CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: 38F with cirrhosis [**1-10**] autoimmune hepatitis complicated by
hepatopulmonary syndrome on 6-8L continuous home O2, portal
hypertension, splenomegaly, and encephalopathy admitted with
shortness of breath. She was at baseline until this weekend when
her shortness of breath worsened. She was admitted at [**Hospital1 1474**]
for 2 days, discharged yesterday, saw Dr. [**Last Name (STitle) 497**] in clinic and
resting O2 sat was in the 60%, improved with non-rebreather.
Denies cough, sputum production, fever, chills, nasal
congestion, headache, sinus tenderness or sick contacts/recent
travel. Has generalized chest discomfort started several days
ago, located across chest, not pleuritic in nature, no
radiation, no known alleviating or aggravating factors. Has
chronic abdominal pain on flanks, she says due to enlarged
spleen. Mild nausea, one episode of bilious vomit 2 days ago.
Has had some diarrhea, no melena or hematochezia. She has
chronic myalgias and arthralgias. No dysuria.
.
Per hepatology clinic she had a PAo2 of 34 and and O2 sat on 6l
of %72. Looked cyanotic on arrival, came up to 100% on NRB, now
back on 6L at 92-96%. No known precipitating event to set
trigger her worsening shortness of breath. No new medications.
.
In ED, vitals were 98.2 90 124/68 32 86% on 50%FM. Labs notable
for WBC# 3.4 (69% PMN no bands) lactate 3.2. ABG showed
7.51/24/34. CXR unchanged from prior. CTA showed no PE. V/S
prior to transfer 75 94/43 19 92%4L
.
Review of systems:
(+) Per HPI

MEDICAL HISTORY: - autoimmune hepatitis dx [**2095**], [**Doctor First Name **] -, SMA +, liver biopsy
[**1-17**]: mild to moderate periportal inflammation including plasma

MEDICATION ON ADMISSION: - omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
- alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
please resume prior schedule. Take 30 minutes before other meds

ALLERGIES: Dilaudid / Shellfish Derived

PHYSICAL EXAM: UPON ADMISSION:
VS - 97.6 106/51 68 22 96-97% 6L O2
GENERAL - well-appearing woman in NAD, respirations slightly
labored
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - breath sounds distant, no r/rh/wh, no accessory muscle
use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, + splenomegaly, could not palpate
liver edge, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

FAMILY HISTORY: No h/o autoimmune illnesses
or liver disease. Father with CAD, mother had a CVA. Her
children are healthy although two of them have asthma. Maternal
uncle with esophageal cancer.

SOCIAL HISTORY: She lives at home with three of her four children. She does not
smoke, use alcohol, or illicit drugs. She is currently
unemployed but worked as a bus driver
previously.
Autoimmune hepatitis,Acute respiratory failure,Portal hypertension,Ostium secundum type atrial septal defect,Splenomegaly,Rash and other nonspecific skin eruption,Depressive disorder, not elsewhere classified,Obesity, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Varices of other sites,Other chronic pain,Body Mass Index 38.0-38.9, adult,Bed confinement status
Autoimmune hepatitis,Acute respiratry failure,Portal hypertension,Secundum atrial sept def,Splenomegaly,Nonspecif skin erupt NEC,Depressive disorder NEC,Obesity NOS,DMII wo cmp nt st uncntr,Varices of other sites,Chronic pain NEC,BMI 38.0-38.9,adult,Bed confinement status
Admission Date:  [**2119-12-13**]              Discharge Date:   [**2120-1-25**]

Date of Birth:  [**2081-2-11**]             Sex:   F

Service: MEDICINE

Allergies:
Dilaudid / Shellfish Derived

Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
None

History of Present Illness:
38F with cirrhosis [**1-10**] autoimmune hepatitis complicated by
hepatopulmonary syndrome on 6-8L continuous home O2, portal
hypertension, splenomegaly, and encephalopathy admitted with
shortness of breath. She was at baseline until this weekend when
her shortness of breath worsened. She was admitted at [**Hospital1 1474**]
for 2 days, discharged yesterday, saw Dr. [**Last Name (STitle) 497**] in clinic and
resting O2 sat was in the 60%, improved with non-rebreather.
Denies cough, sputum production, fever, chills, nasal
congestion, headache, sinus tenderness or sick contacts/recent
travel. Has generalized chest discomfort started several days
ago, located across chest, not pleuritic in nature, no
radiation, no known alleviating or aggravating factors. Has
chronic abdominal pain on flanks, she says due to enlarged
spleen. Mild nausea, one episode of bilious vomit 2 days ago.
Has had some diarrhea, no melena or hematochezia. She has
chronic myalgias and arthralgias. No dysuria.
.
Per hepatology clinic she had a PAo2 of 34 and and O2 sat on 6l
of %72. Looked cyanotic on arrival, came up to 100% on NRB, now
back on 6L at 92-96%. No known precipitating event to set
trigger her worsening shortness of breath. No new medications.
.
In ED, vitals were 98.2 90 124/68 32 86% on 50%FM. Labs notable
for WBC# 3.4 (69% PMN no bands) lactate 3.2. ABG showed
7.51/24/34. CXR unchanged from prior. CTA showed no PE. V/S
prior to transfer 75 94/43 19 92%4L
.
Review of systems:
(+) Per HPI

Past Medical History:
- autoimmune hepatitis dx [**2095**], [**Doctor First Name **] -, SMA +, liver biopsy
[**1-17**]: mild to moderate periportal inflammation including plasma

cells, portal fibrosis and possible stage 3 fibrosis
- DM 2
- portal hypertension
- splenomegaly
- hepatopulmonary syndrome (dx [**1-/2119**] based on platypnea,
orthodeoxya and Aa gradient; she had a ? PFO vs. AVM on TEE w/
some echos showing incr. PAP vs. not)
- hx of hepatic encephalopathy
- migraine headaches
- depression
- Cholecystectomy in [**2112**]
- Endometrial ablation [**2114**] (but pt unsure)
- Cesarian sections

Social History:
She lives at home with three of her four children. She does not
smoke, use alcohol, or illicit drugs. She is currently
unemployed but worked as a bus driver
previously.

Family History:
No h/o autoimmune illnesses
or liver disease. Father with CAD, mother had a CVA. Her
children are healthy although two of them have asthma. Maternal
uncle with esophageal cancer.

Physical Exam:
UPON ADMISSION:
VS - 97.6 106/51 68 22 96-97% 6L O2
GENERAL - well-appearing woman in NAD, respirations slightly
labored
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - breath sounds distant, no r/rh/wh, no accessory muscle
use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, + splenomegaly, could not palpate
liver edge, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-11**] throughout
.
UPON DISCHARGE: pertinent changes only

Pertinent Results:
Labs upon admission:
.
[**2119-12-13**] 09:45AM BLOOD WBC-3.4* RBC-4.34 Hgb-13.4 Hct-37.6
MCV-87 MCH-30.9 MCHC-35.7* RDW-14.6 Plt Ct-139*
[**2119-12-13**] 09:45AM BLOOD Neuts-69.7 Lymphs-23.5 Monos-3.9 Eos-2.4
Baso-0.4
[**2119-12-18**] 05:50AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+
[**2119-12-13**] 09:45AM BLOOD PT-14.5* PTT-26.7 INR(PT)-1.3*
[**2119-12-13**] 09:45AM BLOOD Glucose-211* UreaN-10 Creat-0.8 Na-138
K-3.4 Cl-108 HCO3-21* AnGap-12
[**2119-12-14**] 05:15AM BLOOD ALT-22 AST-30 LD(LDH)-157 AlkPhos-73
TotBili-0.8
[**2119-12-15**] 05:20AM BLOOD Albumin-3.2* Calcium-8.5 Phos-4.3 Mg-1.7
[**2119-12-13**] 09:45AM BLOOD HCG-<5
.
Arterial Blood Gases:
[**2119-12-13**] 08:57AM BLOOD Type-ART pO2-34* pCO2-24* pH-7.51*
calTCO2-20*
[**2119-12-14**] 02:31PM BLOOD Type-ART pO2-175* pCO2-30* pH-7.47*
calTCO2-22
[**2119-12-15**] 01:23PM BLOOD Type-ART pO2-214* pCO2-34* pH-7.44
calTCO2-24
[**2119-12-15**] 03:00PM BLOOD Type-ART O2 Flow-15 pO2-257* pCO2-38
pH-7.42 calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2119-12-15**] 06:42PM BLOOD Type-ART Temp-37.8 FiO2-70 pO2-136*
pCO2-39 pH-7.42 calTCO2-26 Base XS-1 Intubat-NOT INTUBA
[**2119-12-16**] 03:34AM BLOOD Type-ART pO2-173* pCO2-40 pH-7.41
calTCO2-26
[**2119-12-16**] 02:37PM BLOOD Type-ART pO2-107* pCO2-29* pH-7.45
calTCO2-21
[**2119-12-16**] 05:09PM BLOOD Type-ART pO2-84* pCO2-33* pH-7.44
calTCO2-23
[**2119-12-27**] 09:59AM BLOOD Type-ART pO2-91 pCO2-32* pH-7.48*
calTCO2-25
[**2120-1-2**] 04:09PM BLOOD Type-ART pO2-57* pCO2-32* pH-7.49*
calTCO2-25
[**2119-12-13**] 08:57AM BLOOD O2 Sat-69
[**2119-12-14**] 02:31PM BLOOD O2 Sat-98
[**2119-12-15**] 01:23PM BLOOD O2 Sat-99
[**2119-12-27**] 09:59AM BLOOD O2 Sat-96
[**2120-1-2**] 04:09PM BLOOD O2 Sat-90
[**2119-12-15**] 01:23PM BLOOD freeCa-1.13
[**2119-12-13**] 10:05AM BLOOD Lactate-3.2*
.
Labs upon discharge:
[**2120-1-24**] 04:58AM BLOOD WBC-1.9* RBC-3.82* Hgb-12.7 Hct-35.8*
MCV-94 MCH-33.3* MCHC-35.6* RDW-14.7 Plt Ct-145*
[**2120-1-24**] 04:58AM BLOOD PT-13.8* PTT-26.3 INR(PT)-1.2*
[**2120-1-24**] 04:58AM BLOOD Glucose-89 UreaN-14 Creat-0.9 Na-136
K-3.9 Cl-100 HCO3-27 AnGap-13
[**2120-1-24**] 04:58AM BLOOD ALT-44* AST-46* AlkPhos-85 TotBili-0.5
[**2120-1-24**] 04:58AM BLOOD Albumin-3.6 Calcium-9.0 Phos-4.1 Mg-2.0
.
Microbiology:
.
[**2119-12-13**]: Blood culture: negative
[**2119-12-18**]: Respiratory viral screen: negative
[**2119-12-28**]: Stool culture and C.diff: negative
.
Imaging:
.
CXR [**2119-12-13**]: IMPRESSION: No evidence for acute intrathoracic
process.
.
CT-A chest [**2119-12-13**]: IMPRESSION: No evidence for pulmonary
embolism or other acute intrathoracic pathology.  Cirrhosis and
secondary findings or portal hypertension including splenomegaly
and varices.
.
Abdominal ultrasound [**2119-12-16**]: IMPRESSION: Coarsened liver with
nodular contour, compatible with known cirrhosis. Splenomegaly,
similar to prior examinations. Overall, no significant change
from prior ultrasound of [**2119-6-28**].
.
CXR [**2119-12-17**]: IMPRESSION: AP chest compared to [**12-13**]:
There is no definite pulmonary abnormality, as far as one can
see on bedside chest radiographs. Detection of subtle findings
would require at least conventional studies if not CT scans.
None was seen on the chest CTA on [**12-13**]. Heart size is top
normal. There is no pleural effusion.
.
ECHO [**2119-12-20**]: The left atrium is elongated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are structurally normal. No mitral regurgitation is
seen. There is a minimal increased gradient consistent with
trivial tricuspid stenosis. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Preserved biventricular cavity size and systolic
function. Passage of agitated saline at rest via intracardiac
communication or pulmonary AVMs. Estimated pulmonary artery
pressures are indeterminate.
.
Abdominal Ultrasound [**2119-12-22**]; IMPRESSION:
1. Splenomegaly with numerous splenic varices and likely
splenorenal shunt,
all of which appear to be patent. The splenic vein in the
midline can only be partially visualized but it appears patent
and demonstrates appropriate
directional flow.
2. No ascites is identified.
3. Nodular coarsened hepatic architecture with no focal liver
lesion. No
biliary dilatation.
.
CT abdomen w/contrast [**2119-12-28**]: IMPRESSION:
1. No evidence of splenic vein thrombosis as questioned.
2. Nodular and shrunken liver, compatible with cirrhosis.
3. Stigmata of portal hypertension including marked splenomegaly
and varices as described above.
.
ECHO [**2120-1-3**]: The left atrium is mildly dilated. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Mild mitral regurgitation with normal valve
morphology. Normal estimated pulmonary artery systolic pressure.
.
RUQ U/S with Dopplers [**2120-1-7**]: The liver is shrunken and nodular
with coarsened heterogeneous echotexture, compatible with known
cirrhosis. A small fluid colleciton is seen within the
gallbladder fossa, measuring 2.2 x 1.4 cm, stable compared with
prior. The common bile duct is normal in caliber measuring 5 mm.
The spleen is enlarged. There is no ascites. Doppler: Normal
hepatopetal flow is seen within the right, left and main portal
vein. The hepatic veins are patent with normal direction of
flow. There is recanalization of the umbilical vein. Innumerable
varices are seen, as on recent abdominal CT scan. The splenic
vein is patent.
IMPRESSION:
1. Hepatic cirrhosis and US findings of portal HTN.
2. Patent portal veins with hepatopedal flow.
.
HIP UNILAT MIN 2 VIEWS LEFT	Study Date of [**2120-1-14**] 3:33 PM
Two views of the left hip and a frontal view of the pelvis show
no fracture of the hip and no separation of the pelvic ring.
There are no findings in the femur to suggest aseptic necrosis
and no narrowing of the joint space to indicate degeneration.


Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 38 year old female with cirrhosis secondary
to autoimmune hepatitis complicated by hepatopulmonary syndrome
on 6-8L continuous home O2 prior to admission, portal
hypertension, splenomegaly, and history of encephalopathy who
was admitted with progressively worsening shortness of breath.
.
#. Hepatopulmonary Syndrome:  She required 10-12L of oxygen by
face mask at 70-100% and frequently desaturated to 60-70s on
10-12L when pivoting to commode or eating.  She was temporarily
transferred to the SICU [**Date range (1) 29162**] for persistent
desaturations despite supplemental oxygen.  Intubation was not
required.  Her progressive shortness of breath was evaluated
with CXR x2 that were unrevealing for consolidation or pulmonary
edema, respiratory viral screen was negative, and CT-A chest was
negative for pulmonary embolism. Etiology of her dyspnea was
therefore deemed due to progressive hepatopulmonary syndrome.
She was seen by our pulmonary team who recommended evaluation
for superimposed porto-pulmonary hypertension.  Echocardiogram
was favored over right heart catheterization due to high risk
for need for intubation during the procedure.  Echocardiogram on
[**2119-12-28**] confirmed prediction of normal pulmonary artery
pressures and helped confirm etiology of her dyspnea as due to
hepatopulmonary syndrome.  She was noted to have significant
desaturations while sleeping at night.  Sleep medicine was
consulted.  She was started empirically on CPAP after which she
did not desaturate at night.  She was able to maintain oxygen
saturations while asleep in the high 90s on 35% oxygen at 10-12L
while on CPAP.  At the time of discharge she was fairly stable
at rest on 10-12L by facemask at 75% with oxygen saturations in
the mid 90s.  She continues to desaturate to the 60s with very
minimal exertion.  Intermittently she was mildly wheezy which
improved with albuterol nebs which she will continue as an
outpatient as needed.  She remained on supplemental oxygen
support and was transferred to rehab while awaiting a liver
transplant
.
#. Autoimmune hepatitis/cirrhosis: The patient did not present
with any evidence of acute liver decompensation or flare of
autoimmune hepatitis.  Her LFTs remained stable.  Her calculated
MELD was consistently 8 but she was awarded exception points for
a MELD of 30.  Her azathioprine dose was decreased to 50 mg
daily in preparation for surgery as her white blood cell count
was persistently low and it was thought that she would benefit
from improved blood counts prior to transplant.  Her prednisone
dose was decreased to 10 mg daily.  For prophylaxis she is on
single strength bactrim three times per week.  Would strongly
recommend that she be changed to either single strength bactrim
daily or double strength bactrim three times per week for
prophylaxis.  She was continued on alendronate and vitamin D
weekly.  Though she showed no evidence of hepatic
encephalopathy, she has done so in the past and was continued on
lactulose and rifaximin during this admission, as well as lasix
40 mg daily and spironolactone 100 mg daily.
.
#. Left Upper Quadrant Pain:  She had persistent LUQ abdominal
pain with radiation to left flank and L hip due to splenomegaly
and massive splenic varices.  An x-ray of her hip was normal.
She received three abdominal ultrasounds including one with
Dopplers and a CT-A to evaluate her pain, all which confirmed
lack of splenic venous thrombus or splenic infarct.  Her pain
was treated with hot packs, lidocaine patches, oxycontin, and
oxycodone.
.
#. Left Hip Pain: The patient also complained of L hip pain.
X-ray was negative.  This pain is likely secondary to her
bedbound state.  Her pain was treated with hot packs, oxycontin,
and oxycodone.
.
#. Type II Diabetes Mellitus: The patient's blood sugar was
consistently elevated on admission.  Her insulin regimen was
changed with an increased morning NPH dose to 14 units and a
tightened sliding scale (see discharge medications for scale).
.
#. Depression: The patient was quite depressed at times during
her admission. She was supported by social work and continued on
her home dose of fluoxetine.
.
She was FULL CODE for this admission.
.
Ms. [**Known lastname **] asks that when she returns for her transplant, her
children be called only just prior to her going to the OR at
[**Telephone/Fax (1) 29163**] (Shantal) and [**Telephone/Fax (1) 29164**] ([**Doctor First Name 8771**]).

Medications on Admission:
- omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
- alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
please resume prior schedule. Take 30 minutes before other meds

or food. Take with 8 oz water and remain upright for 30 mins
after dose.
- azathioprine 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
- ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week: please resume prior regimen.
- clotrimazole 10 mg Troche Sig: One (1) Mucous membrane five
times a day as needed for white coat on tongue.
- fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
- furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):

take at the same time as spironolactone.
- lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
- oxycodone 5 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for pain.
- prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): please continue as instructed by your Hepatologist.
- rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
- spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take at same time as lasix.
- sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
- folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
- NPH 10 units qAM and Humalog ISS
- Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
twice a day.
- trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.

Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (FR).
4. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
5X/DAY (5 Times a Day).
5. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
10. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer treatment Inhalation Q4H
(every 4 hours) as needed for SOB/wheezing.
13. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
14. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to back/side.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
17. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
18. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
20. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for breakthrough pain.
21. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
22. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to right side.
23. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
24. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H PRN
() as needed for pain: please do not exceed 2 grams per day.
25. NPH insulin human recomb 100 unit/mL Suspension Sig:
Fourteen (14) units Subcutaneous qam.
26. insulin lispro 100 unit/mL Solution Sig: 0-18 units
Subcutaneous QACHS: per attached sliding scale.
27. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
twice a day.
28. Laboratory values
Please check CBC, LFTs, INR, creatinine every week and fax
results to Dr.[**Name (NI) 948**] office: ([**Telephone/Fax (1) 12173**] so we can follow
her MELD score given she is in transplant list.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Primary Diagnoses: Hepatopulmonary Syndrome, Autoimmune
Hepatitis/Cirrhosis
Secondary Diagnoses: Type II Diabetes Mellitus, Depression


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound due to O2 requirements.


Discharge Instructions:
You were admitted to the hospital for shortness of breath caused
by severe hepatopulmonary syndrome secondary to your autoimmune
hepatitis.  You were treated with high flow oxygen by facemask.
You are awaiting a liver transplant which will improve your
breathing.
.
The following changes were made to your medications:
Your azathioprine was decreased to 50 mg.
Your prednisone was increased to 10 mg.
See attached sheet for other changes.
.
We expect your shortness of breath to be stable. Your oxygen
level will go down if you move, eat or try to ambulate. You
tried walking with a NRB 100% SpO2 and you could only do a few
feet. If yous breathing worsens (after sitting 90 degrees, at
rest, with same O2) please come back to the [**Hospital1 18**] for
re-evaluation.

Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] on [**1-31**] at 2:40
PM. His office info is:
[**Hospital1 18**]
Office Location:[**Last Name (NamePattern1) 13209**], [**Location (un) 86**], [**Numeric Identifier 718**]
Patient Phone:([**Telephone/Fax (1) 1582**]
Patient Fax:([**Telephone/Fax (1) 12173**]
{'Autoimmune hepatitis,Acute respiratory failure,Portal hypertension,Ostium secundum type atrial septal defect,Splenomegaly,Rash and other nonspecific skin eruption,Depressive disorder, not elsewhere classified,Obesity, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Varices of other sites,Other chronic pain,Body Mass Index 38.0-38.9, adult,Bed confinement status'}


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: dyspnea

PRESENT ILLNESS: 38F with cirrhosis [**1-10**] autoimmune hepatitis complicated by
hepatopulmonary syndrome on 6-8L continuous home O2, portal
hypertension, splenomegaly, and encephalopathy admitted with
shortness of breath. She was at baseline until this weekend when
her shortness of breath worsened. She was admitted at [**Hospital1 1474**]
for 2 days, discharged yesterday, saw Dr. [**Last Name (STitle) 497**] in clinic and
resting O2 sat was in the 60%, improved with non-rebreather.
Denies cough, sputum production, fever, chills, nasal
congestion, headache, sinus tenderness or sick contacts/recent
travel. Has generalized chest discomfort started several days
ago, located across chest, not pleuritic in nature, no
radiation, no known alleviating or aggravating factors. Has
chronic abdominal pain on flanks, she says due to enlarged
spleen. Mild nausea, one episode of bilious vomit 2 days ago.
Has had some diarrhea, no melena or hematochezia. She has
chronic myalgias and arthralgias. No dysuria.
.
Per hepatology clinic she had a PAo2 of 34 and and O2 sat on 6l
of %72. Looked cyanotic on arrival, came up to 100% on NRB, now
back on 6L at 92-96%. No known precipitating event to set
trigger her worsening shortness of breath. No new medications.
.
In ED, vitals were 98.2 90 124/68 32 86% on 50%FM. Labs notable
for WBC# 3.4 (69% PMN no bands) lactate 3.2. ABG showed
7.51/24/34. CXR unchanged from prior. CTA showed no PE. V/S
prior to transfer 75 94/43 19 92%4L
.
Review of systems:
(+) Per HPI

MEDICAL HISTORY: - autoimmune hepatitis dx [**2095**], [**Doctor First Name **] -, SMA +, liver biopsy
[**1-17**]: mild to moderate periportal inflammation including plasma

MEDICATION ON ADMISSION: - omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
- alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
please resume prior schedule. Take 30 minutes before other meds

ALLERGIES: Dilaudid / Shellfish Derived

PHYSICAL EXAM: UPON ADMISSION:
VS - 97.6 106/51 68 22 96-97% 6L O2
GENERAL - well-appearing woman in NAD, respirations slightly
labored
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - breath sounds distant, no r/rh/wh, no accessory muscle
use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, + splenomegaly, could not palpate
liver edge, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

FAMILY HISTORY: No h/o autoimmune illnesses
or liver disease. Father with CAD, mother had a CVA. Her
children are healthy although two of them have asthma. Maternal
uncle with esophageal cancer.

SOCIAL HISTORY: She lives at home with three of her four children. She does not
smoke, use alcohol, or illicit drugs. She is currently
unemployed but worked as a bus driver
previously. 

### Response:
{'Autoimmune hepatitis,Acute respiratory failure,Portal hypertension,Ostium secundum type atrial septal defect,Splenomegaly,Rash and other nonspecific skin eruption,Depressive disorder, not elsewhere classified,Obesity, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Varices of other sites,Other chronic pain,Body Mass Index 38.0-38.9, adult,Bed confinement status'}
