CHIEF COMPLAINT: Jaundice and malaise

PRESENT ILLNESS: The patient is a 46 year old female with a history of
hypertension, OSA, and depression who was transferred from [**Hospital1 **] after presenting to the ED there with 4 days of
nausea, vomiting, diarrhea, and worsening jaundice.  She was
hypotensive to the 70s in triage and received IV fluids.  She
was noted to have creatinine 8, TBili 10, and Lipase 3400.  RUQ
ultrasound showed biliary sludge with no visible stone.  CT
abdomen showed colitis.  She was treated with Levofloxacin 500
mg IV and Metronidazole 500 mg IV, and transferred to [**Hospital1 18**] for
ERCP due to concern for biliary obstruction, cholangitis, and
gallstone pancreatitis.
.
In the ED, initial vital signs were T 97.1, BP 103/60, HR 100,
RR 20, SpO2 98% on RA.  She arrived on her seventh liter of NS,
but was still hypotensive in the 90s systolic.  Central access
was obtained with a right IJ line.  She also has access with two
18g PIVs.  Foley catheter was placed for urine output
monitoring.  She was mentating well and in no acute distress.
Initial labs showed multiple electrolyte abnormalities including
Na 126, Ca 6.7, and bicarb 12 with anion gap 16 and lactate 2.3.
 Her creatinine had decreased to 4.6 from 8 at OSH after IV
fluids.  Her LFTs were still abnormal but generally improved
from OSH labs.  She had a leukocytosis with WBC 13.9 and anemia
with Hct 23.6.  Her INR was elevated to 1.6.  Her stool was
guaiac negative.  ERCP and Surgery were consulted in the ED, and
she is planned for ERCP this morning.  She was admitted to the
ICU for further monitoring and management.  Vitals prior to
transfer were BP 114/57, HR 102, and CVP 8.
.
Once in the ICU, she denied any pain or other specific
complaints besides the Foley catheter being uncomfortable.  She
was in no acute distress and mentating well.  She denied any
current nausea or abdominal pain.
.
Review of systems:
(+) Per HPI. She noted some chills at home prior to admission
but no fevers.  She reports losing about 25 lbs over the last
few weeks due to lack of appetite.  She has an occasional cough
which has not changed recently.
(-) Denies fever, night sweats. Denies headache, sinus
tenderness, rhinorrhea, or congestion. Denies shortness of
breath or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies abdominal pain. Denies
dysuria, frequency, urgency, or change in urine. Denies
arthralgias or myalgias. Denies rashes or skin changes besides
jaundice.

MEDICAL HISTORY: # Hypertension
# Obstructive Sleep Apnea
-- uses CPAP at home
# Depression

MEDICATION ON ADMISSION: Lexapro 30 mg PO daily
Lisinopril 10 mg PO daily
Metoprolol 50 mg PO BID
Campral (Acamprosate) 333 mg 2 tabs TID
Omeprazole OTC PO daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T 97.1, BP , HR 107, RR 23, SpO2 100% on RA
General: Alert, oriented, no acute distress
HEENT: Scleral icterus, slightly dry MMs, oropharynx clear
Neck: supple, JVP not elevated, no LAD, right IJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Mildtachycardia with regular rhythm. Normal S1, S2.  Blowing
holosystolic murmur at LLSB with radiation to axilla.
Abdomen: Bowel sounds present.  Soft, non-tender, mildly
distended, no rebound tenderness or guarding.
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema

FAMILY HISTORY: Family History:
# Father: died from lymphoma at age 57
# Mother: CAD with CABG, rapidly progressive dementia recently
# Oldest Sister: died from alcohol abuse
# Sister: cholecystectomy
# Brother: GERD and hypertension

SOCIAL HISTORY: Social History:
# Tobacco: Smoked 1 PPD for five years in the distant past.
# Alcohol: Prior alcohol abuse, none in two years, now on
Campral.
# Illicits: None
# Lives at home with husband, [**Name (NI) **] [**Telephone/Fax (1) 90543**]
Acute pancreatitis,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Other and unspecified coagulation defects,Acute alcoholic hepatitis,Other and unspecified alcohol dependence, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Anemia, unspecified,Obesity, unspecified,Depressive disorder, not elsewhere classified,Family history of other lymphatic and hematopoietic neoplasms
Acute pancreatitis,Acute kidney failure NOS,Hyposmolality,Coagulat defect NEC/NOS,Ac alcoholic hepatitis,Alcoh dep NEC/NOS-unspec,Obstructive sleep apnea,Hypertension NOS,Anemia NOS,Obesity NOS,Depressive disorder NEC,Fam hx-lymph neoplas NEC
Admission Date:  [**2186-6-17**]              Discharge Date:   [**2186-6-28**]

Date of Birth:  [**2140-2-8**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Jaundice and malaise

Major Surgical or Invasive Procedure:
ERCP

History of Present Illness:
The patient is a 46 year old female with a history of
hypertension, OSA, and depression who was transferred from [**Hospital1 **] after presenting to the ED there with 4 days of
nausea, vomiting, diarrhea, and worsening jaundice.  She was
hypotensive to the 70s in triage and received IV fluids.  She
was noted to have creatinine 8, TBili 10, and Lipase 3400.  RUQ
ultrasound showed biliary sludge with no visible stone.  CT
abdomen showed colitis.  She was treated with Levofloxacin 500
mg IV and Metronidazole 500 mg IV, and transferred to [**Hospital1 18**] for
ERCP due to concern for biliary obstruction, cholangitis, and
gallstone pancreatitis.
.
In the ED, initial vital signs were T 97.1, BP 103/60, HR 100,
RR 20, SpO2 98% on RA.  She arrived on her seventh liter of NS,
but was still hypotensive in the 90s systolic.  Central access
was obtained with a right IJ line.  She also has access with two
18g PIVs.  Foley catheter was placed for urine output
monitoring.  She was mentating well and in no acute distress.
Initial labs showed multiple electrolyte abnormalities including
Na 126, Ca 6.7, and bicarb 12 with anion gap 16 and lactate 2.3.
 Her creatinine had decreased to 4.6 from 8 at OSH after IV
fluids.  Her LFTs were still abnormal but generally improved
from OSH labs.  She had a leukocytosis with WBC 13.9 and anemia
with Hct 23.6.  Her INR was elevated to 1.6.  Her stool was
guaiac negative.  ERCP and Surgery were consulted in the ED, and
she is planned for ERCP this morning.  She was admitted to the
ICU for further monitoring and management.  Vitals prior to
transfer were BP 114/57, HR 102, and CVP 8.
.
Once in the ICU, she denied any pain or other specific
complaints besides the Foley catheter being uncomfortable.  She
was in no acute distress and mentating well.  She denied any
current nausea or abdominal pain.
.
Review of systems:
(+) Per HPI. She noted some chills at home prior to admission
but no fevers.  She reports losing about 25 lbs over the last
few weeks due to lack of appetite.  She has an occasional cough
which has not changed recently.
(-) Denies fever, night sweats. Denies headache, sinus
tenderness, rhinorrhea, or congestion. Denies shortness of
breath or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies abdominal pain. Denies
dysuria, frequency, urgency, or change in urine. Denies
arthralgias or myalgias. Denies rashes or skin changes besides
jaundice.


Past Medical History:
# Hypertension
# Obstructive Sleep Apnea
-- uses CPAP at home
# Depression


Social History:
Social History:
# Tobacco: Smoked 1 PPD for five years in the distant past.
# Alcohol: Prior alcohol abuse, none in two years, now on
Campral.
# Illicits: None
# Lives at home with husband, [**Name (NI) **] [**Telephone/Fax (1) 90543**]


Family History:
Family History:
# Father: died from lymphoma at age 57
# Mother: CAD with CABG, rapidly progressive dementia recently
# Oldest Sister: died from alcohol abuse
# Sister: cholecystectomy
# Brother: GERD and hypertension


Physical Exam:
Admission Physical Exam:
Vitals: T 97.1, BP , HR 107, RR 23, SpO2 100% on RA
General: Alert, oriented, no acute distress
HEENT: Scleral icterus, slightly dry MMs, oropharynx clear
Neck: supple, JVP not elevated, no LAD, right IJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Mildtachycardia with regular rhythm. Normal S1, S2.  Blowing
holosystolic murmur at LLSB with radiation to axilla.
Abdomen: Bowel sounds present.  Soft, non-tender, mildly
distended, no rebound tenderness or guarding.
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema

ICU Discharge Physical Exam:
VS Tc 36.7 HR 98 BP 120/66 RR 21 O2 97/RA
General: Alert, oriented, no acute distress
HEENT: Scleral icterus, slightly dry MMs, oropharynx clear
Neck: supple, JVP not elevated, no LAD, right IJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Mild tachycardia with regular rhythm. Normal S1, S2.
Blowing holosystolic murmur at LLSB with radiation to axilla.
Abdomen: normoactive bowel sounds present.  Soft, non-tender,
mildly distended, no rebound tenderness or guarding.
GU: no foley
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema

DISCHARGE EXAM:
Vitals: 97.9 98/62 94 20 95/RA 1000+300/BRP
General: AAOx3 NAD
HEENT: Scleral icterus, MMM, oropharynx clear
Neck: supple, no LAD JVP 3+sternal angle
Lungs: CTAB no r/r/w
CV: RRR. Normal S1, S2. holosystolic mumur LLSB radiates to
axilla.
Abdomen: Soft, non-tender, distended no rebound tenderness or
guarding, liver palpable, +BS
Ext: Warm, well perfused, 2+ pulses. No c/c/e


Pertinent Results:
ADMISSION LABS:
[**2186-6-17**] 01:00AM BLOOD WBC-13.9* RBC-2.28* Hgb-8.1* Hct-23.6*
MCV-104* MCH-35.6* MCHC-34.3 RDW-15.0 Plt Ct-200
[**2186-6-18**] 05:17AM BLOOD WBC-16.4* RBC-2.47* Hgb-8.7* Hct-25.3*
MCV-102* MCH-35.3* MCHC-34.5 RDW-15.1 Plt Ct-202
[**2186-6-17**] 01:00AM BLOOD Neuts-86.8* Lymphs-8.5* Monos-2.5 Eos-1.7
Baso-0.4
[**2186-6-18**] 05:17AM BLOOD Plt Ct-202
[**2186-6-18**] 05:17AM BLOOD PT-18.8* PTT-37.1* INR(PT)-1.7*
[**2186-6-18**] 05:17AM BLOOD Glucose-100 UreaN-32* Creat-1.7*# Na-137
K-4.0 Cl-105 HCO3-18* AnGap-18
[**2186-6-17**] 05:58AM BLOOD Glucose-91 UreaN-53* Creat-3.7* Na-131*
K-4.0 Cl-102 HCO3-14* AnGap-19
[**2186-6-18**] 05:17AM BLOOD ALT-50* AST-170* LD(LDH)-429*
AlkPhos-497* TotBili-8.4*
[**2186-6-17**] 01:00AM BLOOD ALT-53* AST-149* AlkPhos-463*
TotBili-8.8*
[**2186-6-18**] 05:17AM BLOOD Lipase-514*
[**2186-6-17**] 01:00AM BLOOD Lipase-760*
[**2186-6-17**] 05:58AM BLOOD TotProt-5.3* Calcium-6.7* Phos-3.6 Mg-1.6
Iron-50
[**2186-6-17**] 05:58AM BLOOD calTIBC-163* VitB12-1777* Folate-6.0
Hapto-142 Ferritn-921* TRF-125*
[**2186-6-17**] 12:34AM BLOOD Lactate-2.3* K-4.5
.
DSICHARGE LABS:
[**2186-6-28**] 06:13AM BLOOD WBC-19.2* RBC-2.39* Hgb-8.4* Hct-25.2*
MCV-106* MCH-35.2* MCHC-33.3 RDW-17.1* Plt Ct-252
[**2186-6-28**] 06:13AM BLOOD Glucose-93 UreaN-13 Creat-1.2* Na-134
K-4.0 Cl-100 HCO3-24 AnGap-14
[**2186-6-28**] 06:13AM BLOOD ALT-29 AST-113* LD(LDH)-202 AlkPhos-324*
TotBili-11.1*
[**2186-6-28**] 06:13AM BLOOD Albumin-2.9* Calcium-9.0 Phos-4.7* Mg-2.2
.
OTHER PERTINENT LABS:
[**2186-6-17**] 05:58AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2186-6-17**] 05:58AM BLOOD HCV Ab-NEGATIVE
[**2186-6-19**] 04:55AM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
[**2186-6-19**] 04:55AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2186-6-17**] 05:58AM BLOOD PEP-NO SPECIFI IgG-1232 IgA-424* IgM-138
IFE-NO MONOCLO
[**2186-6-19**] 04:55AM BLOOD tTG-IgA-61*
[**2186-6-17**] 05:58AM BLOOD calTIBC-163* VitB12-1777* Folate-6.0
Hapto-142 Ferritn-921* TRF-125*
[**2186-6-19**] 04:55AM BLOOD TSH-13*
[**2186-6-19**] 04:55AM BLOOD T4-7.2 T3-56*
.
--------
--------
MICRO
[**6-17**], [**6-20**], [**6-21**], [**6-22**], 8/5 Blood Cultures NEGATIVE except [**11-20**]
bottles on [**6-20**] which grew:
Blood Culture, Routine (Final [**2186-6-26**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.
         Isolated from only one set in the previous five days.
         SENSITIVITIES PERFORMED ON REQUEST..
   Aerobic Bottle Gram Stain (Final [**2186-6-22**]):
      Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2186-6-22**] 8:45AM
9-0958.
      GRAM POSITIVE COCCI IN CLUSTERS.
-------
-------
IMAGING
.
[**6-17**] CXR:
INDICATION: Central line placement.
COMPARISON: None available.
FRONTAL RADIOGRAPH OF THE CHEST: A right internal jugular
central venous line terminates with the tip at the upper
cavoatrial junction. There is no
pneumothorax. Lung volumes are low with resultant vascular
crowding. Cardiac silhouette is top normal. Mediastinal and
hilar contours are normal. There is no pleural effusion or
pneumothorax.
.
[**6-20**] CXR
IMPRESSION No evidence of pneumonia.
.
[**6-25**] CXR
FINDINGS: In comparison with the study of [**6-20**], there is no
interval change or
evidence of acute cardiopulmonary disease. Specifically, no
pneumonia,
vascular congestion, or pleural effusion.
.
[**6-17**] ERCP
Impression: Successful biliary cannulation was achieved.
Partial opacification of the biliary tree was performed because
of clinical suspicion of cholangitis- no evidence of stones or
filling defects was seen.
Successful placement of a 7cm x 10Fr stent for biliary drainage-
with drainage of clear bile.
Otherwise normal ERCP to 3rd portion of duodenum.
Recommendations: Juices when awake and alert, then advance diet
as tolerated.
Continue antibiotics.
No definitive explanation for jaundice found on ERCP, although
contrast opacification limited. It is possible that the patient
passed a stone. Consider evaluation for other causes of jaundice
including viral hepatitis.  Follow-up ERCP will allow for
complete evaluation of intrahepatics given possibility of PSC.
Repeat ERCP in 4 weeks for stent removal and complete evaluation
of biliary tree.
.
[**6-18**] RUQ US
FINDINGS: The liver is diffusely increased in echogenicity,
consistent with
fatty infiltration of the liver. No focal hepatic mass is
definitely noted.
There is no intrahepatic or extrahepatic ductal dilatation with
the common
bile duct measuring 4mm. However, the known common bile duct
stent is not
visualized. The main portal vein is patent with hepatopetal
flow.

The gallbladder is mildly distended, without wall thickening,
pericholecystic
fluid, or son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. Sludge is visualized within
the
gallbladder. Additionally, there are echogenic foci with dirty
posterior
shadowing in nondependent portions of the gallbladder is
consistent with air
within the gallbladder lumen, likely from recent ERCP and
sphincterotomy.

The spleen is mildly enlarged measuring 13 cm. There is no
ascites.
Bilateral kidneys are without evidence of hydronephrosis. The
pancreas is not
well visualized due to overlying bowel gas.

IMPRESSION:
1. Gallbladder sludge without acute cholecystitis. There is also
evidence of
air within the gallbladder lumen, likely from recent ERCP and
sphincterotomy.
2. Echogenic liver consistent with fatty infiltration of the
liver. More
significant liver disease including significant hepatic
fibrosis/cirrhosis
cannot be excluded based on this study.
3. No biliary dilatation, although the common bile duct stent is
not
visualized.
.
[**6-21**] MRCP
MR ABDOMEN WITH IV CONTRAST: There is marked diffuse fatty
deposition of the
liver in addition to more focal areas of almost mass-like fatty
deposition
surrounding the gallbladder fossa (3A:9, 12). There is also
deposits of
increased fat within the periphery of the liver. There is a
heterogeneous
enhancement pattern to the liver suggesting diffuse liver
disease beyond fatty
deposition. This appearance could be seen with chronic fibrosis,
although
there are no other findings on this study to suggest cirrhosis.
The hepatic
and portal veins are patent. There is no intra- or extra-hepatic
biliary
dilation.

A stent is noted in place within the common bile duct. While
there is mild
enhancement of the bile duct wall at the level of the stent,
above the level
of the stent, the bile ducts do not demonstrate any abnormal
enhancement to
suggest cholangitis.

There is diffuse gallbladder wall edema which is likely related
to the
underlying liver process. There is no hyperenhancement of the
gallbladder
wall or surrounding liver to suggest acute cholecystitis. The
gallbladder
contains sludge.

No pancreatic mass is identified. The pancreas demonstrates
normal
homogeneous enhancement throughout. The pancreatic duct appears
normal. There
is small amount of peripancreatic fluid/edema consistent with
patient's
diagnosis of acute pancreatitis. The splenic vein and superior
mesenteric
veins remain patent. There are no fluid collections.

There is a trace amount of perihepatic and perisplenic ascites.
The spleen,
adrenal glands, kidneys, and stomach are within normal limits.
There is no
retroperitoneal or mesenteric lymphadenopathy.

IMPRESSION:
1. No evidence of pancreatic mass. Small amount of
peripancreatic fluid/edema
is consistent with uncomplicated acute pancreatitis. Trace
perihepatic and
perisplenic ascites.

2. Marked diffuse fatty deposition in the liver. However,
heterogeneous
enhancement of the liver suggests diffuse liver disease beyond
fatty liver,
possibly reflecting hepatitis oor fibrosis, though there is not
overt
cirrhosis.

3. Gallbladder wall edema, likely due to underlying liver
disease.
Gallbladder sludge.

4. Biliary stent in place without intra or extraphepatic biliary
dilation.
Mild enhancement of the common bile duct is likely from stent
placement.
There is no evidence of abnormal biliary ductal enhancement
above the level of
the stent to suggest cholangitis.

.
[**6-28**] ECHO
Findings
LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.

LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Estimated cardiac
index is normal (>=2.5L/min/m2). TDI E/e' < 8, suggesting normal
PCWP (<12mmHg). No resting LVOT gradient.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild thickening of mitral valve chordae. No MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR. Moderate PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Suboptimal image quality - poor apical views.

Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mitral regurgitation is seen. There is mild
to moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.

IMPRESSION: Normal global and regional biventricular systolic
function. Mild to moderate pulmonary hypertension.


Brief Hospital Course:
46 year old female with a medical history of hypertension &
depression transferred from [**Hospital6 2561**] after
presenting with 4 days of nausea, vomiting, diarrhea, and
worsening jaundice. Admitted to the ICU, found to have acute
alcoholic pancreatitis and hepatitis.
.
# Acute Alcoholic Pancreatitis:
Pt presented to OSH with symptoms consistent with acute
pancreatitis. The patient has a history of alcohol abuse, but
initial denied alcohol use within the past 2 years, so gallstone
pancreatitis was suspected. RUQ ultrasound at OSH reportedly
showed sludge without visible stone. She underwent ERCP with CBD
stent placement. Lipase was initially quite elevated and trended
down moderately after aggressive IVF. Other possible causes for
her pancreatitis were explored, including the possibility of
abdominal trauma suffered in a single-car accident the patient
suffered two weeks before this admission. However, MRCP was
negative. When TTG was elevated and patient was confronted with
the lack of other explanations for her acute
pancreatitis/hepatitis, she admitted to drinking 1.5 bottles of
wine/day prior to admission (see below, alcohol abuse).
.
# Acute Alcoholic Hepatitis:
Pt also presented with elevated LFTs and jaundice. Alcoholic
hepatitis was diagnosed when biliary obstruction and viral
hepatitis were ruled out. She had initially been started on
antibiotics in the ED, but these were stopped given lack of
concern for infection. Patient provided additional history of
recent MVA with 6 g/day tylenol use for 3 days thereafter
([**Date range (1) 24996**]) + intermittent alcohol use. Hepatology was consulted
in the ICU with concern for PSC or other liver parenchymal
process, in addition to alcohol and possible tylenol overdose;
the patient was transferred to the hepatology service after
discharge from the ICU. Her leukocytosis persisted, LFTs
remained elevated and she continued to spike fevers. These were
thought to be [**12-21**] underlying alcoholic hepatitis rather than
infection, especially since only 1 bottle of many many blood
culture samples was ever positive for bacterial growth, and thus
was thought to be a lab contaminant. She received a 7-day course
of vancomycin, then was started on pentoxyfilline.
.
# Coagulopathy:
Related to hepatitis. The patient??????s INR was elevated to 1.6 on
arrival at the [**Hospital1 18**] ED. She does not have a reported history of
liver disease and is not on anticoagulation at home. Best
explained by new diagnosis of acute alcoholic hepatitis.
.
# Hypotension:
Related to pancreatitis. Patient was hypotensive on admission
with SBP 90s despite receiving significant IV fluids at OSH.
Her hypotension was likely related to fluid shifts from acute
alcoholic pancreatitis rather than sepsis. SBP improved to the
110s with IV fluids. She was restarted on a decreased dose of
home metoprolol (25 mg QD) but home lisinopril was held given
acute renal injury (below). Lisinopril was restarted at
discharge.
.
# Hyponatremia:
Related to pancreatitis/hepatitis. Resolved with current Na 137
in the ICU, up from 126 on admission and 123 at OSH.  This
likely represented hypovolemic hyponatremia from her
pancreatitis and volume depletion from GI losses and poor PO
intake.
.
# [**Last Name (un) **]:
Creatinine 8.0 on admission to OSH, fell gradually during this
admission, to 1.2 at discharge. Baseline creatinine was unknown.
The most likely etiology was prerenal from hypotension and fluid
shifts in the context of pancreatitis. Maintained urine output
in the context of aggressive IVF hydration as above.
.
# Metabolic Acidosis:
Patient had an anion gap acidosis at the OSH. Lactate was 1.2 at
OSH and 2.3 here.  Acidosis thought to be related to
pancreatitis, [**Last Name (un) **], and ketones from alcohol intake/poor
nutrition prior to admission. Resolved by time of discharge,
with bicarb 24 and anion gap 10.
.
# Anemia:
Hct was 28.2 at OSH. Baseline Hct unknown.  She reports recent
diarrhea that was sometimes black, but her stool was guaiac
negative in the ED.  She has not had a menstrual period since
[**Month (only) 404**].  Her RBCs are macrocytic with MCV 104. Iron panel was
difficult to interpret in the setting of her current acute
illness. Hct was trended, iron panel, B12, and folate were
checked. She received B12, folate, and iron supplementation
during this admission.
.
# Leukocytosis:
Patient presented with a leukocytosis, WBC 13.9; this rose
during admission. Attributed to alcoholic hepatitis. Cultures
all negative apart from a single spuriously-positive GPC blood
culture. WBC remained >15 after treatment with vancomycin.
.
# Depression:
Reports 25-lb weight loss in past 3 weeks secondary to stress.
She is on Lexapro for depression and . These should be held for
now pending improvement in her renal and hepatic function, both
of which are currently impaired. Recent alcohol use likely
contributed to her current presentation, and should be
readdressed prior to and after discharge as she will continue to
need support for this ongoing issue.
.
# Alcohol Abuse:
Patient has longstanding history of alcohol abuse; she sees a
therapist [**Hospital1 **]-weekly and a psychopharmacologist for Campral
prescription. Denies alcohol use within the past 2 years until
confronted with laboratory data (GGT) confirming her providers'
suspicion of ongoing alcohol use. Family meeting was held prior
to discharge, to discuss prognosis for alcoholic hepatitis,
request that husband remove all alcohol from the home, agree
upon a plan for post-discharge detox program, and to re-inforce
the absolute importance of abstinence for her survival.
Inpatient social work has arranged for outpatient detox, to
begin the Monday after discharge ([**7-3**]); patient was unwilling
to be discharged directly to a detox facility. Outpatient
therapist aware and will follow-up; psychopharmacologist alerted
by telephone.
.
# Recent motor vehicle accident:
Large bruise noted on pt's lower back during physical
examination in the ICU. Pt reported history of a single-vehicle
car accident on [**6-5**]: she drove over two curbs in trying to
avoid other drivers, resulting in two blown tires. She denies
steering wheel impact and did not seek police or medical
attention after the accident. Denied alcohol use prior to this
accident. Took 6 g/day tylenol in the 3 days following, which
may have contributed to her liver failure.

TRANSITIONAL ISSUES
1. ***Alcohol abuse follow-up.*** Patient has agreed to
inpatient detox but wanted to go home first to see her
8-year-old son. Inpatient social worker [**Name (NI) 636**] [**Name (NI) 12471**] and
outpatient therapist will follow-up to ensure this happens.

Medications on Admission:
Lexapro 30 mg PO daily
Lisinopril 10 mg PO daily
Metoprolol 50 mg PO BID
Campral (Acamprosate) 333 mg 2 tabs TID
Omeprazole OTC PO daily

Discharge Medications:
1. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain: Please limit to 2gm.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lexapro 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Campral 333 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO three times a day.
10. pentoxifylline 400 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO TID (3 times a day).
Disp:*90 Tablet Extended Release(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnoses:
Alcoholic Pancreatitis
Alcoholic Hepatitis
.
Secondary Diagnoses:
Depression
Alcohol Abuse
Sleep Apnea
Hypertension


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


Discharge Instructions:
Thank you for allowing us to participate in your care.
.
You were admitted to the hospital for abdominal pain and
jaundice.
.
You underwent an endoscopic procedure called ERCP, to visualize
your gallbladder and biliary tree. No gallstones or obstruction
was seen. A stent was placed in the bile duct, to allow free
drainage of bile into your intestines, in case there was some
mild obstruction not seen on the test.
.
Your liver and pancreas enzyme levels were followed during this
admission. These were very elevated when you first arrived, but
they trended down with IV fluids and time. However, they were
still elevated at the time of discharge and you were still
jaundiced. You were not having any abdominal pain. We looked for
infection but did not see any signs. The inflammation in your
pancreas and liver appeared to be from another non-infectious
cause.
.
We thought your liver and pancreas inflammation was due to
alcohol consumption. Lab tests showed that this was true. You do
have several reasons for increased stress in your life recently.
You met with a social worker during this hospitalization who
will help coordinate your care after you leave the hospital. We
felt it was very important that you get adequate support after
you leave the hospital so that you can stay sober. Drinking
alcohol will further injury your pancreas and liver, which are
already fragile. You will see your own therapist, [**Female First Name (un) **], twice a
week from now on. She will help you follow-through with your
intention to enroll in a full-time alcohol detox program within
a week after leaving the hospital.
.
When you first arrived, we treated you with intravenous
antibiotics to fight a possible bacterial infection in your
gallbladder. Later we gave you antibiotics again when we
suspected an infection in your blood. Laboratory tests showed
that you were not infected at the time you left the hospital.
.
We made the following changes to your medications:
1. We DECREASED your metoprolol dose to 25 mg per day.
2. We STARTED you on Pentoxifylline 400 mg PO three times daily
3. We STARTED you on multivitamins and thiamine which you should
take daily
.
Please continue to take all other medications as prescribed, or
as instructed by your doctor.
.

Followup Instructions:
We arranged a follow-up appointment with your primary care
doctor:

Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **]
Location: [**Hospital **] MEDICAL ASSOCIATION
Address: [**Apartment Address(1) 83440**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 26774**]
Appointment: Friday [**6-30**] 2:15 PM
.
Please call Dr.[**Name (NI) 90544**] office if you need to reschedule this
appointment.

Please also call your Psychopharmacologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 90545**] at [**Telephone/Fax (1) 90546**] to book a follow up appointment within
1 week.
.
You should also see your therapist next week. The [**Hospital1 18**] social
worker will be in contact with your therapist to ensure a smooth
transition so you can receive the support you need.
.
You will also need to follow-up with the ERCP service, to have
the stent removed. Dr[**Name (NI) 90547**] administrator, [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 15954**],
will call you to arrange this appointment. If you don't hear
from her by next Monday, please call her at [**Telephone/Fax (1) 21143**].
{'Acute pancreatitis,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Other and unspecified coagulation defects,Acute alcoholic hepatitis,Other and unspecified alcohol dependence, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Anemia, unspecified,Obesity, unspecified,Depressive disorder, not elsewhere classified,Family history of other lymphatic and hematopoietic neoplasms'}


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 and malaise

PRESENT ILLNESS: The patient is a 46 year old female with a history of
hypertension, OSA, and depression who was transferred from [**Hospital1 **] after presenting to the ED there with 4 days of
nausea, vomiting, diarrhea, and worsening jaundice.  She was
hypotensive to the 70s in triage and received IV fluids.  She
was noted to have creatinine 8, TBili 10, and Lipase 3400.  RUQ
ultrasound showed biliary sludge with no visible stone.  CT
abdomen showed colitis.  She was treated with Levofloxacin 500
mg IV and Metronidazole 500 mg IV, and transferred to [**Hospital1 18**] for
ERCP due to concern for biliary obstruction, cholangitis, and
gallstone pancreatitis.
.
In the ED, initial vital signs were T 97.1, BP 103/60, HR 100,
RR 20, SpO2 98% on RA.  She arrived on her seventh liter of NS,
but was still hypotensive in the 90s systolic.  Central access
was obtained with a right IJ line.  She also has access with two
18g PIVs.  Foley catheter was placed for urine output
monitoring.  She was mentating well and in no acute distress.
Initial labs showed multiple electrolyte abnormalities including
Na 126, Ca 6.7, and bicarb 12 with anion gap 16 and lactate 2.3.
 Her creatinine had decreased to 4.6 from 8 at OSH after IV
fluids.  Her LFTs were still abnormal but generally improved
from OSH labs.  She had a leukocytosis with WBC 13.9 and anemia
with Hct 23.6.  Her INR was elevated to 1.6.  Her stool was
guaiac negative.  ERCP and Surgery were consulted in the ED, and
she is planned for ERCP this morning.  She was admitted to the
ICU for further monitoring and management.  Vitals prior to
transfer were BP 114/57, HR 102, and CVP 8.
.
Once in the ICU, she denied any pain or other specific
complaints besides the Foley catheter being uncomfortable.  She
was in no acute distress and mentating well.  She denied any
current nausea or abdominal pain.
.
Review of systems:
(+) Per HPI. She noted some chills at home prior to admission
but no fevers.  She reports losing about 25 lbs over the last
few weeks due to lack of appetite.  She has an occasional cough
which has not changed recently.
(-) Denies fever, night sweats. Denies headache, sinus
tenderness, rhinorrhea, or congestion. Denies shortness of
breath or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies abdominal pain. Denies
dysuria, frequency, urgency, or change in urine. Denies
arthralgias or myalgias. Denies rashes or skin changes besides
jaundice.

MEDICAL HISTORY: # Hypertension
# Obstructive Sleep Apnea
-- uses CPAP at home
# Depression

MEDICATION ON ADMISSION: Lexapro 30 mg PO daily
Lisinopril 10 mg PO daily
Metoprolol 50 mg PO BID
Campral (Acamprosate) 333 mg 2 tabs TID
Omeprazole OTC PO daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T 97.1, BP , HR 107, RR 23, SpO2 100% on RA
General: Alert, oriented, no acute distress
HEENT: Scleral icterus, slightly dry MMs, oropharynx clear
Neck: supple, JVP not elevated, no LAD, right IJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Mildtachycardia with regular rhythm. Normal S1, S2.  Blowing
holosystolic murmur at LLSB with radiation to axilla.
Abdomen: Bowel sounds present.  Soft, non-tender, mildly
distended, no rebound tenderness or guarding.
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses. No clubbing, cyanosis, or
edema

FAMILY HISTORY: Family History:
# Father: died from lymphoma at age 57
# Mother: CAD with CABG, rapidly progressive dementia recently
# Oldest Sister: died from alcohol abuse
# Sister: cholecystectomy
# Brother: GERD and hypertension

SOCIAL HISTORY: Social History:
# Tobacco: Smoked 1 PPD for five years in the distant past.
# Alcohol: Prior alcohol abuse, none in two years, now on
Campral.
# Illicits: None
# Lives at home with husband, [**Name (NI) **] [**Telephone/Fax (1) 90543**] 

### Response:
{'Acute pancreatitis,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Other and unspecified coagulation defects,Acute alcoholic hepatitis,Other and unspecified alcohol dependence, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Anemia, unspecified,Obesity, unspecified,Depressive disorder, not elsewhere classified,Family history of other lymphatic and hematopoietic neoplasms'}
