CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: 57 F with Hep C cirrhosis, s/p liver transplant, recurrent
hepatic encephalopathy, admit with altered mental status. Her
husband found her to be confused early this morning and brought
her to the ED. Recently admitted from [**Date range (1) 90625**] at [**Hospital1 1774**] and
then again from about [**Date range (1) 84215**] at [**Hospital **] Hospital for hepatic
encephalopathy (also admitted on at least 2 other occasions in
[**Month (only) **]). Urine, blood, stool studies at [**Hospital1 1774**] admission
without evidence of infectious cause. No [**Doctor First Name 4397**] done. Per
summary, improved with just lactulose and rifaximin (thought
secondary to inadequate lactulose). Since most recent discharge,
husband reports she has been doing well, mental status much more
clear - conversant and appropriate, watched movie with him last
night. Husband gives all meds and reports that she has been med
compliant (including lactulose 60 ml Q4 hours except with break
at nighttime). Was at baseline when went to bed at 10pm; then
husband heard her wake up to go to BR at 1 am and was confused
with worsening gait (baseline some unsteadiness that husband
reports is multifactorial). No trauma, fever, abdominal pain,
cough, shortness of breath, urinary difficulties, headache.
.
Patient was in the process of setting up an appointment to see
Dr. [**Last Name (STitle) **] for purposes of transplant candidancy. Her
hepatologist is Dr. [**First Name8 (NamePattern2) 2174**] [**Last Name (NamePattern1) 1726**] at [**Hospital1 1774**] and she was
previously transplanted at [**Hospital1 1774**]; however, [**Hospital1 1774**] does not
perform second OLTs.
.
In the ED, initial VS were: 97.8, P78, 146/69, R19, 100% RA. She
was moaning and mumbling and minimally responsive but was
protecting her airway. Guaiac postive brown stool. Given
lactulose PR.

MEDICAL HISTORY: - Cirrhosis [**1-3**] Hep C; s/p OLT [**2172**] with recurrent hep C and
autoimmune hepatitis (seen on biopsy); s/p IFN/ribavirin in
past. Complicated by recurrent hepatic encephalopathy, SBP prior
to transplant per husband, GI bleeding (both BRBPR and melena,
last 3-4 months ago per husband, but per husband does not seem
that she has ever required blood transfusions etc).
- recurrent facial cellulitis of cheeks
- asthma
- DM
- HTN
- osteoporosis
- nephrolithiasis
- h/o C.diff
- zoster

MEDICATION ON ADMISSION: - cellcept [**Pager number **] mg daily
- prograf 0.5 mg QHS
- xifaxan 400 mg TID
- lactulose 60 ml Q 4 hours
- mag oxide 400 mg TID
- metoprolol 25 mg [**Hospital1 **]
- Tums 2 tab TID
- Prednisone 10 mg daily
- folate 1 mg daily
- MVI
- vitamin D daily
- protonix 40 mg daily
- lantus 8 units QHS
- Humalog sliding scale

ALLERGIES: Sulfisoxazole

PHYSICAL EXAM: Vitals: T95.6 (ax), 122/55, P72, R19, 100% RA
General: jaundiced, obtunded moaning, withdraws/moans to sternal
rub, minimally responsive to voice (moans).
HEENT: Pupils reactive, L sl larger than R (6->4 vs 5->3),
slight icterus. MM slightly dry. atraumatic.
NECK: supple, no adenopathy.
Chest: CTA anterolaterally, decreased at bases.
Heart: RRR, S1 S2, [**1-7**] SM at RUSB
Abdomen: +BS, soft, appears NT, not particularly distended, no
definite evidence of ascites. No masses. + OLT midline scar.
Extrem: trace to 1+ LE edema, warm.
Neuro: Obtunded, not following commands, responsive to pain as
above, moving all extremities spontaneously in bed.
.

FAMILY HISTORY: Mother with some type of liver disease and CHF.

SOCIAL HISTORY: Lives with husband. [**Name (NI) 4906**] denies etoh, smoking, drug use.
Complications of transplanted liver,Hepatic encephalopathy,Candidiasis of other urogenital sites,Cirrhosis of liver without mention of alcohol,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Osteoporosis, unspecified
Compl liver transplant,Hepatic encephalopathy,Candidias urogenital NEC,Cirrhosis of liver NOS,Anemia NOS,DMII wo cmp nt st uncntr,Hypertension NOS,Osteoporosis NOS
Admission Date:  [**2178-9-15**]              Discharge Date:   [**2178-9-21**]

Date of Birth:  [**2121-1-31**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfisoxazole

Attending:[**First Name3 (LF) 1580**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
None


History of Present Illness:
57 F with Hep C cirrhosis, s/p liver transplant, recurrent
hepatic encephalopathy, admit with altered mental status. Her
husband found her to be confused early this morning and brought
her to the ED. Recently admitted from [**Date range (1) 90625**] at [**Hospital1 1774**] and
then again from about [**Date range (1) 84215**] at [**Hospital **] Hospital for hepatic
encephalopathy (also admitted on at least 2 other occasions in
[**Month (only) **]). Urine, blood, stool studies at [**Hospital1 1774**] admission
without evidence of infectious cause. No [**Doctor First Name 4397**] done. Per
summary, improved with just lactulose and rifaximin (thought
secondary to inadequate lactulose). Since most recent discharge,
husband reports she has been doing well, mental status much more
clear - conversant and appropriate, watched movie with him last
night. Husband gives all meds and reports that she has been med
compliant (including lactulose 60 ml Q4 hours except with break
at nighttime). Was at baseline when went to bed at 10pm; then
husband heard her wake up to go to BR at 1 am and was confused
with worsening gait (baseline some unsteadiness that husband
reports is multifactorial). No trauma, fever, abdominal pain,
cough, shortness of breath, urinary difficulties, headache.
.
Patient was in the process of setting up an appointment to see
Dr. [**Last Name (STitle) **] for purposes of transplant candidancy. Her
hepatologist is Dr. [**First Name8 (NamePattern2) 2174**] [**Last Name (NamePattern1) 1726**] at [**Hospital1 1774**] and she was
previously transplanted at [**Hospital1 1774**]; however, [**Hospital1 1774**] does not
perform second OLTs.
.
In the ED, initial VS were: 97.8, P78, 146/69, R19, 100% RA. She
was moaning and mumbling and minimally responsive but was
protecting her airway. Guaiac postive brown stool. Given
lactulose PR.


Past Medical History:
- Cirrhosis [**1-3**] Hep C; s/p OLT [**2172**] with recurrent hep C and
autoimmune hepatitis (seen on biopsy); s/p IFN/ribavirin in
past. Complicated by recurrent hepatic encephalopathy, SBP prior
to transplant per husband, GI bleeding (both BRBPR and melena,
last 3-4 months ago per husband, but per husband does not seem
that she has ever required blood transfusions etc).
- recurrent facial cellulitis of cheeks
- asthma
- DM
- HTN
- osteoporosis
- nephrolithiasis
- h/o C.diff
- zoster


Social History:
Lives with husband. [**Name (NI) 4906**] denies etoh, smoking, drug use.

Family History:
Mother with some type of liver disease and CHF.

Physical Exam:
Vitals: T95.6 (ax), 122/55, P72, R19, 100% RA
General: jaundiced, obtunded moaning, withdraws/moans to sternal
rub, minimally responsive to voice (moans).
HEENT: Pupils reactive, L sl larger than R (6->4 vs 5->3),
slight icterus. MM slightly dry. atraumatic.
NECK: supple, no adenopathy.
Chest: CTA anterolaterally, decreased at bases.
Heart: RRR, S1 S2, [**1-7**] SM at RUSB
Abdomen: +BS, soft, appears NT, not particularly distended, no
definite evidence of ascites. No masses. + OLT midline scar.
Extrem: trace to 1+ LE edema, warm.
Neuro: Obtunded, not following commands, responsive to pain as
above, moving all extremities spontaneously in bed.
.


Pertinent Results:
[**2178-9-15**] abd u/s
1. Heterogeneous liver without focal liver lesions.
2. No evidence of ascites, thus no site marked for paracentesis.

3. Patent portal vein, with low velocity and bidirectionality of
flow during respiratory cycle.
4. Increased flow in the hepatic arteries.
5. Reversal of flow in splenic vein suggestive of portal
hypertension and
shunt.
.
Head CT [**9-15**]
Normal
.
CT abd [**9-19**]
1. Focal nodule abutting the left lateral lobe of the liver
which may
represent a splenule, however, an exophytic hepatocellular
carcinoma cannot be
entirely excluded. A nuclear medicine liver-spleen scan with
SPECT CT is
recommended for differentiation of these two possibilities.
Otherwise, no
arterially enhancing lesions to suggest hepatocellular carcinoma
identified.
2. Probable 2 mm aneurysm of the proper hepatic artery just
proximal to its bifurction. Calcified stenosis of the origin of
the left hepatic artery.
3. Splenorenal shunt and splenic artery aneurysm.
4. Gastric and paraesophageal varices.
5. Splenomegaly.
6. Anterior wedging fracture deformities of the T11 and T12
vertebral bodies.


[**2178-9-15**] 04:59AM BLOOD WBC-5.0 RBC-3.64* Hgb-10.8* Hct-33.6*
MCV-92 MCH-29.5 MCHC-32.0 RDW-17.0* Plt Ct-82*
[**2178-9-21**] 05:40AM BLOOD WBC-4.4 RBC-2.86* Hgb-9.0* Hct-26.4*
MCV-93 MCH-31.5 MCHC-34.0 RDW-17.4* Plt Ct-66*
[**2178-9-15**] 04:59AM BLOOD Neuts-56.6 Lymphs-30.2 Monos-6.2 Eos-6.8*
Baso-0.3
[**2178-9-17**] 07:10PM BLOOD Neuts-68.1 Lymphs-22.4 Monos-6.4 Eos-3.0
Baso-0.1
[**2178-9-15**] 04:59AM BLOOD PT-25.9* PTT-46.7* INR(PT)-2.6*
[**2178-9-20**] 05:25AM BLOOD PT-24.9* PTT-49.6* INR(PT)-2.4*
[**2178-9-17**] 07:10PM BLOOD Fibrino-90*
[**2178-9-15**] 04:59AM BLOOD Glucose-154* UreaN-22* Creat-0.9 Na-140
K-4.3 Cl-108 HCO3-28 AnGap-8
[**2178-9-21**] 05:40AM BLOOD Glucose-155* UreaN-20 Creat-0.9 Na-135
K-4.0 Cl-107 HCO3-24 AnGap-8
[**2178-9-17**] 07:10PM BLOOD Lipase-70* GGT-56*
[**2178-9-15**] 04:59AM BLOOD Albumin-2.5* Calcium-9.0 Phos-3.2 Mg-1.6
Iron-201*
[**2178-9-21**] 05:40AM BLOOD Calcium-9.1 Phos-4.3 Mg-1.2*
[**2178-9-15**] 04:59AM BLOOD calTIBC-242* VitB12-GREATER TH
Ferritn-220* TRF-186*
[**2178-9-17**] 07:10PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE
[**2178-9-17**] 01:42PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE
[**2178-9-17**] 01:42PM BLOOD Smooth-POSITIVE A
[**2178-9-17**] 07:10PM BLOOD CEA-5.3* AFP-4.9
[**2178-9-17**] 01:42PM BLOOD IgG-3727*
[**2178-9-17**] 07:10PM BLOOD HIV Ab-NEGATIVE
[**2178-9-15**] 04:59AM BLOOD tacroFK-7.4
[**2178-9-20**] 05:25AM BLOOD tacroFK-9.8
[**2178-9-17**] 07:10PM BLOOD HCV Ab-POSITIVE

Brief Hospital Course:
A/P: 57 F with history of Hep C cirrhosis s/p OLT in [**2172**] c/b
recurrence of cirrhosis and recurrent hepatic encephalopathy;
now admited with altered mental status improved on Rifaximin and
Lactulose.

# Altered mental status: In patient with known cirrhosis and
recurrent hepatic encephalopathy, AMS most likely again
represents severe hepatic encephalopathy. AMS improved
dramatically on Lactulose via NGT and Rifaximin with stool
output 1 liter per day. No ascites on US so no paracetesis
performed. Lytes, glucose, tox screen (other than APAP)
negative. Initially treated with NAC but given low suspicion for
tylenol overdose and other more likely etiologies of AMS was
discontinued. No evidence of obvious intracranial pathology on
NCHCT.  Trigger for this episode of encephalopathy unclear;
differential includes infection (including recurrent HCV, SBP),
autoimmune hepatic failure, GI bleed (known guaiac pos stools in
ED), medication noncompliance (though per husband's report seems
to have been very compliant), less likely portal venous
thrombosis.  Admitted with stage 3-4 encephalopathy now much
improved. Liver, transplant teams following. Blood and urine cx
pending at time of transfer. Lactulose 60 mL PO/NG TID, hold for
> 6BMs daily at time of transfer. Mental status had
significantly improved after lactulose and rifaximin; patient
A&Ox3 and followed all commands. She was transferred to the
floor and was A/OX3 for several days, ambulating around the unit
before being d/c'd.

# Cirrhosis.  History of Hep C with OLT in [**2172**] with subsequent
cirrhosis. Etiologies of recurrent cirrhosis include AIH vs.
recurrent Hep C. Seeking potential second OLT, hepatology and
transplant following, will consider OLT depending on etiology of
recurrent cirrhosis. Followed coags, LFTs, transaminases.
Transaminases stable. If remians elevated or any signs of
bleeding will give vitamin K. Discussed patient with her Liver
Transplant Team Nurse ([**Doctor First Name **] at [**Telephone/Fax (1) 62885**]) at [**Hospital3 **],
all old lab and pathology/biopsy reports were faxed to the [**Hospital1 **],
including all old HCV VL which did not include VLs past the
Spring of [**2175**]. At time of transfer, HCV viral loads, [**Doctor First Name **] and
[**Last Name (un) 15412**] for autoimmune hepatitis; and additional labs for
transplant acceptance were pending. Continued on
immunosuppresive agents (cellcept 1000mg qam and 500gm qpm,
prograf 0.5mg PO qHS, prednisone). Husband brought the actual
liver biopsy slides from [**Hospital1 1774**] and they were discussed at liver
pathology confernce.

# Transaminitis:  At or below most recent baseline, stable since
admission.  Thought to have some component of autoimmune
hepatitis ?rejection affecting transplant. Trasnaminitis
trending down. Tylenol level negative . DC'ed NAC since had such
significant improvement on lactulose and has other etiologies of
known liver disease.  Transaminases, AP, Tbili trended slowly
downward through hospitalization.

# Guaiac positive stools: Husband reports past history of GI
bleeds ?source - notes both melena and BRBPR.  Status of varices
unknown.  Guaiac positive but brown stools and no evidence of
very active bleed. Hct trended, decrease of 31-->26 on [**9-16**]
with increase to 28 without intervention. Corrected coagulopathy
with phytonadione.

# Anemia:  baseline from [**Hospital1 1774**] hospitalization is high 20's-low
30's.  Normocytic with normal iron, B12 on admission.  Hct
dropped for a time in the MICU but returned to baseline and
remained stable to time of d/c.
.
# DM.  On lantus and sliding scale.  No hypoglycemia. Continued
outpatient regimen with FSG QID.

# HTN. Continued home metoprolol.BP well controlled.

# ? Pulmonary nodule:  On  first CXR. Will need Outpatient
followup.

# FEN: Regular-Protein diet at time of transfer.

# PPX: PPI, pneumoboots

Code: Full


Medications on Admission:
- cellcept [**Pager number **] mg daily
- prograf 0.5 mg QHS
- xifaxan 400 mg TID
- lactulose 60 ml Q 4 hours
- mag oxide 400 mg TID
- metoprolol 25 mg [**Hospital1 **]
- Tums 2 tab TID
- Prednisone 10 mg daily
- folate 1 mg daily
- MVI
- vitamin D daily
- protonix 40 mg daily
- lantus 8 units QHS
- Humalog sliding scale


Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q4H
(every 4 hours).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
QAM (once a day (in the morning)).
7. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QPM (once a day (in the evening)).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
11. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QHS (once
a day (at bedtime)).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Insulin Glargine 100 unit/mL Solution Sig: Nine (9) Units
Subcutaneous at bedtime.
14. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 1 doses.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary
Hepatic encephalopathy
Recurrent cirrhosis

Secondary
Diabetes Mellitus type II
Hypertension


Discharge Condition:
Stable.


Discharge Instructions:
You have been diagnosed with hepatic encephalopathy. The exact
cause of your repeated episodes is unknown, but you will need to
continue taking your lactulose to have more than 3 bowel
movements per day. You also need to make sure to take your
rifaximin as prescribed. We increased your daily lantus
(insulin) dose to 9 units because your blood sugars were high,
otherwise we did not change your medications. You will hear from
Dr.[**Name (NI) 948**] office eventually regarding your transplant
eligibility status.

Please take all of your medications exactly as prescribed.

If you have any confusion, bleeding, dark stools, vomiting
blood, fevers, chills, night sweats, chest pain, abdominal pain
or any other concerning symptoms please call your doctor
immediately or go to the emergency department.

Followup Instructions:
Please call Dr.[**Name (NI) 948**] office for an appointment next week
([**Telephone/Fax (1) 3618**].

Please call Dr. [**Last Name (STitle) **] for an appointment in [**12-3**] weeks.
[**Doctor Last Name **],ZINAIDA [**Telephone/Fax (1) 7751**].


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1583**] MD, MSC, MPH[**MD Number(3) 1584**]

Completed by:[**2178-9-24**]
{'Complications of transplanted liver,Hepatic encephalopathy,Candidiasis of other urogenital sites,Cirrhosis of liver without mention of alcohol,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Osteoporosis, 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: altered mental status

PRESENT ILLNESS: 57 F with Hep C cirrhosis, s/p liver transplant, recurrent
hepatic encephalopathy, admit with altered mental status. Her
husband found her to be confused early this morning and brought
her to the ED. Recently admitted from [**Date range (1) 90625**] at [**Hospital1 1774**] and
then again from about [**Date range (1) 84215**] at [**Hospital **] Hospital for hepatic
encephalopathy (also admitted on at least 2 other occasions in
[**Month (only) **]). Urine, blood, stool studies at [**Hospital1 1774**] admission
without evidence of infectious cause. No [**Doctor First Name 4397**] done. Per
summary, improved with just lactulose and rifaximin (thought
secondary to inadequate lactulose). Since most recent discharge,
husband reports she has been doing well, mental status much more
clear - conversant and appropriate, watched movie with him last
night. Husband gives all meds and reports that she has been med
compliant (including lactulose 60 ml Q4 hours except with break
at nighttime). Was at baseline when went to bed at 10pm; then
husband heard her wake up to go to BR at 1 am and was confused
with worsening gait (baseline some unsteadiness that husband
reports is multifactorial). No trauma, fever, abdominal pain,
cough, shortness of breath, urinary difficulties, headache.
.
Patient was in the process of setting up an appointment to see
Dr. [**Last Name (STitle) **] for purposes of transplant candidancy. Her
hepatologist is Dr. [**First Name8 (NamePattern2) 2174**] [**Last Name (NamePattern1) 1726**] at [**Hospital1 1774**] and she was
previously transplanted at [**Hospital1 1774**]; however, [**Hospital1 1774**] does not
perform second OLTs.
.
In the ED, initial VS were: 97.8, P78, 146/69, R19, 100% RA. She
was moaning and mumbling and minimally responsive but was
protecting her airway. Guaiac postive brown stool. Given
lactulose PR.

MEDICAL HISTORY: - Cirrhosis [**1-3**] Hep C; s/p OLT [**2172**] with recurrent hep C and
autoimmune hepatitis (seen on biopsy); s/p IFN/ribavirin in
past. Complicated by recurrent hepatic encephalopathy, SBP prior
to transplant per husband, GI bleeding (both BRBPR and melena,
last 3-4 months ago per husband, but per husband does not seem
that she has ever required blood transfusions etc).
- recurrent facial cellulitis of cheeks
- asthma
- DM
- HTN
- osteoporosis
- nephrolithiasis
- h/o C.diff
- zoster

MEDICATION ON ADMISSION: - cellcept [**Pager number **] mg daily
- prograf 0.5 mg QHS
- xifaxan 400 mg TID
- lactulose 60 ml Q 4 hours
- mag oxide 400 mg TID
- metoprolol 25 mg [**Hospital1 **]
- Tums 2 tab TID
- Prednisone 10 mg daily
- folate 1 mg daily
- MVI
- vitamin D daily
- protonix 40 mg daily
- lantus 8 units QHS
- Humalog sliding scale

ALLERGIES: Sulfisoxazole

PHYSICAL EXAM: Vitals: T95.6 (ax), 122/55, P72, R19, 100% RA
General: jaundiced, obtunded moaning, withdraws/moans to sternal
rub, minimally responsive to voice (moans).
HEENT: Pupils reactive, L sl larger than R (6->4 vs 5->3),
slight icterus. MM slightly dry. atraumatic.
NECK: supple, no adenopathy.
Chest: CTA anterolaterally, decreased at bases.
Heart: RRR, S1 S2, [**1-7**] SM at RUSB
Abdomen: +BS, soft, appears NT, not particularly distended, no
definite evidence of ascites. No masses. + OLT midline scar.
Extrem: trace to 1+ LE edema, warm.
Neuro: Obtunded, not following commands, responsive to pain as
above, moving all extremities spontaneously in bed.
.

FAMILY HISTORY: Mother with some type of liver disease and CHF.

SOCIAL HISTORY: Lives with husband. [**Name (NI) 4906**] denies etoh, smoking, drug use. 

### Response:
{'Complications of transplanted liver,Hepatic encephalopathy,Candidiasis of other urogenital sites,Cirrhosis of liver without mention of alcohol,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Osteoporosis, unspecified'}
