CHIEF COMPLAINT: Fever.

PRESENT ILLNESS: Patient is a 46-year-old male
status post liver transplant in [**2121-11-16**] for
cryptogenic cirrhosis, hepatitis C, varices with recent
admission for hyperkalemia now presents with fever of 103.2,
decreased appetite, dehydration. Patient has not eaten or had
any fluid for a couple of days.

MEDICAL HISTORY: Liver transplant
[**2121-11-16**], nutcracker esophagus, elevated prolactin, end-
stage renal disease, cryptogenic pneumonia, thoracotomy with
right upper lobectomy secondary to cavitary lesion,
gastroparesis.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin.

PHYSICAL EXAM: In no acute distress, nonjaundiced. Heart
rate regular. Lungs are clear to auscultation. Abdomen: Soft,
nontender, nondistended.

FAMILY HISTORY: 

SOCIAL HISTORY: 
Complications of transplanted liver,Bacteremia,Cholangitis,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Stricture of artery
Compl liver transplant,Bacteremia,Cholangitis,Enterococcus group d,Stricture of artery
Admission Date: [**2122-2-24**]        Discharge Date: [**2122-3-23**]

Date of Birth:  [**2075-12-28**]        Sex:  M

Service:  [**Last Name (un) **]


CHIEF COMPLAINT:  Fever.

HISTORY OF PRESENT ILLNESS:  Patient is a 46-year-old male
status post liver transplant in [**2121-11-16**] for
cryptogenic cirrhosis, hepatitis C, varices with recent
admission for hyperkalemia now presents with fever of 103.2,
decreased appetite, dehydration. Patient has not eaten or had
any fluid for a couple of days.

PAST SURGICAL AND PAST MEDICAL HISTORY:  Liver transplant
[**2121-11-16**], nutcracker esophagus, elevated prolactin, end-
stage renal disease, cryptogenic pneumonia, thoracotomy with
right upper lobectomy secondary to cavitary lesion,
gastroparesis.

ALLERGIES:  Penicillin.

MEDICATIONS AT HOME:  Prograf 1 mg p.o. b.i.d., Rapamune 2 mg
p.o. daily, prednisone 5 mg daily, fluconazole 400 mg p.o.
daily, Protonix 40 mg b.i.d., Valcyte 450 mg daily, NPH
insulin 28 units q.a.m., Epogen 20,000 units every week,
nifedipine 10 mg p.o. b.i.d., Carafate 1 gram q.i.d., Bactrim
single strength 3 times a week.

VITAL SIGNS:  Temperature 103.7, heart rate 102, BP 101/78,
97% on room air, respiratory rate 18.

LABS:  White count 1.6, hematocrit 25.3, platelet count 51.
PT 14.2, PTT 30.7, INR 1.3. UA was negative. AST 62, ALT 68,
alkaline phosphatase 203, T bilirubin 0.6, amylase 12, lipase
8, creatinine 1.5 with a BUN of 330.

PHYSICAL EXAM:  In no acute distress, nonjaundiced. Heart
rate regular. Lungs are clear to auscultation. Abdomen: Soft,
nontender, nondistended.

HOSPITAL COURSE:  Patient was admitted to the transplant
service and started on vancomycin and levofloxacin IV and
given a dose of Neupogen. Blood cultures were sent off.
Duplex of the liver was done. This demonstrated patent
hepatic veins and portal veins with appropriate direction of
flow. Patent extrahepatic veins, hepatic artery with improved
wave forms. The intrahepatic right and left hepatic arteries
were poorly visualized which suggested decreased flow. There
was no evidence of hepatic ductal dilatation or ascites.

Chest x-ray on admission was stable; postoperative appearance
of the right hemithorax. No evidence of acute pneumonia.

Blood and urine cultures were sent. Blood cultures was less
than 10,000 organisms. Blood cultures demonstrated
Enterococcus faecium resistant to vancomycin, ampicillin, and
penicillin, sensitive to linezolid. Infectious disease was
consulted.

Given pancytopenia, he was started on daptomycin in lieu of
linezolid. Weekly CKs were monitored. These were normal. An
abdominal CT was done. This demonstrated the main hepatic
artery was not opacified beyond the origin of the
gastroduodenal artery. No intrahepatic arterial flow was
noted. The intrahepatic biliary ductal dilatation was noted
more severe in the left than in the right lobe. Several bile
leaks were noted in the left hepatic lobe. There were patent
portal and hepatic veins. Moderate ascites was noted with
stable severe splenomegaly and multiple varices. Multiple
subcentimeter hypodensities in the spleen was noted. This was
felt to represent hemangiomas or other benign entities. A
small right pleural effusion was noted.

He was sent for a T-tube cholangiogram. There was no evidence
of obstruction or leak noted. The biliary anastomosis was
widely patent and there was normal contrast opacification of
the intrahepatic bile ducts and small bowel.

He was then sent on [**2122-2-26**] for a PTC cholangiogram
which demonstrated dilated left-side intrahepatic bile ducts
with nondilated right-sided intrahepatic bile ducts and
irregularly marginated severe stricture of the extrahepatic
common ducts with near complete occlusion was noted. This was
angioplastied with an 8 mm x 4 cm angioplasty balloon and
then a 10 French left-sided internal/external biliary
drainage catheter was placed.

His LFTs improved. AST was 21, ALT 43, alkaline phosphatase
129, total bilirubin 0.3. On [**2122-2-27**], he underwent an
angiogram by the cardiologist in the catheterization lab.
This demonstrated completely occluded hepatic artery. His PTC
drain was left to gravity drainage draining approximately 350-
575 cc of bilious drainage. His vital signs remained stable.
He was afebrile. His white blood cell count remained on the
low side in the range of 1.9-2.5. His hematocrit was stable
on the low side ranging between 26.6-24.6. He continued on IV
hydration as well as IV Levaquin and daptomycin.

He did receive 1 unit of packed red blood cells as well as
Neupogen again with slight improvement in his white blood
cell count. He was medicated with oxycodone for discomfort in
the right upper quadrant and right lateral abdomen. His EKG
demonstrated an ectopic atrial rhythm with diffuse
nonspecific ST-wave abnormalities. Heart rate was in the
range of mid to high 80s. He underwent a transthoracic
echocardiogram to assess for vegetation given bacteremia. It
was noted that he had left ventricular wall thickness, cavity
size and systolic function were normal with left ventricular
ejection fraction of 55%. The regional left ventricular wall
motion was normal and there was no evidence of endocarditis.

A repeat chest x-ray demonstrated no significant interval
change from the prior study. No pneumothorax.

He was seen by podiatry service for toenail care. He stated
that his left hallux nail was painful. He underwent sharp
debridement of nails. Pain diminished after this procedure.
Triple antibiotic was applied to the site without further
problems.

Nutrition followed the patient throughout this hospital
course making recommendations that included sugar-free shakes
t.i.d. Physical therapy cleared him to go home. Dr. [**Last Name (STitle) 724**] from
infectious disease followed Mr. [**Known lastname 1250**] recommending that
fluconazole 200 mg be continued for 1 year given history of
cryptococcal pneumonia. This was reinstituted.

He was retransfused with 2 units of packed red blood cells
for a hematocrit of 24 on [**3-8**]. Repeat hematocrit was 30.

A repeat PTC cholangiogram was done that demonstrated
nondilated intrahepatic biliary tree. There was narrowing of
the common hepatic duct, but contrast slowed from the
intrahepatic biliary tree to the bowel. His PTC drain was
capped. He continued to have low-grade fevers of 100.4 up to
103.4 on [**3-11**]. Repeat blood cultures were drawn almost on
a daily basis for surveillance. These blood cultures were
negative. Bioculture demonstrated enterococcus, 2 different
species both resistant to vancomycin and both sensitive to
linezolid. He remained on IV daptomycin and Levaquin.

His T-tube was uncapped for this febrile episode. He remained
in the hospital for monitoring and IV daptomycin. For the
remainder of the hospital course, he was running low grade
temperatures and then he was afebrile. His T-tube was capped
again and he tolerated this without further fevers. A repeat
chest x-ray was done that demonstrated small right pleural
effusion that was unchanged. No findings suggestive of
pneumonia.

Of note, on [**2122-3-5**], a PICC line was placed at the
cavoatrial junction anticipating that he would need IV
daptomycin. On [**2122-3-18**], his levofloxacin was stopped. He
was started on cefepime 2 grams IV q.12h. Flagyl was started
500 mg p.o. q.8., and the daptomycin was discontinued. A CMV
viral load was done. This was not detected. Cryptococcal
antigen was negative.

On [**2122-3-19**], his PICC line catheter was removed and the
tip was cultured. There was no growth. Repeat blood cultures
on [**2122-3-19**] are still pending at this time.

He was discharged home on [**2122-3-23**] on p.o. linezolid, p.o.
levofloxacin was restarted, and fluconazole 200 mg daily.
Infectious disease recommended repeating an abdominal CT to
rule out abscess or bilomas. Of note, gram-positive cocci
were noted in [**11-19**] bottles on the blood culture likely
representing contaminant. He was ambulatory. Tolerating a
regular diet.

DISCHARGE CONDITION:  Stable.

MEDICATIONS ON DISCHARGE:  Colace 100 mg p.o. b.i.d.,
fluconazole 200 mg p.o. daily, levofloxacin 500 mg p.o.
daily, linezolid 600 mg p.o. b.i.d., nifedipine 10 mg p.o.
b.i.d., oxycodone 5 mg p.o. p.r.n. q.6h. p.r.n. as needed,
Protonix 40 mg p.o. q.12h., Bactrim single strength 1 p.o.
daily, Rapamune 3 mg p.o. daily, Valcyte 450 mg p.o. daily,
NPH insulin 28 units subcutaneous daily, and regular insulin
subcutaneous p.r.n. q.6h.

DISCHARGE DIAGNOSES:  Vancomycin resistant enterococci
bacteremia, vancomycin resistant enterococci in bile, hepatic
artery thrombosis status post liver transplant [**2121-11-16**],
stricture of extrahepatic common duct, and percutaneous
transhepatic catheter placed.

FOLLOW UP:  He was scheduled to followup in the outpatient
transplant clinic on [**2122-3-26**] at 10:50 with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]
and on [**2122-3-26**] at 11:30 with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**].



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]

Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D:  [**2122-3-24**] 12:22:59
T:  [**2122-3-24**] 13:15:18
Job#:  [**Job Number 62178**]
{'Complications of transplanted liver,Bacteremia,Cholangitis,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Stricture of artery'}


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: Fever.

PRESENT ILLNESS: Patient is a 46-year-old male
status post liver transplant in [**2121-11-16**] for
cryptogenic cirrhosis, hepatitis C, varices with recent
admission for hyperkalemia now presents with fever of 103.2,
decreased appetite, dehydration. Patient has not eaten or had
any fluid for a couple of days.

MEDICAL HISTORY: Liver transplant
[**2121-11-16**], nutcracker esophagus, elevated prolactin, end-
stage renal disease, cryptogenic pneumonia, thoracotomy with
right upper lobectomy secondary to cavitary lesion,
gastroparesis.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin.

PHYSICAL EXAM: In no acute distress, nonjaundiced. Heart
rate regular. Lungs are clear to auscultation. Abdomen: Soft,
nontender, nondistended.

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Complications of transplanted liver,Bacteremia,Cholangitis,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Stricture of artery'}
