CHIEF COMPLAINT: Chest pain

PRESENT ILLNESS: Mr. [**Known lastname **] is a 36 yo man with a history of perforated
diverticulosis treated with diverting colostomy and s/p recent
takedown 9 days prior to this presentation of SSCP, etoh
withdrawl, and ? tylenol toxicity.

MEDICAL HISTORY: -perforated sigmoid diverticulitis: Sigmoid colectomy/End
Colostomy, Hartmann's pouch, revision [**2126-9-2**]
-etoh abuse with withdrawl (+ hallucinations, no
seizures/intubation) last detox [**6-8**], last drink 1200 [**9-11**]
-drug abuse: [**2115**], 'tried everything' including cocaine, ivdu,
none since

MEDICATION ON ADMISSION: vicodin 22 pills
6 tylenol pm
prilosec
? antiemetics (from his mother, [**Name8 (MD) **] rn)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE on admission
VS: T: 96.8 HR: 79 BP: 167/95 RR: 21 Sat: 100% on RA
Gen: Cachectic, ill-appearing, slightly anxious man
HEENT: NCAT, PERRL, sclera anicteric, OP clear, mm very dry
Neck: Supple, no LAD, JVD flat
CV: III/VI harsh early SM at the apex, hyperdynamic precordium,
? prominent P2
Resp: CTAB no w/r/r
Abdomen: scaphoid, +BS, midline and left LQ incisions with mild
surrounding erythema, otherwise c/d/i, RUQ exquisitely TTP, no
obvious HSM
Ext: No c/c/e, 2+ DP's B
Neuro: A + O x 3 but closes eyes during interview, CN II-XII
grossly intact, Motor [**4-6**] both upper and lower extremities,
sensation grossly intact to light touch
Skin: Multiple tattoos, no petechia or ecchymosis

FAMILY HISTORY: prostate CA in both GF's;
His family history is unremarkable for any GI malignancies.

SOCIAL HISTORY: Single. Lives alone in [**Location (un) 577**]. Works as a carpenter. Smokes 1
PPD x 24 years. Reports being sober from ETOH for past 5 years.
Had recent relapse after surgery in [**2126-5-3**] due to pain, also
currently. Denies recent use of recreational drugs.
Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Hepatic encephalopathy,Acute respiratory failure,Other and unspecified coagulation defects,Thrombocytopenia, unspecified,Poisoning by aromatic analgesics, not elsewhere classified,Accidental poisoning by aromatic analgesics, not elsewhere classified,Other and unspecified alcohol dependence, continuous
Acute kidney failure NOS,Acute necrosis of liver,Hepatic encephalopathy,Acute respiratry failure,Coagulat defect NEC/NOS,Thrombocytopenia NOS,Pois-arom analgesics NEC,Acc poison-arom analgesc,Alcoh dep NEC/NOS-contin
Admission Date:  [**2126-9-12**]              Discharge Date:   [**2126-9-30**]

Date of Birth:  [**2090-4-13**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Chest pain

Major Surgical or Invasive Procedure:
Hemodialysis
Intensive Care Unit
Intubation

History of Present Illness:
Mr. [**Known lastname **] is a 36 yo man with a history of perforated
diverticulosis treated with diverting colostomy and s/p recent
takedown 9 days prior to this presentation of SSCP, etoh
withdrawl, and ? tylenol toxicity.

He reports severe abdominal pain at his surgical site since
discharge for which he started taking vicodin [**9-11**] (per ED
resident took 22 (1.1 gm) but per pt took 12 (0.6 gm) plus [**5-9**]
tylenol pm. Additionally he has been drinking for pain relief,
12 drinks/day, last [**9-11**] at 1200. He noted SSCP at approx 2200.
It started relatively suddenly, comes and goes, stabbing in
nature, currently [**2129-7-11**], came on at rest, worse with deep
inspiration, which he has never had before. He reports relative
immobility with recent surgery. He denies LE swelling or
tenderness.
.
In the ED, VS: T 95 HR 115 BP 144/105 RR 26 Sat 100% 2L NC. He
was given valium 10mg iv, morphine 4mg iv, zofran 4mg iv, NAC
10grams po, vitamin K 1mg iv.
.
ROS: Significant for 20 lbs weight loss over the last few
months, chills at home but no fevers, nausea ? [**1-4**] etoh use,
some pain with BM's, cough with nausea, and pain at the base of
his spine from lying in bed. No visual changes, photophobia,
sore throat, palpitations, rashes, bleeding (gums, stool,
urine). He reports negative HIV test 1 month ago.

Past Medical History:
-perforated sigmoid diverticulitis: Sigmoid colectomy/End
Colostomy, Hartmann's pouch, revision [**2126-9-2**]
-etoh abuse with withdrawl (+ hallucinations, no
seizures/intubation) last detox [**6-8**], last drink 1200 [**9-11**]
-drug abuse: [**2115**], 'tried everything' including cocaine, ivdu,
none since


Social History:
Single. Lives alone in [**Location (un) 577**]. Works as a carpenter. Smokes 1
PPD x 24 years. Reports being sober from ETOH for past 5 years.
Had recent relapse after surgery in [**2126-5-3**] due to pain, also
currently. Denies recent use of recreational drugs.

Family History:
prostate CA in both GF's;
His family history is unremarkable for any GI malignancies.


Physical Exam:
PE on admission
VS: T: 96.8 HR: 79 BP: 167/95 RR: 21 Sat: 100% on RA
Gen: Cachectic, ill-appearing, slightly anxious man
HEENT: NCAT, PERRL, sclera anicteric, OP clear, mm very dry
Neck: Supple, no LAD, JVD flat
CV: III/VI harsh early SM at the apex, hyperdynamic precordium,
? prominent P2
Resp: CTAB no w/r/r
Abdomen: scaphoid, +BS, midline and left LQ incisions with mild
surrounding erythema, otherwise c/d/i, RUQ exquisitely TTP, no
obvious HSM
Ext: No c/c/e, 2+ DP's B
Neuro: A + O x 3 but closes eyes during interview, CN II-XII
grossly intact, Motor [**4-6**] both upper and lower extremities,
sensation grossly intact to light touch
Skin: Multiple tattoos, no petechia or ecchymosis


Pertinent Results:
HEMATOLOGY:
On admission, the patient had a CBC notable for white count of
15.1, hemoglobin of 15.3, hematocrit of 45.2, and platelet count
of 48,000 which is down from 259,000 on [**2126-9-3**] down from
458,000 on [**2126-7-8**].  His differential at this time was 94%
polys, 0% bands, 4% lymphocytes, 1% monocytes, 0.1% eosinophils
and 0.7% basophils.  During the next day, the patient's platelet
count trended downward reaching a nadir of 7 at 3:30 p.m. on
[**2126-9-12**].  During this time, the patient's hematocrit stayed
stable in the low 30s ranging between 32 and 34.

The patient's white count spiked initially to 29.3 on [**2126-9-13**]
with 96%
neutrophils and trended downward reaching 11.4 on [**2126-9-15**]
before crescendoing again on [**2126-9-23**] with a white count of
36,
79% of polys, 5% lymphocytes and 9% eosinophil count.  At the
time of discharge on [**2126-9-30**], the patient had CBC notable for
white count of 11.9, hematocrit of 24.1, platelet count of
399,000.

Reticulocyte count:  Reticulocyte count was checked on
[**2126-9-26**]
with RCT check of 4.3 with an index of less than 2%.

Heparin-dependent antibodies were performed.  His antiplatelet
antibodies were positive.

ANTIBODY SPECIFICITY:  GP IV.
Heparin-dependent antibody was negative for the PF4 heparin
antibody by [**Doctor First Name **].

COAGULATION:
On admission, the patient had INR of 1.4.  Patient reached a
peak INR
a day later on [**2126-9-13**] of 6.6, not on anticoagulation.
This trended downward over the course of admission and was
discharged with an INR of 1.4 on [**2126-9-30**].  Fibrinogen levels
were checked during the admission with a nadir of 51 on
[**2126-9-13**].  At this time, there was increase in fiber intake,
radiation products between 160 and 320.  The D-dimer at this
time
was elevated at 7937.

CHEMISTRIES:
On admission, the patient had a chem-7 of 136, 3.7, 93, 23, 8,
0.7 and glucose of 281.  The patient over the next
post-admission
day, hospital day 2, 3, and 4 developed rapidly progressing
acute
renal failure with a creatinine of 2.5 on [**9-13**] and a creatinine
of 4.3 on [**9-14**], reaching a peak creatinine of 12.8 on
[**2126-9-19**].  The patient developed an anion gap at its maximum
of
46 on [**2126-9-18**], at which point his bicarbonate was 16.  His
potassium is 3.8.  The creatinine is 12.4.  The patient was
placed on dialysis with removal of dialysis near [**2126-9-28**].
The
patient prior discharge has a stable creatinine ranging between
5.1-5.5.
The day of discharge, the patient's chem-7 was
139, 4.1, 101, 21, 53 and 5.3 with a glucose of 91.

LIVER FUNCTION TESTS AND BILIRUBIN.  On admission, the patient's
LFTs were elevated, ALT of 376 and AST of 920, and LDH of 790
and
alkaline phosphatase of 92 and total bilirubin of 1.5.  During
the course of the next day, the patient had massive elevations
in
his liver function tests with a maximum value on [**2126-9-13**] with
an ALT of 7905 and AST of 36,400, and LDH of 16,150, alkaline
phosphatase of 125, T bilirubin 6.7, direct bilirubin 4.0,
indirect bilirubin 2.7.  The patient had a maximum bilirubin of
20.3 on [**2126-9-20**].  All LFTs began trending down prior to
discharge and on the day of discharge, ALT 52, AST 80,
LDH 304, alkaline phosphatase 159, T bilirubin 8.7.

CARDIAC ISOENZYMES:
The patient underwent a rule out biomarkers on the day of
admission, [**2126-9-12**], which is notable for no troponin less
than
0.01 and CK-MB of 2.

ALBUMIN:  Patient's albumin on admission was 4.3 and on
discharge
it was 3.3.

IRON STUDIES:  [**2126-9-28**] calculated TIBC was 209, ferritin
1138,
transferrin 161 with an iron at this time of 64.

THYROID:  TSH on [**2126-9-27**] was 7.0.  The free T4 was 0.75.

HEPATITIS SEROLOGY:
Serologies were checked twice.
The patient's hepatitis was consistent with an immunized state
with a negative surface antigen, positive surface antibody and
negative core antigen to hepatitis B.  He is hepatitis A
antibody
negative.    He is hepatitis A IgM negative.  His AFP was less
than 1.0.

HEPATITIS C SEROLOGY:  The patient was hepatitis C antibody
negative.Hepatitis C IgM negative.

HIV serology was checked with consent and was negative on
[**2126-9-12**].

TOXICOLOGY:
The patient had acetaminophen level on presentation on
[**2126-9-12**]
at 12:20 in the morning of 102.  He was negative for aspirin,
ethanol, benzodiazepines, barbiturates and tricyclics.

LACTATE:  The patient had a max lactate of 5.5 on [**2126-9-13**].

HERPES SIMPLEX IGG:  The patient was positive for herpes 1-IgG
antibody and negative for herpes 2-IgG antibody.

PARACENTESIS
The patient had two paracenteses during this admission, neither
consistent with SBP.

CULTURE DATA:
The patient underwent blood cultures on [**9-11**], [**9-20**], [**9-21**], [**9-22**], [**9-23**], [**9-26**], [**9-27**], and [**9-28**], all
which showed no growth.  Culture of the BAL from
[**2126-9-23**] showed preliminary yeast with no virus isolated and a
negative respiratory culture.

Stool was tested for C. diff as well as O&P, which
were all negative.  At the time of discharge, his C. diff B
toxin
was pending.

Urine culture was obtained from [**9-13**], [**9-17**],
[**9-20**], [**9-22**], [**9-23**], [**9-26**] and [**9-27**].  The only notable culture
being [**9-22**] which grew approximately 1000 gram negative rods per
mL.

============================================
Computed tomography: [**2126-9-12**]: no intra-abdominal process, and
post surgical change.  Diffuse fatty infiltration of the liver
was noted.
A CTA revealed no pulmonary embolism
==============================================

Computed tomography: sinus [**2126-9-18**]
Multisinus mucosal thickening and a small left sphenoid air cell
fluid level which appear to have evolved since the prior head CT
scan of [**9-13**]. The findings could relate, at least in part to
intubation (aside from the left maxillary retention cyst.)

Abd/Pelvis without Contrast:
1. Small bilateral pleural effusions with associated air-space
disease.
2. Interval increase in cardiac size, development of moderate
amount of ascites and diffuse anasarca.
3. Interval resolution of previously noted pelvic fluid
collection.
4. Several small tiny air pockets in the dependent portion of
the cecum, which is collapsed. In an appropriate clinical
setting, bowel pneumatosis could be considered. No evidence of
bowel obstruction or free air.
===============================================

Computed tomography   Abdomen and pelvis [**2126-9-23**]
CT ABDOMEN WITH INTRAVENOUS CONTRAST: There has been interval
development of bilateral small pleural effusions with adjacent
atelectasis/consolidation, greater on the right.

Again seen is a diffuse fatty infiltration of the liver. The
adrenal glands, spleen, pancreas, gallbladder and kidneys appear
grossly unremarkable.

There is no evidence of a small bowel obstruction. There has
been interval development of moderate amount of free fluid in
the abdomen. There is no free extraluminal air. Retroperitoneal
lymph nodes are seen measuring up to 1.1cm and slightly enlarged
from prior study. The patient is status post resection with
suture in anastomotic sites noted in the right lower quadrant.
Stranding of subcutaneous fat is again seen on the anterior
wall. There is no drainable fluid collection.

CT PELVIS WITH INTRAVENOUS CONTRAST: There is Foley catheter in
the urinary bladder. Air in the bladder is likely related to the
recent instrumentation. Patient is status post sigmoid
resection. There are no pathologically enlarged pelvic or
inguinal lymph nodes. The prostate, seminal vesicles are
unremarkable.

IMPRESSION:
1. No drainable intra-abdominal fluid collection.
2. Interval development of bilateral pleural effusions with
compression atelectasis/consolidation, right greater than left.
3. Interval development of moderate amount of ascites.
4. Mild retroperitoneal lymph adenopathy. Attention will be paid
on follow-up examination.
5. Diffuse fatty liver infiltration.
==========================================
chest x-rays:
the patient had multiple chest films shot over the course
admission.
He did develop a right-sided interstitial process that was clear
by discharge.
===========================================
Echocardiogram [**2126-9-25**]:
 The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Transmitral
and tissue Doppler imaging suggests normal diastolic function,
and a normal left ventricular filling pressure (PCWP<12mmHg).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a trivial/physiologic pericardial effusion.
==============================================


Brief Hospital Course:
In brief, this was a 36 yo man with recent sigmoid diverticular
perforation s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] pouch revision/takedown, who was
admitted to the hospital with acetamenophen overdose who
developed liver and renal failure. He was admitted to the
medical intensive care unit after presenting to the emergency
department.

1. Respiratory Failure- The patient was intubated for his
altered mental status on arrival to the MICU, and was extubated
on [**9-24**]. He developed pulmonary edema believed to be caused by
renal failure and fluid overload, and was started on
hemodialysis with improvement in fluid balance.  BAL was
performed to r/o pneumonia, and showed no bacterial or fungal
growth.

2. Hepatitis: Transaminitis c/w acute toxic insult, likely
secondary to tylenol and alcohol use though per pt last
ingestion and nomogram borderline for toxicity. RUQ us showed
fatty liver, but no biliary disease. Hep serologies were
negative for A/B/C, and HIV was negative as well. NAC drip was
maintained until LFT's were <1000, and then ended.  Transplant
hepatology and transplant surgery were consulted, and determined
that pt was not a candidate for transplant at this time.  Broad
spectrum antimicrobials and antifungals were continued until
LFT's recovered. During episode of hepatitis, lactulose, and
then rifaxamin were given to assist with hepatic encephalopathy.
  With time LFT's and INR improved, and supportive care was
continued.

3. Fevers: Fevers have been ongoing during the course of the
hospitalization, including at the time of discharge, though no
source was identified. He was covered with broad spectrum
antibiotics added over the course of his intensive care stay
including vancomycin, meropenem, flagyl, and fluconazole.
Fluconazole was removed [**9-21**] when LFT's sank below 1000.
Investigation with abdominal and pelvic CT studies showed no
evidence of an intra-abdominal abscess or process.  the patient
also underwent bronchoscopy with bronchial alveolar lavage
showing only  1+ PMNs, Bacterial/Fungal Cx with no growth.  A
urine legionella was negative.  Urine cultures were negative,
with the exception of 1 from [**9-22**] that grew 1000 GNR; also
subsequent cultures with negative. A central line placed [**9-13**]
was removed 8 days later for fear of line infection, but the tip
cultures was negative.  C. Diff was also suspected given long
standing broad spectrum antibiotics, but was negative x 5.
Clostridium difficile B toxin was pending at the time of
discharge. the patient two paracenteses performed which showed
no SBP. Multiple blood cultures show no growth.  ID consult was
obtained twice to evaluate.  Drug fever was also suspected given
eosinophilia.  For this reason Zosyn was changed to meropenem,
but eosinophilia continued.  one by one, antibiotics were
discontinued including meropenem and vancymycin. The patient was
discharged on flagyl awaiting the Clostridium difficile B toxin.
A full understanding of the patients fevers remains elusive, but
inflammatory remains high on the differential.  An occult
infectious source still cannot be ruled out, and the patient was
encouraged to stay within the hospital.
.
4. Acute renal failure -Labs consistent with intrinsic renal
disease, ATN vs. tylenol toxicity. Renal was consulted and began
CVP on [**9-23**].  This was difficult to continue in ICU, so HD was
started on [**9-24**].  In light of renal failure, all medicines were
dosed renally, and phos binder (calcium was started).  HD
initially asisted with volume overload, but then continued for
uremia.  The patient's last day of dialysis was [**2126-9-29**].  He
was discharged on sevelemar. He is to follow up in the
nephrology clinic on the week of discharge, and have every other
day labs checked.
.
5. MS changes/encephalopathy: Initially pt was intubated for
airway protection and started on fentanyl/versed drips.  Pt with
confusion/deliurm likley multifactoria; hepatic encephalapthy,
uremia, alcohol/benzo withdrawl.  Head CT on [**9-13**] showed no
cerebral edema or bleed.  Pt with hypertension and tachycardia,
and treated with benzos for concerns of DT's.  Eventually slowly
withdrew from benzos, and switched to propofol.  With extubation
sedating medications stopped.  The patient became floridly
encephalopathic when he was transferred from the intensive care
unit to the medical floor on [**2126-9-28**].  He improved with Zyprexa
of 5 mg every eight hours standing and required one goes of
haloperidol 1 mg.  Over the next 24 hours the patient cleared
his mental status, and was no longer encephalopathic at the time
of discharge.  He was continued on lactulose as an outpatient.

6. Thrombocytopenia: Unclear etiology, severe with nadir of
seven. Differential diagnosis included Etoh suppression,
sequestion, medication, and HIV.  Smear showed no schistocytes,
and over time platelet count improved in addition to INR.
Prilosec was changed to PPI as concern for thrombocytopenia.
With improving hepatitis, INR improved, and fibrinogen remained
stable. HIT was negative, but anti-platelet AB was positive. PT
did continue to have some oozing from this HD catheter, so DDAVP
and 1 units of prbc were given.  With dialysis, this oozing and
slow drop of hematacrit improved.
.
7. Anemia:  Pt had stable anemia throughout stay, likely related
to oozing from decreased platlets and increased INR, as well as
chronic disease.  Pt was started on epogen with dialysis. The
patients reticulocyte index was low, indicating a component of
marrow suppression.
.
8. s/p Hartmann's pouch revision: Surgery saw pt in ED, and
followed throughoutstay.  CT of the abdomen on [**9-12**] showed post
surgical changes.
.
9.Cardiomegaly: found on CXR, and followed up with TTE echo.
Echo showed dilated LV cavity but normal EF.
.
10. FEN: Pt recieved tube feeds during intubation.  After
extubation advanced to normal diet

.
# Code: Full-confirmed.
.
# Communication: With patient, mother [**Name (NI) 335**] [**Name (NI) **] [**Telephone/Fax (1) 33004**],
[**Telephone/Fax (1) 33005**]


Medications on Admission:
vicodin 22 pills
6 tylenol pm
prilosec
? antiemetics (from his mother, [**Name8 (MD) **] rn)

Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 doses.
Disp:*42 Tablet(s)* Refills:*0*
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO TID
(3 times a day) for 1 months.
Disp:*4050 ML(s)* Refills:*1*
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*84 Tablet(s)* Refills:*2*
7. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
8. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Fulminant Hepatic Failure
Acute Renal Failure


Discharge Condition:
Guarded


Discharge Instructions:
You were admitted with liver and kidney failure related to too
much tylenol (which is contained in tylenol pm and vicodin).
You were treated in the intensive care unit during your stay,
and required hemodialysis. You had ongoing fevers that were
still under investigation when you left the hospital against
medical advice.
.
You will require urgent monitoring as an outpatient, including
every other day lab draws, and follow up with the kidney doctors
and with the liver doctors.
.
You have several important medications on discharge. They
include flagyl (metronidazole) three times a day as antibiotic
renagel (sevelemar) three times a day with meals
levoxyl (thyroid hormone) once a day (will review at primary
care appt)
vitamins, includin folic acid, thiamine, and mltivitamin
lactulose three times a day. This helps remove amines from your
body that are not cleared well by your liver. You should expeect
to continue to have loose stools.
AVOID ANYTHING WITH TYLENOL OR ACETAMENOPHEN
.
Please watch your weight, and weigh yourself daily. Limit your
salt intake, as your kidney function is still quite poor, and
you can accumulate fluid and have imbalances of the electrolytes
in your body that are dangerous.
.
If you experience any abdominal pain, fever with
rigor/shakes/chills, nausea and vomiting, bleeding, low urine
output, confusion, or other concerning symptoms, please return
emergently to the emergency department.

Followup Instructions:
You should have your bloodwork checked every other day, and
results sent to Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) 4427**], and Dr. [**Last Name (STitle) 497**].

You have the following scheduled appointments.

Liver Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2126-10-3**] 10:00

Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2126-10-9**] 4:00


                             [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
{'Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Hepatic encephalopathy,Acute respiratory failure,Other and unspecified coagulation defects,Thrombocytopenia, unspecified,Poisoning by aromatic analgesics, not elsewhere classified,Accidental poisoning by aromatic analgesics, not elsewhere classified,Other and unspecified alcohol dependence, continuous'}


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: Chest pain

PRESENT ILLNESS: Mr. [**Known lastname **] is a 36 yo man with a history of perforated
diverticulosis treated with diverting colostomy and s/p recent
takedown 9 days prior to this presentation of SSCP, etoh
withdrawl, and ? tylenol toxicity.

MEDICAL HISTORY: -perforated sigmoid diverticulitis: Sigmoid colectomy/End
Colostomy, Hartmann's pouch, revision [**2126-9-2**]
-etoh abuse with withdrawl (+ hallucinations, no
seizures/intubation) last detox [**6-8**], last drink 1200 [**9-11**]
-drug abuse: [**2115**], 'tried everything' including cocaine, ivdu,
none since

MEDICATION ON ADMISSION: vicodin 22 pills
6 tylenol pm
prilosec
? antiemetics (from his mother, [**Name8 (MD) **] rn)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE on admission
VS: T: 96.8 HR: 79 BP: 167/95 RR: 21 Sat: 100% on RA
Gen: Cachectic, ill-appearing, slightly anxious man
HEENT: NCAT, PERRL, sclera anicteric, OP clear, mm very dry
Neck: Supple, no LAD, JVD flat
CV: III/VI harsh early SM at the apex, hyperdynamic precordium,
? prominent P2
Resp: CTAB no w/r/r
Abdomen: scaphoid, +BS, midline and left LQ incisions with mild
surrounding erythema, otherwise c/d/i, RUQ exquisitely TTP, no
obvious HSM
Ext: No c/c/e, 2+ DP's B
Neuro: A + O x 3 but closes eyes during interview, CN II-XII
grossly intact, Motor [**4-6**] both upper and lower extremities,
sensation grossly intact to light touch
Skin: Multiple tattoos, no petechia or ecchymosis

FAMILY HISTORY: prostate CA in both GF's;
His family history is unremarkable for any GI malignancies.

SOCIAL HISTORY: Single. Lives alone in [**Location (un) 577**]. Works as a carpenter. Smokes 1
PPD x 24 years. Reports being sober from ETOH for past 5 years.
Had recent relapse after surgery in [**2126-5-3**] due to pain, also
currently. Denies recent use of recreational drugs. 

### Response:
{'Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Hepatic encephalopathy,Acute respiratory failure,Other and unspecified coagulation defects,Thrombocytopenia, unspecified,Poisoning by aromatic analgesics, not elsewhere classified,Accidental poisoning by aromatic analgesics, not elsewhere classified,Other and unspecified alcohol dependence, continuous'}
