CHIEF COMPLAINT: Abdominal pain and fever

PRESENT ILLNESS: 52 yo F with a past medical history of Crohn's disease and
recent post-ERCP pancreatitis c/ pseudocyst formation was
transferred to the [**Hospital1 18**] from an OSH with abdominal pain and
fevers to 102.  The pt was previously admitted to [**Hospital1 18**] from
[**Date range (2) 80978**] with post-ERCP pancreatitis complicated by
pancreatic necrosis and pseudocyst formation.  Her course was
complicated by C. diff associated diarrhea, and she was
discharged on PO Flagyl and PO Vancomycin as well as TPN with a
small amount of PO intake.

MEDICAL HISTORY: PMH:
- ERCP pancreatitis with estimated 50% pancreatic necrosis
- restless leg syndrome
- Crohns disease
- B/L ovarian cancer [**2141**] s/p TAH/SBO and chemotherapy
- GERD

MEDICATION ON ADMISSION: Lomotil, Requip 1mg qhs, Zoldipem 5mg PO QHS PRN, Omeprazole
20mg PO daily.

ALLERGIES: Ciprofloxacin Er

PHYSICAL EXAM: On Admission:
.
Temp 102.6  HR 107  BP 130/62  95%5L
GENERAL: NAD, ill-appearing; alert and responsive.
HEENT: Sclerae anicteric. Mucous membranes moist,intact.
HEART: Tachycardic, no murmurs appreciated.
LUNGS: Diminished breath sounds at bases; faint crackles at
bases
ABDOMEN: Well-healed RUQ and vertical midline scars present.
Soft, distended, diffusely tender to palpation without guarding
or peritoneal signs.
EXTREM: No peripheral edema.
.
On Discharge:
T 98.7 HR 88 BP 121/76 RR 18 96%RA
GENERAL: NAD, AOx3
HEENT:  No scleral icterus.
HEART: RRR, no MRG
LUNGS: CTA bilaterally
ABD: soft, nontender, nondistended
Extremities:  No cyanosis, clubbing or edema

FAMILY HISTORY: Father died of CA of the esophagus. Three healthy siblings.

SOCIAL HISTORY: No cigarettes; occasional alcohol. She does not drink coffee.
Lives with husband; retired from the VA where she worked as a
nursing assistant
Cyst and pseudocyst of pancreas,Other and unspecified mycoses,Other respiratory complications,Regional enteritis of unspecified site,Unspecified pleural effusion,Other and unspecified infection due to central venous catheter,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Restless legs syndrome (RLS),Personal history of malignant neoplasm of ovary
Pancreat cyst/pseudocyst,Mycoses NEC & NOS,Respiratory comp NEC,Regional enteritis NOS,Pleural effusion NOS,Oth/uns inf-cen ven cath,DMII wo cmp nt st uncntr,Esophageal reflux,Restless legs syndrome,Hx of ovarian malignancy
Admission Date:  [**2150-4-27**]              Discharge Date:   [**2150-5-25**]

Date of Birth:  [**2098-3-21**]             Sex:   F

Service: SURGERY

Allergies:
Ciprofloxacin Er

Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain and fever

Major Surgical or Invasive Procedure:
Pancreatic pseudocyst gastrostomy [**2150-4-30**].


History of Present Illness:
52 yo F with a past medical history of Crohn's disease and
recent post-ERCP pancreatitis c/ pseudocyst formation was
transferred to the [**Hospital1 18**] from an OSH with abdominal pain and
fevers to 102.  The pt was previously admitted to [**Hospital1 18**] from
[**Date range (2) 80978**] with post-ERCP pancreatitis complicated by
pancreatic necrosis and pseudocyst formation.  Her course was
complicated by C. diff associated diarrhea, and she was
discharged on PO Flagyl and PO Vancomycin as well as TPN with a
small amount of PO intake.

The patient presented to [**Hospital **] Hospital on [**2150-4-20**] with
persistent abdominal pain, fevers, and shortness of breath.
Broad spectrum antiobiotics were started for presumptive
infected pancreatic necrosis.  She underwent a CT
scan which demonstrated persistent pancreatic collections.  She
continued to spike fevers to 102 and experience respiratory
decompensation requiring ICU care at [**Hospital **] Hospital.  She was
transferred to [**Hospital1 18**] SICU for further management.

Past Medical History:
PMH:
- ERCP pancreatitis with estimated 50% pancreatic necrosis
- restless leg syndrome
- Crohns disease
- B/L ovarian cancer [**2141**] s/p TAH/SBO and chemotherapy
- GERD

PSH:
- s/p cholecystectomy
- s/p appendectomy
- s/p TAH/BSO (chemotherapy)
- s/p L nephrectomy for ovarian metastases

Social History:
No cigarettes; occasional alcohol. She does not drink coffee.
Lives with husband; retired from the VA where she worked as a
nursing assistant

Family History:
Father died of CA of the esophagus. Three healthy siblings.


Physical Exam:
On Admission:
.
Temp 102.6  HR 107  BP 130/62  95%5L
GENERAL: NAD, ill-appearing; alert and responsive.
HEENT: Sclerae anicteric. Mucous membranes moist,intact.
HEART: Tachycardic, no murmurs appreciated.
LUNGS: Diminished breath sounds at bases; faint crackles at
bases
ABDOMEN: Well-healed RUQ and vertical midline scars present.
Soft, distended, diffusely tender to palpation without guarding
or peritoneal signs.
EXTREM: No peripheral edema.
.
On Discharge:
T 98.7 HR 88 BP 121/76 RR 18 96%RA
GENERAL: NAD, AOx3
HEENT:  No scleral icterus.
HEART: RRR, no MRG
LUNGS: CTA bilaterally
ABD: soft, nontender, nondistended
Extremities:  No cyanosis, clubbing or edema

Pertinent Results:
[**2150-4-27**] 05:52PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5
LEUK-MOD
[**2150-4-27**] 05:52PM URINE  RBC-[**5-20**]* WBC-[**2-12**] BACTERIA-MOD YEAST-FEW
EPI-[**10-30**]
[**2150-4-27**] 04:45PM   GLUCOSE-135* UREA N-15 CREAT-0.7 SODIUM-129*
POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-29 ANION GAP-11
[**2150-4-27**] 04:45PM   ALT(SGPT)-20 AST(SGOT)-30 LD(LDH)-297* ALK
PHOS-135* AMYLASE-447* TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1
[**2150-4-27**] 04:45PM   LIPASE-114*
[**2150-4-27**] 04:45PM   ALBUMIN-2.5* CALCIUM-7.8* PHOSPHATE-2.8
MAGNESIUM-1.7
[**2150-4-27**] 04:45PM   WBC-14.8* RBC-2.72* HGB-7.7* HCT-24.0* MCV-88
MCH-28.4 MCHC-32.2 RDW-14.6
[**2150-4-27**] 04:45PM   NEUTS-92.2* LYMPHS-4.4* MONOS-2.2 EOS-0.9
BASOS-0.2
[**2150-4-27**] 04:45PM   PLT COUNT-532*
[**2150-4-27**] 04:45PM   PT-16.5* PTT-31.2 INR(PT)-1.5*
.
CT ABD/PELVIC W/CONTRAST & CTA W & W/O CONTRAST & RECON:
1. No evidence for pulmonary embolus or acute aortic syndrome,
although
evaluation of the subsegmental pulmonary arteries is limited by
suboptimal
contrast bolus timing.
2. Small bilateral pleural effusions, with adjacent bibasilar
consolidation, which could reflect an element of atelectasis,
although pneumonia is not excluded. Additional area of
ground-glass opacity with nodular center is seen at the right
apex. This could represent infection or pulmonary infarct.
However, malignancy such as bronchoalveolar cell carcinoma is
not excluded, and followup to resolution is recommended.
3. Large pancreatic pseudocyst within the pancreatic bed. There
is minimal
residual normal pancreatic tissue identified.
4. New fluid collection within the right mid abdomen, inferior
to the tip of the liver.
5. Status post left nephrectomy.
6. Thickening and fibrofatty proliferation involving the
terminal ileum.
These changes are consistent with chronic Crohn's disease. There
may
also be inflammatory changes involving the sigmoid colon/rectum.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY:
1. No pulmonary embolism.
2. Interval progression of moderate bilateral pleural effusion.
Unchanged
moderate bibasilar atelectasis.
3. New foci of ground-glass opacities in the prebronchovascular
distribution and new foci of consolidation within both lung
apices. The differential diagnoses include infectious and
inflammatory etiologies.
.
CT ABDOMEN W/CONTRAST:
1. Interval decrease in size of the large pancreatic pseudocyst
within the
pancreatic bed and interval decrease in the size of pseudocyst
located in the right upper quadrant area.
2. New fluid accumulation anterior to the body of the stomach.
It is unclear if this might be post-surgical in nature, status
post cyst gastrotomy.
3. No vascular compromise is noted including no pseudoaneurysm
and no
vascular thrombosis.
4. New mild right hydrouretronephrosis, unclear consequence.
Heterogeneous
enhancement of the right kidney could be seen in setting of
pyelonephritis; please correlate with urinalysis/urine culture.
This was called to Dr. [**Last Name (STitle) 21822**] at 4:30pm, [**2150-5-9**].
5. Slight interval increase in the left pleural effusion and
slight interval improvement in bibasal atelectasis.
.
[**2150-5-19**] CT ABDOMEN/PELVIS W/CONTRAST:
1. Interval decrease in the size of large pancreatic pseudocyst
within the
pancreatic bed and interval decrease in the size of pseudocyst
located in the right upper quadrant area. No new focus of fluid
collection is noted.
2. No vascular compromise is noted including no pseudoaneurysm
and no
thrombosis.
3. Slight decrease in the bibasilar atelectasis.
4. Unchanged small left pleural effusion.
.
[**2150-5-21**] PA CXR:
Interval removal of a right-sided catheter. Progressed left
pleural effusion and associated opacities, likely atelectasis.






Brief Hospital Course:
The patient was transferred from the ICU at [**Hospital1 14579**] in [**Location (un) 8973**] to [**Hospital1 18**] SICU with fevers, abdominal pain
and respiratory decompensation for further evaluation and
management. The patient was NPO with a foley catheter, PIV, and
RICC line in place. An A-line and CVL were placed. Present PICC
line discontinued; tip sent for culture. Infectious Disease
consulted upon admission. Pancultures repeated. IV antibiotics
continued/updated. The patient was hemodynamically stable.

[**4-27**]: admitted to SICU, CVL and A-line placed, 1 unit PRBC, no
PE
[**4-28**]: started micafungin, ECHO, restarted TPN
[**4-29**]: triggered for tachy 180s after albuterol treatment; given
Lopressor 5mg x3 doses, discontinued albuterol nebs, and
switched to xopenex nebs with resultant normalization of heart
rate.
[**4-30**]: To OR for cyst-gastrostomy, admitted to SICU thereafter
[**5-1**]: self-extubated, TPN restarted, KVO, micafungin changed to
fluconazole
[**5-3**]: triggered on floor with desats, transferred to SICU, CT
chest, intubated, A-line placed
[**5-4**]: IP consulted for (L) pleural effusion; declined tap, Lasix
20mg x1
[**5-5**]: vanco trough 30, so evening dose held, recruitment
maneuvers, bronchoscopy secretions without plug, attempted vent
wean, but failed T-piece, Cr 1.2 (1.1), FeNa=1.2, d/c'd Zosyn
switched to Levaquin, 5% albumin x1, Lasix held, urine eos neg,
PEEP incr 7 (5)
[**5-6**]: failed SBT, back on vent [**9-14**], held vanco/decreased dose,
FeNa not c/w prerenal, Lasix, diuresis -2L
[**5-7**]: urine greenish sediment, discontinued PO&IV vancomycin,
discontinued Levaquin, TEE, extubated, sips
[**5-8**]: discontinued NGT, NPO, discontinued (L) SCL CVL, placed
(R) SCL CVL, increased fluconazole to 600, CT abdomen
[**5-9**]: Started on sips, continued on [**Hospital 80979**] transferred to floor.
[**5-10**]: Diet advanced to clears with good tolerability, IV fluid
rate decreased to 25mL/hr, foley discontinued, TPN continued
[**5-11**]: Diet advanced to fulls with good tolerability, IV fluids
discontinued, continued on TPN
[**5-12**]: Beta-glucan sent, ambulated frequently
[**5-13**]: Chest/Abdominal CT performed, Tolerated fulls, continued
on TPN
[**5-14**]: Made NPO for TEE performed today - no endocarditis, diet
then advanced to lactose-restricted regular with Boost
supplement, Reglan started
[**5-15**]: Calorie counts started. Several fevers greater than 101;
CVL discontinued with tip sent for culture.
[**5-16**]: TPN discontinued. CVL tip positive for GPCs. IV Vancomycin
added to Flagyl and Fluconazole.
[**5-17**]: Continued with fever 102; daily blood cultures started.
[**5-18**]: Continued with fever greater than 101. Daily blood
cultures continued. received 1 unit PRBC for HCT 23.7 with
post-transfusion increase to 26.1. Flagyl discontinued.
[**5-19**]: Continued with fever greater than 101. Daily blood
cultures continued. Abdominal/pelvic CT with contrast revealed
interval decrease in size of pseudocyts without new fluid
collections.
[**5-20**]: Temperature decreased. Continued on antibiotics.
Tolerating diet. Stool for C.diff sent.
[**5-21**]: Triggered for SVT with Heart rate 170-180; CXR, EKG,
enzymes, and labwork performed. Cardiology was consulted.
Treated with IV Lopressor x3 followed by Adenosine 6mg IV single
dose with return to SR. Continued on low dose Lopressor.
Remained hemodynamically stable. No further episodes during
hospitalization.
[**5-22**]: Follow-up EKG with NSR. Patient stable. No events.
[**5-23**]: Tolerating diabetic, lactose-free diet. Remained stable
from cardiac standpoint. Glucose monitoring/insulin
administration teaching underway; [**Last Name (un) **] following.
[**5-24**]: Vancomycin discontinued; continued on PO Fluconazole.
Hemodynamically stable.

At the time of discharge on [**2150-5-25**], the patient was doing well,
afebrile with stable vital signs.  The patient was tolerating a
regular lactose-free, diabetic  diet, ambulating, voiding
without assistance, and pain was well controlled.  She will be
discharged home with [**Date Range 269**] Services and home Physical Therapy. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.


Medications on Admission:
Lomotil, Requip 1mg qhs, Zoldipem 5mg PO QHS PRN, Omeprazole
20mg PO daily.


Discharge Medications:
1. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4HOURS as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation four times a day as needed for wheeze.
Disp:*1 HFA* Refills:*2*
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*100 Cap(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
9. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours): Thru [**2150-6-12**].
Disp:*40 Tablet(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime.
Disp:*1 vial* Refills:*2*
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
13. Humalog 100 unit/mL Solution Sig: 1-7 units Subcutaneous As
directed per the Humalog Insulin Sliding Scale.
Disp:*1 vial* Refills:*2*
14. Insulin Syringe-Needle U-100 1 mL 30 x [**4-25**]  Syringe Sig:
One (1) syringe per injection Miscellaneous as directed.
Disp:*1 box* Refills:*2*
15. Lancets,Ultra Thin     Misc Sig: One (1) lancet
 Miscellaneous as directed.
Disp:*1 box* Refills:*0*
16. Alcohol Pads     Pads, Medicated Sig: One (1) pad Topical as
directed.
Disp:*1 box* Refills:*0*
17. One Touch Ultra Test     Strip Sig: One (1) strip In [**Last Name (un) 5153**]
as directed QID.
Disp:*100 strips* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Last Name (un) 269**] of Southeastern Mass.

Discharge Diagnosis:
1. Pancreatic pseudocyst.
2. Fungemia.
3. Type 2 Diabtes Mellitus
4. Single episode SVT


Discharge Condition:
Stable.


Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency  Department for any of the following:

*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons.  Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours.  Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.

Please resume all regular home medications , unless specifically
advised not to take a particular medication.  Also, please take
any new medications as prescribed.

Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.  Avoid lifting
weights greater than [**4-19**] lbs until you follow-up with your
surgeon.

Avoid driving or operating heavy machinery while taking pain
medications.

Incision Care:

*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water.  Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD (covering for Dr. [**Last Name (STitle) **]
Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2150-6-8**] 11:15; Location: [**Hospital Ward Name 23**]
3, [**Hospital Ward Name 516**].

Please call ([**Telephone/Fax (1) 71666**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) 1789**] (PCP) in [**1-13**] weeks. Follow-up issues:
Diabetes/Insulin management, single episode SVT while
hospitalized started on low dose Lopressor, standard
post-operative follow-up.



Completed by:[**2150-5-25**]
{'Cyst and pseudocyst of pancreas,Other and unspecified mycoses,Other respiratory complications,Regional enteritis of unspecified site,Unspecified pleural effusion,Other and unspecified infection due to central venous catheter,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Restless legs syndrome (RLS),Personal history of malignant neoplasm of ovary'}


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: Abdominal pain and fever

PRESENT ILLNESS: 52 yo F with a past medical history of Crohn's disease and
recent post-ERCP pancreatitis c/ pseudocyst formation was
transferred to the [**Hospital1 18**] from an OSH with abdominal pain and
fevers to 102.  The pt was previously admitted to [**Hospital1 18**] from
[**Date range (2) 80978**] with post-ERCP pancreatitis complicated by
pancreatic necrosis and pseudocyst formation.  Her course was
complicated by C. diff associated diarrhea, and she was
discharged on PO Flagyl and PO Vancomycin as well as TPN with a
small amount of PO intake.

MEDICAL HISTORY: PMH:
- ERCP pancreatitis with estimated 50% pancreatic necrosis
- restless leg syndrome
- Crohns disease
- B/L ovarian cancer [**2141**] s/p TAH/SBO and chemotherapy
- GERD

MEDICATION ON ADMISSION: Lomotil, Requip 1mg qhs, Zoldipem 5mg PO QHS PRN, Omeprazole
20mg PO daily.

ALLERGIES: Ciprofloxacin Er

PHYSICAL EXAM: On Admission:
.
Temp 102.6  HR 107  BP 130/62  95%5L
GENERAL: NAD, ill-appearing; alert and responsive.
HEENT: Sclerae anicteric. Mucous membranes moist,intact.
HEART: Tachycardic, no murmurs appreciated.
LUNGS: Diminished breath sounds at bases; faint crackles at
bases
ABDOMEN: Well-healed RUQ and vertical midline scars present.
Soft, distended, diffusely tender to palpation without guarding
or peritoneal signs.
EXTREM: No peripheral edema.
.
On Discharge:
T 98.7 HR 88 BP 121/76 RR 18 96%RA
GENERAL: NAD, AOx3
HEENT:  No scleral icterus.
HEART: RRR, no MRG
LUNGS: CTA bilaterally
ABD: soft, nontender, nondistended
Extremities:  No cyanosis, clubbing or edema

FAMILY HISTORY: Father died of CA of the esophagus. Three healthy siblings.

SOCIAL HISTORY: No cigarettes; occasional alcohol. She does not drink coffee.
Lives with husband; retired from the VA where she worked as a
nursing assistant 

### Response:
{'Cyst and pseudocyst of pancreas,Other and unspecified mycoses,Other respiratory complications,Regional enteritis of unspecified site,Unspecified pleural effusion,Other and unspecified infection due to central venous catheter,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Restless legs syndrome (RLS),Personal history of malignant neoplasm of ovary'}
