CHIEF COMPLAINT: CHIEF COMPLAINT: transfer for hepatic encephalopathy

PRESENT ILLNESS: Mr. [**Known lastname **] is a 46 y/o male with ETOH cirrhosis, previous
hepatitis C infection with spontaneous clearance in [**2109**] (recent
HCV VL undetectable), polysubstance abuse with a one-year
abstinence per notes who is transferred from OSH with acute
kidney injury, ascites, and acute encephalopathy.
He initially presented in liver decompensation with variceal
bleeding, ascites, and encephalopathy in [**2109-6-2**], and recently
established care with the transplant center in [**2110-5-4**]. His
endoscopies have shown isolated gastric varices and esophageal
varices (grade II) which have been banded x 3.
Of note, in [**2110-5-4**] while establishing care at our liver
center, he was on lasix and aldactone for ascites. His Cr was
normal at 0.6 at that time. He has also had h/o three large
volume paracentesis, partly felt to be due to poor compliance
with low salt diet. At that time, he had mild hepatic
encephalopathy and was on lactulose, having [**4-6**] BM per day.
He has a long history of alcohol and substance abuse- having
consumed 1 bottle of vodka daily for many years before stopping
last [**Month (only) 116**] upon his diagnosis of cirrhosis. He has used
prescription drugs, heroin, and methadone in the past, though
has been clean for a year. He is enrolled in AA.
Patient is currently transferred from [**Hospital **] hospital. Per Dr [**First Name (STitle) 3636**]
(pager [**Telephone/Fax (1) 110689**]), patient presented the night of [**6-17**] with
dizziness, hepatic encephalopathy, abdominal pain, n/v and [**Last Name (un) **].
She reports that he has not had a bowel movement in "a day or
so" and he was given lactulose X5 yesterday and only had 1 BM.
Per d/w patient's fiancee, he had been having abdominal pain,
nausea, and bilious vomiting 2 days PTA. 1 week PTA patient did
have tooth infection and was given amoxicillin as well as
motrin. He has been taking motrin 1x per day. Fiancee reported
that he has been adherent to medications and denied dietary
indiscretion. He has been taking aldactone 200 mg 2x/day and
lasix 80 mg qAM and 40 mg qPM at home prior to admission. He has
had 5 admissions at RIH in past 2 mo for liver decompensation.
Also, at RIH, renal was consulted and felt that [**Last Name (un) **] was
pre-renal in etiology given FEurea 12.39%. He was started on IVF
and diuretics were held. On [**6-18**], he underwent diagnostic and
therapeutic 5L paracentesis. This did not show SBP. RUQ and RUS
were performed, with results showing, "cirrhosis, portal htn,
reversal of portal venous flow, varices, and splenomegaly, mild
to moderate residual ascites s/p paracentesis, kidneys without
hydronephrosis." Lactulose was unable to be given on date of
transfer and was held due to AMS. NGT was reportedly
unsuccessful due to AMS.
On transfer, he is arousable but combative and they have started
lactulose enema's in order to prevention aspiration. Creat was
4.35. No other labs available due to poor access, but T-bili
2.8, INR 1.5, Creat 4.35. Of note, pt is in the transplant
evaluation process.
On the floor, patient is acutely agitated and without PIV
access. He is not oriented to self or place.
ROS: unable to be obtained [**3-6**] acute hepatic encephalopathy.

MEDICAL HISTORY: 1. Right knee surgery almost 15 years ago.
2. Hypertension.
3. ETOH Cirrhsosis, c/b varices, encephalopathy, and ascites
requiring recurrent large-volume paracenteses
4. Grade II esophageal varices, grade I gastric varices, portal
gastropathy
5. History of hepatitis C, which cleared spontaneously.
6. Variceal UGIB [**12/2109**] s/p banding x 3
7. Hx of IVDU
8. Recurrent pancreatitis

MEDICATION ON ADMISSION: - docusate 100 mg [**Hospital1 **]
- lactulose titrate to 4 BM per day
- lasix 40 mg qPM
- lasix 80 mg qAM
- nexium 40 mg daily
- oxycontin 40 mg q12 hrs
- prochlorperazine prn
- propanolol 10 mg tid
- aldactone 200 mg [**Hospital1 **]
- tramadol 50 mg q6 hrs prn

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
VS: 98.2, 125/80, 71, 16, 99 RA, BG 184
GENERAL: agitated male, looks older than stated age, in
restraints, not oriented to self or place
HEENT: mild scleral icterus. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, S1 S2 without murmurs, rubs or gallops. No S3 or S4
appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB anteriorly, no crackles, wheezes or rhonchi.

FAMILY HISTORY: Negative for liver cancer, GI cancer or liver

SOCIAL HISTORY: He lives alone. He has a fiancee who checks on him every day.
Mom is the HCP. The patient has one son. [**Name (NI) **] is unemployed
applying for disability. He used to work as salesperson. He has
VNA three times a week. He has past history of drug use such as
Percocet and OxyContin nonprescribed as well as methadone. He
also used IV heroin in the past. He has been clean from drugs
for over a year per notes. He smokes cigarettes almost one-half
pack per day.
Hepatic encephalopathy,Esophageal varices in diseases classified elsewhere, with bleeding,Portal vein thrombosis,Paralytic ileus,Other ascites,Acute kidney failure, unspecified,Acidosis,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, in remission,Other, mixed, or unspecified drug abuse, in remission,Other specified disorders of stomach and duodenum,Unspecified essential hypertension,Personal history of other infectious and parasitic diseases,Other convulsions
Hepatic encephalopathy,Bleed esoph var oth dis,Portal vein thrombosis,Paralytic ileus,Ascites NEC,Acute kidney failure NOS,Acidosis,Alcohol cirrhosis liver,Alcoh dep NEC/NOS-remiss,Drug abuse NEC-in remiss,Gastroduodenal dis NEC,Hypertension NOS,Prsnl hst oth nfct parst,Convulsions NEC
Admission Date:  [**2110-6-19**]              Discharge Date:   [**2110-6-28**]

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

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
CHIEF COMPLAINT: transfer for hepatic encephalopathy


Major Surgical or Invasive Procedure:
EGD with 2 bands placed
IR guided paracentesis


History of Present Illness:
Mr. [**Known lastname **] is a 46 y/o male with ETOH cirrhosis, previous
hepatitis C infection with spontaneous clearance in [**2109**] (recent
HCV VL undetectable), polysubstance abuse with a one-year
abstinence per notes who is transferred from OSH with acute
kidney injury, ascites, and acute encephalopathy.
He initially presented in liver decompensation with variceal
bleeding, ascites, and encephalopathy in [**2109-6-2**], and recently
established care with the transplant center in [**2110-5-4**]. His
endoscopies have shown isolated gastric varices and esophageal
varices (grade II) which have been banded x 3.
Of note, in [**2110-5-4**] while establishing care at our liver
center, he was on lasix and aldactone for ascites. His Cr was
normal at 0.6 at that time. He has also had h/o three large
volume paracentesis, partly felt to be due to poor compliance
with low salt diet. At that time, he had mild hepatic
encephalopathy and was on lactulose, having [**4-6**] BM per day.
He has a long history of alcohol and substance abuse- having
consumed 1 bottle of vodka daily for many years before stopping
last [**Month (only) 116**] upon his diagnosis of cirrhosis. He has used
prescription drugs, heroin, and methadone in the past, though
has been clean for a year. He is enrolled in AA.
Patient is currently transferred from [**Hospital **] hospital. Per Dr [**First Name (STitle) 3636**]
(pager [**Telephone/Fax (1) 110689**]), patient presented the night of [**6-17**] with
dizziness, hepatic encephalopathy, abdominal pain, n/v and [**Last Name (un) **].
She reports that he has not had a bowel movement in "a day or
so" and he was given lactulose X5 yesterday and only had 1 BM.
Per d/w patient's fiancee, he had been having abdominal pain,
nausea, and bilious vomiting 2 days PTA. 1 week PTA patient did
have tooth infection and was given amoxicillin as well as
motrin. He has been taking motrin 1x per day. Fiancee reported
that he has been adherent to medications and denied dietary
indiscretion. He has been taking aldactone 200 mg 2x/day and
lasix 80 mg qAM and 40 mg qPM at home prior to admission. He has
had 5 admissions at RIH in past 2 mo for liver decompensation.
Also, at RIH, renal was consulted and felt that [**Last Name (un) **] was
pre-renal in etiology given FEurea 12.39%. He was started on IVF
and diuretics were held. On [**6-18**], he underwent diagnostic and
therapeutic 5L paracentesis. This did not show SBP. RUQ and RUS
were performed, with results showing, "cirrhosis, portal htn,
reversal of portal venous flow, varices, and splenomegaly, mild
to moderate residual ascites s/p paracentesis, kidneys without
hydronephrosis." Lactulose was unable to be given on date of
transfer and was held due to AMS. NGT was reportedly
unsuccessful due to AMS.
On transfer, he is arousable but combative and they have started
lactulose enema's in order to prevention aspiration. Creat was
4.35. No other labs available due to poor access, but T-bili
2.8, INR 1.5, Creat 4.35. Of note, pt is in the transplant
evaluation process.
On the floor, patient is acutely agitated and without PIV
access. He is not oriented to self or place.
ROS: unable to be obtained [**3-6**] acute hepatic encephalopathy.


Past Medical History:
1. Right knee surgery almost 15 years ago.
2. Hypertension.
3. ETOH Cirrhsosis, c/b varices, encephalopathy, and ascites
requiring recurrent large-volume paracenteses
4. Grade II esophageal varices, grade I gastric varices, portal
gastropathy
5. History of hepatitis C, which cleared spontaneously.
6. Variceal UGIB [**12/2109**] s/p banding x 3
7. Hx of IVDU
8. Recurrent pancreatitis


Social History:
He lives alone. He has a fiancee who checks on him every day.
Mom is the HCP. The patient has one son. [**Name (NI) **] is unemployed
applying for disability. He used to work as salesperson. He has
VNA three times a week. He has past history of drug use such as
Percocet and OxyContin nonprescribed as well as methadone. He
also used IV heroin in the past. He has been clean from drugs
for over a year per notes. He smokes cigarettes almost one-half
pack per day.

Family History:
Negative for liver cancer, GI cancer or liver

Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.2, 125/80, 71, 16, 99 RA, BG 184
GENERAL: agitated male, looks older than stated age, in
restraints, not oriented to self or place
HEENT: mild scleral icterus. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, S1 S2 without murmurs, rubs or gallops. No S3 or S4
appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB anteriorly, no crackles, wheezes or rhonchi.

ABDOMEN: moderately distended but soft, umbilical hernia present
which is reducible, non-tender to palpation, mild to moderate
ascites, hepatomegaly appreciated [**3-7**] fingerbreaths below costal
margin, ? splenomegaly, spider angiomas present
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
Minimal non-pitting LE edema bilaterally.
NEURO: patient not cooperative with exam, in restraints,
agitated, not oriented to self or place, not following commands,
asterixis unable to be tested

DISCHARGE PHYSICAL EXAM:
VS: 98.3 110/75 75 20 97%RA
GENERAL: Sitting up in bed, appropriate, NAD. AOx3
HEENT: NC/AT, mild scleral icterus.
NECK: L IJ in place
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. regular rate, S1, S2 without murmurs, rubs or gallops. No
S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB without crackles, wheezes or rhonchi.
ABDOMEN: Moderately distended but soft, umbilical hernia present
which is reducible, nontender, hepatomegaly appreciated [**3-7**]
fingerbreaths below costal margin, spider angiomas present.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
NEURO: A&Ox3, no asterixis


Pertinent Results:
[**2110-6-19**] 08:55PM BLOOD WBC-5.1 RBC-3.61* Hgb-12.0* Hct-36.5*
MCV-101* MCH-33.3* MCHC-32.9 RDW-13.8 Plt Ct-106*
[**2110-6-20**] 09:00AM BLOOD WBC-4.6 RBC-3.39* Hgb-10.9* Hct-34.1*
MCV-101* MCH-32.3* MCHC-32.1 RDW-13.7 Plt Ct-105*
[**2110-6-21**] 05:55AM BLOOD WBC-5.0 RBC-3.62* Hgb-12.3* Hct-36.3*
MCV-100* MCH-33.9* MCHC-33.8 RDW-13.7 Plt Ct-108*
[**2110-6-22**] 05:10AM BLOOD WBC-11.1*# RBC-3.62* Hgb-12.2* Hct-37.3*
MCV-103* MCH-33.7* MCHC-32.7 RDW-14.0 Plt Ct-97*
[**2110-6-22**] 05:01PM BLOOD WBC-9.1 RBC-3.05* Hgb-10.3* Hct-31.0*
MCV-102* MCH-33.8* MCHC-33.3 RDW-14.1 Plt Ct-93*
[**2110-6-22**] 09:00PM BLOOD WBC-8.1 RBC-3.40* Hgb-11.4* Hct-34.3*
MCV-101* MCH-33.7* MCHC-33.4 RDW-14.8 Plt Ct-80*
[**2110-6-23**] 02:01AM BLOOD WBC-7.2 RBC-3.20* Hgb-10.7* Hct-31.9*
MCV-100* MCH-33.5* MCHC-33.5 RDW-15.2 Plt Ct-80*
[**2110-6-23**] 08:22AM BLOOD WBC-7.7 RBC-3.23* Hgb-11.0* Hct-32.3*
MCV-100* MCH-34.0* MCHC-34.0 RDW-15.3 Plt Ct-78*
[**2110-6-23**] 05:00PM BLOOD WBC-7.7 RBC-3.23* Hgb-10.7* Hct-31.8*
MCV-99* MCH-33.0* MCHC-33.5 RDW-15.1 Plt Ct-83*
[**2110-6-24**] 12:30AM BLOOD WBC-6.4 RBC-3.23* Hgb-10.8* Hct-32.3*
MCV-100* MCH-33.3* MCHC-33.3 RDW-15.9* Plt Ct-75*
[**2110-6-24**] 04:00AM BLOOD WBC-6.3 RBC-3.06* Hgb-10.2* Hct-30.4*
MCV-99* MCH-33.4* MCHC-33.6 RDW-15.8* Plt Ct-85*
[**2110-6-24**] 03:50PM BLOOD WBC-6.3 RBC-3.20* Hgb-10.7* Hct-31.9*
MCV-100* MCH-33.4* MCHC-33.4 RDW-15.8* Plt Ct-92*
[**2110-6-25**] 05:00AM BLOOD WBC-4.7 RBC-3.08* Hgb-10.0* Hct-30.7*
MCV-100* MCH-32.6* MCHC-32.7 RDW-16.0* Plt Ct-88*
[**2110-6-26**] 03:45AM BLOOD WBC-8.1# RBC-3.37* Hgb-11.3* Hct-34.9*
MCV-104* MCH-33.6* MCHC-32.4 RDW-17.0* Plt Ct-99*
[**2110-6-28**] 04:58AM BLOOD WBC-6.0 RBC-3.30* Hgb-10.9* Hct-33.0*
MCV-100* MCH-33.2* MCHC-33.2 RDW-16.8* Plt Ct-88*
[**2110-6-19**] 08:55PM BLOOD PT-16.5* INR(PT)-1.6*
[**2110-6-20**] 09:00AM BLOOD PT-19.2* PTT-37.2* INR(PT)-1.8*
[**2110-6-21**] 05:55AM BLOOD PT-18.1* PTT-38.2* INR(PT)-1.7*
[**2110-6-22**] 05:10AM BLOOD PT-22.4* PTT-38.9* INR(PT)-2.1*
[**2110-6-22**] 05:01PM BLOOD PT-24.7* PTT-60.8* INR(PT)-2.4*
[**2110-6-23**] 02:01AM BLOOD PT-21.1* PTT-44.7* INR(PT)-2.0*
[**2110-6-25**] 05:00AM BLOOD PT-25.5* PTT-59.3* INR(PT)-2.4*
[**2110-6-26**] 03:45AM BLOOD PT-23.9* INR(PT)-2.3*
[**2110-6-27**] 05:20AM BLOOD PT-23.0* PTT-47.3* INR(PT)-2.2*
[**2110-6-28**] 04:58AM BLOOD PT-21.6* PTT-42.2* INR(PT)-2.1*
[**2110-6-19**] 08:55PM BLOOD Glucose-99 UreaN-32* Creat-1.7* Na-136
K-4.6 Cl-102 HCO3-21* AnGap-18
[**2110-6-20**] 09:00AM BLOOD Glucose-120* UreaN-32* Creat-1.7* Na-141
K-4.5 Cl-104 HCO3-23 AnGap-19
[**2110-6-21**] 05:55AM BLOOD Glucose-113* UreaN-27* Creat-1.3* Na-143
K-4.1 Cl-109* HCO3-21* AnGap-17
[**2110-6-22**] 05:10AM BLOOD Glucose-164* UreaN-30* Creat-1.2 Na-139
K-4.0 Cl-104 HCO3-18* AnGap-21*
[**2110-6-22**] 05:01PM BLOOD Glucose-114* UreaN-29* Creat-0.9 Na-140
K-4.1 Cl-108 HCO3-19* AnGap-17
[**2110-6-23**] 02:01AM BLOOD Glucose-116* UreaN-23* Creat-0.9 Na-139
K-3.7 Cl-103 HCO3-21* AnGap-19
[**2110-6-24**] 04:00AM BLOOD Glucose-108* UreaN-17 Creat-0.9 Na-137
K-3.4 Cl-103 HCO3-23 AnGap-14
[**2110-6-25**] 05:00AM BLOOD Glucose-103* UreaN-15 Creat-0.9 Na-136
K-3.2* Cl-99 HCO3-25 AnGap-15
[**2110-6-26**] 03:45AM BLOOD Glucose-115* UreaN-16 Creat-1.1 Na-137
K-3.6 Cl-102 HCO3-16* AnGap-23*
[**2110-6-27**] 05:20AM BLOOD Glucose-99 UreaN-14 Creat-1.0 Na-136
K-3.5 Cl-100 HCO3-23 AnGap-17
[**2110-6-28**] 04:58AM BLOOD Glucose-93 UreaN-12 Creat-0.8 Na-135
K-3.7 Cl-97 HCO3-23 AnGap-19
[**2110-6-19**] 08:55PM BLOOD ALT-30 AST-49* LD(LDH)-240 AlkPhos-87
TotBili-3.5*
[**2110-6-20**] 09:00AM BLOOD ALT-29 AST-44* AlkPhos-71 TotBili-4.2*
[**2110-6-21**] 05:55AM BLOOD ALT-29 AST-46* AlkPhos-77 TotBili-4.3*
[**2110-6-22**] 05:10AM BLOOD ALT-27 AST-39 AlkPhos-63 TotBili-4.6*
[**2110-6-23**] 02:01AM BLOOD ALT-24 AST-34 LD(LDH)-185 AlkPhos-52
TotBili-7.3* DirBili-2.1* IndBili-5.2
[**2110-6-24**] 04:00AM BLOOD ALT-22 AST-33 LD(LDH)-174 TotBili-5.7*
[**2110-6-25**] 05:00AM BLOOD ALT-22 AST-34 AlkPhos-56 TotBili-4.9*
[**2110-6-26**] 03:45AM BLOOD ALT-23 AST-38 LD(LDH)-210 CK(CPK)-42*
AlkPhos-65 TotBili-4.3*
[**2110-6-27**] 05:20AM BLOOD ALT-24 AST-40 LD(LDH)-201 AlkPhos-69
TotBili-4.2*
[**2110-6-28**] 04:58AM BLOOD ALT-28 AST-44* AlkPhos-81 TotBili-3.9*
[**2110-6-22**] 05:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2110-6-22**] 05:10AM BLOOD CEA-5.9*
[**2110-6-28**] 04:58AM BLOOD HIV Ab-NEGATIVE
[**2110-6-22**] 05:10AM BLOOD HCV Ab-POSITIVE*
[**2110-6-22**] 05:14PM BLOOD Lactate-3.1*
[**2110-6-22**] 09:12PM BLOOD Lactate-2.9*
[**2110-6-23**] 02:30AM BLOOD Lactate-2.2*
[**2110-6-26**] 04:01AM BLOOD Lactate-10.6*
[**2110-6-26**] 09:42AM BLOOD Lactate-1.7
[**2110-6-22**] 05:10AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Name
[**2110-6-19**] 11:58PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
[**2110-6-26**] 06:10AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2110-6-19**] 11:58PM URINE RBC-6* WBC-2 Bacteri-FEW Yeast-NONE Epi-0
TransE-<1
[**2110-6-19**] 11:58PM URINE Hours-RANDOM UreaN-862 Creat-148 Na-30
K-45 Cl-12
[**2110-6-19**] 11:58PM URINE Osmolal-520
[**2110-6-23**] 04:30PM ASCITES WBC-160* RBC-790* Polys-35* Lymphs-8*
Monos-0 Mesothe-2* Macroph-55*
[**2110-6-23**] 04:30PM ASCITES TotPro-1.3 Glucose-131 LD(LDH)-71
Amylase-10 TotBili-1.2 Albumin-1.0

KUB [**6-20**]:
IMPRESSION:  Nonspecific bowel gas pattern with mild small bowel
dilation.  Early or partial obstruction cannot be excluded.

RUQ U/S [**6-20**]:
IMPRESSION: Cirrhosis with findings of portal hypertension.
Reversal of flow within the left portal vein and antegrade flow
within the main portal vein.

KUB [**6-22**]:
IMPRESSION:  Supine and left decubitus views show there is no
pneumoperitoneum.  However moderate generalized distention of
large and small bowel has progressed since [**6-20**], and
appreciable wall thickening
particularly in the transverse colon and in small bowel loops in
the left
lower abdomen is new.  This is not a pattern of obstruction, but
of ileus and requires careful attention for the possible
contribution of ischemia.

CT Abdomen [**6-22**]:
IMPRESSION:
1.  Diffuse small bowel wall thickening and dilation most likely
secondary to ascites, portal hypertension, and hypoalbuminemia.
There is no evidence of small-bowel obstruction.
2.  There is no flow within the intrahepatic portal veins,
despite adequacy of bolus timing.  Doppler ultrasound from two
days ago did show flow in the intra-hepatic branches (reversed
on the left), but the waveforms were not robust.  Further
evaluation is recommended with multi-phasic CT or abdominal MRI
to confirm the suspicion of portal vein thrombosis
3.  Nodular liver contour, extensive splenic and esophageal
varices consistent with cirrhosis and portal hypertension.

CXR [**6-26**]:
FINDINGS:  As compared to the previous radiograph, there is no
relevant
change.  Low lung volumes.  Normal size of the cardiac
silhouette.  Normal hilar and mediastinal structures.  No
pleural effusions.  No pneumonia, but areas of atelectasis at
the left lung base.  No pneumothorax.  The monitoring and
support devices are constant.

CT Head [**6-26**]:
IMPRESSION:  No acute intracranial hemorrhage or mass effect.
Correlate
clinically to decide on the need for further workup.

CT Neck [**6-26**]:
IMPRESSION:
1. No acute cervical spine fracture. No canal or foraminal
stenosis. Correlate clinically to decide on the need for further
workup.
2. A 2.1x1.8cm mass lesion in right parotid- ?
node/neoplasm-correlate with ultrasound/soft tissue MRI neck on
a non-emergent basis.


Brief Hospital Course:
46 y/o male with ETOH cirrhosis, previous hepatitis C infection
with spontaneous clearance in [**2109**] (recent HCV VL undetectable),
polysubstance abuse with a one-year abstinence per notes, who is
transferred from OSH with acute encephalopathy, acute kidney
injury, and ascites. On [**6-22**] had tachycardia and
hematochezia/[**Hospital 58799**] transferred to the MICU and found with portal
gastropathy/duodenopathy and esophageal varices which were
banded. Stablized and transferred from the unit. On [**6-25**], the
patient had a fall from a likely seizure with elevated lactate
to 10 and transferred to the MICU. Again, he was stabilized in
the ICU and called out to the floor on [**6-26**], without any change
in his previous management.

# Seizure: On [**6-26**] patient was witnessed to fall by roommate
with associated convulsions and bowel incontinence. The patient
was post-ictal afterwards and had an elevated lactate to 10,
which downtrended back to 1 prior to discharge. He had a normal
head CT and neck (only small parotid gland mass noted). Neuro
was consulted who recommended 24 hour EEG, which by report
showed no epileptiform activity however final read is pending at
the time of discharge. The patient has report of seizure-like
activity by fiance in the past when withdrawing from alcohol,
but otherwise has no seizure history. Neurology ultimately
recommended outpatient MRI of the brain to rule out intracranial
mass and felt that there was no indication for AEDs at this
time.

# Upper GIB: On [**6-22**] was noted to be sinus tachycardic to
120-130 with hematochezia, transferred to the unit for emergent
EGD. Bleed likely [**3-6**] esophageal varices (3 cords of grade II
varices) and severe portal gastropathy/duodenopathy. Varices
banded x2. Placed on octreotide gtt with transition to nadolol
upon discharge.  HCTs stable after 2u PRBC and 2u FFP till time
of discharge without any further episodes of hematemesis or
hematochezia.

# Hepatic encephalopathy: Transferred from [**Hospital 792**]Hospital
for dense encephalopathy and acute renal failure. Attempt was
made to clear the patient with PO lactulose however this
produced no effect. On admission here it was felt that the
patient's distended abdomen and nausea/vomiting to any PO was
consistent with an obstructive process, so KUB was performed
which showed a likely small bowel ileus.  The encephalopathy was
managed with PR lactulose initially with some clearing of mental
status.  Eventually when ileus resolved was switched to PO
lactulose with good effect and had stable normal mental status
upon discharge.

# Acute renal failure: Resolved after albumin resuscitation. Cr
reportedly 4.35 at RIH. Renal was consulted and felt that [**Last Name (un) **]
was pre-renal in etiology given FEurea 12.39%. RUS was without
obstruction and no hydronephrosis noted. He was started on
IVF/albumin and diuretics were held, with improvement in Cr back
to baseline.

# Suspected portal vein thrombosis: Suspicion for this based on
CTA on [**6-22**].  From scans it was unclear whether this was a true
thrombosis so anticoagulation was deferred in setting of GIB.

# Ileus: Initially presented with nausea/vomiting at home for 2
days prior to presentation.  After 5L paracentesis at OSH, it
was noted that his abdomen continued to be tense and tympanic to
percussion.  KUB was consistent with early ileus vs SBO.  CT
abdomen ruled out SBO definitively but did note dilated and
edematous loops of bowel.  Eventually his ileus resolved with
standard of care therapy, at which time he was transitioned from
PR to PO lactulose with good effect.

# ETOH cirrhosis: c/b grade II esophageal varices, ascites,
encephalopathy. 5 admissions at RIH in past 2 mo for liver
decompensation. On this admission, complicated by encephalopathy
and GIB, ascites not an issue after restarting home diuretics.
The transplant workup continued.  Outstanding tests include
further imaging studies of the parotid mass noted on CT neck
(per radiology, evaluate with ultrasound or MRI) as well as
PFTs.

Transitional Issues:
- possible MRI brain for seizure workup
- MRI vs ultrasound of parotid mass for transplant workup
- PFTs for transplant workup
- possible MRI for portal vein thrombosis workup


Medications on Admission:
- docusate 100 mg [**Hospital1 **]
- lactulose titrate to 4 BM per day
- lasix 40 mg qPM
- lasix 80 mg qAM
- nexium 40 mg daily
- oxycontin 40 mg q12 hrs
- prochlorperazine prn
- propanolol 10 mg tid
- aldactone 200 mg [**Hospital1 **]
- tramadol 50 mg q6 hrs prn

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): titrate up or down to 3-4 bowel movements daily.
3. furosemide 40 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. spironolactone 100 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
10. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 1 months.
Disp:*120 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Hepatic encephalopathy
Small bowel ileus versus obstruction
Acute renal failure
Upper GI bleeding
Suspected Seizure


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


Discharge Instructions:
You were transferred from [**State 792**]Hospital for further
management of multiple issues.

You had encephalopathy, acute renal failure, decompensation of
cirrhosis, small bowel ileus, acute gastrointestinal bleeding
and had what was likely a seizure.

We treated all of this and you improved.

Note the following changes to your medications:

STOP
Propranolol
Oxycontin - you did not need this while hospitalized here,
instead just use tramadol for pain
Compazine

START
Rifaximin 550mg by mouth twice per day
Nadolol 20mg by mouth once per day
Sucralfate 2g by mouth twice per day for one month only

Otherwise take all medications as prescribed.

Please follow-up with the liver team as below.  It is also
important to get a MRI of your brain.  Please discuss scheduling
this with your primary care doctor.

Followup Instructions:
Department: TRANSPLANT CENTER
When: THURSDAY [**2110-7-3**] at 1:15 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: TRANSPLANT CENTER
When: THURSDAY [**2110-7-3**] at 2:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: MEDICAL SPECIALTIES
When: THURSDAY [**2110-7-3**] at 3:40 PM
With:  BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Hepatic encephalopathy,Esophageal varices in diseases classified elsewhere, with bleeding,Portal vein thrombosis,Paralytic ileus,Other ascites,Acute kidney failure, unspecified,Acidosis,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, in remission,Other, mixed, or unspecified drug abuse, in remission,Other specified disorders of stomach and duodenum,Unspecified essential hypertension,Personal history of other infectious and parasitic diseases,Other convulsions'}


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: CHIEF COMPLAINT: transfer for hepatic encephalopathy

PRESENT ILLNESS: Mr. [**Known lastname **] is a 46 y/o male with ETOH cirrhosis, previous
hepatitis C infection with spontaneous clearance in [**2109**] (recent
HCV VL undetectable), polysubstance abuse with a one-year
abstinence per notes who is transferred from OSH with acute
kidney injury, ascites, and acute encephalopathy.
He initially presented in liver decompensation with variceal
bleeding, ascites, and encephalopathy in [**2109-6-2**], and recently
established care with the transplant center in [**2110-5-4**]. His
endoscopies have shown isolated gastric varices and esophageal
varices (grade II) which have been banded x 3.
Of note, in [**2110-5-4**] while establishing care at our liver
center, he was on lasix and aldactone for ascites. His Cr was
normal at 0.6 at that time. He has also had h/o three large
volume paracentesis, partly felt to be due to poor compliance
with low salt diet. At that time, he had mild hepatic
encephalopathy and was on lactulose, having [**4-6**] BM per day.
He has a long history of alcohol and substance abuse- having
consumed 1 bottle of vodka daily for many years before stopping
last [**Month (only) 116**] upon his diagnosis of cirrhosis. He has used
prescription drugs, heroin, and methadone in the past, though
has been clean for a year. He is enrolled in AA.
Patient is currently transferred from [**Hospital **] hospital. Per Dr [**First Name (STitle) 3636**]
(pager [**Telephone/Fax (1) 110689**]), patient presented the night of [**6-17**] with
dizziness, hepatic encephalopathy, abdominal pain, n/v and [**Last Name (un) **].
She reports that he has not had a bowel movement in "a day or
so" and he was given lactulose X5 yesterday and only had 1 BM.
Per d/w patient's fiancee, he had been having abdominal pain,
nausea, and bilious vomiting 2 days PTA. 1 week PTA patient did
have tooth infection and was given amoxicillin as well as
motrin. He has been taking motrin 1x per day. Fiancee reported
that he has been adherent to medications and denied dietary
indiscretion. He has been taking aldactone 200 mg 2x/day and
lasix 80 mg qAM and 40 mg qPM at home prior to admission. He has
had 5 admissions at RIH in past 2 mo for liver decompensation.
Also, at RIH, renal was consulted and felt that [**Last Name (un) **] was
pre-renal in etiology given FEurea 12.39%. He was started on IVF
and diuretics were held. On [**6-18**], he underwent diagnostic and
therapeutic 5L paracentesis. This did not show SBP. RUQ and RUS
were performed, with results showing, "cirrhosis, portal htn,
reversal of portal venous flow, varices, and splenomegaly, mild
to moderate residual ascites s/p paracentesis, kidneys without
hydronephrosis." Lactulose was unable to be given on date of
transfer and was held due to AMS. NGT was reportedly
unsuccessful due to AMS.
On transfer, he is arousable but combative and they have started
lactulose enema's in order to prevention aspiration. Creat was
4.35. No other labs available due to poor access, but T-bili
2.8, INR 1.5, Creat 4.35. Of note, pt is in the transplant
evaluation process.
On the floor, patient is acutely agitated and without PIV
access. He is not oriented to self or place.
ROS: unable to be obtained [**3-6**] acute hepatic encephalopathy.

MEDICAL HISTORY: 1. Right knee surgery almost 15 years ago.
2. Hypertension.
3. ETOH Cirrhsosis, c/b varices, encephalopathy, and ascites
requiring recurrent large-volume paracenteses
4. Grade II esophageal varices, grade I gastric varices, portal
gastropathy
5. History of hepatitis C, which cleared spontaneously.
6. Variceal UGIB [**12/2109**] s/p banding x 3
7. Hx of IVDU
8. Recurrent pancreatitis

MEDICATION ON ADMISSION: - docusate 100 mg [**Hospital1 **]
- lactulose titrate to 4 BM per day
- lasix 40 mg qPM
- lasix 80 mg qAM
- nexium 40 mg daily
- oxycontin 40 mg q12 hrs
- prochlorperazine prn
- propanolol 10 mg tid
- aldactone 200 mg [**Hospital1 **]
- tramadol 50 mg q6 hrs prn

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
VS: 98.2, 125/80, 71, 16, 99 RA, BG 184
GENERAL: agitated male, looks older than stated age, in
restraints, not oriented to self or place
HEENT: mild scleral icterus. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, S1 S2 without murmurs, rubs or gallops. No S3 or S4
appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB anteriorly, no crackles, wheezes or rhonchi.

FAMILY HISTORY: Negative for liver cancer, GI cancer or liver

SOCIAL HISTORY: He lives alone. He has a fiancee who checks on him every day.
Mom is the HCP. The patient has one son. [**Name (NI) **] is unemployed
applying for disability. He used to work as salesperson. He has
VNA three times a week. He has past history of drug use such as
Percocet and OxyContin nonprescribed as well as methadone. He
also used IV heroin in the past. He has been clean from drugs
for over a year per notes. He smokes cigarettes almost one-half
pack per day. 

### Response:
{'Hepatic encephalopathy,Esophageal varices in diseases classified elsewhere, with bleeding,Portal vein thrombosis,Paralytic ileus,Other ascites,Acute kidney failure, unspecified,Acidosis,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, in remission,Other, mixed, or unspecified drug abuse, in remission,Other specified disorders of stomach and duodenum,Unspecified essential hypertension,Personal history of other infectious and parasitic diseases,Other convulsions'}
