CHIEF COMPLAINT: end stage liver disease

PRESENT ILLNESS: This patient is a 47 year-old
man with end stage liver disease secondary to alcoholism.  He
is admitted to [**Hospital1 69**] on [**2105-5-10**] for changes in mental status and melena.  While in
house the patient required therapy for MRSA bacteremia and
acute renal failure.  The patient went on to have a
transesophageal echocardiogram on [**5-18**] reveling normal
ejection fraction, no vegetations, no valve disease, no
pulmonary hypertension.  On the [**5-20**] there were no
signs of infection, no signs of upper respiratory symptoms,
sore throat, rhinorrhea, cough, earache, shortness of breath,
chest pain, dysuria, hematuria, nor changes in bowel habits.
No nausea or vomiting.

MEDICAL HISTORY: End stage liver disease secondary to
alcoholic cirrhosis.

MEDICATION ON ADMISSION: 1. Protonix 40 mg once a day.
2. Lactulose 30 milliliters twice a day.
3. Propanolol 20 mg twice a day.
4. Lasix 20 mg once a day.
5. Spironolactone 50 mg once a day.
6. Potassium chloride.
7. Mycelex.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Alcoholic cirrhosis of liver,Severe sepsis,Hepatorenal syndrome,Acute kidney failure, unspecified,Methicillin susceptible Staphylococcus aureus septicemia,Other postoperative infection,Unspecified pleural effusion,Other and unspecified alcohol dependence, unspecified
Alcohol cirrhosis liver,Severe sepsis,Hepatorenal syndrome,Acute kidney failure NOS,Meth susc Staph aur sept,Other postop infection,Pleural effusion NOS,Alcoh dep NEC/NOS-unspec
Admission Date: [**2105-5-20**]        Discharge Date:

Date of Birth:  [**2057-6-21**]        Sex:  M

Service:  SURGERY


HISTORY OF PRESENT ILLNESS:  This patient is a 47 year-old
man with end stage liver disease secondary to alcoholism.  He
is admitted to [**Hospital1 69**] on [**2105-5-10**] for changes in mental status and melena.  While in
house the patient required therapy for MRSA bacteremia and
acute renal failure.  The patient went on to have a
transesophageal echocardiogram on [**5-18**] reveling normal
ejection fraction, no vegetations, no valve disease, no
pulmonary hypertension.  On the [**5-20**] there were no
signs of infection, no signs of upper respiratory symptoms,
sore throat, rhinorrhea, cough, earache, shortness of breath,
chest pain, dysuria, hematuria, nor changes in bowel habits.
No nausea or vomiting.

PAST MEDICAL HISTORY:  End stage liver disease secondary to
alcoholic cirrhosis.

Ascites.

Jaundice.

Portal gastropathy.

Not bleeding rectal varices revealed on scope examination [**2105-5-1**].

Cholelithiasis.

At this point it was determined that the patient would be
evaluated and preoped for liver transplant.

MEDICATIONS ON ADMISSION:
1. Protonix 40 mg once a day.
2. Lactulose 30 milliliters twice a day.
3. Propanolol 20 mg twice a day.
4. Lasix 20 mg once a day.
5. Spironolactone 50 mg once a day.
6. Potassium chloride.
7. Mycelex.


PHYSICAL EXAMINATION:  Temperature 99.5 degrees, heart rate
91, blood pressure 98/70, respiratory rate 18, oxygen
saturation 95 percent on room air.  The patient was alert and
oriented times three and in no acute distress, appearing
mildly jaundice throughout.  Cranial nerves I through XII
were shown to be intact. The patient is mildly icteric.
Cardiovascular examination revealed a regular rate and
rhythm.  No murmurs, rubs or gallops.  Respirations cleared
to auscultation bilaterally.  No rales, wheezes or rhonchi.
Abdomen was soft, somewhat distended, nontender.  Extremities
revealed palpable distal pulses bilaterally, 2 plus mild
nonpitting edema.

HOSPITAL COURSE:  The patient was originally admitted on [**2105-5-10**] with mental status changes and melanotic stool and
was treated for MRSA bacteremia and acute renal failure.  The
patient had transesophageal echocardiogram on [**5-18**]
revealing a normal ejection fraction, no vegetations and no
valve disease and  no signs of pulmonary hypertension.  On
the [**5-20**] there were no signs of infection in this
patient and it was determined the patient would be preoped
for possible liver transplant and chest x-ray,
electrocardiogram and laboratories were drawn.  The patient
was given Unasyn, CellCept, ___________, Solu-Medrol,
heparin, Fluconazole on call to the Operating Room and the
patient was placed at nil per os.  Consent was obtained.  The
patient was typed and crossed and laboratories were drawn at
this time revealing a white blood cell count of 13.3,
hematocrit 35.0. platelet count of 72, sodium 130, potassium
42, chloride 104, CO2 15, BUN 50 and a creatinine of 2.4,
glucose 106.  The patient's PT at this time was 10.1, PTT 26
and INR of 5.0, albumin 2.9. The patient was consented and
proceeded to the Operating Room on [**2105-5-20**] and received
an orthotopic liver transplant at this time performed by Dr.
[**Last Name (STitle) **].  The patient was then brought to the Surgical
Intensive Care Unit after the procedure and was followed by
their staff while continued to be followed by the transplant
staff.  The patient was noted to receive multiple
transfusions in the Operating Room of packed red blood cells
and upon admission to the CICU it was noted the patient was
doing well postoperatively.  The patient was intubated at
this time and arterial blood gases were to be followed.  The
patient at this time was on intravenous fluids at 125 cc per
hour, strict Is and Os were monitored in the Surgical
Intensive Care Unit.  The patient was nil per os at this time
and was on an nasogastric tube and his immunosuppressions was
arranged by the transplant team.  On postoperative day one
[**2105-5-21**] the patient continued to progress well and a
duplex angiogram was performed of the liver revealing good
arterial and venous flows and the patient was continued on
immunosuppression regimen of 1000 of CellCept b.i.d., 90 of
Solu-Medrol b.i.d. and 3 mg of Tacrolimus intravenously and
100 mg of Cyclosporin b.i.d.

On postoperative day two the patient continued to improve in
the Surgical Intensive Care Unit.  She received a chest x-ray
revealing mild right pleural effusions.  The patient was on
Vancomycin at this time and received a Vancomycin level of
24.2.  On postoperative day three [**2105-5-23**] the patient
was noted to continue to have a low grade fever of 100.4
degrees and blood cultures were sent that subsequently
revealed to be negative and another chest x-ray was performed
revealing pulmonary edema that was slightly increased from
postoperative day two's prior chest x-ray with some right
pleural effusion.  On postoperative day four [**5-24**] the
patient's temperature maximum was 100.2 degrees and the
patient began to be weaned off the ventilator.  The patient
continued to be followed by the Surgical Intensive Care Unit
and was placed on Haldol prn for agitation.  He continued to
be diuresed using Lasix.  ID's recommendations were for
Vancomycin, Ganciclovir, Bactrim and Fluconazole to continue
at this time.  On postoperative day five [**2105-5-25**] a
thoracentesis was performed revealing 900 cc of
serosanguinous fluid and sedation was then held.  At this
point the plan was to continue to wean the patient off the
ventilator and to eventually perform extubation.  From a
cardiovascular point of view the patient was considered
stable at this time and the patient was NPO with an negative
tube in place.  The patient was receiving total parenteral
nutrition at this time.  Foley catheter was in and the
patient was placed on an insulin drip regimen and was
receiving heparin subcutaneously every eight hours.  The
patient received dry dressings to the wound.  The patient
continued to be followed by infectious disease who suggested
checking Vancomycin levels and continue surveillance of
cultures and to continue Ganciclovir adjusting for renal
function and to continue Fluconazole and Bactrim.  On [**2105-5-26**] the Surgical Intensive Care Unit day six,
postoperative day six the patient had his right IJ swan
changed to a central venous line and was extubated at this
time.  It was determined the patient would likely advanced to
clear liquids at this time and the nasogastric tube could be
discharged.  The patient was receiving morphine sulfate as
needed for pain at this time and his creatinine was noted to
be improving trending downwards from 3.6 to 3.6 on the 20th
and [**5-25**] postoperative days four and five and 3.2 on
[**5-26**] to 2.6 on [**5-27**].

Infectious disease recommendations on [**5-25**] were to
continue to follow the Vancomycin levels and the patient was
on day five of 10 of Vancomycin, because of the preop MRSA
bacteremia and to continue Vancomycin resistant enterococcal
precautions and to continue prophylaxis with Bactrim,
Fluconazole and Ganciclovir.  The patient was being followed
by nutrition at this time and it was recommended that total
parenteral nutrition continue until po reached significant
levels and the patient could advance diet as tolerated at
this time.  On [**2105-5-26**] postoperative day six the
patient pulled the biliary tube and an extension tube needed
to be attached and was noted to be still draining bile
effectively.  The patient was hemodynamically stable at this
time and the patient was continued on immunosuppression
medications and a cholangiogram was scheduled.  On
postoperative day seven [**2105-5-27**] the patient continued
to progress well.  Vancomycin was continued and the patient's
diet was advanced as tolerated.  The patient continued in the
Surgical Intensive Care Unit it was noted the patient started
sips at this time and the cholangiogram showed the tube not
to be in the bile duct.  The patient was treated on this day
with Lopressor for an elevated heart rate reached the 120s to
140s.  The patient began to be followed by physical therapy
on the [**5-27**] postoperative day seven it was suggested
the patient have inpatient rehab and to be evaluated for
progress to see whether the patient would be safe for
discharge to home eventually.  On postoperative day eight the
patient continued to improve in the Surgical Intensive Care
Unit.  KUB was performed for the broken biliary drain
revealing no fragments.  The patient was also noted on this
day to have somewhat decreased oral intake and a Dobhoff tube
was placed.  The patient was continued on his
immunosuppression regimen of Prednisone, CellCept and
____________ at this time.  On postoperative day nine [**2105-5-29**] the patient complained of mild nausea overnight.
The patient had one episode of emesis in the early morning
and the patient was at this  point now upon the floor on Far
10 and had been discharged from the Surgical Intensive Care
Unit on the night of [**2105-5-28**].

On [**2105-5-30**] postoperative day ten the patient noted
improvement without complaint of pain, nausea and vomiting
and was passing gas at this time and having bowel movements.
The patient's liver function tests were noted to be
decreasing at this time.  The patient's sodium was in the
150s.  The patient's tube feeds were supplemented with free
water and the patient was continued on ______________,
Prednisone and CellCept.  The patient was then started on
evaluation by occupational therapy on the [**5-29**]
postoperative day nine and noted the patient to be
functional, but with somewhat decreased mobility and
decreased sense of safety and suggested the patient likely be
needing rehab placement upon discharge.  On [**6-1**]
postoperative day 12 infectious disease was consulted to
assist in evaluation due to new fevers to 102.5 degrees at
this time with an uncertain source.  Blood cultures were sent
off, urine cultures and tip cultures from the patient's
central line, wound cultures were performed and tissue
culture from the wound was performed.  All cultures came back
negative at this time.  C-difficile cultures were also sent
and came back all negative.  On the [**6-2**] the patient
had been afebrile for 24 hours.  On postoperative day 13 and
a CAT scan of the chest was performed revealing a right large
lower lobe effusion and suggestion from infectious disease
was to consider a tap of this under CT guidance.  On the [**6-3**] cultures came back from the wound revealing sparse
enterococcus and infectious disease suggested changing
Vancomycin to Linezolid 600 mg every 12 hours and on the [**6-3**] the patient continued to progress and began feeling
significantly better. He began to get out of bed and
ambulate, passing gas at this time, having bowel movements
and felt the pain was very well controlled and had not had
any nausea or vomiting.  The patient's appetite also began to
progress and Vancomycin was stopped at this time.  On [**6-4**]
the patient continued to progress well and the patient's
Foley was discharged and he was able to ambulate and the
patient began to be screened for rehab placement.  The
patient continued to be followed by infectious disease at
this time and they continued to suggest the use of Linezolid.

On [**6-5**], postoperative day 16 the patient complained of
several episodes of emesis overnight and PICC line was placed
on [**6-5**], postoperative day 16 and infectious disease
continued to suggest the patient to be treated with Linezolid
and Zosyn at this time.  The patient was stable at this time
and the patient's antibiotics regimen was able to be switched
to oral with Levofloxacin 500 mg po once a day and Linezolid
600 mg po twice a day with the suggestion to continue therapy
for 14 days.  On [**2105-6-7**] postoperative day 18 the
patient was continued on tube feeds delivered at 45 cc an
hour and rehab screening continued for possible discharge on
Tuesday [**2105-6-9**] and on [**6-8**] the patient continued
without complaints.  It was noted that there was mild serous
drainage from his operative incision on the left side and the
patient was given one running 4-0 suture, which turned out to
seal the wound and the patient's bandages for the rest of
that day were noted to be dry and clean and the patient
continued to be screened for rehab and tube feeds continued.
At this time the patient continued to have somewhat limited
oral intake and on [**2105-6-9**] the day of discharge the
patient's without complaint at this time with examination
revealing vital signs of temperature maximum 99.5, 104 beats
per minute, blood pressure 124/86, respiratory rate 20, 99
percent on room air.  The patient was in no acute distress.
Lungs were clear to auscultation bilaterally.  Heart
examination was regular rate and rhythm with no murmurs, rubs
or gallops.  The patient's abdomen was soft, nontender,
normoactive bowel sounds with incision with staples in place
with no drainage at this time.  The patient was doing well
and was continued to advise to advance his diet as tolerated,
tube feeds continued and rehabilitation placement to occur
today at [**Hospital1 **].

DISCHARGE DIAGNOSES:  Status post orthotopic liver transplant
for alcoholic hepatitis [**2105-5-20**].

End stage liver disease.

Portal gastropathy.

Multiple varices.

DISCHARGE CONDITION:  Stable.  The patient was instructed to
call if fevers, chills, nausea, vomiting or increased
drainage or redness from the wound site.  The patient was
instructed to follow up with liver transplant staff and to
have twice weekly laboratories drawn Monday and Thursday for
CBC, chem 10, AST, ALT, alkaline phosphatase, albumin, total
bilirubin and immunosuppression levels. The patient's
appointments were to be scheduled by a liver transplant
coordinator.

DISCHARGE MEDICATIONS:
1. Bactrim 400 mg one tablet po q.d.
2. Fluconazole 200 mg one tablet po q.d.
3. Propanolol 20 mg one tablet po b.i.d.
4. Pantoprazole sodium 40 mg po q.d.
5. Prednisone 20 mg one tablet po q.d.
6. _______________ one tablet po q.d.
7. Azathioprine 50 mg one tablet po q.d.
8. Valganciclovir 450 mg one tablet po q.d.
9. Furosemide 10 mg po b.i.d.
10. Neoral per level
Again, laboratories are to be drawn on a twice weekly basis
at this time.

DISPOSITION:  To [**Hospital **] Rehab.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]

Dictated By:[**Last Name (NamePattern1) 52916**]
MEDQUIST36
D:  [**2105-6-9**] 12:14:11
T:  [**2105-6-9**] 14:16:57
Job#:  [**Job Number **]

ADDENDUM: Discharge on [**6-9**] postponed because of wound
infection


Name:  [**Known lastname 9841**],[**Known firstname 140**]                   Unit No:   [**Numeric Identifier 9842**]

Admission Date:  [**2105-5-10**]              Discharge Date:   [**2105-6-19**]

Date of Birth:  [**2057-6-21**]             Sex:   M

Service: [**Doctor First Name 1379**]

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 48**]
Chief Complaint:
end stage liver disease

Major Surgical or Invasive Procedure:
orthotopic liver transplant

History of Present Illness:
RE: prior dictation from [**2105-6-9**]

Brief Hospital Course:
Patient on [**6-9**] was planned to be discharged to rehab but upon
further exploration of wound it was determined that the pateint
would benefit from further wound care and nutritional
supplementation via tube feeds at [**Hospital1 8**].  Patient also began to
have episodes of vomiting at this time and dischrge plans were
held.  An EGD was performed by Dr. [**Last Name (STitle) 833**] at this time that
revealed a normal esophagus and stomach and a nasojejunal tube
was placed to supplement nutrition with tube feeds.  The
following day, [**6-10**] POD 21, staples were removed from the medial
aspect of the wound and packing was put in place and blood
cultures and wound cultures were sent as the patient was febrile
at this time.  Zosyn and linezolid were started at this time.
From this point on patient continued to progress and tube feeds
of probalance were advanced to goal of 77cc/hr and dressing
changes were performed three times a day.  By now patient was
afebrile.  On [**6-15**] POD 26 patient's Dobhoff tube was no longer
in place and patient had to have tube replaced by GI.  Patient
tolerated the procedure well and tube feeds were continued and
physical and occupational therpy began to evaluate the patient
again for services and safety after discharge.  On [**6-18**] POD 29
patient was fully screened for rehab and a bed was found for the
patient at [**Hospital **] Rehabilitation .  On the day of discharge
[**6-19**] patient was stable and prepared to be discharged to
[**Hospital1 **] on three times daily dressing changes, antibiotics, and
an immunosuppressant regimen.  All vital signs were stable on
the day of discharge.

Medications on Admission:
Ambien
Ursodiol
Reglan
Protonix
Vancomycin
Octreotide
Midodrine
Lactulose

Discharge Medications:
Trimethoprim-Sulfamethoxazole 400-80 mg Tablet Sig: One (1)
Tablet PO QD (once a day).
Fluconazole 400 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

Prednisone 15 mg Tablet Sig: One (1) Tablet PO QD (once a day).

Azathioprine 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
Furosemide 10 mg/mL Solution Sig: Two (2)  Injection [**Hospital1 **] (2
times a day).
Neoral 150 mg PO QD

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **]

Discharge Diagnosis:
status post orthotopic liver transplant for alcoholic hepatitis
[**2105-5-20**], end stage liver disease, portal gastropathy, varices.


Discharge Condition:
Stable.

Discharge Instructions:
Patient to be discharged to rehabilitation facility and to be
evaluated for eventual return to home.  Patient instructed to
notify MD if having increasing pain, drainage from wound,
fevers>101.  Patient to have three times daily dressing changes
at rehab facility, to receive tube feeds of Probalance at
75cc/hr.

Followup Instructions:
Patient to follow up with liver transplant staff and to have
twice weekly labs drawn, Mondays and Thursdays for CBC, Chem
7,10, AST, ALT, alk phos, albumin, T Bili, and immunosuppressant
levels.  Patients appointments with transplant staff to be
scheduled by liver transplant coordinator.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**]

Completed by:[**2105-6-19**]
{'Alcoholic cirrhosis of liver,Severe sepsis,Hepatorenal syndrome,Acute kidney failure, unspecified,Methicillin susceptible Staphylococcus aureus septicemia,Other postoperative infection,Unspecified pleural effusion,Other and unspecified alcohol dependence, unspecified'}


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: end stage liver disease

PRESENT ILLNESS: This patient is a 47 year-old
man with end stage liver disease secondary to alcoholism.  He
is admitted to [**Hospital1 69**] on [**2105-5-10**] for changes in mental status and melena.  While in
house the patient required therapy for MRSA bacteremia and
acute renal failure.  The patient went on to have a
transesophageal echocardiogram on [**5-18**] reveling normal
ejection fraction, no vegetations, no valve disease, no
pulmonary hypertension.  On the [**5-20**] there were no
signs of infection, no signs of upper respiratory symptoms,
sore throat, rhinorrhea, cough, earache, shortness of breath,
chest pain, dysuria, hematuria, nor changes in bowel habits.
No nausea or vomiting.

MEDICAL HISTORY: End stage liver disease secondary to
alcoholic cirrhosis.

MEDICATION ON ADMISSION: 1. Protonix 40 mg once a day.
2. Lactulose 30 milliliters twice a day.
3. Propanolol 20 mg twice a day.
4. Lasix 20 mg once a day.
5. Spironolactone 50 mg once a day.
6. Potassium chloride.
7. Mycelex.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Alcoholic cirrhosis of liver,Severe sepsis,Hepatorenal syndrome,Acute kidney failure, unspecified,Methicillin susceptible Staphylococcus aureus septicemia,Other postoperative infection,Unspecified pleural effusion,Other and unspecified alcohol dependence, unspecified'}
