CHIEF COMPLAINT: Altered mental status, fatigue

PRESENT ILLNESS: 56yo man with hepatitis C/ETOH-induced liver cirrhosis with
history of decompensation with recurrent ascites and recurrent
encephalopathy s/p TIPS in [**8-/2156**], who is transferred from [**Location (un) 21541**] Hospital after presenting there with weakness. Per report,
pt called EMS with weakness x 4days with fever and chills. He
reports poor po intake/anorexia during this time. He denies any
dietary indescretion, but he reports increasing abd girth and
leg swelling. He did report a few missed doses of lactulose
prior to weakness.
.
He was found by EMS in pool of stool, BS of 42, given an amp of
D50 and brought to [**Hospital3 **] hospital. He was found to be
confused, but reorientable, incontinent of urine, 3+edema. On
labs he had k of 6.2 and was given kaexalate, insulin/dextrose,
calcium gluconate and repeat of 4.9 on transfer. He had abd CT
and u/s of his abdomen which showed ascites, TIPS occlusion. A
paracentesis was done. He had bld cxs that grew out GNRs. Pt
received 8 vials of albumin for hepatorenal ppx, 1 dose of
ceftriaxone and 1 dose of cefotaxime. He was transferred to
[**Hospital1 18**].
.
Initial ROS was (+)increasing protuberance of abd with abd pain,
He reports that he has gained weight (ideal wt of 149-152),
currently 70kgs. +SOB with increasing abd distension. + maroon
stools.
(-) denies significant confusion, n/v/d/dysuria/cp or any other
symptoms.

MEDICAL HISTORY: - Cirrhosis, s/p TIPS placement [**8-15**]
- HepC, dx [**2129**]: Nonresponder to interferon and ribavirin after
six months of therapy in [**2149**]. From [**Month (only) 116**] to [**2151-12-10**], the
patient was treated with pegylated interferon and ribavirin for
a period of six months. For unclear reasons, this treatment was
discontinued. The patient was subsequently enrolled in the
colchicine arm of the COPILOT trial in the past. [**10-15**] viral load
is 441,000 IU/mL.
- Chronic Renal Insufficiency (baseline Cr 1.1-1.7 over last
year)
- Depression.
- Osteoarthritis
- Hip osteopenia
- Right knee surgery
- Bilateral hip repair
- s/p Umbilical hernia repair
.

MEDICATION ON ADMISSION: 1. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
2. Furosemide 40 mg Tablet Sig: (3) Tablet PO DAILY (Daily).
3. Vicodin/Oxycodone 5 mg PRN pain.
4. Pantoprazole 40 mg Tablet, Delayed Release Daily
5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID
6. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID,
titrate to 3 bowel movements per day, do not exceed > 5 BM.
9. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
10. Rifaxamin 200mg TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On arrival to the MICU

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives on [**Hospital3 **] in a garage apartment which he rents from a
family with whom he has a good relationship.  Also has
supportive ex-wife and daughter. [**Name (NI) **] works in a recording studio
and plays the guitar in a band. He has a history of alcohol
abuse (last drink [**2136-10-9**], drank heavily for 12 years). Also
h/o IV drug use many years ago. Pt smoked occasionally for 30
years, quit a year ago. Denies any recent ETOH ingestion.
Cirrhosis of liver without mention of alcohol,Spontaneous bacterial peritonitis,Hepatorenal syndrome,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Other severe protein-calorie malnutrition,Other ascites,Urinary tract infection, site not specified,Pathologic fracture of vertebrae,Blood in stool,Hyperosmolality and/or hypernatremia,Other postoperative infection,Bacteremia,Unspecified viral hepatitis C without hepatic coma,Other specified disorders of biliary tract,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Benign essential hypertension,Thrombocytopenia, unspecified,Unspecified acquired hypothyroidism,Hypercalcemia,Other testicular hypofunction,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Depressive disorder, not elsewhere classified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Cirrhosis of liver NOS,Spontan bact peritonitis,Hepatorenal syndrome,Acute kidney failure NOS,Pneumonia, organism NOS,Oth severe malnutrition,Ascites NEC,Urin tract infection NOS,Path fx vertebrae,Blood in stool,Hyperosmolality,Other postop infection,Bacteremia,Hpt C w/o hepat coma NOS,Dis of biliary tract NEC,Enterococcus group d,Benign hypertension,Thrombocytopenia NOS,Hypothyroidism NOS,Hypercalcemia,Testicular hypofunc NEC,Osteoarthros NOS-unspec,Depressive disorder NEC,Abn react-org transplant
Admission Date:  [**2157-12-2**]              Discharge Date:   [**2158-1-18**]

Date of Birth:  [**2101-9-15**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Altered mental status, fatigue

Major Surgical or Invasive Procedure:
[**2157-12-12**] liver [**Month/Day/Year **]
[**2157-12-14**] roux en y hepaticojejunostomy
[**2157-12-18**] ex lap
colonoscopy


History of Present Illness:
56yo man with hepatitis C/ETOH-induced liver cirrhosis with
history of decompensation with recurrent ascites and recurrent
encephalopathy s/p TIPS in [**8-/2156**], who is transferred from [**Location (un) 21541**] Hospital after presenting there with weakness. Per report,
pt called EMS with weakness x 4days with fever and chills. He
reports poor po intake/anorexia during this time. He denies any
dietary indescretion, but he reports increasing abd girth and
leg swelling. He did report a few missed doses of lactulose
prior to weakness.
.
He was found by EMS in pool of stool, BS of 42, given an amp of
D50 and brought to [**Hospital3 **] hospital. He was found to be
confused, but reorientable, incontinent of urine, 3+edema. On
labs he had k of 6.2 and was given kaexalate, insulin/dextrose,
calcium gluconate and repeat of 4.9 on transfer. He had abd CT
and u/s of his abdomen which showed ascites, TIPS occlusion. A
paracentesis was done. He had bld cxs that grew out GNRs. Pt
received 8 vials of albumin for hepatorenal ppx, 1 dose of
ceftriaxone and 1 dose of cefotaxime. He was transferred to
[**Hospital1 18**].
.
Initial ROS was (+)increasing protuberance of abd with abd pain,
He reports that he has gained weight (ideal wt of 149-152),
currently 70kgs. +SOB with increasing abd distension. + maroon
stools.
(-) denies significant confusion, n/v/d/dysuria/cp or any other
symptoms.


Past Medical History:
- Cirrhosis, s/p TIPS placement [**8-15**]
- HepC, dx [**2129**]: Nonresponder to interferon and ribavirin after
six months of therapy in [**2149**]. From [**Month (only) 116**] to [**2151-12-10**], the
patient was treated with pegylated interferon and ribavirin for
a period of six months. For unclear reasons, this treatment was
discontinued. The patient was subsequently enrolled in the
colchicine arm of the COPILOT trial in the past. [**10-15**] viral load
is 441,000 IU/mL.
- Chronic Renal Insufficiency (baseline Cr 1.1-1.7 over last
year)
- Depression.
- Osteoarthritis
- Hip osteopenia
- Right knee surgery
- Bilateral hip repair
- s/p Umbilical hernia repair
.


Social History:
Lives on [**Hospital3 **] in a garage apartment which he rents from a
family with whom he has a good relationship.  Also has
supportive ex-wife and daughter. [**Name (NI) **] works in a recording studio
and plays the guitar in a band. He has a history of alcohol
abuse (last drink [**2136-10-9**], drank heavily for 12 years). Also
h/o IV drug use many years ago. Pt smoked occasionally for 30
years, quit a year ago. Denies any recent ETOH ingestion.


Family History:
non-contributory

Physical Exam:
On arrival to the MICU

VS 100.6, 126, 185/90, 27 and 100% on NRB, then 3L NC
GENERAL - chronically ill appearing man in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, slightly icteric sclera, MMM, OP
clear
NECK - supple, no thyromegaly, no JVD
LUNGS - breath sounds in upper lobes, decreased breathsounds at
bases, no r/r/w, no accessory muscle use
HEART - slightly tachy, RR, with systolic murmur, nl S1-S2
ABDOMEN - tense, tender to palpation, shifting dullness,
+splenomegaly, no rebound/guarding, +umbilical hernia - easily
compressed
EXTREMITIES - WWP, 1+ edema on left, 3+ edema on right 2+
peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox2, CNs II-XII grossly

Pertinent Results:
On Admission: [**2157-12-2**]
WBC-12.9* RBC-2.93* Hgb-10.7* Hct-31.8* MCV-109* MCH-36.5*
MCHC-33.6 RDW-16.1* Plt Ct-21*#
PT-31.8* PTT-56.1* INR(PT)-3.3*
Glucose-112* UreaN-63* Creat-2.1*# Na-132* K-4.2 Cl-99 HCO3-26
AnGap-11
ALT-36 AST-76* LD(LDH)-488* AlkPhos-143* TotBili-5.6*
DirBili-3.3* IndBili-2.3 Albumin-3.0* Calcium-10.7* Phos-3.2
Mg-2.4
At Discharge: [**2158-1-17**]
WBC-10.3 RBC-2.92* Hgb-9.6* Hct-28.4* MCV-97 MCH-32.8* MCHC-33.8
RDW-19.2* Plt Ct-220
Glucose-145* UreaN-52* Creat-1.3* Na-134 K-4.8 Cl-101 HCO3-25
AnGap-13
ALT-157* AST-90* AlkPhos-215* TotBili-0.2
Albumin-2.8* Calcium-8.9 Phos-4.3 Mg-1.6
tacroFK-9.3
[**2158-1-2**] TSH-15* T4-3.0* T3-53*


Brief Hospital Course:
Upon arrival at [**Hospital1 18**], patient was admitted to the [**Doctor Last Name 3271**]-[**First Name4 (NamePattern1) 679**]
[**Last Name (NamePattern1) 4869**].  He was treated with Ceftrixone and  albumin for
presumed SBP and hepatorenal syndrome. Diuretics were held.
Lactulose, rifaxamin, and ursodiol were continued. Abdominal
ultrasound confirmed no flow through portal vein and likely TIPS
occlusion.  OSH cultures revealed GNR, speciation revealed
Serratia.  Ceftriaxone was continued.
.
On [**12-3**] a diagnostic paracentesis was performed. Post
procedure, he became rigorous with brief hypoxia to 80% on 2L.
He was then placed on NRB and transfered to the MICU given
concern for impending sepsis, need for high volume resuscitation
and poor respiratory status.
.
Upon arrival the MICU, patient was rigorous, VS 100.6, 126,
185/90, 27 and 100% on NRB, then 3L NC. He denied any pain or
recent fever but did report increase in diarrhea. He quickly was
weaned from the oxygen.  He remained hemodynamically stable with
no evidence of sepsis, although he did have recurrent episode of
rigors.  Blood cultures were negative.
.
Given known occluded TIPS, elevated bilirubin, and severe
ascites, there was consideration of TIPS revision.  This was
decided against out of concern for worsening liver failure.
Therapeutic tap was not performed initially because of infected
peritoneum and later out of concern for worsening renal failure
(see below).  The patient was noted to be on the top of the
liver [**Month/Year (2) **] list.  An NG tube was placed under direct
visualization in order to optimize nutrition.
.
Urinary tract infection: Urine grew enterococcus sensitive to
vanco which was started.  Vancomycin was held for 4 days for a
high level. Creatinine was elevated to 2.1 from 1.0 from three
weeks prior.  Diuretics were held.  Creatinine trended down to
1.4.  However, it then rose again.  Albumin was given for two
days for likely hepatorenal syndrome.
.
Abdominal pain and elevated WBC: On hospital day 7, a day after
beginning tube feeds, the patient complained of abdominal pain
with upward WBC trend.  KUB did not show evidence of
obstruction.  The tube feeds were stopped, and stool studies
sent for c diff.  Repeat diagnositic paracentesis demonstrated
190 leukocytes, 78% PMN.
.
Osteoporosis/hypercalcemia:  Patient had known vertebral
compression fractures and low bone mineral density. The etiology
of osteoporosis was thought to be a combination of poor
nutrition, alcoholism, and hypogonadism (see below). Spine films
to rule out new fracture showed evidence of pelvic fracture.
Follow-up dedicated pelvic films confirmed fractures involving
bilateral superior and inferior pubic rami and bilateral sacral
ala fractures.  The orthopedics consult service saw the patient
and recommended weight bearing as tolerated and brace to be worn
when oob.

The patient was initially given calcitriol and calcium
supplementation for treatment of osteoporosis.  These were
stopped in consultation with the endocrinology consulting
service given borderline elevated calcium and replete 1,25
hydoxy vitamin D levels.  His hypercalcemia was thought to be
due to prolonged immobilization, and PTH levels were
appropriately low.
.
Hypogonadism:  As part of the work-up of his osteoporosis,
testosterone, FSH, and LH were checked and found to be low.  He
was given a testosterone patch for supplementation.  Further
work-up with pitutitary MRI was deferred to the outpatient
setting.

Hypothyroidism:  The patient was found to be hypothyroid, and
levothyroxine supplementation was begun. The dose was raised
early in [**Month (only) **]. Repeat Thyroid studies should be done
mid-Decemeber

On [**12-12**], a liver donor was available and the patient accepted
the donation. He underwent cadaveric liver [**Month/Day (4) **]. Surgeon
was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please see operative report for complete
details. He received standard induction immunosuppression
consisting of solumedrol and cellcept. He received multiple
blood products and was transferred to the SICU intubated
immediately postop where he continued to recieve blood products
for hemostasis. LFTs trended down, but he experienced a large
volume of bilious drainage via the JP drains. Therefore, on
[**12-14**], he returned to the OR and underwent roux en y
hepaticojejunostomy for cystic duct leak and necrotic recipient
bile duct. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Postop, he returned to the
SICU intubated.

On [**12-18**], he had melena and NG aspirate that was blood tinged. A
colonoscopy was performed noting blood in the entire colon from
introduction of the scope in the rectum througout the colon to
the cecum.  there was blood in the terminal ileum. No discrete
bleeding source could be localized in the colon. He received
PRBC,plt and FFP. He was taken to the OR by Dr. [**Last Name (STitle) 816**] for
exploratory laparotomy for GI bleeding. There was no obvious
blood in the stomach and duodenum, the jejunojejunal
anastomosis as well as hepaticojejunostomy were without
bleeding. A small incision was made in the Roux limb and
irrigated. The anastomosis was fine.
There was no obvious blood. Hct stabilized. A PPI drip was
given.TPN was given then discontinued when a post pyloric
feeding tube was placed. Tube feedings were advanced to goal.
Zosyn was stopped on [**12-23**]. He continued to be hypertensive and
tachycardic receiving beta blockers. Free water was given for
hypernatremia to 155. This trended down to 148 11/13 am.  He
became disoriented and a bit paranoid with diffuse tremor. He
received zyprexa briefly for this. Protonix drip changed to [**Hospital1 **].

A cholangiogram was done on [**12-21**] which showed the Roux tube
migrated out of the
biliary tree and out of the Roux limb, terminating within the
peritoneal
cavity.

The patient did not have any more episodes of hematemesis or
hematochezia, Hct remained stable at 35, and so his flexseal was
placed back again and his NGT removed.  His dobhoff tube feeds
continued.  His sodium rose again to 150 and his free water
replacements began.  He continued having loose stool.

[**Date range (1) 46801**] Cellcept was decreased to 500 [**Hospital1 **] from 1000 [**Hospital1 **], and
his stool became less loose. Flexaseal was removed. Multiple
stool samples were sent for c.diff and culture which were all
negative. Banana flakes were added to the feedings. Serum sodium
responded to free water replacements and was down to 136. Water
boluses were stopped. He remained hemodynamically stable, and so
was transferred to the [**Hospital Ward Name 121**] 10 (Med-[**Doctor First Name **] Unit) on [**12-28**].  Tube
feedings were changed from 1/2 strength Nutren Renal to full
strength. Diet was slowly advanced. A speech and swallow eval
cleared him for solid food. He did not have dysphagia, but
lacked lower dentures. Kcal counts were insufficient
(143-545/day).The feeding tube was self removed on [**1-1**] and
attempts were made on [**1-2**] and [**1-3**] in fluoro to place this
post pyloric. This was unsuccessful.

The JP drainage decreased significantly allowing for removal of
the JPs. The foley was removed and he was initially incontinent
requiring a condom catheter.

On [**12-28**], Orthopedics was consulted for the patient's
compression fractures; kyphoplasty was not recommended upon
review of the CT. Though he got a brace for walking, he remained
with back pain. He ambulated a few steps with PT with moderate
to max assist with TLSI brace used.

[**Last Name (un) **] was consulted for hyperglycemia. Low dose NPH insulin was
used with sliding scale. NPH was then stopped and just sliding
scale utilized for glucoses in the 100-170 range.
Immunosuppression was adjusted per protocol with solumedrol
weaned down to prednisone taper which is due to be tapered to
off within the next ten days. cellcept continued at 500mg [**Hospital1 **]
and prograf which was adjusted based on daily trough levels with
goal level of 10. LFTs were normal and stable. Creatinine
fluctuated some likely from prograf.  TSH was noted to be 13 on
[**12-8**]. Levoxyl was started. On [**1-2**], TSH was 15 with T4 of 3.0
and T3 of 53. Levoxyl was increased to 75mcg once daily.

He was started on a 14 day course of H Pylori therapy for
positive antibody and notation of gastritis and esophagitis when
Dobhoff had to be replaced.
He received oxycodone for abdominal and back pain. Social work
followed for support.

He continues with tube feeds at goal with the bridled Dobhoff
tube. Diet remains thin liquids which he is tolerating. He is
ambulating with 2 person assist and brace whenever he is upright
or ambulating. He has intermittent stooling which have all been
C diff negative.


Medications on Admission:
1. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
2. Furosemide 40 mg Tablet Sig: (3) Tablet PO DAILY (Daily).
3. Vicodin/Oxycodone 5 mg PRN pain.
4. Pantoprazole 40 mg Tablet, Delayed Release Daily
5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID
6. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID,
titrate to 3 bowel movements per day, do not exceed > 5 BM.
9. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
10. Rifaxamin 200mg TID


Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheezing.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for wheezing.
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): Hold for SBP < 110 or HR < 60.
9. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal DAILY (Daily).
12. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (MO).
13. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 8 days: H pylori prophylaxis.
Through [**1-26**].
16. Amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours): H pylori prophylaxis.
Through [**1-26**].
17. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
18. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
20. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
21. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days: [**1-18**] - [**1-22**] then decrease to 5 mg daily on [**1-23**].

22. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
starting [**1-23**].
23. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
24. Tacrolimus
Please provide 0.25 mg PO BID in suspension form


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
HCV cirrhosis
s/p liver [**Hospital1 **] [**2157-12-12**]
bile leak
GI bleeding: resolved
malnutrition
serratia bacteremia
UTI< Enterococcus
vertebral compression fractures


Discharge Condition:
stable, fair


Discharge Instructions:
Please call the [**Month/Day/Year 1326**] Office [**Telephone/Fax (1) 673**] if fever > 101,
chills, nausea, vomiting, inability to take any of your
medications, abdominal pain, worsening diarrhea, abdominal
distension, continued weight loss or any concerns
Labs every Monday and Thursday
[**Telephone/Fax (1) 1326**] office to adjust all medications
Continue tube feeds as ordered

Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2158-1-26**] 10:00
[**Last Name (LF) **],[**First Name3 (LF) 156**] [**First Name3 (LF) **] SOCIAL WORK Date/Time:[**2158-1-26**] 11:00



Completed by:[**2158-1-18**]
{'Cirrhosis of liver without mention of alcohol,Spontaneous bacterial peritonitis,Hepatorenal syndrome,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Other severe protein-calorie malnutrition,Other ascites,Urinary tract infection, site not specified,Pathologic fracture of vertebrae,Blood in stool,Hyperosmolality and/or hypernatremia,Other postoperative infection,Bacteremia,Unspecified viral hepatitis C without hepatic coma,Other specified disorders of biliary tract,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Benign essential hypertension,Thrombocytopenia, unspecified,Unspecified acquired hypothyroidism,Hypercalcemia,Other testicular hypofunction,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Depressive disorder, not elsewhere classified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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, fatigue

PRESENT ILLNESS: 56yo man with hepatitis C/ETOH-induced liver cirrhosis with
history of decompensation with recurrent ascites and recurrent
encephalopathy s/p TIPS in [**8-/2156**], who is transferred from [**Location (un) 21541**] Hospital after presenting there with weakness. Per report,
pt called EMS with weakness x 4days with fever and chills. He
reports poor po intake/anorexia during this time. He denies any
dietary indescretion, but he reports increasing abd girth and
leg swelling. He did report a few missed doses of lactulose
prior to weakness.
.
He was found by EMS in pool of stool, BS of 42, given an amp of
D50 and brought to [**Hospital3 **] hospital. He was found to be
confused, but reorientable, incontinent of urine, 3+edema. On
labs he had k of 6.2 and was given kaexalate, insulin/dextrose,
calcium gluconate and repeat of 4.9 on transfer. He had abd CT
and u/s of his abdomen which showed ascites, TIPS occlusion. A
paracentesis was done. He had bld cxs that grew out GNRs. Pt
received 8 vials of albumin for hepatorenal ppx, 1 dose of
ceftriaxone and 1 dose of cefotaxime. He was transferred to
[**Hospital1 18**].
.
Initial ROS was (+)increasing protuberance of abd with abd pain,
He reports that he has gained weight (ideal wt of 149-152),
currently 70kgs. +SOB with increasing abd distension. + maroon
stools.
(-) denies significant confusion, n/v/d/dysuria/cp or any other
symptoms.

MEDICAL HISTORY: - Cirrhosis, s/p TIPS placement [**8-15**]
- HepC, dx [**2129**]: Nonresponder to interferon and ribavirin after
six months of therapy in [**2149**]. From [**Month (only) 116**] to [**2151-12-10**], the
patient was treated with pegylated interferon and ribavirin for
a period of six months. For unclear reasons, this treatment was
discontinued. The patient was subsequently enrolled in the
colchicine arm of the COPILOT trial in the past. [**10-15**] viral load
is 441,000 IU/mL.
- Chronic Renal Insufficiency (baseline Cr 1.1-1.7 over last
year)
- Depression.
- Osteoarthritis
- Hip osteopenia
- Right knee surgery
- Bilateral hip repair
- s/p Umbilical hernia repair
.

MEDICATION ON ADMISSION: 1. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
2. Furosemide 40 mg Tablet Sig: (3) Tablet PO DAILY (Daily).
3. Vicodin/Oxycodone 5 mg PRN pain.
4. Pantoprazole 40 mg Tablet, Delayed Release Daily
5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID
6. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID,
titrate to 3 bowel movements per day, do not exceed > 5 BM.
9. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
10. Rifaxamin 200mg TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On arrival to the MICU

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives on [**Hospital3 **] in a garage apartment which he rents from a
family with whom he has a good relationship.  Also has
supportive ex-wife and daughter. [**Name (NI) **] works in a recording studio
and plays the guitar in a band. He has a history of alcohol
abuse (last drink [**2136-10-9**], drank heavily for 12 years). Also
h/o IV drug use many years ago. Pt smoked occasionally for 30
years, quit a year ago. Denies any recent ETOH ingestion. 

### Response:
{'Cirrhosis of liver without mention of alcohol,Spontaneous bacterial peritonitis,Hepatorenal syndrome,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Other severe protein-calorie malnutrition,Other ascites,Urinary tract infection, site not specified,Pathologic fracture of vertebrae,Blood in stool,Hyperosmolality and/or hypernatremia,Other postoperative infection,Bacteremia,Unspecified viral hepatitis C without hepatic coma,Other specified disorders of biliary tract,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Benign essential hypertension,Thrombocytopenia, unspecified,Unspecified acquired hypothyroidism,Hypercalcemia,Other testicular hypofunction,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Depressive disorder, not elsewhere classified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
