CHIEF COMPLAINT: Altered mental status

PRESENT ILLNESS: 47M with decompensated alcoholic and HCV cirrhosis, with history
of hepatic encephalopathy, ascites, esophageal varices s/p
banding and Budd-Chiari syndrome treated conservatively without
anticoagulation, several recent admissions (last [**Date range (1) 29493**]),
who presents now with altered mental status, hyponatremia, and
[**Last Name (un) **].

MEDICAL HISTORY: 1. Right knee surgery almost 15 years ago.
2. Hypertension.
3. ETOH Cirrhosis
   o Varices - last EGD in [**6-/2110**] with three cords of
non-bleeding grade II varices s/p banding x 2, severe portal
gastropathy with possible gastric varix, duodenopathy; hx of
variceal bleed in [**12/2109**] s/p banding x 3
   o Encephalopathy requiring multiple recent admissions to RIH
   o Ascites requiring recurrent large-volume paracenteses, last
on [**6-23**], no SBP
4. History of hepatitis C, which cleared spontaneously, most
recent VL [**2110-6-24**] of 1,105 IU/mL.
5. Hx of IVDU
6. Recurrent pancreatitis
7. ?Seizure disorder - reportedly had seizures in setting of
EtOH withdrawal in past, most recent hospital stay also notable
for witnessed seizure with negative EEG, not on AEDs

MEDICATION ON ADMISSION: The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Docusate Sodium 100 mg PO BID
2. Lactulose 30 mL PO TID
3. Midodrine 10 mg PO TID
4. Pantoprazole 40 mg PO Q24H
5. Rifaximin 550 mg PO BID
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
hold if sedated or RR < 12

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
==============
Vitals: T97.4 105/54 76 RR14 SaO297% RA.
General: elderly appearing male, eyes open, somnolent but
arrousable, appearing moderately anxious.
HEENT: Sclera icteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: poor inspiratory effort, clear to auscultation
anteriorly, no wheezes, rales, rhonchi
Abdomen: soft, non-tender, distended, bowel sounds present, well
healing umbilical scar.
SKIN: spider telangectasias
GU: foley
Ext: bilateral peripheral edema to the knees with patchy well
defined erythemia on bilateral calves. pulses by doppler
Neuro: opens eyes to command. withdraws to pain, moving all four
extremities.

FAMILY HISTORY: -Negative for EtOH abuse, heart disease, liver disease, cancer

SOCIAL HISTORY: He lives alone but has a fiancee who checks on him every day and
helps around the house and with medications. Also has a VNA who
comes by three times a week. He used to work in contract sales
but is currently unemployed and applying for disability. Going
to be starting relapse prevention therapy soon.
Drugs: Past history of narcotic, methadone, and IV heroin abuse
but has been clean for 1.5 years.
EtOH: History of heavy abuse but last drink was 1.5 yrs ago
Smoking: 10 pack-year history, quit 3 months ago
Acute and subacute necrosis of liver,Toxic encephalopathy,Hepatorenal syndrome,Budd-chiari syndrome,Other ascites,Esophageal varices without mention of bleeding,Hyposmolality and/or hyponatremia,Acute kidney failure with other specified pathological lesion in kidney,Chronic pancreatitis,Cellulitis and abscess of leg, except foot,Urinary tract infection, site not specified,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, in remission,Combinations of opioid type drug with any other drug dependence, in remission,Unspecified viral hepatitis C without hepatic coma,Other specified disorders of stomach and duodenum,Anemia of other chronic disease,Personal history of noncompliance with medical treatment, presenting hazards to health,Unspecified essential hypertension,Do not resuscitate status,Encounter for palliative care
Acute necrosis of liver,Toxic encephalopathy,Hepatorenal syndrome,Budd-chiari syndrome,Ascites NEC,Esoph varices w/o bleed,Hyposmolality,Acute kidney failure NEC,Chronic pancreatitis,Cellulitis of leg,Urin tract infection NOS,Alcohol cirrhosis liver,Alcoh dep NEC/NOS-remiss,Opioid/other dep-remiss,Hpt C w/o hepat coma NOS,Gastroduodenal dis NEC,Anemia-other chronic dis,Hx of past noncompliance,Hypertension NOS,Do not resusctate status,Encountr palliative care
Admission Date:  [**2110-11-19**]              Discharge Date:   [**2110-11-21**]

Date of Birth:  [**2063-6-19**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
None

History of Present Illness:
47M with decompensated alcoholic and HCV cirrhosis, with history
of hepatic encephalopathy, ascites, esophageal varices s/p
banding and Budd-Chiari syndrome treated conservatively without
anticoagulation, several recent admissions (last [**Date range (1) 29493**]),
who presents now with altered mental status, hyponatremia, and
[**Last Name (un) **].

Was admitted [**Date range (1) 29751**]/12 with leaking umbilical hernia, and is
s/p umbilical herniorrhaphy on [**2110-9-23**]. His post-op course was
c/b HRS, which was treated w/octreotide and mitodrine. Was
discharged for social reasons, and readmitted [**Date range (1) 26596**] to
continue treatment for HRS. Also developed hypervolemic
hyponatremia, which improved with diet education. Admitted again
[**Date range (1) 29493**] after he was found to have hyponatremia to 115 at
time of a scheduled paracentesis. Was felt to be secondary to
non-adherence to salt and fluid restriction, as well as ongoing
diuresis. Was started on 1L daily fluid restriction, low salt
diet, and lasix d/c'd. Na was in 118-120 range, when patient
asked to leave AMA to attend a dentist appt. Of note, during
that time had paracentesis on [**11-12**], with 1.75L removed.

Since leaving AMA, has developed worsening confusion and was
brought by his mother to [**Name (NI) **] today for evaluation. In the ED,
initial VS 97.3 74 119/97 18 99%. Patient confused, unable to
answer questions, but in NAD. Labs notable for Na 119, K 7.1
(hemolyzed), BUN 61, Cr 3.1 (baseline 1.0-1.2), ALT 53, AST 113,
Tbili 3.2, alb 3.4, WBC 6.2, INR 1.3, and lactate 1.9. Underwent
abdominal paracentesis; fluid not concerning for SBP. UA not
suggestive of UTI. CXR and CT head negative for acute process.
Received 2L NS and zofran for nausea. Sodium not yet repeated.
Has not received any lactulose in ED. He is admitted now to ICU
for further management of AMS, [**Last Name (un) **], and hyponatremia.

On arrival to the MICU, initial vitals were T97.4 105/54 76 RR14
SaO297% RA. He was stuporous but arrousable, unable to
contribute to the medical history.


Past Medical History:
1. Right knee surgery almost 15 years ago.
2. Hypertension.
3. ETOH Cirrhosis
   o Varices - last EGD in [**6-/2110**] with three cords of
non-bleeding grade II varices s/p banding x 2, severe portal
gastropathy with possible gastric varix, duodenopathy; hx of
variceal bleed in [**12/2109**] s/p banding x 3
   o Encephalopathy requiring multiple recent admissions to RIH
   o Ascites requiring recurrent large-volume paracenteses, last
on [**6-23**], no SBP
4. History of hepatitis C, which cleared spontaneously, most
recent VL [**2110-6-24**] of 1,105 IU/mL.
5. Hx of IVDU
6. Recurrent pancreatitis
7. ?Seizure disorder - reportedly had seizures in setting of
EtOH withdrawal in past, most recent hospital stay also notable
for witnessed seizure with negative EEG, not on AEDs

Social History:
He lives alone but has a fiancee who checks on him every day and
helps around the house and with medications. Also has a VNA who
comes by three times a week. He used to work in contract sales
but is currently unemployed and applying for disability. Going
to be starting relapse prevention therapy soon.
Drugs: Past history of narcotic, methadone, and IV heroin abuse
but has been clean for 1.5 years.
EtOH: History of heavy abuse but last drink was 1.5 yrs ago
Smoking: 10 pack-year history, quit 3 months ago


Family History:
-Negative for EtOH abuse, heart disease, liver disease, cancer

Physical Exam:
ADMISSION EXAM
==============
Vitals: T97.4 105/54 76 RR14 SaO297% RA.
General: elderly appearing male, eyes open, somnolent but
arrousable, appearing moderately anxious.
HEENT: Sclera icteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: poor inspiratory effort, clear to auscultation
anteriorly, no wheezes, rales, rhonchi
Abdomen: soft, non-tender, distended, bowel sounds present, well
healing umbilical scar.
SKIN: spider telangectasias
GU: foley
Ext: bilateral peripheral edema to the knees with patchy well
defined erythemia on bilateral calves. pulses by doppler
Neuro: opens eyes to command. withdraws to pain, moving all four
extremities.

Discharge Exam:
HR T 98.1, 74, BP 106/59, RR 11, Sat 98%RA
General: elderly appearing male, eyes closed and somnolent,
minimally arousable
HEENT: Sclera icteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: poor inspiratory effort, clear to auscultation
anteriorly, no wheezes, rales, rhonchi
Abdomen: soft, non-tender, significantly distended, normoactive
bowel sounds not high pitched, well healing umbilical scar.
SKIN: spider telangectasias
GU: foley
Ext: bilateral peripheral edema to the knees with patchy well
defined erythemia on bilateral calves/shins. pulses by doppler
Neuro: opens eyes to command. withdraws to pain, moving all four
extremities.

Pertinent Results:
ADMISSION LABS
==============
[**2110-11-19**] 09:50AM BLOOD WBC-6.2 RBC-3.46* Hgb-11.6* Hct-34.4*#
MCV-99* MCH-33.6* MCHC-33.8 RDW-14.7 Plt Ct-118*
[**2110-11-19**] 09:50AM BLOOD PT-14.4* PTT-28.4 INR(PT)-1.3*
[**2110-11-19**] 09:50AM BLOOD Glucose-84 UreaN-61* Creat-3.1*# Na-119*
K-7.1* Cl-88* HCO3-19* AnGap-19
[**2110-11-19**] 09:50AM BLOOD ALT-53* AST-113* AlkPhos-110 TotBili-3.2*
[**2110-11-19**] 09:50AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2110-11-19**] 09:28PM BLOOD Ethanol-NEG

DISCHARGE LABS
==============
[**2110-11-20**] 05:22AM BLOOD WBC-5.6 RBC-2.90* Hgb-9.9* Hct-28.4*
MCV-98 MCH-34.2* MCHC-34.9 RDW-15.0 Plt Ct-124*
[**2110-11-20**] 05:22AM BLOOD PT-18.0* PTT-56.3* INR(PT)-1.7*
[**2110-11-20**] 04:58PM BLOOD Glucose-130* UreaN-69* Creat-4.0* Na-131*
K-4.1 Cl-93* HCO3-19* AnGap-23*
[**2110-11-20**] 05:22AM BLOOD ALT-37 AST-67* TotBili-4.2*
[**2110-11-20**] 04:58PM BLOOD Calcium-9.3 Phos-6.8* Mg-2.6

Urine Analysis on Admission:
[**2110-11-19**] 09:28PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2110-11-19**] 09:28PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2110-11-19**] 09:28PM URINE RBC-9* WBC-56* Bacteri-FEW Yeast-NONE
Epi-0

Ascites Fluid on Admission:
[**2110-11-19**] 10:45AM ASCITES WBC-95* RBC-265* Polys-6* Lymphs-24*
Monos-0 Macroph-70*

Micro:
[**2110-11-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2110-11-19**] URINE URINE CULTURE-NEGATIVE
[**2110-11-19**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2110-11-19**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-PRELIMINARY EMERGENCY
[**Hospital1 **]
[**2110-11-19**] BLOOD CULTURE Blood Culture, Routine-PENDING


Imaging:
[**11-19**] CXR: Low lung volumes.  No acute cardiopulmonary process.
[**11-19**] CT head: No acute intracranial process.
[**11-20**] KUB: Nonspecific bowel gas pattern.
[**11-20**] RUQ US:
1. Slow predominantly reversed flow in the main portal vein.
The right
hepatic vein is patent to the IVC.  No additional Doppler
information could be obtained due to the large amount of
ascites.
2. Massive ascites.
3. Nodular hepatic architecture consistent with cirrhosis.
4. Splenomegaly.

Brief Hospital Course:
A 47 year old male with PMH ETOH/HCV Cirrhosis complicated by
hepatic encepthlopathy, varices, portal gastropathy, and ascites
is admitted with toxic metabolic encephalopathy and acute renal
failure.

# Goals of care: Patient admitted with progressive liver failure
and hepatic encephalopathy refractory to traditional treatment.
He then developed anuric renal failure and hepato-renal
syndrome. Given that he was not a candidate for transplant and
had exceeded the limits of medical therapy, a family meeting was
held with his mother and HCP [**Name (NI) **] and goals of care were
transitioned to comfort.

#Acute toxic-metabolic encephalopathy: related to hepatic
encephalopathy, infectious work up was remarkable for positive
U/A. He was treated with lactulose via NGT which was limited by
vomiting, he did not have many bowel movements initially and
goals of care were then transitioned to comfort measures and NGT
was discontinued.

# Renal failure: patient admitted with creatinine at 3.1 above
baseline 1.5 Urine Na:<10 consistend tiwht hepatorenal syndrome
(HRS). He was treated for preseumed HRS with albumin, octreotide
and mitodrine. GFR continued to decline and he became anuric.
Goals of care were transitioned to comfort.

#Alcoholic/HCV Cirrhosis: complicated by hepatic encepthlopathy,
varaces, portal gastropathy, and ascites. Not listed since he
has yet to start ETOH abstinance program. Hepatology was
consulted and did not think he was a candidate for transplant.

#Hyponatremia: Hypervoemic hyponatremia related to cirrhosis.
Baseline sodium has been between 115-120.  Patient admitted with
Na 119, acute encephalopathy was thought to be unrelated to
hyponatremia. He was placed on fluid restriction and sodium
trended up to 131.

# Hyperkalemia: Initial labs showed elevated potassium (7.1) in
the setting of hemolyzed labs, on re-check potassium is 6.0 and
likely related to acute renal failure.  After Keyexylate, K
trended down to 4.0.

# Possible cellulitis: Exam remarkable for ill defined
erythematous patches on the calves bilaterally. He was treated
with cephalexin which was changed to ceftriaxone to cover
urinary tract infection. Antibiotics were discontinued when
goals of care were changed to comfort.

# Pyuria: U/A on admission was negative however repeat u/a
following foley placement showed positive leuks and bactereia.
He was started on ceftriaxone given acute encephalopathy as UTI
could have contributed to confusion. Ceftriaxone was d/c when
goals of care were changed to comfort.

Transitional Issues:
Patient is being discharged to an inpatient hospice facility
where his care will be focused around his comfort.
# Communication: [**First Name5 (NamePattern1) 14171**] [**Last Name (NamePattern1) 110690**] is alternate [**Telephone/Fax (1) 110691**]
(fiance)
# Code: DNR/DNI

Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Docusate Sodium 100 mg PO BID
2. Lactulose 30 mL PO TID
3. Midodrine 10 mg PO TID
4. Pantoprazole 40 mg PO Q24H
5. Rifaximin 550 mg PO BID
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
hold if sedated or RR < 12

7. OxycoDONE (Immediate Release)  10 mg PO ONCE pain Duration: 1
Doses


Discharge Medications:
1. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
1 flush per protocol Disp #*5 Syringe Refills:*0
2. HYDROmorphone (Dilaudid) 1 mg IV Q3H:PRN pain
RX *hydromorphone 2 mg/mL (1 mL) 1mg (0.5mL) Q3H Disp #*1 Bottle
Refills:*0
3. Ondansetron 4 mg IV Q8H:PRN nausea
RX *ondansetron HCl 4 mg/2 mL 4mg every eight (8) hours Disp #*1
Bottle Refills:*0
4. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
RX *sodium chloride 0.9 % [Saline Flush] 0.9 % Flush with 3 mL
Normal Saline every 8 hours and PRN Disp #*1 Syringe Refills:*0
5. Haloperidol 0.5 mg IM TID:PRN agitation, nausea, anxiety
RX *haloperidol lactate [Haldol] 5 mg/mL 0.5mg three times a day
Disp #*1 Bottle Refills:*0


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary Diagnosis: Decompensated Liver Failure
Secondary Diagnosis:
Hepatorenal Syndrome
Hepatic Encephalopathy


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic, minimally arousable.
Activity Status: Bedbound.


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

You came to the hospital because your liver has failed. We tried
to give you medications to improve your mental status, but you
continued to decline. Your doctors and the [**Name5 (PTitle) **] who care about
you have decided to focus on keeping you comfortable. You are
going to be going to a nursing facility where you will continue
to be taken care of and made comfortable.

Followup Instructions:
You will be taken care of by the facility you are going to.
{'Acute and subacute necrosis of liver,Toxic encephalopathy,Hepatorenal syndrome,Budd-chiari syndrome,Other ascites,Esophageal varices without mention of bleeding,Hyposmolality and/or hyponatremia,Acute kidney failure with other specified pathological lesion in kidney,Chronic pancreatitis,Cellulitis and abscess of leg, except foot,Urinary tract infection, site not specified,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, in remission,Combinations of opioid type drug with any other drug dependence, in remission,Unspecified viral hepatitis C without hepatic coma,Other specified disorders of stomach and duodenum,Anemia of other chronic disease,Personal history of noncompliance with medical treatment, presenting hazards to health,Unspecified essential hypertension,Do not resuscitate status,Encounter for palliative care'}


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: 47M with decompensated alcoholic and HCV cirrhosis, with history
of hepatic encephalopathy, ascites, esophageal varices s/p
banding and Budd-Chiari syndrome treated conservatively without
anticoagulation, several recent admissions (last [**Date range (1) 29493**]),
who presents now with altered mental status, hyponatremia, and
[**Last Name (un) **].

MEDICAL HISTORY: 1. Right knee surgery almost 15 years ago.
2. Hypertension.
3. ETOH Cirrhosis
   o Varices - last EGD in [**6-/2110**] with three cords of
non-bleeding grade II varices s/p banding x 2, severe portal
gastropathy with possible gastric varix, duodenopathy; hx of
variceal bleed in [**12/2109**] s/p banding x 3
   o Encephalopathy requiring multiple recent admissions to RIH
   o Ascites requiring recurrent large-volume paracenteses, last
on [**6-23**], no SBP
4. History of hepatitis C, which cleared spontaneously, most
recent VL [**2110-6-24**] of 1,105 IU/mL.
5. Hx of IVDU
6. Recurrent pancreatitis
7. ?Seizure disorder - reportedly had seizures in setting of
EtOH withdrawal in past, most recent hospital stay also notable
for witnessed seizure with negative EEG, not on AEDs

MEDICATION ON ADMISSION: The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Docusate Sodium 100 mg PO BID
2. Lactulose 30 mL PO TID
3. Midodrine 10 mg PO TID
4. Pantoprazole 40 mg PO Q24H
5. Rifaximin 550 mg PO BID
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
hold if sedated or RR < 12

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
==============
Vitals: T97.4 105/54 76 RR14 SaO297% RA.
General: elderly appearing male, eyes open, somnolent but
arrousable, appearing moderately anxious.
HEENT: Sclera icteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: poor inspiratory effort, clear to auscultation
anteriorly, no wheezes, rales, rhonchi
Abdomen: soft, non-tender, distended, bowel sounds present, well
healing umbilical scar.
SKIN: spider telangectasias
GU: foley
Ext: bilateral peripheral edema to the knees with patchy well
defined erythemia on bilateral calves. pulses by doppler
Neuro: opens eyes to command. withdraws to pain, moving all four
extremities.

FAMILY HISTORY: -Negative for EtOH abuse, heart disease, liver disease, cancer

SOCIAL HISTORY: He lives alone but has a fiancee who checks on him every day and
helps around the house and with medications. Also has a VNA who
comes by three times a week. He used to work in contract sales
but is currently unemployed and applying for disability. Going
to be starting relapse prevention therapy soon.
Drugs: Past history of narcotic, methadone, and IV heroin abuse
but has been clean for 1.5 years.
EtOH: History of heavy abuse but last drink was 1.5 yrs ago
Smoking: 10 pack-year history, quit 3 months ago 

### Response:
{'Acute and subacute necrosis of liver,Toxic encephalopathy,Hepatorenal syndrome,Budd-chiari syndrome,Other ascites,Esophageal varices without mention of bleeding,Hyposmolality and/or hyponatremia,Acute kidney failure with other specified pathological lesion in kidney,Chronic pancreatitis,Cellulitis and abscess of leg, except foot,Urinary tract infection, site not specified,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, in remission,Combinations of opioid type drug with any other drug dependence, in remission,Unspecified viral hepatitis C without hepatic coma,Other specified disorders of stomach and duodenum,Anemia of other chronic disease,Personal history of noncompliance with medical treatment, presenting hazards to health,Unspecified essential hypertension,Do not resuscitate status,Encounter for palliative care'}
