CHIEF COMPLAINT: abdominal pain, acute liver failure

PRESENT ILLNESS: 37 YOF nurse who presents with nausea/vomiting and RUQ pain x 3
days. Presented initially to OSH where she was found to have ALT
8856 AST 7932 TB 5.9 and INR 3.4. Creat and bicarb normal. She
then revealed that she has been taking upwards of 6G APAP/day
since [**Month (only) 958**] for back pain. Isn't sure exactly how many tablets
she takes, but estimates 10 extra-strength Tylenol tabs and [**2-28**]
Tylenol PM, as well as occasional Vicodin. Denies poor PO in the
days preceeding onset of sx but since then hasn't been eating
well as oral intake has exacerbated her sx. Denies other toxic
habits/ingestions. Feels sleepy now since she has been up all
night but denies changes in mental status or excessive
sleepiness preceeding presentation. Drinks socially (about [**5-3**]
beers in one sitting, once per week or every 2 weeks) including
the night prior to the onset of her sx. Denies any suicidal
intent.
.
Reports that she lives at home w husband and 5 kids. She was
fired from her nursing job becuase of her back/neck pain, she
reports. She feels happy and safe at home and reports a close
family support system. She does admit to a suicide attempt at
age 14 but doesn't remember the details.
.
In speaking with her huband he reports that she also takes
Fioricet and Nyquil occasionally in addition to the other meds,
and agrees that this was not a deliberate attempt to hurt
herself. He corroborates that she does not use street drugs.

MEDICAL HISTORY: Body Dysmorphic Disorder
Anxiety
chronic neck/back pain [**1-29**] work-related injury
remote hx of OD suicide attempt as teen
GERD
IBS
Bilateral breast augmentation 00' and 04'

MEDICATION ON ADMISSION: Tylenol
Percocet
Klonopin 5mg PRN

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VS - Temp afebrile, BP 91/46, HR 86, R 18, O2-sat 98% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate

FAMILY HISTORY: No liver dz, AI disease, IBD or cancer

SOCIAL HISTORY: Lives w/ husband and 5 kids (age [**4-8**]). Married 4 years. Last
worked as RN but injured back at work and was then laid off.
Parents live on [**Hospital3 **].
-Reports up to 4 drinks 3x a week (2 drinks 4 days a week) per
husband. + blackouts. [**12-31**] CAGE. No previous detoxes.
-Denies IV drugs, tobacco, cocaine
Poisoning by aromatic analgesics, not elsewhere classified,Acute and subacute necrosis of liver,Other encephalopathy,Urinary tract infection, site not specified,Hepatitis, unspecified,Chronic pain due to trauma,Cervicalgia,Backache, unspecified,Adjustment disorder with mixed anxiety and depressed mood,Abdominal pain, right upper quadrant,Nausea alone,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Hypoxemia,Herpes simplex without mention of complication,Accidental poisoning by aromatic analgesics, not elsewhere classified
Pois-arom analgesics NEC,Acute necrosis of liver,Encephalopathy NEC,Urin tract infection NOS,Hepatitis NOS,Chronc pain d/t trauma,Cervicalgia,Backache NOS,Adjust dis w anxiety/dep,Abdmnal pain rt upr quad,Nausea alone,Enterococcus group d,Hypoxemia,Herpes simplex NOS,Acc poison-arom analgesc
Admission Date:  [**2132-12-11**]              Discharge Date:   [**2132-12-17**]

Date of Birth:  [**2095-6-17**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 949**]
Chief Complaint:
abdominal pain, acute liver failure

Major Surgical or Invasive Procedure:
none


History of Present Illness:
37 YOF nurse who presents with nausea/vomiting and RUQ pain x 3
days. Presented initially to OSH where she was found to have ALT
8856 AST 7932 TB 5.9 and INR 3.4. Creat and bicarb normal. She
then revealed that she has been taking upwards of 6G APAP/day
since [**Month (only) 958**] for back pain. Isn't sure exactly how many tablets
she takes, but estimates 10 extra-strength Tylenol tabs and [**2-28**]
Tylenol PM, as well as occasional Vicodin. Denies poor PO in the
days preceeding onset of sx but since then hasn't been eating
well as oral intake has exacerbated her sx. Denies other toxic
habits/ingestions. Feels sleepy now since she has been up all
night but denies changes in mental status or excessive
sleepiness preceeding presentation. Drinks socially (about [**5-3**]
beers in one sitting, once per week or every 2 weeks) including
the night prior to the onset of her sx. Denies any suicidal
intent.
.
Reports that she lives at home w husband and 5 kids. She was
fired from her nursing job becuase of her back/neck pain, she
reports. She feels happy and safe at home and reports a close
family support system. She does admit to a suicide attempt at
age 14 but doesn't remember the details.
.
In speaking with her huband he reports that she also takes
Fioricet and Nyquil occasionally in addition to the other meds,
and agrees that this was not a deliberate attempt to hurt
herself. He corroborates that she does not use street drugs.

Past Medical History:
Body Dysmorphic Disorder
Anxiety
chronic neck/back pain [**1-29**] work-related injury
remote hx of OD suicide attempt as teen
GERD
IBS
Bilateral breast augmentation 00' and 04'

Social History:
Lives w/ husband and 5 kids (age [**4-8**]). Married 4 years. Last
worked as RN but injured back at work and was then laid off.
Parents live on [**Hospital3 **].
-Reports up to 4 drinks 3x a week (2 drinks 4 days a week) per
husband. + blackouts. [**12-31**] CAGE. No previous detoxes.
-Denies IV drugs, tobacco, cocaine


Family History:
No liver dz, AI disease, IBD or cancer


Physical Exam:
PHYSICAL EXAMINATION:
VS - Temp afebrile, BP 91/46, HR 86, R 18, O2-sat 98% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate

HEENT -  PERRL, EOMI, sclerae mildly icteric with B/L lateral
conjunctival hemorrhages, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, TTP in RUQ & epigastrium, ND, no masses or
HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-30**] throughout, sensation grossly intact throughout, gait not
observed, no asterixis


Pertinent Results:
[**2132-12-10**] EKG: Sinus tachycardia. Modest diffuse ST-T wave
changes are non-specific. No previous tracing available for
comparison.
.
[**2132-12-11**] ECHO: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF 80%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve is not well seen. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
.
[**2132-12-11**] CXR: The lungs are well expanded and clear without
focal consolidation, pleural effusion or pneumothorax. The
cardiac and mediastinal silhouette and hilar contours are
normal.
.
[**2132-12-11**] RUQ U/S: Ultrasound of the right upper quadrant
demonstrates no focal liver lesions. The gallbladder is
contracted, accentuating wall thickness. The portal vein is
patent with hepatopetal flow. No ascites is seen. No intra- or
extra-hepatic biliary dilation is seen. The CBD measures 3 mm.
No evidence of cholelithiasis is seen. IMPRESSION: 1. Patent
portal vein with hepatopetal flow. 2. Contracted gallbladder
without specific signs to suggest cholecystitis.
.
Labs:

Brief Hospital Course:
37 yo W with acute hepatitis and liver injury secondary to
chronic acetaminophen use
.
#. Acute hepatitis/liver failure: Determined to be secondary to
chronic, unintentional, overuse of tylenol for control of a
work-related back injury. On presentation the patient had grade
I encephalopathy and a transplant evaluation was initiated. She
was started on the NAC protocol. Her liver function tests
improved obviating the need for urgent transplant. She remained
on the NAC gtt for a total of 5 days, then was monitored for an
additional day, and discharged after it was ensured that her
labs were all improving. We instructed her to abstain from all
alcohol and acetaminophen until she follows up with Dr. [**Last Name (STitle) 497**] in
the Liver Clinic. At that time she will have her ceruloplasm
levels re-checked, as this was found to be low during her
transplant work-up.
.
#. Chronic back pain: secondary to a work-related injury, and
the reason she was taking large amounts of tylenol daily. The
patient has been seeing an Orthopedic Pain Specialist for
steroid injections and plans to continue this treatment. Her
pain was controlled on Tramadol, which we provided a
prescription for at discharge. She will need to follow up with
her Primary Care Physician and [**Name9 (PRE) 1194**] Specialist to develop a plan
to manage her chronic pain. She was instructed to stop all
medications with acetaminophen.
.
#. Adjustment Disorder with Anxious and Depressed Mood: The
patient was evaluated by Psychiatry and Social Work upon
admission. It was determined that her chronic acetaminophen
ingestion was not intentional. She was not currently on an
antidepressant, but has tried some in the past and discontinued
use secondary to bothersome side effects. She would likely
benefit from a SSRI or SNRI, which can be determined by the
patient and her Primary Care Physician on an outpatient basis.
.
#. RUQ abdominal pain and nausea: likely secondary to her liver
injury. The patient remained afebrile, without leukocytosis. She
was started on a daily PPI.
.
#. Urinary Tract Infection: The patient was treated with three
days of Ampicillin for an Enterococcal UTI. Her dysuria
resolved.
.
#. Herpes labialis: The patient was started on Valtrex for
recurrent HSV cold sores.
.
#. Pancytopenia: Unclear etiology, possibly secondary to
acetaminophen or NAC. Also, may have had an element of
hemodilution from the large amount of fluids received during the
admission. She had no evidence of bleeding and remained
hemodynamically stable throughout the admission.

Medications on Admission:
Tylenol
Percocet
Klonopin 5mg PRN

Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 1 weeks.
Disp:*42 Tablet(s)* Refills:*0*
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for breakthrough abdominal pain for 1 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 4 days.
Disp:*14 Tablet(s)* Refills:*0*
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO as instructed
as needed for anxiety.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
acute hepatitis secondary to chronic acetaminophen overuse
abdominal pain
urinary tract infection
adjustment disorder
pancytopenia


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


Discharge Instructions:
Dear Mrs. [**Known lastname 19499**],
.
You were recently admitted to the [**Hospital1 1170**] for continued evaluation and management of your abdominal
pain secondary to acute liver failure from chronic overuse of
tylenol. You were initially admitted to the Intensive Care Unit,
and then transferred to the floor. We provided you with
medications and you improved. We also found evidence of a
urinary tract infection and started you on antibiotics. We also
provided you with treatment for herpes labialis (cold sores).
Please continue to see your outpatient therapist, and consider
seeing a Psychiatrist in the future for your anxiety. Also, it
is important that you keep all of your follow up appointments
after discharge.
.
We are also giving you a short course of pain medications that
are safe to take during your liver injury. You will need to
follow up with your Primary Care Physician and [**Name9 (PRE) 1194**] Specialist
to figure out the best regimen for yout to continu on to treat
your chronic neck pain.
.
We are making the following changes to your outpatient
medication regimen:
-Please STOP all products containing acetaminophen (tylenol,
eccedrin, percocet) until you follow up with Dr. [**Last Name (STitle) 497**]. Please
read all of the labels of your over the counter medications to
ensure they do not contain acetaminophen.
-Please START Famotidine twice daily
-Please START Valtrex twice daily until [**2132-12-20**]
-Please take Tramadol every 4 hours as needed for pain
-Please take Oxycodone 5 mg every 6 hours as needed for pain
(please note that this medication can be sedating as well as
cause constipation)
- You may also take colace (a stool softener to prevent
constipation)
.
It was a pleasure taking care of you during this
hospitalization.

Followup Instructions:
Name: [**Name6 (MD) 19500**] [**Name8 (MD) **],MD
Specialty: Internal Medicine
When: Thursday [**12-18**] at 10:30am
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6698**]
Phone: [**Telephone/Fax (1) 6699**]
** Please note that this appointment is in the [**Location (un) **] office **
.
Department: LIVER CENTER
When: FRIDAY [**2133-1-9**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Poisoning by aromatic analgesics, not elsewhere classified,Acute and subacute necrosis of liver,Other encephalopathy,Urinary tract infection, site not specified,Hepatitis, unspecified,Chronic pain due to trauma,Cervicalgia,Backache, unspecified,Adjustment disorder with mixed anxiety and depressed mood,Abdominal pain, right upper quadrant,Nausea alone,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Hypoxemia,Herpes simplex without mention of complication,Accidental poisoning by aromatic analgesics, not elsewhere classified'}


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, acute liver failure

PRESENT ILLNESS: 37 YOF nurse who presents with nausea/vomiting and RUQ pain x 3
days. Presented initially to OSH where she was found to have ALT
8856 AST 7932 TB 5.9 and INR 3.4. Creat and bicarb normal. She
then revealed that she has been taking upwards of 6G APAP/day
since [**Month (only) 958**] for back pain. Isn't sure exactly how many tablets
she takes, but estimates 10 extra-strength Tylenol tabs and [**2-28**]
Tylenol PM, as well as occasional Vicodin. Denies poor PO in the
days preceeding onset of sx but since then hasn't been eating
well as oral intake has exacerbated her sx. Denies other toxic
habits/ingestions. Feels sleepy now since she has been up all
night but denies changes in mental status or excessive
sleepiness preceeding presentation. Drinks socially (about [**5-3**]
beers in one sitting, once per week or every 2 weeks) including
the night prior to the onset of her sx. Denies any suicidal
intent.
.
Reports that she lives at home w husband and 5 kids. She was
fired from her nursing job becuase of her back/neck pain, she
reports. She feels happy and safe at home and reports a close
family support system. She does admit to a suicide attempt at
age 14 but doesn't remember the details.
.
In speaking with her huband he reports that she also takes
Fioricet and Nyquil occasionally in addition to the other meds,
and agrees that this was not a deliberate attempt to hurt
herself. He corroborates that she does not use street drugs.

MEDICAL HISTORY: Body Dysmorphic Disorder
Anxiety
chronic neck/back pain [**1-29**] work-related injury
remote hx of OD suicide attempt as teen
GERD
IBS
Bilateral breast augmentation 00' and 04'

MEDICATION ON ADMISSION: Tylenol
Percocet
Klonopin 5mg PRN

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VS - Temp afebrile, BP 91/46, HR 86, R 18, O2-sat 98% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate

FAMILY HISTORY: No liver dz, AI disease, IBD or cancer

SOCIAL HISTORY: Lives w/ husband and 5 kids (age [**4-8**]). Married 4 years. Last
worked as RN but injured back at work and was then laid off.
Parents live on [**Hospital3 **].
-Reports up to 4 drinks 3x a week (2 drinks 4 days a week) per
husband. + blackouts. [**12-31**] CAGE. No previous detoxes.
-Denies IV drugs, tobacco, cocaine 

### Response:
{'Poisoning by aromatic analgesics, not elsewhere classified,Acute and subacute necrosis of liver,Other encephalopathy,Urinary tract infection, site not specified,Hepatitis, unspecified,Chronic pain due to trauma,Cervicalgia,Backache, unspecified,Adjustment disorder with mixed anxiety and depressed mood,Abdominal pain, right upper quadrant,Nausea alone,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Hypoxemia,Herpes simplex without mention of complication,Accidental poisoning by aromatic analgesics, not elsewhere classified'}
