CHIEF COMPLAINT: Splenic aneursym rupture.

PRESENT ILLNESS: 71 year-old male with history of alcoholic cirrhosis and
pancytopenia who was transferred from an OSH [**2162-3-31**] with a
ruptured splenic hematoma.  Briefly, the patient had a fall with
a rib fracture and splenic injury 11/[**2160**].  He was managed
nonoperatively and presented to OSH [**Date range (3) 78486**] with E. coli
urosepsis and splenic pseudoaneurysm.  He re-presented to the
OSH [**2162-3-31**] with weakness and hypotension and found to have
ruptured splenic hematoma.  He was transferred to the [**Hospital1 18**]
surgical service [**3-31**] for further evaluation and treatment.  He
had an IR embolization of the splenic artery [**3-31**].  He received
3 units PRBC and one unit FFP since admission, with stable
hematocrit since [**4-1**].
.
He was noted to be hypotensive and required pressors even when a
stable hematocrit.  He was started on zosyn and vancomycin for
empiric infectious coverage and had a diagnostic paracentesis on
[**3-31**] that subsequently grew out e.coli.  His antibiotic coverage
was transitioned to ceftriaxone [**4-1**].  Pressors were discontinued
[**4-1**].
.
His course was further complicated by worsening renal function.
Creatinine increased from 1.7 [**3-31**] to 3.0 today [**4-3**] from
baseline 0.7 at OSH.  He has been oliguric with UOP of ~220-250
cc/day over the last two days prior to transfer to the MICU.
UOP has not increased with albumin.  He was started on
octreotide and midodrine for increasing creatinine.  He also had
a [**4-6**] liter paracentesis for tense ascites.
.
Currently he complains of abdominal pain, chest pain at the site
of his rib fracture and nausea.

MEDICAL HISTORY: 1. Alcoholic cirrhosis complicated by esophageal varices and
ascites
2. History of upper gastrointestinal bleed
3. Pancytopenia, anti-JK antibody positive
4. Hypertension
5. Gout
6. Hiatal hernia
7. History of falls

MEDICATION ON ADMISSION: Nadolol 40 mg daily
Colchicine 0.6 mg daily
Prilosec 20 mg daily
Spirinolactone 12.5 mg daily
Thiamine 100 mg daily
Folic acid 1 mg daily
MVI
Ultram 50 mg q6 hour prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Tc: 97.1 HR: 66 BP: 95/42 RR: 15 O2 sat: 98% 4L NC
Gen: chronically ill appearing, appears uncomfortable,
attempting to vomit
HEENT: anicteric sclera, dry MM, pupils equal and round
Neck: supple, JVP 2 cm above clavicle
Pulm: crackles bilaterally
Cardio: RRR, 2/6 systolic murmur, no rubs or gallops
Abd: very distended, tense ascites with dullness to percussion,
diffuse abdominal pain to light touch
Ext: trace b/l LE edema
Neuro: A&ox3

FAMILY HISTORY: No CAD or liver disease.

SOCIAL HISTORY: Last drink was 3 weeks ago. Formerly used to drink a fifth of
brandy but now has several drinks. Smokes [**12-2**] ppd x 10 years. No
drugs. Lives alone.
Unspecified septicemia,Acute kidney failure, unspecified,Peritonitis (acute) generalized,Paralytic ileus,Hepatorenal syndrome,Severe sepsis,Aneurysm of splenic artery,Alcoholic cirrhosis of liver,Unspecified essential hypertension,Gout, unspecified
Septicemia NOS,Acute kidney failure NOS,Peritonitis (acute) gen,Paralytic ileus,Hepatorenal syndrome,Severe sepsis,Splenic artery aneurysm,Alcohol cirrhosis liver,Hypertension NOS,Gout NOS
Admission Date:  [**2162-3-31**]              Discharge Date:   [**2162-4-9**]

Date of Birth:  [**2091-4-9**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Splenic aneursym rupture.

Major Surgical or Invasive Procedure:
Status post coiling of splenic artery pseudoaneurysm.
Paracentesis.


History of Present Illness:
71 year-old male with history of alcoholic cirrhosis and
pancytopenia who was transferred from an OSH [**2162-3-31**] with a
ruptured splenic hematoma.  Briefly, the patient had a fall with
a rib fracture and splenic injury 11/[**2160**].  He was managed
nonoperatively and presented to OSH [**Date range (3) 78486**] with E. coli
urosepsis and splenic pseudoaneurysm.  He re-presented to the
OSH [**2162-3-31**] with weakness and hypotension and found to have
ruptured splenic hematoma.  He was transferred to the [**Hospital1 18**]
surgical service [**3-31**] for further evaluation and treatment.  He
had an IR embolization of the splenic artery [**3-31**].  He received
3 units PRBC and one unit FFP since admission, with stable
hematocrit since [**4-1**].
.
He was noted to be hypotensive and required pressors even when a
stable hematocrit.  He was started on zosyn and vancomycin for
empiric infectious coverage and had a diagnostic paracentesis on
[**3-31**] that subsequently grew out e.coli.  His antibiotic coverage
was transitioned to ceftriaxone [**4-1**].  Pressors were discontinued
[**4-1**].
.
His course was further complicated by worsening renal function.
Creatinine increased from 1.7 [**3-31**] to 3.0 today [**4-3**] from
baseline 0.7 at OSH.  He has been oliguric with UOP of ~220-250
cc/day over the last two days prior to transfer to the MICU.
UOP has not increased with albumin.  He was started on
octreotide and midodrine for increasing creatinine.  He also had
a [**4-6**] liter paracentesis for tense ascites.
.
Currently he complains of abdominal pain, chest pain at the site
of his rib fracture and nausea.

Past Medical History:
1. Alcoholic cirrhosis complicated by esophageal varices and
ascites
2. History of upper gastrointestinal bleed
3. Pancytopenia, anti-JK antibody positive
4. Hypertension
5. Gout
6. Hiatal hernia
7. History of falls


Social History:
Last drink was 3 weeks ago. Formerly used to drink a fifth of
brandy but now has several drinks. Smokes [**12-2**] ppd x 10 years. No
drugs. Lives alone.

Family History:
No CAD or liver disease.

Physical Exam:
VS: Tc: 97.1 HR: 66 BP: 95/42 RR: 15 O2 sat: 98% 4L NC
Gen: chronically ill appearing, appears uncomfortable,
attempting to vomit
HEENT: anicteric sclera, dry MM, pupils equal and round
Neck: supple, JVP 2 cm above clavicle
Pulm: crackles bilaterally
Cardio: RRR, 2/6 systolic murmur, no rubs or gallops
Abd: very distended, tense ascites with dullness to percussion,
diffuse abdominal pain to light touch
Ext: trace b/l LE edema
Neuro: A&ox3


Pertinent Results:
Labwork on admission:
[**2162-3-31**] 07:37AM   WBC-16.6* RBC-3.16* HGB-9.5* HCT-27.9* MCV-88
MCH-30.2 MCHC-34.2 RDW-16.6*
[**2162-3-31**] 07:37AM   PLT SMR-LOW PLT COUNT-129*
[**2162-3-31**] 07:37AM   PT-17.8* PTT-30.5 INR(PT)-1.6*
[**2162-3-31**] 07:37AM   FIBRINOGE-403*
[**2162-3-31**] 07:52AM   GLUCOSE-86 LACTATE-2.9* NA+-138 K+-4.8
CL--109 TCO2-21
[**2162-3-31**] 07:37AM   UREA N-25* CREAT-1.7* SODIUM-140
[**2162-3-31**] 07:37AM   ALT(SGPT)-165* AST(SGOT)-626* LD(LDH)-650*
ALK PHOS-137* AMYLASE-32 TOT BILI-2.6*
[**2162-3-31**] 07:37AM   ALBUMIN-2.5*
[**2162-3-31**] 07:37AM   ASA-NEG ETHANOL-NEG ACETMNPHN-6.4
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**3-31**] peritoneal fluid

   GRAM STAIN (Final [**2162-3-31**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2162-4-3**]):
      ESCHERICHIA COLI.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMIKACIN--------------     4 S
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     8 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------     8 I
TRIMETHOPRIM/SULFA----  =>16 R
.
[**2162-4-4**] peritoneal fluid
[**2162-4-4**] 2:08 pm PERITONEAL FLUID

   GRAM STAIN (Final [**2162-4-4**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2162-4-7**]):    NO GROWTH.

   ANAEROBIC CULTURE (Preliminary):    NO GROWTH.
.
MESSENERTIC Study Date of [**2162-3-31**]
IMPRESSION:
1. Selective splenic artery arteriogram demonstrates an area of
hypoperfusion at the mid portion of the spleen and corresponding
irregularity at the vessel supplying the upper lobe of the
spleen. Also, an area of small pseudoaneurysm stump at the upper
branch of the splenic artery.
2. Successful coil embolization of this branch with two 3 mm and
4 mm coils deployed at this level.
3. Diagnostic paracentesis with 60 cc of bloody ascitic fluid
drawn and sent for analysis.
.
RENAL U.S. Study Date of [**2162-4-3**]
IMPRESSION:
1. No hydronephrosis.
2. Splenomegaly.
3. Large amount of ascites.
.
CHEST (PORTABLE AP) Study Date of [**2162-4-4**]
HISTORY: Liver disease, possible pneumonia on recent chest
x-ray.
One view. Comparison with the previous study done [**2162-4-3**]. Lung
volumes are
low, as before. There is interval improvement in bilateral
subsegmental
atelectasis and hazy density at the left base which was most
suggestive of
pleural fluid. The cardiac silhouette is prominent, as before.
Mediastinal
structures are unchanged.
IMPRESSION: Limited study demonstrating improvement in
subsegmental
atelectasis, pulmonary vascular congestion cannot be excluded.
.
PORTABLE ABDOMEN  [**2162-4-4**]
Two supine portable views. The diaphragm is not included. There
is increased gas in mildly dilated small bowel. Soft tissue
shadows are indistinct and there is hazy density throughout the
abdomen. No significant bony abnormality is identified. There
are small metallic radiopacities projected in the left upper
quadrant. These may lie outside the patient or represent foreign
bodies. There are irregularly shaped calcifications in the right
upper quadrant most consistent with gallstones.
IMPRESSION: Nonspecific bowel gas pattern. Hazy increased
density most suggestive of ascites. CT may be helpful for
further evaluation.

Brief Hospital Course:
70M PMH EtOH cirrhosis, recent splenic injury s/p coiling of
splenic pseudoaneurysm, transferred to MICU from TSICU with E.
coli SBP and anuric renal failure.  Given the patient's poor
prognosis the goals of care were changed to comfort.  He died on
[**2162-4-9**] on the medical floor. Palliative care team followed
patient in hospital.
.
1. Splenic artery pseudoaneurysm: He presented with splenic
hematoma and hypotension.  He underwent coiling of the
pseudoaneurysm [**2162-3-31**] and hematocrit subsequently remained
stable.
.
2. Sepsis/SBP: The patient was hypotensive upon arrival and
required pressors for a short period of time.  The hypotension
was initially thought to be due to splenic laceration, but
pressures remained low after treatment and stabilization of
hematocrit.  Evaluation for infectious sources positive for E.
coli peritonitis.  The patient was started on ceftriaxone and
then transitioned to vancomycin, zosyn, and flagyl given rising
white blood cell count.  Urine and blood cultures were negative.
 Antibiotics were discontinued once made CMO.
.
3. Acute renal failure: Baseline creatinine approximately 0.7.
The patient's creatinine rose to 4.5.  Urine electrolytes
demonstrate FeBUN of 16.42%, suggesting pre-renal etiology,
although there was no response with saline and albumin infusion.
 Renal ultrasound with no evidence of obstruction.  The patient
was followed by Renal consult during admission.  His renal
failure was believed due to contrast nephropathy versus
hepatorenal syndrome.  The patient's lasix and aldactone were
held.  The patient was initially maintained on octreotide,
midodrine, and standing albumin but these were discontinued
prior to transfer.  The patient became anuric, his creatinine
continued to rise, and he developed electrolyte abnormalities.
The patient's family declined to initiate hemodialysis.
.
4. Hypoxia: The patient had a new oxygen requirement of 4L NC
during admission.  The hypoxia is likely due to massive
abdominal distension.  Chest x-rays showed low lung volumes but
no clear effusion or pneumonia.
.
5. Alcoholic cirrhosis: The patient has a significant history of
alcohol abuse; states his last drink was three weeks prior.  His
cirrhosis has been complicated by esophageal varices, ascites
and SBP.  MELD 27 during admission.  The patient's lasix,
spironolactone, and nadolol were initially held in the setting
of renal insufficiency and recent hypotension and were not
restarted prior to transfer.  The patient underwent two five
liter paracenteses during admission.
.
6. Pancytopenia: The patient has a documented history of
pancytopenia of unclear etiology.  The patient's hematocrit
remained stable at 29.  The patient's platelets trended down
from 129 on admission which was likely hemoconcentrated given
his baseline 50s-60s.
.
7. Gout: The patient was on colchicine as an outpatient, which
was held for renal failure.  There were no active issues during
admission.
.
8. Ileus.  The patient's abdominal films during admission showed
ileus.  He was made NPO, but then allowed a regular diet as
tolerated once goals of care were changed.

*** Of note - the patient did not have a PCP [**Name Initial (PRE) **] [**Name10 (NameIs) 3**] confirmed with
daughter - [**Name (NI) 1785**].

Medications on Admission:
Nadolol 40 mg daily
Colchicine 0.6 mg daily
Prilosec 20 mg daily
Spirinolactone 12.5 mg daily
Thiamine 100 mg daily
Folic acid 1 mg daily
MVI
Ultram 50 mg q6 hour prn

Discharge Medications:
not applicable


Discharge Disposition:
Expired

Discharge Diagnosis:
Primary:
1. Ruptured splenic aneurysm
2. Anuric renal failure, hepatorenal syndrome
3. Spontaneous bacterial peritonitis

Secondary:
1. Alcoholic cirrhosis complicated by esophageal varices and
ascites
2. History of upper gastrointestinal bleed
3. Pancytopenia, anti-JK antibody positive
4. Hypertension
5. Gout
6. Hiatal hernia
7. History of falls


Discharge Condition:
Expired


Discharge Instructions:
not applicable

Followup Instructions:
not applicable
{'Unspecified septicemia,Acute kidney failure, unspecified,Peritonitis (acute) generalized,Paralytic ileus,Hepatorenal syndrome,Severe sepsis,Aneurysm of splenic artery,Alcoholic cirrhosis of liver,Unspecified essential hypertension,Gout, 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: Splenic aneursym rupture.

PRESENT ILLNESS: 71 year-old male with history of alcoholic cirrhosis and
pancytopenia who was transferred from an OSH [**2162-3-31**] with a
ruptured splenic hematoma.  Briefly, the patient had a fall with
a rib fracture and splenic injury 11/[**2160**].  He was managed
nonoperatively and presented to OSH [**Date range (3) 78486**] with E. coli
urosepsis and splenic pseudoaneurysm.  He re-presented to the
OSH [**2162-3-31**] with weakness and hypotension and found to have
ruptured splenic hematoma.  He was transferred to the [**Hospital1 18**]
surgical service [**3-31**] for further evaluation and treatment.  He
had an IR embolization of the splenic artery [**3-31**].  He received
3 units PRBC and one unit FFP since admission, with stable
hematocrit since [**4-1**].
.
He was noted to be hypotensive and required pressors even when a
stable hematocrit.  He was started on zosyn and vancomycin for
empiric infectious coverage and had a diagnostic paracentesis on
[**3-31**] that subsequently grew out e.coli.  His antibiotic coverage
was transitioned to ceftriaxone [**4-1**].  Pressors were discontinued
[**4-1**].
.
His course was further complicated by worsening renal function.
Creatinine increased from 1.7 [**3-31**] to 3.0 today [**4-3**] from
baseline 0.7 at OSH.  He has been oliguric with UOP of ~220-250
cc/day over the last two days prior to transfer to the MICU.
UOP has not increased with albumin.  He was started on
octreotide and midodrine for increasing creatinine.  He also had
a [**4-6**] liter paracentesis for tense ascites.
.
Currently he complains of abdominal pain, chest pain at the site
of his rib fracture and nausea.

MEDICAL HISTORY: 1. Alcoholic cirrhosis complicated by esophageal varices and
ascites
2. History of upper gastrointestinal bleed
3. Pancytopenia, anti-JK antibody positive
4. Hypertension
5. Gout
6. Hiatal hernia
7. History of falls

MEDICATION ON ADMISSION: Nadolol 40 mg daily
Colchicine 0.6 mg daily
Prilosec 20 mg daily
Spirinolactone 12.5 mg daily
Thiamine 100 mg daily
Folic acid 1 mg daily
MVI
Ultram 50 mg q6 hour prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Tc: 97.1 HR: 66 BP: 95/42 RR: 15 O2 sat: 98% 4L NC
Gen: chronically ill appearing, appears uncomfortable,
attempting to vomit
HEENT: anicteric sclera, dry MM, pupils equal and round
Neck: supple, JVP 2 cm above clavicle
Pulm: crackles bilaterally
Cardio: RRR, 2/6 systolic murmur, no rubs or gallops
Abd: very distended, tense ascites with dullness to percussion,
diffuse abdominal pain to light touch
Ext: trace b/l LE edema
Neuro: A&ox3

FAMILY HISTORY: No CAD or liver disease.

SOCIAL HISTORY: Last drink was 3 weeks ago. Formerly used to drink a fifth of
brandy but now has several drinks. Smokes [**12-2**] ppd x 10 years. No
drugs. Lives alone. 

### Response:
{'Unspecified septicemia,Acute kidney failure, unspecified,Peritonitis (acute) generalized,Paralytic ileus,Hepatorenal syndrome,Severe sepsis,Aneurysm of splenic artery,Alcoholic cirrhosis of liver,Unspecified essential hypertension,Gout, unspecified'}
