CHIEF COMPLAINT: eval for liver transplant

PRESENT ILLNESS: 45 yo m with h/o cryptogenic cirrhosis, end stage liver disease,
frequent episodes of hepatic encephalopathy exacerbations. He
presented on [**5-4**] to [**Hospital **] hospital after being found unconscious
[**12-18**] to missing a lactulose dose. He was given lactulose by NGT
in the ER and his mental status cleared. The patient underwent a
diagnostic tap in the ED there, but there was not sufficient
fluid to send to cell count. He was tapped again on [**5-6**] at OSH
and this tap showed increased cell count to 9045, 83% PNMs c/w
SBP therefore he was started on cefotaxime. The patient reported
blood in stools (patient thought this was from his hemorrhoids),
therefore he underwent an upper and lower endoscopy. Upper
showed grade I varices, gastropathy, and gastric varices. Lower
showed diverticulitis, polyp (not clipped [**12-18**] to increase INR),
and internal hemorrhoids. He was hypotensive after the procedure
to systolic of 80's (had been 120 - 150) which responded to
fluid boluses.  Also significant was the fact his Cr increased
from 1.8 to 2.6 during his short hospital stay, thought to be
due to acute renal failure [**12-18**] bowel prep vs. hepatorenal
syndrome. He was transferred to [**Hospital1 18**] for transplant eval on
[**5-6**].

MEDICAL HISTORY: cryptogenic cirrhosis
right inguinal hernia - cannot repair [**12-18**] to liver disease

MEDICATION ON ADMISSION: on transfer:
albumin 40mg IV q8
cefotaxime 2g q24
neomycin 500mg q6
lactulose 20 po q6
aldactone 50 po qam

ALLERGIES: Penicillins

PHYSICAL EXAM: vs: HR 60, BP 110/48, O2 sat 99%, 99.1 at 12:00, CVP 5
HEENT: EOMI, sclerae anicteric, oropharynx clear c no lesions
Lungs: CTA at apices/bases
Heart: RRR, S1, S2, no r/m/g
Abd: soft, + splenomegaly, NT, obese, + striae
Ext: [**11-17**] + edema to ankles b/l
Skin: large area ecchymoses over L shoulder.  No spider angiomas
noted, + gynecomastia.

FAMILY HISTORY: positive for diabetes but no known history of iron overload.
His father died of small cell carcinoma of the lung

SOCIAL HISTORY: No longer working but used to work as a chef. live with his
mother, not married or has children. Does not drink or smoke
Acute and subacute necrosis of liver,Cryptococcosis,Cirrhosis of liver without mention of alcohol,Acquired coagulation factor deficiency,Acute kidney failure, unspecified,Hepatorenal syndrome,Candidiasis of lung,Congestive heart failure, unspecified,Surgical or other procedure not carried out because of contraindication,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Panniculitis, other site,Unspecified essential hypertension,Chronic ulcer of other specified sites
Acute necrosis of liver,Cryptococcosis,Cirrhosis of liver NOS,Acq coagul factor defic,Acute kidney failure NOS,Hepatorenal syndrome,Candidiasis of lung,CHF NOS,No proc/contraindication,Esoph varice oth dis NOS,Panniculitis, site NEC,Hypertension NOS,Chronic skin ulcer NEC
Admission Date:  [**2121-5-6**]              Discharge Date:   [**2121-6-24**]

Date of Birth:  [**2075-12-28**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 943**]
Chief Complaint:
eval for liver transplant

Major Surgical or Invasive Procedure:
[**5-13**] EGD
R thoracotomy
LP done through IR


History of Present Illness:
45 yo m with h/o cryptogenic cirrhosis, end stage liver disease,
frequent episodes of hepatic encephalopathy exacerbations. He
presented on [**5-4**] to [**Hospital **] hospital after being found unconscious
[**12-18**] to missing a lactulose dose. He was given lactulose by NGT
in the ER and his mental status cleared. The patient underwent a
diagnostic tap in the ED there, but there was not sufficient
fluid to send to cell count. He was tapped again on [**5-6**] at OSH
and this tap showed increased cell count to 9045, 83% PNMs c/w
SBP therefore he was started on cefotaxime. The patient reported
blood in stools (patient thought this was from his hemorrhoids),
therefore he underwent an upper and lower endoscopy. Upper
showed grade I varices, gastropathy, and gastric varices. Lower
showed diverticulitis, polyp (not clipped [**12-18**] to increase INR),
and internal hemorrhoids. He was hypotensive after the procedure
to systolic of 80's (had been 120 - 150) which responded to
fluid boluses.  Also significant was the fact his Cr increased
from 1.8 to 2.6 during his short hospital stay, thought to be
due to acute renal failure [**12-18**] bowel prep vs. hepatorenal
syndrome. He was transferred to [**Hospital1 18**] for transplant eval on
[**5-6**].

At [**Hospital1 **]:

# End stage liver failure: The cause of his liver failure is
currently unknown and his MELD score was 30 on admission. He
underwent a workup for a liver transplant - echo, PFTs, viral
studies. He had multiple episodes of encephalopathy when not
taking lactulose. He was continued on lactulose while here.
Neomycin, which was started at RIH, was stopped for concern of
nephrotoxicity. His diuretics were held [**12-18**] low BP.  Pt.
scheduled for transplant but chest CT showed nodules (SEE lung
nodule hx below); intubated for surgery and weaned off on [**5-19**] in
SICU...transplant deferred.
.
# Acute renal failure: His baseline Cr was 1.5 - 1.8 and he has
had a sudden increase of his Cr from 1.8 -> 3.1 in a matter of 3
days. Of note, his Cr began to increase before he became
hypotensive and before any procedure was done at the OSH. This
is worrisome for hepatorenal failure exacerbated by infection
and intravascular volume depletion [**12-18**] to colonoscopy prep. He
was given 50mg of albumin x2 on admission and started on
octreotide and midodrine. and renal consulted; transfused for
improved forward flow and his creatinine improved.  On txf from
SICU, creat. trended down to 1.8.
.
# SBP: This was diagnosed on the day of admission at RIH and he
was started on cefotaxime there. He was switched to ceftriaxone
here. His cultures at RIH are currently not growing anything. He
was gently hydrated on the night of admission for concern that
his hypotension was [**12-18**] to infection (though he had a normal
lactate).  Switched from ceftriaxone to oral cipro for SBP
therapy ([**5-10**]) - to end on ([**5-22**])
.
# Hypotension/anemia: This is likely multifactorial . His
initial BP at the OSH was between 120 - 150 and decreased after
the colonoscopy. Perforation unlikely since has no pain.
Possibly [**12-18**] to SBP, volume depletion from colonoscopy prep, or
arterial and vasodilatation from HRS. on hospital day 2, his HCT
dropped from 25.7 on [**5-6**] to 18 on [**5-7**]. It was thought that he
was bleeding into his peritoneum from the paracentesis on [**5-6**]
or from his gastric varices. (He did not have abdominal pain,
vomiting, or BRBPR). His INR was 4.3 on [**5-7**] as well. He was
given 2 units PRBC and 2 units FFP for this HCT drop and
coagulopathy.  His BP on transfer from ICU.
.
# Rectal bleeding at OSH: The patient underwent a colonoscopy
and EGD on [**5-6**] that did not show evidence of active bleeding.
He does have gastric varices therefore at high risk for bleeding
event.  Resolved on transfer to medicine.
.
# Lung nodules - Chest CT on [**5-8**] showed scattered small
pulmonary opacities within both lungs, of varying sizes and
morphologies, suggestive of an acute infectious or inflammatory
process.  Bronchoscopy performed [**5-9**] - normal on visual
inspection, but BAL ctx grew out sensitive enterobacter and
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] sensitive to caspo/vori.  Tx c caspo c plan for
transplant after treatment of yeast infection in lungs.
Continue caspo * 2 weeks ([**5-18**]) with repeat CT to assess for
interval change.
.
# Panniculitis - tx c IV vancomycin.  Swab sent for MRSA screen
and pending; currently being treated with vancomycin.

Past Medical History:
cryptogenic cirrhosis
right inguinal hernia - cannot repair [**12-18**] to liver disease

Social History:
No longer working but used to work as a chef. live with his
mother, not married or has children. Does not drink or smoke

Family History:
positive for diabetes but no known history of iron overload.
His father died of small cell carcinoma of the lung

Physical Exam:
vs: HR 60, BP 110/48, O2 sat 99%, 99.1 at 12:00, CVP 5
HEENT: EOMI, sclerae anicteric, oropharynx clear c no lesions
Lungs: CTA at apices/bases
Heart: RRR, S1, S2, no r/m/g
Abd: soft, + splenomegaly, NT, obese, + striae
Ext: [**11-17**] + edema to ankles b/l
Skin: large area ecchymoses over L shoulder.  No spider angiomas
noted, + gynecomastia.


Pertinent Results:
Labs from outside hospital on morning of admission:
Na 136, K 3.5, Cl 118, Bicarb 11, BUN 23, Cr 2.6 up from 1.8 on
admission to RI, Glu 116. INR 2.3 up from 1.8 on admission.
Tbili 40. up from 1.8, HCT 26, WBC 14.8 with 90% neutrophils
Ascites: fluid cloudy yellow, Nu cells [**Pager number **], RBCs 675, 89%
Neutrophils therefore 7000 nuc cells.
.
Admission labs at [**Hospital1 **]:
[**2121-5-7**] 06:35AM BLOOD WBC-3.6* RBC-1.99* Hgb-5.9* Hct-18.2*
MCV-92 MCH-29.7 MCHC-32.4 RDW-16.1* Plt Ct-65*
[**2121-5-7**] 06:35AM BLOOD PT-25.6* PTT-57.8* INR(PT)-4.3
[**2121-5-7**] 06:35AM BLOOD Glucose-139* UreaN-31* Creat-3.1* Na-135
K-3.6 Cl-114* HCO3-10* AnGap-15
[**2121-5-7**] 06:35AM BLOOD ALT-37 AST-41* AlkPhos-98 TotBili-1.4
[**2121-5-7**] 06:35AM BLOOD Albumin-3.5 Calcium-8.1* Phos-4.7* Mg-1.7
Iron-47
[**2121-5-7**] 06:35AM BLOOD calTIBC-88* VitB12-1342* Folate-11.5
Ferritn-348 TRF-68*
[**2121-5-7**] 06:35AM BLOOD TSH-1.4
[**2121-5-7**] 02:04AM BLOOD Lactate-1.5
.
[**2121-5-8**] CT Chest and Abdomen:  Patents portal and hepatic veins.

IMPRESSION:  1. Scattered small pulmonary opacities within both
lungs, of varying sizes and morphologies, suggestive of an acute
infectious or inflammatory process. An additional area of
fibronodular thickening within the right lung apex may be
secondary to chronic lung disease, but could also be associated
with the above described smaller nodular opacities. Correlation
with the patient's clinical exam and follow up of these nodules,
to document their stability or resolution, is recommended. Given
the patient's history, a neoplastic process cannot be entirely
excluded.
2. New bilateral pleural effusions, smaller in size.
3. Prominent mediastinal and axillary lymph nodes, none meeting
the size criteria for pathologic enlargement, which may related
to the above described process within the lung parenchyma.
4. Stable perihepatic and perisplenic ascites.
5. Gynecomastia.
.
[**2121-5-8**] Echo: The left atrium is markedly dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60-70%). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
.
[**2121-5-7**] blood cultures neg. x 2
[**2121-5-8**] RPR neg, VZV IgG pos, EBV IgG pos, EBV IgM neg, Toxo IgG
neg, Toxo IgM neg, CMV IgG pos, CMV IgM neg,
[**2121-5-8**] 05:37AM BLOOD HIV Ab-NEGATIVE
[**2121-5-10**] 07:40AM BLOOD PEP-NO SPECIFIC ABNORMALITIES.
[**2121-5-9**] 11:53 am BRONCHOALVEOLAR LAVAGE GRAM STAIN positive for
4+ (>10 per 1000X FIELD):   POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN.
RESPIRATORY CULTURE positive for ENTEROBACTER CLOACAE, ~[**2115**]/ML,
but not considered a pathogen unless >=10,000 cfu/ml.
BAL FUNGAL CULTURE (Preliminary): YEAST, PRESUMPTIVELY NOT C.
ALBICANS.  FURTHER IDENTIFICATION TO FOLLOW.
ACID FAST SMEAR negative, ACID FAST CULTURE (Pending):

[**5-19**] repeat chest CT
1. Thick walled, irregular right upper lobe cavitary lesion.
Differential considerations include an infectious process such
as reactivation TB, particularly given the lymphadenopathy.
Vasculitis, such as Wegener's, can have a similar appearance and
be associated with tracheal thickening as seen on this study. A
cavitary neoplasm is considered less likely given the irregular
shaped of the cavity.
2. Bibasilar consolidation and pleural effusions, right greater
than left.

Pleural Fluid [**5-28**]
GRAM STAIN (Final [**2121-5-29**]): 1+    (<1 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
ACID FAST SMEAR (Final [**2121-5-29**]): NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR. ACID FAST CULTURE (Pending):
FLUID CULTURE (Final [**2121-5-31**]):    NO GROWTH.
ANAEROBIC CULTURE (Preliminary):    NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
.
Lung Tissue [**5-27**]
rare growth coag (-) staph, oxacillin resistant, no ctx growth -
anaerobes, legionella, fungus, AFB
.
Histo Urinary Ag - P
.
LP [**6-19**]-->WBC, CSF 0 #/uL
  CLEAR AND COLORLESS
PERFORMED AT WEST STAT LAB
RBC, CSF 71* #/uL 0 - 0
  PERFORMED AT WEST STAT LAB
Polys 25 %
  4 CELL DIFFERENTIAL
PERFORMED AT WEST STAT LAB
Lymphs 25 %
Monocytes 50 %
..
[**6-22**] CXR: There is continued large right pleural effusion, which
is unchanged since the previous study. The previously identified
mild congestive heart failure has been slightly improving. The
right-sided PICC line remains in place. No pneumothorax is seen.


Brief Hospital Course:
This patient, who had initially seen Dr. [**Last Name (STitle) 497**] and transplant
social work a few weeks ago, was transferred to [**Hospital1 18**] for an
expedited liver transplant workup because he developed acute
renal failure and SBP; was about to receive liver txp which was
aborted because of lung infxn; currently undergoing tx for
cavitary lesion in lung prior to txp.
.
End stage liver failure; followed by liver service.  He was
continued on octreotide and midodrine until his creatinine came
down; he was considered to be out of hepatorenal syndrome and
octreotide/midodrine stopped.  Prior to R lobectomy, pt. was
diuresed aggressively in anticipation of large amount of blood
products during surgery.  He was kept on lactulose with a goal
of [**1-17**] BM daily.  He was on cipro for SBP prophylaxis and
protonix for gastritis/prophylaxis.  Post lobectomy we continued
to diurese him aggressively with lasix, spironolactone and
repleted his electrolytes accordingly.  It was determined the
week of [**6-9**] that the pt. actually has cryptococcus in the RUL
specimen, not histoplasmosis based on mucicarmine stain and
Fontana-Masson1 stain. As a result, he had a w/u for CNS crypto
which included an LP performed under fluoroscopy.  However, this
procedure was complicated by patient's coagulopathy, and pt
required multiple transfusions of FFP and platelets.  In
addition, patient required 4800mcg of Factor VII, which was
given immediately prior to procedure and successfully reversed
his INR.  As a result of the blood products, pt became fluid
overloaded and developed a R sided pleural effusion.  This was
treated with aggressive IV diuretics in addition to his oral
aldactone.  Pt was kept in negative balance of at least 1.5L
daily, and his weight was tracked as well.  His creatinine
remained between 1.3-1.4.  Diuresis was slowly decreased once
patient able to breathe comfortably on room air and his weight
decreased by a few pounds.  He was changed over to oral lasix
and continued on the spironolactone.
.
SBP; this resolved with a 2 week course of cipro/ceftriaxone.
He was kept on prophylaxis with cipro and did not c/o any
increasing abdominal pain.
.
Lung nodules/cavitary lesion RUL; prior to R lobectomy, he was
ruled out for TB with three negative induced sputums.  He
underwent R lobectomy and path showed large palisading caseating
granulomas with many yeast forms ([**1-18**] microns) in the caseous
material.  Post lobectomy, he was treated with ambisome IV.  A
discussion whether he needed a w/u for disseminated histo
occurred and it was decided that the w/u should include a MRI to
assess for meningeal involvement as well as a BM biopsy/aspirate
culture.  This was considered necessary as it may impact his
prognosis should he go for emergent liver txp as well as his
relative response to a non-cidal [**Doctor Last Name 360**] (itraconazole) should he
not tolerate ambisome.  As of [**6-6**] he had a negative MRI and a
BM aspirate culture was going to be done [**6-6**].  The BM was never
done b.c. of high risk and possibility to treat empirically.
Concurrently (see above) it was determined that he had
cryptococcus, not histoplasmosis.  This was based on fungal
stains.  As a result, he requires a LP to r/o CNS crypto.  The
LP was to be done under fluoroscopy because he has such poor
landmarks and he is a high risk candidate, because of this, the
[**Hospital1 **] protocol for LP, which is that the procedure service must
attempt, then neurology, then the pain service, and then IR as a
last resort;  was bypassed.  The LP was negative for crypto, at
which point the patient was changed from ambisome to oral
fluconazole, 400mg daily, to complete an eight week course per
ID recommendations.
.
Panniculitis; treated with IV vancomycin and this resolved;
vanco stopped [**5-23**].
.
Central line; pt. central line placed [**2121-5-15**]; plan was to
remove central line [**6-6**] AM and position 2 peripheral IVs.
Central line removed, tip (-) ctx, PICC placed for plan for
outpt. abx, however, as patient did not require IV antibiotics,
this PICC was removed prior to discharge.
.
Pt was also followed by thoracic service for management of chest
tubes.  Drained for nearly 1 week post surgery. Chest tubes
pulled when drainage < 400 cc/24 hr.  Pt. continued to have
sporadic drainage usually worsened by activity.  Pt. had ostomy
bag intermittently applied over chest tube site to control
drainage.  Tramadol and oxycodone used for pain control and pt.
able to use incentive spirometer.  Stitch over CT site applied
by thoracic team.  As of [**6-14**], his chest tube site was draining
minimal fluid and was covered with dry gauze.  Staples over his
incision site were removed 2 days prior to discharge and covered
with steri-strips.
.
Patient was evaluated by PT/OT and was cleared for discharge to
his home.  VNA was arranged for the patient prior to discharge.
After a stable dose of lasix was determined that would provide
patient with optimal diuresis, patient was cleared for discharge
to home with services.  Patient was scheduled for follow-up
appointments with Dr. [**Last Name (STitle) 497**], Dr. [**Last Name (STitle) 4334**], and Dr. [**Last Name (STitle) 724**].  On day of
discharge, patient was ambulating, afebrile, hemodynamically
stable, and tolerating a house diet.  Patient was given a
prescription for all of his medications as he stated that he did
not have any at home.  However, a few days after discharge,
patient called needing clarification with two of the
prescriptions, at which point he was [**Name (NI) 653**], but stated that
the problem had already been resolved.


Medications on Admission:
on transfer:
albumin 40mg IV q8
cefotaxime 2g q24
neomycin 500mg q6
lactulose 20 po q6
aldactone 50 po qam


Discharge Medications:
1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for legs.
Disp:*1 * Refills:*1*
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  PRN
(as needed).
Disp:*1 * Refills:*2*
5. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 * Refills:*1*
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*112 Tablet(s)* Refills:*0*
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
VNA of [**Doctor Last Name **]

Discharge Diagnosis:
cryptococcal pneumonia
cryptogenic cirrhosis
end stage liver disease


Discharge Condition:
stable

Discharge Instructions:
Please take all of your medications as prescribed.

Please maintain all of your follow up appointments listed below.

Please call your doctor or return to the hospital if you develop
fevers, chills, nausea or vomiting, or develop chest pain or
shortness of breath.

Followup Instructions:
1.Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 3126**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2121-7-2**] 3:20

2.Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2121-7-17**] 10:30

3.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Where: LM [**Hospital Unit Name 3126**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2121-8-12**] 10:00
{'Acute and subacute necrosis of liver,Cryptococcosis,Cirrhosis of liver without mention of alcohol,Acquired coagulation factor deficiency,Acute kidney failure, unspecified,Hepatorenal syndrome,Candidiasis of lung,Congestive heart failure, unspecified,Surgical or other procedure not carried out because of contraindication,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Panniculitis, other site,Unspecified essential hypertension,Chronic ulcer of other specified sites'}


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: eval for liver transplant

PRESENT ILLNESS: 45 yo m with h/o cryptogenic cirrhosis, end stage liver disease,
frequent episodes of hepatic encephalopathy exacerbations. He
presented on [**5-4**] to [**Hospital **] hospital after being found unconscious
[**12-18**] to missing a lactulose dose. He was given lactulose by NGT
in the ER and his mental status cleared. The patient underwent a
diagnostic tap in the ED there, but there was not sufficient
fluid to send to cell count. He was tapped again on [**5-6**] at OSH
and this tap showed increased cell count to 9045, 83% PNMs c/w
SBP therefore he was started on cefotaxime. The patient reported
blood in stools (patient thought this was from his hemorrhoids),
therefore he underwent an upper and lower endoscopy. Upper
showed grade I varices, gastropathy, and gastric varices. Lower
showed diverticulitis, polyp (not clipped [**12-18**] to increase INR),
and internal hemorrhoids. He was hypotensive after the procedure
to systolic of 80's (had been 120 - 150) which responded to
fluid boluses.  Also significant was the fact his Cr increased
from 1.8 to 2.6 during his short hospital stay, thought to be
due to acute renal failure [**12-18**] bowel prep vs. hepatorenal
syndrome. He was transferred to [**Hospital1 18**] for transplant eval on
[**5-6**].

MEDICAL HISTORY: cryptogenic cirrhosis
right inguinal hernia - cannot repair [**12-18**] to liver disease

MEDICATION ON ADMISSION: on transfer:
albumin 40mg IV q8
cefotaxime 2g q24
neomycin 500mg q6
lactulose 20 po q6
aldactone 50 po qam

ALLERGIES: Penicillins

PHYSICAL EXAM: vs: HR 60, BP 110/48, O2 sat 99%, 99.1 at 12:00, CVP 5
HEENT: EOMI, sclerae anicteric, oropharynx clear c no lesions
Lungs: CTA at apices/bases
Heart: RRR, S1, S2, no r/m/g
Abd: soft, + splenomegaly, NT, obese, + striae
Ext: [**11-17**] + edema to ankles b/l
Skin: large area ecchymoses over L shoulder.  No spider angiomas
noted, + gynecomastia.

FAMILY HISTORY: positive for diabetes but no known history of iron overload.
His father died of small cell carcinoma of the lung

SOCIAL HISTORY: No longer working but used to work as a chef. live with his
mother, not married or has children. Does not drink or smoke 

### Response:
{'Acute and subacute necrosis of liver,Cryptococcosis,Cirrhosis of liver without mention of alcohol,Acquired coagulation factor deficiency,Acute kidney failure, unspecified,Hepatorenal syndrome,Candidiasis of lung,Congestive heart failure, unspecified,Surgical or other procedure not carried out because of contraindication,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Panniculitis, other site,Unspecified essential hypertension,Chronic ulcer of other specified sites'}
