CHIEF COMPLAINT: fever, nausea, abdominal pain

PRESENT ILLNESS: 37 yo F w/o significant [**Hospital 63245**] transferred from OSH for
management of pyelonephritis, bilateral pleural effusions,
ascites.
.
Pt originally admitted to OSH on [**2114-9-30**] after presenting w/CC
of vomiting, malaise, fever and back pain X4d, and Hx of recent
UTI (treated in [**Month (only) 216**] w/unknown Abx as outpt). At the time, T
102, had upper abd tenderness, bilateral CVA tenderness, WBC
[**Numeric Identifier **], (+) Ua, CT abd confirmed severe Rt pyelonephritis with no
other abnormalities. Pt started on Levoflox 500 IV q24h and
Rocephin 2 gr IV q24h. Pt became afebrile within 36 h. Ux (+)
for E.coli sensitive to ceftiaxone, resistant to levoflox.
Levoflox D/Ced on [**10-2**] and replaced with gentamycin. On [**10-3**], pt
afebrile w/WBC down to 8100, however c/o HA/ abd and flank pain
and SOB. O2 sat 92-97% on RA. Vomited and became bradycardic
(42, then up to the 50s). ECG sinus brady. On Lovenox 60 mg sc.
Repeat CT of the abdomen showed new bilateral pleural effusions
R>L, ascites and "generalized inflammation of the liver". Rt
kidney looks improved compared to [**9-30**]. Sent to [**Hospital1 18**] for
further management.

MEDICAL HISTORY: Hospitalized only for vaginal delivery X2.
Recent UTI in [**Month (only) 216**].
No surgeries.
LMP: [**2114-9-27**].

MEDICATION ON ADMISSION: None at home
(ceftriaxone 2g q24h, gent 80 mg [**Hospital1 **], promethazine, ambien,
ibuprofen, vicodin on transfer)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tc 101.1  HR 48  BP 110/70  RR 16  O2sat 95% RA
general- sitting up in bed, ill-appearing, no respiratory
distress
HEENT- sclerae anicteric, dry MM
Neck- HOB 45deg: JVD to mandible
Pulm- poor inspiratory effort, poor air movement, no audible
wheezes
Heart- bradycardic, regular, no m/r/g
Abd- distended but soft, hypoactive bowel sounds, + tenderness
to mild palpation of RUQ/epigastrium, + peritoneal signs, +
guarding
Ext- no peripheral edema, +2 PT pulses b/l
Neuro- CN III-XII intact, strength exam limited by poor effort

FAMILY HISTORY: NC

SOCIAL HISTORY: moved from [**Country 4194**] in [**4-10**], works in housecleaning, not married,
2 children in [**Country 4194**]; currently sexually active with 1 male
partner ("rare" unprotected sex); No STDs
Unspecified pleural effusion,Acute pyelonephritis without lesion of renal medullary necrosis,Other specified cardiac dysrhythmias,Cephalosporin group causing adverse effects in therapeutic use
Pleural effusion NOS,Ac pyelonephritis NOS,Cardiac dysrhythmias NEC,Adv eff cephalosporin
Admission Date:  [**2114-10-3**]              Discharge Date:   [**2114-10-13**]

Date of Birth:  [**2077-7-5**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
fever, nausea, abdominal pain

Major Surgical or Invasive Procedure:
Lumbar puncture


History of Present Illness:
37 yo F w/o significant [**Hospital 63245**] transferred from OSH for
management of pyelonephritis, bilateral pleural effusions,
ascites.
.
Pt originally admitted to OSH on [**2114-9-30**] after presenting w/CC
of vomiting, malaise, fever and back pain X4d, and Hx of recent
UTI (treated in [**Month (only) 216**] w/unknown Abx as outpt). At the time, T
102, had upper abd tenderness, bilateral CVA tenderness, WBC
[**Numeric Identifier **], (+) Ua, CT abd confirmed severe Rt pyelonephritis with no
other abnormalities. Pt started on Levoflox 500 IV q24h and
Rocephin 2 gr IV q24h. Pt became afebrile within 36 h. Ux (+)
for E.coli sensitive to ceftiaxone, resistant to levoflox.
Levoflox D/Ced on [**10-2**] and replaced with gentamycin. On [**10-3**], pt
afebrile w/WBC down to 8100, however c/o HA/ abd and flank pain
and SOB. O2 sat 92-97% on RA. Vomited and became bradycardic
(42, then up to the 50s). ECG sinus brady. On Lovenox 60 mg sc.
Repeat CT of the abdomen showed new bilateral pleural effusions
R>L, ascites and "generalized inflammation of the liver". Rt
kidney looks improved compared to [**9-30**]. Sent to [**Hospital1 18**] for
further management.


Past Medical History:
Hospitalized only for vaginal delivery X2.
Recent UTI in [**Month (only) 216**].
No surgeries.
LMP: [**2114-9-27**].


Social History:
moved from [**Country 4194**] in [**4-10**], works in housecleaning, not married,
2 children in [**Country 4194**]; currently sexually active with 1 male
partner ("rare" unprotected sex); No STDs

Family History:
NC

Physical Exam:
Tc 101.1  HR 48  BP 110/70  RR 16  O2sat 95% RA
general- sitting up in bed, ill-appearing, no respiratory
distress
HEENT- sclerae anicteric, dry MM
Neck- HOB 45deg: JVD to mandible
Pulm- poor inspiratory effort, poor air movement, no audible
wheezes
Heart- bradycardic, regular, no m/r/g
Abd- distended but soft, hypoactive bowel sounds, + tenderness
to mild palpation of RUQ/epigastrium, + peritoneal signs, +
guarding
Ext- no peripheral edema, +2 PT pulses b/l
Neuro- CN III-XII intact, strength exam limited by poor effort

Pertinent Results:
[**2114-10-3**] 08:35PM   PT-13.7* PTT-34.8 INR(PT)-1.3
[**2114-10-3**] 08:35PM   WBC-7.4 RBC-3.12* HGB-9.8* HCT-29.3* MCV-94
MCH-31.5 MCHC-33.5 RDW-13.1
[**2114-10-3**] 08:35PM   ALT(SGPT)-17 AST(SGOT)-21 LD(LDH)-165 ALK
PHOS-130* AMYLASE-27 TOT BILI-0.3
[**2114-10-3**] 08:35PM   GLUCOSE-89 UREA N-8 CREAT-0.8 SODIUM-140
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-20* ANION GAP-16
[**2114-10-3**] 08:35PM   CALCIUM-7.9* PHOSPHATE-3.0 MAGNESIUM-1.8
.
Hepatitis B Surface Antigen NEGATIVE
Hepatitis B Core Antibody, IgM NEGATIVE
Hepatitis A Virus IgM Antibody NEGATIVE
Hepatitis C Virus Antibody NEGATIVE
[**Doctor First Name **] negative
.
ESR  64*
Parst S   NEGATIVE
.
CT abd/pelv (OSH, [**9-30**]): R sided pyelonephritis, "generalized
inflammation of the liver"
.
RUQ US: normal gallbladder, no gallstones, CBD 5mm, small
calcification in R lobe of the liver likely representing
granuloma, normal portal vein, no intrahepatic biliary ductal
dilatation, small pleural effusion
.
[**2114-10-5**], CT HEAD WITHOUT CONTRAST: No intracranial mass effect,
hydrocephalus, shift of normally midline structures, minor or
major vascular territorial infarct is apparent. The density
values of the brain parenchyma are normal. The surrounding soft
tissue and osseous structures are unremarkable.
.
[**2114-10-5**], CT ABDOMEN WITH IV CONTRAST: There are bilateral
pleural effusions with atelectatic changes. There are no nodules
visualized. The liver is enlarged and heterogeneous, which could
be consistent with hepatitis. The gallbladder contains high
attenuation material within the lumen consistent with sludge,
but is not distended and there is no evidence of stones. There
is a moderate amount of abdominal ascites. The pancreas, adrenal
glands, spleen, left kidney, stomach, and abdominal loops of
small and large bowel are within normal limits. The right kidney
is enlarged and there are mottled wedge shaped areas of
hypodensity. This appearance is suggestive of infarct versus
pyelonephritis. The appendix is visualized and there are no
signs of acute appendicitis. There is no free air and no
pathologic mesenteric or retroperitoneal lymphadenopathy.
.
CT PELVIS WITH CONTRAST: The bladder, uterus, rectum, and
sigmoid colon are within normal limits. There is a moderate
amount of fluid surrounding the uterus, but no evidence for
tubo-ovarian abscess. There is no pathologic mesenteric or
inguinal lymph adenopathy.
.
BONE WINDOWS: No lytic or sclerotic foci are visualized.

.
TTE [**10-8**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is top normal. There is a
very small likely loculated pericardial effusion around the
right atrium (?small pericardial cyst)..

.
MICRO:
[**2114-10-6**] 9:41 am urine/serology

                            **FINAL REPORT [**2114-10-7**]**

   Legionella Urinary Antigen  (Final [**2114-10-7**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.

   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2114-10-8**]):    POSITIVE
BY EIA.

   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2114-10-8**]):    POSITIVE
BY EIA.

   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2114-10-8**]):
      NEGATIVE <1:10 BY IFA.
      INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.


   TOXOPLASMA IgG ANTIBODY (Final [**2114-10-9**]):
      NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
      0.0 IU/ML.
      Reference Range:  Negative < 4 IU/ml, Positive >= 8 IU/ml.


   TOXOPLASMA IgM ANTIBODY (Final [**2114-10-9**]):
      NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
      INTERPRETATION:  NO ANTIBODY DETECTED.

   CMV IgG ANTIBODY (Final [**2114-10-9**]):
      POSITIVE FOR CMV IgG ANTIBODY BY EIA.
      60 AU/ML.
      Reference Range:  Negative < 4 AU/ml, Positive >= 6 AU/ml.


   CMV IgM ANTIBODY (Final [**2114-10-9**]):
      NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
      INTERPRETATION:  INFECTION AT UNDETERMINED TIME.

   Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
      [**2114-10-5**]):    Negative for Chlamydia trachomatis by PCR.

   NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
      (Final [**2114-10-5**]):    Negative for Neisseria Gonorrhoeae by
PCR.

   LYME SEROLOGY (Final [**2114-10-8**]):
      NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
      Reference Range:  No antibody detected.

   RAPID PLASMA REAGIN TEST (Final [**2114-10-8**]):
      NONREACTIVE.
      Reference Range: Non-Reactive.



Brief Hospital Course:
A/P: 37yo F with pyelonephritis, ascites, and pleural effusions.
.
1) Pyelonephritis: > 100K colonies of E. coli grew on urine
culture from OSH ([**Hospital6 18346**]), which was
sensitive to ceftriaxone, resistant to levoflox and cipro.
Patient was initially treated with ceftriaxone here but due to
development of serositis (pleural eff, ascites), without rash or
arthralgias, which was thought to be possibly secondary to
ceftriaxone.  Because of this possibilty, she was changed to
aztreonam per infectious disease recommendations.  Another more
plausible etiology of her serositis may have been due to
inlfammatory response to overwhelming infectious process.  The
patient's symptoms of abdominal pain and dyspnea improved
dramatically after 2 days of being on Aztreonam.  A repeat
abdominal and pelvis CT revealed wedge-shaped densities in R
kidney: radiologically consistent with infarct vs.
pyelonephritis, and not indicative of abscess or necrosis. Blood
cultures have had no growth to date here or at OSH. Repeat urine
cultures here showed no growth of organisms. WBC count improved
throughout her stay and back to normal range prior to discharge.
 She completed a complete 14d course of IV antibiotics prior to
discharge.  It was felt, with assistance of an allergist, that
this patient should not receive ceftriaxone in the future but
can take other cephalosporins and other beta-lactam antibiotics.
.
2) RUQ pain: Unclear what the cause was but felt to be most
likely all secondary to her severe pyelonephritis. CT showed a
heterogeneously enlarged liver with some small amt of ascites
but LFTs were in normal range. Gallbladder with sludge but no
stones.  Hepatitis panel for Hep A, B and C were negative. Given
Fitz-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] syndrome was on differential diagnosis a pelvic
exam was performed which was negative for cervical motion
tenderness, a normal bimanual exam, and cultures for
Chlamydia/gonorrhea were negative. No tubo-ovarian abscess was
seen on CT scan.
.
Additional serologies were sent for more rare causes of
hepatitis.  Given her living environment ([**Hospital1 6687**] and [**Country 4194**]),
she was at risk for tick-borne illnesses as well as tropical
diseases.  Serologies for Lyme, Ehrlichia, babesiosis were
negative.  Her smear (thick and thin) showed no parasites
basically ruling out malaria. In addition, her EBV IgM, CMV IgM,
and Toxo. serologies were negative.
.
3) Neck pain: Patient complained of severe neck pain and
stiffness.  An LP was performed on Hospital Day 2 to eval for
meningitis. CT Head showed no gross abnormality.  Her CSF had 1
WBC, 7 RBCs, glucose and protein wnl, bacterial culture with no
growth, viral culture no growth to date.  Her neck pain improved
throughout her stay especially with use of NSAIDs.

.
4) Sinus bradycardia: Patient had profound sinus bradycardia
initially during her first 5-6 days of hospitalization with
heart rates in 20-40s.  She maintained adequate blood pressures
despite this heart rate.  Her EKG consistently revealed a sinus
rhythm with normal intervals.  Given her bradycardia, abdominal
pain and infectious condition, typhoid fever or other enteric
fever were entertained as possible diagnoses.  In addition, her
bradycardia and relative normotensive state was concerning for
possible increase intracranial pressure.  Her CT head was
unremarkable and blood cx never grew an organism likely ruling
out these possible etiologies.  In addition, an echocardiogram
was obtained to evaluate for myocarditis, cardiomyopathy, or
evidence of valvular vegetations.  Her echo was basically normal
with normal valves, normal EF, etc.  Thus, her bradycardia
remains a mystery and her heart rate improved to rates in
60s-70s prior to discharge.  ? If bradycardia was due to
increased vagal response from nausea and pain (? with normal
BP).
.
5) Dyspnea: Patient complained of inability to take deep breaths
and shortness of breath during her first several days in the
hospital.  Her dyspnea was attributed to her bilateral pleural
effusions and likely resulting pleurisy.  Her symptoms improved
and her oxygenation was never a significant issue.  She was
ambulating well without evidence of effusions or hypoxia prior
to discharge home.
.

Medications on Admission:
None at home
(ceftriaxone 2g q24h, gent 80 mg [**Hospital1 **], promethazine, ambien,
ibuprofen, vicodin on transfer)

Discharge Medications:
None

Discharge Disposition:
Home

Discharge Diagnosis:
1. Pyelonephritis
2. Serositis
3. Reaction to ceftriaxone


Discharge Condition:
Stable, afebrile, no pain


Discharge Instructions:
If you experience any fevers, chills, shortness of breath, back
pain, abdominal pain; please call your doctor or go to ER.

You should not take the antibiotic ceftriaxone again.

Followup Instructions:
Please make an appt with your primary doctor in 2 weeks.



Completed by:[**2114-10-13**]
{'Unspecified pleural effusion,Acute pyelonephritis without lesion of renal medullary necrosis,Other specified cardiac dysrhythmias,Cephalosporin group causing adverse effects in therapeutic use'}


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: fever, nausea, abdominal pain

PRESENT ILLNESS: 37 yo F w/o significant [**Hospital 63245**] transferred from OSH for
management of pyelonephritis, bilateral pleural effusions,
ascites.
.
Pt originally admitted to OSH on [**2114-9-30**] after presenting w/CC
of vomiting, malaise, fever and back pain X4d, and Hx of recent
UTI (treated in [**Month (only) 216**] w/unknown Abx as outpt). At the time, T
102, had upper abd tenderness, bilateral CVA tenderness, WBC
[**Numeric Identifier **], (+) Ua, CT abd confirmed severe Rt pyelonephritis with no
other abnormalities. Pt started on Levoflox 500 IV q24h and
Rocephin 2 gr IV q24h. Pt became afebrile within 36 h. Ux (+)
for E.coli sensitive to ceftiaxone, resistant to levoflox.
Levoflox D/Ced on [**10-2**] and replaced with gentamycin. On [**10-3**], pt
afebrile w/WBC down to 8100, however c/o HA/ abd and flank pain
and SOB. O2 sat 92-97% on RA. Vomited and became bradycardic
(42, then up to the 50s). ECG sinus brady. On Lovenox 60 mg sc.
Repeat CT of the abdomen showed new bilateral pleural effusions
R>L, ascites and "generalized inflammation of the liver". Rt
kidney looks improved compared to [**9-30**]. Sent to [**Hospital1 18**] for
further management.

MEDICAL HISTORY: Hospitalized only for vaginal delivery X2.
Recent UTI in [**Month (only) 216**].
No surgeries.
LMP: [**2114-9-27**].

MEDICATION ON ADMISSION: None at home
(ceftriaxone 2g q24h, gent 80 mg [**Hospital1 **], promethazine, ambien,
ibuprofen, vicodin on transfer)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tc 101.1  HR 48  BP 110/70  RR 16  O2sat 95% RA
general- sitting up in bed, ill-appearing, no respiratory
distress
HEENT- sclerae anicteric, dry MM
Neck- HOB 45deg: JVD to mandible
Pulm- poor inspiratory effort, poor air movement, no audible
wheezes
Heart- bradycardic, regular, no m/r/g
Abd- distended but soft, hypoactive bowel sounds, + tenderness
to mild palpation of RUQ/epigastrium, + peritoneal signs, +
guarding
Ext- no peripheral edema, +2 PT pulses b/l
Neuro- CN III-XII intact, strength exam limited by poor effort

FAMILY HISTORY: NC

SOCIAL HISTORY: moved from [**Country 4194**] in [**4-10**], works in housecleaning, not married,
2 children in [**Country 4194**]; currently sexually active with 1 male
partner ("rare" unprotected sex); No STDs 

### Response:
{'Unspecified pleural effusion,Acute pyelonephritis without lesion of renal medullary necrosis,Other specified cardiac dysrhythmias,Cephalosporin group causing adverse effects in therapeutic use'}
