CHIEF COMPLAINT: "Feeling unwell"

PRESENT ILLNESS: Mr. [**Known lastname 96073**] is a 58 year old man with history of end-stage
liver disease status-post liver transplant, with recurrence of
his hepatitis C, who presents today with nausea, vomiting,
diarrhea, and overall feeling unwell.

MEDICAL HISTORY: - Status-post OLT liver transplant [**2107**] for HCV cirrhosis and
hepatocellular carcinoma
- Hepatitis C: recurred after transplant
- Hypertension
- Diabetes mellitus
- BPH
- Tobacco use
- Depression
- Back pain
- History of prior IV drug use
- Grade I of esophageal varices

MEDICATION ON ADMISSION: - Aspirin 81 mg
- Bactrim 400 mg-80 mg daily
- Citalopram 40 mg
- Clonidine 0.1 mg [**Hospital1 **]
- Fish Oil
- Gabapentin 600 mg QHS
- Humalog
- Lisinopril 10 mg
- Multivitain 1 tablet daily
- Oxycodone/Acetaminophen
- Pegasys injection
- Ribavirin 200mg --three capsules BIG
- Terazosin 2 mg QHS
- Viagra 50-100 mg
- Tacrolimus 2.5 mg [**Hospital1 **]
- Mycophenolate Mofetil (CellCept) 250 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam (upon admission)
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress, resting comfortably
in bed talking on telephone
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient lives with his sister. Married, however has complicated
relationship with wife. [**Name (NI) **] daughter in her 20's. History of
prior IV drug use. History of alcohol abuse. Currently on
narcotic contract.
Other shock without mention of trauma,Liver replaced by transplant,Opioid type dependence, continuous,Unspecified viral hepatitis C without hepatic coma,Diarrhea,Personal history of malignant neoplasm of liver,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Depressive disorder, not elsewhere classified
Shock w/o trauma NEC,Liver transplant status,Opioid dependence-contin,Hpt C w/o hepat coma NOS,Diarrhea,Hx of liver malignancy,BPH w/o urinary obs/LUTS,DMII wo cmp nt st uncntr,Depressive disorder NEC
Admission Date:  [**2111-6-26**]              Discharge Date:   [**2111-6-28**]

Date of Birth:  [**2053-3-13**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
"Feeling unwell"

Major Surgical or Invasive Procedure:
--Central venous line placement


History of Present Illness:
Mr. [**Known lastname 96073**] is a 58 year old man with history of end-stage
liver disease status-post liver transplant, with recurrence of
his hepatitis C, who presents today with nausea, vomiting,
diarrhea, and overall feeling unwell.

He reports that for the last 3-4 weeks, he has had on-going
watery diarrhea. He was admitted to [**Hospital1 18**] on the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**]
service from [**6-7**] until the 8th for work-up of the diarrhea. A
discharge summary is not yet available, however he reports that
a CT scan was completed that demonstrated "colitis," for which
he was treated with ciprofloxacin and metronidazole, having
finished a course yesterday. During that admission, stool O&P
was negative, as was c. difficile assay. Of note, around that
time, he had been tapering off methadone and started on
clonidine for his withdrawal symptoms.

He followed up with his liver physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 696**], on [**6-24**],
at which time he reported his symptoms had improved. At that
visit, the plan was to resume ribavirin and interferon for
treatment of his recurrent hepatitis C after transplant; these
had been stopped earlier this year due to concerns over suicide
ideation.

Today he reports that his diarrhea got slightly better at some
points over the last weeks, but has worsened over the last few
days. He is unable to quantify, but states he has had "too many
to count" when asked number of bowel movements. They have been
watery without blood or melena. He has also had emesis
(non-bloody and non-bilious) for the last two days. He reports
poor PO intake and that he vomitted after attempting to eat soup
yesterday. He has been urinating less as well.

He had some lightheadedness and dizziness today that prompted
him to seek medical attention along with feeling overall very
poorly.

In the ED, initial vital signs were: temperature of 98.0, blood
pressure of 71/40, heart rate of 88, respiratory rate of 18, and
oxygen saturation of 99% on room air. During his time in the ED,
he received three liters of normal saline, 1 gram of vancomycin,
and 4.5 grams of zosyn.

During his ED stay, his systolic blood pressure ranged from
74-109. Levophed was written for, but never started given
response of blood pressure to IVF. A chest x-ray was
unremarkable, and an abdominal ultrasound did not demonstrate
any ascites.

Upon arrival to the ICU, he reported that he was very hungry and
wanted to eat. He stated he fele the best he had felt in days.

Past Medical History:
- Status-post OLT liver transplant [**2107**] for HCV cirrhosis and
hepatocellular carcinoma
- Hepatitis C: recurred after transplant
- Hypertension
- Diabetes mellitus
- BPH
- Tobacco use
- Depression
- Back pain
- History of prior IV drug use
- Grade I of esophageal varices


Social History:
Patient lives with his sister. Married, however has complicated
relationship with wife. [**Name (NI) **] daughter in her 20's. History of
prior IV drug use. History of alcohol abuse. Currently on
narcotic contract.

Family History:
Non-contributory

Physical Exam:
Physical Exam (upon admission)
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress, resting comfortably
in bed talking on telephone
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear

Neck: supple, JVP flat, no LAD, right IJ appears
clean/dry/intact
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CN's sym
Psych: Appropriate


Pertinent Results:
Labs at Admission:

[**2111-6-26**] 11:05AM BLOOD WBC-4.5 RBC-5.00 Hgb-15.2 Hct-47.4 MCV-95
MCH-30.5 MCHC-32.2 RDW-13.5 Plt Ct-259
[**2111-6-26**] 11:05AM BLOOD Neuts-55.7 Lymphs-30.0 Monos-13.2*
Eos-0.6 Baso-0.6
[**2111-6-26**] 11:05AM BLOOD PT-12.0 PTT-24.8 INR(PT)-1.0
[**2111-6-26**] 11:05AM BLOOD Glucose-202* UreaN-36* Creat-2.7*#
Na-131* K-4.7 Cl-98 HCO3-20* AnGap-18
[**2111-6-26**] 11:05AM BLOOD ALT-180* AST-209* AlkPhos-180*
TotBili-0.7
[**2111-6-26**] 11:05AM BLOOD Calcium-10.0 Phos-4.0 Mg-2.2
[**2111-6-26**] 11:21AM BLOOD Lactate-2.6* K-4.6
[**2111-6-26**] 11:21AM BLOOD Hgb-16.5 calcHCT-50

Labs at Discharge:

[**2111-6-28**] 05:25AM BLOOD WBC-2.5* RBC-3.82* Hgb-11.8* Hct-35.9*
MCV-94 MCH-30.8 MCHC-32.7 RDW-13.4 Plt Ct-184
[**2111-6-28**] 05:25AM BLOOD PT-11.7 PTT-29.6 INR(PT)-1.0
[**2111-6-28**] 05:25AM BLOOD Glucose-128* UreaN-29* Creat-1.3* Na-137
K-4.7 Cl-106 HCO3-23 AnGap-13
[**2111-6-28**] 05:25AM BLOOD ALT-98* AST-117* LD(LDH)-145 AlkPhos-120
TotBili-0.6
[**2111-6-28**] 05:25AM BLOOD Albumin-3.3* Calcium-8.5 Phos-3.9 Mg-1.7

Microbiology Data:

[**2111-6-27**] Immunology (CMV) CMV Viral Load- pending
[**2111-6-26**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-PENDING; OVA + PARASITES-PENDING; MICROSPORIDIA
STAIN-PENDING; CYCLOSPORA STAIN-PENDING; CLOSTRIDIUM DIFFICILE
TOXIN A & B TEST-FINAL; VIRAL CULTURE-PENDING INPATIENT
[**2111-6-26**] URINE URINE CULTURE- negative
[**2111-6-26**] MRSA SCREEN MRSA SCREEN- pending
[**2111-6-26**] BLOOD CULTURE Blood Culture, Routine-
negative
[**2111-6-26**] BLOOD CULTURE Blood Culture, Routine-
negative

Imaging Studies:

Abdominal ultrasound with doppler ([**6-27**]):
1. Status post liver transplant with patent hepatic vasculature.
2. No definite focal liver lesion seen; however, multi-phase
MRI/CT are more sensitive for focal liver lesions and can be
obtained if clinically warranted.

CXR ([**6-27**]):
Status post right IJ central venous line placement with tip in
the upper SVC. No pneumothorax.


Brief Hospital Course:
1.) Hypotension/Shock
Upon admission to the ICU, the patient had received three liters
of IVF, producing a SBP>100.  Given the patient's history and
response to IVF, the cause was most likely  hypovolemic shock
given GI losses and poor PO intake.  Also considered (given
immunocompromised host) were infections, as well as adrenal
insufficiency and cardiogenic) cuases.  Aggressive fluid
resuscitation was continued in the ICU with a goal MAP>65 and
UOP>50cc/hr.  Lisinopril, clonidine, terazosin were held.
Patient was continued on vancomycin and zosyn since the ED, with
metronidazole added for empiric coverage of c. difficile and
anaerobic organisms (seems unlikely to need coverage for MSRA
given lack of indwelling lines, no pulmonary/skin symptoms).
Flagyl was removed due to redundant coverage.  The patient
remained hypotensive throughout the stay. On [**6-27**] the patient
was transferred to [**Hospital Ward Name 121**] 10. He was observed over night and his
blood pressure ranged from 107-115/69-87. At the time of
discharge his BP was 131/86. He was asymptomatic overnight. His
clonidine was restarted at his home dose. His lisnopril was
held.

2.) Diarrrhea, nausea, vomiting
Patient had long history of nausea, vomiting, and diarrhea (for
about 3-4 weeks prior to admission).  Initially felt to possibly
be viral gastroenteritis versus symptoms from methadone
withdrawal.  Previous imaging showed evidence of jejunitis.
Patient was started on broad coverage with vanc and zosyn in ED.
 Flagyl was added in ICU.  C. difficile was negative, so flagyl
was stopped.  He did resume interferon/ribavirin recent to
admission, but the symptoms began previous to this.  O&P, viral
cultures, and microsporidium/crytposporidium were sent out and
pending upon discharge.  Patient was beginning to advance diet
towards a BRAT diet upon discharge. On morning of discharge
patient reported improvement in diarrheal symptoms. While an
infectious cause is possible, the fact that C diff and fecal
culture were negative makes infectious diarrhea less likely. It
is more likely that the syptoms were due to his recent cessation
of methadone.  He was discharged home with a script for
loperamide.

3.) Status-post liver transplant with recurrent HCV
Patient was continued on home regimen of immunosuppressives and
prophylaxis.  Ribavirin and interferon continued. Liver doppler
was negative for focal lesions. AFP was pending at time of
dischage. Patient is scheduled to follow up with transplant team
in two weeks time.

4.) Depression
HCV therapy was stopped due to suicide ideation, though per last
OMR note, was cleared to resume therapy.  Patient continued on
home dose of citalopram throughout stay.

5.) Diabetes Mellitus
Continued on home regimen of insulin.

Medications on Admission:
- Aspirin 81 mg
- Bactrim 400 mg-80 mg daily
- Citalopram 40 mg
- Clonidine 0.1 mg [**Hospital1 **]
- Fish Oil
- Gabapentin 600 mg QHS
- Humalog
- Lisinopril 10 mg
- Multivitain 1 tablet daily
- Oxycodone/Acetaminophen
- Pegasys injection
- Ribavirin 200mg --three capsules BIG
- Terazosin 2 mg QHS
- Viagra 50-100 mg
- Tacrolimus 2.5 mg [**Hospital1 **]
- Mycophenolate Mofetil (CellCept) 250 mg [**Hospital1 **]


Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

2. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
3. Tacrolimus 1 mg Capsule Sig: 2.5 Capsules PO Q12H (every 12
hours).
4. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
7. Fish Oil  Oral
8. Humalog Mix 75-25  Subcutaneous
9. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO QHS PRN () as needed for back pain.
11. Ribavirin 200 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
12. Pegasys  Subcutaneous
13. Terazosin 2 mg Capsule Sig: One (1) Capsule PO at bedtime.
14. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day.

15. Viagra  Oral
16. Loperamide 2 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for diarrhea.
Disp:*30 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnoses
--Hypotension secondary to diarrhea

Secondary Diagnoses
--Status-post OLT liver transplant [**2107**] for HCV cirrhosis and
hepatocellular carcinoma
--Hepatitis C: recurred after transplant
--Hypertension
--Diabetes mellitus
--Benign prostatic hypertrophy
--Tobacco use
--Depression
--Back pain


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


Discharge Instructions:
You were admitted to the hospital for treatment of low blood
pressures and diarrhea. You were treated with intravenous fluid
hydration and intravenous antibiotics and your symptoms
improved. Stool studies did not reveal an infectious cause for
your symptoms. We are therefore stopping antibiotics. Please
take loperamide (Immodium) as needed for diarrhea.

We made the following changes to your medicines:
--we DISCONTINUED the lisinopril. Please restart this medicine
at the discretion of your primary care provider.
[**Name10 (NameIs) **] ADDED Immodium (loperamide) to be taken as needed for
diarrhea.
There were no other changes to your medicines.

Followup Instructions:
--[**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2111-7-1**]
2:20
--[**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3736**] Date/Time:[**2111-7-7**] 10:00
[**Hospital **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2111-7-8**]
8:00



Completed by:[**2111-6-29**]
{'Other shock without mention of trauma,Liver replaced by transplant,Opioid type dependence, continuous,Unspecified viral hepatitis C without hepatic coma,Diarrhea,Personal history of malignant neoplasm of liver,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Depressive disorder, not elsewhere classified'}


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: "Feeling unwell"

PRESENT ILLNESS: Mr. [**Known lastname 96073**] is a 58 year old man with history of end-stage
liver disease status-post liver transplant, with recurrence of
his hepatitis C, who presents today with nausea, vomiting,
diarrhea, and overall feeling unwell.

MEDICAL HISTORY: - Status-post OLT liver transplant [**2107**] for HCV cirrhosis and
hepatocellular carcinoma
- Hepatitis C: recurred after transplant
- Hypertension
- Diabetes mellitus
- BPH
- Tobacco use
- Depression
- Back pain
- History of prior IV drug use
- Grade I of esophageal varices

MEDICATION ON ADMISSION: - Aspirin 81 mg
- Bactrim 400 mg-80 mg daily
- Citalopram 40 mg
- Clonidine 0.1 mg [**Hospital1 **]
- Fish Oil
- Gabapentin 600 mg QHS
- Humalog
- Lisinopril 10 mg
- Multivitain 1 tablet daily
- Oxycodone/Acetaminophen
- Pegasys injection
- Ribavirin 200mg --three capsules BIG
- Terazosin 2 mg QHS
- Viagra 50-100 mg
- Tacrolimus 2.5 mg [**Hospital1 **]
- Mycophenolate Mofetil (CellCept) 250 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam (upon admission)
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress, resting comfortably
in bed talking on telephone
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient lives with his sister. Married, however has complicated
relationship with wife. [**Name (NI) **] daughter in her 20's. History of
prior IV drug use. History of alcohol abuse. Currently on
narcotic contract. 

### Response:
{'Other shock without mention of trauma,Liver replaced by transplant,Opioid type dependence, continuous,Unspecified viral hepatitis C without hepatic coma,Diarrhea,Personal history of malignant neoplasm of liver,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Depressive disorder, not elsewhere classified'}
