CHIEF COMPLAINT: Headache, blurry vision and HD line displacement

PRESENT ILLNESS: This is a 31 yo male with h/o biliary atresia s/p liver
[**First Name3 (LF) **] age 4, now again with cirrhosis, ESRD on HD, awaiting
liver/kidney [**First Name3 (LF) **], recently discharged with klebsiella
bacteremia and MSSA cellulitis, completed abx therapy on
Tuesday, who presented to the ED after his HD catheter fell out.
He reported nausea, vomiting, and dark stools. He also reported
"white vision" as well while in the ED.
.
In the ED, initial VS: 98.2 F, BP 131/83, HR 108, R 21, O2-sat
98% RA. Given the visual changes, patient had an initial head CT
which was negative. Neurology evaluated the patient and
recommended an MRI/MRA. That was also obtained in the ED with
multiple cortical/subcortical infarcts which could be consistent
with septic emboli. The patient was being evaluated by
ophthalmology for the visual loss, and while he was being
examined, the patient had a seizure. Ativan 1 mg x 1 was given,
and the patient was then noted to be post-ictal and not
following commands. He was placed on a NRB for his O2 sats. At 4
pm, when he was re-evaluated by neurology, he was following come
commands, and also was moving all extremities. LP was not
performed in the ED because consent could not be obtained while
patient was post-ictal. He was given vancomycin and 2 gm CTX in
the ED for meningitis coverage. He is also being given
ampicillin as well. The patient also had a new HD catheter
placed and a new post pyloric tube placed by IR while he was in
the ED as well. Blood cultures were drawn and pending. Neurology
recommended a repeat head CT while he was in the ED, which was
performed prior to transfer. He was also loaded with Keppra, 500
mg x 1, followed by repeat 500 mg in 4 hours, followed by 500 mg
daily with add'l 500 mg after HD. LENI's were also ordered in
the ED given his h/o of R to L shunt on prior ECHO with bubble
study and were negative for DVT. An ECHO was also ordered, but
not done prior to transfer. ID was notified of the patient's
admission and agreed with the above antibiotic regimen.
.
Currently, patient appears comfortable. HA still present but
unchanged from earlier in the day. Otherwise denies pain, denies
blurred vision. States he is hungry, eager for dinner. Generally
speaks in simple sentences but is cooperative with exam.

MEDICAL HISTORY: -biliary Atresia s/p liver [**First Name3 (LF) **] at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia
-small bowel resection

MEDICATION ON ADMISSION: albuterol sulfate inhaler [**11-26**] every 6 hours PRN
furosemide 20 mg by mouth once daily
ipratropium bromide 1 daily PRN
Lactulose 30 ml up to 1 times daily (written for up to 4times
daily but doesnt need it)
metoprolol 25mg twice daily
oxycodone 5 mg Q8 hours PRN pain
Reglan 1 tablet 4 times a day
sucralfate 10 ml 4 times a day
tacrolimus 0.5 mg twice daily.
Caltrate 600 Plus Vit D
Omeprazole 40mg twice daily
Lidoderm patch 5% on low back

ALLERGIES: Ibuprofen

PHYSICAL EXAM: Vitals - T: 98.4 BP: 132/92 HR: 102 RR: 22 02 sat: 95% on RA
GENERAL: Awake, oriented to [**Hospital1 18**], date, in NAD laying in bed in
MICU at time of exam
HEENT: No cervical LAD, no thyroidmegaly, neck supple, no JVD,
HD catheter in place R neck
CARDIAC: Tachycardic to ~100, regular, no clear murmur
LUNG: CTA bilaterally
ABDOMEN: Soft, NT/ND, +NABS, no organomegaly
EXT: Pitting edema of LE bilaterally, 2+ radial and DP pulses
b/l
NEURO: Strength 5/5 in UE and LE; sensation grossly intact b/L,
CN II-XII intact, although eye movements (vertical and
horizontal) are not smooth (unclear whether patient has
difficulty following commands; looks away frequently during
exam). No Babinski. Patellar reflexes difficult to assess (given
absence of reflex hammer) but are present and equal ([**11-26**]+).
DERM: Multiple (dozens) discrete skin lesions on arms, abdomen,
lower legs that appear to be the result of
scratching/excoriations, scabbed over, some with surrounding
erythema suggestive of possible superinfection. No lesions on
back where patient is unable to reach. Marks on lower spine
where LP was attempted. Well-healed scars on abdomen from
[**Month/Day (2) **] at age 4.

FAMILY HISTORY: NC

SOCIAL HISTORY: denies any tobacco, EtOH or illict drug use. Lives at home with
parents. Has one child with a prior girlfriend. Does not work.
Cerebral embolism with cerebral infarction,End stage renal disease,Encephalopathy, unspecified,Complications of transplanted liver,Unspecified protein-calorie malnutrition,Other ascites,Precipitous drop in hematocrit,Renal dialysis status,Cirrhosis of liver without mention of alcohol,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other convulsions,Other specified cardiac dysrhythmias,Profound impairment, both eyes, impairment level not further specified,Nausea with vomiting
Crbl emblsm w infrct,End stage renal disease,Encephalopathy NOS,Compl liver transplant,Protein-cal malnutr NOS,Ascites NEC,Drop, hematocrit, precip,Renal dialysis status,Cirrhosis of liver NOS,Abn react-org transplant,Convulsions NEC,Cardiac dysrhythmias NEC,Both eyes blind-who def,Nausea with vomiting
Admission Date:  [**2135-12-9**]              Discharge Date:   [**2135-12-16**]

Date of Birth:  [**2104-8-11**]             Sex:   M

Service: MEDICINE

Allergies:
Ibuprofen

Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Headache, blurry vision and HD line displacement

Major Surgical or Invasive Procedure:
HD Tunneled Line Placement


History of Present Illness:
This is a 31 yo male with h/o biliary atresia s/p liver
[**First Name3 (LF) **] age 4, now again with cirrhosis, ESRD on HD, awaiting
liver/kidney [**First Name3 (LF) **], recently discharged with klebsiella
bacteremia and MSSA cellulitis, completed abx therapy on
Tuesday, who presented to the ED after his HD catheter fell out.
He reported nausea, vomiting, and dark stools. He also reported
"white vision" as well while in the ED.
.
In the ED, initial VS: 98.2 F, BP 131/83, HR 108, R 21, O2-sat
98% RA. Given the visual changes, patient had an initial head CT
which was negative. Neurology evaluated the patient and
recommended an MRI/MRA. That was also obtained in the ED with
multiple cortical/subcortical infarcts which could be consistent
with septic emboli. The patient was being evaluated by
ophthalmology for the visual loss, and while he was being
examined, the patient had a seizure. Ativan 1 mg x 1 was given,
and the patient was then noted to be post-ictal and not
following commands. He was placed on a NRB for his O2 sats. At 4
pm, when he was re-evaluated by neurology, he was following come
commands, and also was moving all extremities. LP was not
performed in the ED because consent could not be obtained while
patient was post-ictal. He was given vancomycin and 2 gm CTX in
the ED for meningitis coverage. He is also being given
ampicillin as well. The patient also had a new HD catheter
placed and a new post pyloric tube placed by IR while he was in
the ED as well. Blood cultures were drawn and pending. Neurology
recommended a repeat head CT while he was in the ED, which was
performed prior to transfer. He was also loaded with Keppra, 500
mg x 1, followed by repeat 500 mg in 4 hours, followed by 500 mg
daily with add'l 500 mg after HD. LENI's were also ordered in
the ED given his h/o of R to L shunt on prior ECHO with bubble
study and were negative for DVT. An ECHO was also ordered, but
not done prior to transfer. ID was notified of the patient's
admission and agreed with the above antibiotic regimen.
.
Currently, patient appears comfortable. HA still present but
unchanged from earlier in the day. Otherwise denies pain, denies
blurred vision. States he is hungry, eager for dinner. Generally
speaks in simple sentences but is cooperative with exam.

Past Medical History:
-biliary Atresia s/p liver [**First Name3 (LF) **] at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia
-small bowel resection


Social History:
denies any tobacco, EtOH or illict drug use. Lives at home with
parents. Has one child with a prior girlfriend. Does not work.


Family History:
NC

Physical Exam:
Vitals - T: 98.4 BP: 132/92 HR: 102 RR: 22 02 sat: 95% on RA
GENERAL: Awake, oriented to [**Hospital1 18**], date, in NAD laying in bed in
MICU at time of exam
HEENT: No cervical LAD, no thyroidmegaly, neck supple, no JVD,
HD catheter in place R neck
CARDIAC: Tachycardic to ~100, regular, no clear murmur
LUNG: CTA bilaterally
ABDOMEN: Soft, NT/ND, +NABS, no organomegaly
EXT: Pitting edema of LE bilaterally, 2+ radial and DP pulses
b/l
NEURO: Strength 5/5 in UE and LE; sensation grossly intact b/L,
CN II-XII intact, although eye movements (vertical and
horizontal) are not smooth (unclear whether patient has
difficulty following commands; looks away frequently during
exam). No Babinski. Patellar reflexes difficult to assess (given
absence of reflex hammer) but are present and equal ([**11-26**]+).
DERM: Multiple (dozens) discrete skin lesions on arms, abdomen,
lower legs that appear to be the result of
scratching/excoriations, scabbed over, some with surrounding
erythema suggestive of possible superinfection. No lesions on
back where patient is unable to reach. Marks on lower spine
where LP was attempted. Well-healed scars on abdomen from
[**Month/Day (2) **] at age 4.

Pertinent Results:
[**2135-12-9**] 04:10PM   GLUCOSE-95 UREA N-20 CREAT-2.3* SODIUM-137
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
[**2135-12-9**] 04:10PM   CALCIUM-8.0* PHOSPHATE-5.7*# MAGNESIUM-2.0
[**2135-12-9**] 11:00AM   CK(CPK)-49
[**2135-12-9**] 11:00AM   cTropnT-0.01
[**2135-12-9**] 04:00AM ASCITES  WBC-45* RBC-1605* POLYS-0 LYMPHS-70*
MONOS-0 MESOTHELI-0 MACROPHAG-30*
[**2135-12-9**] 12:19AM   GLUCOSE-115* LACTATE-1.9 NA+-139 K+-3.3*
CL--101 TCO2-30
[**2135-12-9**] 12:05AM   GLUCOSE-119* UREA N-15 CREAT-2.1* SODIUM-138
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-28 ANION GAP-10
[**2135-12-9**] 12:05AM   ALT(SGPT)-13 AST(SGOT)-40 CK(CPK)-57 ALK
PHOS-418* TOT BILI-0.7
[**2135-12-9**] 12:05AM   LIPASE-28
[**2135-12-9**] 12:05AM   ALBUMIN-1.2* CALCIUM-7.6* PHOSPHATE-3.5
MAGNESIUM-1.8
[**2135-12-9**] 12:05AM   ASA-NEG ETHANOL-NEGIMPRESSION:

MR [**Name13 (STitle) 430**]: [**2135-12-9**]
1. Multiple foci of acute infarction in both cerebral
hemispheres. The wide, inter-territorial distribution and
uniform temporal appearance of the lesions, in this clinical
context, are strongly suggestive of "watershed" infarction; an
embolic etiology is less likely.
2. Normal MRA and MRV of the brain and MRA neck. ACETMNPHN-8.0*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
Repeat MR [**Name13 (STitle) 430**]: IMPRESSION: Evolution of previously seen foci of
decreased diffusion. The distribution may represent a
combination of a "watershed" type infarct related to
hypoperfusion and embolic (either bland or septic) phenomenon.
However, there is no new infarct identified.

EEG:  This is an abnormal noncontinuous extended routine EEG due
to slowing and disorganization of the background rhythm and
bursts of
semirhythmic, moderate voltage, bifrontally predominant
generalized
theta/delta activity. The first finding suggests a mild to
moderate
encephalopathy. Medications, toxic/metabolic disturbances, and
infections are common causes. The generalized slowing suggests
possible
deep or midline dysfunction. No epileptiform discharges or
electrographic seizures were seen during this recording and this
telemetry captured no pushbutton activations.

TEE: No thrombus is seen in the left atrial appendage. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 30 cm from the
incisors. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve. Moderate (2+) mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion.
.
MRI L spine:
IMPRESSION: No valvular vegetations seen. Moderate mitral
regurgitation. Normal biventricular function.IMPRESSION:
1. Diffuse central clumping of the cauda equina in this patient
with a
congenitally narrow canal. The findings suggest arachnoiditis
and are similar to the prior study.
2. Severe canal narrowing just inferior to the L4-5 disc space
secondary to
osseous proliferative changes and epidural lipomatosis.
3. Moderate bilateral subarticular zone narrowing at L4-5 with
what appeared to be mildly swollen bilateral L5 roots.
4. Bilateral L5 spondylolysis with fluid clefts and surrounding
edema is most likely all degenerative. No drainable fluid
collection is identified and the lack of interval change from
the study one month prior makes infection unlikely though should
be correlated with clinical findings.
.


Brief Hospital Course:
Mr [**Known lastname 40167**] was admitted for (1) replaced of his tunneled line
and (2) a constellation of neurological findings including
headache, changes in vision, and while in ED, a seizure.  He was
admitted to the ICU for airway protection and loaded with
Keppra.  EEG was negative for epileptiform activity.  Two MICU
teams attempted an LP however they were unsuccessful in
obtaining fluid.  He was empirically started on antibiotics for
meningitis, however all of his symptoms acutely resolved.  He
was transferred to the floor where repeat EEG again was
non-epileptiform although showing nonspecific activity in the
occipital area.  An MRI showed evidence for embolization; septic
emboli was a possibility, however other embolic phenomena were
also a possibility, given that embolization could have occured
at the moment of displacement of his HD line.  The presence of
AV shunts secondary to hepatopulmonary syndrome would have
allowed for migration of venous emboli.  Infectious work up
repeatedly revealed negative blood and urine cultures.  Chest
x-ray was unremarkable.  MRI of L spine given prior fluid
collection was not suspicious for infection.  Peritoneal fluid
was negative for SBP. TEE was negative for vegetations.  Repeat
MRI showed continued presence of previously seen MRI but again
was not necessarily consistent with septic phenomena.  Given
resolution of symptoms, antibiotics were discontinued and he
continued to remain at his baseline.  Keppra was continued given
his prior seizure with instruction to discontinue Keppra after 2
weeks if no seizure event occured.   Follow up with renal,
neurology, and opthamology was obtained and time of discharge.

Medications on Admission:
albuterol sulfate inhaler [**11-26**] every 6 hours PRN
furosemide 20 mg by mouth once daily
ipratropium bromide 1 daily PRN
Lactulose 30 ml up to 1 times daily (written for up to 4times
daily but doesnt need it)
metoprolol 25mg twice daily
oxycodone 5 mg Q8 hours PRN pain
Reglan 1 tablet 4 times a day
sucralfate 10 ml 4 times a day
tacrolimus 0.5 mg twice daily.
Caltrate 600 Plus Vit D
Omeprazole 40mg twice daily
Lidoderm patch 5% on low back

Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for titrate to 3 BMs daily.
2. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO HD
PROTOCOL (HD Protochol): please take 1 tablet during
hemodialysis .
Disp:*30 Tablet(s)* Refills:*2*
6. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itchiness.
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
15. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).


Discharge Disposition:
Home With Service

Facility:
VNA Southeastern MA

Discharge Diagnosis:
1. Emboli to brain causing seizure, nausea/vomiting, blurry
vision - now clinically resolved, unlikely septic, more likely
ischemic
2. Cirrhosis secondary to congenital biliary atresia
3. End stage renal disease secondary to post-strep GN on
hemodialysis


Discharge Condition:
Stable for home, saturating normally at room air.


Discharge Instructions:
Dear Mr [**Known lastname 40167**],

It was a pleasure caring for you while you were at [**Hospital1 **].  You were admitted because your [**Hospital1 2286**] line fell
out; you also experienced multiple symptoms including nausea,
vomiting, and blurry vision.  You also had a seizure while you
were here.  We performed an imaging study of your brain which
showed several areas that were concerning for a stroke or
infection.  Because we were worried about infection, we
performed several studies to search for an infectious source,
however we could not find any sign of infection in your body. We
did briefly start you on antibiotics but your symptoms cleared
spontaneously, which suggests that this is less likely to be an
infection. For this reason, you do not need to take antibiotics
when you go home.
.
Because you had a seizure, we started you on a medicine called
Keppra, which helps prevent seizures.  You should continue to
take this medicine for another two week period.  This helps to
prevent further seizures.  If by the end of two weeks, you have
had no further seizures, neurology can help you to stop this
medicine.  You will need to see neurology as an outpatient.
Your follow up appointments are scheduled below.
.
The medication changes we made during this hospitalization are:
(1) We started you on keppra 500 mg daily.  You should continue
to take this daily and you will also receive it just prior to
hemodialysis.
(2) Instead of taking tacrolimus 0.5 mg twice a day, you should
take tacrolimus 0.5 mg daily in the morning.
(3) You should take nephrocaps 1 capsule daily every morning.
This medicine is good for your kidneys.
(4) We have decreased your metoprolol dose to 12.5 mg twice a
day.
(5) We have decreased your omeprazole to 40 mg daily.
(6) We started you on Vitamin D 800 units daily.



Followup Instructions:
1. Please follow up with Dr [**Last Name (STitle) **] from Neurology on [**1-16**] [**2135**] at 230 PM at the [**Hospital 878**] clinic at [**Hospital1 **].
2. Please follow up with your liver doctor [**First Name (Titles) **] [**2135-12-28**]
at 1 PM.  If you have any questions regarding this appointment,
please call [**Telephone/Fax (1) 673**].
3. Please follow up with opthomology at [**Hospital 13128**] given
your vision difficulties.  Please call [**Telephone/Fax (1) 78900**] to set up
this appointment at your earliest convenience.
{'Cerebral embolism with cerebral infarction,End stage renal disease,Encephalopathy, unspecified,Complications of transplanted liver,Unspecified protein-calorie malnutrition,Other ascites,Precipitous drop in hematocrit,Renal dialysis status,Cirrhosis of liver without mention of alcohol,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other convulsions,Other specified cardiac dysrhythmias,Profound impairment, both eyes, impairment level not further specified,Nausea with vomiting'}


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: Headache, blurry vision and HD line displacement

PRESENT ILLNESS: This is a 31 yo male with h/o biliary atresia s/p liver
[**First Name3 (LF) **] age 4, now again with cirrhosis, ESRD on HD, awaiting
liver/kidney [**First Name3 (LF) **], recently discharged with klebsiella
bacteremia and MSSA cellulitis, completed abx therapy on
Tuesday, who presented to the ED after his HD catheter fell out.
He reported nausea, vomiting, and dark stools. He also reported
"white vision" as well while in the ED.
.
In the ED, initial VS: 98.2 F, BP 131/83, HR 108, R 21, O2-sat
98% RA. Given the visual changes, patient had an initial head CT
which was negative. Neurology evaluated the patient and
recommended an MRI/MRA. That was also obtained in the ED with
multiple cortical/subcortical infarcts which could be consistent
with septic emboli. The patient was being evaluated by
ophthalmology for the visual loss, and while he was being
examined, the patient had a seizure. Ativan 1 mg x 1 was given,
and the patient was then noted to be post-ictal and not
following commands. He was placed on a NRB for his O2 sats. At 4
pm, when he was re-evaluated by neurology, he was following come
commands, and also was moving all extremities. LP was not
performed in the ED because consent could not be obtained while
patient was post-ictal. He was given vancomycin and 2 gm CTX in
the ED for meningitis coverage. He is also being given
ampicillin as well. The patient also had a new HD catheter
placed and a new post pyloric tube placed by IR while he was in
the ED as well. Blood cultures were drawn and pending. Neurology
recommended a repeat head CT while he was in the ED, which was
performed prior to transfer. He was also loaded with Keppra, 500
mg x 1, followed by repeat 500 mg in 4 hours, followed by 500 mg
daily with add'l 500 mg after HD. LENI's were also ordered in
the ED given his h/o of R to L shunt on prior ECHO with bubble
study and were negative for DVT. An ECHO was also ordered, but
not done prior to transfer. ID was notified of the patient's
admission and agreed with the above antibiotic regimen.
.
Currently, patient appears comfortable. HA still present but
unchanged from earlier in the day. Otherwise denies pain, denies
blurred vision. States he is hungry, eager for dinner. Generally
speaks in simple sentences but is cooperative with exam.

MEDICAL HISTORY: -biliary Atresia s/p liver [**First Name3 (LF) **] at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia
-small bowel resection

MEDICATION ON ADMISSION: albuterol sulfate inhaler [**11-26**] every 6 hours PRN
furosemide 20 mg by mouth once daily
ipratropium bromide 1 daily PRN
Lactulose 30 ml up to 1 times daily (written for up to 4times
daily but doesnt need it)
metoprolol 25mg twice daily
oxycodone 5 mg Q8 hours PRN pain
Reglan 1 tablet 4 times a day
sucralfate 10 ml 4 times a day
tacrolimus 0.5 mg twice daily.
Caltrate 600 Plus Vit D
Omeprazole 40mg twice daily
Lidoderm patch 5% on low back

ALLERGIES: Ibuprofen

PHYSICAL EXAM: Vitals - T: 98.4 BP: 132/92 HR: 102 RR: 22 02 sat: 95% on RA
GENERAL: Awake, oriented to [**Hospital1 18**], date, in NAD laying in bed in
MICU at time of exam
HEENT: No cervical LAD, no thyroidmegaly, neck supple, no JVD,
HD catheter in place R neck
CARDIAC: Tachycardic to ~100, regular, no clear murmur
LUNG: CTA bilaterally
ABDOMEN: Soft, NT/ND, +NABS, no organomegaly
EXT: Pitting edema of LE bilaterally, 2+ radial and DP pulses
b/l
NEURO: Strength 5/5 in UE and LE; sensation grossly intact b/L,
CN II-XII intact, although eye movements (vertical and
horizontal) are not smooth (unclear whether patient has
difficulty following commands; looks away frequently during
exam). No Babinski. Patellar reflexes difficult to assess (given
absence of reflex hammer) but are present and equal ([**11-26**]+).
DERM: Multiple (dozens) discrete skin lesions on arms, abdomen,
lower legs that appear to be the result of
scratching/excoriations, scabbed over, some with surrounding
erythema suggestive of possible superinfection. No lesions on
back where patient is unable to reach. Marks on lower spine
where LP was attempted. Well-healed scars on abdomen from
[**Month/Day (2) **] at age 4.

FAMILY HISTORY: NC

SOCIAL HISTORY: denies any tobacco, EtOH or illict drug use. Lives at home with
parents. Has one child with a prior girlfriend. Does not work. 

### Response:
{'Cerebral embolism with cerebral infarction,End stage renal disease,Encephalopathy, unspecified,Complications of transplanted liver,Unspecified protein-calorie malnutrition,Other ascites,Precipitous drop in hematocrit,Renal dialysis status,Cirrhosis of liver without mention of alcohol,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other convulsions,Other specified cardiac dysrhythmias,Profound impairment, both eyes, impairment level not further specified,Nausea with vomiting'}
