CHIEF COMPLAINT: Acute on Chronic Kidney Disease

PRESENT ILLNESS: This is a 59 year old male with history of hepatitis C cirrhosis
and recurrent HCC as well as stage IV CKD who presents today
with [**Last Name (un) **] on CKD.  Pt presented to renal clinic yesterday for
evaluation of treatment for recurrent HCC.  Labs showed Cr. of
5.9, which was new and therefore he was told to go to the ED.
Pt acknowledged edema, weight gain, and fatigue but denied
fevers or chills. He also endorses a dry cough and congestion.
The patient denies vomiting any blood or having any bloody or
tarry stools.
.
In ED, vitals were 97.4 73 122/97 18 99% RA.  Exam notable for
bilaterally warm, edematous legs, with calf tenderness.  U/S
negative for DVT.  Liver U/S negative for any acute pathology.
No asterixis.  Received 2 mg IV morphine.
.
Review of systems:
(+) Per HPI, patient also endorses a dry cough, congestion, and
occasional shortness of breath while climbing stairs. He also
endorses some left arm pain made worse with climbing stairs,
worse in the AM when he wakes up
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: #. Cholelithiasis
#. Hepatocellular Carcinoma
- two bx lesions c (+) path
- s/p RFA [**2103-8-29**]
#. Severe cellulitis of lower extremities requiring
hospitalizations
#. Hep C Genotype 1
- Pegylated interferon, ribavirin ([**2096**]): Viral relapse
- Liver bx ([**2099**]): Stage 3 fibrosis, grade 2 inflammation
- EGD ([**1-/2104**]): [**Doctor First Name **]-[**Doctor Last Name **] tear, Varices at the
gastroesophageal junction and lower third of the esophagus,
Blood in the fundus
- Colonoscopy ([**2104-1-15**]) Polyps in appendiceal orifice,
transverse colon, and sigmoid colon, otherwise normal
- AFP 9578
#. Hypertension
#. DMII: c/b neuropathy
#. Psoriasis
#. Anxiety
#. GERD
#. Chronic anemia
#. s/p laminectomy ([**11/2095**])
#. Chronic pain [**2-3**] laminectomy managed by methadone
#. s/p right ankle surgery ([**2089**])

MEDICATION ON ADMISSION: 1. pantoprazole 40 mg PO Q24H .
2. ciprofloxacin 250 mg PO Q24H
3. ergocalciferol 50,000 unit PO 1X/WEEK
4. spironolactone 50 mg ablet PO DAILY
5. nadolol 30 mg PO DAILY
6. clonazepam 0.5 mg PO daily PRN anxiety.
7. furosemide 20 mg PO DAILY
8. methadone 40 mg PO QAM, 30 mg PO QPM
9. lactulose 15 mL PO TID
10. Insulin
11. calcitriol 0.25 mcg PO DAILY
12. calcitriol 0.25 mcg PO EVERY OTHER DAY
15. calcipotriene 0.005 % Cream Topical DAILY
16. rifaximin 200 mg PO twice a day.
17. Nifedipine XR 30 mg PO once a day.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS - Temp 97.1 F, BP 134/66, HR 65, RR 18, 99% on RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - positive for JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - soft, some mild TTP in the RLQ without rebound,
protruberant abdomen with dullness to percussion
EXTREMITIES - Bilateral lower extremity edema to the knees,
venous stasis changes with cracking skin bilaterally
SKIN - multiple areas on both hands with psoriasis
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-6**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, mild asterixis

FAMILY HISTORY: Family members with diabetes mellitus. No history of liver
disease or liver cancer.

SOCIAL HISTORY: Lives at home alone. Wife passed away in [**2104-9-2**]. He
admits to occasional tobacco use. Denies any recent use of etoh,
 illicit drugs or herbal medications.
Hepatorenal syndrome,Esophageal varices in diseases classified elsewhere, with bleeding,Encephalopathy, unspecified,Spontaneous bacterial peritonitis,Acute respiratory failure,Malignant neoplasm of liver, primary,Acute kidney failure, unspecified,Chronic kidney disease, Stage IV (severe),Other ascites,Shock, unspecified,Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Thrombocytopenia, unspecified,Anxiety state, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Other chronic pain,Polyneuropathy in diabetes,Anemia in chronic kidney disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other specified disorders of stomach and duodenum
Hepatorenal syndrome,Bleed esoph var oth dis,Encephalopathy NOS,Spontan bact peritonitis,Acute respiratry failure,Mal neo liver, primary,Acute kidney failure NOS,Chr kidney dis stage IV,Ascites NEC,Shock NOS,Hpt C w/o hepat coma NOS,Cirrhosis of liver NOS,Thrombocytopenia NOS,Anxiety state NOS,DMII neuro nt st uncntrl,Chronic pain NEC,Neuropathy in diabetes,Anemia in chr kidney dis,Hy kid NOS w cr kid I-IV,Gastroduodenal dis NEC
Admission Date:  [**2106-3-31**]              Discharge Date:   [**2106-4-18**]

Date of Birth:  [**2046-10-17**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Acute on Chronic Kidney Disease

Major Surgical or Invasive Procedure:
- Paracentesis


History of Present Illness:
This is a 59 year old male with history of hepatitis C cirrhosis
and recurrent HCC as well as stage IV CKD who presents today
with [**Last Name (un) **] on CKD.  Pt presented to renal clinic yesterday for
evaluation of treatment for recurrent HCC.  Labs showed Cr. of
5.9, which was new and therefore he was told to go to the ED.
Pt acknowledged edema, weight gain, and fatigue but denied
fevers or chills. He also endorses a dry cough and congestion.
The patient denies vomiting any blood or having any bloody or
tarry stools.
.
In ED, vitals were 97.4 73 122/97 18 99% RA.  Exam notable for
bilaterally warm, edematous legs, with calf tenderness.  U/S
negative for DVT.  Liver U/S negative for any acute pathology.
No asterixis.  Received 2 mg IV morphine.
.
Review of systems:
(+) Per HPI, patient also endorses a dry cough, congestion, and
occasional shortness of breath while climbing stairs. He also
endorses some left arm pain made worse with climbing stairs,
worse in the AM when he wakes up
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

Past Medical History:
#. Cholelithiasis
#. Hepatocellular Carcinoma
- two bx lesions c (+) path
- s/p RFA [**2103-8-29**]
#. Severe cellulitis of lower extremities requiring
hospitalizations
#. Hep C Genotype 1
- Pegylated interferon, ribavirin ([**2096**]): Viral relapse
- Liver bx ([**2099**]): Stage 3 fibrosis, grade 2 inflammation
- EGD ([**1-/2104**]): [**Doctor First Name **]-[**Doctor Last Name **] tear, Varices at the
gastroesophageal junction and lower third of the esophagus,
Blood in the fundus
- Colonoscopy ([**2104-1-15**]) Polyps in appendiceal orifice,
transverse colon, and sigmoid colon, otherwise normal
- AFP 9578
#. Hypertension
#. DMII: c/b neuropathy
#. Psoriasis
#. Anxiety
#. GERD
#. Chronic anemia
#. s/p laminectomy ([**11/2095**])
#. Chronic pain [**2-3**] laminectomy managed by methadone
#. s/p right ankle surgery ([**2089**])

Social History:
Lives at home alone. Wife passed away in [**2104-9-2**]. He
admits to occasional tobacco use. Denies any recent use of etoh,
 illicit drugs or herbal medications.


Family History:
Family members with diabetes mellitus. No history of liver
disease or liver cancer.


Physical Exam:
VS - Temp 97.1 F, BP 134/66, HR 65, RR 18, 99% on RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - positive for JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - soft, some mild TTP in the RLQ without rebound,
protruberant abdomen with dullness to percussion
EXTREMITIES - Bilateral lower extremity edema to the knees,
venous stasis changes with cracking skin bilaterally
SKIN - multiple areas on both hands with psoriasis
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-6**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, mild asterixis


Pertinent Results:
Labs on Admission:
[**2106-3-31**] 11:58AM   COMMENTS-GREEN TOP
[**2106-3-31**] 11:58AM   LACTATE-2.7*
[**2106-3-31**] 10:20AM   GLUCOSE-156* UREA N-72* CREAT-6.1* SODIUM-134
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-13
[**2106-3-31**] 10:20AM   ALT(SGPT)-87* AST(SGOT)-202* LD(LDH)-681*
CK(CPK)-2158* ALK PHOS-173* AMYLASE-112* TOT BILI-2.4*
[**2106-3-31**] 10:20AM   LIPASE-83*
[**2106-3-31**] 10:20AM   cTropnT-0.10*
[**2106-3-31**] 10:20AM   CK-MB-39* MB INDX-1.8 proBNP-1337*
[**2106-3-31**] 10:20AM   ALBUMIN-1.8* CALCIUM-8.5 PHOSPHATE-5.4*#
MAGNESIUM-1.9
[**2106-3-31**] 10:20AM   WBC-11.9* RBC-2.80* HGB-8.9* HCT-27.9*
MCV-100* MCH-31.7 MCHC-31.9 RDW-16.3*
[**2106-3-31**] 10:20AM   NEUTS-70.9* LYMPHS-19.3 MONOS-6.9 EOS-2.5
BASOS-0.5
[**2106-3-31**] 10:20AM   PLT COUNT-209
[**2106-3-31**] 10:20AM   PT-24.8* PTT-35.6* INR(PT)-2.4*

Labs on Discharge:
[**2106-4-8**] 04:25AM BLOOD WBC-8.7 RBC-2.62* Hgb-8.1* Hct-25.2*
MCV-96 MCH-30.9 MCHC-32.1 RDW-20.0* Plt Ct-74*
[**2106-4-8**] 04:25AM BLOOD Plt Ct-74*
[**2106-4-8**] 04:25AM BLOOD PT-38.0* PTT-53.8* INR(PT)-3.9*
[**2106-4-8**] 04:25AM BLOOD Glucose-90 UreaN-58* Creat-3.8* Na-140
K-3.9 Cl-104 HCO3-23 AnGap-17
[**2106-4-8**] 04:25AM BLOOD ALT-56* AST-78* AlkPhos-69 TotBili-5.0*
[**2106-4-8**] 04:25AM BLOOD Mg-1.9

Microbiology:
[**2106-4-1**] 1:18 am URINE   NO GROWTH.
[**2106-3-31**] 11:50 am BLOOD CULTURE    FINAL NO GROWTH
[**2106-4-1**] 8:52 am PERITONEAL FLUID      PERITONEAL FLUID.

   GRAM STAIN (Final [**2106-4-1**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2106-4-4**]):    NO GROWTH.

   ANAEROBIC CULTURE (Final [**2106-4-7**]):    NO GROWTH.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

[**2106-4-1**] 08:52
ASCITES ANALYSIS 	WBC 	RBC 	Polys 	Lymphs 	Monos 	Macroph
                	245* 	[**Numeric Identifier **]* 30* 	23* 	0 	47*1

 ASCITES ANALYSIS 	WBC 	RBC 	Polys 	Lymphs 	Monos 	Macroph
[**2106-4-9**] 16:44   	[**2095**]* 	[**Numeric Identifier 17631**]* 	32* 	38* 	0 	30*

[**2106-4-9**] 4:44 pm PERITONEAL FLUID      PERITONEAL FLUID.

   GRAM STAIN (Final [**2106-4-9**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Preliminary):

   ANAEROBIC CULTURE (Preliminary):

Imaging:

- ECG	Study Date of [**2106-3-31**]  10:08:48 AM
Sinus rhythm. Q-T interval prolongation. Early R wave
transition.
Non-specific ST-T wave changes. compared to the previous tracing
of [**2105-10-3**]
the ventricular rate has increased.

- DUPLEX DOP ABD/PEL LIMITED	Study Date of [**2106-3-31**] 11:50 AM
IMPRESSION:
1. Coarsened liver texture consistent with known history of
cirrhosis.
2. Patent hepatic vasculature. SMV not visualized due to
overlying bowel
gas. Splenic vein patient at level of hilum.
3. Increased size of hyperechoic lesion thought to be concerning
for
hepatocellular carcinoma.

- BILAT LOWER EXT VEINS	Study Date of [**2106-3-31**] 11:51 AM
IMPRESSION: No definite evidence of bilateral lower extremity
deep vein
thrombosis.

- CHEST (PA & LAT)	Study Date of [**2106-3-31**] 2:03 PM
FINDINGS: Frontal and lateral views of the chest are obtained.
There are
relatively low lung volumes. Given this, no focal consolidation,
pleural
effusion, or pneumothorax is seen. No overt pulmonary edema is
seen. The
cardiac and mediastinal silhouettes are stable.


Brief Hospital Course:
59 year old male with history of hepatitis C cirrhosis and
recurrent HCC as well as stage IV CKD who presents with [**Last Name (un) **] on
CKD.

# VARICEAL BLEED:  He had a very large upper GI bleed on [**2106-4-11**]
secondary to known esophageal varices.  The massive transfusion
protocol was initiated, a right femoral cortis was placed, and
he received 10 units PRBC, 10FFP, 1cryo.  [**Last Name (un) **] placed for
hemostasis and he was intubated for airway protection. [**Last Name (un) **]
removed on [**4-12**] prior to EGD, and 4 oozing varices were banded.
He had no further bleeding episodes and transfused 2 units of
FFP [**4-12**] for elevated INR with some transient improvement and
was extubated.  [**4-14**] stopped ocreotide and PPI drip and patient
transfered to floor.  After discussion with family, decision was
made to make patient CMO.  Patient expired on [**4-18**].

#. Hepatitis C cirrhosis (decompensated): Following esophageal
bleed, and stably worsening liver function, it was felt that the
patient was not a candidate for TIPS or liver [**Month/Year (2) **].  The
hepatology team communicated this to the patient, and subsequent
meetings with the family directed goals towards comfort. He had
significant encephalopathy following extubation, and was not
following commands though would arouse to voice.  Palliative
care team was involved- he was placed on a fentanyl drip, and
then dilaudid boluses for comfort.  He expired on [**4-18**] as above.

# AOCKD: Cr elevated from 3.2 on [**2106-3-5**] to 6 on admission.
Sources considered for decompesnation included SBP (paracentesis
negative), GI bleed (guiaic negative, pt without symptoms), and
portal [**Last Name (un) **] thrombosis (RUQ U/S was negative). Per renal c/s
urine sediment was bland. Patient presentation felt to be most
consistent with hepato-renal syndrome. Patient was started on
octreotide, midodrine, and albumine, with subsequent improvement
in Cr. Both antihypertensive home medication (Nadolol and
Nifedipine) were held in house, and given the patient was
normotensive, were discontinued on discharge. Diuretic
medications were held in house, and were held upon discharge
with a plan to follow up with nephrology.

#. Hepatocellular Carcinoma: No further treatment indicated

#. Spontaneous Bacterial Peritonitis: The patient underwent a
diagnostic and therapeutic tap on [**2106-4-9**], which revealed
evidence of greater than 250 PMNs; he was started on Ceftrixaone
to cover SPB.  He was changed to vanco/cefepime/flagyl on [**4-11**]
to co-treat an aspiration event.  He received 5 days of
antibiotics, which were then discontinued due to CMO status
change.

#. DMII: Patient noted to be hypoglycemic in the AM with
glucoses of 38 twice, and 54 in the AM. The patient's night-time
lantus was lowered to 32 U at night (per the patient, he had
been taking 60 [**Location 17632**] at night), and the patient was
covered with SSI.

#. Hypertension: Patient was not hypertensive in house, although
he was off his blood pressure medication.

#. Thrombocytopenia: Patient has platelt of 76, drop in 6 days
from 207 on admission, and has intermittently received heparin
here in house as well as on admission on [**2106-3-5**]. There is an
intermediate probability that this patient has HITT based on the
4T score. However, heparin antibody was negative, and patient's
thrombocytopenia was attributed to his liver disease, and
heparin SC was restarted.

#. Elevated lactate: Noted to be elevated on admission to 3.5.
Patient without anion gap currently, and without hypoperfusion
physiology. Lactate felt to be most likely secondary patient's
known malignancy.

#. Elevated cardiac enzymes: Likely elevated in the setting of
kidney injury, and stable without chest pain and without acute
changes on EKG.

#. Anxiety: Manged with home dose clonazepam 0.5 mg daily PRN

#. GERD: Managed with rantidine in house secondary to initial
concerns for AIN, was switched to home dose of pantoprazole 40
mg PO Q24H on discharge

#. Chronic Pain: Patient was started on 30 Q AM / 20 Q PM doses
of his home methadone given his acute kidney injury. As his
creatinine improved, his pain medication was uptitated back to
him home dose.

# Macrocytic anemia: Most consistent with anemia of chronic
inflammation given elevated ferritin, normal iron. B12 and
folate WNL.

Medications on Admission:
1. pantoprazole 40 mg PO Q24H .
2. ciprofloxacin 250 mg PO Q24H
3. ergocalciferol 50,000 unit PO 1X/WEEK
4. spironolactone 50 mg ablet PO DAILY
5. nadolol 30 mg PO DAILY
6. clonazepam 0.5 mg PO daily PRN anxiety.
7. furosemide 20 mg PO DAILY
8. methadone 40 mg PO QAM, 30 mg PO QPM
9. lactulose 15 mL PO TID
10. Insulin
11. calcitriol 0.25 mcg PO DAILY
12. calcitriol 0.25 mcg PO EVERY OTHER DAY
15. calcipotriene 0.005 % Cream Topical DAILY
16. rifaximin 200 mg PO twice a day.
17. Nifedipine XR 30 mg PO once a day.

Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
Primary Diagnosis:
- Hepatorenal syndrome
- Hepatitis C Cirrhosis
- Hepatocellular Carcinoma


Discharge Condition:
patient expired


Discharge Instructions:
Mr. [**Known lastname 805**], was admitted because he was found to be in renal
failure, his hospital course was complicated by a large variceal
bleed.  Given his multiple comorbidities and decompensated liver
disease, after a family meeting it was decided to make him
comfort measures only and he passed away on inpatient hospice.

Followup Instructions:
patient expired
{'Hepatorenal syndrome,Esophageal varices in diseases classified elsewhere, with bleeding,Encephalopathy, unspecified,Spontaneous bacterial peritonitis,Acute respiratory failure,Malignant neoplasm of liver, primary,Acute kidney failure, unspecified,Chronic kidney disease, Stage IV (severe),Other ascites,Shock, unspecified,Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Thrombocytopenia, unspecified,Anxiety state, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Other chronic pain,Polyneuropathy in diabetes,Anemia in chronic kidney disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other specified disorders of stomach and duodenum'}


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: Acute on Chronic Kidney Disease

PRESENT ILLNESS: This is a 59 year old male with history of hepatitis C cirrhosis
and recurrent HCC as well as stage IV CKD who presents today
with [**Last Name (un) **] on CKD.  Pt presented to renal clinic yesterday for
evaluation of treatment for recurrent HCC.  Labs showed Cr. of
5.9, which was new and therefore he was told to go to the ED.
Pt acknowledged edema, weight gain, and fatigue but denied
fevers or chills. He also endorses a dry cough and congestion.
The patient denies vomiting any blood or having any bloody or
tarry stools.
.
In ED, vitals were 97.4 73 122/97 18 99% RA.  Exam notable for
bilaterally warm, edematous legs, with calf tenderness.  U/S
negative for DVT.  Liver U/S negative for any acute pathology.
No asterixis.  Received 2 mg IV morphine.
.
Review of systems:
(+) Per HPI, patient also endorses a dry cough, congestion, and
occasional shortness of breath while climbing stairs. He also
endorses some left arm pain made worse with climbing stairs,
worse in the AM when he wakes up
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: #. Cholelithiasis
#. Hepatocellular Carcinoma
- two bx lesions c (+) path
- s/p RFA [**2103-8-29**]
#. Severe cellulitis of lower extremities requiring
hospitalizations
#. Hep C Genotype 1
- Pegylated interferon, ribavirin ([**2096**]): Viral relapse
- Liver bx ([**2099**]): Stage 3 fibrosis, grade 2 inflammation
- EGD ([**1-/2104**]): [**Doctor First Name **]-[**Doctor Last Name **] tear, Varices at the
gastroesophageal junction and lower third of the esophagus,
Blood in the fundus
- Colonoscopy ([**2104-1-15**]) Polyps in appendiceal orifice,
transverse colon, and sigmoid colon, otherwise normal
- AFP 9578
#. Hypertension
#. DMII: c/b neuropathy
#. Psoriasis
#. Anxiety
#. GERD
#. Chronic anemia
#. s/p laminectomy ([**11/2095**])
#. Chronic pain [**2-3**] laminectomy managed by methadone
#. s/p right ankle surgery ([**2089**])

MEDICATION ON ADMISSION: 1. pantoprazole 40 mg PO Q24H .
2. ciprofloxacin 250 mg PO Q24H
3. ergocalciferol 50,000 unit PO 1X/WEEK
4. spironolactone 50 mg ablet PO DAILY
5. nadolol 30 mg PO DAILY
6. clonazepam 0.5 mg PO daily PRN anxiety.
7. furosemide 20 mg PO DAILY
8. methadone 40 mg PO QAM, 30 mg PO QPM
9. lactulose 15 mL PO TID
10. Insulin
11. calcitriol 0.25 mcg PO DAILY
12. calcitriol 0.25 mcg PO EVERY OTHER DAY
15. calcipotriene 0.005 % Cream Topical DAILY
16. rifaximin 200 mg PO twice a day.
17. Nifedipine XR 30 mg PO once a day.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS - Temp 97.1 F, BP 134/66, HR 65, RR 18, 99% on RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - positive for JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - soft, some mild TTP in the RLQ without rebound,
protruberant abdomen with dullness to percussion
EXTREMITIES - Bilateral lower extremity edema to the knees,
venous stasis changes with cracking skin bilaterally
SKIN - multiple areas on both hands with psoriasis
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-6**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, mild asterixis

FAMILY HISTORY: Family members with diabetes mellitus. No history of liver
disease or liver cancer.

SOCIAL HISTORY: Lives at home alone. Wife passed away in [**2104-9-2**]. He
admits to occasional tobacco use. Denies any recent use of etoh,
 illicit drugs or herbal medications. 

### Response:
{'Hepatorenal syndrome,Esophageal varices in diseases classified elsewhere, with bleeding,Encephalopathy, unspecified,Spontaneous bacterial peritonitis,Acute respiratory failure,Malignant neoplasm of liver, primary,Acute kidney failure, unspecified,Chronic kidney disease, Stage IV (severe),Other ascites,Shock, unspecified,Unspecified viral hepatitis C without hepatic coma,Cirrhosis of liver without mention of alcohol,Thrombocytopenia, unspecified,Anxiety state, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Other chronic pain,Polyneuropathy in diabetes,Anemia in chronic kidney disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other specified disorders of stomach and duodenum'}
