CHIEF COMPLAINT: hypernatremia

PRESENT ILLNESS: Ms. [**Known lastname 32457**] is a 36 y/o woman primary sclerosing cholangitis
status post living unrelated liver transplant on [**2161-4-13**],
complicated by small for size graft with graft failure,
necessitating retransplantation on [**2161-4-19**], as well as as
permanent brain injury, recurrent primary sclerosing cholangitis
on liver bx, who was transferred from [**Hospital6 8432**]
Center on [**2165-12-7**] w/ hypernatremia & renal failure in setting
of diarrhea.
.
Prior to transfer to [**Hospital1 18**], while at EMMC, Mrs. [**Known lastname 32457**] was found
to have acute renal failure with Cr 3.8/BUN 164 and sodium 155.
She was treated with IVF. Sodium ranged from 154 up to 161. She
was covered empirically for C diff with metronidazole for
diarrhea.

MEDICAL HISTORY: * ESLD secondary to primary sclerosing cholangitis, s/p living
unrelated donor transplant in [**3-/2161**] which failed leading to
cerebral edema necessitating second transplant in [**3-/2161**]
* IBD - UC diagnosed [**2156**] after p/w bloody stools
* h/o cerebral edema s/p VP shunt
* h/o prolonged mechanical ventilation and tracheostomy
* h/o G tube placement (now removed)
* h/o seizures
* Ulcerative colitis
* Anoxic brain injury [**1-26**] respiratory arrest
* Hypothyroidism
* h/o dysphagia

MEDICATION ON ADMISSION: risperdal 0.25 mg daily
mvi daily
lexapro 5 mg daily
clonazepam 0.25 mg qhs
flonase [**Hospital1 **]
keppra 750 mg [**Hospital1 **]
asacol 1600 mg tid
Enlive supplement with meals
lactose ms/ tid between meals
ritalin 5 mg daily
ursodiol 600 mg [**Hospital1 **]
immodium 4 mg after each loose stool
synthroid 25 mcg daily
ibuprofen 200 mg up to four times per day prn
bisacodyl 10 mg prn
milk of mag prn
glycerin suppository prn

ALLERGIES: Morphine Sulfate

PHYSICAL EXAM: PE: T: 97.6 BP: 95/67 (90-120s/50-70s) HR: 108 (100-110s) RR: 24
O2 98% RA
Gen: Pleasant woman, appears younger than stated age
HEENT: OP clear, MMM, pupils small but reactive bilaterally
NECK: supple, no lad, evidence of prior trach
CV: tachycardic but regular, no murmurs
LUNGS: clear bilaterally, no wheezing
ABD: soft, slightly tender, no guarding, normoactive bowel
sounds
EXT: warm, well perfused, dp pulses 2+ bilaterally
SKIN: No rashes/lesions, ecchymoses.
NEURO: alert, talks softly in short phrases and tends to repeat
(such as "no no no no" or "hello hello hello"), face symmetric,
moving all extremities

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Living at rehab facility chronically following anoxic brain
injury in [**2161**]. Husband, [**Name (NI) **], very dedicated and involved in
her care.
Ulcerative colitis, unspecified,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Cholangitis,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Complications of transplanted liver,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified acquired hypothyroidism
Ulceratve colitis unspcf,Acute kidney failure NOS,Hyperosmolality,Cholangitis,Ac DVT/embl low ext NOS,Compl liver transplant,Protein-cal malnutr NOS,Urin tract infection NOS,Epilep NOS w/o intr epil,Hypothyroidism NOS
Admission Date:  [**2165-12-7**]              Discharge Date:   [**2165-12-18**]

Date of Birth:  [**2129-8-16**]             Sex:   F

Service: MEDICINE

Allergies:
Morphine Sulfate

Attending:[**First Name3 (LF) 7616**]
Chief Complaint:
hypernatremia

Major Surgical or Invasive Procedure:
Sigmoidoscopy [**2165-12-7**]


History of Present Illness:
Ms. [**Known lastname 32457**] is a 36 y/o woman primary sclerosing cholangitis
status post living unrelated liver transplant on [**2161-4-13**],
complicated by small for size graft with graft failure,
necessitating retransplantation on [**2161-4-19**], as well as as
permanent brain injury, recurrent primary sclerosing cholangitis
on liver bx, who was transferred from [**Hospital6 8432**]
Center on [**2165-12-7**] w/ hypernatremia & renal failure in setting
of diarrhea.
.
Prior to transfer to [**Hospital1 18**], while at EMMC, Mrs. [**Known lastname 32457**] was found
to have acute renal failure with Cr 3.8/BUN 164 and sodium 155.
She was treated with IVF. Sodium ranged from 154 up to 161. She
was covered empirically for C diff with metronidazole for
diarrhea.

Past Medical History:
* ESLD secondary to primary sclerosing cholangitis, s/p living
unrelated donor transplant in [**3-/2161**] which failed leading to
cerebral edema necessitating second transplant in [**3-/2161**]
* IBD - UC diagnosed [**2156**] after p/w bloody stools
* h/o cerebral edema s/p VP shunt
* h/o prolonged mechanical ventilation and tracheostomy
* h/o G tube placement (now removed)
* h/o seizures
* Ulcerative colitis
* Anoxic brain injury [**1-26**] respiratory arrest
* Hypothyroidism
* h/o dysphagia

Social History:
Living at rehab facility chronically following anoxic brain
injury in [**2161**]. Husband, [**Name (NI) **], very dedicated and involved in
her care.

Family History:
non-contributory

Physical Exam:
PE: T: 97.6 BP: 95/67 (90-120s/50-70s) HR: 108 (100-110s) RR: 24
O2 98% RA
Gen: Pleasant woman, appears younger than stated age
HEENT: OP clear, MMM, pupils small but reactive bilaterally
NECK: supple, no lad, evidence of prior trach
CV: tachycardic but regular, no murmurs
LUNGS: clear bilaterally, no wheezing
ABD: soft, slightly tender, no guarding, normoactive bowel
sounds
EXT: warm, well perfused, dp pulses 2+ bilaterally
SKIN: No rashes/lesions, ecchymoses.
NEURO: alert, talks softly in short phrases and tends to repeat
(such as "no no no no" or "hello hello hello"), face symmetric,
moving all extremities

Pertinent Results:
On Admission:
[**2165-12-7**] 01:40PM BLOOD WBC-10.0 RBC-3.62* Hgb-10.6* Hct-32.0*
MCV-89 MCH-29.3 MCHC-33.1 RDW-16.2* Plt Ct-104*
[**2165-12-7**] 01:40PM BLOOD PT-17.0* PTT-27.9 INR(PT)-1.5*
[**2165-12-7**] 05:36AM BLOOD Glucose-143* UreaN-86* Creat-1.7* Na-160*
K-3.1* Cl-140* HCO3-12* AnGap-11
[**2165-12-7**] 05:36AM BLOOD ALT-11 AST-14 LD(LDH)-249 AlkPhos-105
TotBili-0.3
[**2165-12-7**] 01:40PM BLOOD Albumin-3.0* Calcium-8.3* Phos-1.6*#
Mg-2.0
[**2165-12-7**] 01:40PM BLOOD tacroFK-3.2*
.
.
Labs On Discharge:
[**2165-12-18**] 04:27AM    WBC 8.6 Hgb 11.0* Hct 32.5* Plt 408
[**2165-12-18**] 04:27AM    PT 13.9*    INR 1.2*
[**2165-12-18**] 04:27AM    Gluc 105 BUN 18 Crt 0.9 Na 141 K 4.1 Cl
110 HC03 25
.
Stool for OVA + PARASITES (Final [**2165-12-13**]):
      NO OVA AND PARASITES SEEN.
      This test does not reliably detect Cryptosporidium,
Cyclospora or
      Microsporidium. While most cases of Giardia are detected
by routine
      O+P, the Giardia antigen test may enhance detection when
organisms
      are rare.
.
   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2165-12-11**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).
.
CMV Viral Load (Final [**2165-12-11**]):  CMV DNA not detected.
Performed by PCR.
.
URINE CULTURE (Final [**2165-12-10**]):  ESCHERICHIA COLI. >100,000
ORGANISMS/ML. OF TWO COLONIAL  MORPHOLOGIES. PRESUMPTIVE
IDENTIFICATION.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----  =>16 R
.
.
Imaging:
.
Lower extremity ultrasound:  [**Doctor Last Name **] scale and Doppler son[**Name (NI) **] of
the
bilateral common femoral, superficial femoral and popliteal
veins was
performed. There is extensive clot in the left common femoral,
superficial
femoral and popliteal veins. There is normal compressibility,
flow and
augmentation of the right common femoral, superficial femoral
and popliteal
veins. IMPRESSION: Complete left lower extremity DVT.
.
GI biopsy: Sigmoid colon, biopsy:
1) Chronic active colitis.
2)  No viral inclusions, granulomas or dysplasia.  VIRAL CULTURE
(Preliminary):    No Virus isolated so far.
.
[**2165-12-12**] BILATERAL LOWER EXTREMITY ULTRASOUND: [**Doctor Last Name **] scale and
Doppler son[**Name (NI) **] of the bilateral common femoral, superficial
femoral and popliteal veins was
performed. There is extensive clot in the left common femoral,
superficial
femoral and popliteal veins. There is normal compressibility,
flow and
augmentation of the right common femoral, superficial femoral
and popliteal veins.  IMPRESSION: Complete left lower extremity
DVT.


Brief Hospital Course:
Brief Summary:
36 y/o W with PSC s/p liver transplantation X 2, anoxic brain
injury who is transferred with diarrhea, hypernatremia, and
acute renal failure.  On arrival to [**Hospital1 18**], she was sent to the
MICU for treatment hypernatremia (Na 160) & renal failure. These
improved w/ IVF. Renal failure was thought to be pre-renal in
origin. She was noted to have frequent diarrhea, and underwent
sigmoidoscopy, which was suggestive of a UC flare.  CMV viral
load & viral culture of sigmoid tissue were negative.  The
patient was started on prednisone for presumed UC flare.  She
was also found to have complete Left lower extremity DVT, and
was started on lovenox [**Hospital1 **]--she was tried on coumadin, but this
was discontinued after two doses as her INR rose to >17 after
only two doses.

Detailed Course by Problem:
# Hypernatremia: Due to hypovolemia from diarrhea + poor po
intake. At OSH, her sodium was as high as 160s.  It improved
with continuous IVF.  As diarrhea slowed & pt's PO intake
improved, IVF was discontinued and Mrs. [**Known lastname 32457**] was able to
maintain adequate PO intake with Na in the low 140s.  Please
encourage po intake and have water available to her at all
times.
.
# Diarrhea: Patient had regular, non-bloody diarrhea. Cdiff X 2
negative, CMV viral load negative, O&P negative X 2, salmonella,
shigella, campylobacter negative. Biopsy showed active colitis.
She started on Prednisone for presumed UC flare (40 mg po qd for
2 weeks than taper 5 mg a week).  She was continued on
Mesalamine DR 1600 mg PO TID for UC.  Her diarrhea improved with
the prednisone, though she was still having up to 5 BM daily at
time of discharge.  Ursodiol was held since it could worsen her
diarrhea, but it will need to be re-started once her diarrhea
slows. (She was started on vitamin D & calcium since she will be
on steroids for prolonged period.)
.
# L lower extremity swelling: She was found to have a large DVT
in her left lower extremity, despite being on DVT prophylaxis
with SC heparin.  This DVT is her first known thrombotic event,
and it was felt to be due to her dehydration plus her immobility
during her acute illness.  She was initiated on a heparin drip,
and then given coumadin.  Following 2 doses of coumadin at a
dose of 2 mg, her INR increased to 17.6.  No active bleeding was
found.  The warfarin was discontinue and her INR was reversed
with 4 units FFP.  Her INR improved to 2.4 and was stable.  She
was also given Vitamin K 5 mg X 3 days.  Hematology was
consulted.  Her supratherapeutic INR was thought to be secondary
to low Vit K stores from her diarrhea, antibiotics, and
malnutrition.  Her underlying hepatic dysfunction may have also
contributed to her elevated INR.  She should not be given
coumadin given the unpredictability of her response to the
anti-coagulant.  (Of note, she is not thought to be a rapid
metabolizer of the drug.)  She should receive Lovenox therapy at
minimun for 6 months for her DVT.
.
# PSC/Liver Transplant: Her primary liver disease is primary
sclerosing cholangitis, which is treated with Ursodiol.  This
was held as it could worsen her diarrhea, but it will need to be
re-started as outpatient.  She was continued on tacrolimus
(Prograf) for immunosuppression, and the dose was adjusted based
on trough levels.  Her discharge dose will be 1.5mg every twelve
hours.
.
# UTI: Mrs. [**Known lastname 32457**] was found to have a urinary tract infection.
Her Ucx grew Ecoli resistant to Cipro.  She was given Cefazolin
1g q8hr, which she should receive for a total of 14 days, until
[**2165-12-24**].
.
# Anemia: Pt's Hct 23.7 on [**12-17**].  She has had a slow decrease
in her hct following an admission Hct of 32.  Her stool was
repeatedly guaiac negative, and there was no evidence of gross
bleeding.  Her drop in hematocrit may have been a reflection of
her baseline anemia (hct has reportedly w/ been in the upper-20s
at her nursing home) plus a dilutional component in the setting
of IVF.  She was transfused 2units of packed red blood cells on
[**2165-12-17**].  Her discharge hematocrit was 32.5 on [**2165-12-18**].
.
# Cognitive deficits: Continued home medications, including
ritalin, escitalopram, and risperdal.
.
# Code Status: full code - confirmed by husband, [**Name (NI) **], who is
also her guardian.


Medications on Admission:
risperdal 0.25 mg daily
mvi daily
lexapro 5 mg daily
clonazepam 0.25 mg qhs
flonase [**Hospital1 **]
keppra 750 mg [**Hospital1 **]
asacol 1600 mg tid
Enlive supplement with meals
lactose ms/ tid between meals
ritalin 5 mg daily
ursodiol 600 mg [**Hospital1 **]
immodium 4 mg after each loose stool
synthroid 25 mcg daily
ibuprofen 200 mg up to four times per day prn
bisacodyl 10 mg prn
milk of mag prn
glycerin suppository prn

Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day): 750mg twice daily.
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
5. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for apply to raw skin on bottom.
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO Bedtime as
needed for insomnia.
10. Escitalopram 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).

11. Tacrolimus 1 mg Capsule Sig: 1.5 Capsules PO Q12H (every 12
hours).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
14. Cefazolin in Dextrose (Iso-os) 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q8H (every 8 hours) as needed for UTI
for 8 days: Last day [**2165-12-24**] for total 14 day course. .
15. Enoxaparin 60 mg/0.6 mL Syringe Sig: Fifty (50) mg
Subcutaneous [**Hospital1 **] (2 times a day).
16. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Taper: 40 mg dose until [**2165-12-25**] for total 14 day
course. Then 5 mg reduction per week. .


Discharge Disposition:
Extended Care

Facility:
[**Hospital 32458**] Rehab

Discharge Diagnosis:
Ulcerative colitis
Deep vein thrombosis
Hypernatremia
Acute renal failure (pre-renal)
Primary sclerosing cholangitis
Anoxic brain injury
Anemia


Discharge Condition:
Fair


Discharge Instructions:
You were admitted for renal failure and high sodium. Both
improved with IV hydration. It is important you drink lots of
fluid.
You were having frequent diarrhea and are being treated on
prednisone for an ulcerative colitis flare.
You were found to have a blood clot in your left leg and started
on anticoagulation therapy called Lovenox - you will need to
take this for 6 months.
.
Please review your medication list closely. You are on a steroid
taper: 40 mg until [**2165-12-25**] then 5 mg reductions per week. Your
ursodiol was held due to possible diarrhea side effect. This
should be re-started when your diarrhea improves. You are being
discharged on Lovenox for anti-coagulation.
.
Attend all your follow up appointments.
.
Return to the ER if you experience fever, chills, nausea,
vomiting, diarrhea, bleeding or any other concerning symptoms.

Followup Instructions:
Please follow up with your primary care doctor in [**12-26**] weeks.
Please follow up with your liver doctor in [**1-28**] weeks.


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(1) 7619**]
{'Ulcerative colitis, unspecified,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Cholangitis,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Complications of transplanted liver,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified acquired hypothyroidism'}


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: hypernatremia

PRESENT ILLNESS: Ms. [**Known lastname 32457**] is a 36 y/o woman primary sclerosing cholangitis
status post living unrelated liver transplant on [**2161-4-13**],
complicated by small for size graft with graft failure,
necessitating retransplantation on [**2161-4-19**], as well as as
permanent brain injury, recurrent primary sclerosing cholangitis
on liver bx, who was transferred from [**Hospital6 8432**]
Center on [**2165-12-7**] w/ hypernatremia & renal failure in setting
of diarrhea.
.
Prior to transfer to [**Hospital1 18**], while at EMMC, Mrs. [**Known lastname 32457**] was found
to have acute renal failure with Cr 3.8/BUN 164 and sodium 155.
She was treated with IVF. Sodium ranged from 154 up to 161. She
was covered empirically for C diff with metronidazole for
diarrhea.

MEDICAL HISTORY: * ESLD secondary to primary sclerosing cholangitis, s/p living
unrelated donor transplant in [**3-/2161**] which failed leading to
cerebral edema necessitating second transplant in [**3-/2161**]
* IBD - UC diagnosed [**2156**] after p/w bloody stools
* h/o cerebral edema s/p VP shunt
* h/o prolonged mechanical ventilation and tracheostomy
* h/o G tube placement (now removed)
* h/o seizures
* Ulcerative colitis
* Anoxic brain injury [**1-26**] respiratory arrest
* Hypothyroidism
* h/o dysphagia

MEDICATION ON ADMISSION: risperdal 0.25 mg daily
mvi daily
lexapro 5 mg daily
clonazepam 0.25 mg qhs
flonase [**Hospital1 **]
keppra 750 mg [**Hospital1 **]
asacol 1600 mg tid
Enlive supplement with meals
lactose ms/ tid between meals
ritalin 5 mg daily
ursodiol 600 mg [**Hospital1 **]
immodium 4 mg after each loose stool
synthroid 25 mcg daily
ibuprofen 200 mg up to four times per day prn
bisacodyl 10 mg prn
milk of mag prn
glycerin suppository prn

ALLERGIES: Morphine Sulfate

PHYSICAL EXAM: PE: T: 97.6 BP: 95/67 (90-120s/50-70s) HR: 108 (100-110s) RR: 24
O2 98% RA
Gen: Pleasant woman, appears younger than stated age
HEENT: OP clear, MMM, pupils small but reactive bilaterally
NECK: supple, no lad, evidence of prior trach
CV: tachycardic but regular, no murmurs
LUNGS: clear bilaterally, no wheezing
ABD: soft, slightly tender, no guarding, normoactive bowel
sounds
EXT: warm, well perfused, dp pulses 2+ bilaterally
SKIN: No rashes/lesions, ecchymoses.
NEURO: alert, talks softly in short phrases and tends to repeat
(such as "no no no no" or "hello hello hello"), face symmetric,
moving all extremities

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Living at rehab facility chronically following anoxic brain
injury in [**2161**]. Husband, [**Name (NI) **], very dedicated and involved in
her care. 

### Response:
{'Ulcerative colitis, unspecified,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Cholangitis,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Complications of transplanted liver,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified acquired hypothyroidism'}
