CHIEF COMPLAINT: "acute liver failure" (transfer from OSH)

PRESENT ILLNESS: 48F w/ PMH of chronic alcohol intake, htn, copd, and [**Hospital 23051**]
transferred from OSH for blood pressure instability
(hypotension) and decreased urine output and acute liver failure
of unclear etiology. Pt w/ confusion, multiple episodes of
emesis, and diarrhea.

MEDICAL HISTORY: htn
chronic alcohol abuse
dm
copd

MEDICATION ON ADMISSION: hctz
actos
asa
niacin
citalopram
protonix
xanax

ALLERGIES: Codeine / Ibuprofen

PHYSICAL EXAM: 98.6 92/67 96 20 94%ra
scleral icterus, perrl, eomi, op c/ white exudate, multiple
aphthous ulcers
tender cervical LAD, clear tm
minimal crackles in LLL
RRR, nl S1, S2, no m/r/g
soft distended, minimally ttp in rlq, no [**Doctor Last Name **], no rebound, no
guarding, +fluid wave
extr wwp, from, 1+ edema in LE bilaterally
aaox3, cn 2-12 intact grossly

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: etoh abuse ([**11-23**] bottle wine, [**1-23**] vodka per day x 20 yrs)
tobacco 20 pack year hx
denies ivdu
lives w/ partner and hcp, [**Name (NI) **]
Unspecified septicemia,Acute and subacute necrosis of liver,Alcoholic cirrhosis of liver,Septic shock,Acute respiratory failure,Acute kidney failure, unspecified,Hepatorenal syndrome,Spontaneous bacterial peritonitis,Urinary tract infection, site not specified,Chronic airway obstruction, not elsewhere classified,Hyposmolality and/or hyponatremia,Candidiasis of mouth,Severe sepsis,Other and unspecified alcohol dependence, continuous,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Septicemia NOS,Acute necrosis of liver,Alcohol cirrhosis liver,Septic shock,Acute respiratry failure,Acute kidney failure NOS,Hepatorenal syndrome,Spontan bact peritonitis,Urin tract infection NOS,Chr airway obstruct NEC,Hyposmolality,Thrush,Severe sepsis,Alcoh dep NEC/NOS-contin,Hypertension NOS,DMII wo cmp nt st uncntr
Admission Date:  [**2133-10-1**]              Discharge Date:   [**2133-10-18**]

Date of Birth:  [**2085-4-3**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine / Ibuprofen

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
"acute liver failure" (transfer from OSH)

Major Surgical or Invasive Procedure:
paracentesis

History of Present Illness:
48F w/ PMH of chronic alcohol intake, htn, copd, and [**Hospital 23051**]
transferred from OSH for blood pressure instability
(hypotension) and decreased urine output and acute liver failure
of unclear etiology. Pt w/ confusion, multiple episodes of
emesis, and diarrhea.

Past Medical History:
htn
chronic alcohol abuse
dm
copd

Social History:
etoh abuse ([**11-23**] bottle wine, [**1-23**] vodka per day x 20 yrs)
tobacco 20 pack year hx
denies ivdu
lives w/ partner and hcp, [**Name (NI) **]

Family History:
noncontributory

Physical Exam:
98.6 92/67 96 20 94%ra
scleral icterus, perrl, eomi, op c/ white exudate, multiple
aphthous ulcers
tender cervical LAD, clear tm
minimal crackles in LLL
RRR, nl S1, S2, no m/r/g
soft distended, minimally ttp in rlq, no [**Doctor Last Name **], no rebound, no
guarding, +fluid wave
extr wwp, from, 1+ edema in LE bilaterally
aaox3, cn 2-12 intact grossly

Pertinent Results:
[**2133-10-2**] 12:11PM BLOOD WBC-63.2* RBC-3.22* Hgb-13.2 Hct-39.2
MCV-122* MCH-40.9* MCHC-33.6 RDW-15.8* Plt Ct-256
[**2133-10-2**] 06:30PM BLOOD WBC-66.0* RBC-3.12* Hgb-12.5 Hct-37.6
MCV-121* MCH-40.2* MCHC-33.3 RDW-16.0* Plt Ct-327
[**2133-10-3**] 05:29AM BLOOD WBC-55.7* RBC-2.88* Hgb-11.3* Hct-33.7*
MCV-117* MCH-39.3* MCHC-33.5 RDW-16.6*
[**2133-10-4**] 03:29AM BLOOD WBC-61.7* RBC-2.79* Hgb-11.3* Hct-34.1*
MCV-122* MCH-40.5* MCHC-33.1 RDW-15.7* Plt Ct-243
[**2133-10-5**] 04:12AM BLOOD WBC-60.6* RBC-2.46* Hgb-9.7* Hct-29.1*
MCV-118* MCH-39.5* MCHC-33.4 RDW-16.2* Plt Ct-190
[**2133-10-9**] 01:56PM BLOOD WBC-49.0* RBC-2.17* Hgb-8.5* Hct-26.9*
MCV-124* MCH-39.4* MCHC-31.7 RDW-16.4* Plt Ct-139*
[**2133-10-9**] 11:17PM BLOOD Hct-31.2*
[**2133-10-10**] 04:27AM BLOOD WBC-58.0* RBC-2.84*# Hgb-10.7*# Hct-32.9*
MCV-116*# MCH-37.8* MCHC-32.7 RDW-20.1* Plt Ct-157
[**2133-10-17**] 03:36AM BLOOD WBC-41.1* RBC-2.28* Hgb-8.4* Hct-26.7*
MCV-117* MCH-36.6* MCHC-31.2 RDW-19.4* Plt Ct-83*
[**2133-10-18**] 04:56AM BLOOD WBC-40.0* RBC-2.14* Hgb-7.7* Hct-25.8*
MCV-120* MCH-36.2* MCHC-30.1* RDW-19.6* Plt Ct-82*
[**2133-10-3**] 05:29AM BLOOD Neuts-90* Bands-2 Lymphs-4* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2133-10-12**] 05:07AM BLOOD Neuts-81* Bands-7* Lymphs-8* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2133-10-17**] 03:36AM BLOOD Neuts-85* Bands-0 Lymphs-4* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-3* Myelos-1*
[**2133-10-2**] 12:11PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-2+ Target-1+ Burr-1+
[**2133-10-17**] 03:36AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Target-OCCASIONAL
Burr-1+ Acantho-1+
[**2133-10-2**] 12:11PM BLOOD PT-18.1* PTT-31.2 INR(PT)-2.3
[**2133-10-2**] 06:30PM BLOOD PT-19.4* PTT-34.8 INR(PT)-2.6
[**2133-10-4**] 03:29AM BLOOD PT-20.4* PTT-36.3* INR(PT)-2.9
[**2133-10-6**] 02:58PM BLOOD PT-16.9* INR(PT)-2.0
[**2133-10-9**] 05:10AM BLOOD PT-20.1* PTT-41.8* INR(PT)-2.9
[**2133-10-14**] 03:26AM BLOOD PT-20.2* PTT-40.0* INR(PT)-2.9
[**2133-10-16**] 04:31AM BLOOD PT-23.2* PTT-45.8* INR(PT)-3.9
[**2133-10-17**] 03:36AM BLOOD PT-23.4* PTT-48.4* INR(PT)-4.0
[**2133-10-18**] 04:56AM BLOOD PT-24.4* PTT-51.6* INR(PT)-4.3
[**2133-10-18**] 04:56AM BLOOD Plt Ct-82*
[**2133-10-7**] 03:43AM BLOOD Fibrino-341
[**2133-10-2**] 12:11PM BLOOD Glucose-117* UreaN-50* Creat-0.9 Na-127*
K-5.5* Cl-91* HCO3-25 AnGap-17
[**2133-10-2**] 06:30PM BLOOD Glucose-100 UreaN-53* Creat-1.5* Na-127*
K-4.5 Cl-91* HCO3-20* AnGap-21*
[**2133-10-3**] 05:29AM BLOOD Glucose-103 UreaN-54* Creat-1.2* Na-128*
K-4.2 Cl-94* HCO3-20* AnGap-18
[**2133-10-4**] 03:29AM BLOOD Glucose-127* UreaN-46* Creat-0.9 Na-131*
K-3.5 Cl-99 HCO3-17* AnGap-19
[**2133-10-6**] 03:01AM BLOOD Glucose-113* UreaN-49* Creat-0.6 Na-135
K-3.6 Cl-106 HCO3-19* AnGap-14
[**2133-10-9**] 05:10AM BLOOD Glucose-160* UreaN-58* Creat-1.2* Na-142
K-3.4 Cl-111* HCO3-17* AnGap-17
[**2133-10-10**] 04:27AM BLOOD Glucose-159* UreaN-62* Creat-1.3* Na-138
K-3.2* Cl-108 HCO3-17* AnGap-16
[**2133-10-10**] 04:52PM BLOOD Glucose-91 UreaN-63* Creat-1.2* Na-143
K-4.2 Cl-114* HCO3-16* AnGap-17
[**2133-10-14**] 03:26AM BLOOD Glucose-121* UreaN-60* Creat-1.1 Na-145
K-3.5 Cl-117* HCO3-17* AnGap-15
[**2133-10-15**] 01:52AM BLOOD Glucose-132* UreaN-62* Creat-1.3* Na-146*
K-3.7 Cl-120* HCO3-15* AnGap-15
[**2133-10-18**] 04:56AM BLOOD Glucose-125* UreaN-84* Creat-1.8* Na-144
K-3.8 Cl-117* HCO3-14* AnGap-17
[**2133-10-3**] 05:29AM BLOOD ALT-66* AST-130* AlkPhos-284* Amylase-50
TotBili-21.4*
[**2133-10-4**] 03:29AM BLOOD ALT-75* AST-131* AlkPhos-272*
TotBili-20.1*
[**2133-10-6**] 03:01AM BLOOD ALT-61* AST-140* LD(LDH)-196 AlkPhos-215*
TotBili-21.0*
[**2133-10-12**] 05:07AM BLOOD ALT-65* AST-109* LD(LDH)-255*
AlkPhos-412* Amylase-16 TotBili-13.3*
[**2133-10-14**] 03:26AM BLOOD ALT-43* AST-83* LD(LDH)-204 AlkPhos-337*
TotBili-10.8*
[**2133-10-16**] 04:31AM BLOOD ALT-34 AST-81* LD(LDH)-169 AlkPhos-318*
TotBili-10.6*
[**2133-10-18**] 04:56AM BLOOD ALT-29 AST-84* LD(LDH)-176 AlkPhos-313*
TotBili-12.0*
[**2133-10-2**] 12:11PM BLOOD Lipase-53
[**2133-10-3**] 05:29AM BLOOD Lipase-62*
[**2133-10-12**] 05:07AM BLOOD Lipase-18
[**2133-10-2**] 12:11PM BLOOD Albumin-2.4* Calcium-9.1 Phos-5.8* Mg-2.3
Iron-68
[**2133-10-10**] 04:27AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0
[**2133-10-10**] 04:52PM BLOOD Calcium-8.8 Phos-3.3 Mg-2.0
[**2133-10-17**] 03:36AM BLOOD Albumin-3.5 Calcium-9.0 Phos-2.1* Mg-1.9
[**2133-10-18**] 04:56AM BLOOD Albumin-3.8 Calcium-9.0 Phos-2.3* Mg-1.9
[**2133-10-2**] 12:11PM BLOOD calTIBC-90* Ferritn-1553* TRF-69*
[**2133-10-2**] 06:30PM BLOOD calTIBC-86* Ferritn-1494* TRF-66*
[**2133-10-12**] 05:07AM BLOOD Ammonia-64*
[**2133-10-3**] 04:16PM BLOOD Cortsol-19.8
[**2133-10-3**] 05:51PM BLOOD Cortsol-39.0*
[**2133-10-11**] 02:53PM BLOOD Cortsol-28.3*
[**2133-10-11**] 04:27PM BLOOD Cortsol-46.7*
[**2133-10-2**] 12:11PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
[**2133-10-2**] 06:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
[**2133-10-2**] 06:30PM BLOOD Smooth-NEGATIVE
[**2133-10-2**] 12:11PM BLOOD Smooth-NEGATIVE
[**2133-10-2**] 06:30PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2133-10-2**] 12:11PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2133-10-2**] 06:30PM BLOOD IgG-780
[**2133-10-2**] 12:11PM BLOOD IgG-813
[**2133-10-2**] 12:11PM BLOOD HCV Ab-NEGATIVE
[**2133-10-2**] 06:30PM BLOOD HCV Ab-NEGATIVE
[**2133-10-10**] 05:15PM BLOOD Type-MIX Temp-35.8 Rates-/22 pO2-39*
pCO2-38 pH-7.29* calHCO3-19* Base XS--7 Intubat-NOT INTUBA
Comment-NC
[**2133-10-12**] 01:02AM BLOOD Type-[**Last Name (un) **] Temp-36.2 pO2-46* pCO2-38
pH-7.26* calHCO3-18* Base XS--9
[**2133-10-16**] 04:43AM BLOOD Type-ART Temp-36.6 Rates-26/3 Tidal V-400
PEEP-10 FiO2-60 pO2-127* pCO2-29* pH-7.32* calHCO3-16* Base
XS--9 -ASSIST/CON Intubat-INTUBATED
[**2133-10-18**] 05:16AM BLOOD Type-ART pO2-92 pCO2-28* pH-7.32*
calHCO3-15* Base XS--10
[**2133-10-3**] 01:52PM BLOOD Lactate-3.0*
[**2133-10-12**] 01:02AM BLOOD Lactate-1.8
[**2133-10-15**] 03:52PM BLOOD Lactate-2.2* K-3.2*
.
CHEST (PORTABLE AP)  [**2133-10-1**] 9:30 PM

CHEST (PORTABLE AP)

Reason: eval for pna, effusion, edema, ptx

[**Hospital 93**] MEDICAL CONDITION:
48 year old woman with liver failure, leukocytosis
REASON FOR THIS EXAMINATION:
eval for pna, effusion, edema, ptx
AP CHEST 9:49 P.M. ON [**10-1**].

HISTORY: Liver failure.

IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs.

Lungs are low in volume but clear. The heart is normal size.
There is no pleural abnormality.
.
ABDOMEN U.S. (COMPLETE STUDY)  [**2133-10-2**] 3:42 PM

ABDOMEN U.S. (COMPLETE STUDY)

Reason: eval liver, ascites, mark ascites for paracentesis

[**Hospital 93**] MEDICAL CONDITION:
48 year old woman with liver failure, please use doppler
REASON FOR THIS EXAMINATION:
eval liver, ascites, mark ascites for paracentesis
INDICATION: Liver failure, please perform Doppler evaluation of
the liver and mark ascites for paracentesis.

COMPARISON: None.

TECHNIQUE: Right upper quadrant ultrasound.

RIGHT UPPER QUADRANT ULTRASOUND: The liver is diffusely
echogenic consistent with fatty infiltration. No definite
nodules or masses are identified within the hepatic parenchyma.
The hepatic veins are patent with flow in the proper direction.
The hepatic arteries are prominent, with flow in the appropriate
direction and with normal waveforms. There is apparent reversal
of flow in the main portal vein, which is patent. There is
moderate amount of perihepatic ascites. Elsewhere within the
abdomen, no substantial pocket of ascites is identified to mark
for tap.

IMPRESSION:
1. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease, including more significant hepatic
fibrosis or cirrhosis, cannot be excluded on the basis of this
examination.

2. Reversal of direction of flow in the main portal vein. The
portal vein is patent. Hepatic arteries and hepatic veins are
patent with flow in the appropriate direction.

3. Moderate amount of perihepatic ascites. No mark was placed
for tap.
.
Cardiology Report ECG Study Date of [**2133-10-2**]  6:56:42 AM


Normal sinus rhythm, rate 100. Vertical axis. Non-diagnostic
inferior Q waves.
Borderline low voltage. No previous tracing available for
comparison.
.
ABDOMEN U.S. (PORTABLE)  [**2133-10-3**] 10:36 PM

ABDOMEN U.S. (PORTABLE)

Reason: ? ascites amenable to paracentesis, if so then please
mark s

[**Hospital 93**] MEDICAL CONDITION:
48 year old woman with liver failure, now with worsening
hyotension despite fluid challenge
REASON FOR THIS EXAMINATION:
? ascites amenable to paracentesis, if so then please mark site
for paracentesis
INDICATION: 48-year-old female with liver failure, now with
worsening hypotension despite fluid challenge. Evaluate for
ascites, and mark spot for paracentesis.

COMPARISON: CT abdomen and pelvis dated [**2133-10-2**].

LIMITED ABDOMINAL ULTRASOUND: The liver is echogenic consistent
with fatty infiltration. No focal nodules or masses are seen. No
color flow is detected in the portal vein, most likely related
to technique. The main hepatic artery and IVC are patent with
appropriate flow and waveforms.

Limited imaging of the abdomen reveals a large amount of
intraabdominal ascites. The largest pocket was seen within the
midline pelvis and the skin was marked for paracentesis to be
performed by the clinical staff.

IMPRESSION:
1) No flow is seen within the portal vein. This is most likely
related to technique, as the portal vein was demonstrated to be
patent with heptofugal flow on [**2133-10-2**] and no power doppler
imaging was performed on today's study. Recommend repeat imaging
if clincal concern for portal vein thrombosis.

2) Echogenic liver consisent with fatty infiltration. Other
forms of liver disease and more advanced liver disease,
including hepatic fibrosis/cirrhosis cannot be excluded on this
study.

3) Moderate abdominal ascites with spot marked for paracentesis.
.
DUPLEX DOP ABD/PEL LIMITED  [**2133-10-6**] 4:07 PM

US ABD LIMIT, SINGLE ORGAN; DUPLEX DOP ABD/PEL LIMITED

Reason: Please reevaluate [**Name (NI) 5283**] sono for potal vein flow, question
of

[**Hospital 93**] MEDICAL CONDITION:
48 year old woman with liver failure and right upper quadrant
sono concerning for portal vein thrombosis, ? of portal vain
flow
REASON FOR THIS EXAMINATION:
Please reevaluate [**Name (NI) 5283**] sono for potal vein flow, question of
thrombosis. Thank you
ULTRASOUND OF ABDOMEN

INDICATION: Patient with end-stage liver disease. For evaluation
for possible paracentesis and also for evaluation of portal
system.

TECHNIQUE: Grayscale imaging of the abdomen was performed.

COMPARISON: [**2133-10-3**].

REPORT:

The liver is small and coarsened, consistent with advanced
cirrhosis. No focal intrahepatic mass is seen. There is a mild
amount of ascites present. The right kidney measures 10.87 cm
and appears normal in size, shape, and echotexture. Within the
liver, no intra- or extra-hepatic biliary dilatation is seen.
There is definite reversal of flow within the main portal vein.
The portal vein is, however, patent. A spot suitable for
paracentesis was marked in the patient's pelvis following the
completion of the examination.

CONCLUSION:

Limited examination reveals mild-to-moderate ascites with
evidence of flow reversal within a patent main portal vein.
.

INTERPRETATION:

Findings:

LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.

LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). No resting LVOT gradient.

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

AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.

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

MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Normal
mitral valve supporting structures. Normal LV inflow pattern for
age.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal
tricuspid valve supporting structures.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA

PERICARDIUM: No pericardial effusion.

Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF 70%). 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. There is no mitral valve prolapse. There is no
pericardial
effusion.
.
CT RECONSTRUCTION  [**2133-10-10**] 5:51 PM

CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST

Reason: Please perform WITH ORAL CONTRAST ONLY, NO IV
CONTRASTPlease

[**Hospital 93**] MEDICAL CONDITION:
48 yo female with liver failure, leukocytosis and hypotension
REASON FOR THIS EXAMINATION:
Please perform WITH ORAL CONTRAST ONLY, NO IV CONTRASTPlease
evaluate for intrabdominal source of infection.
CONTRAINDICATIONS for IV CONTRAST: renal failure

INDICATION: Liver failure, leukocytosis, and hypotension.

TECHNIQUE: Multidetector CT images of the abdomen and pelvis
were obtained with oral contrast. No intravenous contrast was
administered.

ABDOMEN CT WITHOUT IV CONTRAST: Bibasilar atelectasis is
present. There is a moderate-sized right pleural effusion and a
tiny left pleural effusion. There is a moderate amount of
ascites. The patient is status post cholecystectomy. There is a
low-attenuation focus along the edge of the liver in segment V
anteriorly. This appears to extend in a band-like fashion along
the inside of the liver capsule and measures 1.3 cm in depth.
This is not fully characterized on this noncontrast study. The
pancreas, spleen, adrenal glands, kidneys, stomach, and small
bowel are unremarkable. There is mild diffuse thickening of the
wall of the cecum and ascending colon. No abnormalities are seen
in the transverse or descending colon.

PELVIS CT WITHOUT IV CONTRAST: The distal ureters, uterus, and
adnexa are unremarkable. There is gas within the bladder, likely
due to Foley insertion. Extensive diffuse subcutaneous fat
stranding is present consistent with edema. The osseous
structures are unremarkable.

IMPRESSION:

1. No fever source identified in the abdomen or pelvis.

2. Small bilateral pleural effusions and bilateral lower lobe
atelectasis.

3. Ascites.

4. Low-attenuation region within segment V of the liver, poorly
characterized in this study. Further evaluation may be obtained
with multiphasic liver examination or MRI to rule out a
neoplastic lesion.

5. Mild diffuse thickening of the cecum and ascending colon.
This is a nonspecific finding and may be infectious or
inflammatory.
.
u/s: IMPRESSION: No evidence of DVT.
.
CT HEAD W/O CONTRAST  [**2133-10-11**] 9:31 AM

CT HEAD W/O CONTRAST

Reason: NEW ALTERED MENTAL STATUS, ? INTRACRANIAL BLEED

[**Hospital 93**] MEDICAL CONDITION:
48 year old woman with DM, CPOD, EtOH cirrhosis, hypotension,
new AMS
REASON FOR THIS EXAMINATION:
r/o intracranial bleed
CONTRAINDICATIONS for IV CONTRAST: renal insufficiency

INDICATION: Diabetes mellitus, alcoholic cirrhosis, acute mental
status change, hypertension.

COMPARISONS: None.

TECHNIQUE: Axial non-contrast MDCT images were obtained through
the head.

CT HEAD WITHOUT IV CONTRAST: There is no evidence of
intracranial hemorrhage, hydrocephalus, shift of normally
midline structures, or edema. The [**Doctor Last Name 352**]-white matter
differentiation appears intact throughout. The paranasal sinuses
appear well aerated.

IMPRESSION: No evidence of intracranial hemorrhage or edema.
.
CHEST (PORTABLE AP)  [**2133-10-13**] 8:48 AM

CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN

Reason: pneumothorax after line removal.

[**Hospital 93**] MEDICAL CONDITION:
48 year old woman with liver failure, leukocytosis with basilar
crackles, and right IJ removal since last film.
REASON FOR THIS EXAMINATION:
pneumothorax after line removal.
HISTORY: Liver failure and basal crackles. Right IJ line
removed.

IMPRESSION: AP chest compared to [**10-12**] and 22:

Vascular engorgement widens the superior mediastinum, unchanged
since [**10-12**], but worsened appreciably since [**10-9**].
Lung volumes are low due in part to elevation of the lung bases.
There may be a small-to-moderate right subpulmonic pleural
effusion. Moderately severe pulmonary edema has progressed since
earlier on [**10-12**]. Heart is mildly enlarged, exaggerated
by low lung volumes. Nasogastric feeding tube is looped in the
upper stomach. No pneumothorax.
.
CHEST (PORTABLE AP)  [**2133-10-14**] 10:48 PM

CHEST (PORTABLE AP)

Reason: please evaluate for placement of ET tube

[**Hospital 93**] MEDICAL CONDITION:
48 year old woman with liver failure, leukocytosis with basilar
crackles, s/p intubation for respiratory distress
REASON FOR THIS EXAMINATION:
please evaluate for placement of ET tube
CLINICAL HISTORY: Liver failure, leukocytosis, endotracheal tube
placed, check position.

CHEST: An endotracheal tube has been placed. It lies in a
satisfactory position approximately 3.1 cm above the carinal
angle.

Evidence of failure is again noted.


Brief Hospital Course:
The patient was a pleasant 48 year old woman who had acute liver
failure of unclear etiology. She was seen by hepatology
throughout. She had multiple diagnostic and therapeutic
paracenteses during her course. Her fluid status was
persistently difficult to manage due to her liver disease
coupled with her kidney disease. A thorough search was done for
causes of hepatitis other than chronic alcohol intake, but none
was found. She was treated with a battery of hepatology
medications (pyridoxine, octreotide, etc) as well as multiple
lengthy courses of antibiotics for presumed spontaneous
peritonitis. She strugged to maintain euvolemia. She was
transferred to the floor, though required intensive care shortly
after.
.
Toward the end of her hospitalization, there were many family
meetings with the patient's mother, domestic partner [**Name (NI) **], and a
multitude of other family members. Over the course of a few
days, in consultation with the hepatology team, a guarded to
poor prognosis was predicted. In multiple discussions with the
family, the decision was agreed upon by all that the patient's
wishes would have been to withdraw aggressive measures and
proceed with comfort care only. This was done, and the patient
died shortly after peacefully.

Medications on Admission:
hctz
actos
asa
niacin
citalopram
protonix
xanax

Discharge Medications:
n/a

Discharge Disposition:
Expired

Discharge Diagnosis:
Liver failure.
death.

Discharge Condition:
Deceased.

Discharge Instructions:
n/a

Followup Instructions:
n/a
{'Unspecified septicemia,Acute and subacute necrosis of liver,Alcoholic cirrhosis of liver,Septic shock,Acute respiratory failure,Acute kidney failure, unspecified,Hepatorenal syndrome,Spontaneous bacterial peritonitis,Urinary tract infection, site not specified,Chronic airway obstruction, not elsewhere classified,Hyposmolality and/or hyponatremia,Candidiasis of mouth,Severe sepsis,Other and unspecified alcohol dependence, continuous,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: "acute liver failure" (transfer from OSH)

PRESENT ILLNESS: 48F w/ PMH of chronic alcohol intake, htn, copd, and [**Hospital 23051**]
transferred from OSH for blood pressure instability
(hypotension) and decreased urine output and acute liver failure
of unclear etiology. Pt w/ confusion, multiple episodes of
emesis, and diarrhea.

MEDICAL HISTORY: htn
chronic alcohol abuse
dm
copd

MEDICATION ON ADMISSION: hctz
actos
asa
niacin
citalopram
protonix
xanax

ALLERGIES: Codeine / Ibuprofen

PHYSICAL EXAM: 98.6 92/67 96 20 94%ra
scleral icterus, perrl, eomi, op c/ white exudate, multiple
aphthous ulcers
tender cervical LAD, clear tm
minimal crackles in LLL
RRR, nl S1, S2, no m/r/g
soft distended, minimally ttp in rlq, no [**Doctor Last Name **], no rebound, no
guarding, +fluid wave
extr wwp, from, 1+ edema in LE bilaterally
aaox3, cn 2-12 intact grossly

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: etoh abuse ([**11-23**] bottle wine, [**1-23**] vodka per day x 20 yrs)
tobacco 20 pack year hx
denies ivdu
lives w/ partner and hcp, [**Name (NI) **] 

### Response:
{'Unspecified septicemia,Acute and subacute necrosis of liver,Alcoholic cirrhosis of liver,Septic shock,Acute respiratory failure,Acute kidney failure, unspecified,Hepatorenal syndrome,Spontaneous bacterial peritonitis,Urinary tract infection, site not specified,Chronic airway obstruction, not elsewhere classified,Hyposmolality and/or hyponatremia,Candidiasis of mouth,Severe sepsis,Other and unspecified alcohol dependence, continuous,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
