CHIEF COMPLAINT: abdominal pain, n/v

PRESENT ILLNESS: 50F s/p cholecystectomy, h/o depression, h/o pyelonephritis
presents with abdominal pain, nausea and vomiting that has
acutely worsened but has been present over last 6 weeks. She has
a h/o of frequent gallstones now s/p choly and nephrolithiasis
for which she often receives lithiotripsy. Patient reports
significant financial stress at home and since then has had
persistent GI complaints. Her abdominal pain is different from
her gallbladder or kidney pain. She describes the pain as
epigastric radiating to her umbilicus and left lower quadrant,
no pain radiating to her back. The pain has worsened and she is
unable to keep anything down and she finally decided to present
to the ED. She also reported diarrhea for one month but has not
had a bowel movement for 6 days. She denies any fevers or
chills. She has lost significant weight and has gone from size
10 pant to size 6 and her dentures no longer fit. She c/o
palpitations and tightness in her chest that often radiates to
her neck and arm. She believes it is related to her anxiety and
she has been having frequent panic attacks. She denies any
shortness of breath.  She reports productive cough over last few
weeks of green sputum. On further ROS, pt reports severe
depression recently but denies SI or SA. She denies any EtOH
use. She also reports a longer history of occasional
word-finding difficulty but no weakness or memory deficits. She
denies dysuria or hematuria. She is post-menopausal but had e/o
vaginal bleeding last month. Had normal pap.
.
In the ED the patient was noted to have elevated lipase and CT
abdomen showed pancreatitis. She received dilaudid 3mg IV and
Morphine 12mg IV with minimal relief of her pain.

MEDICAL HISTORY: s/p cholecystectomy
h/o pyelonephritis
recurrent nephrolithiasis s/p multiple episodes lithiotripsy
depression
h/o thrombocytosis thought to be acute phase reaction
h/o pneumonia
fibromyalgia

MEDICATION ON ADMISSION: 1.Bupropion [Wellbutrin SR]-150 mg Tablet Sustained Release-2
Tablet(s) by mouth twice a day- (POE Med Reconciliation)
2.Carisoprodol [Soma]-350 mg Tablet-1 Tablet(s) by mouth four
times a day- (POE Med Reconciliation)
3.Clonazepam [Klonopin]-0.5 mg Tablet-[**12-19**] Tablet(s) by mouth
twice a day- (POE Med Reconciliation)
4.Escitalopram [Lexapro]-10 mg Tablet-1 Tablet(s) by mouth
daily- (POE Med Reconciliation)
5.Eszopiclone [Lunesta]-1 mg Tablet-1 Tablet(s) by mouth at
bedtime- (POE Med Reconciliation)
6.Morphine [MS Contin]-100 mg Tablet Sustained Release-1
Tablet(s) by mouth twice a day- (POE Med Reconciliation)

ALLERGIES: Penicillins / Elavil

PHYSICAL EXAM: 98.0   108/70   100   20   95%RA
GEN'L: ill appearing, appears in pain, no acute distress
HEENT: nc/at, conjunctivae pink, sclera anicteric, MM dry, OP
clear, edentulous with caries
NECK: supple, no [**Last Name (un) **]/submandib/supraclavic LN
CVS: tachy, regular, no m/r/g
PUL: crackles left lung base
[**Last Name (un) **]: distended, no bowel sounds, +guarding esp RUQ and
epigastrium, no masses clearly felt, no rebound or peritoneal
signs
EXT: dry skin, no c/c/e, 2+ radia, 2+ DP pulses bilaterally
NEURO: alert and oriented, sad affect

FAMILY HISTORY: nc

SOCIAL HISTORY: Used to work as nurse, stopped 15 years ago to take care of her
2 daughters. Lives with her husband and children.  Reports
financial strain and recently lost house to foreclosure.  She
smokes about one pack per day. She denies any drug use.
Acute pancreatitis,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Urinary tract infection, site not specified,Other ascites,Pneumonia, organism unspecified,Other and unspecified coagulation defects,Personal history of urinary calculi,Depressive disorder, not elsewhere classified,Tobacco use disorder,Myalgia and myositis, unspecified,Other acute pain,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus]
Acute pancreatitis,Ac kidny fail, tubr necr,Acute respiratry failure,Urin tract infection NOS,Ascites NEC,Pneumonia, organism NOS,Coagulat defect NEC/NOS,Prsnl hst urnr dsrd calc,Depressive disorder NEC,Tobacco use disorder,Myalgia and myositis NOS,Acute pain NEC,Enterococcus group d
Admission Date:  [**2188-6-3**]              Discharge Date:   [**2188-6-20**]

Date of Birth:  [**2137-12-4**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Elavil

Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
abdominal pain, n/v

Major Surgical or Invasive Procedure:
Intubation/Mechanical Ventilation
Right internal jugular central venous catheter


History of Present Illness:
50F s/p cholecystectomy, h/o depression, h/o pyelonephritis
presents with abdominal pain, nausea and vomiting that has
acutely worsened but has been present over last 6 weeks. She has
a h/o of frequent gallstones now s/p choly and nephrolithiasis
for which she often receives lithiotripsy. Patient reports
significant financial stress at home and since then has had
persistent GI complaints. Her abdominal pain is different from
her gallbladder or kidney pain. She describes the pain as
epigastric radiating to her umbilicus and left lower quadrant,
no pain radiating to her back. The pain has worsened and she is
unable to keep anything down and she finally decided to present
to the ED. She also reported diarrhea for one month but has not
had a bowel movement for 6 days. She denies any fevers or
chills. She has lost significant weight and has gone from size
10 pant to size 6 and her dentures no longer fit. She c/o
palpitations and tightness in her chest that often radiates to
her neck and arm. She believes it is related to her anxiety and
she has been having frequent panic attacks. She denies any
shortness of breath.  She reports productive cough over last few
weeks of green sputum. On further ROS, pt reports severe
depression recently but denies SI or SA. She denies any EtOH
use. She also reports a longer history of occasional
word-finding difficulty but no weakness or memory deficits. She
denies dysuria or hematuria. She is post-menopausal but had e/o
vaginal bleeding last month. Had normal pap.
.
In the ED the patient was noted to have elevated lipase and CT
abdomen showed pancreatitis. She received dilaudid 3mg IV and
Morphine 12mg IV with minimal relief of her pain.

Past Medical History:
s/p cholecystectomy
h/o pyelonephritis
recurrent nephrolithiasis s/p multiple episodes lithiotripsy
depression
h/o thrombocytosis thought to be acute phase reaction
h/o pneumonia
fibromyalgia

Social History:
Used to work as nurse, stopped 15 years ago to take care of her
2 daughters. Lives with her husband and children.  Reports
financial strain and recently lost house to foreclosure.  She
smokes about one pack per day. She denies any drug use.

Family History:
nc

Physical Exam:
98.0   108/70   100   20   95%RA
GEN'L: ill appearing, appears in pain, no acute distress
HEENT: nc/at, conjunctivae pink, sclera anicteric, MM dry, OP
clear, edentulous with caries
NECK: supple, no [**Last Name (un) **]/submandib/supraclavic LN
CVS: tachy, regular, no m/r/g
PUL: crackles left lung base
[**Last Name (un) **]: distended, no bowel sounds, +guarding esp RUQ and
epigastrium, no masses clearly felt, no rebound or peritoneal
signs
EXT: dry skin, no c/c/e, 2+ radia, 2+ DP pulses bilaterally
NEURO: alert and oriented, sad affect

Pertinent Results:
Admission Labs:
--------------
[**2188-6-3**]   WBC-19.1*# HGB-14.6 HCT-43.6 MCV-106*
[**2188-6-3**]   GLUCOSE-101 UREA N-13 CREAT-0.7 SODIUM-139
POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-21* ANION GAP-20
[**2188-6-3**]   TRIGLYCER-118 HDL CHOL-18 CHOL/HDL-6.4 LDL(CALC)-74
[**2188-6-3**]   ALT(SGPT)-9 AST(SGOT)-24 LD(LDH)-467* CK(CPK)-67 ALK
PHOS-113 TOT BILI-0.6   LIPASE-[**2085**]*
.
Discharge labs:
--------------
[**2188-6-20**] WBC-11.0 RBC-3.02* Hgb-10.0* Hct-30.2* MCV-100* Plt
Ct-450*
[**2188-6-20**] Glucose-99 UreaN-53* Creat-4.2* Na-142 K-3.7 Cl-102
HCO3-26
.
CTA abdomen:
There is new bibasilar atelectasis, without evidence of
effusion. There is a small amount of perihepatic fluid. There is
marked peripancreatic fluid, extending into the anterior
pararenal space bilaterally, with fat stranding without any
evidence of an organizing fluid collection or pseudocyst. There
is normal parenchymal pancreatic enhancement without evidence of
necrosis. The surrounding vessels are normal without evidence of
pseudoaneurysm. There is trace perisplenic fluid, the spleen is
normal. The right adrenal is normal. The left adrenal is
somewhat crowded due to fluid in the lesser sac. There has been
prior cholecystectomy. The kidneys enhance symmetrically and
excrete contrast normally without evidence of hydronephrosis.
There is no mesenteric or retroperitoneal adenopathy. There is
no free air. The visualized small and large bowel is normal.
CT PELVIS WITH IV CONTRAST: There is some free fluid in the
pelvis. The
rectum, bladder, and distal ureters are normal.
MUSCULOSKELETAL: There is minimal DJD.
IMPRESSION:
1. Acute pancreatitis. Marked peripancreatic fluid without
evidence of
organization into a focal collection. No pseudocyst, pancreatic
necrosis or pseudoaneurysm is detected.
2. There is bibasilar atelectasis.
.
MRI abdomen (w/o contrast):
The entire pancreas is swollen and edematous, of heterogeneous
but increased signal intensity on T2-weighted sequence. There is
no evidence of pancreatic ductal dilatation. There is increased
retroperitoneal fluid in addition to ascites. There is a
loculated area of fluid in the anterior pararenal space,
anterior to the head of the pancreas measuring a maximum of 2.8
cm in diameter. There is no evidence of biliary dilatation.
There is no evidence of choledocholithiasis.  There is no focal
liver lesion.
Both kidneys are essentially normal. There is no evidence of
adrenal mass.  There is subcutaneous edema.  It is noted that
the images are degraded by artifacts, and subtle hepatic lesions
for example cannot be excluded.
IMPRESSION:
1. Acute pancreatitis.
2. No evidence of choledocholithiasis.
3. Retroperitoneal fluid and ascites. Loculated area of fluid
anterior to
the head of the pancreas measuring 2.8 cm in maximum diameter.
.
TTE [**2188-6-10**]:
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened. No masses or vegetations are seen on the
aortic valve, but cannot be fully excluded due to suboptimal
image quality. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Mild (1+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. No masses or vegetations are seen
on the tricuspid valve, but cannot be fully excluded due to
suboptimal image quality. Moderate [2+] tricuspid regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.  IMPRESSION: Suboptimal image quality. No
definite evidence of endocarditis. Minimal aortic stenosis. Mild
mitral regurgitation. Moderate tricuspid regurgitation.
Preserved biventricular systolic function
.
CT TORSO ON [**2188-6-9**]
FINDINGS: Right IJ central line terminates at the cavoatrial
junction. There is no pericardial effusion. Hyperdense
interventricular septum indicates underlying anemia. There is a
small left pleural effusion and a tiny right pleural effusion.
Associated atelectatic changes are noted in the surrounding
pulmonary parenchyma. There is a diffuse prominence to the
interlobular septa with peripheral nodular opacities seen
bilaterally which is likely indicative of fluid overload;
however, developing multifocal consolidations is a
consideration. There is underlying mild emphysematous change;
however, respiratory motion artifact limits thorough evaluation.
Trachea and main central airways are patent. There are numerous
mediastinal lymph nodes, the largest seen in prevascular
location measuring approximately 16 x 10 mm.
Large area of peripancreatic stranding and inflammatory change
is again seen around the pancreas without interval change,
allowing for lack of contrast administration. There is a small
fluid collection anterior to the pancreas, as seen on prior
study. There is no developing abscess evident. Complications
such as splenic vein thrombosis, pancreatic necrosis and/or
pseudoaneurysm formation are unable to be evaluated on
non-contrast study. No biliary dilatation. Small amount of
ascites. The remainder of the abdomen is unchanged when compared
to four days previously. There is a non-obstructing left renal
calculus. Atherosclerotic calcifications are present. Within the
pelvis there is increasing amount of free fluid as compared to
study of [**6-3**]. No dilated loops of bowel or peritoneal gas is
evident. There is a Foley catheter within a normally distended
bladder. Soft tissue anasarca is seen throughout. No mass or
lymphadenopathy.
IMPRESSION:
1. Essentially stable pancreatitis, within the limitations of a
non-contrast examination.
2. Prominent pulmonary interstitial markings and scattered
bilateral
peripheral opacities, small bilateral pleural effusions, left
greater than
right, and underlying anemia, all most suggestive of fluid
overload.
Developing pneumonia cannot be entirely excluded, and continued
clinical
surveillance will be necessary.


Brief Hospital Course:
The patient is a 50 year-old woman s/p cholecystectomy, with a
history of depression, fibromyalgia, and recurrent
nephrolithiasis who presents with acute pancreatitis.  Her
hospital course was complicated by severe ATN due to contrast
nephropathy as well as respiratory failure, requiring a period
of mechanical ventilation.

#  Pancreatitis:  She was treated with dilaudid PCA, NPO, and
IVF resuscitation. She underwent three seperate CT
abd/pelvis--two of which were done with IV contrast.  These were
done to evaluate for evolution of pancreatic abscesses,
psuedocysts, or other fluid collections.  She did show a
possible area of fluid collection anterior to the head of the
pancreas.  MRCP was also done.  This showed no evidence of
cholelidolithiasis or dilated biliary ducts but did confirm a
loculated area of fluid anterior to the head of the pancreas
measuring 2.8 cm in maximum diameter.
The cause of her pancreatitis was never determined.  She had no
evidence of gall stones on MRCP.  Her history lacked evidence of
alcohol abuse.  Two of her medications for depression,
escitalopram and buspirone, were both stopped on the remote
chance that they may have triggered the process, though these
rarely cause pancreatitis.  Malignancy is still in the
differential, though there is no clear evidence of this.
However, the patient reportedly described some weight loss on
admission.  She was seen by the GI consult team and they did
recommend pancreas protocol abdominal imaging in [**3-23**] weeks to
assess for a mass lesion.  However, the timing of this study
will depend on her renal recovery.
Days prior to discharge, her diet was advanced as tolerated.
She advanced to regular diet, though she still experienced some
bouts of nausea and vomiting, for which she received Zofran ODT,
which she will be discharged with this as a PRN medication.

# Respiratory Failure: The patient was transferred to MICU in
setting of hypoxia while on the wards. Initial hypoxia and
respiratory distress thought to either be due PNA vs. ARDs from
pancreatitis.  However, there was also likely components of
volume overload from her severe ATN as well as decreased
ventilatory drive due to opiate-related narcosis from high dose
MScontin given for her pancreatitis pain.  She required
intubation for hypoxic/hypercarbic respiratory failure. Given
the multiple possible causes of her respiratory failure, she was
treated with antibiotics, diuretics, and with ARDS-like
ventilation protocol.  Her anti-biotic coverage included broad
spectrum antibiotics (Aztreonam, Levofloxacin, and Vancomycin)
to cover for a possible HAP.  She completed an 8 day course of
these antibiotics.  She was diuresed with lasix.  Opiates were
also held during this period.  The patient was intubated for 3
days, and extubated without complication.  She was transferred
to the wards, where she was weaned off of all supplemental
oxygen.

# Acute renal failure: In setting of receiving two IV contrast
studies in a span of 3 days the patient developed rapidly rising
creatinine.  Her creatinine started at 0.6 and peaked at 7.2.
She was followed closely by the renal team, lead by attending
Dr. [**Last Name (STitle) 7473**].  It was thought that her renal failure was
primarily from acute tubular necrosis due to contrast
nephropathy.  She never required hemodialysis.  Her renal
function is slowly improving.  It is expected that she should
eventually recover full renal function.  If she does not, she
should follow-up with a nephrologist.

# Acute on chronic pain:  Patient has history of fibromyalgia.
On admission, she also complained of pain due to her
pancreatitis.  The pain service was initially consulted to help
manage her pain.  A dilaudid PCA was used along with neurontin,
tizanidine, and a lidocaine patch.  She was eventually
transitioned to MS Contin.  This was discontinued after she
became confused and somewhat sedated.  After extubation and with
improvement in her renal function, low-dose MS Contin was
restarted.  She will be discharged on low dose MScontin.  As her
renal function improves, this may be increased as necessary.
She continued using the lidocaine patch.

# Enterococcus UTI: Noted from urine culture on admission. Given
PCN allergy, pt was treated with 3 day course of IV vancomycin
with subsequent urine cultures with no growth.

# Depression/anxiety - Mrs. [**Doctor Last Name 93973**] has a history of
depression and anxiety disorder. Psych was consulted during the
hospital, and suggested decreasing benzo dosing and reducing
buproprion from 300mg to 150 mg.  These medications were held
upon transfer to the ICU in the setting of acute renal failure
and altered mental status.  Following extubation, the psychiatry
team visited patient and recommmended continuing to hold
escitalopram & buspirone, though they felt in near future she
would likely need to restart some anti-depressant.  They
recommended close follow-up with her outpatient psychiatrist.

# Anemia:  Noted to have 3 point Hct drop on day of transfer to
MICU. Initial smear did reveal rare schistocytes which was
thought to possibly be [**1-19**] low grade DIC; however, upon repeat
peripheral smear review, no schistocytes were visualized. The
patient was transfused 1 unit pRBC and subsequently had a
relatively stable Hct. No signs of GI bleed during hospital
course. Iron studies did show reduced B12 and Fe levels with
increased ferritin. Methylmalonic acid was nml.  Her hct
stabilized.  She was recommended to have this followed-up as an
outpatient.

CODE: Full.

CONTACT:  [**Name (NI) 4906**] [**Name (NI) **] ([**Name2 (NI) 3788**]) [**Telephone/Fax (1) 93974**] (mobile);
[**Telephone/Fax (1) 93975**] (work); sister [**Name (NI) **] [**Telephone/Fax (1) 93976**]


Medications on Admission:
1.Bupropion [Wellbutrin SR]-150 mg Tablet Sustained Release-2
Tablet(s) by mouth twice a day- (POE Med Reconciliation)
2.Carisoprodol [Soma]-350 mg Tablet-1 Tablet(s) by mouth four
times a day- (POE Med Reconciliation)
3.Clonazepam [Klonopin]-0.5 mg Tablet-[**12-19**] Tablet(s) by mouth
twice a day- (POE Med Reconciliation)
4.Escitalopram [Lexapro]-10 mg Tablet-1 Tablet(s) by mouth
daily- (POE Med Reconciliation)
5.Eszopiclone [Lunesta]-1 mg Tablet-1 Tablet(s) by mouth at
bedtime- (POE Med Reconciliation)
6.Morphine [MS Contin]-100 mg Tablet Sustained Release-1
Tablet(s) by mouth twice a day- (POE Med Reconciliation)


Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours) for 7 days.
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
4. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO WITH MEALS () for 10 days: Take 1/2 hour prior
to eating.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*
5. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day for 30 days: Adjust
PRN potassium levels.
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
6. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
with meals: Continue until phosphate level normalizes.
7. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
PRIMARY:
pancreatitis
acute tubular necrosis due to contrast nephropathy
respiratory failure

SECONDARY:
anxiety and depression
acute on chronic pain


Discharge Condition:
Good, ambulating, off oxygen.


Discharge Instructions:
You were admitted with acute pancreatitis--the cause of this was
not clearly determined.  While hospitalized, you developed acute
kidney failure and respiratory failure.  You required support
for your breathing with a mechanical ventilator for a few days.
Your lung and kidney injuries are improving.  Your creatinine on
discharge is 4.2.

You will need a follow-up imaging study of your pancreas within
6 weeks of discharge or when your kidney fuction has recovered.
Please talk with you PCP about scheduling this.

If you develop any fevers, inability to tolerate food/drink,
shortness of breath, chest pain, abdominal pain or any other
concerning symptoms, please call your physician or proceed to
the emergency department.

Your escitalopram and buspirone were discontinued while you were
in the hospital.  These medications can--on rare occasion--cause
pancreatitis, thus they were stopped.

Additionally, the following medications were discontinued or
changed because they are cleared by the kidney.  They may be
restarted--as necessary--once your kidney function normalizes:
- Soma (Carisoprodol)-->discontinued
- MS Contin-->dose reduced

Followup Instructions:
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) **] on Wednesday [**2188-6-25**] at
5:15pm

Please see your psychiatrist Dr. [**Last Name (STitle) 93977**] at [**Hospital3 18648**] for follow-up as soon as possible.


                             [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]
{'Acute pancreatitis,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Urinary tract infection, site not specified,Other ascites,Pneumonia, organism unspecified,Other and unspecified coagulation defects,Personal history of urinary calculi,Depressive disorder, not elsewhere classified,Tobacco use disorder,Myalgia and myositis, unspecified,Other acute pain,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus]'}


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, n/v

PRESENT ILLNESS: 50F s/p cholecystectomy, h/o depression, h/o pyelonephritis
presents with abdominal pain, nausea and vomiting that has
acutely worsened but has been present over last 6 weeks. She has
a h/o of frequent gallstones now s/p choly and nephrolithiasis
for which she often receives lithiotripsy. Patient reports
significant financial stress at home and since then has had
persistent GI complaints. Her abdominal pain is different from
her gallbladder or kidney pain. She describes the pain as
epigastric radiating to her umbilicus and left lower quadrant,
no pain radiating to her back. The pain has worsened and she is
unable to keep anything down and she finally decided to present
to the ED. She also reported diarrhea for one month but has not
had a bowel movement for 6 days. She denies any fevers or
chills. She has lost significant weight and has gone from size
10 pant to size 6 and her dentures no longer fit. She c/o
palpitations and tightness in her chest that often radiates to
her neck and arm. She believes it is related to her anxiety and
she has been having frequent panic attacks. She denies any
shortness of breath.  She reports productive cough over last few
weeks of green sputum. On further ROS, pt reports severe
depression recently but denies SI or SA. She denies any EtOH
use. She also reports a longer history of occasional
word-finding difficulty but no weakness or memory deficits. She
denies dysuria or hematuria. She is post-menopausal but had e/o
vaginal bleeding last month. Had normal pap.
.
In the ED the patient was noted to have elevated lipase and CT
abdomen showed pancreatitis. She received dilaudid 3mg IV and
Morphine 12mg IV with minimal relief of her pain.

MEDICAL HISTORY: s/p cholecystectomy
h/o pyelonephritis
recurrent nephrolithiasis s/p multiple episodes lithiotripsy
depression
h/o thrombocytosis thought to be acute phase reaction
h/o pneumonia
fibromyalgia

MEDICATION ON ADMISSION: 1.Bupropion [Wellbutrin SR]-150 mg Tablet Sustained Release-2
Tablet(s) by mouth twice a day- (POE Med Reconciliation)
2.Carisoprodol [Soma]-350 mg Tablet-1 Tablet(s) by mouth four
times a day- (POE Med Reconciliation)
3.Clonazepam [Klonopin]-0.5 mg Tablet-[**12-19**] Tablet(s) by mouth
twice a day- (POE Med Reconciliation)
4.Escitalopram [Lexapro]-10 mg Tablet-1 Tablet(s) by mouth
daily- (POE Med Reconciliation)
5.Eszopiclone [Lunesta]-1 mg Tablet-1 Tablet(s) by mouth at
bedtime- (POE Med Reconciliation)
6.Morphine [MS Contin]-100 mg Tablet Sustained Release-1
Tablet(s) by mouth twice a day- (POE Med Reconciliation)

ALLERGIES: Penicillins / Elavil

PHYSICAL EXAM: 98.0   108/70   100   20   95%RA
GEN'L: ill appearing, appears in pain, no acute distress
HEENT: nc/at, conjunctivae pink, sclera anicteric, MM dry, OP
clear, edentulous with caries
NECK: supple, no [**Last Name (un) **]/submandib/supraclavic LN
CVS: tachy, regular, no m/r/g
PUL: crackles left lung base
[**Last Name (un) **]: distended, no bowel sounds, +guarding esp RUQ and
epigastrium, no masses clearly felt, no rebound or peritoneal
signs
EXT: dry skin, no c/c/e, 2+ radia, 2+ DP pulses bilaterally
NEURO: alert and oriented, sad affect

FAMILY HISTORY: nc

SOCIAL HISTORY: Used to work as nurse, stopped 15 years ago to take care of her
2 daughters. Lives with her husband and children.  Reports
financial strain and recently lost house to foreclosure.  She
smokes about one pack per day. She denies any drug use. 

### Response:
{'Acute pancreatitis,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Urinary tract infection, site not specified,Other ascites,Pneumonia, organism unspecified,Other and unspecified coagulation defects,Personal history of urinary calculi,Depressive disorder, not elsewhere classified,Tobacco use disorder,Myalgia and myositis, unspecified,Other acute pain,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus]'}
