CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 41 year old
white female with end stage liver disease secondary to
primary sclerosing cholangitis plus auto immune hepatitis
overlap with cirrhosis and hypertension who was complaining
of vomiting which had begun the morning of her admission
date.  The patient stated that she had felt ill over the past
night and after eating breakfast today had some projectile
vomiting.  She had a total of two episodes of emesis.  She
denied any nausea, blood in her emesis or bile in her emesis.
The patient also complained of intermittent belly pain which
she could not localize.  She also had diarrhea, although she
attributed this to being on Lactulose.  She noted that her
belly had gotten larger over the past few days and that she
has found it harder to concentrate recently.  She also
complained of weight loss since being discharged on [**9-8**], just three days previously from [**Hospital6 649**], where she had been a patient for
approximately three weeks for treatment of hyponatremia
secondary to diuretic use, anemia secondary to
gastrointestinal bleeding, coagulopathy secondary to end
stage liver disease, and resulting pulmonary and peripheral
edema secondary to discontinuing diuretics.  With respect to
this current admission the patient states that in addition to
the symptoms mentioned above, she also has noted some
blood-tinged sputum of yellowish color when she coughs.  She
denies any shortness of breath but states that she has been
generally winded and tired recently.  She denies any urinary
symptoms.

MEDICAL HISTORY: 1.  Primary sclerosing
cholangitis/auto immune hepatitis overlap, causing end stage
liver disease diagnosed in [**2164**], sequelae includes massive
hemorrhoids, encephalopathy and ascites; 2.  Hypertrophic
pulmonary osteoarthropathy; 3.  Lower back disc herniation;
4.  Duodenal ulcers, status post esophagogastroduodenoscopy.

MEDICATION ON ADMISSION: 

ALLERGIES: Questionable allergy to Sulfa.

PHYSICAL EXAM: 

FAMILY HISTORY: Non-contributory, the patient has two
children, ages 5 and 3 who are alive and well.

SOCIAL HISTORY: The patient denies alcohol, tobacco or drug
use.
Acute and subacute necrosis of liver,Other chronic hepatitis,Cholangitis,Hyposmolality and/or hyponatremia,Acute kidney failure with lesion of tubular necrosis,Acute pancreatitis,Intestinal infection due to Clostridium difficile,Other postoperative infection
Acute necrosis of liver,Chronic hepatitis NEC,Cholangitis,Hyposmolality,Ac kidny fail, tubr necr,Acute pancreatitis,Int inf clstrdium dfcile,Other postop infection
Admission Date:  [**2167-9-11**]       Discharge Date:

Date of Birth:   [**2126-4-23**]       Sex:  F

Service:  Medicine-[**Hospital1 139**] Firm

HISTORY OF PRESENT ILLNESS:  The patient is a 41 year old
white female with end stage liver disease secondary to
primary sclerosing cholangitis plus auto immune hepatitis
overlap with cirrhosis and hypertension who was complaining
of vomiting which had begun the morning of her admission
date.  The patient stated that she had felt ill over the past
night and after eating breakfast today had some projectile
vomiting.  She had a total of two episodes of emesis.  She
denied any nausea, blood in her emesis or bile in her emesis.
The patient also complained of intermittent belly pain which
she could not localize.  She also had diarrhea, although she
attributed this to being on Lactulose.  She noted that her
belly had gotten larger over the past few days and that she
has found it harder to concentrate recently.  She also
complained of weight loss since being discharged on [**9-8**], just three days previously from [**Hospital6 649**], where she had been a patient for
approximately three weeks for treatment of hyponatremia
secondary to diuretic use, anemia secondary to
gastrointestinal bleeding, coagulopathy secondary to end
stage liver disease, and resulting pulmonary and peripheral
edema secondary to discontinuing diuretics.  With respect to
this current admission the patient states that in addition to
the symptoms mentioned above, she also has noted some
blood-tinged sputum of yellowish color when she coughs.  She
denies any shortness of breath but states that she has been
generally winded and tired recently.  She denies any urinary
symptoms.

PAST MEDICAL HISTORY:  1.  Primary sclerosing
cholangitis/auto immune hepatitis overlap, causing end stage
liver disease diagnosed in [**2164**], sequelae includes massive
hemorrhoids, encephalopathy and ascites; 2.  Hypertrophic
pulmonary osteoarthropathy; 3.  Lower back disc herniation;
4.  Duodenal ulcers, status post esophagogastroduodenoscopy.

FAMILY HISTORY:  Non-contributory, the patient has two
children, ages 5 and 3 who are alive and well.

SOCIAL HISTORY:  The patient denies alcohol, tobacco or drug
use.

MEDICATIONS PRIOR TO ADMISSION:
1.  Multivitamin one a day
2.  Vitamin D 400 units q.d.
3.  Calcium carbonate 800 mg q.i.d.
4.  Estradiol 600 mg b.i.d.
5.  Protonix 40 mg b.i.d.
6.  Aldactone 100 mg q.d.
7.  [**Doctor First Name 233**]-Ciel 20 mg q.d.
8.  Levaquin 500 mg q.d.
9.  Lactulose 30 cc q.i.d.
10. Lasix 40 mg p.o. q.d.
11. Carafate 1 gm q.i.d.
12. Mycelex 5 times a day
13. Magnesium oxide 400 mg b.i.d.

ALLERGIES:  Questionable allergy to Sulfa.

PHYSICAL EXAMINATION:  Vital signs, temperature 99.2, blood
pressure 92/50, heartrate 76, respiratory rate 18.  In
general, ill-appearing, tired jaundiced thin female in no
apparent distress.  Head, eyes, ears, nose and throat, yellow
ictera, pupils equally round and reactive to light and
accommodation.  Jaundiced under the tongue, no thrush.  Neck
was supple with no masses or jugulovenous distension.
Cardiac examination, regular rate and rhythm, no rubs or
gallops but a III/VI murmur present at the left sternal
border.  Pulmonary examination, clear to auscultation
bilaterally.  Abdomen, positive bowel sounds, abdomen is
distended but soft.  Positive splenomegaly.  Extremities, no
cyanosis or edema, positive clubbing.

LABORATORY DATA:  Laboratory data on admission showed white
blood cell count 5, hemoglobin 10.9, hematocrit 31.5,
platelets 60, MCV 92, sodium 134, potassium 3.9, chloride
100, bicarbonate 28, BUN 21, creatinine 1.0, glucose 78, PT
17.1, INR 2.0, PTT 43.5, calcium 7.7, phosphorus 2.7,
magnesium 1.8.  ALT 59, AST 90, alkaline phosphatase 169,
amylase 118, total bilirubin 25.

ASSESSMENT/PLAN:  The patient is a 41 year old female with
end stage liver disease, admitted directly from clinic after
presenting with a complaint of vomiting.  The differential
diagnosis that was generated to explain the patient's
vomiting included gastric outlet obstruction, biliary
obstruction, infection, gastrointestinal bleed, portal vein
thrombosis and ascites and medication side effects.

HOSPITAL COURSE:  The patient received an adequate workup in
the hospital and the following is a system by system account
of what took place:

1.  Gastrointestinal/hepatology - The patient's nausea and
vomiting was worked up.  Esophagogastroduodenoscopy was
performed the day of admission and was negative for any new
bleed, erosion or mass.  An ultrasound of the abdomen was
also done to evaluate for portal vein thrombosis and ascites
but it too was negative.  Because the patient's bilirubin was
elevated a cholestatic or hepatic etiology was also feared.
However, magnetic resonance cholangiopancreatography of the
liver and gallbladder revealed no obstructive strictures,
although in general the ductal distribution appeared to be
more affected than previously.  The patient was also worked
up for infectious etiologies of her nausea and vomiting and
those we mentioned below in the infectious disease section.
With respect to the patient's hepatobiliary disease, it is
important to note that the patient's ALT was elevated ranging
from 98 to 111 throughout the hospitalization; likewise her
AST was also elevated and ranged from 136 to 212.  The
patient's LDH was high and ranged from 225 to 316; alkaline
phosphatase ranged from 189 to 227.  Total bilirubin ranged
from 35.6 to 42.5, and albumin was 2.1 to 2.8.  The bilirubin
was fractionated and shown to be mostly direct bilirubin
although both direct and indirect bilirubins were increased.
With respect to pancreatic enzymes, lipase ranged from 52 to
160 whereas amylase ranged from 85 to 150 during the
hospitalization.  On hospital day #4 the patient was noted to
have asterixes, as well as experiencing changes in her mental
status, i.e. lethargy, slurred speech.  The patient's regimen
of Lactulose was increased so as to have four to six bowel
movements per day.  Within a few days the patient's
encephalopathy improved as there were no asterixes found on
examination by hospital day #8.

2.  Fluids, electrolytes and nutrition - On hospital day #2
the patient developed hyponatremia, perhaps secondary to
diuretic use as the patient had developed before in a prior
admission.  The sodium on [**9-12**] was 125.  The patient
complained of fatigue and still some nausea but did not show
any other signs or symptoms of hyponatremia.  The
hyponatremia had been treated since then with fluid
restriction of 1 to 1.5 liters, holding all diuretics,




                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.

Dictated By:[**Last Name (NamePattern1) 1595**]
MEDQUIST36

D:  [**2167-9-18**]  20:40
T:  [**2167-9-18**]  20:49
JOB#:  [**Job Number 32981**]


Admission Date:  [**2167-9-11**]       Discharge Date:  [**2167-10-9**]

Date of Birth:   [**2126-4-23**]       Sex:  F

Service:Liver Transplant Service
PRINCIPAL DIAGNOSIS:
End stage liver disease secondary to primary sclerosing
cholangitis and/or autoimmune hepatitis requiring orthotopic
transplant during this admission.

dictated summary of [**Hospital 228**] hospital course covering period
[**2167-9-11**] to [**2167-9-21**] for history of present illness, past
medical history, family history, social history, medications
on admission, initial physical examination and early hospital
course.

HOSPITAL COURSE FROM [**2167-9-21**] THROUGH [**2167-10-9**]:  The patient
[**2167-9-21**] (hospital day number eleven).  The patient was
subsequently transferred to the Intensive Care Unit.  Notable
events while in the Intensive Care Unit from [**2167-9-21**] through
[**2167-9-25**] include acute renal failure attributed to acute
tubular necrosis manifested by gradually worsening
creatinine, peaking at 3.6 on [**2167-9-24**] and then improving to
baseline of 1.0 by the day of discharge.  In the Intensive
Care Unit, the patient was also started on total parenteral
nutrition.  On discharge from the Intensive Care Unit on
postoperative day number five the patient was alert and
oriented, tolerating ice chips and sips with medications.
She was noted to be anxious and emotionally labile at times.
By system, following the notable events during the rest of
her hospital stay.

1.  Hepatic/transplant:  The patient was started on an
immunosuppression regimen of CellCept, Cyclosporin and
Prednisone in the postoperative period and she was also on
Rapamycin briefly.  The patient's liver function tests were
noted to trend downward steadily.  Optimal Cyclosporin dosing
was still to be determined on the day of discharge, but it
was expected with continue to monitoring Cyclosporin levels
following discharge.  This should be completed soon.  The
patient is to be discharged on Cyclosporin dose of 175 mg
b.i.d.  The patient's incision was monitored for infection in
collaboration with the Infectious Disease Service during the
immediate postop period.  It went from purulent drainage as
noted from the unction point of her [**Last Name (un) 8314**] incision.
Culture swabs from the incision were unremarkable and the
drainage was minimal by the day of discharge.  The patient
was not treated with antibiotics specifically targeting this
incision and dry gauze dressing was used to cover the
draining area prn.  The incision will need to be monitored
for evidence of developing or worsening infection.  The
patient's post surgical abdominal pain was managed with
Percocet one to two tablets every four to six hours as needed
for pain with good relief.  The patient had some residual
ascites by the date of discharge.

2.  Gastrointestinal:  The patient was reported to have had
an episode of pancreatitis in the immediate postoperative
period, but this was resolved by the time of the [**Hospital 228**]
transfer to the floor on postop day number five.  The patient
was started on a regular diet on postoperative day number
five and her total parenteral nutrition was discontinued.
The patient's appetite was, however, noted to be poor in the
period immediately after initiation of regular diet by mouth.
This was confirmed by a calorie count and the decision was
made to initiate cycled tube feedings on postoperative day
number eight with Mepro.  Preference was given to a low
potassium formula given the patient's hyperkalemia during
that period.  The patient's appetite remained marginal on the
day of discharge and continued tube feeding as likely to be
needed in the short term.  A calorie count on the day prior
to the patient's discharge revealed the patient was only
meeting 6% of her protein needs by mouth and only 22% of her
caloric needs.

3.  Renal:  As mentioned above the patient's acute renal
failure resolved steadily with serum creatinine falling from
a peak of 3.6 on postoperative day number three to a baseline
of about 1 by postoperative day number fifteen.

4.  Infectious disease:  The patient's stool tested positive
for C-difficile on her day of admission and [**2167-9-11**] and the
patient was started on treatment for this infection.  By
hospital day number two the day prior to surgery the
patient's stool was negative for C-difficile.  The decision
was made to keep the patient on prophylaxis against this
infection following surgery to complete a fourteen day
course.  Out of concern about the ability of her gut to
adequately absorb, the patient was double covered with po
Vancomycin and intravenous Flagyl.  C-difficile toxin
performed on postoperative day number ten were negative.  The
patient's intravenous Flagyl was discontinued and po
Vancomycin continued to postoperative day number fourteen.
The patient was also on standard post transplant prophylactic
antibiotics.  Valcyte, Bactrim and Fluconazole.

5.  Respiratory:  No issues on this admission.

6.  Hematology:  The patient required platelet transfusion on
postop day number three and seven, but by the time of
discharge her platelet count was increasing.  The patient
required transfusions for decreases in hematocrit on postop
day number fourteen and seventeen.  The patient was evaluated
for a source of bleeding, none could be identified.  Her
stool was guaiac negative.  The patient's hematocrit will
need to be monitored following discharge.

7.  Endocrine:  The patient's blood glucose levels were
controlled with insulin on a sliding scale.  Her insulin
requirements were noted to be increasing on postoperative day
number thirteen through fourteen.  Her sliding scale coverage
was increased and the [**Hospital **] Clinic consult team was asked to
see her.. Their recommendations included placing the patient on
six units of NPH at breakfast and dinner and continued the use of
sliding scale insulin. The patient's diabetic teaching was
deferred for fear of overwhelming the patient.  It is believed
that the patient's current high blood glucose may be attributable
to some of her immunosuppressive medications and may resolve in
two to three months.  Arrangements were made for the patient to
visit the [**Hospital **] Clinic for appointments on days to coincide with
her visits to the [**Hospital1 69**] Transplant
Center.  TSH level was noted to increase from 1.2 on [**2167-9-18**]
to 14 on [**2167-10-3**] and ultimately to 25 on [**2167-10-7**].  The cause
for the increase in TSH was unclear, but thyroid function
tests were drawn on the day prior to admission and follow up
is expected from the [**Hospital **] Clinic.  The patient was started
on a minimal dose of Synthroid at 0.125 mg q.d. to be
discontinued if this medication is deemed unnecessary.

8.  Musculoskeletal:  The patient was seen by physical
therapy following transfer to the floor from the Intensive
Care Unit and with therapy the patient was ultimately able to
ambulate safely and independently on the floor with a walker.
It is anticipated that she will continue to receive physical
therapy following discharge.

9.  Fluid and electrolytes:  The patient was noted to be
hypokalemic with serum potassium in the 5 to 7 range from
postoperative day number eight through fifteen, requiring use
of Kayexalate twice during that period, and administration of
Lasix with the duel purpose of treating hyperkalemia and
assisting in diuresis of the patient.  The patient was stable
on telemetry during the period of highest serum potassium.
The etiology for the hyperkalemia was unclear, although it
was believed that the patient's ongoing treatment with
Fluconazole, Cyclosporin and Vancomycin were contributing
factors.  The patient's potassium was down to within normal
limits by the day of discharge.  The patient was also started
on 800 mg of magnesium by mouth twice a day when her
magnesium levels were noted to be trending downward.  Her
magnesium levels will need to be monitored following
discharge.

10.  Neurological:  The patient was at times noted to be
anxious and emotionally labile by staff (intermittent crying
episodes, expressions of frustration and difficulty coping).
Neuro/psychiatric evaluation was requested prior to the
patient's discharge.  Findings from evaluation included the
fact that the patient had deficits in memory, visual planning
and organization as well as flexibility of attention and
naming and as such is prone to confusion.  The patient will
need to be followed up, preferably by a local psychiatrist in
[**Doctor Last Name 792**]after discharge.  In the interim she will
continue to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10166**] here at the [**Hospital1 346**].

DISCHARGE MEDICATIONS:  CellCept 1 gram b.i.d., prednisone 15
mg po q.d., Neural 175 mg b.i.d., Lasix 40 mg po q.d.,
Protonix 40 mg b.i.d., Bactrim double strength one tablet
q.d., Fluconazole 400 mg q.d., Valcyte 450 mg b.i.d.,
magnesium oxide 800 mg b.i.d., Seraquel 25 mg q.h.s.,
Percocet 5 mg one to two tabs po q 4 to 6 hours prn, Colace
100 mg b.i.d., NPH insulin 9 units subQ at breakfast and 6
units subQ at dinner as well as sliding scale insulin.

DISCHARGE CONDITION:  Stable.

FOLLOW UP LABORATORY REQUIREMENTS:  The patient will need to
have blood drawn for the following tests every Monday and
Thursday, a CBC, chem 7, albumin, AST, ALT, alkaline
phosphatase, total bilirubin, direct bilirubin, cyclosporin.
The results of these tests should be faxed to Dr. [**Last Name (STitle) **] at
fax number [**Telephone/Fax (1) 697**].  The patient's blood glucose will
need to be checked four times a day with coverage of sliding
scale insulin.

FOLLOW UP:  1.  The patient will need follow up with her
primary transplant surgeon Dr. [**Last Name (STitle) **] with her first
appointment at 10:00 a.m. on [**10-14**] and a further appointment
at 9:30 a.m. on [**10-21**].  Dr.[**Name (NI) 1369**] office number is
[**Telephone/Fax (1) 673**].  2.  The patient needs to follow up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10166**] of Psychiatry here at the [**Hospital1 190**] for the next three months.  3.  The patient
needs to be linked up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], a psychiatrist
for complete neuro/psych evaluation following discharge.  4.
The patient will need to follow up at the [**Hospital **] Clinic for
diabetic teaching.  Her first appointment is scheduled for
[**2167-11-4**] on Wednesday at 9:00 a.m. with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] nurse
educator at the clinic.  At 10:00 a.m. on that same day she
is to see [**Last Name (un) **] physician on the [**Location (un) 1773**] of the [**Last Name (un) **]
Center.






                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D.  02-366

Dictated By:[**Name8 (MD) 997**]
MEDQUIST36

D:  [**2167-10-9**]  08:08
T:  [**2167-10-9**]  08:35
JOB#:  [**Job Number 32982**]
{'Acute and subacute necrosis of liver,Other chronic hepatitis,Cholangitis,Hyposmolality and/or hyponatremia,Acute kidney failure with lesion of tubular necrosis,Acute pancreatitis,Intestinal infection due to Clostridium difficile,Other postoperative infection'}


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: 

PRESENT ILLNESS: The patient is a 41 year old
white female with end stage liver disease secondary to
primary sclerosing cholangitis plus auto immune hepatitis
overlap with cirrhosis and hypertension who was complaining
of vomiting which had begun the morning of her admission
date.  The patient stated that she had felt ill over the past
night and after eating breakfast today had some projectile
vomiting.  She had a total of two episodes of emesis.  She
denied any nausea, blood in her emesis or bile in her emesis.
The patient also complained of intermittent belly pain which
she could not localize.  She also had diarrhea, although she
attributed this to being on Lactulose.  She noted that her
belly had gotten larger over the past few days and that she
has found it harder to concentrate recently.  She also
complained of weight loss since being discharged on [**9-8**], just three days previously from [**Hospital6 649**], where she had been a patient for
approximately three weeks for treatment of hyponatremia
secondary to diuretic use, anemia secondary to
gastrointestinal bleeding, coagulopathy secondary to end
stage liver disease, and resulting pulmonary and peripheral
edema secondary to discontinuing diuretics.  With respect to
this current admission the patient states that in addition to
the symptoms mentioned above, she also has noted some
blood-tinged sputum of yellowish color when she coughs.  She
denies any shortness of breath but states that she has been
generally winded and tired recently.  She denies any urinary
symptoms.

MEDICAL HISTORY: 1.  Primary sclerosing
cholangitis/auto immune hepatitis overlap, causing end stage
liver disease diagnosed in [**2164**], sequelae includes massive
hemorrhoids, encephalopathy and ascites; 2.  Hypertrophic
pulmonary osteoarthropathy; 3.  Lower back disc herniation;
4.  Duodenal ulcers, status post esophagogastroduodenoscopy.

MEDICATION ON ADMISSION: 

ALLERGIES: Questionable allergy to Sulfa.

PHYSICAL EXAM: 

FAMILY HISTORY: Non-contributory, the patient has two
children, ages 5 and 3 who are alive and well.

SOCIAL HISTORY: The patient denies alcohol, tobacco or drug
use. 

### Response:
{'Acute and subacute necrosis of liver,Other chronic hepatitis,Cholangitis,Hyposmolality and/or hyponatremia,Acute kidney failure with lesion of tubular necrosis,Acute pancreatitis,Intestinal infection due to Clostridium difficile,Other postoperative infection'}
