CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 46-year-old
male with a known history of hepatitis B virus for
approximately 18 years, which has been resistant to
lamivudine therapy as well as study drug ACH-[**Numeric Identifier 33100**] for ten
weeks.  Prior to admission he had recently been on a long
trip to [**Country 651**] and [**Country 33101**] and was seen in the liver clinic on
[**2161-5-26**] and found to have elevated liver enzymes with an AST
to 2,620 and ALT to 3,742 with a total bilirubin of 11.8 and
coagulopathy with an INR of 2.1.  He presented to [**Hospital1 346**] for management of liver failure in
the setting of what was probably an acute hepatitis B flare.

MEDICAL HISTORY: 1. Hepatitis B virus as above.  2.
Diabetes mellitus type 2.

MEDICATION ON ADMISSION: 1. Glucotrol 5 mg p.o. q. day.  2.
ACH study drug [**Numeric Identifier 33100**].  3. Adefovir 10 mg q. day started on
[**2161-5-28**].

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: No tobacco, occasional alcohol.
Viral hepatitis B with hepatic coma, acute or unspecified, without mention of hepatitis delta,Acute and subacute necrosis of liver,Cirrhosis of liver without mention of alcohol,Hepatic encephalopathy,Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Atrial flutter,Herpetic meningoencephalitis
Hpt B acte coma wo dlta,Acute necrosis of liver,Cirrhosis of liver NOS,Hepatic encephalopathy,React-oth vasc dev/graft,Bacteremia,Atrial flutter,Herpetic encephalitis
Admission Date:  [**2161-5-29**]       Discharge Date:  [**2161-7-9**]

Date of Birth:   [**2114-11-20**]       Sex:  M

Service:Transplant Surgery

ADDENDUM:  On [**2161-6-13**] the patient underwent orthotopic liver
transplant with Drs. [**Last Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) 955**].  The
anastomosis PHA to right CHA, portal vein was anastomosed to
portal vein, duct was anastomosed to duct, graft type was
cadaveric.  The patient tolerated the procedure well with
approximately 3,000 cc of crystalloid given intraoperatively,
14 units of fresh frozen plasma, three units of packed red
cells, two units of platelets with an estimated blood loss of
only 300 cc.

Postoperatively the patient was transferred intubated to the
intensive care unit.  He remained intubated until
postoperative day 14, which was [**2161-6-26**].

1. Infectious disease:  The patient continued to spike fevers
in the intensive care unit with temperatures to 102-103
through postoperative day seven, at which point the patient
defervesced, remained afebrile with temperatures 97-98
throughout the remainder of his hospitalization.  For
immediate postoperative prophylaxis the patient was placed on
Unasyn, valacyclovir, fluconazole, vancomycin, Zosyn and
Bactrim.  Vancomycin was continued for a 16-day course, the
Zosyn for a 10-day course.  The valacyclovir was changed on
postoperative day ten, [**2161-6-23**], following a CT scan of the
patient's head which revealed temporal lobe enhancement
consistent with possible herpes virus infection.  At this
point the patient was changed to acyclovir 800 mg t.i.d.
which he continued throughout the remainder of his
hospitalization.  At the time of discharge the patient was
changed back to valacyclovir for prophylaxis.  Cultures were
drawn throughout the patient's hospitalization with
temperature spikes.  For the most part these remained
negative.  One culture came back positive, which was central
venous line, on the 13th, which grew coagulase-negative
Staphylococcus.  He was continued on vancomycin for this.
Cultures after that point were negative.

2. Fluids, electrolytes and nutrition:  Postoperatively the
patient was begun on TPN for the first four postoperative
days.  On postoperative day four the patient was begun on
tube feeds for nutritional support.  Throughout his
hospitalization he has remained on a Regular Insulin sliding
scale.  At the time of discharge he was placed on glyburide
10 mg b.i.d.  Postintubation swallowing study was performed
given that the patient was intubated for a number of weeks
prior to transplant.  This demonstrated a failure of bedside
swallow as well as videoscopic examination.  The patient was
thought to be a high risk for aspiration.  On postoperative
day 27 again a video swallow was repeated.  As the patient's
voice became stronger he was able to tolerate swallowing.  At
that point he was placed on a diet of nectar-thickened
liquids and soft solids, to avoid thin liquids.  At the time
of discharge he is to follow up with the speech and swallow
service in approximately two weeks for reevaluation and
questionable progression of diet.

3. Pulmonary:  The patient was intubated on [**2161-6-3**].  He
remained intubated postoperatively until postoperative day
seven at which point he was able to tolerate extubation and
breathe on his own.  Numerous chest x-rays remained negative
for pulmonary disease.  There was some difficulty with his
oxygenation in his postoperative course; this resolved and
the patient had good oxygenation saturations on room air by
the time of discharge.

4. Neurologic:  The patient had an ICP monitor placed almost
immediately preoperatively for his liver transplant.  His
ICPs remained stable in the 9-14 range as measured by a
bullet.  His ICPs remained stable postoperatively and the
bullet was discontinued postoperatively on postoperative day
two, [**2161-6-16**].  It was discontinued without complications.
Numerous head CT scans obtained during the time in which he
had the bullet demonstrated no evidence of intracranial
bleed.  The neurology service continued to follow the patient
through his hospitalization.  Postoperatively his
encephalopathy cleared.  At the time of discharge he was
mentating well without any problems.

5. Cardiovascular:  The patient did have a fair amount of
hypertension postoperatively.  Postoperatively in the
intensive care unit the patient's blood pressures ranged from
180 to 202.  Over successive days following transfer from the
intensive care unit the patient's blood pressures resumed
with values in the 120s to 130s.  He was maintained on a
regimen of hydralazine 20 mg p.o. q. 6 hours, clonidine patch
for control of his hypertension.  On [**2161-6-20**] the patient had
an episode of atrial flutter.  The cardiology service was
consulted for this and Lopressor was added to his regimen for
rate control.  It was felt he may require ablation at some
point postoperatively.  The patient on the floor has had no
further episodes of atrial flutter.  His rate has been well
controlled.  He is to follow up with the cardiology service
post discharge.

6. Lines, drains, tubes:  The patient was transferred out of
the operating room with two [**Location (un) 1661**]-[**Location (un) 1662**] drains.  These
successfully decreased in output over the first 18 days
postoperatively.  The first drain was removed on
postoperative day 12, the second drain was removed on
postoperative day 18.  The drain sites remained clean, dry
and intact.  Additionally the patient came out of the
operating room with a central venous line.  This was also
removed postoperatively before discharge.  The patient has a
T-tube in place.  This T-tube was clamped on postoperative
day 18 as well.  The T-tube site remained clean, dry and
intact by the time of discharge.

7. Renal:  The patient's creatinine remained relatively
stable with a value in the 1.1 to 1.7 range.  Immediately
postoperatively he was maintained on a Lasix drip for low
urine output and diuresis following approximately a 20-liter
net positive gain immediately postoperatively.

8. Immunosuppression:  The patient was begun on CellCept on
postoperative day zero, 1,000 mg b.i.d. and this was
maintained throughout his hospitalization.  He was begun on a
Solu-Medrol taper initially with 1 gram of Solu-Medrol given
on postoperative day zero, slowly tapered down to 50 mg of
Solu-Medrol by postoperative day six.  He remained on this
until the time of discharge at which time he was changed to
oral prednisone 15 mg p.o. q.d.  The patient was also begun
on cyclosporine on postoperative day four.  His levels were
maintained in the 300 range.  Daily levels were checked and
at the time of discharge the patient was to be discharged on
a dose of 150 mg b.i.d.  He is to follow up with the
transplant service for frequent checks of this.  Additionally
the patient received two doses of Simulect, one on
postoperative day zero and one on postoperative day four.

9. Hepatology:  Initially the patient was maintained on a
dose of hepatitis B immune globulin for the first six days
postoperatively, at which point he was switched over to a q.
week dosing.  At the time of discharge he has received two
weeks of a four-week regimen of 10,000 units of hepatitis B
immune globulin.  He is to receive two more doses on
Wednesdays post discharge.  Additionally for hepatitis B the
patient remained on adefovir 2 mg p.o. q. day.  He is to be
discharged on this medication as well.

CONDITION ON DISCHARGE:  Good.

DISCHARGE DIAGNOSES:
1. Orthotopic liver transplant.
2. End-stage liver disease secondary to hepatitis B.
3. Insulin dependent diabetes mellitus.
4. Encephalopathy status post intracranial pressure
monitoring.
5. Hypertension.
6. Multiple line infections.
7. Herpes encephalitis.

DISCHARGE MEDICATIONS:
1. Adefovir dipivoxil 2 mg p.o. q. 24 hours.
2. Hydralazine 20 mg p.o. q. 6 hours.
3. Metoprolol 50 mg p.o. b.i.d.
4. Hepatitis B immune globulin 10,000 units IV q. Wednesday
for two weeks.
5. Clonidine TTS patch, one patch transdermal q. Saturday.
6. Bactrim DS one tablet p.o. q. day.
7. Protonix 40 mg p.o. q. day.
8. Valcyte 450 mg p.o. q. day.
9. Fluconazole 400 mg p.o. q. day.
10. Glipizide 10 mg p.o. b.i.d.
11. CellCept 1,000 mg p.o. b.i.d.
12. Prednisone 15 mg p.o. q. day.
13. Cyclosporine 150 mg p.o. b.i.d.

FOLLOW UP:  The patient is to follow up as previously
arranged with the transplant surgery service coordinator.
The patient is to be transferred to rehabilitation with a
diet consisting of soft solids and nectar-thick liquids.  He
is to follow up with the speech and swallow service
additionally for evaluation of his swallow and questionable
progression of diet.





                      DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-366

Dictated By:[**Name8 (MD) 16207**]
MEDQUIST36

D:  [**2161-7-9**]  04:12
T:  [**2161-7-9**]  07:16
JOB#:  [**Job Number 33099**]


Admission Date:  [**2161-5-29**]       Discharge Date:  [**2161-7-10**]

Date of Birth:   [**2114-11-20**]       Sex:  M

Service:  Transplant Surgery

HISTORY OF PRESENT ILLNESS:  The patient is a 46-year-old
male with a known history of hepatitis B virus for
approximately 18 years, which has been resistant to
lamivudine therapy as well as study drug ACH-[**Numeric Identifier 33100**] for ten
weeks.  Prior to admission he had recently been on a long
trip to [**Country 651**] and [**Country 33101**] and was seen in the liver clinic on
[**2161-5-26**] and found to have elevated liver enzymes with an AST
to 2,620 and ALT to 3,742 with a total bilirubin of 11.8 and
coagulopathy with an INR of 2.1.  He presented to [**Hospital1 346**] for management of liver failure in
the setting of what was probably an acute hepatitis B flare.

PAST MEDICAL HISTORY:  1. Hepatitis B virus as above.  2.
Diabetes mellitus type 2.

PAST SURGICAL HISTORY:  Slipped capital femoral epiphysis
repair.

MEDICATIONS ON ADMISSION:  1. Glucotrol 5 mg p.o. q. day.  2.
ACH study drug [**Numeric Identifier 33100**].  3. Adefovir 10 mg q. day started on
[**2161-5-28**].

ALLERGIES:  The patient has no known drug allergies.

SOCIAL HISTORY:  No tobacco, occasional alcohol.

REVIEW OF SYSTEMS:  His review of systems was significant for
fatigue and nonproductive cough x 10 days, dark urine,
moderate amount of diarrhea, increased abdominal distention,
acholic stools.

PHYSICAL EXAMINATION:  On admission his temperature was 97.6,
pulse 65, blood pressure 132/80, respiratory rate 18, 96 on
room air.  He was a pleasant male in no apparent distress.
Head/Neck:  Icteric sclerae, intact extraocular movements,
clear oropharynx, moist mucous membranes, supple neck and 1
cm bilateral submandibular nodes.  Lungs:  Clear to
auscultation bilaterally.  Cardiovascular:  Regular rate and
rhythm.  Abdomen:  Soft, nontender, obese, nondistended with
bowel sounds.  There was no hepatosplenomegaly.  Extremities:
Without cyanosis, clubbing or edema.  Neurologic:  He was
alert and oriented x 3 and was otherwise grossly intact.

LABORATORY DATA:  Admission laboratory studies demonstrated a
white count of 4.4, hematocrit 48.6, platelet count 97,
coagulation studies of 19.7 for PT, 36.1 PTT, 2.6 INR.  BUN
11.7 and glucose 209.  Urinalysis was negative on admission.
ALT on admission was 3,631, AST 2,534, GGT 166, alkaline
phosphatase 109, total bilirubin 14.2, albumin 3.3, amylase
44.  The patient was hepatitis A virus antibody positive, IgM
negative, with hepatitis B serologies pending at the time of
admission.

Ultrasound on [**2161-5-28**] demonstrated that the patient had a
normal liver with 17.5 cm of splenomegaly.  There was no free
abdominal fluid.

Chest x-ray on admission demonstrated no pneumonia.
Echocardiogram demonstrated left ventricular function to be
approximately 60%.

HOSPITAL COURSE:  The patient was initially admitted to the
[**Hospital1 139**] medicine firm for management of his hepatitis as well
as coagulopathy management.  He was initially placed on
prophylaxis for spontaneous bacterial peritonitis, a regimen
of levofloxacin, Flagyl as well as vancomycin and Nystatin.
He was managed supportively for the first part of his
hospital course and observed until approximately [**2161-6-2**].
At this point he began to demonstrate increasing confusion,
disorientation and other signs and symptoms consistent with
encephalopathy.  For this he was transferred to the medical
intensive care unit and thought to be a grade II
encephalopathy at that point.  Upon discussions with the
patient's family and the patient it was decided to intubate
the patient secondary to aspiration risk electively on
[**2161-6-3**].  Throughout his medical intensive care unit course
his coagulopathy was aggressively managed with fresh frozen
plasma and vitamin K.  Additionally on [**2161-6-3**] the patient
had a right internal jugular line placed and tube feeds were
initiated.  At the beginning of the [**Hospital 228**] hospital course
the hepatology service was consulted.  They continued to
follow the patient throughout his admission.

In the medical intensive care unit the patient was observed
closely for neurologic deterioration and he was placed on the
transplant list and given approximately an 80% mortality with
his encephalopathic picture and hepatic failure.  His hepatic
enzymes remained elevated though slightly decreased from
admission throughout the initial part of his hospital course.

From [**2161-6-3**] to [**2161-6-8**] the patient had a relatively stable
medical intensive care unit course.  He remained intubated
and sedated.  On [**2161-6-8**] the patient felt less responsive to
examination.  Head CT was obtained and this was negative.  On
[**2161-6-9**] the patient spiked a temperature to 102 degrees.
Surveillance cultures done throughout his MICU course had
been negative to that point and the patient had been covered
with broad-spectrum antibiotics.  Because of this the
infectious disease service was consulted.  Initially they
recommended change of the patient's central venous line and
tip culture as well as a change of antibiotics to Zosyn,
vancomycin and fluconazole.  Initially CMV PCR was sent and
VRE and MRSA screens were sent.  These were negative.  On
[**2161-6-11**] the patient was again recultured for a temperature
spike.  These also in turn were negative.

From a neurologic standpoint the patient demonstrated
progressive encephalopathy.  Given that it was unclear at
that time when a liver would be available for transplant, the
neurosurgery service was consulted on [**2161-6-11**] for bullet
placement for ICP management.  The patient's INR was
corrected to a value of 1.5 with vitamin K and fresh frozen
plasma.  The bullet was placed on [**2161-6-11**] and demonstrated
ICPs in good range of approximately [**10-18**].  On [**2161-6-12**] again
the patient had a head CT post bullet placement which
demonstrated no signs of intracranial bleed.  At this point
the neurology service was consulted for evaluation of her
irreversible neurologic deficit.  The patient became a high
priority transplant candidate.  They felt that while he had
had progressive encephalopathy there was no evidence of
irreversible neurologic deficit.  The patient remained
transplant listed as a high-priority candidate.



ADDENDUM TO BE DICTATED. THIS IS AN INCOMPLETE SUMMARY

                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D.
02-366

Dictated By:[**Name8 (MD) 16207**]
MEDQUIST36

D:  [**2161-7-8**]  03:46
T:  [**2161-7-8**]  07:28
JOB#:  [**Job Number 33102**]
{'Viral hepatitis B with hepatic coma, acute or unspecified, without mention of hepatitis delta,Acute and subacute necrosis of liver,Cirrhosis of liver without mention of alcohol,Hepatic encephalopathy,Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Atrial flutter,Herpetic meningoencephalitis'}


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: 

PRESENT ILLNESS: The patient is a 46-year-old
male with a known history of hepatitis B virus for
approximately 18 years, which has been resistant to
lamivudine therapy as well as study drug ACH-[**Numeric Identifier 33100**] for ten
weeks.  Prior to admission he had recently been on a long
trip to [**Country 651**] and [**Country 33101**] and was seen in the liver clinic on
[**2161-5-26**] and found to have elevated liver enzymes with an AST
to 2,620 and ALT to 3,742 with a total bilirubin of 11.8 and
coagulopathy with an INR of 2.1.  He presented to [**Hospital1 346**] for management of liver failure in
the setting of what was probably an acute hepatitis B flare.

MEDICAL HISTORY: 1. Hepatitis B virus as above.  2.
Diabetes mellitus type 2.

MEDICATION ON ADMISSION: 1. Glucotrol 5 mg p.o. q. day.  2.
ACH study drug [**Numeric Identifier 33100**].  3. Adefovir 10 mg q. day started on
[**2161-5-28**].

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: No tobacco, occasional alcohol. 

### Response:
{'Viral hepatitis B with hepatic coma, acute or unspecified, without mention of hepatitis delta,Acute and subacute necrosis of liver,Cirrhosis of liver without mention of alcohol,Hepatic encephalopathy,Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Atrial flutter,Herpetic meningoencephalitis'}
