CHIEF COMPLAINT: Fever and abdominal pain

PRESENT ILLNESS: Ms. [**Known lastname 26442**] is a 55 yo female with a history of chronic hepatitis
C infection (last HCV viral load 3190 copies on [**8-9**])
complicated by cirrhosis on weekly pegylated interferon therapy,
now presenting with a 1-day history of fever and 2-day history
of abdominal pain.

MEDICAL HISTORY: 1. Chronic hepatitis C infection on pegylated interferon therapy
since [**66**]/[**2169**]. Last HCV viral load 3190 copies on [**8-9**]. Last
AFP 11.1 on [**2169-6-21**]. Normal abdominal U/S on [**8-9**] without
ascites or focal hepatic lesion.
2. Cirrhosis [**2-15**] chronic hepatitis C infection
3. Status post TAH-BSO for fibroid uterus in [**2155**]

MEDICATION ON ADMISSION: 1. Weekly pegylated interferon therapy, last dose on [**2169-8-9**]
2. Lexapro 10 mg PO QD (has been taking only intermittently)

ALLERGIES: Demerol

PHYSICAL EXAM: PHYSICAL EXAMINATION ON ADMISSION:
VITALS: Tm 104.9, Tc 101.6 after 650 mg of Tylenol, BP
99-130/40-70, Hr 100-115, Sat 98% on room air.
GEN: Lying flat, looks tired.
HEENT: Sclera anicteric. Slightly dry MM. Clear OP, without
lesions.
NECK: No nuchal rigidity. No cervical [**Doctor First Name **].
RESP: Chest CTAB. No adventitious sounds.
CVS: Normal S1, S2. No S3, S4. No murmur or rub.
GI: BS NA. Abdomen non-distended. Hypogastric abdominal scar.
RUQ tenderness, without guarding or rebound. No mass palpable.
No [**Doctor Last Name **] sign. Mild right CVA tenderness. DRE performed --> no
stool in rectal vault. Guaiac negative, but limited sample. No
rectal mass.
EXT: Without edema. Warm, well-perfused. Strong pedal pulses.
NEURO: Alert and oriented X 3. Non-focal.
INTEG: No rash. No ulcer.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: She lives alone. SHe has one son who lives in [**Name (NI) 108**]. Active
smoker, about 3 packs/week X >20 years. No EtOH, no history of
IVDU. History of blood transfusion in [**2155**]. She works as a store
manager.
Septicemia due to escherichia coli [E. coli],Urinary tract infection, site not specified,Acidosis,Cirrhosis of liver without mention of alcohol,Chronic hepatitis C without mention of hepatic coma,Renal and perinephric abscess,Sepsis
E coli septicemia,Urin tract infection NOS,Acidosis,Cirrhosis of liver NOS,Chrnc hpt C wo hpat coma,Renal/perirenal abscess,Sepsis
Admission Date:  [**2169-8-13**]              Discharge Date:   [**2169-8-21**]

Date of Birth:  [**2113-12-18**]             Sex:   F

Service: MEDICINE

Allergies:
Demerol

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Fever and abdominal pain

Major Surgical or Invasive Procedure:
Central venous line placement [**8-13**]

History of Present Illness:
Ms. [**Known lastname 26442**] is a 55 yo female with a history of chronic hepatitis
C infection (last HCV viral load 3190 copies on [**8-9**])
complicated by cirrhosis on weekly pegylated interferon therapy,
now presenting with a 1-day history of fever and 2-day history
of abdominal pain.

She was seen in the [**Hospital **] clinic on [**8-9**] for administration of
interferon, at which time a routine U/S was also performed which
was normal. She was doing well at that time. She first noted
some malaise and weakness on [**8-11**], along with new onset
abdominal pain, which has persisted. She describes constant RUQ
abdominal pain, approximately [**2174-4-18**], non-cramping, some
radiation to back/right flank, associated with some N/V. Emesis
X 3 one day PTA, non-bloody, no coffee grounds. She also reports
a 2-day history of watery BM, about [**2-16**] BMs per day, small
volume, ? some mucous. No relief of abominal pain with
defecation. Yesterday, she woke up with severe chills, did not
measure temperature. ROS otherwise remarkable for a 3-day
history of headache, no photophobia or phonophobia. No URI
symptoms, no GU symptoms. No recent abx, no recent travel, no
known sick contacts, no unusual food. Poor appetite, little PO
intake in past 3 days.

In ED, initial vitals T 104.9, BP 138/65, HR 118 regular, RR 22,
Sat 98% on room air. She was pancultured and given Levofloxacin
500 mg IV and Flagyl 500 mg IV and aggressively hydrated with NS
4L. Lactate 4.4, RUQ U/S negative for acute pathology.

Past Medical History:
1. Chronic hepatitis C infection on pegylated interferon therapy
since [**66**]/[**2169**]. Last HCV viral load 3190 copies on [**8-9**]. Last
AFP 11.1 on [**2169-6-21**]. Normal abdominal U/S on [**8-9**] without
ascites or focal hepatic lesion.
2. Cirrhosis [**2-15**] chronic hepatitis C infection
3. Status post TAH-BSO for fibroid uterus in [**2155**]

Social History:
She lives alone. SHe has one son who lives in [**Name (NI) 108**]. Active
smoker, about 3 packs/week X >20 years. No EtOH, no history of
IVDU. History of blood transfusion in [**2155**]. She works as a store
manager.


Family History:
Non-contributory

Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VITALS: Tm 104.9, Tc 101.6 after 650 mg of Tylenol, BP
99-130/40-70, Hr 100-115, Sat 98% on room air.
GEN: Lying flat, looks tired.
HEENT: Sclera anicteric. Slightly dry MM. Clear OP, without
lesions.
NECK: No nuchal rigidity. No cervical [**Doctor First Name **].
RESP: Chest CTAB. No adventitious sounds.
CVS: Normal S1, S2. No S3, S4. No murmur or rub.
GI: BS NA. Abdomen non-distended. Hypogastric abdominal scar.
RUQ tenderness, without guarding or rebound. No mass palpable.
No [**Doctor Last Name **] sign. Mild right CVA tenderness. DRE performed --> no
stool in rectal vault. Guaiac negative, but limited sample. No
rectal mass.
EXT: Without edema. Warm, well-perfused. Strong pedal pulses.
NEURO: Alert and oriented X 3. Non-focal.
INTEG: No rash. No ulcer.


Pertinent Results:
LABS on admission:
CBC:
WBC 9.5, Hct 43.0, Plt 53 (down from 81 on [**8-9**]), MCV 90. Diff
with N 94.2, 4.2 Ly.

Chemistry:
Na 132, K 3.3, Cl 98, HCO3 21, BUN 16, Creat 0.9, Gluc 184.
ALT 94, AST 69, ALP 92, Amylase 52, Lipase 32, T bili 1.2
(direct 0.6 up from 0.2). LFTs stable versus [**8-9**].
Fibrinogen 592, D-dimer 3266

U/A: Clear, sg 1.018, Blood mod, Prot tr, gluc 100. Neg leuk,
neg nitrite. RBC 0-2, WBC [**6-23**], many bacteria.

Other Petinent Labs:
.
[**2169-8-13**] 09:38PM   O2 SAT-78
[**2169-8-13**] 09:16PM   HCT-34.7*
[**2169-8-13**] 09:00PM   CORTISOL-37.2*
[**2169-8-13**] 08:03PM   LACTATE-1.1
[**2169-8-13**] 07:37PM   GLUCOSE-132* UREA N-10 CREAT-0.6 SODIUM-139
POTASSIUM-3.6 CHLORIDE-115* TOTAL CO2-18* ANION GAP-10
CALCIUM-6.7* PHOSPHATE-2.4*# MAGNESIUM-1.4*
[**2169-8-13**] 07:37PM   WBC-7.2 RBC-3.99* HGB-12.4 HCT-35.9* MCV-90
MCH-31.0 MCHC-34.4 RDW-13.7 NEUTS-90.4* BANDS-0 LYMPHS-7.5*
MONOS-2.0 EOS-0 BASOS-0.1  PLT SMR-VERY LOW PLT COUNT-44*
.
[**2169-8-13**] 01:30PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
     BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-100 KETONE-NEG
BILIRUBIN-NEG
     UROBILNGN-NEG PH-5.0 LEUK-NEG   RBC-0-2 WBC-[**6-23**]*
BACTERIA-MANY YEAST-
     NONE EPI-0-2 TRANS EPI-<1  MUCOUS-FEW
     Urine grew E.coli
.
[**2169-8-13**] 12:15PM   ALT(SGPT)-94* AST(SGOT)-69* ALK PHOS-92
AMYLASE-52 TOT BILI-1.2 DIR BILI-0.6* INDIR BIL-0.6  LIPASE-32
[**2169-8-13**] 12:15PM   CRP-107.0*
[**2169-8-13**] 12:15PM   PT-13.7* PTT-28.2 INR(PT)-1.2
[**2169-8-13**] 12:15PM   FIBRINOGE-594* D-DIMER-3266*
*
MICRO:
[**8-13**] Blood cx X 2 Positive for E.coli, Urine Cx Positive for
E.coli
      10,000-100,000; Pan-sensitive
[**8-14**] Blood Cx x 2: negative
[**8-14**] Stool Cx: negative for C. diff, Campylobacter
[**8-16**] IJ Catheter Tip culture: negative for growth
[**2169-8-17**]: Right Renal Abscess Drainage:
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S) =
Levofloxacin-sensitive E.coli.
[**8-17**] Urine cx: negative
[**8-/2169**] Blood Cx: negative
[**8-18**] Stool Cx: negative for C.diff
[**8-19**] Blood Cx: negative
[**8-19**] Urine Cx: negative
[**8-21**] Blood Cx: negative
.
IMAGING:
[**2169-8-13**] CXR: No acute cardiopulmonary process.
[**2169-8-13**] RUQ U/S (preliminary): Pericholecystic fluid, small
amount of sludge, no biliary ductal dilatation, no [**Doctor Last Name 515**], no
son[**Name (NI) 493**] evidence of cholecystitis
[**2169-8-17**] Abdominal CT: Semisolid, semi-cystic mass in the
superior pole of the right kidney measuring approximately 3.2 x
4.4 cm, and which is likely infectious in etiology given the
associated perinephric stranding and fascial thickening; Shotty
lymphadenopathy in the pre-pericardial as well as the
retroperitoneal areas; Bilateral pleural effusions, periportal
and pericholecystic fluid which could all be consistent with
slight volume overload.  Successful aspiration of a right renal
lesion, which is suspected to be a renal abscess.


Brief Hospital Course:
55 year old female with history of HepC admitted with fever,
chills, abdominal pain found to have urosepsis with E.coli by
urine and blood cultures, and renal abscess seen by CT Scan was
drained and grew E.coli.

Hospital course was significant for the following issues:

1.  Sepsis: The patient had high grade GNR bacteremia with
pan-sensitive E. coli from urinary source.  She was entered in
the sepsis protocol and a R IJ central line was placed.  Her
hypotension and lactic acidosis responded to aggressive fluid
resuscitation.  She was treated with levofloxacin.  She was also
initially treated with metronidazole given her diarrhea but this
was stopped as her diarrhea improved.  Stool cultures were
negative for C. Diff, Campylobacter, Enteric GNR, Salmonella,
and Shigella.  SIRS + evidence of lactic acidosis and
hypotension responded to IVF without addition of pressors.
  RUQ US revealed no acute biliary process, no ascites.  The
patient had a CT of the abdomen which revealed a bulging, but
wedge-shaped area of hypoattenuation within the upper pole of
the right kidney which likely represents a focal area of
pyonephrosis. Less likely, this may represent a renal mass and
follow- up is recommended after treatment.  Urology was
consulted regarding whether there was a fluid collection/abscess
that required drainage.  Ultimately the area was determined to
be an abscess and was drained by interventional radiology.
Aspirate from abscess on R kidney from [**8-17**] showed 3+ PMNs and 1+
GNR, which was determined to be E.coli without anaerobes,
susceptible to Levofloxacin, with which the patient was being
treated.  Following drainage of the right renal abscess the
patient's temperature increased to 102 initially and was treated
with ibuprofen with good effect.  She was also monitored for
blood in urine; inability to urinate; shaking, chills or fever;
back pain; or severe pain at biopsy site.  The patient did not
develop any such complications due to the renal abscess drainage
during her hostpital course.
  The patient's pain was controlled with oxycodone 5mg q4-6
hours, which the patient required 2 - 3 times per day.  Her pain
at baseline and pain on palpation improved, allowing the patient
to ambulate normally on [**8-20**] and [**8-21**].  The patient will have a
follow-up CT in 4 weeks and will see urology for a follow-up
appointment after that.

2.  Hepatitis C/cirrhosis: The patient's last HCV viral load
down to 3190 copies on pegylated interferon therapy. The patient
was followed by the hepatology service while in house.  Her
interferon therapy was discontinued while in house.  She will
follow up with her Hepatologist Dr. [**Last Name (STitle) 7033**] following discharge
for discussion regarding treatment of her Hepatitis C.
Hepatotoxic medications were avoided. The patient was counseled
to avoid Acetominophen.  There were no acute issues related to
the patient' Hepatitis C during her hospital course and LFTs
were stable and within the normal range.

3.  Thrombocytopenia: The patient's platelets count decreased
down to 53 upon admission, down from 81 on [**8-9**]. This was
suspected to be secondary to the patient's Hepatitis C with
cirrhosis and possibly due to the interferon therapy. DIC
work-up negative with fibrinogen >300, INR stable.  The patient
had faint petechiae around her ankles on [**8-18**] and [**8-19**] which had
resolved by [**8-20**].  The patient had no other evidence of bleeding.
 Her platelet count steadily rose during her hospital course,
and was 198 at discharge.




Medications on Admission:
1. Weekly pegylated interferon therapy, last dose on [**2169-8-9**]
2. Lexapro 10 mg PO QD (has been taking only intermittently)

Discharge Medications:
1. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for fever.
3. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for 7 days.
Disp:*14 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
bacteremia with E.coli, likely urosepsis
urinary tract infection
right pyelonephrosis and kidney abscess


Discharge Condition:
stable, tolerating POs, ambulating

Discharge Instructions:
-contact MD if you develop fever/chills, abdominal pain,
worsening flank pain, or other concerning symptoms
-follow-up with Liver Clinic about when to restart your
interferon medication

Followup Instructions:
-follow-up with primary care physician [**Name Initial (PRE) 176**] 2-4 weeks
-Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2169-11-8**] 11:15
-you have a Cat Scan ordered for [**2169-9-18**] to relook at
your right kidney. Please call 617=[**Telephone/Fax (1) 57066**] within the next week
to schedule an exact appointment time.
-please call [**Hospital 159**] Clinic ([**Telephone/Fax (1) 164**]) for an appointment in
late [**Month (only) **] or Early [**Month (only) 359**] for follow-up on your kidney
infection.



Completed by:[**2169-8-22**]
{'Septicemia due to escherichia coli [E. coli],Urinary tract infection, site not specified,Acidosis,Cirrhosis of liver without mention of alcohol,Chronic hepatitis C without mention of hepatic coma,Renal and perinephric abscess,Sepsis'}


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 and abdominal pain

PRESENT ILLNESS: Ms. [**Known lastname 26442**] is a 55 yo female with a history of chronic hepatitis
C infection (last HCV viral load 3190 copies on [**8-9**])
complicated by cirrhosis on weekly pegylated interferon therapy,
now presenting with a 1-day history of fever and 2-day history
of abdominal pain.

MEDICAL HISTORY: 1. Chronic hepatitis C infection on pegylated interferon therapy
since [**66**]/[**2169**]. Last HCV viral load 3190 copies on [**8-9**]. Last
AFP 11.1 on [**2169-6-21**]. Normal abdominal U/S on [**8-9**] without
ascites or focal hepatic lesion.
2. Cirrhosis [**2-15**] chronic hepatitis C infection
3. Status post TAH-BSO for fibroid uterus in [**2155**]

MEDICATION ON ADMISSION: 1. Weekly pegylated interferon therapy, last dose on [**2169-8-9**]
2. Lexapro 10 mg PO QD (has been taking only intermittently)

ALLERGIES: Demerol

PHYSICAL EXAM: PHYSICAL EXAMINATION ON ADMISSION:
VITALS: Tm 104.9, Tc 101.6 after 650 mg of Tylenol, BP
99-130/40-70, Hr 100-115, Sat 98% on room air.
GEN: Lying flat, looks tired.
HEENT: Sclera anicteric. Slightly dry MM. Clear OP, without
lesions.
NECK: No nuchal rigidity. No cervical [**Doctor First Name **].
RESP: Chest CTAB. No adventitious sounds.
CVS: Normal S1, S2. No S3, S4. No murmur or rub.
GI: BS NA. Abdomen non-distended. Hypogastric abdominal scar.
RUQ tenderness, without guarding or rebound. No mass palpable.
No [**Doctor Last Name **] sign. Mild right CVA tenderness. DRE performed --> no
stool in rectal vault. Guaiac negative, but limited sample. No
rectal mass.
EXT: Without edema. Warm, well-perfused. Strong pedal pulses.
NEURO: Alert and oriented X 3. Non-focal.
INTEG: No rash. No ulcer.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: She lives alone. SHe has one son who lives in [**Name (NI) 108**]. Active
smoker, about 3 packs/week X >20 years. No EtOH, no history of
IVDU. History of blood transfusion in [**2155**]. She works as a store
manager. 

### Response:
{'Septicemia due to escherichia coli [E. coli],Urinary tract infection, site not specified,Acidosis,Cirrhosis of liver without mention of alcohol,Chronic hepatitis C without mention of hepatic coma,Renal and perinephric abscess,Sepsis'}
