CHIEF COMPLAINT: pancreatitis

PRESENT ILLNESS: 48 yo primarily Portuguese-speaking woman with a several year
history of intermittent RUQ/epigastric pain precipitated by
certain foods (salmon, red meat, beans, chocolate) who noted an
acute exacerbation of this pain after eating some chocolate on
[**2200-3-8**].  This was associated with significant nausea and
bilious emesis but no diarrhea, constipation, fevers, chills, or
sweats.  She went to an OSH where she was diagnosed with acute
pancreatitis based upon lab data (amylase 8289, lipase 36,687)
and imaging studies (abdominal CT scan done [**3-9**] showed
extensive pancreatitis with a large amount of ascites and poor
enhancement in the body and tail raising a question of
necrosis).  The etiology was presumed to be due to gallstones;
her initial CT scan reportedly showed 7 cm CBD dilatation
without evidence of cholelithiasis.  She was treated
supportively with IV fluids, analgesics, and IV antibiotics
(initially Unasyn, then Zosyn, and finally imipenem) and
initially did well with decreasing pain and improving lab
parameters.

MEDICAL HISTORY: 1. cesarean section
2. breast implants

MEDICATION ON ADMISSION: Home:

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp-100.5 HR-115 BP-162/65 RR-30 SpO2-95% room air
Gen: Pleasant, Portuguese speaking, tachypneic but able to speak
in full sentences, non-toxic
HEENT: NCAT, no sinus tenderness, PERRL, conjunctivae clear
without icterus, OP slightly dry, no sublingual jaundice
Neck: 2+ carotid pulses, no bruits, soft, supple
CV: Hyperdynamic, flow murmur, normal S1 and S2
Pulm: Decreased bibasilar breath sounds without crackles,
egophony at both bases, decreased resonance to percussion at
both bases
Abd: Soft, mildly tender over the RUQ, moderately distended,
active bowel sounds, no periumbilical ecchymosis
Back: No CVA or spinal tenderness
Ext: No edema, 2+ DP and femoral pulses
Skin: No rashes, ecchymoses, or lesions
Neuro: Grossly non-focal

FAMILY HISTORY: Mother and brother had gallbladder disease (presumably
cholelithiasis vs. cholecystitis).  No known history of
pancreatic or hepatic disease.

SOCIAL HISTORY: Quit drinking alcohol 15 years ago, previously drank 1-2 beers
per week.  Denies tobacco or illicit drug use. Unemployed. Lives
with her husband.
Acute pancreatitis,Calculus of bile duct without mention of cholecystitis, with obstruction,Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Alkalosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Polycythemia vera
Acute pancreatitis,Choledochlith NOS w obst,SIRS-noninf w/o ac or ds,Alkalosis,DMII wo cmp nt st uncntr,Long-term use of insulin,Polycythemia vera
Admission Date:  [**2200-3-15**]              Discharge Date:   [**2200-3-31**]

Date of Birth:  [**2151-12-2**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
pancreatitis

Major Surgical or Invasive Procedure:
none


History of Present Illness:
48 yo primarily Portuguese-speaking woman with a several year
history of intermittent RUQ/epigastric pain precipitated by
certain foods (salmon, red meat, beans, chocolate) who noted an
acute exacerbation of this pain after eating some chocolate on
[**2200-3-8**].  This was associated with significant nausea and
bilious emesis but no diarrhea, constipation, fevers, chills, or
sweats.  She went to an OSH where she was diagnosed with acute
pancreatitis based upon lab data (amylase 8289, lipase 36,687)
and imaging studies (abdominal CT scan done [**3-9**] showed
extensive pancreatitis with a large amount of ascites and poor
enhancement in the body and tail raising a question of
necrosis).  The etiology was presumed to be due to gallstones;
her initial CT scan reportedly showed 7 cm CBD dilatation
without evidence of cholelithiasis.  She was treated
supportively with IV fluids, analgesics, and IV antibiotics
(initially Unasyn, then Zosyn, and finally imipenem) and
initially did well with decreasing pain and improving lab
parameters.

Despite her initial improvement, she subsequently developed a
recrudescence of fever to 101 with an associated leukocytosis to
26,000 on [**3-14**].  A repeat CT scan reportedly showed progression
of pancreatitis with increasing ascites.  On [**3-15**] her
leukocytosis rose to 29,000 and she was therefore transferred
here for further management and possible surgical debridement.

Past Medical History:
1. cesarean section
2. breast implants

Social History:
Quit drinking alcohol 15 years ago, previously drank 1-2 beers
per week.  Denies tobacco or illicit drug use. Unemployed. Lives
with her husband.

Family History:
Mother and brother had gallbladder disease (presumably
cholelithiasis vs. cholecystitis).  No known history of
pancreatic or hepatic disease.

Physical Exam:
Temp-100.5 HR-115 BP-162/65 RR-30 SpO2-95% room air
Gen: Pleasant, Portuguese speaking, tachypneic but able to speak
in full sentences, non-toxic
HEENT: NCAT, no sinus tenderness, PERRL, conjunctivae clear
without icterus, OP slightly dry, no sublingual jaundice
Neck: 2+ carotid pulses, no bruits, soft, supple
CV: Hyperdynamic, flow murmur, normal S1 and S2
Pulm: Decreased bibasilar breath sounds without crackles,
egophony at both bases, decreased resonance to percussion at
both bases
Abd: Soft, mildly tender over the RUQ, moderately distended,
active bowel sounds, no periumbilical ecchymosis
Back: No CVA or spinal tenderness
Ext: No edema, 2+ DP and femoral pulses
Skin: No rashes, ecchymoses, or lesions
Neuro: Grossly non-focal

Pertinent Results:
ABG on admission: 7.51/29/60 on room air, lactate 1.2, ionized
Ca 1.17

WBC-29.3 (diff pending) Hct-30.4 MCV-88 Plt-393

PT-13.7 PTT-22.0 PT-1.2

Na-143 K-3.2 Cl-109 Bicarb-25 BUN-9 Cr-0.6 Glu-136
Ca-8.3 Mg-2.1 Phos-1.1 Alb-2.7
ALT-54 AST-44 Alk Phos-181 TBili-1.2 [**Doctor First Name **]-113 Lip-pending

OSH Data ([**2200-3-15**]):

WBC-29.0 Hct-30.6 MCV-89.1 Plt-351

WBC trend:
[**3-8**]: 27.7 (N-75 band-15 L-6 M-2) (Hct-46.6)
[**3-9**]: 19.4
[**3-10**]: 21.0
[**3-11**]: 17.2 (N-67 band-18 L-12 M-3)
[**3-12**]: 20.7
[**3-14**]: 26.9
[**3-15**]: 29.0

Na-138 K-2.8 Cl-104 Bicarb-25 BUN-7 Cr-0.5 Gluc-242
Ca-7.5 Mg-1.9 Phos-1.4 Trig-213 (up from 101 [**3-11**])

[**3-13**]: ALT-70 AST-45 Alk Phos-106 TBili-0.6 TP-5.0 Alb-2.1
[**Doctor First Name **]-204
(all stable/trending down)

Guaiac negative [**3-14**]

Blood Cultures 4/1: NGTD

CT Abd [**3-14**]: Extensive pancreatitis with increasing
peri-pancreatic fluid, small right pleural effusion, larger left
pleural effusion, compressive bibasilar atelectasis, ascites,
diffuse ileus
CXR [**3-14**]: Well-placed R subclavian TLC, L pleural effusion vs.
infiltrate

Brief Hospital Course:
48 yo woman with severe pancreatitis and leukocytosis.

1. Pancreatitis: Appears most likely to be due to gallstones or
biliary sludge despite lack of evidence of cholelithiasis on OSH
CT scans.  There is no history of recent EtOH use, and the
patient was not hypercalcemic or hyperlipidemic on admission to
the OSH.  She was not taking any medications known to cause
pancreatitis, and there was no antecedent viral prodrome or
trauma.  By all lab parameters, her pancreatitis is improving,
but the severity of her pancreatitis is worsening by CT
scanning.  Her pancreatic inflammation also appears to have
resulted in significant pleural effusions that now appear to be
causing signficant tachypnea and hypoxemia (see below).
  - NPO
  - Maintenance IV fluids
  - Pain control with hydromorphone as needed
  - RUQ U/S now to evaluate for cholelithiasis or cholecystitis

2. Fever and Leukocytosis: [**Month (only) 116**] be attributable to worsening
pancreatitis given increasing severity on CT scan.  There is
clear concern for a secondary bacterial infection, however.
Possible sources include infected pleural or ascitis fluid,
pneumonia, bacteremia from bacterial gut translocation, or UTI.
Absent evidence of pancreatic necrosis on CT scanning, there is
no apparent indication for empiric antibiotics.
  - D/C imipenem
  - CXR now to evaluate pleural effusions, r/o infiltrate
  - Abd U/S now to evaluate extent of ascites
  - Consider thoracentesis vs. paracentesis to r/o secondary
infection
  - Blood cultures x2 now
  - U/A and urine culture now
  - Stool for C. diff (patient developed diarrhea at OSH);
consider metronidazole
  - Low threshold to repeat CT scan to r/o necrosis or abscess

3. Respiratory Alkalemia: Likely due to mechanical compression
of the pulmonary parenchyma caused by atelectasis, pleural
effusions, and ascites.  The primary process is respiratory; her
serum bicarb is 25.
  - CXR now as above
  - Consider therapeutic paracentesis, although fluid will
likely reaccumulate
  - Supplemental oxygen
  - [**Month (only) 116**] require intubation for adequate oxygenation
  - Consider arterial line

4. Anemia: Patient has no chronic diseases, so anemia of chronic
inflammation appears unlikely.  There is concern for hemorrhagic
pancreatitis given the severity of her inflammation, but there
is no physical exam evidence of this.
  - Send iron studies, folate, B12, retic count
  - TFTs likely to be unhelpful in acute setting
  - Send type and screen
  - Transfuse for Hct less than 21

5. Proph: IV famotidine, heparin sq

6. Access: R subclavian TLC placed [**3-13**] at OSH

7. F/E/N: Maintenance IV fluids, follow lytes closely, NPO

8. Code: Full (presumed)

9. Communication: Patient, family

10. Dispo: MICU for now

HD7: patient was transfered to the floor.  She remained on
Imipenem. Her tube feeds were advanced.  Vivonex 1/2 strength
starting at 20cc/hr and advancing.  Her central venous catheter
was taken out and sent for culture.  None of her cxs. for the
hospital course grew any organisms.

HD8: Continued Abx and advanced tube feeds.  She continued to
spike fevers to 101.2 and slightly tachy at 102.  She was on
Metoprolol 5mg IV Q6.  Tube feeds where changed to Peptamen
3/4strength.

HD 9: she was advanced to sips and medications were made PO.
Continued to monitor her LFTs which stayed stable.

HD 11: Pt's pain continued to decrease.  Her diet was changed to
Low fat.

over the subsequent week the patient was able to tolerate more
of her Low fat diet and required less tube feeding.  Her tube
feeding was stopped on HD 13.  Her pain also decreased slowly
over the week.  [**Last Name (un) **] was consulted and helped manager her
insulin requirements.  While in house she was kept on imipenem,
but will not require it as an outpatient.  Over the course of
her hospitalization her platelets went from 393 to 1108 at which
time she was started on ASA 81 qd.


Medications on Admission:
Home:

1. MVI
2. vitamin C
3. vitamin E
4. ginseng


Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection as directed: see sliding scale.
Disp:*qs large bottle* Refills:*2*
5. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed  Subcutaneous twice a day: 8units breakfast
8units Bedtime
.
Disp:*qs large bottle* Refills:*2*
6. Insulin Syringe .5cc/28G     Syringe Sig: as directed
Miscell.  as directed: 29G preferable.
Disp:*qs large box* Refills:*2*
7. Lancets     Misc Sig: as directed  Miscell.  as directed:
compatable with
One touch Ultra.
Disp:*qs large box* Refills:*2*
8. test strips  Sig: as directed   as directed: compatable with
One touch Ultra.
Disp:*qs large box* Refills:*2*


Discharge Disposition:
Home with Service

Discharge Diagnosis:
necrotizing pancreatitis
DM insulin requiring
polycythemia [**Doctor First Name **]


Discharge Condition:
stable

Discharge Instructions:
Please monitor for the following: fever, chills, nausea,
vomiting, inability to tolerate food/drink.  If any of these
occur, please call your physician [**Name Initial (PRE) 2227**].

Followup Instructions:
Please call Dr.[**Name (NI) **] office for a follow up appointment
in 3-4weeks. ([**Telephone/Fax (1) 2047**]

Please call Dr. [**First Name (STitle) **] [**Name (STitle) 61010**] office for an appointment
regarding your gallbladder. [**Telephone/Fax (1) 2799**]

Please call [**Last Name (un) **] Diabetes Center for an appointment. You need
to be followed by someone for your Diabetes care.



Completed by:[**2200-3-31**]
{'Acute pancreatitis,Calculus of bile duct without mention of cholecystitis, with obstruction,Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Alkalosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Polycythemia vera'}


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: pancreatitis

PRESENT ILLNESS: 48 yo primarily Portuguese-speaking woman with a several year
history of intermittent RUQ/epigastric pain precipitated by
certain foods (salmon, red meat, beans, chocolate) who noted an
acute exacerbation of this pain after eating some chocolate on
[**2200-3-8**].  This was associated with significant nausea and
bilious emesis but no diarrhea, constipation, fevers, chills, or
sweats.  She went to an OSH where she was diagnosed with acute
pancreatitis based upon lab data (amylase 8289, lipase 36,687)
and imaging studies (abdominal CT scan done [**3-9**] showed
extensive pancreatitis with a large amount of ascites and poor
enhancement in the body and tail raising a question of
necrosis).  The etiology was presumed to be due to gallstones;
her initial CT scan reportedly showed 7 cm CBD dilatation
without evidence of cholelithiasis.  She was treated
supportively with IV fluids, analgesics, and IV antibiotics
(initially Unasyn, then Zosyn, and finally imipenem) and
initially did well with decreasing pain and improving lab
parameters.

MEDICAL HISTORY: 1. cesarean section
2. breast implants

MEDICATION ON ADMISSION: Home:

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp-100.5 HR-115 BP-162/65 RR-30 SpO2-95% room air
Gen: Pleasant, Portuguese speaking, tachypneic but able to speak
in full sentences, non-toxic
HEENT: NCAT, no sinus tenderness, PERRL, conjunctivae clear
without icterus, OP slightly dry, no sublingual jaundice
Neck: 2+ carotid pulses, no bruits, soft, supple
CV: Hyperdynamic, flow murmur, normal S1 and S2
Pulm: Decreased bibasilar breath sounds without crackles,
egophony at both bases, decreased resonance to percussion at
both bases
Abd: Soft, mildly tender over the RUQ, moderately distended,
active bowel sounds, no periumbilical ecchymosis
Back: No CVA or spinal tenderness
Ext: No edema, 2+ DP and femoral pulses
Skin: No rashes, ecchymoses, or lesions
Neuro: Grossly non-focal

FAMILY HISTORY: Mother and brother had gallbladder disease (presumably
cholelithiasis vs. cholecystitis).  No known history of
pancreatic or hepatic disease.

SOCIAL HISTORY: Quit drinking alcohol 15 years ago, previously drank 1-2 beers
per week.  Denies tobacco or illicit drug use. Unemployed. Lives
with her husband. 

### Response:
{'Acute pancreatitis,Calculus of bile duct without mention of cholecystitis, with obstruction,Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Alkalosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Polycythemia vera'}
