CHIEF COMPLAINT: Liver failure, kidney failure, and altered mental status

PRESENT ILLNESS: This is a 47-year-old woman with a pmhx. significant for alcohol
abuse and bipolar disorder who is transferred to [**Hospital1 18**] for acute
liver failure, acute kidney injury, and altered mental status.
According to records obtained from various outside facilities,
patient was brought into [**Hospital6 6640**] on [**2102-3-18**] by
a friend who was concerned that patient was "drinking a pint of
vodka" for the past 5 days.  At that time, patient declined
detox, and checked out of the hospital, stating that she would
follow-up with her outpatient therapist.  On [**3-19**], patient had a
normal chemistry panel (BUN of of 20, creatinine of 0.8), AST of
28, ALT of 27, acetaminophen level of <2.0 and serum alcohol
level of 360.  Patient denied SI and was discharged home.
.
The following day ([**3-20**]), patient was admitted to NORCAP Lodge
(detox facility) in [**Location (un) 26671**], where she was monitored for ETOH
and ?opiate withdrawal.  She was given clonidine (in tapered
doses), acetaminophen (total of 3 doses of 325mg over 2 days),
mylanta, benadryl, motrin, imodium, ativan, melatonin, reglan,
triaminic cold relief, and desyrel per withdrawal protocol.
Patient also reports taking "8 vicodin) on [**3-21**] for shoulder
pain, stating that she is prescribed 24 pills of vicodin/month
by her physician.  [**Name10 (NameIs) **] to healthcare providers at NORCAP,
patient complained of extreme nausea and abdominal pain on [**3-22**],
and she was transferred to [**Hospital3 **] for further work-up.
.
At [**Hospital3 **], patient was found to have a serum acetaminophen
level of <10 but positive urine level, an ETOH level of 10,
lipase of 798, bili of 1.9, AST of [**Numeric Identifier 16092**], ALT of 8010, and
ultrasound with trace ascites and normal portal and hepatic
flow.  Patient was given zofran, magnesium, and 9545mg of NAC
and transferred to [**Hospital1 18**].
.
In [**Hospital1 18**] ED, initial vitals were: 98.7 74 172/108 16 100%.  She
was given 2 L of IVF, 3.25grams of NAC, 4mg IV morphine, cipro
400mg for presumed UTI, and seen by transplant, hepatology, and
toxicology services.  LFTs were trending down with AST of [**Numeric Identifier 4731**],
ALT of 6585, LDH: 8245, and lipase of 840.  BUN/ creatinine was
47/4.7, and patient was making minimal concentrated urine.  RUQ
ultrasound showed good portal and hepatic flow, and CT abdomen
(without contrast) was remarkable only for pancreatic stranding.
 Patient was deemed not to be a transplant candidate due to her
current ETOH abuse, and was admitted to the MICU for further
work-up and treatment.

MEDICAL HISTORY: --ETOH abuse
--Bipolar disorder
--History of acetaminophen overdose as a teenager (was taking it
for menstrual cramps) and needed to get her "stomach pumped"

MEDICATION ON ADMISSION: Vicodin (dose unknown)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: Afebrile, HR: 73, BP 182/103 (though not accurate [**Location (un) 1131**] as
per nursing), SP02 92% on RA
GENERAL:  Somnolent, responsive to voice, no acute distress
HEENT: PEARLA, throat clear and non-erythematous
CHEST: Clear to auscultation bilaterally
CARDIAC: RRR, no murmurs, rubs, or gallops
ABDOMEN: +BS, diffusely tender, more so in RUQ
EXTREMITIES: Warm and dry, no edema bilaterally
NEURO: Knows she's in [**Location (un) 86**], thinks she's at [**Hospital1 112**], responsive to
voice

FAMILY HISTORY: According to outside notes, strong family history of alcoholism
and mother with depression.

SOCIAL HISTORY: Patient is reportedly a binge drinker.  As per notes from [**Hospital1 56809**], patient was sober for 8 years until [**2099**] when
she went through a divorce, death of a loved one, and lost her
job.  Other social history unable to be obtained due to
patient's mental status on admission.
Toxic effect of ethyl alcohol,Acute and subacute necrosis of liver,Acute pancreatitis,Acute kidney failure with lesion of tubular necrosis,Methicillin resistant Staphylococcus aureus septicemia,Metabolic encephalopathy,Other ascites,Acidosis,Urinary tract infection, site not specified,Infection and inflammatory reaction due to other vascular device, implant, and graft,Poisoning by other opiates and related narcotics,Accidental poisoning by alcoholic beverages,Accidental poisoning by other opiates and related narcotics,Phlebitis and thrombophlebitis of upper extremities, unspecified,Bipolar disorder, unspecified,Tobacco use disorder,Other and unspecified alcohol dependence, unspecified,Other chronic pain,Disorders of bursae and tendons in shoulder region, unspecified,Thrombocytopenia, unspecified,Constipation, unspecified,Other specified anemias,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Substance abuse in family,Family history of psychiatric condition,Long-term (current) use of non-steroidal anti-inflammatories (NSAID)
Toxic eff ethyl alcohol,Acute necrosis of liver,Acute pancreatitis,Ac kidny fail, tubr necr,MRSA septicemia,Metabolic encephalopathy,Ascites NEC,Acidosis,Urin tract infection NOS,React-oth vasc dev/graft,Poisoning-opiates NEC,Acc poisn-alcohol bevrag,Acc poison-opiates NEC,Phlbts vn NOS up extrm,Bipolar disorder NOS,Tobacco use disorder,Alcoh dep NEC/NOS-unspec,Chronic pain NEC,Rotator cuff synd NOS,Thrombocytopenia NOS,Constipation NOS,Anemia NEC,Abn react-procedure NEC,Accid in resident instit,Substance abuse-family,Fam hx-psychiatric cond,Long-term anti-inflamtry
Admission Date:  [**2102-3-22**]              Discharge Date:   [**2102-4-13**]

Date of Birth:  [**2054-5-2**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Liver failure, kidney failure, and altered mental status

Major Surgical or Invasive Procedure:
-Tunneled line for hemodialysis
-PICC line
-Transfusion with 2u pRBCs


History of Present Illness:
This is a 47-year-old woman with a pmhx. significant for alcohol
abuse and bipolar disorder who is transferred to [**Hospital1 18**] for acute
liver failure, acute kidney injury, and altered mental status.
According to records obtained from various outside facilities,
patient was brought into [**Hospital6 6640**] on [**2102-3-18**] by
a friend who was concerned that patient was "drinking a pint of
vodka" for the past 5 days.  At that time, patient declined
detox, and checked out of the hospital, stating that she would
follow-up with her outpatient therapist.  On [**3-19**], patient had a
normal chemistry panel (BUN of of 20, creatinine of 0.8), AST of
28, ALT of 27, acetaminophen level of <2.0 and serum alcohol
level of 360.  Patient denied SI and was discharged home.
.
The following day ([**3-20**]), patient was admitted to NORCAP Lodge
(detox facility) in [**Location (un) 26671**], where she was monitored for ETOH
and ?opiate withdrawal.  She was given clonidine (in tapered
doses), acetaminophen (total of 3 doses of 325mg over 2 days),
mylanta, benadryl, motrin, imodium, ativan, melatonin, reglan,
triaminic cold relief, and desyrel per withdrawal protocol.
Patient also reports taking "8 vicodin) on [**3-21**] for shoulder
pain, stating that she is prescribed 24 pills of vicodin/month
by her physician.  [**Name10 (NameIs) **] to healthcare providers at NORCAP,
patient complained of extreme nausea and abdominal pain on [**3-22**],
and she was transferred to [**Hospital3 **] for further work-up.
.
At [**Hospital3 **], patient was found to have a serum acetaminophen
level of <10 but positive urine level, an ETOH level of 10,
lipase of 798, bili of 1.9, AST of [**Numeric Identifier 16092**], ALT of 8010, and
ultrasound with trace ascites and normal portal and hepatic
flow.  Patient was given zofran, magnesium, and 9545mg of NAC
and transferred to [**Hospital1 18**].
.
In [**Hospital1 18**] ED, initial vitals were: 98.7 74 172/108 16 100%.  She
was given 2 L of IVF, 3.25grams of NAC, 4mg IV morphine, cipro
400mg for presumed UTI, and seen by transplant, hepatology, and
toxicology services.  LFTs were trending down with AST of [**Numeric Identifier 4731**],
ALT of 6585, LDH: 8245, and lipase of 840.  BUN/ creatinine was
47/4.7, and patient was making minimal concentrated urine.  RUQ
ultrasound showed good portal and hepatic flow, and CT abdomen
(without contrast) was remarkable only for pancreatic stranding.
 Patient was deemed not to be a transplant candidate due to her
current ETOH abuse, and was admitted to the MICU for further
work-up and treatment.

Past Medical History:
--ETOH abuse
--Bipolar disorder
--History of acetaminophen overdose as a teenager (was taking it
for menstrual cramps) and needed to get her "stomach pumped"

Social History:
Patient is reportedly a binge drinker.  As per notes from [**Hospital1 56809**], patient was sober for 8 years until [**2099**] when
she went through a divorce, death of a loved one, and lost her
job.  Other social history unable to be obtained due to
patient's mental status on admission.

Family History:
According to outside notes, strong family history of alcoholism
and mother with depression.

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Afebrile, HR: 73, BP 182/103 (though not accurate [**Location (un) 1131**] as
per nursing), SP02 92% on RA
GENERAL:  Somnolent, responsive to voice, no acute distress
HEENT: PEARLA, throat clear and non-erythematous
CHEST: Clear to auscultation bilaterally
CARDIAC: RRR, no murmurs, rubs, or gallops
ABDOMEN: +BS, diffusely tender, more so in RUQ
EXTREMITIES: Warm and dry, no edema bilaterally
NEURO: Knows she's in [**Location (un) 86**], thinks she's at [**Hospital1 112**], responsive to
voice

DISCHARGE PHYSICAL EXAM:

VS: T-99.2 BP-140/82 HR-93 RR-18 O2Sat-98%RA

Gen: NAD, well-appearing
HEENT: PERRLA, EOMI, sclerae anicteric, OP clear, no cervical
lymphadenopathy, trachea midline
CV: RRR. Normal S1,S2. No m/r/g.
Resp: CTAB.
Abdomen: Soft, NT, ND. Bowel sounds active. No abnormal masses.
No hepatosplenomegaly.
Extr: 2+DP pulses bilaterally. No LE edema.
Neuro: A&Ox3. CN2-12 grossly intact.


Pertinent Results:
Labs upon admission:
[**2102-3-22**] 09:49PM   TYPE-ART TEMP-37.2 PO2-69* PCO2-40 PH-7.33*
TOTAL CO2-22 BASE XS--4 INTUBATED-NOT INTUBA
[**2102-3-22**] 09:49PM   LACTATE-1.5
[**2102-3-22**] 08:50PM URINE  HOURS-RANDOM CREAT-181 SODIUM-73
POTASSIUM-36 CHLORIDE-51 TOT PROT-478 CALCIUM-3.9 PROT/CREA-2.6*
albumin-167 alb/CREA-922.7*
[**2102-3-22**] 08:50PM URINE  OSMOLAL-287
[**2102-3-22**] 08:50PM URINE  bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2102-3-22**] 08:50PM URINE  COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2102-3-22**] 08:50PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2102-3-22**] 08:50PM URINE  RBC-13* WBC-64* BACTERIA-MANY YEAST-NONE
EPI-4
[**2102-3-22**] 08:50PM URINE  WBCCLUMP-FEW
[**2102-3-22**] 07:51PM   GLUCOSE-98 LACTATE-1.9 NA+-137 K+-3.9 CL--96*
TCO2-24
[**2102-3-22**] 07:51PM   HGB-13.2 calcHCT-40
[**2102-3-22**] 07:40PM   GLUCOSE-106* UREA N-47* CREAT-4.7* SODIUM-135
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-26 ANION GAP-16
[**2102-3-22**] 07:40PM   estGFR-Using this
[**2102-3-22**] 07:40PM   ALT(SGPT)-6585* AST(SGOT)-[**Numeric Identifier 4731**]*
LD(LDH)-8245* CK(CPK)-280* ALK PHOS-110* TOT BILI-1.1
[**2102-3-22**] 07:40PM   LIPASE-840*
[**2102-3-22**] 07:40PM   CK-MB-2
[**2102-3-22**] 07:40PM   CALCIUM-8.3* PHOSPHATE-2.6* MAGNESIUM-2.2
[**2102-3-22**] 07:40PM   HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE
[**2102-3-22**] 07:40PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2102-3-22**] 07:40PM   HCV Ab-NEGATIVE
[**2102-3-22**] 07:40PM   HCV Ab-NEGATIVE
[**2102-3-22**] 07:40PM   WBC-5.6 RBC-4.06* HGB-13.0 HCT-37.9 MCV-93
MCH-32.0 MCHC-34.3 RDW-14.4
[**2102-3-22**] 07:40PM   NEUTS-81.3* LYMPHS-15.7* MONOS-0.5* EOS-2.2
BASOS-0.4
[**2102-3-22**] 07:40PM   PLT SMR-LOW PLT COUNT-84*
[**2102-3-22**] 07:40PM   PT-15.7* PTT-26.9 INR(PT)-1.4*
.
Labs upon discharge:


CT Abdomen [**2102-3-22**]:
IMPRESSION:
1. Diffuse hepatic hypoattenuation, may be related to edema from
hepatitis, or possibly due to more longstanding fatty
infiltration.
2. Suggestion of edema at the pancreatic head and moderate
amount of
peripancreatic stranding concerning for pancreatitis in the
appropriate
clinical setting.
3. Free fluid tracking along the right paracolic gutter into the
pelvis.
4. Perinephric fluid, possibly resulting from acute renal
failure.
5. Diverticulosis without diverticulitis.
.
Abdominal ultrasound [**3-22**]
1. Mildly coarsened liver echotexture, without focal lesion.
2. Normal gallbladder.
3. Patent hepatic arteries, portal veins, and hepatic veins.
Patent IVC and splenic vein.
4. Small amount of perinephric fluid about the left kidney.
.
Renal ultrasound [**3-23**]:
1. No hydronephrosis identified. Scant trace of free fluid seen
bilaterally surrounding the kidney.
2. No evidence of renal artery stenosis. Mildly elevated
resistive indices
consistent with chronic renal disease.

MRCP [**4-1**]: Wet read
1. Mild heterogeneous texture of the head and body of the
pancreas
accompanied by peripancreatic fluid and interstitial edema
consistent with
pancreatitis.
2. Small-to-moderate amount of ascites in perihepatic,
perisplenic and
paracolic gutters.
3. Loss of corticomedullary differentiation in both kidneys
consistent with
renal failure.
4. Small-to-moderate amount of pleural effusion.
.
[**2102-3-23**]: Renal ultrasound:
IMPRESSION:
1. No hydronephrosis identified. Scant trace of free fluid seen
bilaterally surrounding the kidney.
2. No evidence of renal artery stenosis. Mildly elevated
resistive indices
consistent with chronic renal disease.
.
[**2102-4-3**]: Echocardiogram:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. No mass or vegetation is seen on
the mitral valve. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
.
[**2102-4-3**]: Chest X-ray
IMPRESSION: Compared to [**3-23**] and 27:
Mild pulmonary edema, bibasilar atelectasis, and small pleural
effusions have increased since [**4-2**], cardiomegaly is
borderline, and mediastinal veins are not dilated. Dialysis
catheter ends in the mid SVC. No pneumothorax.
.
[**2102-4-5**]: Tunnel Line Placement U/S
Uncomplicated placement of a angiodynamics 23 cm double-lumen,
tunneled hemodialysis catheter via the left internal jugular
vein with the tip in the right atrium.
.
[**2102-4-12**]: PICC Line Placement CXR
IMPRESSION:
1. New left PICC, tip at upper SVC.
2. Mild cardiomegaly.

Microbiology:

[**2102-3-23**]
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2102-3-23**]): POSITIVE BY EIA.

[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2102-3-23**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2102-3-23**]):
      NEGATIVE <1:10 BY IFA.
      INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
CMV IgG ANTIBODY (Final [**2102-3-24**]):
      POSITIVE FOR CMV IgG ANTIBODY BY EIA.
      89 AU/ML.
      Reference Range:  Negative < 4 AU/ml, Positive >= 6 AU/ml.

CMV IgM ANTIBODY (Final [**2102-3-24**]):
      NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
      INTERPRETATION:  INFECTION AT UNDETERMINED TIME.
VARICELLA-ZOSTER IgG SEROLOGY (Final [**2102-3-24**]):
      POSITIVE BY EIA.
.
[**2102-4-1**]: Blood cultures:
_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------     2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S

[**2102-4-2**] - [**2102-4-5**]: blood cultures no growth

[**2102-4-4**]: Urine culture:  GRAM POSITIVE BACTERIA.    >100,000
ORGANISMS/ML. Alpha hemolytic colonies consistent with alpha
streptococcus or        Lactobacillus sp.


Brief Hospital Course:
47-year-old woman with a history of ETOH abuse who is
transferred from OSH for acute ETOH and Tylenol hepatitis,
pancreatitis, ARF, and altered mental status.

# Acute Renal Failure: Due to tylenol toxicity, which can occur
in up to 50% of pts with acetaminophen induced fulminant hepatic
failure. Pt with primary AG metabolic acidosis from uremia. Pt
was started on HD for acidosis and continued on this for volume
overload. She was transiently given sodium bicarb supplements.
She was also given replacement dosing Vit D (Vit D=13)
supplements. Remainder of electrolytes stayed within normal
limits.  Pt had complete pre-HD workup with negative hepatitis
panel and PPD negative.  Starting [**2102-4-6**], her urine output
increased remarkably (~4-5L urine output daily) as she entered
the diuresis stage of ATN and HD was discontinued.  She required
fluid boluses to maintain euvolemia, and was encouraged to drink
2-3L of oral fluids until her urine output decreases.

#Septic Thrombophlebitis: Pt had left dorsum of hand septic
thrombophlebitis from IV line infection. 4 blood cultures
positve for GPC and she had fevers of 100.8. Pt was given
vancomycin IV with hemodialysis with goal trough 15-20. Given
development of thrombocytopenia, patient switched from
vancomycin to daptomycin. 1st dose of daptomycin 400 mg IV q48h
on [**2102-4-10**] and 2nd dose on [**2102-4-12**]. She received transthoracic
echocardiogram which did not show valvular vegetation.
Thrombophlebitis healed well and she will f/u with ID and
continue on daptomycin until [**2102-4-29**].

# Fulminant Hepatitis: secondary to ETOH coupled with
acetaminphen toxicity.  Completed course of NAC IV for 20 hrs
and had impressive improvement of hepatic function. Over course
of admission LFTs downtrended AST 20,000->35 and ALT 8000->50s.
INR and Tbili normalized.  Workup for other etiologies of
hepatitis was negative. She will follow with hepatology as
outpatient for further monitoring of liver failure.

# Pancreatitis: Likely secondary to ETOH. Over course of
admission, lipase downtrended 840->100->78. She was kept NPO
until abd pain improved and was given dilaudid for pain control.
MRCP showed no signs of necrosis or pseudocysts or complications
of pancreatits.  Her diet was advanced to regular which she
tolerated well.

# Altered Mental Status: Initially presented with somonlence
likely multifactorial: ETOH withdrawel, benzos, renal failure,
hepative failure.  Last drink [**3-21**] or [**3-22**]. She was initialy
started on CIWA and then weaned off. Pts mental status cleared
and she became lucid and was discharged with normal mental
status.

# Substance Abuse: Psych evaluated pt and did not see any signs
of suicidaility. They did not recommend antidepressents in the
setting of acute illness. Pt encouraged to continue psych follow
up after discharge.  She was quite anxious throughout her stay
requiring intermittent benzodiazepines.  These should be
discontinued one week after discharge (only 5 tabs provided upon
discharge) in order to avoid the possibility of continued
substance abuse.

# UTI: E. coli UTI sensitive to cipro. She completed 7 day
course for complicated cystitis.

# Hypertension: Pt with HTN (160s) and was started on amlodipine
5mg daily, which was later uptitrated to 7.5 mg daily.  She has
a PCP follow up appointment in 1 week at which time BP can be
evaluated and medication regimen changed if needed.

She was full code for this admission.  She will be discharged to
home (independently ambulating and was evaluated by physical
therapy) where her mother will be living with her for several
weeks to aid in her care.

Transition of Care:
-renal follow up: plan for complete recovering of renal
function. Continue to assess renal function regularly and urine
output.
-needs continued psych support for her drug addiction and
depressive issues
-needs continued follow up with hepatology service to continue
to assess liver
-needs PCP f/u for blood pressure management
-needs ID f/u for complete resolution of MRSA bacteremia,
Outpatient lab results planned and will be faxed to ID

Medications on Admission:
Vicodin (dose unknown)

Discharge Medications:
1. Outpatient Lab Work
Please draw the following once per week starting [**2102-4-17**] and
continuing through [**2102-5-7**]: CBC/diff, BUN, Cr, ESR, CRP, and fax
results to the [**Hospital **] clinic at ([**Telephone/Fax (1) 1353**], PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
at [**Telephone/Fax (1) 90248**] and her new nephrologist (name and fax # to be
determined).
2. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 6 weeks: use 14mg patch x6 weeks
then decrease to 7mg patch x2 weeks then stop.  YOU CANNOT SMOKE
WHILE ON THE PATCH.  Talk to your primary care for refills of
the patch in 2 weeks.
Disp:*14 Patch 24 hr(s)* Refills:*0*
4. amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (TU) for 7 weeks: Last dose to be taken [**5-23**], [**2102**].  After this, start taking 1000 units of vit D daily
(you can find this over the counter).
Disp:*7 Capsule(s)* Refills:*0*
6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q4H PRN () as needed for nausea.
Disp:*24 Tablet, Rapid Dissolve(s)* Refills:*0*
7. daptomycin 500 mg Recon Soln Sig: Four Hundred (400) mg
Intravenous q48H for 16 days: stop [**2102-4-29**].
Disp:*3600 mg* Refills:*0*
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for anxiety.
Disp:*5 Tablet(s)* Refills:*0*
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO three times a day: Please take WITH
MEALS.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
10. Daily PICC maintenance


Discharge Disposition:
Home With Service

Facility:
Community VNA

Discharge Diagnosis:
Fulmanent Hepatitic failure - secondary to alcohol and tylenol
Acute renal failure- acute tubular necrosis secondary to tylenol
Pancreatitis
MRSA bactermia
Normocytic anemia - due to renal failure
Alcohol withdrawl
Urinary Tract Infection
Alcohol abuse


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


Discharge Instructions:
You were admitted to the hospital for alcohol and tylenol
toxicity. Your liver, pancreas and kidneys were all severely
inflamed and affected by these drugs. We urge you to continue to
get help regarding your drinking and drug abuse problems. This
is very serious. Drugs can damage your organs and be fatal.

Your liver function gradually improved with time. You were given
NAC, a medicine to help oppose the dangerous effects that
tylenol has on the liver. You have an follow up appointment with
the liver center (Dr. [**Last Name (STitle) **] as detailed below.  Your liver
function tests will be completed at that time.

You had a pancreatitis which caused your abdominal pain. It
gradually improved and you tolerated a regular diet.

Your kidneys were not functioning normally and you were started
on hemodialysis temporarily to clear your body toxins.  However,
during your admission your kidney function has improved and you
are urinating which is a good prognostic sign.  You will not
need dialysis upon leaving the hospital, but you should follow
closely with your new kidney doctor.  Because you are urinating
a lot, please continue to drink 2-3 liters of fluid by mouth
daily until your urine output decreases.

You also developed an infection in your skin around an IV site
that resulted in a blood infection with Methicillin Resistant
Staph Aureus.  You received a PICC line and will be receiving
antibiotics until [**2102-4-29**] for this infection.  Home nursing
services will administer this antibiotic for you.  You received
an echocardiogram which did not show infection on the valves in
your heart.  You will follow up with the infectious disease
doctors [**Name5 (PTitle) 7928**].

You have anemia likely due to your kidney failure and received
blood transfusions.  As your kidney's recover, your anemia is
expected to improve.

Medication Changes:
START multivitamin 1 tab daily
START nicotine patch 14mg daily x6 weeks then 7mg daily x2 weeks
then stop.  YOU CANNOT SMOKE WHILE ON THE PATCH
START amlodipine 7.5mg daily
START vitamin D 50,000 units daily x7 weeks then vitamin D
1000units daily thereafter(this can be found over the counter)
START zofran 4mg by mouth every 4-6 hours as needed for nausea
START daptomycin 400mg IV every other day until [**2102-4-29**]
START lorazepam 0.5mg 1 tab at night for anxiety
START calcium carbonate 500mg three times daily (TAKE WITH
MEALS) - this is important to lower your phosphorus

It was a pleasure caring for you.  We wish you a speedy
recovery.

Followup Instructions:
The following appointments have been scheduled for you:

Name: [**Last Name (LF) 1112**],[**First Name3 (LF) 20**]
Location: [**Location (un) 90249**] MEDICAL CENTER
Address: [**Location (un) 90250**], [**Location (un) **],[**Numeric Identifier 90251**]
Phone: [**Telephone/Fax (1) 87481**]
Appointment: Tuesday [**2102-4-18**] 3:15pm

With: Dr. [**Last Name (STitle) 90252**] [**Name (STitle) 90253**]- Nephrologist
Location: [**Hospital3 8544**]- dept is out of the Wound Care Clinic
Address: [**Street Address(2) 90254**] [**Location (un) 8545**], [**Numeric Identifier 42074**]
Phone: [**Telephone/Fax (1) 71884**]
Appointment: Friday [**2102-4-21**] 11:00am

Department: INFECTIOUS DISEASE
When: TUESDAY [**2102-4-25**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: INFECTIOUS DISEASE
When: FRIDAY [**2102-5-19**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: LIVER CENTER
When: WEDNESDAY [**2102-5-24**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Completed by:[**2102-4-16**]
{'Toxic effect of ethyl alcohol,Acute and subacute necrosis of liver,Acute pancreatitis,Acute kidney failure with lesion of tubular necrosis,Methicillin resistant Staphylococcus aureus septicemia,Metabolic encephalopathy,Other ascites,Acidosis,Urinary tract infection, site not specified,Infection and inflammatory reaction due to other vascular device, implant, and graft,Poisoning by other opiates and related narcotics,Accidental poisoning by alcoholic beverages,Accidental poisoning by other opiates and related narcotics,Phlebitis and thrombophlebitis of upper extremities, unspecified,Bipolar disorder, unspecified,Tobacco use disorder,Other and unspecified alcohol dependence, unspecified,Other chronic pain,Disorders of bursae and tendons in shoulder region, unspecified,Thrombocytopenia, unspecified,Constipation, unspecified,Other specified anemias,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Substance abuse in family,Family history of psychiatric condition,Long-term (current) use of non-steroidal anti-inflammatories (NSAID)'}


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: Liver failure, kidney failure, and altered mental status

PRESENT ILLNESS: This is a 47-year-old woman with a pmhx. significant for alcohol
abuse and bipolar disorder who is transferred to [**Hospital1 18**] for acute
liver failure, acute kidney injury, and altered mental status.
According to records obtained from various outside facilities,
patient was brought into [**Hospital6 6640**] on [**2102-3-18**] by
a friend who was concerned that patient was "drinking a pint of
vodka" for the past 5 days.  At that time, patient declined
detox, and checked out of the hospital, stating that she would
follow-up with her outpatient therapist.  On [**3-19**], patient had a
normal chemistry panel (BUN of of 20, creatinine of 0.8), AST of
28, ALT of 27, acetaminophen level of <2.0 and serum alcohol
level of 360.  Patient denied SI and was discharged home.
.
The following day ([**3-20**]), patient was admitted to NORCAP Lodge
(detox facility) in [**Location (un) 26671**], where she was monitored for ETOH
and ?opiate withdrawal.  She was given clonidine (in tapered
doses), acetaminophen (total of 3 doses of 325mg over 2 days),
mylanta, benadryl, motrin, imodium, ativan, melatonin, reglan,
triaminic cold relief, and desyrel per withdrawal protocol.
Patient also reports taking "8 vicodin) on [**3-21**] for shoulder
pain, stating that she is prescribed 24 pills of vicodin/month
by her physician.  [**Name10 (NameIs) **] to healthcare providers at NORCAP,
patient complained of extreme nausea and abdominal pain on [**3-22**],
and she was transferred to [**Hospital3 **] for further work-up.
.
At [**Hospital3 **], patient was found to have a serum acetaminophen
level of <10 but positive urine level, an ETOH level of 10,
lipase of 798, bili of 1.9, AST of [**Numeric Identifier 16092**], ALT of 8010, and
ultrasound with trace ascites and normal portal and hepatic
flow.  Patient was given zofran, magnesium, and 9545mg of NAC
and transferred to [**Hospital1 18**].
.
In [**Hospital1 18**] ED, initial vitals were: 98.7 74 172/108 16 100%.  She
was given 2 L of IVF, 3.25grams of NAC, 4mg IV morphine, cipro
400mg for presumed UTI, and seen by transplant, hepatology, and
toxicology services.  LFTs were trending down with AST of [**Numeric Identifier 4731**],
ALT of 6585, LDH: 8245, and lipase of 840.  BUN/ creatinine was
47/4.7, and patient was making minimal concentrated urine.  RUQ
ultrasound showed good portal and hepatic flow, and CT abdomen
(without contrast) was remarkable only for pancreatic stranding.
 Patient was deemed not to be a transplant candidate due to her
current ETOH abuse, and was admitted to the MICU for further
work-up and treatment.

MEDICAL HISTORY: --ETOH abuse
--Bipolar disorder
--History of acetaminophen overdose as a teenager (was taking it
for menstrual cramps) and needed to get her "stomach pumped"

MEDICATION ON ADMISSION: Vicodin (dose unknown)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: Afebrile, HR: 73, BP 182/103 (though not accurate [**Location (un) 1131**] as
per nursing), SP02 92% on RA
GENERAL:  Somnolent, responsive to voice, no acute distress
HEENT: PEARLA, throat clear and non-erythematous
CHEST: Clear to auscultation bilaterally
CARDIAC: RRR, no murmurs, rubs, or gallops
ABDOMEN: +BS, diffusely tender, more so in RUQ
EXTREMITIES: Warm and dry, no edema bilaterally
NEURO: Knows she's in [**Location (un) 86**], thinks she's at [**Hospital1 112**], responsive to
voice

FAMILY HISTORY: According to outside notes, strong family history of alcoholism
and mother with depression.

SOCIAL HISTORY: Patient is reportedly a binge drinker.  As per notes from [**Hospital1 56809**], patient was sober for 8 years until [**2099**] when
she went through a divorce, death of a loved one, and lost her
job.  Other social history unable to be obtained due to
patient's mental status on admission. 

### Response:
{'Toxic effect of ethyl alcohol,Acute and subacute necrosis of liver,Acute pancreatitis,Acute kidney failure with lesion of tubular necrosis,Methicillin resistant Staphylococcus aureus septicemia,Metabolic encephalopathy,Other ascites,Acidosis,Urinary tract infection, site not specified,Infection and inflammatory reaction due to other vascular device, implant, and graft,Poisoning by other opiates and related narcotics,Accidental poisoning by alcoholic beverages,Accidental poisoning by other opiates and related narcotics,Phlebitis and thrombophlebitis of upper extremities, unspecified,Bipolar disorder, unspecified,Tobacco use disorder,Other and unspecified alcohol dependence, unspecified,Other chronic pain,Disorders of bursae and tendons in shoulder region, unspecified,Thrombocytopenia, unspecified,Constipation, unspecified,Other specified anemias,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Substance abuse in family,Family history of psychiatric condition,Long-term (current) use of non-steroidal anti-inflammatories (NSAID)'}
