CHIEF COMPLAINT: Pancytopenia status post liver transplant.

PRESENT ILLNESS: Patient is a 46-year-old male
status post liver transplant in [**2121-11-16**] whose course
has been complicated by hepatic artery thrombosis status post
PTC catheter placement, high-grade VRE bacteremia on long-
term linezolid currently, PTC placement for biliary sepsis.
He has been followed closely by Dr. [**Last Name (STitle) 816**] and Dr. [**Last Name (STitle) 724**] from ID
as a outpatient. Recently Valcyte was stopped on [**3-26**] after
3 months of treatment. Patient has been having labs drawn
every 2-3 days, which revealed hematocrit, white blood cell,
and platelet count being low that had been steadily trending
down reaching critical levels today with a white count of 1,
hematocrit of 17, and a platelet count of 45.

MEDICAL HISTORY: Liver transplant on [**2121-11-16**], then
Roux-en-Y hepaticojejunostomy, hepatitis C, cryptogenic
cirrhosis complicated by hepatic artery thrombosis, very high-
grade VRE bacteremia on [**2122-2-14**], source was the biliary
tree treated with linezolid, status post PTC drain in [**2122-2-14**] for stricture, now capped, methemoglobinemia in [**2122-2-14**] from Hurricaine spray during TEE, history of
Cryptococcal pneumonia on fluconazole long-term. He should be
on 200 mg p.o. daily for 1 year, nutcracker esophagus,
chronic renal insufficiency, creatinine baseline is 1.2,
right inguinal hernia, diverticulitis, esophageal varices,
history of hyperkalemia treated with Kayexalate p.r.n. and
increased prolactin.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin, benzocaine.

PHYSICAL EXAM: Temperature was 101. He was in no acute
distress. Lungs are clear. Heart was regular rate and rhythm.
Abdomen: Soft, nondistended. PTC catheter was in place and
capped. Reducible left inguinal hernia on the left and right.
Extremities: No clubbing, cyanosis, or edema.

FAMILY HISTORY: 

SOCIAL HISTORY: 
Complications of transplanted liver,Embolism and thrombosis of other specified artery,Abscess of liver,Hernia of other specified sites, with obstruction,Bacteremia,Cholangitis,Paralytic ileus,Pressure ulcer, lower back,Unspecified protein-calorie malnutrition,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified antibiotics causing adverse effects in therapeutic use
Compl liver transplant,Arterial embolism NEC,Abscess of liver,Hernia, site NEC w obstr,Bacteremia,Cholangitis,Paralytic ileus,Pressure ulcer, low back,Protein-cal malnutr NOS,Oth specf bacteria,DMII wo cmp nt st uncntr,Adv eff antibiotics NEC
Admission Date: [**2122-4-15**]        Discharge Date: [**2122-6-2**]

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

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


CHIEF COMPLAINT:  Pancytopenia status post liver transplant.

HISTORY OF PRESENT ILLNESS:  Patient is a 46-year-old male
status post liver transplant in [**2121-11-16**] whose course
has been complicated by hepatic artery thrombosis status post
PTC catheter placement, high-grade VRE bacteremia on long-
term linezolid currently, PTC placement for biliary sepsis.
He has been followed closely by Dr. [**Last Name (STitle) 816**] and Dr. [**Last Name (STitle) 724**] from ID
as a outpatient. Recently Valcyte was stopped on [**3-26**] after
3 months of treatment. Patient has been having labs drawn
every 2-3 days, which revealed hematocrit, white blood cell,
and platelet count being low that had been steadily trending
down reaching critical levels today with a white count of 1,
hematocrit of 17, and a platelet count of 45.

The patient was called at home and asked to come in. His ALT
and AST were also elevated. ALT was 124, AST 146 for which
this is the 1st time since his transplant that his liver
function tests had been abnormal. He denied any fevers,
chills, nausea, vomiting, diarrhea, constipation, shortness
of breath. He says he has had sweats x2 days and some
increased fatigue over the past few weeks, but otherwise
feels well. Appetite was unchanged.

ALLERGIES:  Penicillin, benzocaine.

PAST MEDICAL HISTORY:  Liver transplant on [**2121-11-16**], then
Roux-en-Y hepaticojejunostomy, hepatitis C, cryptogenic
cirrhosis complicated by hepatic artery thrombosis, very high-
grade VRE bacteremia on [**2122-2-14**], source was the biliary
tree treated with linezolid, status post PTC drain in [**2122-2-14**] for stricture, now capped, methemoglobinemia in [**2122-2-14**] from Hurricaine spray during TEE, history of
Cryptococcal pneumonia on fluconazole long-term. He should be
on 200 mg p.o. daily for 1 year, nutcracker esophagus,
chronic renal insufficiency, creatinine baseline is 1.2,
right inguinal hernia, diverticulitis, esophageal varices,
history of hyperkalemia treated with Kayexalate p.r.n. and
increased prolactin.

MEDICATIONS AT HOME:  Oxycodone 5 mg p.r.n., multivitamin 1
daily, regular insulin sliding scale, Protonix 40 daily, NPH
28 units q.a.m., Epogen 20,000 units every week, Colace,
nifedipine 10 mg p.o. b.i.d., Bactrim single strength 1
daily, fluconazole 200 mg daily, Kayexalate 15 grams p.r.n.,
linezolid 600 mg p.o. b.i.d., Valcyte 450 mg daily, Rapamune
3 mg daily, ferrous sulfate daily.

PHYSICAL EXAM:  Temperature was 101. He was in no acute
distress. Lungs are clear. Heart was regular rate and rhythm.
Abdomen: Soft, nondistended. PTC catheter was in place and
capped. Reducible left inguinal hernia on the left and right.
Extremities: No clubbing, cyanosis, or edema.

LABS ON ADMISSION:  White count was 2.1, hematocrit 17.2. He
was transfused with a total of 3 units of packed red blood
cells. His hematocrit increased to 24. He was given an
additional 2 units of packed red blood cells for a repeat
hematocrit of 30. He was started on IV fluid. He spiked a
temperature up to 102 in the evening of hospital day 1. Blood
cultures were sent off. He had 4/4 bottles positive for
Enterococcus faecium resistant to ampicillin, penicillin, and
vancomycin, sensitive to daptomycin and linezolid. He
remained on daptomycin as he had been previously on this for
long-term.

He was sent for an abdominal CT. This revealed markedly
increased ascites seen throughout the abdomen and pelvis
without fat stranding diffusely in the abdomen, especially
surrounding the liver. There was a 7-cm fluid collection
filled with contrast at the tip of the tube in the subhepatic
area which likely represented a leak, abscess, or loop of
bowel. It was noted that this was a limited study for
evaluation of a major abdominal organs due to the lack of
intravenous contrast [**Doctor Last Name 360**]. It was noted that he had a
cirrhotic-appearing liver and splenomegaly, bilateral
hydrocele greater on the right, bibasilar atelectasis, and
tubular opacity in the left lower lobe measuring 1.2 cm
unchanged since prior study, and gynecomastia.

HOSPITAL COURSE:  On [**4-17**], a Roux tube cholangiogram was
done. This revealed a large contrast collection in the region
of the left hepatic lobe consistent with a large bile leak.
There was associated dilatation of the intrahepatic ducts
with numerous filling defects consistent with sloughed mucosa
and debris. These findings were concerning for biliary
ischemia.

On [**4-18**], he went to CT for successful aspiration and a
drainage catheter placement in the large hepatic fluid
collection. He also underwent a TTE which was negative for
vegetations on the heart valves. Ejection fraction was
approximately 55%. The fluid from the above tap of abdominal
fluid grew 3 organisms: Enterococcus gallinarum, Strep
viridans heavy growth, and enterococcus. The enterococcus was
pansensitive and indeterminate for vancomycin. The
enterococcus 2nd species was resistant to ampicillin,
levofloxacin, penicillin, and tetracycline.

He remained on daptomycin. He continued on his Rapamune
throughout this hospital course with dose adjustments based
on level. His appetite was poor. He received calorie counts.
He was taking in anywhere from 845 kilocalories per day to
1,100 kilocalories per day. His liver function tests on
admission demonstrated an AST of 126, ALT of 79, alkaline
phosphatase of 134 with a total bilirubin of 0.4. These
remained relatively stable. There was slight increase in the
alkaline phosphatase noted.

He went for repositioning of the CT-guided drain on [**4-23**].
On [**4-26**], he spiked a temperature up to 101 again while on
the daptomycin. Repeat blood cultures were drawn daily on
[**4-20**] through [**4-24**]. These were all negative.

On [**4-27**], he underwent another CT-guided drainage. His
pigtail catheter was in place. There was interval decrease in
the size of the intrahepatic abscess with persistent ascites.
He continued to drain small amounts of fluid from this
pigtail catheter.

Infectious disease was consulted and followed the patient
closely throughout this hospital course making
recommendations with respect to antibiotic coverage. A CMV
viral load was sent off on [**2122-4-15**]. This was
subsequently found to be negative. Bile was sent from the PTC
drain. This demonstrated E. coli and Enterococcus gallinarum.
The E. coli was resistant to ampicillin, ciprofloxacin,
levofloxacin, and Bactrim. Otherwise, pansensitive. The
enterococcus was pansensitive.

He was started on levofloxacin on hospital day 16, and he
remained on levofloxacin for a total of 7 days. He continued
to complain of upper abdominal discomfort for several days.
White blood cell count improved from admission. White count
of 2.1; it rose to 9.9 on hospital day 13. Given poor
appetite and low calorie counts, he was started on total
parenteral nutrition via PICC line. A right arm PICC line was
placed on [**2122-4-21**]. [**Last Name (un) **] followed the patient for
hyperglycemia helping to titrate his insulin. Nutrition also
followed this patient throughout this hospital course making
recommendations.

On [**4-30**], hospital day 16, he underwent successful
ultrasound-guided therapeutic and diagnostic paracentesis.
Three-point 2 liters of dark-yellow fluid was withdrawn. This
fluid demonstrated no growth and 4+ polymorphonuclear
leukocytes.

Around hospital day 13, he started to complain of abdominal
distention and tenderness in the upper abdominal area. He had
a reducible hernia. He did experience some nausea and had
some emesis. He was medicated with Anzemet. He continued to
complain of persistent burning upper abdominal pain that
waxed and waned. The patient refused an upper endoscopy to
evaluate nausea. It was noted that on his paracentesis, he
had elevated white blood cells consistent with peritonitis
for which he remained on Levaquin for approximately 1 week. A
NG tube was placed on hospital day 18 for nausea and
vomiting.

NG tube put out approximately 4 liters per day consistent
with outlet obstruction. Hepatology followed the patient
closely throughout this hospital course. It is felt the
patient had an ileus related to opioids for abdominal pain
for which he was receiving p.r.n. Dilaudid with good effect.
He was taken to the OR on [**2122-5-3**] for complete small
bowel obstruction secondary to an internal hernia. He
underwent a reduction of internal hernia, closure of
mesocolon defect, Tru-Cut biopsy of the liver, and feeding
jejunostomy. Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] did the surgery, assisted
by resident, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 955**] under general anesthesia.
Patient tolerated the procedure well. Please see operative
report. He did receive 2 units of packed red blood cells.
Blood loss was minimal.

His abdominal pain was much better postsurgery. He remained
on IV daptomycin and Levaquin. He spiked a temperature on
[**5-11**] to 104, which he had a chest x-ray that demonstrated
no pneumonia with improving right apical hydropneumothorax.
He underwent an abdominal CT with successful replacement and
drainage of the left hepatic lobe collection with a small 3.2
cm residual collection along its anteromedial aspect. Of
note, a new hypodense collection in the lateral subcapsular
segment 5 yielded only a small amount of [**11-17**] cc of purulent
material. A small hemoperitoneum was noted postaspiration.

He was transferred to the SICU for further management. Blood
cultures demonstrated E. coli. Bile also grew E. coli
resistant to ampicillin, levofloxacin, Cipro, and Bactrim.
Enterococcus was indeterminate to vancomycin, otherwise
pansensitive. A urine culture was negative. He remained on
daptomycin. In addition to the temperature spike of 104, his
white blood cell count increased to 20.4. He also complained
of some lightheadedness and dizziness. He was transferred to
the surgical intensive care unit for IV resuscitation and
monitoring.

He was started on vasopressin. He remained on Levaquin,
Flagyl, ceftazidime, and daptomycin as well as linezolid.
Repeat abdominal CT was done on [**5-12**] with successful
replacement and drainage of the left hepatic lobe collection
as previously stated. He underwent a renal ultrasound at that
time. This demonstrated patent main renal arteries
bilaterally. Renal artery stenosis could not be excluded on
this technically limited exam. This was done for elevated
creatinine of 1.4. Creatinine trended back down with IV
hydration.

He experienced postop ileus as well. He had been started on
J. tube feedings, and his TPN had been weaned off. While in
the surgical intensive care unit, he was intubated. He was
started on meropenem. The ceftazidime was discontinued. The
left liver abscess collection had gram-positive cocci. The
right abscess had also gram-positive cocci. Blood cultures
were positive for E. coli and gram-negative rods.

Gradually he improved. He was extubated on [**5-16**]. His white
blood cell count trended down. A repeat abdominal CT was done
on [**5-15**]. This demonstrated improving 5-cm segment 4 liver
abscess with pigtail catheter. Two other dominant fluid
collections were unchanged. Ascites was worse. There was
resolution of the small bowel obstruction.

On [**5-15**], he was relisted for liver transplant with
resolution of small bowel obstruction. His J. tube feeding
was resumed. He tolerated this without event. He continued to
do well. He received a total of 6 days of meropenem.

He was transferred out of the surgical intensive care unit on
[**5-19**]. He did experience some diarrhea for which stools were
sent for C. difficile. These were subsequently negative. He
remained on p.o. fluconazole for cryptococcal treatment. He
had a history of cryptococcal pneumonia and was to remain on
fluconazole for 1 year. He received empiric Flagyl for
diarrhea.

On [**5-19**], he underwent an abdominal CT with contrast. This
demonstrated slight increase in size of the previously seen
segment 4 hepatic abscess/bile collection. Previously placed
pigtail catheter appeared to have been removed. There was
slight increase also in segment 2 abscess with a new drainage
catheter in place. The 3rd collection in the right lobe was
unchanged. There was abundant ascites tracking into the
pelvis and scrotum via the inguinal canals. This was
unchanged. There were also bilateral small pleural effusions
with associated atelectasis.

A repeat abdominal CT was done on [**5-21**]. A right-sided liver
pigtail drain was inserted as well as the left side liver
pigtail drain was placed. Paracentesis was done, and the
drain was inserted. Three liters of straw-color fluid was
sent off for culture and cell count. This demonstrated 2+
polymorphonuclear leukocytes and enterococcus resistant to
ampicillin, penicillin, and vancomycin, but sensitive to
linezolid. No anaerobes were isolated.

On [**2122-5-22**], the ascites fluid was increased. He still
had a pigtail drain in place. Two liters of fluid were
drained off utilizing low wall suction, then 5 additional
liters were removed via the standard paracentesis tube with
suction bottle. Patient tolerated this without incident, and
the pigtail catheter was removed. This ascites fluid
demonstrated Enterococcus faecium resistant to vancomycin and
sensitive to linezolid. He continued on daptomycin. He was
started on caspofungin IV for yeast that was detected in the
abscess drainage drawn on [**5-21**].

He received 2 units of blood on [**5-23**] for a hematocrit of
26. He was started on Epogen. He received another unit of
blood on [**5-24**] for hematocrit of 29.5. His temperature
spiked to 101 again on [**5-24**]. PICC was removed. No growth
was demonstrated. Urine culture was negative. Blood cultures
were sent daily for surveillance. These were all negative.
His white blood cell count started to trend down into the 2.3
range.

Repeat abdominal CT was done on [**5-24**] for this temperature
spike of 101. No evidence of contrast extravasation or large
hematoma within the abdomen or pelvis was noted to explain
the patient's drop in hematocrit from 34.9 down to 26.2.
There was persistent pleural effusions with bibasilar
atelectasis. He had a stable appearing hepatic abscesses and
bile collections within segments 4 and 2 of the liver. There
was slight decrease in the size of the right lobe collection
with a new drainage catheter in place. There was also slight
interval decrease in abundant ascites tracking into the
pelvis and scrotum.

He was given IV Lasix for edema. This was stopped when his
blood pressure dropped down to 90/70. He had been on IV
Lopressor as well as p.o. Lopressor for some tachycardia;
though, the Lopressor was stopped. He received some IV
hydration.

A podiatry consult was obtained for long toenails. These were
debrided. An ophthalmology consult was also obtained for
patient's complaint of progressive decrease vision in both
eyes. Findings demonstrated left greater than right
subcapsular cataracts, presbyopia, and refractive error.
[**Location (un) **] glasses were suggested, and cataract evaluation as an
outpatient.

Given drop in white blood cell count, meropenem was stopped.
He had received a total of 14 days of this. Caspofungin was
also stopped after a total of 6 days, and ceftriaxone 1 gram
was started daily as well as AmBisome 675 mg daily. His white
blood cell count still continued to stay in the 2.1-2.8
range. His hematocrit trended downward to 23.7. Epogen was
increased. His creatinine remains stable. His LFTs were
stable. Rapamune was continued. His levels trended downward
to 3.8. He was tolerating his tube feeding. Foley catheter
remained in place given large scrotal edema. Physical therapy
worked with him and recommended rehab.

He was started on AmBisome on [**5-27**] for concern for mold in
the abscess that could be consistent with Zygomycetes. He
continued to have low grade temperatures of 100.9. He
remained on ceftriaxone for Strep viridans replacing the
meropenem. A repeat CT was done on [**5-28**]. Several fluid
collections were again noted within the left and right lobes
of the liver which were unchanged in size. There were 3
external percutaneous drainage catheters in place and 1
internal/external biliary catheter was unchanged in position.
Bilateral pleural effusions were noted and large amount of
ascites was noted.

Wound care consult was obtained for sacral decubitus. He has
a full-thickness ulcer coccyx site unable to stage due to
yellow fibrinous wound bed. The ulcer is approximately 2 x 1
cm. Wound bed is 100% yellow and fibrinous. Wound edges were
defined. There was minimal drainage from the site. No
cellulitis was noted. Wound gel, DuoDerm gel was applied to
the ulcer. He remained on a ________low air loss pressure
release mattress.

In summary, the patient had a prolonged hospital course and
became debilitated. He was relisted for a liver transplant
pending clearance of multiple liver abscesses, infections.
His p.o. intake was poor. He remained on cycled J. tube
feedings at night. Foley remained in place for large amount
of scrotal edema. His right JP abscess drain continued to
drain murky discharge with bilious drainage from his liver
abscesses. His PTC catheter remained capped. He was assisted
out of bed to the chair by PT.

Plan is to send him to rehab on daptomycin, caspofungin, and
ceftriaxone. He will follow up with infectious disease.

DISCHARGE DIAGNOSES:  Status post liver transplant, status
post hepatic artery thrombosis, liver abscesses growing
yeast, enterococcus, vancomycin-resistant enterococci,
malnutrition, status post small bowel obstruction with
hernia, ascites, depression, sacral decubitus, history of
cryptococcal pneumonia.

DISCHARGE MEDICATIONS:  Albuterol nebulizers p.r.n. q.6.,
AmBisome 675 mg IV q.24h. with prehydration, ceftriaxone 1
gram IV q.24h., daptomycin 450 mg IV daily, Epogen 10,000
units subcutaneously every Monday, Wednesday, and Friday,
heparin 5,000 units subcutaneous twice a day, Dilaudid 1 mg
IV p.r.n. q.3-4h. for pain, insulin sliding scale and fixed
dose of Lantus, loperamide 2 mg p.o. b.i.d. for loose stools
to be held if no bowel movements, nifedipine 10 mg p.o.
b.i.d., oxycodone 5-10 mg p.o. p.r.n. q.4-6h., Protonix 40 mg
p.o. daily, Rapamune 2 mg p.o. daily, Bactrim single strength
1 tablet p.o. daily, Tylenol p.r.n.



                        [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]

Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D:  [**2122-6-1**] 21:53:57
T:  [**2122-6-2**] 05:45:26
Job#:  [**Job Number 62179**]


Name:  [**Known lastname **],[**Known firstname **] V.                   Unit No:   [**Numeric Identifier 11193**]

Admission Date:  [**2122-4-15**]              Discharge Date:   [**2122-8-19**]

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

Service: SURGERY

Allergies:
Penicillins / Benzocaine

Attending:[**First Name3 (LF) 2648**]
Addendum:
He remained in hospital after discovering that liver abscesses
grew sparse mucor. ID recommended posoconazole in addition to
ambisone. This was started and he continued on this for the
remainder of hospital course. The decision was made to keep him
hospitalized until re-transplanted.
     Psychiatry was consulted for depression. Dextroamphetamine
was recommended as first choice with zoloft being an alternative
[**Doctor Last Name 932**]. Zoloft was started and dose increase during remainder of
hospital stay with some improvement in mood.
     2 units of PRBC were given for a hct of 22 on [**6-4**]. Epogen
was continued. On [**6-5**] an abd ct revealed mod ascites for which
hepatology was consulted. A paracentesis was performed. He was
cultured for a temp of 101.7 on [**6-7**] for which the c-line was
changed. The tip was neg for growth as well as urine and blood.
     On [**6-9**] he grew gram +cocci (VRE-enterococcus faecium)only
sensitive to linezolid. Given past h/o myelosuppression, he was
started on Tigecycline. Tigecycline continued for 16 days. He
spiked a temp on [**6-12**] and again the c-line was changed over a
wire. A rpt ABD CT revealed two fluid collections within the
left and right lobes of the liver. The collection within the
right lobe of the liver appeared to have increased in size,
measuring 5.6 x 4.1 cm. The left liver lobe collection was
essentially unchanged. Bilateral pleural effusions, greater on
the left, were decreased slightly and a large amount of ascites,
which was decreased slightly. There was evidence of peritoneal
enhancement. The fluid extended into the inguinal canals, and
was loculated on the right side. Ceftriaxone which was used for
E.coli was stopped after 18 days and  Meropenum was started for
E.coli & Strep veridins to broaden coverage. Dapto was stopped.
He remained on meromenum for 38 days. He continued to spike
temps.
     Repeat paracentesis was done on [**6-15**]. Cultures were
negative. On [**6-18**], he was removed from the Transplant list given
multidrug resistant multifocal liver abscesses, poor nutritional
status despite J tube feedings, debilitation and poor prior
outcomes in other patients with similar setting. On [**6-16**] blood
cultures grew yeast. Ambisone was started [**6-19**]. Repeat blood and
drain cultures were sent. A TTE was done to r/o vegetations.
This was negative. An Ophthalmology exam was negative as well.
On [**6-23**] a repeat abd CT revealed two large fluid collections
within the left and right lobes of the liver. The left lobe
fluid collection had decreased in size, whereas the right lobe
fluid collection had increased in size. A large well
circumscribed fluid collection extending down the right inguinal
canal into the right scrotum was seen. A head CT was done to r/o
infection. This was negative.
     On [**6-24**] an 8 Fr catheter was repostitioned in RLQ. Culure of
the fluid grew ENTEROCOCCUS SP,CITROBACTER FREUNDII COMPLEX.
SPARSE GROWTH, NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA.
[**Female First Name (un) **] (TORULOPSIS) GLABRATA.MODERATE GROWTH and CITROBACTER
FREUNDII COMPLEX. Blood cultures from [**6-23**] continued to grow
yeast and VRE. Blood cultures were done q 3 days.  On [**7-1**] CT
findings showed new area of decreased enhancement in segment [**Doctor First Name **]
of the liver, worrisome for a new area of ischemia/infarction.
Internal air bubbles were present, and superinfection of this
area could not be excluded. The area did not appear to have
adequate liquification for percutaneous catheter drainage. Two
collections in left lobe of the liver had appropriately
positioned drainage catheters appeared slightly smaller and a
collection in right lobe of the liver, which contained an
appropriately positioned catheter was unchanged in size. On [**6-30**]
Dapto was restarted as well as gentamycin for synergy to attempt
to clear VRE.
Ambisone was changed to Caspo on [**7-3**]. On [**7-7**],the catheter in
right lobe of liver was advanced several centimeters with
aspiration of approximately 20 cc of purulent material. This
appeared in continuity with multiple bilomas/dilated ducts,
which were slightly more prominent than on the previous study.
ID recommended a TTE to r/o vegetation, but the patient refused
TTE.
     Synercid was started perioperatively for VRE coverage. On
[**7-17**] he was taken to the OR for irrigation and debridement of
hepatic abscess, right lobe by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 40-50cc of
purulent, bile stained drainage was removed. A large drain was
left in place and placed to suction. He tolerated this procedure
well. Blood cultures and cline tip on [**7-7**] were negative.
Cultures were negative until [**7-14**]. He was relisted for liver
transplantation. Subsequent cultures grew  enterococcus faeceum.
Repeat cultures were negative, but then reculture grew
enterococcus faeceum and presumed torulopsis glabrata (per
ID).Levaquin was added for additional gram negative coverage.
       Repeat Abd CT showed interval placement of JP drain into
the right lobe of the liver with associated focal subcutaneous
air/surgical emphysema. Air containing abscess in the right lobe
superior to this appeared to have increased in size.
Splenomegaly and ascites were again noted. On [**7-21**], he underwent
successful CT-guided pigtail cath placement in enlarging fluid
collection at the junction of segments 8 and 4A.

     On [**7-29**] abd CT revealed 1) S/p multiple drains. Confluent
biloma/abscess involving segment [**Doctor First Name **] and VIII of the liver, the
component in the right lobe is smaller compared to the CT of
[**2122-7-21**].
2) Small bilateral pleural effusions.
3) Persisting ascites, predominantly left-sided and partially
loculated.
4) Nonvisualized proper hepatic artery, likely occluded. Partial
SMV occlusion.
5) Prominent right-sided hydrocele.
6) Splenomegaly.
     Abscess cultures persistently grew VRE and [**Female First Name (un) **]
(TORULOPSIS) GLABRATA. P.
     On [**7-31**]  Caspofungin and meropenum was stopped. The 2
drains in the left lobe were removed. A repeat CT on [**8-3**]
revealed collection in left lobe and a drain was placed into
this site and 10cc was sent for culture. Results are pending.
     On [**8-6**] the capped PTC drain fell out with no adverse
effects. Developed diarrhea after tube feed formula changed.
Stool was sent for c.diff. Stool neg on [**8-5**] and pending for
[**8-6**]
     On [**8-14**] the right liver abscess catheter fell out. This
area was then loosely packed with normal saline moist gauze [**Hospital1 **].
Potassium was consistently running high. A renal consult was
obtained. Bactrim and synercid were felt to be contributing to
hyperkalemia. Bactrim SS was decreased to 3x/week and the tube
feeding was changed back to 1/2 strength Nepro. Potassium
decreased within the normal range.
     In summary, this hospital course was extremely long and
complicated. He has remained afebrile for last few weeks.
Posoconazole, Levaquin, Synercid will continue. Rifaximin is to
prevent encephalopathy. Bactrim is for pcp [**Name Initial (PRE) 2515**]. The plan
is to send [**Doctor First Name **] to [**Hospital **] Rehab Hospital with the hope of
building him up nutritionally and increasing his physical
strength and independence with the hope of keeping him afebrile
while awaiting re-transplantation of a second liver.  He will be
followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Transplant Surgeon) and Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 25**] (ID).




Major Surgical or Invasive Procedure:
polymicrobial liver abscesses-ecoli, mucor, yeast, vre [**12-18**]
ischemic biliary ducts

Pertinent Results:
Hematology
  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2122-8-17**] 05:15AM    2.4* 3.14* 9.0* 26.4* 84 28.7 34.2 20.7*
68*
  DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2122-5-2**] 06:36PM    87* 3 3* 4 1 0 1* 1* 0
  RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Ovalocy Schisto
[**2122-5-2**] 06:36PM    1+1 1+ OCCASIONAL NORMAL 2+ OCCASIONAL

1 1+
MANUAL

  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2122-8-17**] 05:15AM          68*
  BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2122-5-17**] 04:17AM    523*

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2122-8-17**] 05:15AM    162* 34* 0.7 133 4.4 99 29 9
  ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2122-8-18**] 06:00AM          18*1
1 VERIFIED BY REPLICATE ANALYSIS



Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1)  Injection
QMOWEFR (Monday -Wednesday-Friday).
5. Posaconazole  Sig: Two Hundred (200) mg  QID (4 times a day).

6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Nifedipine 10 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Psyllium     Packet Sig: One (1) Packet PO DAILY (Daily).
11. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous  DAILY (Daily) as needed: picc line care.
14. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
Intravenous  Q24H (every 24 hours).
15. Quinupristin-Dalfopristin 500 mg Recon Soln Sig: One (1)
Recon Soln Intravenous  Q12H (every 12 hours).
16. Hydromorphone 2 mg/mL Syringe Sig: One (1) mg Injection prn:
q4-6.
17. Insulin Glargine 100 unit/mL Solution Sig: Twenty One (21)
units Subcutaneous once a day.
18. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale  Injection four times a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**]

Completed by:[**2122-8-19**]
{'Complications of transplanted liver,Embolism and thrombosis of other specified artery,Abscess of liver,Hernia of other specified sites, with obstruction,Bacteremia,Cholangitis,Paralytic ileus,Pressure ulcer, lower back,Unspecified protein-calorie malnutrition,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified antibiotics causing adverse effects in therapeutic use'}


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: Pancytopenia status post liver transplant.

PRESENT ILLNESS: Patient is a 46-year-old male
status post liver transplant in [**2121-11-16**] whose course
has been complicated by hepatic artery thrombosis status post
PTC catheter placement, high-grade VRE bacteremia on long-
term linezolid currently, PTC placement for biliary sepsis.
He has been followed closely by Dr. [**Last Name (STitle) 816**] and Dr. [**Last Name (STitle) 724**] from ID
as a outpatient. Recently Valcyte was stopped on [**3-26**] after
3 months of treatment. Patient has been having labs drawn
every 2-3 days, which revealed hematocrit, white blood cell,
and platelet count being low that had been steadily trending
down reaching critical levels today with a white count of 1,
hematocrit of 17, and a platelet count of 45.

MEDICAL HISTORY: Liver transplant on [**2121-11-16**], then
Roux-en-Y hepaticojejunostomy, hepatitis C, cryptogenic
cirrhosis complicated by hepatic artery thrombosis, very high-
grade VRE bacteremia on [**2122-2-14**], source was the biliary
tree treated with linezolid, status post PTC drain in [**2122-2-14**] for stricture, now capped, methemoglobinemia in [**2122-2-14**] from Hurricaine spray during TEE, history of
Cryptococcal pneumonia on fluconazole long-term. He should be
on 200 mg p.o. daily for 1 year, nutcracker esophagus,
chronic renal insufficiency, creatinine baseline is 1.2,
right inguinal hernia, diverticulitis, esophageal varices,
history of hyperkalemia treated with Kayexalate p.r.n. and
increased prolactin.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillin, benzocaine.

PHYSICAL EXAM: Temperature was 101. He was in no acute
distress. Lungs are clear. Heart was regular rate and rhythm.
Abdomen: Soft, nondistended. PTC catheter was in place and
capped. Reducible left inguinal hernia on the left and right.
Extremities: No clubbing, cyanosis, or edema.

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Complications of transplanted liver,Embolism and thrombosis of other specified artery,Abscess of liver,Hernia of other specified sites, with obstruction,Bacteremia,Cholangitis,Paralytic ileus,Pressure ulcer, lower back,Unspecified protein-calorie malnutrition,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified antibiotics causing adverse effects in therapeutic use'}
