CHIEF COMPLAINT: # Lethargy
# Confusion
# Hyponatremia

PRESENT ILLNESS: 48F h/o Hep C cirrhosis c/b ascites, encephalopathy and BLE
edema, presented to clinic with lethargy, Na = 113.  Pt reported
that her mother, who helps pt manage her pills, also noted that
pt was "making no sense" this morning.  Pt denied any recent
alcohol or drug intake, and reported that she had a productive
cough with somewhat yellow sputum.  Pt reported that she had not
been having three bowel movements daily, and at least one day
had no stools.
.
In the ED, she was oriented x 2, with positive asterixis.  Pt
received albumin 50g.
.
On first arrival to the floor, pt denied fever, vomiting,
diarrhea, dysuria, bloody stool, joint pain, muscle pain, sore
throat, or changes in vision.  Pt endorsed hunger, fatigue,
tremors, and dizziness.  It was unclear whether pt endorsed or
denied nausea as her account changed, and she was not focused
during the interview.  Pt conducted her admission interview with
her eyes closed, and spoke in a shaky mumble throughout.

MEDICAL HISTORY: (1) Hepatitis C cirrhosis
--Encephalopathy
--Ascites
--Edema s/p TIPS ([**11-8**])
--Hydrothorax
--Thrombocytopenia
--Hyponatremia (baseline 124-128)
(2) Asthma
(3) Adrenal insufficiency [**1-7**] ESLD
(4) GERD
(5) Anxiety

MEDICATION ON ADMISSION: Lactulose 30 g q8H PRN
Hydroxyzine HCl 25 mg q6H PRN for bilirubin-related itch
Rifaximin 400 mg TID
Albuterol PRN
Ferrous Sulfate 325 mg daily
Clotrimazole 10 mg Troche QID
Montelukast 10 mg daily
Oxybutynin Chloride 5 mg [**Hospital1 **]
Fluticasone-Salmeterol 100-50 mcg/dose [**Hospital1 **]
Pseudoephedrine HCl 30 mg q6H PRN
Lidocaine 5 %(700 mg/patch) patch daily
Lorazepam 0.5 mg [**Hospital1 **] PRN
Clonidine 0.1 mg [**Hospital1 **]
Prednisone 5 mg DAILY
Pantoprazole 40 mg EC DAILY
Glipizide 5 mg [**Hospital1 **]
Prochlorperazine 10 mg q8H PRN
Spironolactone 50 mg daily
Furosemide 20 mg daily
Metoclopramide 10 mg TID PRN

ALLERGIES: Shellfish / Flexeril

PHYSICAL EXAM: VS = T 97.1, BP 106/50, HR 83, RR 26, O2 96%, FS 148
GEN: Tremulous in bed with covers pulled up and eyes closed
throughout the interview
HEENT: Scleral ictera, MMM, CN II-XII grossly normal
CV: RRR, S1S2, III/VI SEM, no r/g
PULM: CTA @ L, decreased breath sounds at R base, no
rales/rhonchi/wheezes
ABD: BS+, soft, NT, protuberant, no rebound.  Tympanic.
EXT: 3+ BLE edema.  + asterixis.
NEURO: Slow to respond.  A&O x 3.  Could not remember three
words.

FAMILY HISTORY: # Mother, 60s: DM2, HTN, hypercholesterolemia
# Father, d. 51: COPD, alcohol-induced cirrhosis
# Brother

SOCIAL HISTORY: # Recreational drugs: Past IV drug use with needle sharing, last
use 7 years ago.  Past drug-snorting.
# Alcohol: Past alcohol use, last drink at age 46.
# Tobacco: Past [**Month/Day (2) 1818**] with 10 pack-year history
# Personal: Single with one child.  Lives with mother, who
manages medications
# Employment: Former waitress, unemployed on disability.
Pneumonitis due to inhalation of food or vomitus,Chronic hepatitis C with hepatic coma,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Thrombocytopenia, unspecified,Other and unspecified coagulation defects,Other pulmonary insufficiency, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Carrier or suspected carrier of other specified infectious organism,Anemia, unspecified,Esophageal reflux,Other specified hypotension,Other and unspecified mycoses
Food/vomit pneumonitis,Chrnc hpt C w hepat Coma,Hyposmolality,Urin tract infection NOS,Thrombocytopenia NOS,Coagulat defect NEC/NOS,Other pulmonary insuff,DMII wo cmp nt st uncntr,Asthma NOS,Carrier NEC,Anemia NOS,Esophageal reflux,Hypotension NEC,Mycoses NEC & NOS
Admission Date:  [**2157-7-5**]              Discharge Date:   [**2157-8-4**]

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

Service: MEDICINE

Allergies:
Shellfish / Flexeril

Attending:[**First Name3 (LF) 949**]
Chief Complaint:
# Lethargy
# Confusion
# Hyponatremia

Major Surgical or Invasive Procedure:
# MICU intubation
# L arm PICC placement
# Bedside [**Last Name (un) **]-gastric tube placement
# Fluoroscopy-guided [**Last Name (un) **]-jejunal tube placement


History of Present Illness:
48F h/o Hep C cirrhosis c/b ascites, encephalopathy and BLE
edema, presented to clinic with lethargy, Na = 113.  Pt reported
that her mother, who helps pt manage her pills, also noted that
pt was "making no sense" this morning.  Pt denied any recent
alcohol or drug intake, and reported that she had a productive
cough with somewhat yellow sputum.  Pt reported that she had not
been having three bowel movements daily, and at least one day
had no stools.
.
In the ED, she was oriented x 2, with positive asterixis.  Pt
received albumin 50g.
.
On first arrival to the floor, pt denied fever, vomiting,
diarrhea, dysuria, bloody stool, joint pain, muscle pain, sore
throat, or changes in vision.  Pt endorsed hunger, fatigue,
tremors, and dizziness.  It was unclear whether pt endorsed or
denied nausea as her account changed, and she was not focused
during the interview.  Pt conducted her admission interview with
her eyes closed, and spoke in a shaky mumble throughout.

Past Medical History:
(1) Hepatitis C cirrhosis
--Encephalopathy
--Ascites
--Edema s/p TIPS ([**11-8**])
--Hydrothorax
--Thrombocytopenia
--Hyponatremia (baseline 124-128)
(2) Asthma
(3) Adrenal insufficiency [**1-7**] ESLD
(4) GERD
(5) Anxiety

Social History:
# Recreational drugs: Past IV drug use with needle sharing, last
use 7 years ago.  Past drug-snorting.
# Alcohol: Past alcohol use, last drink at age 46.
# Tobacco: Past [**Month/Day (2) 1818**] with 10 pack-year history
# Personal: Single with one child.  Lives with mother, who
manages medications
# Employment: Former waitress, unemployed on disability.


Family History:
# Mother, 60s: DM2, HTN, hypercholesterolemia
# Father, d. 51: COPD, alcohol-induced cirrhosis
# Brother

Physical Exam:
VS = T 97.1, BP 106/50, HR 83, RR 26, O2 96%, FS 148
GEN: Tremulous in bed with covers pulled up and eyes closed
throughout the interview
HEENT: Scleral ictera, MMM, CN II-XII grossly normal
CV: RRR, S1S2, III/VI SEM, no r/g
PULM: CTA @ L, decreased breath sounds at R base, no
rales/rhonchi/wheezes
ABD: BS+, soft, NT, protuberant, no rebound.  Tympanic.
EXT: 3+ BLE edema.  + asterixis.
NEURO: Slow to respond.  A&O x 3.  Could not remember three
words.


Pertinent Results:
Admission labs:
.
[**2157-7-5**] 12:19PM   GLUCOSE-137* K+-4.3
[**2157-7-5**] 12:00PM   GLUCOSE-155* UREA N-18 CREAT-0.8 SODIUM-113*
POTASSIUM-4.4 CHLORIDE-89* TOTAL CO2-18* ANION GAP-10
[**2157-7-5**] 12:00PM   estGFR-Using this
[**2157-7-5**] 12:00PM   ALT(SGPT)-54* AST(SGOT)-101* ALK PHOS-377*
AMYLASE-69 TOT BILI-19.6*
[**2157-7-5**] 12:00PM   ALBUMIN-2.3* CALCIUM-7.7* PHOSPHATE-3.1
MAGNESIUM-1.9
[**2157-7-5**] 12:00PM   ETHANOL-NEG bnzodzpn-NEG
[**2157-7-5**] 12:00PM   WBC-7.7# RBC-2.90* HGB-10.0* HCT-28.9*
MCV-100* MCH-34.5* MCHC-34.5 RDW-19.4*
[**2157-7-5**] 12:00PM   NEUTS-83* BANDS-0 LYMPHS-10* MONOS-3 EOS-3
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2157-7-5**] 12:00PM   HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-2+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SCHISTOCY-OCCASIONAL BURR-2+ BITE-OCCASIONAL
ACANTHOCY-OCCASIONAL
[**2157-7-5**] 12:00PM   PLT COUNT-65*
[**2157-7-5**] 12:00PM   PT-23.8* PTT-50.5* INR(PT)-2.4*
.
# CXR [**2157-7-9**]:
Multifocal patchy opacities seen in the left upper and lower
lung
zones, with cardiomegaly.  This may represent asymmetric
pulmonary edema; however, aspiration/pneumonia cannot be
excluded.  The ill-defined opacity in the right upper lung zone
seen on the prior study has resolved.  A TIPS shunt is present.
.
# ABD US [**2157-7-8**]:
1. Minimal intra-abdominal ascites.  There was insufficient
fluid to mark a location for bedside tap.
2.  Patent appearance of the main portal vein. Measured TIPS
velocities are similar to comparison examination.
.
# CXR [**2157-7-22**]:
IMPRESSION:  Improved aeration in the upper lobes.  Persistent
bilateral
patchy opacities more confluent in the bases, greater on the
right side.

# CXR [**2157-8-1**]:

FINDINGS:  A PA and lateral of the chest were obtained and
compared to the
prior examination dated [**2157-7-30**].  Allowing for differences in
technique,
there is no significant interval change.  The left subclavian
PICC line is
unchanged in position terminating within the expected region of
the proximal superior vena cava.  The enteric feeding catheter
extends beyond the inferior margin of the film.  The diffuse
patchy opacities throughout both lungs are grossly unchanged.
The left patchy opacity obscuring the left hemidiaphragm is
unchanged.  A persistent right pleural effusion is noted.
Cardiomediastinal silhouette is unchanged.
IMPRESSION:  Stable examination as above.

# RUQ Ultrasound [**2157-8-3**]:
FINDINGS:  Comparison is made to [**2157-7-6**].  The study is
limited
secondary to patient's inability to breath-hold.  There is a
large right
pleural effusion.  Color flow imaging demonstrates a patent TIPS
with wall-to-wall flow though velocities cannot be measured
secondary to respiratory
motion.  The right portal vein is patent and appears to be
hepatofugal though evaluation markedly limited. There is trace
ascites in the pelvis, but inadequate for paracentesis.
IMPRESSION:
1.  Limited exam.  Patent TIPS with wall-to-wall flow.
2.  Trace ascites.


Brief Hospital Course:
48F h/o HCV cirrhosis, admitted to [**Hospital Ward Name 121**] 10 with hyponatremia,
hepatic encephalopathy, and questionable respiratory symptoms.
.
# PNA: As pt reported syptoms of productive cough, admission CXR
was obtained which demonstrated RUL infiltrate suspicious for
infection.  In light of her recent hospitalization, pt was
started on ciprofloxacin 400mg IV q12H ([**7-6**]) for nosocomial PNA.
 To cover the possibility of aspiration PNA as pt's hepatic
encephalopathy persisted, abx were broadened to vancomycin
([**7-9**])/pip-taz ([**7-9**])/azithromycin ([**Date range (1) 11067**]).  Abx were
discontinued on [**7-18**] given completed total abx course of
approximately 10 days.  Serial chest xrays every other day
showed gradual interval improvement.
.
# Respiratory compromise: On admission, pt was ambulatory with
no oxygen requirement, and pt was placed on home regimen of
albuterol and fluticasone-salmeterol 100-50 mcg/dose [**Hospital1 **].  On
[**7-8**], pt received 1 unit PRBC for Hct = 20.9.  On [**7-9**], HD#3,
patient c/o increasing SOB, with RR = 30, PaO2 = 61 on 4L NC,
PCO2 = 33, pH 7.44.  Repeat CXR demonstrated new L upper and
lower lung infiltrates and likely volume overload.  Pt's acute
respiratory compromise was considered to be possibly
multifactorial, with contributions from asthma exacerbation,
PNA, fluid overload, and possible TRALI.  TTE performed in the
MICU demonstrated hyperdynamic EF, enlarged LA, and no evidence
of pulmonary HTN.  Pt was intubated from [**2163-7-13**] to support
respiratory capacity.  On [**7-21**] transfer to floor, pt had been
extubated for four days, with improved respiratory status and
O2sat in the mid-90s on 4L.  She was weened down to 3L, where
she remained stable.
.
# Adrenal insufficiency [**1-7**] liver failure: Pt was initially
maintained on her home regimen of prednisone 5 mg daily.  Upon
transfer to the MICU, stress dose steroids were administered in
the setting of infection, respiratory compromise, and pt's
background adrenal insufficiency.  After transferring back to
the floor, pt was transitioned ultimately to hydrocortisone to
provide both glucocorticoid and mineralocorticoid activity.  She
is discharged on 20 mg hydrocortisone qday.
.
# Asthma: After pt's episode of respiratory insufficiency, pt
was continued on standing albuterol and fluticasone-salmeterol
nebs, with home regimen of montelukast held.  She continued
albuterol and fluticasone/salmeteral nebs throughout her stay.
.
# [**Female First Name (un) 564**] overgrowth:  In the MICU, pt was started on casofungin
x 4-5 days given yeast in sputum, as it was felt to be
colonization.  Repeat sputum and urine cultures, however,
demonstrated continued heavy yeast colonization, with urine
growing C. glabrata, and sputum growing C. albicans (sensitive
to fluconazole) as well as another yeast organism with
indeterminate speciation.  Pt was started therefore on
fluconazole 200mg daily on [**7-26**].  Per ID recommendations,
fluconazole was stopped since yeast was likely colonizer and not
reflecting true infection.
.
# HCV cirrhosis: On admission, pt's MELD was 27.  On [**2157-7-21**], pt
was removed from the transplant list given respiratory
compromise but was relisted after transferring back to the
floor.  Pt's MELD remained in the 20s during this admission.
She will need to have weekly MELD scores, reflected in weekly
lab draws to be faxed to her hepatologist Dr. [**Last Name (STitle) 497**], as outlined
in the discharge plan.
.
# Hepatic encephalopathy:  Pt was given regular doses of
rifaximin, lactulose PO, and lactulose PR, titrated to achieve
four bowel movements daily.  Pt's mental status was noted to wax
and wane throughout admission, and therefore an NG tube, later a
N-J tube, was placed to prevent aspiration.  Pt was placed on
pureed foods with sips of thin liquids only after a bedside
speech and swallow noted no active aspiration, but the need for
precautions.  On day of discharge she was cleared by speech and
swallow for a regular diet, but should be watched directly
whenever she is eating to keep her from trying to swallow too
much at once - one bit and sip at a time(per speech).  Her
encephalopathy showed improvement daily.
.
# Hyponatremia/hypernatremia: Pt initially presented with Na =
113 and total body water overload.  Pt therefore was intially
fluid-restricted and administered albumin, with furosemide and
spironolactone initially held.  Diuretics were later
reintroduced.  Pt was noted to become hypernatremic (Na = 155)
in the MICU after aggressive diuresis, and therefore NGT free
water was given with normalization of Na.  Free water was
stopped when her Na reached 130.  On day of discharge, her Na
was 130.
.
# DM2: Pt's blood glucose was controlled with HISS, with home
regimen of glipizide first reduced and then ultimately held out
of concern for hypoglycemia in the setting of hepatic
dysfunction.  Pt was placed on glargine 12 units at bedtime to
provide basal glucose control, which was subsequently increased
to 17 and then 20 on day of discharge to better control her
glucose.
.
# Anemia: Hct was noted to drift downwards to a low of 20.9 on
[**7-8**], and pt was therefore transfused 1 unit PRBC.  On [**7-9**], pt
was noted to have severe respiratory insufficiency, with PaO2 =
61, requiring transfer to MICU.  There, pt was noted to have
guaiac-positive stool in the setting of known hemorrhoids, no
esophageal varices.  Hct ultimately stablized in the high 20s,
near pt's preadmission baseline.
.
# Hematuria: Pt presented with gross hematuria on [**7-11**], with INR
= 3.4.  Hematuria was considered to be due to spontaneous
bleeding in the bladder given supratherapeutic INR and possible
irritation from foley catheter.  FFP 2 units were transfused
with resolution of hematuria.  On day of discharge, her Hct was
25.9.
.
# UTI: Pt was noted to have entercoccus in urine culture on [**7-9**],
treated with vancomycin. Urinalysis on [**7-29**] grew pan-sensitive
Klebsiella, and has been receiving a course of Ciprofloxacin, to
complete on [**8-8**].
.
# FEN:  Pt was placed on a low Na diet.  After extubation, pt
was given NutrenPulmonary tube feeds at 60cc/hr, cycled from
1800 hrs to 1200 hrs, to increase her caloric intake, which was
then changed to continuous 24 hr.  She passed swallow and is
cleared to take a full diet, but should be watched directly
whenever she is eating to keep her from trying to swallow too
much at once (per speech).
.
# Full code

Medications on Admission:
Lactulose 30 g q8H PRN
Hydroxyzine HCl 25 mg q6H PRN for bilirubin-related itch
Rifaximin 400 mg TID
Albuterol PRN
Ferrous Sulfate 325 mg daily
Clotrimazole 10 mg Troche QID
Montelukast 10 mg daily
Oxybutynin Chloride 5 mg [**Hospital1 **]
Fluticasone-Salmeterol 100-50 mcg/dose [**Hospital1 **]
Pseudoephedrine HCl 30 mg q6H PRN
Lidocaine 5 %(700 mg/patch) patch daily
Lorazepam 0.5 mg [**Hospital1 **] PRN
Clonidine 0.1 mg [**Hospital1 **]
Prednisone 5 mg DAILY
Pantoprazole 40 mg EC DAILY
Glipizide 5 mg [**Hospital1 **]
Prochlorperazine 10 mg q8H PRN
Spironolactone 50 mg daily
Furosemide 20 mg daily
Metoclopramide 10 mg TID PRN

Discharge Medications:
1. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Forty Five (45) ML PO TID (3
times a day).
Disp:*4050 ML(s)* Refills:*2*
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
Inhalation Q4H (every 4 hours).
3. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1)  Inhalation
Q6H (every 6 hours).
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
Inhalation Q2H (every 2 hours) as needed for dyspnea.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Rifaximin 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a
day).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for Back pain.
8. Hydrocortisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).

10. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Spironolactone 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
12. Lactulose 10 g/15 mL Syrup [**Last Name (STitle) **]: Forty Five (45) ML PO Q4H
(every 4 hours) as needed.
13. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Last Name (STitle) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Ciprofloxacin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: Please give through [**2157-8-8**].
15. Insulin sliding scale with glargine
Finger sticks QACHS
Glargine 20 Units qhs
HISS per protocol attached
16. Heparin Flush 100 unit/mL Kit [**Month/Day/Year **]: One (1) flush Intravenous
once a day: Heparin flush for PICC. Flush daily and as needed. .

17. Outpatient Lab Work
Lab work on [**2157-8-9**] and weekly thereafter. FAX results to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] at [**Telephone/Fax (1) 697**].
Labwork:
PT/INR, Chem-7 (sodium, potassium, chloride, bicarb, BUN,
creatinine), AST, ALT, alk phos, total bilirubin.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary diagnosis:
# Hyponatremia
# Hypernatremia
# HCV cirrhosis
# Hepatic encephalopathy
# Pneumonia
# [**Female First Name (un) 564**] overgrowth
# Adrenal insufficiency
.
Secondary diagnosis
# Asthma


Discharge Condition:
Stable

Discharge Instructions:
You were admitted because you had a very low sodium level, and
you were confused.  We found that you had pneumonia and started
antibiotics for you.  You had a difficult time keeping your
oxygen saturation normal, and therefore you had to go to the
intensive care unit.  There, you had to be intubated to breathe,
and you continued receiving antibiotics.  Afterwards, you were
able to breathe on your own, and you returned to [**Hospital Ward Name 121**] 10.  You
continued to be very confused, so we gave you medications so
that you could move your bowels.  You were also found to have a
urinary tract infection, and are currently on antibiotics for
that.
.
We have given you some new medications:
hydrocortisone 20mg daily
folic acid 1mg daily
ciprofloxacin 250mg every 12 hours until [**2157-7-8**]
lactulose was increased to 45 ml three times titrated to 3 bowel
movements with 45 ml as needed in addition.
.
You should be watched when you eat because of the potential to
aspirate your food.  You should eat one bite and one sip at a
time.
.
You should return to the hospital or contact your primary care
physician if you experience worsening concentration and mental
status, increased bleeding, fever > 101.4 degrees F, worsening
shortness of breath, or coughing up blood.

Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2157-8-10**] 10:50
{'Pneumonitis due to inhalation of food or vomitus,Chronic hepatitis C with hepatic coma,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Thrombocytopenia, unspecified,Other and unspecified coagulation defects,Other pulmonary insufficiency, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Carrier or suspected carrier of other specified infectious organism,Anemia, unspecified,Esophageal reflux,Other specified hypotension,Other and unspecified mycoses'}


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: # Lethargy
# Confusion
# Hyponatremia

PRESENT ILLNESS: 48F h/o Hep C cirrhosis c/b ascites, encephalopathy and BLE
edema, presented to clinic with lethargy, Na = 113.  Pt reported
that her mother, who helps pt manage her pills, also noted that
pt was "making no sense" this morning.  Pt denied any recent
alcohol or drug intake, and reported that she had a productive
cough with somewhat yellow sputum.  Pt reported that she had not
been having three bowel movements daily, and at least one day
had no stools.
.
In the ED, she was oriented x 2, with positive asterixis.  Pt
received albumin 50g.
.
On first arrival to the floor, pt denied fever, vomiting,
diarrhea, dysuria, bloody stool, joint pain, muscle pain, sore
throat, or changes in vision.  Pt endorsed hunger, fatigue,
tremors, and dizziness.  It was unclear whether pt endorsed or
denied nausea as her account changed, and she was not focused
during the interview.  Pt conducted her admission interview with
her eyes closed, and spoke in a shaky mumble throughout.

MEDICAL HISTORY: (1) Hepatitis C cirrhosis
--Encephalopathy
--Ascites
--Edema s/p TIPS ([**11-8**])
--Hydrothorax
--Thrombocytopenia
--Hyponatremia (baseline 124-128)
(2) Asthma
(3) Adrenal insufficiency [**1-7**] ESLD
(4) GERD
(5) Anxiety

MEDICATION ON ADMISSION: Lactulose 30 g q8H PRN
Hydroxyzine HCl 25 mg q6H PRN for bilirubin-related itch
Rifaximin 400 mg TID
Albuterol PRN
Ferrous Sulfate 325 mg daily
Clotrimazole 10 mg Troche QID
Montelukast 10 mg daily
Oxybutynin Chloride 5 mg [**Hospital1 **]
Fluticasone-Salmeterol 100-50 mcg/dose [**Hospital1 **]
Pseudoephedrine HCl 30 mg q6H PRN
Lidocaine 5 %(700 mg/patch) patch daily
Lorazepam 0.5 mg [**Hospital1 **] PRN
Clonidine 0.1 mg [**Hospital1 **]
Prednisone 5 mg DAILY
Pantoprazole 40 mg EC DAILY
Glipizide 5 mg [**Hospital1 **]
Prochlorperazine 10 mg q8H PRN
Spironolactone 50 mg daily
Furosemide 20 mg daily
Metoclopramide 10 mg TID PRN

ALLERGIES: Shellfish / Flexeril

PHYSICAL EXAM: VS = T 97.1, BP 106/50, HR 83, RR 26, O2 96%, FS 148
GEN: Tremulous in bed with covers pulled up and eyes closed
throughout the interview
HEENT: Scleral ictera, MMM, CN II-XII grossly normal
CV: RRR, S1S2, III/VI SEM, no r/g
PULM: CTA @ L, decreased breath sounds at R base, no
rales/rhonchi/wheezes
ABD: BS+, soft, NT, protuberant, no rebound.  Tympanic.
EXT: 3+ BLE edema.  + asterixis.
NEURO: Slow to respond.  A&O x 3.  Could not remember three
words.

FAMILY HISTORY: # Mother, 60s: DM2, HTN, hypercholesterolemia
# Father, d. 51: COPD, alcohol-induced cirrhosis
# Brother

SOCIAL HISTORY: # Recreational drugs: Past IV drug use with needle sharing, last
use 7 years ago.  Past drug-snorting.
# Alcohol: Past alcohol use, last drink at age 46.
# Tobacco: Past [**Month/Day (2) 1818**] with 10 pack-year history
# Personal: Single with one child.  Lives with mother, who
manages medications
# Employment: Former waitress, unemployed on disability. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Chronic hepatitis C with hepatic coma,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Thrombocytopenia, unspecified,Other and unspecified coagulation defects,Other pulmonary insufficiency, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Carrier or suspected carrier of other specified infectious organism,Anemia, unspecified,Esophageal reflux,Other specified hypotension,Other and unspecified mycoses'}
