.
# Lung nodule- The CT scan of the abdomen done at [**Hospital3 **]
hospital noted a 0.5 cm right lower lobe lung nodule. The OSH
radiologists did not state a follow up duration, but given her
low risk a CT scan at 3-6 months seem reasonable. The patient
and PCP were notified about this finding.


Medications on Admission:
Transfer Medications:
tylenol 650 mg po q 4hr prn
dilaudid 0.5 mg IV q 2 hr prn
dilaudid 2 mg IM q 4hr prn
serax 10 mg po qHS prn insomnia (did not receive)
nexium 40 mg IV q day
trazodone 50 mg po q hs
propranolol 60 mg po q hs
paroxetine 40 mg po q hs
fentanyl 25 mcg/hr patch q 3 days (placed 9 am [**1-25**])
docusate 100 mg po BID prn
.
Ampicillin/Sulbactam 3gm IV q 6hr (last dose 1/13 8am)
Ertapenem (dose?) IV q 24 hrs (las dose 11pm [**1-25**])
.
D5 1/2 NS +KCl @ 125 cc/hr

Home Medications:
Fentanyl patch 25 mcg/hr q 72 hr
Paroxetine 40 mg po q day
Prilosec 40 mg po q day
Propranolol 60 mg po q day
Trazodone 50 mg po q day
Vicodin 10/325 mg po bid prn

Discharge Medications:
1. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Propranolol 40 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).

5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Vicodin ES  Oral
7. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day: ?DURATION OF THERAPY.
8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day: NEEDS
DURATION AND DOSE ADJUSTED.
9. Outpatient Lab Work
Check Chem 7 and CBC on Thursday, [**2128-2-4**].
Fax results to: [**Last Name (LF) 12832**], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**Hospital1 18**], ONE PEARL ST, [**Apartment Address(1) 12833**], [**Hospital1 **],[**Numeric Identifier 8728**] Phone: [**Telephone/Fax (1) 12834**], Fax: [**Telephone/Fax (1) 12835**]

10. Outpatient Imaging
MRI Abdomen to be done at [**Hospital1 18**] by [**2129-2-21**].
11. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
12. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis: 790.7 BACTEREMIA
Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE
(GERD)
Secondary Diagnosis: 584.9 ACUTE RENAL FAILURE
Secondary Diagnosis: 572.0 ABSCESS, LIVER
Secondary Diagnosis: 724.2 PAIN, BACK LUMBAR


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

Discharge Instructions:
As we discussed, you were admitted with an infection in your
liver that entered your blood stream.  Please make sure to
complete the entire antibiotic course.  You were also found to
have injury to your kidneys. This will improve with time but
will need to be followed after you leave. If it does not improve
you will need to see a kidney specialist as an outpatient.
As we discussed, the CT scan done at the outside hospital showed
a nodule in your right lung which will need to be rechecked with
a CT scan in the future.  Please discuss this with your PCP to
arrange the appropriate followup.
You will be discharged on two antibiotics (Ciprofloxacin and
Flagyl).  Please continue taking these medications until your
follow up appointment with Infectious Disease.

Followup Instructions:
1. Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12832**] to schedule follow up
within a week of your discharge.  We expect your kidney function
will return to normal within 10 days and that you will NOT need
to follow up with the kidney doctors.  However, if your primary
doctor finds that your kidney function has not returned to
[**Location 213**], he will help you arrange follow up with a kidney
specialist.
.
Name: [**Last Name (LF) 12832**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **]
Address: ONE PEARL ST, [**Apartment Address(1) 12836**], [**Hospital1 **],[**Numeric Identifier 8728**]
Phone: [**Telephone/Fax (1) 12834**]
Fax: [**Telephone/Fax (1) 12835**]
.
2. You need to follow up with Dr [**Last Name (STitle) 696**] (Hepatology/Liver
Clinic) within 1 week of discharge.  Call ([**Telephone/Fax (1) 1582**] to
schedule this appointment. His office is located in the [**Hospital Ward Name 12837**] in the [**Hospital **] Medical Office Building.
.
3. You need to follow up with Dr [**Last Name (STitle) 12838**] in the Infectious
Disease Clinic on [**2-23**] at 2:00 PM.  Call ([**Telephone/Fax (1) 4170**]
with questions. This clinic is located in the [**Hospital Ward Name 517**] in the
[**Hospital **] Medical Office Building.  ** You need to have an MRI of
your abdomen here at [**Hospital1 **] before this visit (ie, by [**2-21**])** Your
PCP will help you arrange this test if it has not already been
done by Dr [**Last Name (STitle) 696**].
{'Septicemia due to escherichia coli [E. coli],Abscess of liver,Acute edema of lung, unspecified,Acute kidney failure with lesion of tubular necrosis,Esophageal reflux,Backache, unspecified,Other chronic pain,Anxiety state, unspecified,Bariatric surgery status,Arthrodesis status,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Severe sepsis,Other specified disorders of liver'}


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, bacteremia, fevers; concern for possible hepatic
abscess and/or cholangitis

PRESENT ILLNESS: 50 yo female with hx of gastric bypass ([**2125**]), spinal fusion,
anxiety, GERD, presents in transfer from [**Hospital3 **] Hospital for
concern of possible hepatic abscess.
3 days ago, pt began to develop abdominal discomfort, for which
she took Gas-x, as she has a hx of gas pains s/p gastric bypass,
although the nature of the pain seemed different.  Pain was
located in RUQ and radiated around R side to R back.  Pain
progressively worsened to [**10-23**], and began to develop fevers
which started off mild, but progressed to 104+.  She was noted
to have mild elevation of LFT's with AST to 103, ALT 106, alk
phos 75.  Bili 0.8.  WBC on [**1-25**] showed WBC 7.7 and bandemia
40%.  Pt was treated with IV Unasyn, and Ertapenem was later
added last night.  Pt feels that she has continued to clinically
worsen with increased pain, fevers, rigors, worst at night.
.
She had multiple imaging studies, which revealed 4.4 cm mass in
lateral segment of of L lobe of the liver, and a 2.7 cm lesion
in medial segment of L lobe of liver.  MRCP was performed to
further evaluate, however the report is currently pending
(awaiting fax).
Pt had blood cultures drawn, and micro showed e.coli, with some
resistances.

MEDICAL HISTORY: Migraines
GERD
Anxiety
Chronic back pain
Hx hysterectomy, [**2119**]
Hx gastric bypass surgery, [**2125**]. No complications.
Hx spinal fusion, [**2116**]

MEDICATION ON ADMISSION: Transfer Medications:
tylenol 650 mg po q 4hr prn
dilaudid 0.5 mg IV q 2 hr prn
dilaudid 2 mg IM q 4hr prn
serax 10 mg po qHS prn insomnia (did not receive)
nexium 40 mg IV q day
trazodone 50 mg po q hs
propranolol 60 mg po q hs
paroxetine 40 mg po q hs
fentanyl 25 mcg/hr patch q 3 days (placed 9 am [**1-25**])
docusate 100 mg po BID prn
.
Ampicillin/Sulbactam 3gm IV q 6hr (last dose 1/13 8am)
Ertapenem (dose?) IV q 24 hrs (las dose 11pm [**1-25**])
.
D5 1/2 NS +KCl @ 125 cc/hr

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 99.3  103/61  63  20  96RA
GEN: AAOx3. non-toxic.
HEENT: eomi, perrl, MMM.
Neck:  No LAD. JVP WNL. No cervial or supraclavicular LAD.
RESP:  CTA B. No WRR.
CV:  RRR. No mrg.
ABD:  +BS. Soft, ND.  Mildly uncomfortable on palp of RUQ.
Ext:  No CEE.
Neuro:  CN 2-12 grossly intact.

FAMILY HISTORY: Family hx of colon cancer.
DM
Father: lung cancer, smoker

SOCIAL HISTORY: Lives in [**Location **], MA.  On disability d/t back pain.  Married,
children.
Tobacco: quit [**2129-1-14**]; previously 1 pack/wk x 1yr
ETOH: occasional
Drugs: denies 

### Response:
{'Septicemia due to escherichia coli [E. coli],Abscess of liver,Acute edema of lung, unspecified,Acute kidney failure with lesion of tubular necrosis,Esophageal reflux,Backache, unspecified,Other chronic pain,Anxiety state, unspecified,Bariatric surgery status,Arthrodesis status,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Severe sepsis,Other specified disorders of liver'}
