CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: 57 F with Hep C cirrhosis, s/p liver transplant, recurrent
hepatic encephalopathy, recently admitted with altered mental
status from [**2090-9-14**]. During that admission, she was in the ICU,
then on the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service. Prior to that she was recently
admitted from [**Date range (1) 90625**] at [**Hospital1 1774**] and then again from about
[**Date range (1) 84215**] at [**Hospital **] Hospital for hepatic encephalopathy (also
admitted on at least 2 other occasions in [**Month (only) **]). During
last admission, was seen by Transplant Nurse [**First Name (Titles) **] [**Last Name (Titles) 109027**]y of 2nd OLT. On discharge, patient was A & O x 3.
.
EMS was called [**9-26**] [**1-3**] increasing AMS. Initial FS 120 w/ EMS.
In the ED, initial VS were 99.0, 107, 119/66, 17, 99/RA. PE
notable 'moaning, nonverbal, protects airway and purposeful
movement' and for guaiac negative. RUQ u/s with no ascites to
tap for SBP. CXR obtained and read as 'cannot r/o PNA'. EKG with
sinus tachycardia, early R-wave progression but no significant
interval change from prior UA equivacol with WBC and bacteria,
but no LE or nitrites. Labs with ammonia of 262. LFTs without
acute changes. Given lactulose 60mL PR and Unasyn 3g IV for UTI
and 2500ml NS. Per ED resident, she was moaning and mumbling and
minimally responsive but was protecting her airway. Upon
transfer, VS 99.4, 120, 135/92, 99%/RA.
.

MEDICAL HISTORY: - Cirrhosis [**1-3**] Hep C; s/p OLT [**2172**] with recurrent hep C and
autoimmune hepatitis (seen on biopsy); s/p IFN/ribavirin in
past. Complicated by recurrent hepatic encephalopathy, SBP prior
to transplant per husband, GI bleeding (both BRBPR and melena,
last 3-4 months ago per husband, but per husband does not seem
that she has ever required blood transfusions etc).
- recurrent facial cellulitis of cheeks
- asthma
- DM
- HTN
- osteoporosis
- nephrolithiasis
- h/o C.diff
- zoster

MEDICATION ON ADMISSION: - cellcept [**Pager number **] mg daily
- prograf 0.5 mg QHS
- xifaxan 400 mg TID
- lactulose 60 ml Q 4 hours
- mag oxide 400 mg TID
- metoprolol 25 mg [**Hospital1 **]
- Tums 2 tab TID
- Prednisone 10 mg daily
- folate 1 mg daily
- MVI
- vitamin D daily
- protonix 40 mg daily
- lantus 8 units QHS
- Humalog sliding scale

ALLERGIES: Sulfisoxazole

PHYSICAL EXAM: On transfer to the hepato-renal service:
VS - T 98.0, BP 118/86, P 68, RR 20, O2 Sat 100% RA
GENERAL - Middle aged mildly jaundiced woman in NAD, rambling
HEENT - Scleral icterus, MMM, OP clear
NECK - supple, no thyromegaly
LUNGS - CTAB
HEART - RRR, no MRG,
ABDOMEN - Well-healed scar. Soft, distended, nontender.
EXTREMITIES - warm, no edema. Bilateral lower extremities
tender.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, appropriate, CNs II-XII grossly intact, no
asterixis

FAMILY HISTORY: Mother with some type of liver disease and CHF.

SOCIAL HISTORY: Lives with husband. [**Name (NI) 4906**] denies etoh, smoking, drug use.
Cirrhosis of liver without mention of alcohol,Hepatic encephalopathy,Urinary tract infection, site not specified,Complications of transplanted liver,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Other and unspecified coagulation defects,Esophagitis, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Anemia, unspecified
Cirrhosis of liver NOS,Hepatic encephalopathy,Urin tract infection NOS,Compl liver transplant,Esoph varice oth dis NOS,Coagulat defect NEC/NOS,Esophagitis, unspecified,DMII wo cmp nt st uncntr,Asthma NOS,Anemia NOS
Admission Date:  [**2178-9-26**]              Discharge Date:   [**2178-10-3**]

Date of Birth:  [**2121-1-31**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfisoxazole

Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
endoscopy and colonoscopy


History of Present Illness:
57 F with Hep C cirrhosis, s/p liver transplant, recurrent
hepatic encephalopathy, recently admitted with altered mental
status from [**2090-9-14**]. During that admission, she was in the ICU,
then on the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service. Prior to that she was recently
admitted from [**Date range (1) 90625**] at [**Hospital1 1774**] and then again from about
[**Date range (1) 84215**] at [**Hospital **] Hospital for hepatic encephalopathy (also
admitted on at least 2 other occasions in [**Month (only) **]). During
last admission, was seen by Transplant Nurse [**First Name (Titles) **] [**Last Name (Titles) 109027**]y of 2nd OLT. On discharge, patient was A & O x 3.
.
EMS was called [**9-26**] [**1-3**] increasing AMS. Initial FS 120 w/ EMS.
In the ED, initial VS were 99.0, 107, 119/66, 17, 99/RA. PE
notable 'moaning, nonverbal, protects airway and purposeful
movement' and for guaiac negative. RUQ u/s with no ascites to
tap for SBP. CXR obtained and read as 'cannot r/o PNA'. EKG with
sinus tachycardia, early R-wave progression but no significant
interval change from prior UA equivacol with WBC and bacteria,
but no LE or nitrites. Labs with ammonia of 262. LFTs without
acute changes. Given lactulose 60mL PR and Unasyn 3g IV for UTI
and 2500ml NS. Per ED resident, she was moaning and mumbling and
minimally responsive but was protecting her airway. Upon
transfer, VS 99.4, 120, 135/92, 99%/RA.
.


Past Medical History:
- Cirrhosis [**1-3**] Hep C; s/p OLT [**2172**] with recurrent hep C and
autoimmune hepatitis (seen on biopsy); s/p IFN/ribavirin in
past. Complicated by recurrent hepatic encephalopathy, SBP prior
to transplant per husband, GI bleeding (both BRBPR and melena,
last 3-4 months ago per husband, but per husband does not seem
that she has ever required blood transfusions etc).
- recurrent facial cellulitis of cheeks
- asthma
- DM
- HTN
- osteoporosis
- nephrolithiasis
- h/o C.diff
- zoster


Social History:
Lives with husband. [**Name (NI) 4906**] denies etoh, smoking, drug use.


Family History:
Mother with some type of liver disease and CHF.

Physical Exam:
On transfer to the hepato-renal service:
VS - T 98.0, BP 118/86, P 68, RR 20, O2 Sat 100% RA
GENERAL - Middle aged mildly jaundiced woman in NAD, rambling
HEENT - Scleral icterus, MMM, OP clear
NECK - supple, no thyromegaly
LUNGS - CTAB
HEART - RRR, no MRG,
ABDOMEN - Well-healed scar. Soft, distended, nontender.
EXTREMITIES - warm, no edema. Bilateral lower extremities
tender.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, appropriate, CNs II-XII grossly intact, no
asterixis

Pertinent Results:
Admission labs:
[**2178-9-26**] 11:45AM   WBC-5.6 RBC-3.44* HGB-11.2* HCT-33.1* MCV-96
MCH-32.6* MCHC-33.9 RDW-18.5*
[**2178-9-26**] 11:45AM   NEUTS-59.2 LYMPHS-27.3 MONOS-9.5 EOS-3.5
BASOS-0.5
[**2178-9-26**] 11:45AM   GLUCOSE-119* UREA N-18 CREAT-0.8 SODIUM-143
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-28 ANION GAP-13

LFTs:
[**2178-9-26**] 11:45AM   ALT(SGPT)-93* AST(SGOT)-121* CK(CPK)-51 ALK
PHOS-85 TOT BILI-5.4*
[**2178-10-3**] 05:55AM BLOOD ALT-77* AST-126* LD(LDH)-332* AlkPhos-83
TotBili-4.3*

Urine:

[**2178-9-26**] 12:12PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-NEG

[**2178-9-26**] 12:12 pm URINE     Site: CATHETER

                            **FINAL REPORT [**2178-9-29**]**

   URINE CULTURE (Final [**2178-9-29**]):
      ESCHERICHIA COLI.
         >100,000 ORGANISMS/ML. PRESUMPTIVE IDENTIFICATION.
      KLEBSIELLA PNEUMONIAE.    >100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |          KLEBSIELLA PNEUMONIAE
                             |          |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S        8 S
CEFAZOLIN-------------   <=4 S      <=4 S
CEFEPIME--------------   <=1 S      <=1 S
CEFTAZIDIME-----------   <=1 S      <=1 S
CEFTRIAXONE-----------   <=1 S      <=1 S
CEFUROXIME------------     4 S        2 S
CIPROFLOXACIN---------<=0.25 S   <=0.25 S
GENTAMICIN------------   <=1 S      <=1 S
MEROPENEM-------------<=0.25 S   <=0.25 S
NITROFURANTOIN--------  <=16 S       64 I
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S      <=4 S
TOBRAMYCIN------------   <=1 S      <=1 S
TRIMETHOPRIM/SULFA----   <=1 S      <=1 S

RUQ US [**2178-9-26**]:

1. No focal hepatic lesions identified.

2. Patent hepatic vasculature as described above.

3. No ascites.

[**2178-9-26**] 11:45AM   ALBUMIN-2.2*

Brief Hospital Course:
Altered mental status:  The patient was initially admitted to
the medical ICU for altered mental status.  Tox screen was
negative, and hepatic encephalopathy or infection were
considered most likely.   She was given lactulose, titrating to
5 bowel movements per day, and treated for her infection (as
below), and her mental status quickly improved to baseline.
.
Urinary tract infection:  Urine culture grew pansensitive E Coli
and Klebsiella.  She was treated initially with Unasyn and
subsequently with Augmentin for a total 5 day course.
.
Cirrhosis:  Lactulose and rifaxamin were continued.   LFTs were
stable. The transplant team evaluated the patient and obtained
her recent biopsy results from [**Hospital3 **] to consider if she
might be a candidate for re-transplant. MELD was 27.  There was
some debate as to whether her recurrent cirrhosis s/p orthotopic
liver transplant in [**2173**] represented autoimmune hepatitis or
recurrent hepatitis C.  Recent hepatitis C viral load was 372
000.   Pre-transplant evaluation was continued, including Pap
smear and ABG.  She had recent PFT and echo.
.
Coagulopathy:  INR was [**1-4**], likely secondary to advancing liver
failure.  She received PO vitamin K for 3 days with no
improvement.
.
Anemia:  Iron studies suggestive of anemia of chronic
inflammation.  Patient also noted to be guaiac positive.  EGD
and colonoscopy were done, demonstrating a normal colon and only
2 cords of grade I varices in the esophagus.  She did not
require transfusion support.
.
Urethral prolapse:  The patient reported blood in her urine,
which was confirmed on urinalysis.  She was found on exam to
have a prolapsed urethra.  Both the gynecology and urology
services evaluated her.  Urology advised that no surgical
intervention was necessary, and bacitracin ointment was applied
to the mucosa to relieve irritation.


Medications on Admission:
- cellcept [**Pager number **] mg daily
- prograf 0.5 mg QHS
- xifaxan 400 mg TID
- lactulose 60 ml Q 4 hours
- mag oxide 400 mg TID
- metoprolol 25 mg [**Hospital1 **]
- Tums 2 tab TID
- Prednisone 10 mg daily
- folate 1 mg daily
- MVI
- vitamin D daily
- protonix 40 mg daily
- lantus 8 units QHS
- Humalog sliding scale


Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
QAM (once a day (in the morning)).
2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QPM (once a day (in the evening)).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO TID (3
times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
8. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QPM (once a
day (in the evening)).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Insulin Glargine
9 Units at bedtime
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical QID (4 times a day): apply to urethra.
Disp:*1 tube* Refills:*2*
15. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 109028**] Homecare

Discharge Diagnosis:
Primary:
cirrhosis s/p transplant with recurrent cirrhosis
encephalopathy
urinary tract infection
prolapsed urethra
anemia
Secondary
Diabetes
Hypertension


Discharge Condition:
Stable.  Not confused.  Afebrile.


Discharge Instructions:
You were admitted with confusion and found to have a urinary
tract infection.  Your urinary tract infection was treated with
antibiotics which you have completed.  While in the hospital you
were found to have a prolapsed uretrha and seen by gynecology
and urology.  It should improve with time.

The following medications were changed in the hospital:
furosemide was added
Augmentin was added (unasyn started [**9-28**])
lactulose was decreased to three times daily

Otherwise, please continue all of your old medications.

Please return to the emergency department or call the liver
clinic at [**Telephone/Fax (1) 673**] if you experience fevers and chills,
confusion, chest pain or shortness of breath, or other symptoms
that are concerning to you.

Followup Instructions:
Please follow up as below:

Dr. [**Last Name (STitle) 497**] in liver clinic on [**2178-11-2**] at 9 am.  The phone number
is [**Telephone/Fax (1) 673**] Date/Time:[**2178-11-2**] 9:00.
.
On [**10-14**] you have three apts:
1. Nutrition with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2178-10-14**] 10:00
2. Transplant hepatology clinic: Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2178-10-14**] 11:00
3. Mammogram: RADIOLOGY Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2178-10-14**]
3:45
.
You should also follow up with urology.  Please call ([**Telephone/Fax (1) 18591**] to arrange an appointment.



Completed by:[**2178-10-3**]
{'Cirrhosis of liver without mention of alcohol,Hepatic encephalopathy,Urinary tract infection, site not specified,Complications of transplanted liver,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Other and unspecified coagulation defects,Esophagitis, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Anemia, unspecified'}


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: altered mental status

PRESENT ILLNESS: 57 F with Hep C cirrhosis, s/p liver transplant, recurrent
hepatic encephalopathy, recently admitted with altered mental
status from [**2090-9-14**]. During that admission, she was in the ICU,
then on the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service. Prior to that she was recently
admitted from [**Date range (1) 90625**] at [**Hospital1 1774**] and then again from about
[**Date range (1) 84215**] at [**Hospital **] Hospital for hepatic encephalopathy (also
admitted on at least 2 other occasions in [**Month (only) **]). During
last admission, was seen by Transplant Nurse [**First Name (Titles) **] [**Last Name (Titles) 109027**]y of 2nd OLT. On discharge, patient was A & O x 3.
.
EMS was called [**9-26**] [**1-3**] increasing AMS. Initial FS 120 w/ EMS.
In the ED, initial VS were 99.0, 107, 119/66, 17, 99/RA. PE
notable 'moaning, nonverbal, protects airway and purposeful
movement' and for guaiac negative. RUQ u/s with no ascites to
tap for SBP. CXR obtained and read as 'cannot r/o PNA'. EKG with
sinus tachycardia, early R-wave progression but no significant
interval change from prior UA equivacol with WBC and bacteria,
but no LE or nitrites. Labs with ammonia of 262. LFTs without
acute changes. Given lactulose 60mL PR and Unasyn 3g IV for UTI
and 2500ml NS. Per ED resident, she was moaning and mumbling and
minimally responsive but was protecting her airway. Upon
transfer, VS 99.4, 120, 135/92, 99%/RA.
.

MEDICAL HISTORY: - Cirrhosis [**1-3**] Hep C; s/p OLT [**2172**] with recurrent hep C and
autoimmune hepatitis (seen on biopsy); s/p IFN/ribavirin in
past. Complicated by recurrent hepatic encephalopathy, SBP prior
to transplant per husband, GI bleeding (both BRBPR and melena,
last 3-4 months ago per husband, but per husband does not seem
that she has ever required blood transfusions etc).
- recurrent facial cellulitis of cheeks
- asthma
- DM
- HTN
- osteoporosis
- nephrolithiasis
- h/o C.diff
- zoster

MEDICATION ON ADMISSION: - cellcept [**Pager number **] mg daily
- prograf 0.5 mg QHS
- xifaxan 400 mg TID
- lactulose 60 ml Q 4 hours
- mag oxide 400 mg TID
- metoprolol 25 mg [**Hospital1 **]
- Tums 2 tab TID
- Prednisone 10 mg daily
- folate 1 mg daily
- MVI
- vitamin D daily
- protonix 40 mg daily
- lantus 8 units QHS
- Humalog sliding scale

ALLERGIES: Sulfisoxazole

PHYSICAL EXAM: On transfer to the hepato-renal service:
VS - T 98.0, BP 118/86, P 68, RR 20, O2 Sat 100% RA
GENERAL - Middle aged mildly jaundiced woman in NAD, rambling
HEENT - Scleral icterus, MMM, OP clear
NECK - supple, no thyromegaly
LUNGS - CTAB
HEART - RRR, no MRG,
ABDOMEN - Well-healed scar. Soft, distended, nontender.
EXTREMITIES - warm, no edema. Bilateral lower extremities
tender.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, appropriate, CNs II-XII grossly intact, no
asterixis

FAMILY HISTORY: Mother with some type of liver disease and CHF.

SOCIAL HISTORY: Lives with husband. [**Name (NI) 4906**] denies etoh, smoking, drug use. 

### Response:
{'Cirrhosis of liver without mention of alcohol,Hepatic encephalopathy,Urinary tract infection, site not specified,Complications of transplanted liver,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Other and unspecified coagulation defects,Esophagitis, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Anemia, unspecified'}
