CHIEF COMPLAINT: hepatic hydrothorax with bloody thoracentesis

PRESENT ILLNESS: 53 yoM with HCV and ETOH related
cirrhosis (Childs Class C) on [**Month/Day/Year **] list complicated by
chronic hydrothorax (always on right) requiring thoracentesis
throughout past year, ascites, PVT, hepatic encephalopathy,
grade
1 varices, and h/o SBP. Over the past few months he has been
needing biweekly taps. He reports that the amount of fluid taken
out has decreased per tap from initially 5-6l now down to 2-3L.
He was tapped on [**2158-8-1**] for 1.3L. There is no history of
infection related to the thoracentesis and per patient he has
never had talc/pleurodesis. Over past week his taps have been
showing signs of blood and so he was admitted for evaluation by
thoracic surgery for possible chest tube placement with
talc/pleurodesis.

MEDICAL HISTORY: - HCV Cirrhosis, c/b esophageal variceal hemorrhage, ascites,
portal vein thrombosis, hepatic hydrothorax, episodes of
encephalopathy
- Chronic Hyponatremia
- Type II DM
- h/o SMV thrombus, portal vein thrombus, not anticoagulated
- Thrombocytopenia
- ARF
- h/o Klebsiella bacteremia
-s/p inguinal and umbilical hernia repair

MEDICATION ON ADMISSION: - folic acid 1mg daily
- furosemide 80mg in AM and 20 at PM
- lactulose 30mL [**Hospital1 **]
- prochlorperazine maleate 10mg q6h prn
- rifaximin 550mg [**Hospital1 **]
- spironolactone 100mg daily
- ursodiol 250mg TID
- ferrous sulfate 300mg daily
- simethicone 80mg QID prn
- thiamine HCl 100mg daily
- Calcium QID prn
- nadolol 20mg daily
- ciprofloxacin 250mg q24hr
- tolvaptan 60mg daily
- omeprazole 20mg [**Hospital1 **]
- VitD 50,000 units qweekly
- glargine 20 units qAM, 34 units qHS
- Humalog sliding scale

ALLERGIES: Motrin / Chlorhexidine

PHYSICAL EXAM: Admission Exam:
VS - 97.5 88 107/66 14 98%RA
GENERAL - Moderate distress, sitting up in bed
HEENT - PERRL, MM dry, OP clear
NECK - supple, +8cm JVD
LUNGS - Mildly decreased lung sounds @ right base, otherwise
clear with good air movement, + accessory muscles
HEART - Tachy, no mrg
ABDOMEN - naBS, distended, tympanitic, nontender, no
rebound/guarding
EXTREMITIES - WWP, 1+ edema to mid-shin, no c/c
SKIN - small wound over RLE, c/d/i; maculopapular [**Location **] over
extremities and trunk, blanching
NEURO - AOx2-3, CNs II-XII grossly intact, no asterixis

FAMILY HISTORY: Mother and father with DM2

SOCIAL HISTORY: SOCIAL HISTORY: Lives with roommate in [**Location 30150**]. Has
girlfriend.
-tobacco: none
-EtOH: quit 25 years ago
-Drugs: former drug use, including IVDU with cocaine. Patient
denies drug use during past 25 years.
Other specified forms of effusion, except tuberculous,Portal vein thrombosis,Pneumonia, organism unspecified,Other ascites,Portal hypertension,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Hyposmolality and/or hyponatremia,Cirrhosis of liver without mention of alcohol,Unspecified viral hepatitis C without hepatic coma,Hypotension, unspecified,Hypoxemia,Anemia, unspecified,Rash and other nonspecific skin eruption,Eosinophilia
Effusion NEC exc tb,Portal vein thrombosis,Pneumonia, organism NOS,Ascites NEC,Portal hypertension,Esoph varice oth dis NOS,Hyposmolality,Cirrhosis of liver NOS,Hpt C w/o hepat coma NOS,Hypotension NOS,Hypoxemia,Anemia NOS,Nonspecif skin erupt NEC,Eosinophilia
Admission Date:  [**2158-8-1**]              Discharge Date:   [**2158-8-11**]

Date of Birth:  [**2104-3-11**]             Sex:   M

Service: MEDICINE

Allergies:
Motrin / Chlorhexidine

Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
hepatic hydrothorax with bloody thoracentesis

Major Surgical or Invasive Procedure:
[**2158-8-4**]:  Right video-assisted thoracoscopic surgery
evacuation of hemothorax, removal of clotted hemothorax, talc
pleurodesis.


History of Present Illness:
53 yoM with HCV and ETOH related
cirrhosis (Childs Class C) on [**Month/Day/Year **] list complicated by
chronic hydrothorax (always on right) requiring thoracentesis
throughout past year, ascites, PVT, hepatic encephalopathy,
grade
1 varices, and h/o SBP. Over the past few months he has been
needing biweekly taps. He reports that the amount of fluid taken
out has decreased per tap from initially 5-6l now down to 2-3L.
He was tapped on [**2158-8-1**] for 1.3L. There is no history of
infection related to the thoracentesis and per patient he has
never had talc/pleurodesis. Over past week his taps have been
showing signs of blood and so he was admitted for evaluation by
thoracic surgery for possible chest tube placement with
talc/pleurodesis.

He has required frequent banding for esophageal varices and has
failed TIPs procedure in past. He was started on Cipro PPX after
admission for SBP in 3/[**2157**].

He has recent PNA now s/p azithromycin course with residual
cough
but SOB, CP, fevers/chills. States that he has been gaining
weight over the past few months.

 In brief, this is a 53yo M PMHx HCV cirrhosis c/b
encephalopathy, varices, SBP, portal vein thrombus, ascites w
recurrent hepatic hydrothorax, hypervolemic hyponatremia (on
tolvaptan), initially presenting after patient had bloody
thoracenteses, with patient remaining hemodynamically stable w
unchanged Hct; hospital course notable for R chest tube
placement and pleurodesis by Thoracic Surgery on hospital day 3;
prior to undergoing chest tube placement, patient developed
whole body [**Year (4 digits) **], blanching, maculopapular, thought to be
allergic reaction to chlorhexadine wash.  Over 12 hours after
chest tube placement and pleurodesis, patient had 400cc
serosanguinous output; UOP fell overnight to <10cc/hour; HR
increased from 70s to 150s, SBPs 130s to 90s, and patient
developed new O2 requirement (initially on room air, slowly
escalating to 4L then nonrebreather).  CXR did not demonstrate
signs of PTX or new infection; given worsening symptoms, patient
transferred to MICU for further management.


Past Medical History:
- HCV Cirrhosis, c/b esophageal variceal hemorrhage, ascites,
portal vein thrombosis, hepatic hydrothorax, episodes of
encephalopathy
- Chronic Hyponatremia
- Type II DM
- h/o SMV thrombus, portal vein thrombus, not anticoagulated
- Thrombocytopenia
- ARF
- h/o Klebsiella bacteremia
-s/p inguinal and umbilical hernia repair



Social History:
SOCIAL HISTORY: Lives with roommate in [**Location 30150**]. Has
girlfriend.
-tobacco: none
-EtOH: quit 25 years ago
-Drugs: former drug use, including IVDU with cocaine. Patient
denies drug use during past 25 years.


Family History:
Mother and father with DM2


Physical Exam:
Admission Exam:
VS - 97.5 88 107/66 14 98%RA
GENERAL - Moderate distress, sitting up in bed
HEENT - PERRL, MM dry, OP clear
NECK - supple, +8cm JVD
LUNGS - Mildly decreased lung sounds @ right base, otherwise
clear with good air movement, + accessory muscles
HEART - Tachy, no mrg
ABDOMEN - naBS, distended, tympanitic, nontender, no
rebound/guarding
EXTREMITIES - WWP, 1+ edema to mid-shin, no c/c
SKIN - small wound over RLE, c/d/i; maculopapular [**Location **] over
extremities and trunk, blanching
NEURO - AOx2-3, CNs II-XII grossly intact, no asterixis

Discharge Exam:
GENERAL -  Comfortable in NAD
HEENT - PERRL, MM dry, OP clear
NECK - supple, JVP flat
LUNGS - CTAB
HEART - rrr, no mrg
ABDOMEN - naBS, distended, tympanitic, nontender, no
rebound/guarding
EXTREMITIES - WWP, 1+ edema to mid-shin, no c/c
SKIN - maculopapular [**Location **] over extremities and trunk
NEURO - AOx3, no asterixis

Pertinent Results:
Admissoin Exam:
[**2158-8-1**] 07:00AM BLOOD WBC-4.6 RBC-2.74* Hgb-8.6* Hct-26.2*
MCV-96 MCH-31.6 MCHC-33.0 RDW-16.3* Plt Ct-57*
[**2158-8-1**] 07:00AM BLOOD Neuts-58 Bands-0 Lymphs-9* Monos-10
Eos-23* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2158-8-1**] 07:00AM BLOOD PT-18.5* INR(PT)-1.7*
[**2158-8-1**] 07:00AM BLOOD Creat-1.0 Na-139 K-4.2 Cl-108
[**2158-8-1**] 07:00AM BLOOD TotBili-2.0*

Labs on admission to MICU:
[**2158-8-5**] 12:37AM BLOOD WBC-9.3# RBC-3.75* Hgb-11.7* Hct-33.8*
MCV-90 MCH-31.2 MCHC-34.6 RDW-17.4* Plt Ct-103*
[**2158-8-5**] 09:44AM BLOOD Neuts-85* Bands-0 Lymphs-1* Monos-6
Eos-7* Baso-0 Atyps-0 Metas-1* Myelos-0
[**2158-8-5**] 03:15PM BLOOD PT-22.5* PTT-40.2* INR(PT)-2.1*
[**2158-8-5**] 12:37AM BLOOD Glucose-66* UreaN-12 Creat-0.8 Na-137
K-3.9 Cl-104 HCO3-24 AnGap-13
[**2158-8-5**] 03:15PM BLOOD ALT-12 AST-46* TotBili-5.2*
[**2158-8-5**] 09:44AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.8
[**2158-8-5**] 11:53PM BLOOD Lactate-4.4*
[**2158-8-5**] 03:40PM BLOOD freeCa-0.91*

Lactate Trend:
[**2158-8-5**] 10:13AM BLOOD Lactate-5.8*
[**2158-8-5**] 03:40PM BLOOD Lactate-5.6*
[**2158-8-5**] 11:53PM BLOOD Lactate-4.4*
[**2158-8-6**] 09:15AM BLOOD Lactate-2.8*
[**2158-8-6**] 03:33PM BLOOD Lactate-3.6*
[**2158-8-6**] 07:31PM BLOOD Lactate-3.0*
.

Imaging:
[**8-1**] CXR: IMPRESSION: Slight increase in size of
small-to-moderate right pleural effusion.

[**8-5**] TTE (PRELIM): IMPRESSION: Normal biventricular function. No
echocardiographic evidence of PE, though is not definitive test
for evaluation of pulmonary embolism.

[**8-5**] CXR: There is a small right apical pneumothorax. There is a
right-sided chest tube with distal lead tip in the right apex
and the second chest tube at the right base. There has been
decreased size of the right small pleural effusion. There is
coarsening of the bronchovascular markings without signs for
overt pulmonary edema. Atelectasis at the right lung base is
seen. Cardiac silhouette and mediastinum are grossly within
normal limits.

[**8-6**] CXR: FINDINGS: There is a right-sided chest tube with tip
in the apex. There is no pneumothoraces. There is a right-sided
pleural effusion with some loculation along the right chest
wall. This is stable. Heart size is stable.There is improvement
of pulmonary vascular marking and congestion. There is some
atelectasis versus developing infiltrates at the lung bases,
which are stable. The right IJ central venous catheter has the
distal lead tip in the proximal right atrium.
.
[**8-7**]
abd US
Limited four-quadrant ultrasound of the abdomen demonstrates a
trace amount of
ascites in the perihepatic and perisplenic regions. Given the
trace ascites
and the patient's elevated INR, this was deemed unsafe for a
diagnostic/therapeutic paracentesis.
.
[**2158-8-10**]
CXR PA and Lat
IMPRESSION:
1. No pneumothorax after chest tube removal.
2. Persistent small bilateral pleural effusions.


Discharge labs:
.
[**2158-8-11**] 04:25AM BLOOD WBC-4.1 RBC-2.79* Hgb-8.7* Hct-25.5*
MCV-92 MCH-31.0 MCHC-33.9 RDW-16.9* Plt Ct-30*
[**2158-8-9**] 04:06AM BLOOD Neuts-67 Bands-1 Lymphs-9* Monos-3
Eos-20* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2158-8-11**] 04:25AM BLOOD Plt Ct-30*
[**2158-8-11**] 04:25AM BLOOD PT-21.8* INR(PT)-2.0*
[**2158-8-11**] 04:25AM BLOOD Glucose-311* UreaN-23* Creat-0.9 Na-137
K-3.6 Cl-106 HCO3-25 AnGap-10
[**2158-8-11**] 04:25AM BLOOD ALT-11 AST-30 LD(LDH)-209 AlkPhos-57
TotBili-2.0*
[**2158-8-11**] 04:25AM BLOOD Albumin-2.2* Calcium-7.5* Phos-2.8
Mg-1.5*
.
Urine
[**2158-8-5**] 06:44PM URINE RBC-75* WBC-7* Bacteri-FEW Yeast-NONE
Epi-1 TransE-<1
[**2158-8-5**] 06:44PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2158-8-5**] 06:44PM URINE Hours-RANDOM UreaN-271 Creat-160 Na-20
K-48 Cl-14
.
Pleural fluid analysis
[**2158-8-1**] 08:40AM PLEURAL WBC-685* Hct,Fl-4.0* Polys-26* Bands-1*
Lymphs-24* Monos-0 Eos-30* Atyps-3* Plasma-1* Macro-15*
[**2158-8-1**] 08:40AM PLEURAL TotProt-2.4 Glucose-204 LD(LDH)-570
.
micro
[**2158-8-4**]
stool neg for O&P
CMV viral load negative
Pleural fluid and pleural bx negative bacterial, acid fast and
fungal cx
[**2158-8-5**]
blood cx negative
.
Pleural fluid cytology:
negative for malignant cells
.
Pleural bx:
Right pleural debris, excision (A):
Chronic fibrinous and organizing pleuritis.
Right pleura, biopsy (B):
Chronic fibrosing pleuritis.


Brief Hospital Course:
53yo M PMHx HCV cirrhosis c/b varices, ascites w recurrent
hepatic hydrothorax, presented with recent history of blood
thoracenteses in liver clinic.  Admitted for eval by thoracics
for CP and talc pleurodesis.  Course was complicated by [**Month/Day/Year **] and
hypoxia s/p CT placement requiring short stay in MICU.
.
# Hepatic Hydrothorax: Pt was previously receiving biweekly
thoracentesis for management of hepatic hydrothorax but past
several taps have come back bloody with hct of pleural fluid
ranging from 4 to 13.  Pt was evaluated by thoracic surgery and
CT with talc pleurodesis was performed twice.  Post procedure,
course was complicated by pain and hypoxia requiring transfer to
MICU (see below).  Pleural fluid analysis was consistent with
hepatic hydrothorax and cultures and cytology were negative.
Pleurodesis ultimately was successful and chest tube pulled when
drainage stopped.  On day prior to discharge, CXR revealed no
new effusion indicating successful pleurodesis.
.
#[**Name (NI) 10540**] - pt transferred to MICU with hypoxia in setting of recent
chest tube placement.  PTX, PE and worsening pleural effusion
were all ruled out.  Pt was splinting and taking small breaths
from pain [**1-18**] procedure which could have exacerbated his ability
to oxygenate well.  Pt was also noted to be overly sedated when
he became hypoxic which was most likely [**1-18**] to high dose
narcotic administration.  CXR revealed R cardiac border
infiltrate and pt's WBC increased to 27K.  In setting of AMS,
aspiration pneumonia was diagnosed and pt was started on
vancomycin, levaquin and zosyn for broad spectrum coverage.  His
oxygen saturation remained stable on 2L NC in ICU and he was
transferred back to the floor.  Pt was weaned off of O2 and
oxygenation improved.  On floor zosyn was d/ced.  He was treated
with vancomycin and levaquin for a total of seven days.
.
# Distributive shock - pt w hypotension to SBP 80s, tachycardia,
borderline febrile on floor, but afebrile by the time he was
transferred to unit.  Blood cultures never speciated but pt met
SIRS criteria and had suspected PNA suggesting sepsis as cause
of shock.   CVPs in unit were consistently <8 which responded to
500cc fluid boluses suggesting distributive rather than
cardiogenic etiology. He was empirically covered with Vanc/Zosyn
and he received 8 L of 500cc boluses over course of MICU stay
until his CVPs were consistently around [**8-26**]. His ascites
worsened in setting of chest tube draining hydrathorax and 8L NS
boluses.  Pt remained normotensive when he returned to the
floor.

# [**Name (NI) **] - Pt developed diffuse pruritic morbilliform eruption
over extremities and trunk one day after washing with
chlorhexadine soap for OR.  Derm evaluated pt and determined
that [**Name (NI) **] is drug reaction most likely secondary to systemic
antibiotic.  Most likely culprits are azithromycin (which the pt
took 10 days pta, and is known to cause delayed morbilliform
eruption) or PCN (took zosyn during admission).  Derm felt that
[**Name (NI) **] is not typical for hypersensitivity [**Name (NI) **] to chlorhexadine.
Pt was treated with zyrtec, sarna, clobetasol cream and
antihistamines.  At time of discharge, [**Name (NI) **] had improved but was
still present.  Pt was advised not to take chlorhexadine, and
avoid azithromycin.
.
# Anemia - Secondary to iron deficiency and ACD.  Pt had several
crit drops to low 20's but never had any source of acute bleed.
.
# Cirrhosis - pt w HCV cirrhosis with varices, ascites, prior
history of SBP and hepatic encephalopathy. Chronic and stable on
floor with worsening ascites in setting of multiple fluid
boluses.  In unit diuretics were held and restarted when he hit
the floor.  Ascites improved with diuresis and pt was not given
paracentesis.  After ICU stay, pt had ileus secondary to
narcotics.  His lactulose was held transiently and narcotics
were tapered.  Ultimately he started moving his bowels again and
lactulose was restarted.  He did not experience any episodes of
encephalopathy at this point.  Pt was d/ced on all of his home
medications.

# Eosinophilia: h/o peripheral and pleural fluid eosinophilia,
uncertain etiology.  Chronic thoracenteses have been documented
to cause peripheral eosinophilia with pleural eosinophilia.
Stool was negative for O&P and pt was not on any medication that
would be responsible for eosinophilia.

#. Chronic Hyponatremia: Pt w h/o hyponatremia thought to be [**1-18**]
cirrhosis, maintained on tolvaptan, with normal Na levels.
During stay in ICU, tolvaptan was held, but restarted when pt
was transferred back to floor.  He was discharged on home dose
with low Na and fluid restricted diet.
.
#. DM: Pt was continued on home glargine and ISS.

Transitionals:
- final pleural bx read
- avoid chlorhexadine in future.  Avoid azithromycin
- needs outpatient paracentesis
- f/u with thoracics and in hepatology clinic

Medications on Admission:
- folic acid 1mg daily
- furosemide 80mg in AM and 20 at PM
- lactulose 30mL [**Hospital1 **]
- prochlorperazine maleate 10mg q6h prn
- rifaximin 550mg [**Hospital1 **]
- spironolactone 100mg daily
- ursodiol 250mg TID
- ferrous sulfate 300mg daily
- simethicone 80mg QID prn
- thiamine HCl 100mg daily
- Calcium QID prn
- nadolol 20mg daily
- ciprofloxacin 250mg q24hr
- tolvaptan 60mg daily
- omeprazole 20mg [**Hospital1 **]
- VitD 50,000 units qweekly
- glargine 20 units qAM, 34 units qHS
- Humalog sliding scale


Discharge Medications:
1. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day: SBP ppx.
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. furosemide 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day.
6. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day) for 5 days.
7. lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO twice
a day: restart this dose 6 days after discharge.
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
q6hr PRN as needed for nausea.
9. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. ursodiol 250 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
11. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
13. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. calcium carbonate 500 mg calcium (1,250 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO four times a day as needed for
indigestion.
15. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. tolvaptan 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
18. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
19. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for [**Hospital1 **].
Disp:*1 bottle* Refills:*0*
20. clobetasol 0.05 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 14 days.
Disp:*1 bottle* Refills:*0*
21. cetirizine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for [**Hospital1 **], itching, allergy symptoms.
Disp:*60 Tablet(s)* Refills:*2*
22. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous qAM.
23. insulin glargine 100 unit/mL Solution Sig: Thirty Four (34)
units Subcutaneous at bedtime.
24. Humalog 100 unit/mL Solution Sig: 1-19 units Subcutaneous
four times a day: as per home sliding scale.


Discharge Disposition:
Home

Discharge Diagnosis:
Right hepatic hydrothorax/hemothorax.
Shock
[**Hospital1 10540**]
morbilliform drug [**Hospital1 **]
peripheral mild eosinophilia of unknown origin


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


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure taking care of you.  You were admitted  to the
hospital for several bloody thoracenteses.  We found that your
blood count was low and treated you with two units of blood.
You also had a procedure done by cardio-thoracic surgery called
a talc pleurodesis.  The purpose of this procedure is the scar
the lining of your lung against your chest wall to prevent fluid
from re-accumulating in that space.  A chest tube was placed to
help the scarring process.  The surgeons removed the chest tube
and you did not re-accumulate fluid in your lungs.  However,
there is still a possibility that the fluid can come back.  As
such, we are scheduling you for another thoracentesis on Friday
[**8-18**], which you can cancel if you do not feel that you will
need it at that time.
.
Of note, your hospital course was complicated by pneumonia,
increased difficulty breathing, and decreased blood pressures.
You were transferred to the ICU for a day and treated with with
IV fluids, pressors and IV antibiotics.  We treated your
infection and you will not need any more antibiotic treatment.
When you returned from the ICU your abdomen was distended and it
was determined that you had an ileus, likely secondary to
narcotic medication.  We held your lactulose for several days
and your ileus improved.
.
You also developed a skin [**Month (only) **] due to a medication you took.
Although this happened right after you washed with
chlorhexadine, it is also possible that the azithromycin that
you recently took caused a delayed allergic reaction.  Please
avoid both of these medications in the future.
.
We have made the following changes to your home medications:
CHANGE Lactulose to 15 mL by mouth twice daily.  Please take
this dose for five days and then restart your normal lactulose
dose: 30 mL by mouth twice daily.
.
Please START the following medications:
camphor-menthol  0.5-0.5 % Lotion  One (1) Appl Topical TID (3
times a day) as needed for [**Month (only) **].
clobetasol  0.05 % Lotion One (1) Appl Topical [**Hospital1 **] (2 times a
day) for 14 days.
cetirizine  10 mg Tablet  Sig:  One (1) Tablet PO BID (2 times a
day) as needed for [**Hospital1 **].
.
-Continue your other home medications as previously prescribed.

Followup Instructions:
Department: RADIOLOGY CARE UNIT
When: FRIDAY [**2158-8-18**] at 7:00 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] [**2158-8-22**] 2:00 on the
[**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment.

Department: [**Location (un) **]
When: WEDNESDAY [**2158-8-23**] at 9:20 AM
With: [**Year (4 digits) **] [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
{'Other specified forms of effusion, except tuberculous,Portal vein thrombosis,Pneumonia, organism unspecified,Other ascites,Portal hypertension,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Hyposmolality and/or hyponatremia,Cirrhosis of liver without mention of alcohol,Unspecified viral hepatitis C without hepatic coma,Hypotension, unspecified,Hypoxemia,Anemia, unspecified,Rash and other nonspecific skin eruption,Eosinophilia'}


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: hepatic hydrothorax with bloody thoracentesis

PRESENT ILLNESS: 53 yoM with HCV and ETOH related
cirrhosis (Childs Class C) on [**Month/Day/Year **] list complicated by
chronic hydrothorax (always on right) requiring thoracentesis
throughout past year, ascites, PVT, hepatic encephalopathy,
grade
1 varices, and h/o SBP. Over the past few months he has been
needing biweekly taps. He reports that the amount of fluid taken
out has decreased per tap from initially 5-6l now down to 2-3L.
He was tapped on [**2158-8-1**] for 1.3L. There is no history of
infection related to the thoracentesis and per patient he has
never had talc/pleurodesis. Over past week his taps have been
showing signs of blood and so he was admitted for evaluation by
thoracic surgery for possible chest tube placement with
talc/pleurodesis.

MEDICAL HISTORY: - HCV Cirrhosis, c/b esophageal variceal hemorrhage, ascites,
portal vein thrombosis, hepatic hydrothorax, episodes of
encephalopathy
- Chronic Hyponatremia
- Type II DM
- h/o SMV thrombus, portal vein thrombus, not anticoagulated
- Thrombocytopenia
- ARF
- h/o Klebsiella bacteremia
-s/p inguinal and umbilical hernia repair

MEDICATION ON ADMISSION: - folic acid 1mg daily
- furosemide 80mg in AM and 20 at PM
- lactulose 30mL [**Hospital1 **]
- prochlorperazine maleate 10mg q6h prn
- rifaximin 550mg [**Hospital1 **]
- spironolactone 100mg daily
- ursodiol 250mg TID
- ferrous sulfate 300mg daily
- simethicone 80mg QID prn
- thiamine HCl 100mg daily
- Calcium QID prn
- nadolol 20mg daily
- ciprofloxacin 250mg q24hr
- tolvaptan 60mg daily
- omeprazole 20mg [**Hospital1 **]
- VitD 50,000 units qweekly
- glargine 20 units qAM, 34 units qHS
- Humalog sliding scale

ALLERGIES: Motrin / Chlorhexidine

PHYSICAL EXAM: Admission Exam:
VS - 97.5 88 107/66 14 98%RA
GENERAL - Moderate distress, sitting up in bed
HEENT - PERRL, MM dry, OP clear
NECK - supple, +8cm JVD
LUNGS - Mildly decreased lung sounds @ right base, otherwise
clear with good air movement, + accessory muscles
HEART - Tachy, no mrg
ABDOMEN - naBS, distended, tympanitic, nontender, no
rebound/guarding
EXTREMITIES - WWP, 1+ edema to mid-shin, no c/c
SKIN - small wound over RLE, c/d/i; maculopapular [**Location **] over
extremities and trunk, blanching
NEURO - AOx2-3, CNs II-XII grossly intact, no asterixis

FAMILY HISTORY: Mother and father with DM2

SOCIAL HISTORY: SOCIAL HISTORY: Lives with roommate in [**Location 30150**]. Has
girlfriend.
-tobacco: none
-EtOH: quit 25 years ago
-Drugs: former drug use, including IVDU with cocaine. Patient
denies drug use during past 25 years. 

### Response:
{'Other specified forms of effusion, except tuberculous,Portal vein thrombosis,Pneumonia, organism unspecified,Other ascites,Portal hypertension,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Hyposmolality and/or hyponatremia,Cirrhosis of liver without mention of alcohol,Unspecified viral hepatitis C without hepatic coma,Hypotension, unspecified,Hypoxemia,Anemia, unspecified,Rash and other nonspecific skin eruption,Eosinophilia'}
