CHIEF COMPLAINT: End-stage liver disease secondary to
primary sclerosing cholangitis.

PRESENT ILLNESS: Patient is a 31-year-old female
with longstanding history of primary sclerosing cholangitis
complicated by cirrhosis, portal hypertension, right upper
quadrant abdominal pain and hyperbilirubinemia.  Patient had
undergone a liver transplant evaluation and had been on the
waiting list since [**2160-9-30**].  Following evaluation, an
appropriate match was found for living unrelated liver
transplant from her friend.  The patient was admitted to the
Medical Center on [**2161-4-13**] for living unrelated liver
transplant.

MEDICAL HISTORY: 1. Ulcerative colitis.
2. Primary sclerosing cholangitis.
3. Psoriasis.

MEDICATION ON ADMISSION: 1. Calcium.
2. Vitamin D.
3. Mesalamine 1200 mg p.o. b.i.d.
4. Amitriptyline 25 mg p.o. q.h.s.
5. Atarax 50 mg p.o. q.h.s.
6. Mycelex.
7. Phenergan 25 mg p.o. t.i.d. prn.
8. Fiorinal prn.
9. Ultram 50 mg p.o. t.i.d. prn.
10.      Ursodiol 500 mg p.o. b.i.d.

ALLERGIES: The patient is allergic to Morphine.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is married without children.
She has an Associates Degree in human services, but was on
medical leave prior to admission for transplant.  She stopped
working in [**2158**].
Cholangitis,Cirrhosis of liver without mention of alcohol,Other and unspecified coagulation defects,Infection and inflammatory reaction due to other vascular device, implant, and graft,Embolism and thrombosis of other specified artery,Portal vein thrombosis,Other convulsions
Cholangitis,Cirrhosis of liver NOS,Coagulat defect NEC/NOS,React-oth vasc dev/graft,Arterial embolism NEC,Portal vein thrombosis,Convulsions NEC
Admission Date: [**2161-4-13**]        Discharge Date: [**2161-5-22**]

Date of Birth:  [**2129-8-16**]        Sex:  F

Service:  TRANSPLANT SURGERY


CHIEF COMPLAINT:  End-stage liver disease secondary to
primary sclerosing cholangitis.

HISTORY OF PRESENT ILLNESS:  Patient is a 31-year-old female
with longstanding history of primary sclerosing cholangitis
complicated by cirrhosis, portal hypertension, right upper
quadrant abdominal pain and hyperbilirubinemia.  Patient had
undergone a liver transplant evaluation and had been on the
waiting list since [**2160-9-30**].  Following evaluation, an
appropriate match was found for living unrelated liver
transplant from her friend.  The patient was admitted to the
Medical Center on [**2161-4-13**] for living unrelated liver
transplant.

PAST MEDICAL HISTORY:
1. Ulcerative colitis.
2. Primary sclerosing cholangitis.
3. Psoriasis.


MEDICATIONS ON ADMISSION:
1. Calcium.
2. Vitamin D.
3. Mesalamine 1200 mg p.o. b.i.d.
4. Amitriptyline 25 mg p.o. q.h.s.
5. Atarax 50 mg p.o. q.h.s.
6. Mycelex.
7. Phenergan 25 mg p.o. t.i.d. prn.
8. Fiorinal prn.
9. Ultram 50 mg p.o. t.i.d. prn.
10.      Ursodiol 500 mg p.o. b.i.d.


ALLERGIES:  The patient is allergic to Morphine.

SOCIAL HISTORY:  The patient is married without children.
She has an Associates Degree in human services, but was on
medical leave prior to admission for transplant.  She stopped
working in [**2158**].

HOSPITAL COURSE:  Patient was admitted to the [**Hospital1 346**] on [**2161-4-13**] and taken to the OR,
where she underwent a living unrelated liver transplant.  For
details of this surgery, please refer to the dictated
operative note.  The patient's intraoperative course was
complicated by portal vein thrombosis.  The patient received
7.5 liters of crystalloid, 7 units of fresh-frozen plasma, 13
units of packed red blood cells in the operating room.  Urine
output was 2100 cc.

The patient was transferred to the Surgical Intensive Care
Unit while intubated as is customary.  The patient's
postoperative course was marked by poor graft function with
persisting coagulopathy requiring multiple transfusions of
fresh-frozen plasma and cryoprecipitate.  In the period
following the surgery, the patient did wake up and was alert
and following commands and in no apparent distress.  She was
moving all extremities.  The patient remained coagulopathic
through postoperative day number two and into postoperative
day number three.

On postoperative day number three, the patient was noted to
be increasingly somnolent and more difficult to arouse.
Later in the day on postoperative day number three, the
patient was observed to have some seizure-like activity
beginning in the upper extremities and generalizing to a
tonic-clonic seizures.  Neurology consultation was
immediately requested, and the patient underwent a CAT scan
evaluation of her head.  Her CAT scan revealed no immediate
etiology for this seizure.  There was no acute hemorrhage.
There is no mass effect or shift of the normally midline
structures.

Given concern for increasing intracranial pressure secondary
to edema given the patient's poor liver function,
Neurosurgery consultation was also requested, and the
decision was made to place an intracranial pressure monitor.
This was placed on postoperative day number four.  The
patient had been started on Mannitol for diuresis.  The
patient's neurologic examination was closely monitored, and
continued to deteriorate.  A CAT scan of the patient's head
obtained on [**2161-4-19**] revealed progression of the patient's
diffuse bilateral cerebral edema.  There were also findings
consistent with tonsillar herniation.  There was also
possible subarachnoid hemorrhage.

On postoperative day number four, the patient was also
witnessed to have four seizure events, which were initially
focal and which generalized lasting as long as 10 minutes.
Neurology involvement was once again solicited and decision
was made to initiate pentobarbital.  Bedside EEG monitoring
was also initiated.

The patient had been relisted for transplant on postoperative
day number three given the persistent poor graft function,
and on postoperative day number five, which was [**2161-4-19**], an
organ became available for the patient.  The patient was
taken back to the operating room and underwent cadaveric
liver transplant.  The patient received 2 liters of
crystalloid, 2 units of fresh-frozen plasma, 2 units of
packed red blood cells, and 1 unit of cryoprecipitate in the
OR.  Her urine output was 2 liters.

Following this second transplant procedure, the patient's
liver function quickly improved and her coagulopathy
resolved.  Unfortunately, the patient's neurologic status
remained a grave concern.

On [**2161-4-21**], the patient underwent a repeat CAT scan of her
head, which revealed a reduction in her cerebral edema.  The
degree of injury the patient may have suffered secondary to
sustained effusion deficits from the cerebral edema could not
be ascertained from the study.

On [**2161-4-22**], the patient had a fever for which cultures were
sent, and an Infectious Disease consultation was requested.
The patient was started on vancomycin and Zosyn.  Cultures
drawn following this event were ultimately negative.  X-ray
imaging of the chest suggested the patient may have a
pneumonia.

On [**2161-4-23**], the patient's pentobarbital, was discontinued.
Given her limited liver function, the duration of effect of
the pentobarbital was uncertain.  The patient was expected to
wake up slowly.  A CAT scan of the patient's head on [**2161-4-24**]
was largely unchanged from the previous study on [**2161-4-21**].

By [**2161-4-25**], the patient was opening her eyes to speech, but
not following commands.  Her intracranial pressure had
remained stable at less than 10.  The patient's Levophed drip
had been turned off.

On [**2161-4-26**], the patient's Swan catheter was removed and
exchanged with a central venous line.  The patient's
intracranial pressure bolt was also removed.  In the period
around [**2161-4-26**], the patient's respiratory status was noted
to be particularly poor, and the patient underwent a workup
for pulmonary embolism.  A CT angiogram of her chest revealed
no evidence of clot and lower extremity ultrasound also
revealed no evidence of deep venous thrombosis.

By [**2161-4-28**], the patient was occasionally appearing to track
when caretakers were present in her room.  She showed minimal
spontaneous movement.  The patient was started on tube feeds.

On [**2161-5-1**], the patient once again underwent a CAT scan of
her head to evaluate the degree of cerebral edema.  There was
decreased edema evidenced by decreased effacement of the
patient's sulci, but with diffuse patchy hypodensities noted
throughout both cerebral hemispheres.

On [**2161-5-4**], the patient underwent a MRI of her brain to
further evaluate the degree of injury she had suffered.
Extensive bilateral cerebral edema was noted involving the
cortex particularly in the insular region.  The degree of
edema was noted to be far less extensive than originally seen
on CAT scan.

On [**2161-5-6**], the patient was taken to the OR for a
tracheostomy.  This was performed without complications.

On [**2161-5-9**], the patient again had a temperature spike and
cultures were once again drawn.  There was ultimately no
growth from her cultures.  The patient's central line was
exchanged over wire.  Cultures of the catheter were also
negative.
On [**5-9**], some attempt to wean down the patient's mechanical
ventilation was attempted, but the patient was unable to
tolerate a pressure support trial.

On [**2161-5-13**], an attempt was made to place a percutaneous
endoscopic gastrostomy tube, but this was unsuccessful
secondary to equipment difficulties.  Specifically, there
were difficulties encountered in transilluminating through
the patient's abdominal wall.

On [**2161-5-15**], the patient underwent an open gastrostomy tube
placement in the OR without complications.  Use of the
gastrostomy tube for feedings was initiated on [**2161-5-19**].

Discharge planning was initiated at about this time with
expectation that the patient could be transferred to a rehab
facility following placement of the G tube.  The patient
continued to be seen by the Neurology service as well as
Physical and Occupational Therapies.  Although patient
appeared more awake and alert, the patient was really not
following commands and showed minimal spontaneous movement
and little, if any purposeful movement.  The patient was
expected to have a prolonged recovery with long-term
prognosis unclear at this point.

The patient's liver function was essentially normal at the
time of discharge.  The patient's liver function tests as
well as her coagulation studies had been normal in the days
prior to discharge.  The patient's T tube had been capped.

DISCHARGE CONDITION:  Stable.

DISCHARGE DIAGNOSES:
1. Primary sclerosing cholangitis now status post orthotopic
   liver transplant times two.
2. Severe cerebral injury secondary to edema.
3. Respiratory failure bilateral.
4. Aspiration pneumonia versus atelectasis.


DISCHARGE MEDICATIONS:
1. Neoral (final dose to be determined).
2. Magnesium oxide 400 mg p.o. b.i.d.
3. Metoprolol 12.5 mg p.o. b.i.d.
4. Prednisone 50 mg p.o. q.d.
5. Albuterol/ipratropium inhaler 1-2 puffs q6 prn.
6. Prevacid oral suspension 30 mg/nasogastric tube q.d.
7. Nystatin oral suspension 5 mL p.o. q.i.d. prn.
8. Valcyte 450 mg p.o. b.i.d.
9. Keppra 750 mg p.o. b.i.d.
10.      Artificial tears 1-2 drops to each eye prn.
11.      CellCept 1 gram/nasogastric tube b.i.d.
12.      Heparin 5000 units subcutaneously t.i.d.
13.      Bactrim SS one tablet p.o. q.d.
14.      Fluconazole 400 mg p.o. q.d.
15.      NPH insulin 25 units at breakfast and at bedtime.


FOLLOW UP:  The patient is to followup with Dr. [**Last Name (STitle) **] in the
[**Hospital 1326**] Clinic within 1-2 weeks following discharge.  The
patient is also to followup with the Neurology team within 1-
2 weeks following discharge.  The patient is expected to
setup an appointment with her primary care physician
following discharge.  The patient will also need to followup
with Hepatology service following discharge.

MISCELLANEOUS:  The patient is currently on tube feedings
using Impact with fiber at full strength running at 70
mL/hour through her G tube.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **]

Dictated By:[**Last Name (NamePattern1) 32451**]
MEDQUIST36
D:  [**2161-5-19**] 01:43:20
T:  [**2161-5-19**] 06:11:36
Job#:  [**Job Number 32452**]


Name:  [**Known lastname 5620**], [**Known firstname **]          Unit No:  [**Numeric Identifier 5621**]

Admission Date: [**2161-4-13**]        Discharge Date: [**2161-5-22**]

Date of Birth:  [**2129-8-16**]        Sex:  F

Service:  TRANSPLANT SURGERY


The night of [**2161-5-18**], the patient spiked a temperature
to 101.2 and she was pancultured as per routine protocol.
The blood cultures were negative and the
central venous catheter tip from which these cultures were
drawn partially was D/C'd and eventually grew staph coag
negative as well.  The patient continued to have low grade
temperature to 99 and on [**2161-5-21**], she was started on IV
vancomycin for empiric coverage.  She defervesced and
continued to do well.  She has continued to slowly improve
from the neurologic standpoint and now she is able to move her
left upper extremity more consistently.  She grabs her chin
and rubs her face.  She also has a strong grip in that hand.
Surveillance cultures were sent again on [**2161-5-21**], and
there has been no growth so far.  At this time we find her
stable to be discharged to [**Hospital3 **] to continue her
recovery.  Upon her leaving, a last UA C&S and culture were
sent as surveillance as well.

CONDITION ON DISCHARGE:  Stable.

DISCHARGE MEDICATIONS:
1. Heparin 5000 units subcu q.eight hours.
2. Magnesium oxide 400 mg per G-tube b.i.d.
3. Metoprolol 100 mg per G-tube b.i.d.
4. Albuterol ipratropium inhaler one to two puffs q.six hours
   p.r.n.
5. Prevacid oral suspension 30 mg per G-tube q.day.
6. Nystatin oral suspension 5 ml p.o. q.i.d. p.r.n.
7. Valcyte 450 mg per G-tube t.i.d.
8. Keppra 750 mg per G-tube b.i.d.
9. Artificial Tears one to two drops to each eye p.r.n.
10.      Bactrim single strength one tablet per G-tube q.day.
11.      Fluconazole 400 mg per G-tube q.day.
12.      NPH insulin 25 units at breakfast and at bed time.
13.      Regular insulin sliding scale.
14.      Fentanyl 25 to 50 mcg IV q.six hours p.r.n.
15.      Prednisone 10 mg per G-tube q.day.
16.      CellCept [**Pager number **] mg per G-tube q.12 hours.
17.      Cyclosporine 175 mg per G-tube q.12 hours.

The patient is currently on continuous enteral feeding
through her G-tube with full strength Impact with fiber at 80
ml an hour.  She will be seen in transplant clinic in the
next two weeks.  Neurology appointment was also scheduled for
her by the transplant coordinator.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5622**]

Dictated By:[**Last Name (NamePattern1) 5623**]
MEDQUIST36
D:  [**2161-5-22**] 20:00:37
T:  [**2161-5-22**] 20:36:41
Job#:  [**Job Number 5624**]
{'Cholangitis,Cirrhosis of liver without mention of alcohol,Other and unspecified coagulation defects,Infection and inflammatory reaction due to other vascular device, implant, and graft,Embolism and thrombosis of other specified artery,Portal vein thrombosis,Other convulsions'}


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: End-stage liver disease secondary to
primary sclerosing cholangitis.

PRESENT ILLNESS: Patient is a 31-year-old female
with longstanding history of primary sclerosing cholangitis
complicated by cirrhosis, portal hypertension, right upper
quadrant abdominal pain and hyperbilirubinemia.  Patient had
undergone a liver transplant evaluation and had been on the
waiting list since [**2160-9-30**].  Following evaluation, an
appropriate match was found for living unrelated liver
transplant from her friend.  The patient was admitted to the
Medical Center on [**2161-4-13**] for living unrelated liver
transplant.

MEDICAL HISTORY: 1. Ulcerative colitis.
2. Primary sclerosing cholangitis.
3. Psoriasis.

MEDICATION ON ADMISSION: 1. Calcium.
2. Vitamin D.
3. Mesalamine 1200 mg p.o. b.i.d.
4. Amitriptyline 25 mg p.o. q.h.s.
5. Atarax 50 mg p.o. q.h.s.
6. Mycelex.
7. Phenergan 25 mg p.o. t.i.d. prn.
8. Fiorinal prn.
9. Ultram 50 mg p.o. t.i.d. prn.
10.      Ursodiol 500 mg p.o. b.i.d.

ALLERGIES: The patient is allergic to Morphine.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is married without children.
She has an Associates Degree in human services, but was on
medical leave prior to admission for transplant.  She stopped
working in [**2158**]. 

### Response:
{'Cholangitis,Cirrhosis of liver without mention of alcohol,Other and unspecified coagulation defects,Infection and inflammatory reaction due to other vascular device, implant, and graft,Embolism and thrombosis of other specified artery,Portal vein thrombosis,Other convulsions'}
