CHIEF COMPLAINT: Abdominal pain, melena, seizure

PRESENT ILLNESS: This is a 59 year-old female with history of hepatitis C
cirrhosis, hypertension, cryoglobulinemia, who presented with
abdominal pain.  She had been having nausea, vomiting, diarrhea,
and abdominal pain for 3 days prior to presentation.  In the
emergency department, she had a focal seizure that generalized
in the setting of hypertension to the 200s systolic.  She
responded to ativan and returned to her baseline mental status.

MEDICAL HISTORY: 1. Hepatitis C: She is followed in liver clinic, but declined
any interventions.  She has evidence of cirrhosis and ascites.
This is believed to have resulted from transfusion 20 years ago
following an ectopic pregnancy
2. Hypertension
3. Cryoglobinemia diagnosed in [**3-23**]
4. Varicose veins status post stripping in [**5-27**] and [**12-29**]
5. Vasculitis: Leukocytoblastic diagnosed on biopsy from [**2-21**]
following 3 year history of difficulty walking and leg pain and
swelling.
6. Hypothyroidism
7. Cholecystectomy in [**2174**] that is thought to be due to chronic
vasculitis from untreated Hepatitis C.

MEDICATION ON ADMISSION: Medications on Admission:
Roxicet
Clonadine patch 600 mcg qweek

ALLERGIES: Percocet / Ceftriaxone / Flagyl / Levofloxacin / Iodine Strong /
Unasyn / Bactrim / Vancomycin

PHYSICAL EXAM: Vitals: Temperature:96.9 Blood Pressure:127/48 Pulse:95
Respiratory Rate:14 Oxygen Saturation:99% on room air
General:Lying in bed no acute distress.
HEENT: Pupils equal and reactive, moist mucous membranes,
extraoccular movements intact.
Cardiac: Regular rate and rhythm no murmurs, rubs, gallops.
Pulmonary: Clear to auscultation bialterally.
Abdomen: Normoactive bowel sounds, distended, nontender.
Extremities: Warm and well perfused, no edema, surgical scars on
anterior right shin.
Neuro: Cranial nerves II-XII grossly intact, strength and
sensation symmetric

FAMILY HISTORY: Her mother died of coronary arterty disease and hypertension at
the age of 72

SOCIAL HISTORY: She came to the US from [**Country 532**] about 15 years ago.  She lives
with her son and ex-husband.  She is independent in daily
activities.  She denies alcohol or tobacco use.
Spontaneous bacterial peritonitis,Other convulsions,Acute kidney failure, unspecified,Paralytic ileus,Iron deficiency anemia secondary to blood loss (chronic),Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Esophageal varices with bleeding,Urinary tract infection, site not specified,Unspecified essential hypertension,Dermatitis due to drugs and medicines taken internally,Sulfonamides causing adverse effects in therapeutic use
Spontan bact peritonitis,Convulsions NEC,Acute kidney failure NOS,Paralytic ileus,Chr blood loss anemia,Hpt C w/o hepat coma NOS,Cirrhosis of liver NOS,Esophag varices w bleed,Urin tract infection NOS,Hypertension NOS,Drug dermatitis NOS,Adv eff sulfonamides
Admission Date:  [**2177-12-31**]              Discharge Date:   [**2178-1-17**]

Date of Birth:  [**2118-12-13**]             Sex:   F

Service: MEDICINE

Allergies:
Percocet / Ceftriaxone / Flagyl / Levofloxacin / Iodine Strong /
Unasyn / Bactrim / Vancomycin

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Abdominal pain, melena, seizure

Major Surgical or Invasive Procedure:
Colonoscopy
Upper endoscopy
Ultrasound guided paracentesis


History of Present Illness:
This is a 59 year-old female with history of hepatitis C
cirrhosis, hypertension, cryoglobulinemia, who presented with
abdominal pain.  She had been having nausea, vomiting, diarrhea,
and abdominal pain for 3 days prior to presentation.  In the
emergency department, she had a focal seizure that generalized
in the setting of hypertension to the 200s systolic.  She
responded to ativan and returned to her baseline mental status.

.
Review of systems was notable for burning with urination.  She
denies any fevers, chills, fatigue, weakness, lightheadedness,
dizzyness, or headaches.


Past Medical History:
1. Hepatitis C: She is followed in liver clinic, but declined
any interventions.  She has evidence of cirrhosis and ascites.
This is believed to have resulted from transfusion 20 years ago
following an ectopic pregnancy
2. Hypertension
3. Cryoglobinemia diagnosed in [**3-23**]
4. Varicose veins status post stripping in [**5-27**] and [**12-29**]
5. Vasculitis: Leukocytoblastic diagnosed on biopsy from [**2-21**]
following 3 year history of difficulty walking and leg pain and
swelling.
6. Hypothyroidism
7. Cholecystectomy in [**2174**] that is thought to be due to chronic
vasculitis from untreated Hepatitis C.


Social History:
She came to the US from [**Country 532**] about 15 years ago.  She lives
with her son and ex-husband.  She is independent in daily
activities.  She denies alcohol or tobacco use.

Family History:
Her mother died of coronary arterty disease and hypertension at
the age of 72

Physical Exam:
Vitals: Temperature:96.9 Blood Pressure:127/48 Pulse:95
Respiratory Rate:14 Oxygen Saturation:99% on room air
General:Lying in bed no acute distress.
HEENT: Pupils equal and reactive, moist mucous membranes,
extraoccular movements intact.
Cardiac: Regular rate and rhythm no murmurs, rubs, gallops.
Pulmonary: Clear to auscultation bialterally.
Abdomen: Normoactive bowel sounds, distended, nontender.
Extremities: Warm and well perfused, no edema, surgical scars on
anterior right shin.
Neuro: Cranial nerves II-XII grossly intact, strength and
sensation symmetric

Pertinent Results:
Hematology:
WBC-6.0 HGB-10.9 HCT-31.5 PLT COUNT-243
NEUTS-86.7 BANDS-0 LYMPHS-11.6 MONOS-1.1 EOS-0.1 BASOS-0.4
.
Chemistries:
SODIUM-138 POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-19 UREA N-16
CREAT-0.9 GLUCOSE-181
.
Liver Function:
ALT(SGPT)-27 AST(SGOT)-34 ALK PHOS-85 AMYLASE-74 TOT BILI-1.1
LIPASE-22
ALBUMIN-4.3
.
Urinalysis: [**10-12**] RBC, [**5-2**] WBC, few bacteria, 0-2 epithelial
cells.
.
Lactate:6.7
CRP: 6.7
SED-Rate: 5
.
Imaging:
1. Head CT: No evidence of intracranial hemorrhage or acute
intracranial pathology. Bilateral occipital encephalomalacia
consistent with chronic infarct. Please note that noncontrast CT
scan cannot exclude acute infarction. MRI with
diffusion-weighted images is more sensitive for evaluation of
this entity.
2. Abdominal CT: Small amount of intra-abdominal and pelvic
ascites.Thsi maybe secondary to teh background of liver disease
or low protein state but acute intraabdominal process cannot be
excluded. No pneumoperitoneum or localized collection
demonstrated. No evidence of bowel obstruction on the current
study. Some localised fluid in the gallbladder fossa remains
unchanged to the previous CT.  Small right basal pleural
effusion, minimal rim of fluid at the left lung base. A 1.6 cm
densely calcified right splenic artery aneurysm, 1-cm pancreatic
head lipoma unchanged.   Mild sigmoid diverticulosis.


Brief Hospital Course:
This is 59 year-old female with hepatitis C, cryoglobulinemia,
and hypertension who presented with nausea, vomiting, abdominal
pain who had a witnessed seizure in the ED in the setting of
hypertensive urgency.
.
1. Seizure: In the Emergency department, she had a seizure in
the setting of blood pressure to 214/82.  A head CT was
unrevealing for an acute bleed or mass effect.  It is unclear
the etiology of her seizure, although it is likely that it was
triggered by hypertensive changes.  She was evaluated by
neurology.  The patient, however, refused further diagnostic
work-up including and MRI/MRA, lumbar puncture, and EEG.  She
also refused empiric antibiotics.  She was monitored in the
intensive care unit immediately post-seizure.  She did not have
any further seizures during this admission.
.
2. Urinary tract infection: She had a positive urinalysis and
her urine culture grew out e.coli.  Initially, she refused
antibiotic treatment for several days.  She then accepted
antibiotic treatment and was treated with Bactrim for 3 days.
She refused repeat urine culture to see if the bacturia had
cleared.
.
3. GI bleed: She was guaiac positive and had an episode of
melena in the intensive care unit.  Initially, she refused
evaluation with an upper endoscopy but was willing to undergo
colonoscopy.  The colonoscopy did not show any source of
bleeding.  Several days later, she consented to an upper
endoscopy that showed 4 grade III varices with stigmata of
recent bleed.  Three bands were placed and she was told that she
would need repeat banding every 3 weeks until her varices were
resolved.  She was started on nadolol, which she took for a few
days until she started refusing.  Per her request, she was
switched to propranolol, which she tolerated on previous
admissions.  However, she never took this medication and refused
to take it throughout the remainder of the admission.  The
endoscopy also showed gastritis and she was started on
pantoprazole twice daily as well as sucralfate.
.
4. Spontaneous bacterial peritonitis (SBP): On admission, she
had abdominal pain.  An ultrasound did not show adequate ascites
to tap.  A few days post-endoscopy, she began having worsening
abdominal pain with fevers to 102.  A repeat ultrasound showed
significant ascites, and a paracentesis under ultrasound
guidance drained about 2L of fluid.  The ascites had greater
than 4000 neutrophils.  Gram stain and culture were both
negative; however, the patient had recently completed a course
of Bactrim for her urinary tract infection.  In it unclear that
inciting factor for her SBP whether it was her urinary tract
infection or recent variceal bleed without prophylactic
antibiotics as she refused.  She was started on Unasyn for her
SBP.  After 2 doses, she developed a macular papular blanching
rash over her flexor and extensor surfaces of her elbows and
over her groin bilaterally.  Dermatology felt that her rash was
consistent with a drug hypersensitivity reaction from either
Bactrim or Unasyn.  At that point she refused to take any
medications saying that all medications were hurting her and
causing the rash.  After several long discussion with the
patient and interpreter, she agreed to take aztreonam.  She took
1 dose and then refused to take them again since she was not
improving.  Over the course of several days, she would refuse
antibiotics and then take a single dose and then refuse them
again for several days.  A repeat paracentesis under ultrasound
guidance was done after she had been off of antibiotics for
several days.  The fluid again had about 4,000 neutrophils and
the fluid culture continued to not grow anything.  Finally, with
the help of her daughter, she agreed to take the aztreonam on
schedule.  After 3 days of antibiotics, she was convinced that
they were not helping despite her pain improving and her fever
curve trending down.  At one point during the admission, she
requested to be diuresed for comfort.  She received 2 days of
Bumex.  Her creatinine, however, increased, so the diuresis was
stopped.
.
5. Possible small bowel obstruction: Her abdomen became
progressively more tympanic with increased abdominal pain.  An
abdominal plain film was suggestive of an early small bowel
obstruction.  She was made NPO until her symptoms improved.  Her
diet was advance to soft solids as she tolerated.  Towards the
end of the admission, she began having worsening abdominal pain
and a repeat x-ray showed another early small bowel obstruction.
 However, the patient left AMA before that could be resolved.
.
6. Rash: She developed a drug hypersensitivity reaction to
either Unasyn or Bactrim.  Her rash progressed to her whole
body, and she developed urticaria.  She refused Benadryl
initially.  She did agree to take 1 dose of Benadryl late in her
hospital stay.  Initially, she also refused topical steroid
creams and Sarna lotion, but then agreed to them intermittently.
 Her rash improved after about 1 week.
.
7. Hypertension: She has a long standing history of hypertension
and will only take clonidine patch at home.  Her hypertension
was poorly controlled on the clonidine patch initially.  Once
she was started on the nadolol, her blood pressure improved
transiently.  Her blood pressure also improved with diuresis
.
8. Hepatitis C: The patient and family are in denial of her
hepatitis and therefore do not want to pursue any treatment.
The have the fixed false belief that she was given an infection
in her liver at the time of her cholecystectomy in [**2174**] despite
documentation that she had hepatitis C in [**2172**].
.
9. Anemia: Her anemia is secondary to anemia of chronic disease
and blood loss from probable variceal bleed.  She did except 1
transfusion but refused all other suggestions for transfusion.
When she left AMA, her hematocrit was 22.
.
10. FEN: Initially, she was maintained on a low sodium diet.
She was NPO for early small bowel obstruction and her diet was
advanced as above.  She persistently refused repletion of all
electrolytes.
.
11. Access: She had peripheral IVs.
.
12. Code: Full.  Her code status was readdressed when she was
persistently refusing treatments.
.
13. Dispo: Throughout this admission, she intermittently refused
antibiotics and other medical treatments.  Towards the end of
the admission, she persistently refused all treatment.  Ethics
and legal were involved and felt that the patient could not be
forced to take medications.  Psychiatry evaluated the patient
and felt that she had capacity to make her own decisions.
Numerous discussions were held with the patient with an
interpreter present.  During these discussion, she demonstrated
that she understood the risks of refusing treatments.  She
clearly stated that she would rather be home.  Her son came to
take her home against medical advice.  Her daughter could not be
reached at the time that the son was taking her home.  The
patient and her son refused to sign the AMA form.  She was given
prescriptions for her medications in case she decided to take
them.  She was told to follow-up with her primary care physician
or return to the emergency room (even if at another hospital)
for worrisome symptoms.

Medications on Admission:
Medications on Admission:
Roxicet
Clonadine patch 600 mcg qweek


Discharge Disposition:
Home

Discharge Diagnosis:
Seizure
Urinary tract infection
Spontaneous bacterial peritonitis
Esophageal varices
GI bleed
Hypertension
Hepatitis C with cirrhosis


Discharge Condition:
Patient is leaving against medical advice.


Discharge Instructions:
Please take all medications as prescribed and keep all follow-up
appointments.
.
At the present moment you are leaving against medical advice.
On x-ray you have a small bowel obstruction.  This could become
fatal.  Please seek medical services if you having worsening
abdominal pain, fevers or chills.  Only eat if you are passing
gas and/or having bowel movements.

Followup Instructions:
You should follow-up with your primary care physician:
[**Name Initial (NameIs) 2169**]: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-2-6**] 1:30
.
You also have the following appointments:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2178-1-7**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2178-4-1**] 10:00



Completed by:[**2178-1-18**]
{'Spontaneous bacterial peritonitis,Other convulsions,Acute kidney failure, unspecified,Paralytic ileus,Iron deficiency anemia secondary to blood loss (chronic),Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Esophageal varices with bleeding,Urinary tract infection, site not specified,Unspecified essential hypertension,Dermatitis due to drugs and medicines taken internally,Sulfonamides 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: Abdominal pain, melena, seizure

PRESENT ILLNESS: This is a 59 year-old female with history of hepatitis C
cirrhosis, hypertension, cryoglobulinemia, who presented with
abdominal pain.  She had been having nausea, vomiting, diarrhea,
and abdominal pain for 3 days prior to presentation.  In the
emergency department, she had a focal seizure that generalized
in the setting of hypertension to the 200s systolic.  She
responded to ativan and returned to her baseline mental status.

MEDICAL HISTORY: 1. Hepatitis C: She is followed in liver clinic, but declined
any interventions.  She has evidence of cirrhosis and ascites.
This is believed to have resulted from transfusion 20 years ago
following an ectopic pregnancy
2. Hypertension
3. Cryoglobinemia diagnosed in [**3-23**]
4. Varicose veins status post stripping in [**5-27**] and [**12-29**]
5. Vasculitis: Leukocytoblastic diagnosed on biopsy from [**2-21**]
following 3 year history of difficulty walking and leg pain and
swelling.
6. Hypothyroidism
7. Cholecystectomy in [**2174**] that is thought to be due to chronic
vasculitis from untreated Hepatitis C.

MEDICATION ON ADMISSION: Medications on Admission:
Roxicet
Clonadine patch 600 mcg qweek

ALLERGIES: Percocet / Ceftriaxone / Flagyl / Levofloxacin / Iodine Strong /
Unasyn / Bactrim / Vancomycin

PHYSICAL EXAM: Vitals: Temperature:96.9 Blood Pressure:127/48 Pulse:95
Respiratory Rate:14 Oxygen Saturation:99% on room air
General:Lying in bed no acute distress.
HEENT: Pupils equal and reactive, moist mucous membranes,
extraoccular movements intact.
Cardiac: Regular rate and rhythm no murmurs, rubs, gallops.
Pulmonary: Clear to auscultation bialterally.
Abdomen: Normoactive bowel sounds, distended, nontender.
Extremities: Warm and well perfused, no edema, surgical scars on
anterior right shin.
Neuro: Cranial nerves II-XII grossly intact, strength and
sensation symmetric

FAMILY HISTORY: Her mother died of coronary arterty disease and hypertension at
the age of 72

SOCIAL HISTORY: She came to the US from [**Country 532**] about 15 years ago.  She lives
with her son and ex-husband.  She is independent in daily
activities.  She denies alcohol or tobacco use. 

### Response:
{'Spontaneous bacterial peritonitis,Other convulsions,Acute kidney failure, unspecified,Paralytic ileus,Iron deficiency anemia secondary to blood loss (chronic),Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Esophageal varices with bleeding,Urinary tract infection, site not specified,Unspecified essential hypertension,Dermatitis due to drugs and medicines taken internally,Sulfonamides causing adverse effects in therapeutic use'}
