CHIEF COMPLAINT: Abdominal pain/nausea/vomiting

PRESENT ILLNESS: Ms. [**Known lastname **] is a 45 year old woman with a complicated medical
history including aortic root replacement for acortic ectasis in
[**2123-1-23**]. She has had multiple hospitalizations since that
time for wound debridement and superficial sternal infections.

MEDICAL HISTORY: 1. Aortic ectasia status post aortic root replacement in [**Month (only) 958**]
[**2122**] with re-do in [**2123-12-22**] and one vessel CABG with SVG-->RCA.
2. Sternal wound debridement in [**2123-6-25**]; further sternal
wound debridement in [**2123-9-25**].
3. Zenker's diverticulum.
4. Gastroesophageal reflux disease.
5. Hypertension.
6. Nephrolithiasis with renal surgery [**2094**].
7. Depression.
8. Anxiety.
9. Cholecystectomy [**2108**].
10. Appendectomy [**2083**].
11. Total abdominal hysterectomy [**2092**].
12. Exploratory laparotomy [**2115**] for SBO.
13. Lysis of adhesions.
14. Ovarian cyst [**2105**] and [**2107**]

MEDICATION ON ADMISSION: Rifampin 600 po daily
Prevacid 30

ALLERGIES: Codeine / Erythromycin Base / Sulfa (Sulfonamides) / Prednisone
/ Percocet / Tetracycline / Bactrim / Ampicillin / Amoxicillin /
Albuterol / Ipratropium / Heparin Agents

PHYSICAL EXAM: VS- Tm 98.6 Tc 98.4 HR 57-84  76  BP 133/63  118-169/50-82  RR
19 17-26  O2 sat: 96-98% 1L
I/O: 2610/330

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives in [**Location 7661**] with her family of four children and boyfriend
of many years. Smoked [**11-26**] PPD for 20 years but has quit. Rare
Alcohol use. Denies blood transfusion, IVDU, tatoos. Denies any
recreational drug use.
Acute pancreatitis,Hepatitis, unspecified,Autoimmune hemolytic anemias,Acute kidney failure with lesion of tubular necrosis,Congestive heart failure, unspecified,Antimycobacterial antibiotics causing adverse effects in therapeutic use,Anticoagulants causing adverse effects in therapeutic use,Long-term (current) use of antibiotics,Personal history of other infectious and parasitic diseases,Obesity, unspecified,Esophageal reflux,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins
Acute pancreatitis,Hepatitis NOS,Autoimmun hemolytic anem,Ac kidny fail, tubr necr,CHF NOS,Adv eff antmycob antbiot,Adv eff anticoagulants,Long-term use antibiotic,Prsnl hst oth nfct parst,Obesity NOS,Esophageal reflux,Mth sus Stph aur els/NOS,Inf mcrg rstn pncllins
Admission Date:  [**2124-11-5**]              Discharge Date:   [**2124-11-17**]

Date of Birth:  [**2078-6-20**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine / Erythromycin Base / Sulfa (Sulfonamides) / Prednisone
/ Percocet / Tetracycline / Bactrim / Ampicillin / Amoxicillin /
Albuterol / Ipratropium / Heparin Agents

Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Abdominal pain/nausea/vomiting

Major Surgical or Invasive Procedure:
ERCP

History of Present Illness:
Ms. [**Known lastname **] is a 45 year old woman with a complicated medical
history including aortic root replacement for acortic ectasis in
[**2123-1-23**]. She has had multiple hospitalizations since that
time for wound debridement and superficial sternal infections.

Her course was complicated by a motor vehicle accident, [**12-4**], [**2123**], as an unrestrained driver with airbag deployment,
head-on into a truck at approximately 50-60 mph. The patient
sustained facial and nasal fractures, bruises to chest and
knees. She was evaluated at [**Hospital6 5016**] and was also
found to have a T12-L1 compression spine fracture.

She was admitted to the CT service at [**Hospital1 18**] on [**2123-12-19**] for a
sternal hematoma and was found to have a fluid collection
anterior to the manubrium, with an enlarged pseudoaneurysm
measuring 3.3 x 5.6.

On [**12-22**], the patient was brought to the Operating Room at
which time she underwent an aortic root replacement and coronary
artery bypass grafting times one with SVG-->RCA. She returned to
the OR on [**2123-12-25**] and underwent a clean-out of her chest and
primary closure of her chest. She was discharged on [**2124-1-4**] with
a back brace for her spinal fracture. She was discharged on
Vancomycin 1 g b.i.d., stop date of [**1-30**], Rifampin 300 mg q.8
hours, to be continued indefinately, Gentamicin 100 mg q.8
hours, stop date of [**1-8**]. Following completion of
Gentamicin course, the patient was to start on Levofloxacin 500
mg q.d., and this is to continue indefinitely.

Patient presented to an outside hospital on [**2124-11-4**] with 11
hours of chest pain which was epigastric in character and
associated with nausea and bilious emesis and SOB with exertion.
It occurred suddenly while she was at work. She works as a nurse
at a nursing home in [**Hospital1 487**]. The pain began in the epigastric
area and then spread to her back, shoulders and down her legs.
Last BM was day prior to admission and pt was passing gas. She
reported that her temperature at work was 101. In the ED at [**Hospital 28941**] she was given vancomycin 1 gm and Levaquin 500 IV. She
also got compazine, zofran and morphine. T 100.4 BP 157/70 HR 96
RR 24 O2 98% RA.

Given her history of aortic root replacement she was transfered
to the CSRU at [**Hospital1 18**] for further evaluation. She underwent a CT
scan which showed no pathology of the aortic root and no
evidence of sternal osteomyelitis. She was noted to have
markedly elevated bilirubin, amylase and lipase. Her rifampin
was held due to concern for hepatitis. She was continued on
vancomycin and levaquin.

On further history she reports that she has been off rifampin
for the past 3-4 weeks as it causes nausea and vomiting. She
restarted it 4 days ago and has had increasing nausea and
epigastric pain since, but on the day of admission the pain was
far worse in nature than prior. The pain was different from the
pain she had with her aortic aneurysm. When the patient first
started rifampin in [**11-28**] she did not tolerate it due to N/V and
also developed mildly elevated transaminases, therefore the dose
was decreased from 800 to 600 and the patient tolerated the
medication better. She has been taking acetominophen and tylenol
but cannot quantify how much.


Past Medical History:
1. Aortic ectasia status post aortic root replacement in [**Month (only) 958**]
[**2122**] with re-do in [**2123-12-22**] and one vessel CABG with SVG-->RCA.
2. Sternal wound debridement in [**2123-6-25**]; further sternal
wound debridement in [**2123-9-25**].
3. Zenker's diverticulum.
4. Gastroesophageal reflux disease.
5. Hypertension.
6. Nephrolithiasis with renal surgery [**2094**].
7. Depression.
8. Anxiety.
9. Cholecystectomy [**2108**].
10. Appendectomy [**2083**].
11. Total abdominal hysterectomy [**2092**].
12. Exploratory laparotomy [**2115**] for SBO.
13. Lysis of adhesions.
14. Ovarian cyst [**2105**] and [**2107**]

Social History:
Lives in [**Location 7661**] with her family of four children and boyfriend
of many years. Smoked [**11-26**] PPD for 20 years but has quit. Rare
Alcohol use. Denies blood transfusion, IVDU, tatoos. Denies any
recreational drug use.

Family History:
non-contributory

Physical Exam:
VS- Tm 98.6 Tc 98.4 HR 57-84  76  BP 133/63  118-169/50-82  RR
19 17-26  O2 sat: 96-98% 1L
I/O: 2610/330

GEN: Ill appearing, woman, lying in bed in some distress. NGT in
place. Breathing comfortably on 1 liter oxygen.
HEENT: PERRL, EOMI, sclera icteric. MMM. Scant petechiae on
posterior pharynx, no erythema, edema or exudate.
Neck: No LAD.
Lungs: CTA bilaterally.
CV: Regular, no murmurs, rubs or gallops appreciated.
Abd: Soft, non distended, active bowel sounds in all four
quadrants. Moderate tenderness in the epigastric area. No
rebound and no guarding. Liver edge palpable 2 cm below the
costal margin. Spleen non palpable.
Ext: No edema, 2+ DP pulses bilaterally.
Neuro: Alert and oriented x 3.

Pertinent Results:
At OSH: WBC 8.4 Hct 41.5 plt 215 Poly 56% lymph 28% mono 9.5%
eos 5.0% Na 138 K 3.3 Cl104, HCO3 26, BUN 23 Creat 1.0. glucose
90 UA: large blood, + nitrites, sm LE, [**4-3**] RBC, 20-50 RBC
casts, 0-2 WBC, many urate cyrstals, sm bilirubin. PH 5.0 SG
1.030 Pr 100. Total bilirubin 3.4 direct 1.5. AP 93 AST 84 ALT
18 Albumin 3.5 TP 6.4 amylase 50 LDH 622 CK 76 TnI < 0.04. D
dimer > 40

MICRO:
[**2123-2-18**]: blood MRSA 1/2 bottles
[**2124-2-19**]: swab MRSA
[**2123-5-6**]: swab MRSA
[**2124-7-9**]: swab MRSA
[**2123-9-20**]: blood: MRSA 2/4 bottles
[**2123-9-21**]: abscess MRSA
[**2123-9-22**]: swab MRSA
[**2123-12-22**]: swab MRSA

[**2124-11-5**] 03:35AM BLOOD WBC-11.4* RBC-4.73 Hgb-13.5 Hct-37.6
MCV-80* MCH-28.4 MCHC-35.8* RDW-14.0 Plt Ct-97*#
[**2124-11-5**] 03:35AM BLOOD Neuts-78* Bands-14* Lymphs-4* Monos-1*
Eos-0 Baso-1 Atyps-1* Metas-1* Myelos-0
[**2124-11-14**] 06:16AM BLOOD WBC-7.1 RBC-3.42* Hgb-9.6* Hct-27.7*
MCV-81* MCH-28.1 MCHC-34.7 RDW-13.5 Plt Ct-305
[**2124-11-5**] 03:35AM BLOOD PT-15.8* PTT-32.0 INR(PT)-1.6
[**2124-11-5**] 03:35AM BLOOD Glucose-144* UreaN-44* Creat-1.8* Na-139
K-4.3 Cl-103 HCO3-24 AnGap-16
[**2124-11-13**] 05:00AM BLOOD Glucose-142* UreaN-74* Creat-8.6* Na-140
K-3.9 Cl-101 HCO3-25 AnGap-18
[**2124-11-5**] 03:35AM BLOOD ALT-164* AST-483* LD(LDH)-2137*
CK(CPK)-146* AlkPhos-205* Amylase-342* TotBili-11.9*
DirBili-6.5* IndBili-5.4
[**2124-11-5**] 01:56PM BLOOD ALT-127* AST-261* LD(LDH)-1648*
AlkPhos-171* Amylase-157* TotBili-2.9*
[**2124-11-6**] 03:04AM BLOOD ALT-82* AST-89* AlkPhos-122* Amylase-53
TotBili-0.9
[**2124-11-14**] 06:16AM BLOOD ALT-12 AST-7 LD(LDH)-251* AlkPhos-88
Amylase-15 TotBili-0.3
[**2124-11-5**] 03:35AM BLOOD Lipase-1328*
[**2124-11-14**] 06:16AM BLOOD Lipase-14
[**2124-11-5**] 03:35AM BLOOD Albumin-4.1 Calcium-9.9 Phos-3.2# Mg-2.0
UricAcd-7.7*
[**2124-11-14**] 06:16AM BLOOD VitB12-361 Folate-13.1 Ferritn-238*
TRF-PND
----
HEPARIN DEPENDENT ANTIBODIES        POSITIVE

COMMENT:    POSITIVE FOR HEPARIN PF4 ANTIBODY BY [**Doctor First Name **]
            REPORTED TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],RN [**2124-11-8**] 2PM
----

[**2124-11-5**] 12:42PM URINE Color-Brown Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2124-11-5**] 12:42PM URINE Blood-LG Nitrite-POS Protein->300
Glucose-TR Ketone-TR Bilirub-SM Urobiln-1 pH-6.5 Leuks-SM
[**2124-11-5**] 12:42PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2124-11-9**] 10:00AM URINE Eos-NEGATIVE
[**2124-11-10**] 12:17PM URINE Hours-RANDOM Creat-19 Na-98 TotProt-43
Prot/Cr-2.3* Albumin-23.9 Alb/Cre-1257.9*
----


Brief Hospital Course:
A/P: 46 year old woman with a history of aortic root replacement
x 2 complicated by MRSA bacteremia and chest wound presents now
with acute pancreatitis, obstructive cholangitis and acute renal
failure.

1) Pancreatitis and obstructive cholangitis: She initially had
transminitis and enzymatic evidence of pancreatitis.  Patient is
s/p cholecystectomy and therefore one etiology was a retained
gallstone.   Also, possible that rifampin may be causing
symptoms, as she has had similar repsonse of abd pain/V/N to
this medication in past.  This was not restarted.  Also had RUQ
U/S, Abd/pelvis CT, and renal U/S which were all WNL. Finally,
she had an ERCP which was nL and showed no evidence of a stone.
The etiology of her symptoms was never fully determined, but
rifampin and possible gallstones that passed before ERCP are on
list.  She needs to stay on chronic ppx for her sternal MRSA
osteo.  Spoke with her outpt ID doctor and decided on
levofloxacin based on her large allergy list.  Her enzymes
trended down quickly while in SICU, and were normal when we
picked her up.  Her abd pain/N/V had basically resolved as well.
 However, she began to c/o GERD, and then had more of her
symptoms on the floor.  Wondering if reaction to levofloxacin,
as she has N/V to many other antibiotics. Continued her on PPI
throughout and treated with Anzemet standing and prn compazine.

2) Acute renal failure: Although liver and pancreatic enzymes
improved, her creatinine continued to rise indicitive of
worsening renal failure. Seen by renal and felt was c/w ATN, not
AIN from rifampin ingestion.  However, ? of RBC casts at OSH
which would point to more of a glomerulonephritis.  Not seen
here.  She was never oliguric, but did have fairly significant
creatinine elevation.  Etiology was felt to be reponse to CT
contrast along with prerenal state.  Initially treated with
Lasix as she was symptomatically volume overloaded. After she
was euvolemic, cr continued to climb. Lasix stopped.  She then
began an apparent post-ATN diuresis, putting out 3-4 liters/day.
 Half of this amount was replaced as IVFs each day. Her creat
peaked at 8.6 and then began to trend down.

4) Heme: Initial labs showed a Hct drop. Other studies were c/w
hemolysis(high indirect bili, LDH).  Can be seen with rifampin,
but also several other drugs she was on(levo, lasix). Unclear
which may have caused this.  Continued to have a slow Hct drop
while here.  No evidence of bleeding.  Fe studies c/w anemia of
chronic disease.
5)HITT:She had a fast drop in her platelets, so heparin was
stopped and PF4 antibody test was sent and positive.  She was
not immediately staretd on anticoag in SICU, but when we picked
her up 5 days later, argatroban was initiated.  She was then
transitioned to warfarin.  She will need to stay in this for [**12-28**]
months as she is hypercoagulable for this amount of time after
acute HITT episode.  She showed no evidence of thrombosis.
6)ID:Pt needs chronic ppx for MRSA sternal infection/aortic root
graft ppx. Rifampin may be acute cause of her GI symptoms +/-
pancreatitis, so will not give this again. Pt has Bactrim
allergy, so started Levo, renally dosed. Talked with her outpt
ID doctor about this. If levoflox causing N/V, may need to stop
it in future.

She improved while in the hospital, and she was discharged on
coumadin 4 mg qhs. She has close f/u with her PCP for lab work
and can have her dose adjusted as appropriate.

Medications on Admission:
Rifampin 600 po daily
Prevacid 30


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
4. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
5. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [**5-2**]
hours.
Disp:*30 Tablet(s)* Refills:*2*
6. Prevacid 30 mg Tablet,Lingual Delayed Release Sig: One (1)
Tablet,Lingual Delayed Release PO once a day.
Disp:*30 Tablet,Lingual Delayed Release(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
ATN, likely result of contrast nephropathy
Heparin induced thrombocytopenia
GERD
Chronic MRSA sternal infection


Discharge Condition:
Stable. She had some residual nausea.

Discharge Instructions:
Please call your doctor or return to the ED if you experience
chest pain, shortness of breath, increased abdominal pain,
nausea, or vomiting that you can't control with medications.
Also call if you have fevers, chills, or night sweats.

-Take all of your medications as prescribed.

Followup Instructions:
Please call your primary care doctor to be seen on this Monday
to have bloodwork including a CBC, Chem 7 and INR.

Call Dr. [**Last Name (STitle) 952**] at ([**Telephone/Fax (1) 1504**] to make an appointment for [**12-29**]
weeks from now.

Call Dr. [**Last Name (STitle) 103855**] from the department of infectious diseases for
an appoinment in the next month regarding the Levofloxacin for
your sternal infection.
{'Acute pancreatitis,Hepatitis, unspecified,Autoimmune hemolytic anemias,Acute kidney failure with lesion of tubular necrosis,Congestive heart failure, unspecified,Antimycobacterial antibiotics causing adverse effects in therapeutic use,Anticoagulants causing adverse effects in therapeutic use,Long-term (current) use of antibiotics,Personal history of other infectious and parasitic diseases,Obesity, unspecified,Esophageal reflux,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins'}


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/nausea/vomiting

PRESENT ILLNESS: Ms. [**Known lastname **] is a 45 year old woman with a complicated medical
history including aortic root replacement for acortic ectasis in
[**2123-1-23**]. She has had multiple hospitalizations since that
time for wound debridement and superficial sternal infections.

MEDICAL HISTORY: 1. Aortic ectasia status post aortic root replacement in [**Month (only) 958**]
[**2122**] with re-do in [**2123-12-22**] and one vessel CABG with SVG-->RCA.
2. Sternal wound debridement in [**2123-6-25**]; further sternal
wound debridement in [**2123-9-25**].
3. Zenker's diverticulum.
4. Gastroesophageal reflux disease.
5. Hypertension.
6. Nephrolithiasis with renal surgery [**2094**].
7. Depression.
8. Anxiety.
9. Cholecystectomy [**2108**].
10. Appendectomy [**2083**].
11. Total abdominal hysterectomy [**2092**].
12. Exploratory laparotomy [**2115**] for SBO.
13. Lysis of adhesions.
14. Ovarian cyst [**2105**] and [**2107**]

MEDICATION ON ADMISSION: Rifampin 600 po daily
Prevacid 30

ALLERGIES: Codeine / Erythromycin Base / Sulfa (Sulfonamides) / Prednisone
/ Percocet / Tetracycline / Bactrim / Ampicillin / Amoxicillin /
Albuterol / Ipratropium / Heparin Agents

PHYSICAL EXAM: VS- Tm 98.6 Tc 98.4 HR 57-84  76  BP 133/63  118-169/50-82  RR
19 17-26  O2 sat: 96-98% 1L
I/O: 2610/330

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives in [**Location 7661**] with her family of four children and boyfriend
of many years. Smoked [**11-26**] PPD for 20 years but has quit. Rare
Alcohol use. Denies blood transfusion, IVDU, tatoos. Denies any
recreational drug use. 

### Response:
{'Acute pancreatitis,Hepatitis, unspecified,Autoimmune hemolytic anemias,Acute kidney failure with lesion of tubular necrosis,Congestive heart failure, unspecified,Antimycobacterial antibiotics causing adverse effects in therapeutic use,Anticoagulants causing adverse effects in therapeutic use,Long-term (current) use of antibiotics,Personal history of other infectious and parasitic diseases,Obesity, unspecified,Esophageal reflux,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins'}
