CHIEF COMPLAINT: Bacteremia, sz

PRESENT ILLNESS: HPI : MICU admission note reviewed. Briefly, this is a 38 yo M
h/o ETOH cirrhosis, MELD 27 on tx list initially presenting from
OSH with szs. ADmit to OSH [**2191-1-3**] with abd pain/fevers to 103.
Bl cxs grew MSSA in [**3-2**] bottles [**1-3**], 1/4 [**1-4**]. Started on
nafcillin. TTE neg for veg. CT abd neg. Started on flagyl for ?
C diff though no cx data. Afebrile since [**1-5**]. Has been
pancytopenic at OSH. On [**1-9**], pt had witnessed T-C sz X 2 min.
Givne IV ativan CT head neg. Debate re: starting AED, given
cirrhosis/tx status. Pt continued to have T-C szs q hour X 5.
Dr. [**Last Name (STitle) 497**] called and pt dilantin loaded. Pt tx'd to [**Hospital1 **] MICU for
further management.
.
Pt has remained afebrile and HD stable in the MICU. No further
szs. EEG and MRI head negative. Pt with HA on admission, but
resolved shortly so team decided no LP. TEE neg. Abd US with nml
doppler, mod ascites but no suitable spot for tap.
.
ROS: Pt currently denies HA/LH. Denies CP/SOB. +baseline mild
abd pain. No melena/brbpr.

MEDICAL HISTORY: HepC cirrhosis; patient has never been treated with
interferon/ribavirin
Alcoholic hepatitis in [**2190-4-29**] after a four month drinking
binge
anxiety
s/p appendectomy

MEDICATION ON ADMISSION: Meds (home):
1. Restoril 30mg QHS
2. Alprazolam 1mg TID
3. Furosemide 40mg QD
4. Aldactone 100mg QD
5. Lactulose 30cc TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp 99.2
BP 121/68
Pulse 81
Resp 21
O2 sat 98% RA
Gen - Alert, no acute distress
HEENT - extraocular motions intact, +icterus, mucous membranes
moist
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - Soft, mild R and LUQ tenderness, distended, +BS
Extr -trace b/l LE edema. 2+ DP pulses bilaterally
Neuro - no asterixis
Skin - spider angiomoas over chest

FAMILY HISTORY: Grandparents c diabetes.
No history of CAD or liver disease.

SOCIAL HISTORY: SH - Lives in RI with his parents, currently unemployed. Has a
h/o IVDU, starting at age 17, ended in his early 20s when he
spent several years in a residential drug rehab program He was
previously on methadone to treat heroin addiction; stopped in
[**2189-11-29**] He endorses only social alcohol use until [**Month (only) 958**]
[**2189**], when he began binge drinking up to a fifth of vodka a day
to cope with unemployment and methadone withdrawal; no alcohol
since [**2190-4-29**]. Smokes 1 ppd x 20 yrs.
.
Bacteremia,Other convulsions,Acute kidney failure, unspecified,Acute glomerulonephritis with other specified pathological lesion in kidney,Alcoholic cirrhosis of liver,Chronic hepatitis C without mention of hepatic coma,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other sequelae of chronic liver disease
Bacteremia,Convulsions NEC,Acute kidney failure NOS,Acute nephritis NEC,Alcohol cirrhosis liver,Chrnc hpt C wo hpat coma,Mth sus Stph aur els/NOS,Oth sequela, chr liv dis
Admission Date:  [**2191-1-10**]              Discharge Date:   [**2191-1-19**]

Date of Birth:  [**2152-11-26**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Bacteremia, sz

Major Surgical or Invasive Procedure:
Paracentesis


History of Present Illness:
HPI : MICU admission note reviewed. Briefly, this is a 38 yo M
h/o ETOH cirrhosis, MELD 27 on tx list initially presenting from
OSH with szs. ADmit to OSH [**2191-1-3**] with abd pain/fevers to 103.
Bl cxs grew MSSA in [**3-2**] bottles [**1-3**], 1/4 [**1-4**]. Started on
nafcillin. TTE neg for veg. CT abd neg. Started on flagyl for ?
C diff though no cx data. Afebrile since [**1-5**]. Has been
pancytopenic at OSH. On [**1-9**], pt had witnessed T-C sz X 2 min.
Givne IV ativan CT head neg. Debate re: starting AED, given
cirrhosis/tx status. Pt continued to have T-C szs q hour X 5.
Dr. [**Last Name (STitle) 497**] called and pt dilantin loaded. Pt tx'd to [**Hospital1 **] MICU for
further management.
.
Pt has remained afebrile and HD stable in the MICU. No further
szs. EEG and MRI head negative. Pt with HA on admission, but
resolved shortly so team decided no LP. TEE neg. Abd US with nml
doppler, mod ascites but no suitable spot for tap.
.
ROS: Pt currently denies HA/LH. Denies CP/SOB. +baseline mild
abd pain. No melena/brbpr.


Past Medical History:
HepC cirrhosis; patient has never been treated with
interferon/ribavirin
Alcoholic hepatitis in [**2190-4-29**] after a four month drinking
binge
anxiety
s/p appendectomy

Social History:
SH - Lives in RI with his parents, currently unemployed. Has a
h/o IVDU, starting at age 17, ended in his early 20s when he
spent several years in a residential drug rehab program He was
previously on methadone to treat heroin addiction; stopped in
[**2189-11-29**] He endorses only social alcohol use until [**Month (only) 958**]
[**2189**], when he began binge drinking up to a fifth of vodka a day
to cope with unemployment and methadone withdrawal; no alcohol
since [**2190-4-29**]. Smokes 1 ppd x 20 yrs.
.


Family History:
Grandparents c diabetes.
No history of CAD or liver disease.

Physical Exam:
Temp 99.2
BP 121/68
Pulse 81
Resp 21
O2 sat 98% RA
Gen - Alert, no acute distress
HEENT - extraocular motions intact, +icterus, mucous membranes
moist
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - Soft, mild R and LUQ tenderness, distended, +BS
Extr -trace b/l LE edema. 2+ DP pulses bilaterally
Neuro - no asterixis
Skin - spider angiomoas over chest


Pertinent Results:
[**2191-1-9**]
132  100  9  / 148    AGap=13
3.1  22  1.0 \
Ca: 7.8 Mg: 1.8 P: 3.2
ALT: 29 AP: 91 Tbili: 8.6 Alb: 3.1
AST: 55 LDH: 233 Dbili:  TProt:
[**Doctor First Name **]: 49 Lip: 34
Phenytoin: 5.2
.
          108
3.7 \ 9.6  / 61
    / 27.9 \
 N:68.1 L:23.5 M:6.6 E:1.3 Bas:0.6
Anisocy: 1+ Macrocy: 3+
Gran-Ct: 2490
PT: 24.7  PTT: 42.2  INR: 2.5
.
MICRO:
Blood cultures negative
.
IMAGING:
MRI HEAD:
FINDINGS: There is no slow diffusion to indicate an acute
infarct. There are no enhancing abnormalities. There is
increased T1 signal within the basal ganglia prior to the
administration of IV contrast. These findings are commonly seen
in patients with liver failure. There is no midline shift, mass
effect, or hydrocephalus. No areas of abnormal magnetic
susceptibility are noted. Normal vascular flow voids are
present.

IMPRESSION: No evidence of an enhancing abnormality or mass.

No acute infarct.

Increased T1 signal in the basal ganglia bilaterally consistent
with the patient's history of hepatic failure.
.
TEE:
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
section). The posterior pharynx was anesthetized with 2% viscous
lidocaine. No TEE related complications. 0.1 mg of IV
glycopyrrolate was given as an antisialogogue prior to TEE probe
insertion.
Conclusions:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular systolic function is normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. No mass
or vegetation is seen on the mitral valve.
IMPRESSION: No echo evidence of endocarditis.
.
RUQ Ultrasound:
IMPRESSION:
1. Successful ultrasound-guided diagnostic and therapeutic
paracentesis.
2. Hepatopetal flow of the main portal vein
.
RENAL ULTRASOUND:
The right kidney measures approximately 11.8 cm and the left
kidney measures approximately 11.5 cm. There is no evidence of
hydronephrosis or renal lithiasis bilaterally. Areas of ascites
are again demonstrated throughout the abdomen. No focal bladder
wall masses are identified in the prostate appears slightly
enlarged measuring approximately 5.1 x 4.3 x 4.3 cm.
IMPRESSION:

1. No evidence of hyrdronephrosis or renal lithiasis.
2. Mild prostatic hypertrophy.
3. Abdominal ascites
.
BONE SCAN
IMPRESSION:
1) No definite evidence of osteomyelitis.
2) Linear increased
lower sacral uptake consistent with a fracture.
3) Marked, diffuse bilateral increased renal uptake is
non-specific and may be secondary to interstitial nephritis


Brief Hospital Course:
38 y/o M w/ Alcohol/HepC cirrhosis with admitted with s. aureus
bacteremia, and seizure.
.
1) [**Name (NI) 11646**] unclear source.  Patient did not have localizing
signs or symptoms (other than chronic abdominal pain) and did
not have a history c/w meningitis/meningoencephalitis.  He
underwent TTE and TEE while in the ICU, both w/o evidence of
vegetation.  Surveillance cultures remained negative (although
all drawn on abx) and patient was w/o evidence of embolic or
immunologic phenomena on examination.  He remaineed afebrile in
house.  He also underwent bone scan to r/o occult osteomyelitis,
which did not show evidence of infectious focus.  LP was
deferred per neuro recommendations- it was felt that the patient
had been on antibiotics for approximately 5days on transfer from
OSH and his coagulopathy and thrombocytopenia would induce
additional risk for the procedure.  At the OSH, the patient was
initially started on vancomycin and CTX.  When sensitivities
returned as MSSA the patient was switched to nafcillin.  He
completed 12 days of antibiotic therapy and subsequently
developed ARF (Cr peaked at 3.5) but rapidly recovered.
FENA>1%, u/s neg, eos neg (including peripheral), sediment
bland.  Bone scan did show evidence of increased renal uptake
c/w intersitial nephritis.  He completed the last two days of a
total 14 day course with vancomycin.   He was afebrile on
discharge, w/ plan to obtain repeat blood cultures on Monday
[**1-24**].
.
2) [**Name (NI) **] unclear etiology. Patient w/o sz hx.  Interestingly,
the patient seized at the OSH on hospital d3.  This course was
concerning for etoh w/d but patient vehemently denies further
alcohol use.   He was initially loaded on dilantin and
subsequently maintained on keppra.   EEG did not show evidence
of sz focus.  Plan for patient to f/u w/ Dr. [**First Name (STitle) 951**] of Neurology.
.
3) Acute hepatitis- patient admitted to OSH with AST of approx
80, ALT approx 40.  These trended down following admission but
the patient subsequently developed a cholestatic appearance on
labs, with his bilirubin peaking at 15.7 and INR at 2.7.  Both
were trending down on discharge.  Again, the patient denied
alcohol use.
.
4) ARF- likely interstitial nephritis, as discussed above
.
5) ESLD- on discharge, plan to start re-start diuretics pending
evaluation of renal function on Monday.  Patient was continued
on lactulose in house.
.
6) Abdominal Pain - chronic abdominal pain in house.  Minimal
ascites but underwent ultrasound guided paracentesis that ruled
out SBP.
.
7) FULL code for this admission

Medications on Admission:
Meds (home):
1. Restoril 30mg QHS
2. Alprazolam 1mg TID
3. Furosemide 40mg QD
4. Aldactone 100mg QD
5. Lactulose 30cc TID


Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
4. Temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Labwork  Sig: One (1)   once for 1 days: On Monday [**1-24**] you
need to have the following labs drawn: cbc, chem 10,
ast/alt/bili/inr, and blood cultures x2. Please ask the lab to
fax the results to [**Telephone/Fax (1) **].
Disp:*1 1* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Doctor Last Name 792**]VNA

Discharge Diagnosis:
1) ESLD
2) seizure
3) Staph aureus bacteremia


Discharge Condition:
Good, VSS, afebrile, renal function normal


Discharge Instructions:
1) Please continue to take your medications as directed.
2) You have been given a prescription for labs to be performed
on Monday, [**1-24**].
3) Please avoid taking NSAIDs (i.e. ibuprofen, naproxen, etc)
until your PCP or Dr. [**Last Name (STitle) 497**] has verified that your renal
function is OK.  You should also avoid Ultram (tramadol)

Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**6-7**] days.
.
Please follow up with Dr. [**Last Name (STitle) 497**] in Liver clinic as already
scheduled.
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2191-1-27**] 11:40
.
Please follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 951**] from Neurology in [**1-2**]
weeks. ([**Telephone/Fax (1) 12456**]
{'Bacteremia,Other convulsions,Acute kidney failure, unspecified,Acute glomerulonephritis with other specified pathological lesion in kidney,Alcoholic cirrhosis of liver,Chronic hepatitis C without mention of hepatic coma,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other sequelae of chronic liver disease'}


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: Bacteremia, sz

PRESENT ILLNESS: HPI : MICU admission note reviewed. Briefly, this is a 38 yo M
h/o ETOH cirrhosis, MELD 27 on tx list initially presenting from
OSH with szs. ADmit to OSH [**2191-1-3**] with abd pain/fevers to 103.
Bl cxs grew MSSA in [**3-2**] bottles [**1-3**], 1/4 [**1-4**]. Started on
nafcillin. TTE neg for veg. CT abd neg. Started on flagyl for ?
C diff though no cx data. Afebrile since [**1-5**]. Has been
pancytopenic at OSH. On [**1-9**], pt had witnessed T-C sz X 2 min.
Givne IV ativan CT head neg. Debate re: starting AED, given
cirrhosis/tx status. Pt continued to have T-C szs q hour X 5.
Dr. [**Last Name (STitle) 497**] called and pt dilantin loaded. Pt tx'd to [**Hospital1 **] MICU for
further management.
.
Pt has remained afebrile and HD stable in the MICU. No further
szs. EEG and MRI head negative. Pt with HA on admission, but
resolved shortly so team decided no LP. TEE neg. Abd US with nml
doppler, mod ascites but no suitable spot for tap.
.
ROS: Pt currently denies HA/LH. Denies CP/SOB. +baseline mild
abd pain. No melena/brbpr.

MEDICAL HISTORY: HepC cirrhosis; patient has never been treated with
interferon/ribavirin
Alcoholic hepatitis in [**2190-4-29**] after a four month drinking
binge
anxiety
s/p appendectomy

MEDICATION ON ADMISSION: Meds (home):
1. Restoril 30mg QHS
2. Alprazolam 1mg TID
3. Furosemide 40mg QD
4. Aldactone 100mg QD
5. Lactulose 30cc TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp 99.2
BP 121/68
Pulse 81
Resp 21
O2 sat 98% RA
Gen - Alert, no acute distress
HEENT - extraocular motions intact, +icterus, mucous membranes
moist
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - Soft, mild R and LUQ tenderness, distended, +BS
Extr -trace b/l LE edema. 2+ DP pulses bilaterally
Neuro - no asterixis
Skin - spider angiomoas over chest

FAMILY HISTORY: Grandparents c diabetes.
No history of CAD or liver disease.

SOCIAL HISTORY: SH - Lives in RI with his parents, currently unemployed. Has a
h/o IVDU, starting at age 17, ended in his early 20s when he
spent several years in a residential drug rehab program He was
previously on methadone to treat heroin addiction; stopped in
[**2189-11-29**] He endorses only social alcohol use until [**Month (only) 958**]
[**2189**], when he began binge drinking up to a fifth of vodka a day
to cope with unemployment and methadone withdrawal; no alcohol
since [**2190-4-29**]. Smokes 1 ppd x 20 yrs.
. 

### Response:
{'Bacteremia,Other convulsions,Acute kidney failure, unspecified,Acute glomerulonephritis with other specified pathological lesion in kidney,Alcoholic cirrhosis of liver,Chronic hepatitis C without mention of hepatic coma,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other sequelae of chronic liver disease'}
