CHIEF COMPLAINT: Hyponatremia, hypokalemia

PRESENT ILLNESS: HPI: This is a 51 y/o F c/ a significant past medical history of
Hep C/cirrhosis, removal of prosthetic right hip for hardware
infection, recent hospitalization for sepsis (pseudomonas +
blood
cultures), was admitted to the hepatology service yesterday
afternoon for hyponatremia and [**First Name3 (LF) **] (Na of 120 and a K
of
6.2). The patient's lactulose was stopped one week ago for
diarrhea. In addition, the patient was recently seen at an
outside hospital where a CT showed possible osteomyelitis of the
right sternoclavicular joint. Based on nursing assessment, the
patient was obtunded on admission. Overnight, she was hypoxic
(O2
sat 87% RA), hypoglycemic, and hypothermic (T 93.4). Her O2 sats
improved with 2L FM. Her BP remained normal the entire evening
(SBP 100-130s). While her O2 saturations improved, the patient
continued with an altered mental status. The patient was
transferred to the SICU and the [**First Name3 (LF) **] surgery service.

MEDICAL HISTORY: PMH: HCV Cirrhosis ('[**51**], nonresponder to interferon/
ribavirin, no varices on EGD [**5-15**] c/b encephalopathy,
thrombocytopenia, ascites, and hydrothorax), Hyponatremia
baseline 128-133, Secondary adrenal insufficiency, Asthma,
Diabetes mellitus, GERD, Anxiety, UTIs, MRSA bacteremia and
septic arthritis([**10-14**], [**12-16**]), LE Cellulitis, Hypercalcemia
.
PSH: TIPS [**11-8**] for ascites, R hip fracture and ORIF in [**11/2157**],
(c/b polymicrobial septic hip: E. Coli, enterococcus, coag neg
Staph, Klebisiella), s/p washout [**6-/2158**], hardware removal
[**9-/2158**]

MEDICATION ON ADMISSION: Albuterol Inhaler 2 PUFF IH [**Hospital1 **]
Ipratropium Bromide MDI 2 PUFF IH [**Hospital1 **]:PRN wheezing
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
Montelukast Sodium 10 mg PO/NG DAILY
Lasix 80 mg qd
SPIRONOLACTONE - 150mg qd
Rifaximin 550 mg PO/NG [**Hospital1 **]
Glargine 22 qHS
Lispro SS
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit MWF
Calcitriol 0.25 mcg PO EVERY OTHER DAY
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain
KETOCONAZOLE - 2 % Cream - apply to the area twice daily
NYSTATIN - 100,000 unit/gram Powder - TID
PREDNISONE - 5 mg Tablet - One Tablet(s) by mouth daily
CALCIUM CARBONATE - 2 x 500 mg Tablet TID
MAGNESIUM OXIDE - 400 mg Tablet 2-3 times MULTIVITAMIN
FoLIC Acid 1 mg PO/NG DAILY
Gabapentin 100 mg PO/NG Q12H
Venlafaxine 75 mg PO BID
Doxycycline 100 mg b.i.d.
Multivitamin 1 tab daily

ALLERGIES: Shellfish / Flexeril / Tricyclic Compounds

PHYSICAL EXAM: On admission:
VS: T 97.9 BP 120/80 P 85 RR 18 O2 sat 100% on RA
General: thin, chronically ill appearing woman tremulous, but in
NAD
HEENT: EOMI, sclera mildly icteric, MMM
Neck: no JVD
Lungs: CTAB; no wheezes, rhonchi, rales
CV: RRR, nl S1 and S2, II/VI systolic murmur over RUSB; no rubs
or gallops; 2-3 cm area of swelling and erythema over right
sterno-clavicular junction; not warm to touch, tender to deep
palpation
Abdomen: +BS, soft, non distended, non tender, no hepatomegaly
Ext: WWP, 1+ brawny and pitting LE edema, ecchymoses of UEs; 2+
DPs and PTs
Neuro: AAOx3, tremor but no asterixis; CNII-XII intact. motor
and sensation grossly intact, decreased ROM in right UE.

FAMILY HISTORY: Father - COPD, alcohol cirrhosis
Mother - diabetes, HTN, HL
Daughter - congenital heart dz

SOCIAL HISTORY: Lives currently with her mother. [**Name (NI) **] 1 daughter and a
granddaughter. Smoking d/c in [**2154**], smoked 1/2ppd for several
years. Sober since [**2148**], h/o iv-heroin (d/c in [**2148**]).
Chronic hepatitis C with hepatic coma,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Other ascites,Glucocorticoid deficiency,Non-healing surgical wound,Cellulitis and abscess of leg, except foot,Cirrhosis of liver without mention of alcohol,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Infection with microorganisms without mention of resistance to multiple drugs,Esophageal reflux,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Accidents occurring in residential institution,Anxiety state, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Asthma, unspecified type, unspecified,Aftercare for healing traumatic fracture of other bone,Other accidents
Chrnc hpt C w hepat Coma,Pneumonia, organism NOS,Urin tract infection NOS,Ascites NEC,Glucocorticoid deficient,Non-healing surgcl wound,Cellulitis of leg,Cirrhosis of liver NOS,Enterococcus group d,Inf mcr rst ot drg nt ml,Esophageal reflux,DMII oth nt st uncntrld,Long-term use of insulin,Adv eff insulin/antidiab,Accid in resident instit,Anxiety state NOS,Abn react-surg proc NEC,Asthma NOS,Aftrce traum fx bone NEC,Accident NEC
Admission Date:  [**2160-8-13**]              Discharge Date:   [**2160-8-24**]

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

Service: MEDICINE

Allergies:
Shellfish / Flexeril / Tricyclic Compounds

Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Hyponatremia, hypokalemia

Major Surgical or Invasive Procedure:
none

History of Present Illness:
HPI: This is a 51 y/o F c/ a significant past medical history of
Hep C/cirrhosis, removal of prosthetic right hip for hardware
infection, recent hospitalization for sepsis (pseudomonas +
blood
cultures), was admitted to the hepatology service yesterday
afternoon for hyponatremia and [**First Name3 (LF) **] (Na of 120 and a K
of
6.2). The patient's lactulose was stopped one week ago for
diarrhea. In addition, the patient was recently seen at an
outside hospital where a CT showed possible osteomyelitis of the
right sternoclavicular joint. Based on nursing assessment, the
patient was obtunded on admission. Overnight, she was hypoxic
(O2
sat 87% RA), hypoglycemic, and hypothermic (T 93.4). Her O2 sats
improved with 2L FM. Her BP remained normal the entire evening
(SBP 100-130s). While her O2 saturations improved, the patient
continued with an altered mental status. The patient was
transferred to the SICU and the [**First Name3 (LF) **] surgery service.


Past Medical History:
PMH: HCV Cirrhosis ('[**51**], nonresponder to interferon/
ribavirin, no varices on EGD [**5-15**] c/b encephalopathy,
thrombocytopenia, ascites, and hydrothorax), Hyponatremia
baseline 128-133, Secondary adrenal insufficiency, Asthma,
Diabetes mellitus, GERD, Anxiety, UTIs, MRSA bacteremia and
septic arthritis([**10-14**], [**12-16**]), LE Cellulitis, Hypercalcemia
.
PSH: TIPS [**11-8**] for ascites, R hip fracture and ORIF in [**11/2157**],
(c/b polymicrobial septic hip: E. Coli, enterococcus, coag neg
Staph, Klebisiella), s/p washout [**6-/2158**], hardware removal
[**9-/2158**]


Social History:
Lives currently with her mother. [**Name (NI) **] 1 daughter and a
granddaughter. Smoking d/c in [**2154**], smoked 1/2ppd for several
years. Sober since [**2148**], h/o iv-heroin (d/c in [**2148**]).


Family History:
Father - COPD, alcohol cirrhosis
Mother - diabetes, HTN, HL
Daughter - congenital heart dz


Physical Exam:
On admission:
VS: T 97.9 BP 120/80 P 85 RR 18 O2 sat 100% on RA
General: thin, chronically ill appearing woman tremulous, but in
NAD
HEENT: EOMI, sclera mildly icteric, MMM
Neck: no JVD
Lungs: CTAB; no wheezes, rhonchi, rales
CV: RRR, nl S1 and S2, II/VI systolic murmur over RUSB; no rubs
or gallops; 2-3 cm area of swelling and erythema over right
sterno-clavicular junction; not warm to touch, tender to deep
palpation
Abdomen: +BS, soft, non distended, non tender, no hepatomegaly
Ext: WWP, 1+ brawny and pitting LE edema, ecchymoses of UEs; 2+
DPs and PTs
Neuro: AAOx3, tremor but no asterixis; CNII-XII intact. motor
and sensation grossly intact, decreased ROM in right UE.

In ICU:
VS: T 97.5  HR 105  BP 104/64  RR 26  96% 2L
GEN: eyes closed, answers questions in one word answers,
withdraws from sternal rub
HEENT: dry mucous membranes, no scleral icterus
CHEST: CTA B/L, slightly tachypneic with shallow breaths,
decreased BS at bases B/L
HEART: S1, S2, tachycardic
ABD: soft, slightly distended, did not ellicit withdrawal or
grimacing on deep palpation
EXT: warm, 1+ edema, warm, B/L calf cellulitis (warm,
blanching),
right hip VAC dressing intact with no erythema and minimal
drainage

On discharge:
VS 97.2, 93/47, 96, 18, 97RA
General: thin, chronically ill appearing woman, tremulous, NAD
HEENT: EOMI, sclera mildly icteric
Lungs: CTAB; no rhonchi, rales, or wheezes
CV: RRR, nl S1 and S2, III/VI systolic murmur loudest along
LUSB, no rubs, or gallops
Abdomen: +BS, soft, non distended, non tender
Ext: WWP, no edema; 2+ DPs and PTs
Neuro: A&O x3; appropriate, motor and sensation grossly intact;
+ fine tremor, slight asterixis

Pertinent Results:
Admission Labs:
[**2160-8-13**] 05:30PM   PT-15.2* INR(PT)-1.3*
[**2160-8-13**] 05:30PM   PLT COUNT-145*#
[**2160-8-13**] 05:30PM   NEUTS-85.2* LYMPHS-8.8* MONOS-5.4 EOS-0.4
BASOS-0.3
[**2160-8-13**] 05:30PM   WBC-14.8*# RBC-3.77*# HGB-11.7*# HCT-35.8*#
MCV-95 MCH-31.0 MCHC-32.6 RDW-20.4*
[**2160-8-13**] 05:30PM   ALBUMIN-2.5* CALCIUM-9.3 PHOSPHATE-4.3#
MAGNESIUM-2.1
[**2160-8-13**] 05:30PM   ALT(SGPT)-30 AST(SGOT)-77* ALK PHOS-250* TOT
BILI-1.4
[**2160-8-13**] 05:30PM   GLUCOSE-124* UREA N-46* CREAT-0.9 SODIUM-120*
POTASSIUM-6.4* CHLORIDE-93* TOTAL CO2-21* ANION GAP-12
[**2160-8-13**] 07:38PM URINE  RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2160-8-13**] 07:38PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2160-8-13**] 07:38PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2160-8-13**] 07:38PM URINE  OSMOLAL-328

Micro:
[**8-13**] Urine Cx- enteroccocus (VRE)
[**8-13**] Blood Cx- No growth
[**8-14**] Blood Cx- No growth
[**8-15**] Urine legionella- negative
[**8-16**] C. diff- negative
[**8-18**] Joint fluid (sternoclavicular jt)- GS negative; 1 PMN; cx -
no growth
[**8-22**] Urine cx- no growth
[**8-23**] Blood cx- NGTD
[**8-23**] C. diff- negative

Studies:
[**8-13**] CXR: 1. Although lower lobe opacities have improved from the
prior radiograph, the possibility of residual or recurrent
infection should be considered in the appropriate clinical
setting. 2. Dilated loops of bowel in upper abdomen are
incompletely evaluated on this chest radiograph. Dedicated
abdominal radiographs may be helpful to exclude an obstructive
process.

[**8-14**] CXR: 1. NG tube in appropriate position. 2. Small bilateral
pleural effusions, left greater than right, slightly increased.
3. Increased retrocardiac opacity concerning for worsening
atelectasis or infection.

[**8-14**] Duplex Doppler Abd U/S:  Decline in MPV velocity and high
distalTIPS velocities concerning for distal stenosis at the
TIPS/HV junction. Further evaluation recommended.

[**8-14**] CT Head: 1. No acute intracranial process. 2. Aerosolized
secretions and mucosal thickening within the right sphenoid
sinus.

[**8-14**] LENI: No DVT of either lower extremity.

[**8-15**] CT R clavicle: 1) Destruction of medial right clavicle with
exuberant adjacent callus formation. The appearance may be
post-traumatic, but infection cannot be excluded. If clinical
concern for infection remains, biopsy/aspiration could be
performed with CT guidance. 2) Patchy opacification
predominantly in right lower lobe incompletely assessed on this
examination however appears similar to findings of [**2160-7-4**]
and may represent chronic atelectasis with possible
infectious/inflammatory process.

Discharge Labs:

[**2160-8-24**] 06:00AM BLOOD WBC-4.8 RBC-2.28* Hgb-7.6* Hct-21.2*
MCV-93 MCH-33.5* MCHC-36.0* RDW-19.5* Plt Ct-23*
[**2160-8-24**] 06:00AM BLOOD PT-15.7* INR(PT)-1.4*
[**2160-8-24**] 06:00AM BLOOD Glucose-159* UreaN-99* Creat-1.1 Na-135
K-5.3* Cl-100 HCO3-30 AnGap-10
[**2160-8-24**] 06:00AM BLOOD ALT-18 AST-42* AlkPhos-89 TotBili-2.5*
[**2160-8-24**] 06:00AM BLOOD Calcium-9.3 Phos-3.6 Mg-3.0*
[**2160-8-14**] 03:27PM BLOOD CRP-24.4*

Brief Hospital Course:
51 yo woman with h/o HCV cirrhosis (c/b encephalopathy, ascites,
s/p TIPS) and septic hip, with recent admission for pseudomonas
bacteremia, admitted with hyponatremia, [**Month/Day/Year **] and
subsequent decompensation with hepatic encephelopathy in the
setting of pneumonia and UTI. Her hospital course by problem was
as follows:
.
# Hyponatremia- Likely secondary to poor PO intake superimposed
on chronic hyponatremia in setting of cirrhosis. Patient's
baseline sodium is 128-133. She was given albumin with gradual
improvement of her sodium levels.
.
# [**Month/Day/Year **]- On admission, patient with K of 6.4. Had peaked
T waves on EKG and is complaining of myalgias for the past week.
She was treated with insulin, calcium gluconate, albuterol, and
kayexelate. Her [**Month/Day/Year **] was attributed to her recent
decrease in lasix dose from 120 to 80 mg. Lasix was increased
during this hospitalization to 80 mg [**Hospital1 **] and spironolactone was
decreased to 100 mg daily. Patient was monitored on telemetry
with no cardiac events.
.
# HCV cirrhosis (c/b ascites, thrombocytopenia, encephelopathy,
coagulopathy, s/p TIPS). Pt is currently not a [**Hospital1 **]
candidate due to recurrent infections. During this
hospitalization, patient decompensated and became
encephelopathic in the setting of infection (UTI and pneumonia,
see below) with a possible contribution from distal stenosis of
her TIPS diagnosed on duplex doppler U/S. She required
aggressive lactulose therapy (which she had stopped at home for
one week prior to admission) and was transferred to the SICU for
management of hypoxia and hypothermia in the setting of
encephelopathy. She was transferred back to the floor after a
couple of days, stable and lucid with her aggressive lactulose
regimen. In addition to lactulose, she was continued on her home
rifaximin. Lasix was uptitrated to 80 mg [**Hospital1 **] and spironolactone
was downtitrated to 100 mg daily given her [**Hospital1 **] on
presentation. A Dobhoff was placed in the post-pyloric position
for tube feeds as the patient exhibited poor PO intake. She was
discharged with instructions to continue her tubefeeds.
.
# UTI- Patient grew out VRE in urine and completed a 8 day
course of linezolid.
.
# Pneumonia- Patient became hypoxic and hypothermic one day
after admission, though she remained hemodynamically stable.
Leukocytosis to 14.8 with 85% polys. She was transferred to the
SICU where she was empirically treated with zosyn for a possible
pneumonia seen on CXR. Her blood cultures were negative to date.
She completed 8 days of treatment with zosyn and was given
albuterol, ipratroprium nebs PRN. She was breathing comfortably
on room air with oxygen saturations in the high 90s on room air
at the time of discharge.
.
# R clavicle fracture- There was some concern for osteomyelitis
given the patient's recurrent hip infections. She was seen by
orthopedics and per their recs CT scan was performed which
showed a traumatic injury but was inconclusive for infection.
Patient underwent CT guided sternoclavicular joint aspiration
which showed a negative GS negative and cx. ESR was 18 and CRP
24.4. Infectious disease consultants recommended holding
treatment for osteomyelitis given the negative biopsy results
and low likelihood of osteo.
.
# Acute renal insufficiency- Patient experienced a short-lived
bump in her creatinine to 1.2 from her baseline of 0.8-0.9. This
was attributed to a pre-renal etiology in the setting of poor PO
intake despite tube feeds. Patient was given albumin and
encouraged to increase PO intake. At the time of discharge,
creatinine was trending down.
.
# Thrombocytopenia- On admission, platelets were 145, which
trended down to a low of 23. Her thrombocytopenia was attributed
to baseline poor hepatic function in the setting of cirrhosis
with superimposed linezolid related toxicity. Linezolid was
discontinued after 8 days of treatment. Patient was
hemodynamically stable without any bleeding during this
hospitalization. Would advise monitoring and follow up in the
outpatient setting.
.
# Adrenal insufficiency: Patient was continued on her home
prednisone 5 mg daily. She was on stress dose steriods briefly
during the time of her SICU transfer, but these were promptly
discontinued as her condition quickly stabilized.
.
# Hip wound: s/p R hip ORIF in [**2156**], c/b multiple joint/hardware
infections and sepsis, spacer inside, wound vac in place. No
signs of active infection. The wound was evaluated by wound care
nursing along with Dr. [**Last Name (STitle) **]. They recommended discontinuing
the wound vac due to concern for premature closure of the wound
with atypical granulation tissue (cauliflower tissue) which
could potentially cause collection or abscess formation. Daily
dressing changes with AMD were performed per wound care recs and
patient was discharged with instructions to continue this care
plan. She was continued on her oxycodone for pain control during
this hospitalization.
.
# Depression- Patient reported saddened mood, without SI/HI. Her
venlafaxine dose was increased from 75 to 150 mg PO BID.
.
# Nutrition- Patient with poor PO intake for past 2-3 weeks
prior to admission. Nutrition consulted and recommended Dobhoff
placement with tubefeeds (isosource 1.5 tube feeds at 45 cc/hr).
She was continued on a diabetic diet and her home vitamins.
.
# Diabetes- Patients sugars were up and down given her acute
infections. On discharge she had achieved good glucose control
with glargine 20 units qHS and ISS.
.
# Asthma: Stable. Patient was continued on her home albuterol,
ipratroprium, and fluticasone.
.
Pending on Discharge:
[**8-23**] Blood cultures

Agree with plan above. Patient d/c to home with the
understanding that she will return to this medical center for
further hosptial care should her condition deteriorate.

Medications on Admission:
Albuterol Inhaler 2 PUFF IH [**Hospital1 **]
Ipratropium Bromide MDI 2 PUFF IH [**Hospital1 **]:PRN wheezing
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
Montelukast Sodium 10 mg PO/NG DAILY
Lasix 80 mg qd
SPIRONOLACTONE - 150mg qd
Rifaximin 550 mg PO/NG [**Hospital1 **]
Glargine 22 qHS
Lispro SS
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit MWF
Calcitriol 0.25 mcg PO EVERY OTHER DAY
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain
KETOCONAZOLE - 2 % Cream - apply to the area twice daily
NYSTATIN - 100,000 unit/gram Powder - TID
PREDNISONE - 5 mg Tablet - One Tablet(s) by mouth daily
CALCIUM CARBONATE - 2 x 500 mg Tablet TID
MAGNESIUM OXIDE - 400 mg Tablet 2-3 times MULTIVITAMIN
FoLIC Acid 1 mg PO/NG DAILY
Gabapentin 100 mg PO/NG Q12H
Venlafaxine 75 mg PO BID
Doxycycline 100 mg b.i.d.
Multivitamin 1 tab daily

Discharge Medications:
1. Tube feeds
Please give  Isosource 1.5 Cal Full strength (or equivalent);
Starting rate: 20 ml/hr; Advance rate by 10 ml q6h Goal rate: 45
ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 50 ml water q6h
2. Tube feed pump and supplies
Please provide tube feed pump and supplies.
3. Outpatient Lab Work
Please check CBC, chem 7, bilirubin, albumin and INR weekly. Fax
results to results to [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] ([**Last Name (NamePattern1) 1326**] Coordinator),
[**Hospital1 18**] Liver Center at [**Telephone/Fax (1) 697**].

4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Please take additional lactulose if you are
feeling confused, sleepy, or otherwise not yourself.
5. Rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
12. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QMOWEFR (Monday -Wednesday-Friday).
13. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO TID (3 times a day).
14. Spironolactone 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
15. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
16. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation twice a day as needed for shortness of
breath or wheezing.
17. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
18. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) puffs Inhalation twice a day as needed for
shortness of breath or wheezing.
19. Doxycycline Hyclate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
20. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO every
twelve (12) hours.
21. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO every twelve (12) hours as
needed for pain: Do not drink or drive while taking this
medication.
22. Oxycodone 5 mg Capsule Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
23. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.

24. Ketoconazole  Topical
25. Wound Care
For Right Hip Wound:

Daily dressing changes to hip site with AMD (anti-microbial
dressing) packing strips into the depth of the wound - this is
best achieved with 90 or greater degree flexion of pt's right
leg. Cover top with dry gauze and ABD pad.

[**Location (un) **] straps to decrease the need for adhesive
placement and removal which can strip pt skin and cause pain.
26. Insulin Sliding Scale
Please resume lispro sliding scale as previously taking


Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
Primary:
Hepatitis C virus cirrhosis complicated by hepatic
encephelopathy
Pneumonia
Urinary tract infection

Secondary:
Secondary adrenal insufficiency
Asthma
Diabetes mellitus
GERD
Depression/Anxiety


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Ms. [**Known lastname 68459**],

It was a pleasure taking care of you at the [**Hospital1 18**]. You were
admitted to the hospital because of some abnormalities in your
blood chemistries related to your liver disease. You were
continued on your home medications and restarted on your
lactulose and improved.

While you were here, you were also diagnosed with a pneumonia
and urinary tract infection for which you were treated with
antibiotics. You required a short stay in the intensive care
unit because your oxygen levels were low, but you improved. We
also performed a biopsy of your sternoclavicular joint to see if
there was any infection- these results showed no infection.

While you were in the hospital you had a poor appetite and were
unable to eat very much food. In order to ensure you received
adequate nutrition, we placed a feeding tube and started giving
you tubefeeds. It is important that you continue the tube feeds
at home to increase your calorie intake and build your strength.

While you were in the hospital you were seen by wound care
specialists for your right hip wound- they felt that the wound
vac was not appropriate for your wound and advised daily
dressing changes - we advise that you continue to do this at
home.

We have made the following changes to your medications:
- RESTART taking your lactulose as indicated
- CHANGE your dose of venlafaxine to 150 mg twice daily
- CHANGE your dose of insulin glargine at night and change your
sliding scale to regular insulin
- CHANGE your dose of furosemide to 80 mg twice daily
- CHANGE your dose of spironolactone to 100 mg daily
- STOP taking magnesium

You may continue to take your other medications as you were
previously.

Please follow up at the appointments below.

Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2160-9-3**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2160-9-8**] 11:20



Completed by:[**2160-8-24**]
{'Chronic hepatitis C with hepatic coma,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Other ascites,Glucocorticoid deficiency,Non-healing surgical wound,Cellulitis and abscess of leg, except foot,Cirrhosis of liver without mention of alcohol,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Infection with microorganisms without mention of resistance to multiple drugs,Esophageal reflux,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Accidents occurring in residential institution,Anxiety state, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Asthma, unspecified type, unspecified,Aftercare for healing traumatic fracture of other bone,Other accidents'}


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, hypokalemia

PRESENT ILLNESS: HPI: This is a 51 y/o F c/ a significant past medical history of
Hep C/cirrhosis, removal of prosthetic right hip for hardware
infection, recent hospitalization for sepsis (pseudomonas +
blood
cultures), was admitted to the hepatology service yesterday
afternoon for hyponatremia and [**First Name3 (LF) **] (Na of 120 and a K
of
6.2). The patient's lactulose was stopped one week ago for
diarrhea. In addition, the patient was recently seen at an
outside hospital where a CT showed possible osteomyelitis of the
right sternoclavicular joint. Based on nursing assessment, the
patient was obtunded on admission. Overnight, she was hypoxic
(O2
sat 87% RA), hypoglycemic, and hypothermic (T 93.4). Her O2 sats
improved with 2L FM. Her BP remained normal the entire evening
(SBP 100-130s). While her O2 saturations improved, the patient
continued with an altered mental status. The patient was
transferred to the SICU and the [**First Name3 (LF) **] surgery service.

MEDICAL HISTORY: PMH: HCV Cirrhosis ('[**51**], nonresponder to interferon/
ribavirin, no varices on EGD [**5-15**] c/b encephalopathy,
thrombocytopenia, ascites, and hydrothorax), Hyponatremia
baseline 128-133, Secondary adrenal insufficiency, Asthma,
Diabetes mellitus, GERD, Anxiety, UTIs, MRSA bacteremia and
septic arthritis([**10-14**], [**12-16**]), LE Cellulitis, Hypercalcemia
.
PSH: TIPS [**11-8**] for ascites, R hip fracture and ORIF in [**11/2157**],
(c/b polymicrobial septic hip: E. Coli, enterococcus, coag neg
Staph, Klebisiella), s/p washout [**6-/2158**], hardware removal
[**9-/2158**]

MEDICATION ON ADMISSION: Albuterol Inhaler 2 PUFF IH [**Hospital1 **]
Ipratropium Bromide MDI 2 PUFF IH [**Hospital1 **]:PRN wheezing
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
Montelukast Sodium 10 mg PO/NG DAILY
Lasix 80 mg qd
SPIRONOLACTONE - 150mg qd
Rifaximin 550 mg PO/NG [**Hospital1 **]
Glargine 22 qHS
Lispro SS
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit MWF
Calcitriol 0.25 mcg PO EVERY OTHER DAY
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain
KETOCONAZOLE - 2 % Cream - apply to the area twice daily
NYSTATIN - 100,000 unit/gram Powder - TID
PREDNISONE - 5 mg Tablet - One Tablet(s) by mouth daily
CALCIUM CARBONATE - 2 x 500 mg Tablet TID
MAGNESIUM OXIDE - 400 mg Tablet 2-3 times MULTIVITAMIN
FoLIC Acid 1 mg PO/NG DAILY
Gabapentin 100 mg PO/NG Q12H
Venlafaxine 75 mg PO BID
Doxycycline 100 mg b.i.d.
Multivitamin 1 tab daily

ALLERGIES: Shellfish / Flexeril / Tricyclic Compounds

PHYSICAL EXAM: On admission:
VS: T 97.9 BP 120/80 P 85 RR 18 O2 sat 100% on RA
General: thin, chronically ill appearing woman tremulous, but in
NAD
HEENT: EOMI, sclera mildly icteric, MMM
Neck: no JVD
Lungs: CTAB; no wheezes, rhonchi, rales
CV: RRR, nl S1 and S2, II/VI systolic murmur over RUSB; no rubs
or gallops; 2-3 cm area of swelling and erythema over right
sterno-clavicular junction; not warm to touch, tender to deep
palpation
Abdomen: +BS, soft, non distended, non tender, no hepatomegaly
Ext: WWP, 1+ brawny and pitting LE edema, ecchymoses of UEs; 2+
DPs and PTs
Neuro: AAOx3, tremor but no asterixis; CNII-XII intact. motor
and sensation grossly intact, decreased ROM in right UE.

FAMILY HISTORY: Father - COPD, alcohol cirrhosis
Mother - diabetes, HTN, HL
Daughter - congenital heart dz

SOCIAL HISTORY: Lives currently with her mother. [**Name (NI) **] 1 daughter and a
granddaughter. Smoking d/c in [**2154**], smoked 1/2ppd for several
years. Sober since [**2148**], h/o iv-heroin (d/c in [**2148**]). 

### Response:
{'Chronic hepatitis C with hepatic coma,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Other ascites,Glucocorticoid deficiency,Non-healing surgical wound,Cellulitis and abscess of leg, except foot,Cirrhosis of liver without mention of alcohol,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Infection with microorganisms without mention of resistance to multiple drugs,Esophageal reflux,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Accidents occurring in residential institution,Anxiety state, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Asthma, unspecified type, unspecified,Aftercare for healing traumatic fracture of other bone,Other accidents'}
