CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: 68 M w/ hep C and etoh cirrhosis p/w AMS. other PMH of seizure
disorder, hemicolectomy, barretts, HTN. was doing firn till 2
days PTS. on tue [**4-11**] started vomitting. vomit was bilious. no
blood. also c/o mild to mod belly pain. no diarrhea (baseline
[**1-2**] BM/day, off lactulose). was better on wed. [**11-30**] vomits.
tolerated food well all day. MS off a little bit but was still
able to understand and follow commands. last night at 2.30 am
wife woke up and found the pt sitting naked on the bed. didnt
know where he was and what he was doing. also was agitated.
threw up again. wife called ems. pt more agitataed once ems was
there. denied F/C/C/HA/photophobia/neck
stiffness/CP/SOB/dizziness/palpitations. during last admit pt
had AMS but was not agitated.
.
In the [**Name (NI) **], pt underwent dx para with found SBP, given ctx. He
was given albumin and lactulose (60cc's PO). Unable to pass
NGTx2 c/b nasal bleed. EEG performed that was c/w
encephalopathy.

MEDICAL HISTORY: 1.Hepatitis C,
2.alcohol abuse,
3.seizure disorder (followed by Dr. [**Last Name (STitle) 2442**] from neurology),
status post CVA (left hemisphere with residual right hand
weakness and ataxia, [**2157**]),
4.Barrett's esophagus, history of pancytopenia status post bone
marrow biopsy ([**2164**], negative),
5.status post hemicolectomy secondary to stab wounds,
6.status post penile prosthesis ([**2159**]),
7.hypertension,
8.enlarged prostate status post biopsy (negative).

MEDICATION ON ADMISSION: Meds-per last dis sum:
metoprolol 50mg po BID
levetiracetam 1500mg po qam, 1000mg qpm
protonix 4omg daily
spironolactone 50mg daily
lasix 20mg one daily
folic acid 1 tablet daily
thiamine 100mg daily
lactulose 30ml QID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: 96.7 160/70 110 26 96/RA
gen- AAO x 0. in restarints as pt agitated
HEENT- MM dry, no JVD, no LAD
CHEST- CTABL
Heart- RRR, no M/R/G, nl S1 S2
abd-soft, NT, ND, no HSM, BS +, surgical scar +
ext- [**1-1**]+ b/l edema
neuro-AAO x0. moving all 4 extr, difficult to assess for
asterixis as pt not folowing commands

FAMILY HISTORY: alcoholism

SOCIAL HISTORY: Patient lives in the [**Hospital1 778**] with his wife. [**Name (NI) **] notes, has
a significant alcohol history with multiple beers per night.
Wife
also has occasional drinks. Per Dr.[**Name (NI) 105962**] note in OMR: He
quit
smoking 25 years ago. Drinks 2 beers per day, down from 1 case
per day. No illicit drugs. Lives with his wife in an apartment.
Unspecified septicemia,Spontaneous bacterial peritonitis,Chronic hepatitis C with hepatic coma,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Other pulmonary insufficiency, not elsewhere classified,Other and unspecified coagulation defects,Paralytic ileus,Paroxysmal ventricular tachycardia,Severe sepsis,Epilepsy, unspecified, without mention of intractable epilepsy,Thrombocytopenia, unspecified,Unspecified essential hypertension,Cirrhosis of liver without mention of alcohol,Esophageal reflux,Unspecified deficiency anemia
Septicemia NOS,Spontan bact peritonitis,Chrnc hpt C w hepat Coma,Septic shock,Food/vomit pneumonitis,Acute kidney failure NOS,Other pulmonary insuff,Coagulat defect NEC/NOS,Paralytic ileus,Parox ventric tachycard,Severe sepsis,Epilep NOS w/o intr epil,Thrombocytopenia NOS,Hypertension NOS,Cirrhosis of liver NOS,Esophageal reflux,Deficiency anemia NOS
Admission Date:  [**2175-4-13**]              Discharge Date:   [**2175-4-21**]

Date of Birth:  [**2106-4-27**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
central line placement

History of Present Illness:
68 M w/ hep C and etoh cirrhosis p/w AMS. other PMH of seizure
disorder, hemicolectomy, barretts, HTN. was doing firn till 2
days PTS. on tue [**4-11**] started vomitting. vomit was bilious. no
blood. also c/o mild to mod belly pain. no diarrhea (baseline
[**1-2**] BM/day, off lactulose). was better on wed. [**11-30**] vomits.
tolerated food well all day. MS off a little bit but was still
able to understand and follow commands. last night at 2.30 am
wife woke up and found the pt sitting naked on the bed. didnt
know where he was and what he was doing. also was agitated.
threw up again. wife called ems. pt more agitataed once ems was
there. denied F/C/C/HA/photophobia/neck
stiffness/CP/SOB/dizziness/palpitations. during last admit pt
had AMS but was not agitated.
.
In the [**Name (NI) **], pt underwent dx para with found SBP, given ctx. He
was given albumin and lactulose (60cc's PO). Unable to pass
NGTx2 c/b nasal bleed. EEG performed that was c/w
encephalopathy.


Past Medical History:
1.Hepatitis C,
2.alcohol abuse,
3.seizure disorder (followed by Dr. [**Last Name (STitle) 2442**] from neurology),
status post CVA (left hemisphere with residual right hand
weakness and ataxia, [**2157**]),
4.Barrett's esophagus, history of pancytopenia status post bone
marrow biopsy ([**2164**], negative),
5.status post hemicolectomy secondary to stab wounds,
6.status post penile prosthesis ([**2159**]),
7.hypertension,
8.enlarged prostate status post biopsy (negative).

Social History:
Patient lives in the [**Hospital1 778**] with his wife. [**Name (NI) **] notes, has
a significant alcohol history with multiple beers per night.
Wife
also has occasional drinks. Per Dr.[**Name (NI) 105962**] note in OMR: He
quit
smoking 25 years ago. Drinks 2 beers per day, down from 1 case
per day. No illicit drugs. Lives with his wife in an apartment.

His sole income is [**Social Security Number 105963**]social security check of approximately
$700-800 per month. He does not exercise.


Family History:
alcoholism

Physical Exam:
PE: 96.7 160/70 110 26 96/RA
gen- AAO x 0. in restarints as pt agitated
HEENT- MM dry, no JVD, no LAD
CHEST- CTABL
Heart- RRR, no M/R/G, nl S1 S2
abd-soft, NT, ND, no HSM, BS +, surgical scar +
ext- [**1-1**]+ b/l edema
neuro-AAO x0. moving all 4 extr, difficult to assess for
asterixis as pt not folowing commands


Pertinent Results:
[**2175-4-21**]: IMPRESSION:
1. The lines, tubes, and catheters have not changed since the
prior study.
2. Marked improvement of pulmonary airspace disease, likely
resolution of the edema.
3. Grossly unchanged basal airspace opacities consistent with
ARDS.
.
KUB [**2175-4-19**]: IMPRESSION:
1. Paucity of intestinal gas, bowel loops may be fluid-filled;
however, there is no definite evidence of small bowel
obstruction.
2. Bilateral airspace opacities, left pleural effusion.
.
[**2175-4-17**] EKG: Sinus rhythm with a four beat run of probable
atrial tachycardia. Left atrial abnormality. Low QRS voltage.
Modest ST-T wave changes. Findings are non-specific but clinical
correlation is suggested. Since the previous tracing of [**2175-4-16**]
atrial ectopy appears less frequent and ST-T wave changes are
decreased.
.
[**2175-4-17**]: Left ventricular wall thicknesses and cavity size are
normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
No mass or vegetation is seen on the mitral valve. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
.
Liver/GB U/S [**4-6**]: IMPRESSION:
1. Patent hepatic vasculature, without evidence of portal vein
thrombosis.
2. Moderate loculated ascites.
.
EEG: IMPRESSION: Mildly abnormal EEG due to the slow background
and
excessive drowsiness. These suggest the possibility of an
encephalopathy. Nevertheless, no areas of focal slowing were
evident.
There were no epileptiform features.
.



[**2175-4-13**] 07:29PM URINE  HOURS-RANDOM
[**2175-4-13**] 07:29PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2175-4-13**] 08:45AM URINE  COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2175-4-13**] 08:45AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-MOD UROBILNGN-12* PH-6.5
LEUK-NEG
[**2175-4-13**] 08:45AM URINE  RBC-0-2 WBC-[**2-1**] BACTERIA-NONE YEAST-NONE
EPI-0
[**2175-4-13**] 08:45AM URINE  HYALINE-21-50*
[**2175-4-13**] 08:30AM ASCITES  WBC-3475* RBC-1025* POLYS-87* LYMPHS-0
MONOS-0 MACROPHAG-13*
[**2175-4-13**] 07:34AM   PT-20.3* PTT-44.9* INR(PT)-1.9*
[**2175-4-13**] 06:45AM   GLUCOSE-158* UREA N-36* CREAT-1.4* SODIUM-134
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-21* ANION GAP-20
[**2175-4-13**] 06:45AM   ALT(SGPT)-30 AST(SGOT)-55* LD(LDH)-357* ALK
PHOS-96 AMYLASE-23 TOT BILI-8.6*
[**2175-4-13**] 06:45AM   LIPASE-25
[**2175-4-13**] 06:45AM   ALBUMIN-3.0*
[**2175-4-13**] 06:45AM   AMMONIA-296*
[**2175-4-13**] 06:45AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2175-4-13**] 06:45AM   WBC-10.3# RBC-3.36* HGB-12.8* HCT-37.0*
MCV-110* MCH-38.2* MCHC-34.7 RDW-16.9*
[**2175-4-13**] 06:45AM   NEUTS-79.0* LYMPHS-13.7* MONOS-6.9 EOS-0.3
BASOS-0.1
[**2175-4-13**] 06:45AM   PLT SMR-VERY LOW PLT COUNT-75*#

Brief Hospital Course:
A/P: Pt is a 68 y.o male with HEP C cirrhosis, ETOH abuse,
barrett's esophagitis, CVA, sz d/o who presents with
encephalopathy and SBP.
.
#Shock -Likely that pt was somewhat hypotensive at baseline
given liver dx. On [**4-21**] Maps worsened to 50's on [**4-15**]. Urine
output decreased and IVF boluses were not helpful. Pt eventually
was on three pressors levo/neo/vasopressin. Cause thought to be
either sepsis as mixed venous 02 sat 85%, vs intravascular
volume depletion (CVP low at times) vs hemorrhage (HCT dropped 6
points, then stabilized). PT given IVF to meet goal CVP of 10.
Cultures demonstrated no growth, nonetheless, pt was covered
broadly for infection with vanc/zosyn for SBP and aspiration
pneumonia. Transaminases substantially dose thought to be
element of shock liver, coags worsened, hypoglycemia persisted
and pt eventually required D10gtt.  PT continued to clinically
decompensate, demonstrated shock liver, coagulopathy,
hypoglycemia, a-fib with RVR to 180's. Pt's code status
eventually changed to DNR. Pt eventually succumbed to his
illness on [**4-21**].
.
#Respiratory Failure-hypoxic. Pt initially intubated for airway
protection, but on [**4-15**] increasing O2 requirement and PEEP
requirement, thought to be due to worsening of aspiration. Pt
eventually met criteria for ARDS net ventilation and continued
to require this protocol.
.
#ARF-baseline Cr 0.8. up to 1.4 on admission ddx include
prerenal and hepatorenal. Had many casts making ATN likely
although no h/o hypotension anuric on [**4-20**], creatinine rising.
PT not a candidate for HD, CVVH.
.
#cerebral edema-Pt monitored for cerebral edema.
.
#arrhythmia- Pt had episodes of A-fib with RVR,
bigem/trigem/quadrigem. Pt on 3 pressors. Attempted to wean off
levo/catechols. Pt given anti-nodal agents 2 days ago to attempt
to slow rate. EKG showing afib/flutter. Cardiology called,
suggested diltiazem. Electric cardioversion considered.
.
#Anemia-pt with anemia at baseline, admission hct 37 -likely
hemoconcentrated, [**4-15**] hct dropped form 26 to 20. Pt with
gastroccult postive OGT output, BMs guaiac negative, history of
varices. Tbili was rising, haptoglobin low. PT given folate and
thiamine supplementation.
.
#Ileus-pt with hypoactive BS, increased output from OGT, pt
stooling, diminished bowel sounds.KUB did not show obstruction
and OGT was placed to suction.
.
#Encephalopathy/AMS: hepatic encephalopathy high on ddx. EEG
ruled out status epilepticus, meningitis unlikely, other focus
of infection and toxic metabolic derangements also likely and
contributory.PT given lactulose PR as OGT with high residuals,
unable to give adequate dosing of lactulose. SBP treated with
vanco/zosyn. Tox screen negative.
.
#SBP: pt w/ e/o SBP on dx para. On vanco/zosyn.
.
#ASPiration PNA. Witnessed vomiting while trying to place
NGT/OGT. Pt placed on vanc/zosyn.
.
#Cirrhosis: Hep C and etoh cirrhosis. Liver team followed pt.
Given PR lactulose. Abd u/s with doppler did not show thrombosis
of portal vein.
.
#H/o seizure disorder: EEG showed e/o encephalopathy. Pt had
been on keppra for past 5 yrs. He was continued on this
medication in the inpatient setting.
.
# Thrombocytopenia: within baseline range of 50 to 90. Platelet
count trended, heparin products avoided.
.
# GERD/Barrett's esophagus: pt was continued on his home PPI.
.
PPX: PPI, pneumoboots, lactulose
.
#Access: [**Last Name (LF) **], [**First Name3 (LF) **]


Medications on Admission:
Meds-per last dis sum:
metoprolol 50mg po BID
levetiracetam 1500mg po qam, 1000mg qpm
protonix 4omg daily
spironolactone 50mg daily
lasix 20mg one daily
folic acid 1 tablet daily
thiamine 100mg daily
lactulose 30ml QID


Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
expired.
decompensated liver failure
presumed sepsis
SBP
ards
pneumonia

Discharge Condition:
expired.

Discharge Instructions:
n/a

Followup Instructions:
n/a
{'Unspecified septicemia,Spontaneous bacterial peritonitis,Chronic hepatitis C with hepatic coma,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Other pulmonary insufficiency, not elsewhere classified,Other and unspecified coagulation defects,Paralytic ileus,Paroxysmal ventricular tachycardia,Severe sepsis,Epilepsy, unspecified, without mention of intractable epilepsy,Thrombocytopenia, unspecified,Unspecified essential hypertension,Cirrhosis of liver without mention of alcohol,Esophageal reflux,Unspecified deficiency anemia'}


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

PRESENT ILLNESS: 68 M w/ hep C and etoh cirrhosis p/w AMS. other PMH of seizure
disorder, hemicolectomy, barretts, HTN. was doing firn till 2
days PTS. on tue [**4-11**] started vomitting. vomit was bilious. no
blood. also c/o mild to mod belly pain. no diarrhea (baseline
[**1-2**] BM/day, off lactulose). was better on wed. [**11-30**] vomits.
tolerated food well all day. MS off a little bit but was still
able to understand and follow commands. last night at 2.30 am
wife woke up and found the pt sitting naked on the bed. didnt
know where he was and what he was doing. also was agitated.
threw up again. wife called ems. pt more agitataed once ems was
there. denied F/C/C/HA/photophobia/neck
stiffness/CP/SOB/dizziness/palpitations. during last admit pt
had AMS but was not agitated.
.
In the [**Name (NI) **], pt underwent dx para with found SBP, given ctx. He
was given albumin and lactulose (60cc's PO). Unable to pass
NGTx2 c/b nasal bleed. EEG performed that was c/w
encephalopathy.

MEDICAL HISTORY: 1.Hepatitis C,
2.alcohol abuse,
3.seizure disorder (followed by Dr. [**Last Name (STitle) 2442**] from neurology),
status post CVA (left hemisphere with residual right hand
weakness and ataxia, [**2157**]),
4.Barrett's esophagus, history of pancytopenia status post bone
marrow biopsy ([**2164**], negative),
5.status post hemicolectomy secondary to stab wounds,
6.status post penile prosthesis ([**2159**]),
7.hypertension,
8.enlarged prostate status post biopsy (negative).

MEDICATION ON ADMISSION: Meds-per last dis sum:
metoprolol 50mg po BID
levetiracetam 1500mg po qam, 1000mg qpm
protonix 4omg daily
spironolactone 50mg daily
lasix 20mg one daily
folic acid 1 tablet daily
thiamine 100mg daily
lactulose 30ml QID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: 96.7 160/70 110 26 96/RA
gen- AAO x 0. in restarints as pt agitated
HEENT- MM dry, no JVD, no LAD
CHEST- CTABL
Heart- RRR, no M/R/G, nl S1 S2
abd-soft, NT, ND, no HSM, BS +, surgical scar +
ext- [**1-1**]+ b/l edema
neuro-AAO x0. moving all 4 extr, difficult to assess for
asterixis as pt not folowing commands

FAMILY HISTORY: alcoholism

SOCIAL HISTORY: Patient lives in the [**Hospital1 778**] with his wife. [**Name (NI) **] notes, has
a significant alcohol history with multiple beers per night.
Wife
also has occasional drinks. Per Dr.[**Name (NI) 105962**] note in OMR: He
quit
smoking 25 years ago. Drinks 2 beers per day, down from 1 case
per day. No illicit drugs. Lives with his wife in an apartment. 

### Response:
{'Unspecified septicemia,Spontaneous bacterial peritonitis,Chronic hepatitis C with hepatic coma,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Other pulmonary insufficiency, not elsewhere classified,Other and unspecified coagulation defects,Paralytic ileus,Paroxysmal ventricular tachycardia,Severe sepsis,Epilepsy, unspecified, without mention of intractable epilepsy,Thrombocytopenia, unspecified,Unspecified essential hypertension,Cirrhosis of liver without mention of alcohol,Esophageal reflux,Unspecified deficiency anemia'}
