CHIEF COMPLAINT: Pancreatitis

PRESENT ILLNESS: Pt is a 71 y/o F with PMHx significant for HTN, HLD, IBS, who
was transferred to [**Hospital1 18**] for further management of pancreatitis.
 Pt reports abdominal pain, nausea, vomitting, and diarrhea that
began yesterday evening. Emesis was mildly bilious, non-bloody.
Diarrhea was non-bloody. Describes abdominal pain as diffusely
located across the abdomen. She initially presented to OSH,
where she was tachycardic to 110s initially. Labs there were
significant for WBC 23,000, lipase 5900. Abdominal CT scan was
performed which showed gallbladder wall edema. She received IVF,
analgesics, and zosyn IV prior to transfer.

MEDICAL HISTORY: HTN
HLD
Gout
IBS (diarrhea-predominant)
s/p removal of benign stomach tumor
s/p hysterectomy
s/p bladder sx
s/p rotator cuff cx
s/p gerd sx (? nissen)

MEDICATION ON ADMISSION: acebtulolol 200 mg once a day
benazepril 20 mg once a day
simvastatin 20 mg 2 tablets once a day
omeprazole 20 mg 2 tablets once a day
indomethacin 25 mg 2 tabelts per day or PRN
zolpidem 5 mg qHS
alprazolam 0.5 mg qHS
loperamide 2 mg [**1-6**] capsules per day PRN

ALLERGIES: morphine / Dilaudid

PHYSICAL EXAM: Admission:
Vitals: T: 99.2 BP: 138/90 P: 98 R: 18 O2: 97%2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, diffusely tender to palpation,
bowel sounds present
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses
Neuro: intact

FAMILY HISTORY: Father died of heart disease at 63.
Mother had CHF.
Grandmother with stomach CA.
Significant family history of EtOH abuse.

SOCIAL HISTORY: Rare EtOH use. No tobacco or illicit drug use. Retired, lives
alone.
Acute pancreatitis,Hemangioma of intra-abdominal structures,Diaphragmatic hernia without mention of obstruction or gangrene,Acute gouty arthropathy,Other chronic nonalcoholic liver disease,Diverticulosis of small intestine (without mention of hemorrhage),Unspecified essential hypertension,Other and unspecified hyperlipidemia,Other drugs and medicinal substances causing adverse effects in therapeutic use,Irritable bowel syndrome,Tachycardia, unspecified
Acute pancreatitis,Hemangioma intra-abdom,Diaphragmatic hernia,Acute gouty arthropathy,Chronic liver dis NEC,Dvrtclo sml int w/o hmrg,Hypertension NOS,Hyperlipidemia NEC/NOS,Adv eff medicinal NEC,Irritable bowel syndrome,Tachycardia NOS
Admission Date:  [**2200-6-29**]              Discharge Date:   [**2200-7-7**]

Date of Birth:  [**2129-5-4**]             Sex:   F

Service: MEDICINE

Allergies:
morphine / Dilaudid

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Pancreatitis

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Pt is a 71 y/o F with PMHx significant for HTN, HLD, IBS, who
was transferred to [**Hospital1 18**] for further management of pancreatitis.
 Pt reports abdominal pain, nausea, vomitting, and diarrhea that
began yesterday evening. Emesis was mildly bilious, non-bloody.
Diarrhea was non-bloody. Describes abdominal pain as diffusely
located across the abdomen. She initially presented to OSH,
where she was tachycardic to 110s initially. Labs there were
significant for WBC 23,000, lipase 5900. Abdominal CT scan was
performed which showed gallbladder wall edema. She received IVF,
analgesics, and zosyn IV prior to transfer.

On arrival to the [**Hospital1 18**] ED, VS were 97.2 90 141/102 15 96% 2L.
WBC 21.1. ALT 205 AST 270 Alk Phos 117 Lipase 3230. Lactate was
3.3, downtrended to 2.7 with IVFs. RUQ U/S was performed which
showed fally liver, gall bladder wall edema without stones. ERCP
was consulted in the ED and did not want to take the patient for
urgent ERCP. Surgery was consulted who recommended admission to
medicine for MRCP. VS prior to transfer 98.4, 102, 154/68, 96%
2L.

On arrival to the MICU, the patient endorsed diffuse abdominal
pain that was improved after dilaudid. Nausea had resolved after
zofran. She did not report any other complaints at this time.

Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.

Past Medical History:
HTN
HLD
Gout
IBS (diarrhea-predominant)
s/p removal of benign stomach tumor
s/p hysterectomy
s/p bladder sx
s/p rotator cuff cx
s/p gerd sx (? nissen)

Social History:
Rare EtOH use. No tobacco or illicit drug use. Retired, lives
alone.



Family History:
Father died of heart disease at 63.
Mother had CHF.
Grandmother with stomach CA.
Significant family history of EtOH abuse.

Physical Exam:
Admission:
Vitals: T: 99.2 BP: 138/90 P: 98 R: 18 O2: 97%2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, diffusely tender to palpation,
bowel sounds present
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses
Neuro: intact

Vitals: 98.5 154/82 (SBP 120-150) HR 83 RR 18 pOx 98 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, no LAD
CV: RRR, normal S1 S2, no m/r/g
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: soft, non-distended, non-tender to deep palpation,
bowel sounds present
Ext: warm, erythema over bilateral great toe MTP joint
bilaterally extending up toward the ankle. Mild swelling.

Pertinent Results:
I. Labs

A. Admission
[**2200-6-29**] 05:40AM   LIPASE-3230*
[**2200-6-29**] 05:40AM   WBC-21.1* RBC-5.34 HGB-13.0 HCT-41.2
[**2200-6-29**] 05:40AM   TRIGLYCER-186* HDL CHOL-52 CHOL/HDL-4.3
LDL(CALC)-134*
[**2200-6-29**] 05:40AM   ALT(SGPT)-205* AST(SGOT)-270* LD(LDH)-487*
ALK PHOS-117* TOT BILI-0.6
[**2200-6-29**] 06:16AM   LACTATE-3.3*
[**2200-6-29**] 09:35PM   Lactate-1.1
[**2200-6-30**] 03:09AM   Calcium-8.1* Phos-3.3 Mg-1.8
[**2200-7-1**] 03:44AM   WBC-11.8* RBC-3.79* Hgb-9.6* Hct-29.9*
[**2200-7-1**] 03:44AM   ALT-57* AST-21 AlkPhos-66 TotBili-0.5
[**2200-7-1**] 03:44AM   Calcium-8.2* Phos-2.6* Mg-1.8

B. Discharge

[**2200-7-7**] 05:30AM BLOOD WBC-10.8 RBC-3.97* Hgb-10.0* Hct-30.9*
MCV-78* MCH-25.1* MCHC-32.3 RDW-14.6 Plt Ct-512*
[**2200-7-7**] 05:30AM BLOOD Glucose-162* UreaN-10 Creat-0.7 Na-138
K-4.1 Cl-97 HCO3-29 AnGap-16
[**2200-7-5**] 10:06AM BLOOD ALT-24 AST-16 AlkPhos-84 Amylase-55
TotBili-0.3
[**2200-7-5**] 10:06AM BLOOD Lipase-47

II. Imaging

A. CXR ([**2200-7-2**])
[**Hospital 93**] MEDICAL CONDITION:
   71 year old woman with pancreatitis now with nausea and
abdominal pain and
   bloating
REASON FOR THIS EXAMINATION:
   evaluate for pancreatitis, obstruction, perforation
Final Report
INDICATION:  71-year-old woman with pancreatitis, now with
nausea and
abdominal pain and bloating.  Evaluate for pancreatitis,
obstruction or
perforation.

COMPARISON:  None.

TECHNIQUE:  Portable erect and supine radiographs were provided.
 There is a
nonspecific gas pattern within colon and small bowel, but no
evidence of
obstruction or free air. Retrocardiac opacity may represent
consolidation or
left lower lobe atelectasis.  There is levoscoliosis of the
spine and
degenerative changes.

IMPRESSION:
1. No evidence of obstruction or free air.
2. Retrocardiac opacity may represent consolidation or left
lower lobe
atelectasis.


B. MRCP ([**2200-6-29**])
Final Report
HISTORY:  71-year-old woman with likely gallstone pancreatitis,
please perform
MRCP.

TECHNIQUE:  Multiplanar T1- and T2-weighted images were acquired
on a 1.5
Tesla magnet including dynamic sequential imaging obtained prior
to, during,
and after the uneventful intravenous administration of 0.1
mmol/kg (8 mL) of
Gadavist.

FINDINGS:

There is a large hiatus hernia with approximately 50% of the
stomach within
the thorax.  The liver is not nodular in contour but
demonstrates diffusely
increased signal intensity on T2-weighted images and loss of
signal on
out-of-phase compared to in-phase T1-weighted images, consistent
with hepatic
steatosis.  No focal liver lesions are seen.  No biliary duct
dilatation. The
common bile duct measures 5 mm.

The pancreas is diffusely mildly enlarged and demonstrates
abnormally
increased signal intensity on T2-weighted images and decreased
signal
intensity on T1-weighted images, consistent with pancreatitis.
The pancreas
enhances homogenously on delayed imaging.  No focal pancreatic
lesions are
seen. There is marked peripancreatic fat stranding and a small
amount of free
fluid in the abdomen.  There is gallbladder wall edema and
pericholecystic
fluid that is confluent with the remainder of the peripancreatic
fluid and
likely secondary to the coexisting pancreatitis.  No
choledocholithiasis.  No
cholelithiasis.  There is a duodenal diverticulum just posterior
to the
ampulla.

 There are numerous small T2 hyperintense lesions throughout the
spleen.
Following contrast administration, these are hyperenhancing on
the arterial
phase and demonstrate progressive enhancement on more delayed
phases,
consistent with hemangiomas; given the multiplicity of lesions,
this is
consistent with splenic hemangiomatosis.  Both adrenal glands
and both kidneys
are unremarkable in appearance.  No upper abdominal
lymphadenopathy.  The
visualized bone marrow is unremarkable.  There is a moderate
scoliosis in the
lumbar spine.

IMPRESSION:
1.  Pancreatitis without evidence of necrosis or other
complications.
No cholelithiasis or choledocholithiasis.
2.  Splenic hemangiomatosis.
3.  Large hiatus hernia.
4.  Gallbladder wall edema is noted along with pericholecystic
fluid,
confluent with peripancreatic inflammatory change and likely
secondary to
pancreatitis.
5.  Hepatic steatosis.
6.  Duodenal diverticulum.

C. RUQ US ([**2200-6-29**])
INDICATION:  81-year-old woman with elevated transaminitis and
elevated
lipase.

COMPARISON:  CT from an outside hospital [**2200-6-29**]

FINDINGS:  The liver demonstrates diffuse increase in
echogenicity, consistent
with fatty infiltration.  No focal liver lesions identified.
There is no
intra- or extra-hepatic biliary dilatation.  The common bile
duct is normal
measuring 5 mm.  There is diffuse gallbladder wall edema, which
is likely due
to known pancreatitis.  No gallstones are identified.  The
spleen is normal
measuring 12.2 cm.  The right and left kidneys measure are 10.6
and 10.7 cm
respectively.  No hydronephrosis or stones are seen.  The head
of the pancreas
is normal, but the remainder of the pancreas is obscured by
overlying bowel
gas.  The main portal vein has normal hepatopetal flow.

IMPRESSION:
1. Echogenic liver, consistent with fatty infiltration.
However, other forms
of liver disease including advanced liver disease or cirrhosis
are not
excluded.

2. Mild gallbladder wall edema likely due to known pancreatitis.
 No
gallstones or biliary dilatation.



Brief Hospital Course:
71F history of hypertension, hyperlipidemia, IBS that was
transferred to [**Hospital1 18**] for further management of pancreatitis
likely drug-induced although unknown discrete precipitant with
hospital course complicated by multi-articular gout especially
lower extremities. Patient required MICU admission given BiSAP
score of 3 with uncomplicated course consisting of conservative
and supportive measures. At hospital discharge, patient was able
to digest soft diet and had improving joint pain from gout

# Drug-induced pancreatitis
The patient presented with classic symptoms of pancreatitis
likely secondary to a medication although may also be
idiopathic. Lipase was elevated to 3230 with a significant
transaminitis (ALT 205, AST 270, Tbili 0.6). Laboratory revealed
triglycerides 186 and normal calcium. MRCP and RUQ did not
reveal gallstone or biliary abnormalities although there was
gallbladder wall edema likely secondary to pancreatitis. GI was
consulted and was concerned that this may be medication-induced
pancreatitis. She was fluid resuscitated with 6 L NS along with
IV dilaudid for pain control. She was briefly placed on zosyn
given toxic appearance. Her symptoms improved significant by
hospital day 2 with resolution of aforementioned laboratory
abnormalities.

She was subsequently transferred to the medical floor where her
diet was advanced to a soft diet. She was very anxious about
eating but tolerated a soft diet well. She was told to advance
her diet as tolerated.

In addition, her NSAIDs and benazapril were held although
uncertain if pancreatitis is idiopathic or really drug-induced.
These drugs should be re-initiated cautiously.

She was discharged on PO dilaudid for pain relief of both gout
and abdominal pain although any residual abdominal pain seemed
to be functional rather than related to pancreatitis.

# Hypertension
The patient was hypertensive during hospitalization given
benzapril was held. She was started on norvasc 10 mg PO qD with
good effect in addition to acebutolol. She should have follow-up
blood pressure check in clinic.

# Gout
Patient complained of great bilateral toe pain that was
concerning for gout attack. She was on allopurinol 100 mg PO qD.
Her gout worsened and involved the bilateral MTPs, bilateral
ankles, right knee, and bilateral elbows. Indomethicin was
started without good effect. Rheumatology was consulted and
advanced IV steroids followed by a steroid taper. Patient was
discharged on a step-wise taper of prednisone 60 mg with dose
reduction as written. She will follow-up with rheumatology at
[**Hospital1 18**] for further management. Her allopurinol was held given
that it might have triggered her attack. She will need a
long-term uric acid lowering [**Doctor Last Name 360**] to be determined at clinic
visit.

She was discharged home with PT given gait instability as a
result of her arthritis.

# Fever: Patient had fever on [**7-5**] attributed to crystalline
arthritis and resolving pancreatitis. CXR did reveal a
retrocardiac opacity that could be atelectasis vs. evolving
infiltrate; however, clinically, she did not have any localizing
symptoms to suggest a specific infection. Blood and urine
cultures were negative. She subsequently was afebrile although
assessment is limited in setting of steroid therapy.

CHRONIC ISSUES

# Hyperlipidemia: She was continued on her home statin

# Pending studies
- Blood cultures dated [**2200-7-2**] x 2 are pending and no growth to
date

# Transitional issues
- ongoing management of pancreatitis and ? GI referral if needed

- monitoring of nutrition and PO intake after pancreatitis
episode
- cardiopulmonary assessment regarding blood pressure given
change from ACEi to norvasc
- Gout management and rhematology follow-up, will need to decide
to re-initiate uric acid lowering [**Doctor Last Name 360**] at clinic visit
- Further outpatient work-up of liver findings on US (fatty
infiltration)

# Code: Full

# Emergency contact:
[**Name (NI) **] son/proxy [**Telephone/Fax (1) 112509**]
[**Last Name (un) 3979**]/brother - family spokesperson [**Telephone/Fax (1) 112510**]

Medications on Admission:
acebtulolol 200 mg once a day
benazepril 20 mg once a day
simvastatin 20 mg 2 tablets once a day
omeprazole 20 mg 2 tablets once a day
indomethacin 25 mg 2 tabelts per day or PRN
zolpidem 5 mg qHS
alprazolam 0.5 mg qHS
loperamide 2 mg [**1-6**] capsules per day PRN

Discharge Medications:
1. Omeprazole 40 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. PredniSONE 10 mg PO DAILY
6 tabs (60mg) x2 days (07/02,[**7-8**])
4 tabs (40mg) x2 days (07/04,[**7-10**])
2 tabs (20mg) x2 days (07/06,[**7-12**])
1 tab (10mg) x2 days (07/08,[**7-14**])
Tapered dose - DOWN
RX *prednisone 10 mg as directed Tablet(s) by mouth as directed
Disp #*26 Capsule Refills:*0
4. Acebutolol 200 mg PO DAILY
5. ALPRAZolam 0.5 mg PO QHS
6. Loperamide 2 mg PO DAILY:PRN diarrhea
7. Zolpidem Tartrate 5 mg PO HS
8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *Dilaudid 2 mg 1 Tablet(s) by mouth every four hours Disp
#*30 Capsule Refills:*0
9. Amlodipine 10 mg PO DAILY
Hold for SBP <100
RX *amlodipine 10 mg 1 Tablet(s) by mouth daily Disp #*30
Capsule Refills:*0
10. Docusate Sodium 200 mg PO BID
RX *Colace 100 mg [**1-6**] Capsule(s) by mouth twice daily Disp #*60
Capsule Refills:*0
11. Senna 1 TAB PO BID:PRN constipation
RX *[**Last Name (un) **]-Natural 8.6 mg 1 tab by mouth twice daily Disp #*60
Capsule Refills:*0
12. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg [**1-6**] Tablet(s) by mouth daily Disp #*30
Capsule Refills:*0
13. Polyethylene Glycol 17 g PO DAILY
RX *ClearLax 17 gram 1 packet by mouth daily Disp #*30 Packet
Refills:*0


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Primary: Pancreatitis
Secondary: Gout


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Ms. [**Known lastname 30672**],

You were hospitalized with pancreatitis. We believe that this
was caused by a drug such as your ACEi (benazepril). You slowly
improved during your hospitalization and were able to tolerate
soft diet.  Your hospitalization was complicated by gout in
multiple joints. You were given steroid both orally and through
iv.

For your diet, you should be able to advance to a normal diet as
you feel more comfortable. Avoid fatty foods.

For your gout, this should improve with the steroid taper. You
will follow-up with a joint doctor as below.

Please note the changes in your medication.  We also made the
following appointments for you (see below).

It has been a pleasure taking care of you here at [**Hospital1 18**].  We
wish you a speedy recovery.

Followup Instructions:
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Location: The Medical Group
Address: [**Apartment Address(1) 112511**] [**Hospital1 **], [**Numeric Identifier 26668**]
Phone: [**Telephone/Fax (1) 10508**]
Appointment: Friday [**2200-7-18**] 2:40pm

Department: RHEUMATOLOGY
When: THURSDAY [**2200-8-21**] at 3:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Acute pancreatitis,Hemangioma of intra-abdominal structures,Diaphragmatic hernia without mention of obstruction or gangrene,Acute gouty arthropathy,Other chronic nonalcoholic liver disease,Diverticulosis of small intestine (without mention of hemorrhage),Unspecified essential hypertension,Other and unspecified hyperlipidemia,Other drugs and medicinal substances causing adverse effects in therapeutic use,Irritable bowel syndrome,Tachycardia, unspecified'}


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: Pt is a 71 y/o F with PMHx significant for HTN, HLD, IBS, who
was transferred to [**Hospital1 18**] for further management of pancreatitis.
 Pt reports abdominal pain, nausea, vomitting, and diarrhea that
began yesterday evening. Emesis was mildly bilious, non-bloody.
Diarrhea was non-bloody. Describes abdominal pain as diffusely
located across the abdomen. She initially presented to OSH,
where she was tachycardic to 110s initially. Labs there were
significant for WBC 23,000, lipase 5900. Abdominal CT scan was
performed which showed gallbladder wall edema. She received IVF,
analgesics, and zosyn IV prior to transfer.

MEDICAL HISTORY: HTN
HLD
Gout
IBS (diarrhea-predominant)
s/p removal of benign stomach tumor
s/p hysterectomy
s/p bladder sx
s/p rotator cuff cx
s/p gerd sx (? nissen)

MEDICATION ON ADMISSION: acebtulolol 200 mg once a day
benazepril 20 mg once a day
simvastatin 20 mg 2 tablets once a day
omeprazole 20 mg 2 tablets once a day
indomethacin 25 mg 2 tabelts per day or PRN
zolpidem 5 mg qHS
alprazolam 0.5 mg qHS
loperamide 2 mg [**1-6**] capsules per day PRN

ALLERGIES: morphine / Dilaudid

PHYSICAL EXAM: Admission:
Vitals: T: 99.2 BP: 138/90 P: 98 R: 18 O2: 97%2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, diffusely tender to palpation,
bowel sounds present
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses
Neuro: intact

FAMILY HISTORY: Father died of heart disease at 63.
Mother had CHF.
Grandmother with stomach CA.
Significant family history of EtOH abuse.

SOCIAL HISTORY: Rare EtOH use. No tobacco or illicit drug use. Retired, lives
alone. 

### Response:
{'Acute pancreatitis,Hemangioma of intra-abdominal structures,Diaphragmatic hernia without mention of obstruction or gangrene,Acute gouty arthropathy,Other chronic nonalcoholic liver disease,Diverticulosis of small intestine (without mention of hemorrhage),Unspecified essential hypertension,Other and unspecified hyperlipidemia,Other drugs and medicinal substances causing adverse effects in therapeutic use,Irritable bowel syndrome,Tachycardia, unspecified'}
