CHIEF COMPLAINT: jaundice/abdominal swelling

PRESENT ILLNESS: HPI: 65 yo M with h/o HTN p/w increasing abdominal girth and
jaundice found to have liver failure and erythrocytosis. Pt was
in his USOH until approximately 4 weeks ago when he developed
increasing abdominal swelling, yellowed skin and worsening
fatigue. He gained approximately 10 pounds over 2 weeks before
seeing his PCP who noted some abnormal labs. Pt recalls that he
had an elevated creatinine and bilirubin. He was referred by his
PCP to [**Name Initial (PRE) **] gastroenterologist. Pt had an EGD performed which
demonstrated no varices per the pt, though it did demonstrated
"small ulcers." Pt also had a CT torso [**2118-3-25**] at [**Hospital1 **]
showing an enlarged and heterogeneous liver, indicating either
cirrhosis with regenerating nodules or dysplastic nodules. The
pt was started on diuretics and lost approximately 12 pounds.
The patient's gastroenterologist recommended the pt be
electively admitted to [**Hospital1 18**] for further evaluation.
.
In the ED, vitals: t95, bp 110/64, hr 56, rr 16, sat 97% ra.
Labs notable for hct initially 70->66, plt 146. BUN 75, cr 3.5.
AG 23. INR 3.5. AST 184, ALT 48. T bili 55, d bili 30, AP 238.
S/U tox negative. U/A with 3-5 wbcs, mod bacteria. CXR neg for
an acute process. Abd u/s with portal vein thrombosis and
cirrhotic liver. ekg: nsr@61 bpm, rbbb. Heme saw pt for
erythrocytosis and phlebotomized one unit from pt. Pt
transferred to the MICU for further management.
.
ROS: As above, otherwise denies CP/SOB/fever.

MEDICAL HISTORY: hypertension

MEDICATION ON ADMISSION: Toprol XL
another antihypertensive - name not known
2 new diuretics, name unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp 97.1
BP 94/55
Pulse 62
Resp 20
O2 sat 96% ra
Gen - comfortable, no acute distress
HEENT - PERRL, sclera icteric, mucous membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - palpable liver extending 8 cm below costal border and
across midline, mildly tender to palp, distended, normoactive
bowel sounds
Extr - trace edema in LEs. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, no asterixis
Skin - + jaundice, +palmar erythema
rectal: in ED, black stool, guaiac positive

FAMILY HISTORY: fh: Father with polycythemia or hemachromatosis,treated with
periodic phlebotomy until death at 74yrs. Mother with DM2, HTN.
Daughter with MS.

SOCIAL HISTORY: sh: lives with wife, [**Name (NI) **] 1 ppd x 50 yrs, etoh: 4 drinks/wk, no
illicits, mechanical engineer
Malignant neoplasm of liver, primary,Acute and subacute necrosis of liver,Hepatorenal syndrome,Acute kidney failure, unspecified,Cirrhosis of liver without mention of alcohol,Other ascites,Portal vein thrombosis,Polycythemia vera,Unspecified essential hypertension
Mal neo liver, primary,Acute necrosis of liver,Hepatorenal syndrome,Acute kidney failure NOS,Cirrhosis of liver NOS,Ascites NEC,Portal vein thrombosis,Polycythemia vera,Hypertension NOS
Admission Date:  [**2118-4-8**]              Discharge Date:   [**2118-4-14**]

Date of Birth:  [**2052-8-17**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 330**]
Chief Complaint:
jaundice/abdominal swelling


Major Surgical or Invasive Procedure:
hemodialysis line placement


History of Present Illness:
HPI: 65 yo M with h/o HTN p/w increasing abdominal girth and
jaundice found to have liver failure and erythrocytosis. Pt was
in his USOH until approximately 4 weeks ago when he developed
increasing abdominal swelling, yellowed skin and worsening
fatigue. He gained approximately 10 pounds over 2 weeks before
seeing his PCP who noted some abnormal labs. Pt recalls that he
had an elevated creatinine and bilirubin. He was referred by his
PCP to [**Name Initial (PRE) **] gastroenterologist. Pt had an EGD performed which
demonstrated no varices per the pt, though it did demonstrated
"small ulcers." Pt also had a CT torso [**2118-3-25**] at [**Hospital1 **]
showing an enlarged and heterogeneous liver, indicating either
cirrhosis with regenerating nodules or dysplastic nodules. The
pt was started on diuretics and lost approximately 12 pounds.
The patient's gastroenterologist recommended the pt be
electively admitted to [**Hospital1 18**] for further evaluation.
.
In the ED, vitals: t95, bp 110/64, hr 56, rr 16, sat 97% ra.
Labs notable for hct initially 70->66, plt 146. BUN 75, cr 3.5.
AG 23. INR 3.5. AST 184, ALT 48. T bili 55, d bili 30, AP 238.
S/U tox negative. U/A with 3-5 wbcs, mod bacteria. CXR neg for
an acute process. Abd u/s with portal vein thrombosis and
cirrhotic liver. ekg: nsr@61 bpm, rbbb. Heme saw pt for
erythrocytosis and phlebotomized one unit from pt. Pt
transferred to the MICU for further management.
.
ROS: As above, otherwise denies CP/SOB/fever.


Past Medical History:
hypertension

Social History:
sh: lives with wife, [**Name (NI) **] 1 ppd x 50 yrs, etoh: 4 drinks/wk, no
illicits, mechanical engineer


Family History:
fh: Father with polycythemia or hemachromatosis,treated with
periodic phlebotomy until death at 74yrs. Mother with DM2, HTN.
Daughter with MS.


Physical Exam:
Temp 97.1
BP 94/55
Pulse 62
Resp 20
O2 sat 96% ra
Gen - comfortable, no acute distress
HEENT - PERRL, sclera icteric, mucous membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - palpable liver extending 8 cm below costal border and
across midline, mildly tender to palp, distended, normoactive
bowel sounds
Extr - trace edema in LEs. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, no asterixis
Skin - + jaundice, +palmar erythema
rectal: in ED, black stool, guaiac positive


Pertinent Results:
ekg: nsr@61 bpm, rbbb
.
abd u/s:
IMPRESSION:
1. Left portal vein thrombosis. This finding appears to have
been present on prior ultrasound and CT examinations.
.
2. Biliary sludge and stones but no secondary findings to
suggest acute cholecystitis. Trace amount of pericholecystic
fluid and hepatic dome
ascites.
.
3. Diffusely heterogeneous and coarsened liver echotexture with
nodular external contour, likely related to underlying
cirrhosis. No focal underlying intrahepatic masses were
identified. A biopsy may be of benefit for pathologic
evaluation.
.
cxr:
IMPRESSION: No acute intrathoracic pathology including no
pneumonia
.
[**2118-4-8**] 10:35PM   HAPTOGLOB-LESS THAN
[**2118-4-8**] 09:30PM URINE  HOURS-RANDOM
[**2118-4-8**] 09:30PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2118-4-8**] 09:30PM URINE  COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2118-4-8**] 09:30PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-1 PH-7.0 LEUK-TR
[**2118-4-8**] 09:30PM URINE  RBC-[**6-28**]* WBC-[**3-23**] BACTERIA-MOD
YEAST-NONE EPI-[**6-28**] TRANS EPI-[**3-23**] RENAL EPI-[**3-23**]
[**2118-4-8**] 09:30PM URINE  BILICRYST-MOD
[**2118-4-8**] 06:50PM   WBC-6.8 RBC-6.67* HGB-21.5* HCT-66.7*
MCV-100* MCH-32.2* MCHC-32.1 RDW-22.9*
[**2118-4-8**] 06:50PM   HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-1+ POLYCHROM-2+ STIPPLED-1+ HOW-JOL-1+
PAPPENHEI-1+
[**2118-4-8**] 06:50PM   PLT SMR-LOW PLT COUNT-146*
[**2118-4-8**] 05:50PM   estGFR-Using this
[**2118-4-8**] 05:50PM   LIPASE-38
[**2118-4-8**] 05:50PM   ALBUMIN-3.7 IRON-85
[**2118-4-8**] 05:50PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2118-4-8**] 05:50PM   WBC-7.37 RBC-7.08* HGB-22.3* HCT-70.6*
MCV-100* MCH-31.5 MCHC-31.6 RDW-21.1*
[**2118-4-8**] 05:50PM   HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-1+ POLYCHROM-2+ STIPPLED-1+ PAPPENHEI-1+
[**2118-4-8**] 05:50PM   PLT SMR-LOW PLT COUNT-147*
[**2118-4-8**] 05:50PM   PT-33.8* PTT-58.8* INR(PT)-3.5*

Brief Hospital Course:
65 year old man with history of hypertension p/w increasing
abdominal girth and jaundice found to have liver failure, renal
failure and erythrocytosis
.
Liver failure: On admission, the ultrasound demonstrated that
the patient's liver was diffusely heterogeneous with no discreet
mass. Imaging was consistent with cirrhosis, though biopsy would
be needed to confirm diagnosis. The differential diagnosis was
broad, including infectious disease, autoimmune disease, and
inherited disorders, such as hemosiderosis, which was strongly
considered given the positive family history. The liver service
was consulted and a full work-up was initiated. Hepatitis
serologies were unremarkable. An AFP> 1 million was concerning
for HCC. Iron studies were suggestive of hemochromatosis and
hemochromatosis gene analysis was positive for a homozygous
C282Y mutation. An abdominal MRI demonstrated background
hemosiderosis, a large left lobe liver mass compatible with
hepatoma invading left portal vein with left portal vein
thrombosis, and additional multifocal areas of signal
abnormality scattered throughout both lobes of liver compatible
with multifocal hepatoma. It was felt that the patient had
developed cirrhosis secondary to hemochromatosis and in turn
developed malignant transformation. The liver oncology service
was consulted and felt that given the multifocal involvement,
locoregional therapies or transplantation were not indicated.
Sorafenib was felt to be of limited benefit. The patient
declined further aggressive chemotherapy and elected to be
comfort measures only. He was discharged home with hospice.
.
erythrocytosis: The differential diagnosis included polycythemia
[**Doctor First Name **] vs. epo producing neoplasm such as hepatocellular
carcinoma. The patient had an elevated epo level and evidence of
HCC as above. The patient was treated with serial phlebotomy per
the hematology service.
.
renal failure: The renal service was consulted. The patient was
felt to have hepatorenal syndrome. Dialysis was initiated
in-house and was discontinued on discharge given the change
toward hospice care.
.
portal vein thrombus: Felt to likely be associated with HCC.
Anti-coagulation was initially held given the patient's occult
blood positive stool. Further therapy was held given the
patient's change in goals of care toward palliation.
.
hypertension: The patient's home medications were held given his
borderline blood pressures throughout the admission.
.
FEN: The patient was placed on a renal diet. He was given
dextrose IV as needed for hypoglycemia.
.
ppx: The patient was placed on heparin sc throughout the
admission.
.
Communication: Multiple family meetings were held with the
patient, his wife and children involved.


Medications on Admission:
Toprol XL
another antihypertensive - name not known
2 new diuretics, name unknown

Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Comfort medications per discharge planning sheet.


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **]

Discharge Diagnosis:
liver failure, suspected hepatocellular carcinoma
hepatorenal syndrome
erythrocytosis


Discharge Condition:
The patient is comfortable.


Discharge Instructions:
The patient is being discharged home with hospice.
{'Malignant neoplasm of liver, primary,Acute and subacute necrosis of liver,Hepatorenal syndrome,Acute kidney failure, unspecified,Cirrhosis of liver without mention of alcohol,Other ascites,Portal vein thrombosis,Polycythemia vera,Unspecified essential hypertension'}


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: jaundice/abdominal swelling

PRESENT ILLNESS: HPI: 65 yo M with h/o HTN p/w increasing abdominal girth and
jaundice found to have liver failure and erythrocytosis. Pt was
in his USOH until approximately 4 weeks ago when he developed
increasing abdominal swelling, yellowed skin and worsening
fatigue. He gained approximately 10 pounds over 2 weeks before
seeing his PCP who noted some abnormal labs. Pt recalls that he
had an elevated creatinine and bilirubin. He was referred by his
PCP to [**Name Initial (PRE) **] gastroenterologist. Pt had an EGD performed which
demonstrated no varices per the pt, though it did demonstrated
"small ulcers." Pt also had a CT torso [**2118-3-25**] at [**Hospital1 **]
showing an enlarged and heterogeneous liver, indicating either
cirrhosis with regenerating nodules or dysplastic nodules. The
pt was started on diuretics and lost approximately 12 pounds.
The patient's gastroenterologist recommended the pt be
electively admitted to [**Hospital1 18**] for further evaluation.
.
In the ED, vitals: t95, bp 110/64, hr 56, rr 16, sat 97% ra.
Labs notable for hct initially 70->66, plt 146. BUN 75, cr 3.5.
AG 23. INR 3.5. AST 184, ALT 48. T bili 55, d bili 30, AP 238.
S/U tox negative. U/A with 3-5 wbcs, mod bacteria. CXR neg for
an acute process. Abd u/s with portal vein thrombosis and
cirrhotic liver. ekg: nsr@61 bpm, rbbb. Heme saw pt for
erythrocytosis and phlebotomized one unit from pt. Pt
transferred to the MICU for further management.
.
ROS: As above, otherwise denies CP/SOB/fever.

MEDICAL HISTORY: hypertension

MEDICATION ON ADMISSION: Toprol XL
another antihypertensive - name not known
2 new diuretics, name unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp 97.1
BP 94/55
Pulse 62
Resp 20
O2 sat 96% ra
Gen - comfortable, no acute distress
HEENT - PERRL, sclera icteric, mucous membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - palpable liver extending 8 cm below costal border and
across midline, mildly tender to palp, distended, normoactive
bowel sounds
Extr - trace edema in LEs. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, no asterixis
Skin - + jaundice, +palmar erythema
rectal: in ED, black stool, guaiac positive

FAMILY HISTORY: fh: Father with polycythemia or hemachromatosis,treated with
periodic phlebotomy until death at 74yrs. Mother with DM2, HTN.
Daughter with MS.

SOCIAL HISTORY: sh: lives with wife, [**Name (NI) **] 1 ppd x 50 yrs, etoh: 4 drinks/wk, no
illicits, mechanical engineer 

### Response:
{'Malignant neoplasm of liver, primary,Acute and subacute necrosis of liver,Hepatorenal syndrome,Acute kidney failure, unspecified,Cirrhosis of liver without mention of alcohol,Other ascites,Portal vein thrombosis,Polycythemia vera,Unspecified essential hypertension'}
