CHIEF COMPLAINT: Hyponatremia, Altered Mental Status

PRESENT ILLNESS: 48yo F w/ HCV cirrhosis c/b encephalopathy, ascites, edema/TIPS
[**11-8**], hydrothorax, thrombocytopenia, chronic hyponatremia
(baseline 124-128), adrenal insufficiency, GERD, anxiety
directly admitted for worsening hyponatremia.

MEDICAL HISTORY: 1. HCV cirrhosis s/p TIPS [**11-8**] c/b hydrothorax, encephalopathy,
and ascites
2. Hyponatremia baseline 128-133
3. Asthma
4. Adrenal insufficiency (thought to be [**1-7**] chronic advair use)

MEDICATION ON ADMISSION: Albuterol
Calcium Carbonate
Clotrimazole
Dexamethasone 4 mg IV bid
Fluticasone-Salmeterol (100/50)
FoLIC Acid
Insulin
Lactulose
Lidocaine 5% Patch
Magnesium Oxide
Montelukast Sodium
Morphine Sulfate
Morphine SR (MS Contin)
OxycoDONE (Immediate Release)
Pantoprazole
Rifaximin
Vitamin D

ALLERGIES: Shellfish / Flexeril

PHYSICAL EXAM: VS: 97.7 102 122/51 16 96% i/o 1120/805
Gen: alert to person, place, time, situation. comfortable,
Neuro: fields nl to confrontation
HEENT: EOMI OP clear
Breast: no disharge expressed from nipple
Cards: RRR + murmur
Resp: Clear bilat. nl effort
Abd: BS+, mildly protuberant. no rebound or guarding. soft
Ext: no edema, no hyperpigmentation of scars.

FAMILY HISTORY: Mother w/ DM2, HTN, and hyperlipidemia. Father w/ COPD and EtOH
cirrhosis.

SOCIAL HISTORY: - Recreational drugs: Past IV drug use with needle sharing, last
use 7 years ago.  Past drug-snorting.
- Alcohol: Past alcohol use, last drink at age 46.
- Tobacco: Past [**Month/Day (2) 1818**] with 10 pack-year history
- Personal: Single with one child.  Lives with mother, who
manages medications
- Employment: Former waitress, unemployed on disability.
Hyposmolality and/or hyponatremia,Other adrenal hypofunction,Pathologic fracture of vertebrae,Cirrhosis of liver without mention of alcohol,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Unspecified viral hepatitis C without hepatic coma,Other, mixed, or unspecified drug abuse, in remission,Esophageal reflux,Anxiety state, unspecified,Asthma, unspecified type, unspecified,Awaiting organ transplant status
Hyposmolality,Adrenal hypofunction NEC,Path fx vertebrae,Cirrhosis of liver NOS,DMII wo cmp nt st uncntr,Long-term use of insulin,Hpt C w/o hepat coma NOS,Drug abuse NEC-in remiss,Esophageal reflux,Anxiety state NOS,Asthma NOS,Await organ transplnt st
Admission Date:  [**2157-10-24**]              Discharge Date:   [**2157-11-4**]

Date of Birth:  [**2109-1-23**]             Sex:   F

Service: MEDICINE

Allergies:
Shellfish / Flexeril

Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Hyponatremia, Altered Mental Status

Major Surgical or Invasive Procedure:
None

History of Present Illness:
48yo F w/ HCV cirrhosis c/b encephalopathy, ascites, edema/TIPS
[**11-8**], hydrothorax, thrombocytopenia, chronic hyponatremia
(baseline 124-128), adrenal insufficiency, GERD, anxiety
directly admitted for worsening hyponatremia.

Diagnosis of adrenal insufficiency made [**12-12**] during
hospitalization for SOB, hyponatremia, fluid overload. Cortisol
[**2156-12-10**] was 0.1. At 30 min, cortisol was 1.6. at 60 min, cortisol
was 2.4. ACTH < 5. CBG [**2156-12-11**] 27 (nl). Endo Inpt consulting team
recommended stress dose steroids if needed but did not
recommended chronic replacement steroids as outpatient since she
was on inhaled steroids. Pt was seen by Dr [**Last Name (STitle) 10759**] on
[**2156-12-28**]. She noted that diagnosis of AI was based on
hyponatremia, relative hyperkalemia and eosinophilia. She did
note that HypoNa could be [**1-7**] third spacing [**1-7**] cirrhosis and
chronic diuretics. She noted that pt only had mildly orthostatic
symptoms but these were unchanged whether or not patient was on
oral steroids. She also noted that pt never had N, V, weight
loss, decreased appetite, hypotension. She did note that off
diuretics, patient became short of breath. She then repeated
cortisol and ACTH levels which were persistently low and
subsenquently started Prednisone 5 mg po qd.   Adrenal glands
were noted to be normal on abdominal US. Patient has most
recently been on Hydrocortisone 20 mg po q am and 10 mg po qhs.


On [**10-8**] Na 137, [**10-17**] Na 126, [**10-20**] Na 120 (OSH), [**10-24**] Na 115.
On [**10-20**], her diuretics were held [**1-7**] hyponatremia. She reports
good compliance with medical regimen and has been avoiding free
water. She reports compliance with her low salt diet. She has
had increasing dizziness, nausea, worsening LBP over the last
few days.

She arrived directly on the floor and labs showed the Na of 115.
She was transferred to the unit for closer monitoring and
potential need for hypertonic saline.

On admission to the unit, she reported dizziness, nausea, and
fatigue. She has had no seizure like activity or LOC. She denies
[**Last Name (LF) **], [**First Name3 (LF) **], photophobia, CP, palpitations. With abdominal pain in
RUQ which is unchanged from previous. She denies any fevers,
chills.   Denied change in BMs (normally [**1-8**] daily). No
increased peripheral edema.


Past Medical History:
1. HCV cirrhosis s/p TIPS [**11-8**] c/b hydrothorax, encephalopathy,
and ascites
2. Hyponatremia baseline 128-133
3. Asthma
4. Adrenal insufficiency (thought to be [**1-7**] chronic advair use)

5. GERD
6. Anxiety
7. Hyperglycemia thought [**1-7**] cirrhosis
8. Recent intubation thought [**1-7**] transfusion-related acute lung

injury. Led to prolonged ICU stay then rehab. Also treated for
PNA
9. Recent UTI


Social History:
- Recreational drugs: Past IV drug use with needle sharing, last
use 7 years ago.  Past drug-snorting.
- Alcohol: Past alcohol use, last drink at age 46.
- Tobacco: Past [**Month/Day (2) 1818**] with 10 pack-year history
- Personal: Single with one child.  Lives with mother, who
manages medications
- Employment: Former waitress, unemployed on disability.

Family History:
Mother w/ DM2, HTN, and hyperlipidemia. Father w/ COPD and EtOH
cirrhosis.

Physical Exam:
VS: 97.7 102 122/51 16 96% i/o 1120/805
Gen: alert to person, place, time, situation. comfortable,
Neuro: fields nl to confrontation
HEENT: EOMI OP clear
Breast: no disharge expressed from nipple
Cards: RRR + murmur
Resp: Clear bilat. nl effort
Abd: BS+, mildly protuberant. no rebound or guarding. soft
Ext: no edema, no hyperpigmentation of scars.


Pertinent Results:
[**2157-10-24**] 09:31PM   PT-18.9* PTT-53.9* INR(PT)-1.7*

[**2157-10-24**] 09:31PM
WBC-11.5* RBC-3.21* HGB-11.7* HCT-32.9* MCV-103* MCH-36.6*
MCHC-35.6* RDW-18.5*  NEUTS-79.8* LYMPHS-11.9* MONOS-7.0 EOS-1.0
BASOS-0.2

[**2157-10-24**] 09:31PM
ALBUMIN-3.6 CALCIUM-9.3 PHOSPHATE-2.7 MAGNESIUM-2.1 LIPASE-125*

[**2157-10-24**] 09:31PM
ALT(SGPT)-120* AST(SGOT)-200* LD(LDH)-325* ALK PHOS-447*
AMYLASE-185* TOT BILI-7.6*

[**2157-10-24**] 09:31PM
GLUCOSE-100 UREA N-19 CREAT-0.6 SODIUM-115* POTASSIUM-5.8*
CHLORIDE-83* TOTAL CO2-27 ANION GAP-11

[**2157-10-24**] 10:24PM   LACTATE-1.8

[**2157-10-24**] 11:00PM URINE
RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2  BLOOD-NEG
NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM
UROBILNGN-NEG PH-6.5 LEUK-NEG OSMOLAL-449

[**2157-10-24**] 11:00PM URINE [**2157-10-24**] 11:00PM URINE  HOURS-RANDOM UREA
N-644 CREAT-60 SODIUM-22 POTASSIUM-38

Brief Hospital Course:
A/P: 48yo woman with history of HCV and ETOH induced cirrhosis
complicated by encephalopathy, ascites, s/p TIPS [**11-8**],
hydrothorax, thrombocytopenia, adrenal insufficiency, and
chronic hyponatremia admitted for worsening hyponatremia.

# Hyponatremia: Upon admission patient was noted to have sodium
of 115. She has been admitted multiple times with similar
problems.  [**Name (NI) **] was admitted to the ICU and improved with
3%NS and fluid restriction.  She has a long history of being
noncompliant with fluid restriction as an outpatient.  During
her hospital course her sodium slowly improved from 121-->
126--> 127.  Was continued on fluid restriction with continued
diuresis via lasix and spironolactone.  As there was also a
question that some of this could be adrenal insufficiency, she
was continued on [**Hospital1 **] hydrocortisone 20mg and 10mg for
physiologic dosing.  Briefly treated with IV lasix and albumin
with good effect.  Discharged on lasix, spironolactone and
1000ml fluid restriction.

# Hyperkalemia: Potassium initially elevated on admission to
5.8. No ECG changes.  Transtubular potassium gradient was
suggestive of hypoaldosteronism at 5.6. However, it was
difficult to determine TTKG in patient with decreased distal
delivery of sodium.  Ultimately it was unclear if patient is
truly adrenally insufficienct as hyponatremia is also result of
cirrhosis.  Resolved with treatment as described above.  Upon
discharge K was 4.0

# HCV cirrhosis s/p TIPS [**11-8**] complicated by hydrothorax,
encephalopathy, ascites, and thrombocytopenia. T. Bili has
improved since prior admission and trending down upon this
admit.  ALT/AST, Alk phos, and amylase were increasingly
elevated with unclear etiology.  LFTs were trended and resolved
to baseline.  MELD calculated and found to be 20.  Was continued
on lactulose and rifaximin.  Continued on diuresis as described
above, with the brief addition of IV lasix.

# Vertebral compression fractures: Evaluated by IR for
vertebroplasty on last admission.  IR determined that she was
not to be candidate during this admission secondary to continued
coagulopathy.  Was continued on lidocaine transdermal patch, ice
packs, and oxycodone prn.  Also on MS contin [**Hospital1 **].  PT was
consulted and evaluated the patient, stating she was able to
discharge to home.  Did have acute episodes of increase pain,
but always relieved by oxycodone 5mg.  Patient was concerned
upon discharge that her pain would be difficult to control at
home as her mother is her primary caregiver and does not give
her PRNs.  Discussed at great length that we could not increase
scheduled as she becomes too somnolent and it is not safe.
Discharged on MS contin and oxycodone for breakthrough.

# History of Adrenal Insufficiency:  Upon evaluation she had no
sodium wasting in urine or othrostatic hypotension.  Potassium
levels were noted to be fluctuating.  Hydrocortisone continued
at physiologic dosing.  To follow-up with Endocrine as an
outpatient.

# Asthma: Not an active inpatient issue, continued on inhalers.

# Type 2, DM: Managed as on outpatient with humalog ISS and
glargine.  While in patient her glargine and ISS were adjusted
for improved glycemic control.  Discharged on both these
medications.


Medications on Admission:
Albuterol
Calcium Carbonate
Clotrimazole
Dexamethasone 4 mg IV bid
Fluticasone-Salmeterol (100/50)
FoLIC Acid
Insulin
Lactulose
Lidocaine 5% Patch
Magnesium Oxide
Montelukast Sodium
Morphine Sulfate
Morphine SR (MS Contin)
OxycoDONE (Immediate Release)
Pantoprazole
Rifaximin
Vitamin D


Discharge Medications:
1. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six (6)
hours as needed for 20 doses.
Disp:*20 Tablet(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
3. Clotrimazole 10 mg Troche [**Hospital1 **]: One (1) Troche Mucous membrane
5X DAY ().
Disp:*150 Troche(s)* Refills:*0*
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Folic Acid 1 mg Tablet [**Hospital1 **]: Five (5) Tablet PO DAILY (Daily).

6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. Rifaximin 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).
8. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO three times a day.
9. Morphine 15 mg Tablet Sustained Release [**Hospital1 **]: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
10. Spironolactone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Hydrocortisone 20 mg Tablet [**Hospital1 **]: 0.5-1 Tablet PO Twice
daily, 20mg at 10AM and 10mg at 5pm: Take one tablet each
morning at 10AM and [**12-7**] tablet each evening at 5pm.
Disp:*45 Tablet(s)* Refills:*2*
13. Furosemide 80 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day.

14. Lactulose 10 gram/15 mL Syrup [**Month/Day (2) **]: Forty Five (45) ML PO TID
(3 times a day).
15. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) **]: Two (2)
Tablet PO once a day.
16. Insulin Lispro 100 unit/mL Insulin Pen [**Month/Day (2) **]: One (1) unit
Subcutaneous four times a day as needed for glucose correction:
Please give as directed on your discharge insulin sliding scale.
 Check fingersticks four times daily.
Disp:*QS pen* Refills:*2*
17. Lancets     Misc [**Month/Day (2) **]: One (1) lancet Miscellaneous four
times a day.
Disp:*QS lancet* Refills:*2*
18. Alcohol Prep Pads     Pads, Medicated [**Month/Day (2) **]: One (1) pad
Topical four times a day.
19. Insulin Syringes (Disposable)     Syringe [**Month/Day (2) **]: One (1)
syringe Miscellaneous twice a day.
20. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray [**Month/Day (2) **]:
One (1) spray Nasal twice a day: Alternate nostrils daily.
Disp:*QS unit* Refills:*1*
21. Insulin Glargine 300 unit/3 mL Insulin Pen [**Month/Day (2) **]: Thirty Four
(34) unit Subcutaneous at bedtime.
Disp:*1 month supply* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 6138**] Home Care Services

Discharge Diagnosis:
Primary: Hyponatremia, adrenal insufficiency
Secondary: Hepatitis C, Cirrhosis


Discharge Condition:
Hemodynamically stable and afebrile.


Discharge Instructions:
1)You were admitted to the hospital with low sodium. You also
developed worsening fluid in your legs while you were in the
hospital. We increased your dose of diuretics. You were kept on
a strict regimen of 1000ml (1 liter) of fluid intake. Please
continue to monitor your intake of fluids and keep it within the
1 liter.

2)In the hospital you had a test to rule out tuberculosis on
your arm. Please schedule an appointment with your primary care
physician (you may not need an appointment, but can just stop
by) on Monday to have this looked at.

3)Please take all medications as listed in the discharge
instructions.  Your ipratroprium bromide was held while in the
hospital, please discuss this medication with your regular
doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**] it.  You have also been prescribed a
new medication called Clotrimazole.  Please continue to take
this medication as directed.

4)Please attend all appointments as listed below.

5)If you experience any fevers, chills, chest pain, shortness of
breath, dizziness or any other concerning symptoms please return
to the emergency room.

Followup Instructions:
Please keep all your appointments.

You have the following appointment scheduled to see how you are
doing after discharge:
Dr. [**Last Name (STitle) **]
[**Name (STitle) 3628**] [**Location (un) **]
[**2157-11-24**] at 8am
([**Telephone/Fax (1) 1582**]

Please see you primary care physician on [**Name9 (PRE) 766**], [**2157-11-7**] to have your TB test read.  This was placed on your left
arm.
{'Hyposmolality and/or hyponatremia,Other adrenal hypofunction,Pathologic fracture of vertebrae,Cirrhosis of liver without mention of alcohol,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Unspecified viral hepatitis C without hepatic coma,Other, mixed, or unspecified drug abuse, in remission,Esophageal reflux,Anxiety state, unspecified,Asthma, unspecified type, unspecified,Awaiting organ transplant 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: Hyponatremia, Altered Mental Status

PRESENT ILLNESS: 48yo F w/ HCV cirrhosis c/b encephalopathy, ascites, edema/TIPS
[**11-8**], hydrothorax, thrombocytopenia, chronic hyponatremia
(baseline 124-128), adrenal insufficiency, GERD, anxiety
directly admitted for worsening hyponatremia.

MEDICAL HISTORY: 1. HCV cirrhosis s/p TIPS [**11-8**] c/b hydrothorax, encephalopathy,
and ascites
2. Hyponatremia baseline 128-133
3. Asthma
4. Adrenal insufficiency (thought to be [**1-7**] chronic advair use)

MEDICATION ON ADMISSION: Albuterol
Calcium Carbonate
Clotrimazole
Dexamethasone 4 mg IV bid
Fluticasone-Salmeterol (100/50)
FoLIC Acid
Insulin
Lactulose
Lidocaine 5% Patch
Magnesium Oxide
Montelukast Sodium
Morphine Sulfate
Morphine SR (MS Contin)
OxycoDONE (Immediate Release)
Pantoprazole
Rifaximin
Vitamin D

ALLERGIES: Shellfish / Flexeril

PHYSICAL EXAM: VS: 97.7 102 122/51 16 96% i/o 1120/805
Gen: alert to person, place, time, situation. comfortable,
Neuro: fields nl to confrontation
HEENT: EOMI OP clear
Breast: no disharge expressed from nipple
Cards: RRR + murmur
Resp: Clear bilat. nl effort
Abd: BS+, mildly protuberant. no rebound or guarding. soft
Ext: no edema, no hyperpigmentation of scars.

FAMILY HISTORY: Mother w/ DM2, HTN, and hyperlipidemia. Father w/ COPD and EtOH
cirrhosis.

SOCIAL HISTORY: - Recreational drugs: Past IV drug use with needle sharing, last
use 7 years ago.  Past drug-snorting.
- Alcohol: Past alcohol use, last drink at age 46.
- Tobacco: Past [**Month/Day (2) 1818**] with 10 pack-year history
- Personal: Single with one child.  Lives with mother, who
manages medications
- Employment: Former waitress, unemployed on disability. 

### Response:
{'Hyposmolality and/or hyponatremia,Other adrenal hypofunction,Pathologic fracture of vertebrae,Cirrhosis of liver without mention of alcohol,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Unspecified viral hepatitis C without hepatic coma,Other, mixed, or unspecified drug abuse, in remission,Esophageal reflux,Anxiety state, unspecified,Asthma, unspecified type, unspecified,Awaiting organ transplant status'}
