CHIEF COMPLAINT: elevated LFTs noted on outpatient follow-up

PRESENT ILLNESS: 46M with fulminant hepatic failure c/b HRS likely secondary
to Hepatitis E, s/p ABO mismatch OLTx with splenectomy [**4-/2187**]
complicated by bleeding requiring exploratory laparotomy and
washout, splenic fluid collection requiring drainage x 2 and
decubitus ulcers.  Notably had a recent episode of biopsy-proven
acute rejection one month ago, treated with prednisone taper.

MEDICAL HISTORY: Liver transplant [**2187-4-26**] secondary to Hepatitis E
mild liver rejection [**2187-7-11**] treated with steroids
Tonsillectomy
Hernia Repair
Alcohol Abuse
Tobacco Use

MEDICATION ON ADMISSION: - Prograf 2.5mg PO BID
 - Cellcept 500mg PO QID
 - Prednisone 20mg PO qAM
 - Valcyte 450mg PO qAM
 - Fluconazole 400mg PO qAM
 - Protonix 40mg PO BID
 - Colace 100mg PO BID
 - Ursodiol 300mg PO TID
 - Ferrous Sulfate 325mg PO BID
 - Caltrate / Vit D 600/400mg PO BID
 - Metoprolol 50mg PO TID
 - Dapsone 100mg PO daily
 - Ambien 5mg PO qHS prn sleep
 - ISS

ALLERGIES: Azithromycin

PHYSICAL EXAM: VS  98.6  98  149/101  20  100RA
Gen: NAD
HEENT: sclerae anicteric
CV: RRR
Chest: CTAB
Abd: S/NT/ND, well-healed liver txp scar
Ext: WWP, no C/C/E
Skin: trace jaundice

FAMILY HISTORY: No liver disease.

SOCIAL HISTORY: Divorced, 3 children.  Owns own auto repair and sale business.
Smoked 1 ppd for 20+ years, discontinued with onset of jaundice.
 H/o alcohol abuse.  Recently drank a couple glasses of wine or
beer with dinner discontinued with onset of jaundice.  Remote
history of vicodin and percocet abuse.  Remote history of
marijuana and cocaine use. Remote history of using supplements
from GNC. No IVDU, risky sexual behavior or tattoos.  No sick
contacts.  [**Name (NI) **] foreign travel.
Complications of transplanted liver,End stage renal disease,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction,Bacteremia,Acidosis,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Peritoneal adhesions (postoperative) (postinfection),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified disorders of stomach and duodenum,Unspecified pruritic disorder,Anemia, unspecified
Compl liver transplant,End stage renal disease,Acute kidney failure NOS,Hyp kid NOS w cr kid V,Acute duodenal ulcer NOS,Bacteremia,Acidosis,Urin tract infection NOS,Protein-cal malnutr NOS,Peritoneal adhesions,DMII wo cmp nt st uncntr,Gastroduodenal dis NEC,Pruritic disorder NOS,Anemia NOS
Admission Date:  [**2187-8-21**]              Discharge Date:   [**2187-11-9**]

Date of Birth:  [**2141-8-1**]             Sex:   M

Service: SURGERY

Allergies:
Azithromycin

Attending:[**First Name3 (LF) 668**]
Chief Complaint:
elevated LFTs noted on outpatient follow-up


Major Surgical or Invasive Procedure:
[**2187-8-23**]: ERCP
[**2187-8-27**]: ERCP

History of Present Illness:
46M with fulminant hepatic failure c/b HRS likely secondary
to Hepatitis E, s/p ABO mismatch OLTx with splenectomy [**4-/2187**]
complicated by bleeding requiring exploratory laparotomy and
washout, splenic fluid collection requiring drainage x 2 and
decubitus ulcers.  Notably had a recent episode of biopsy-proven
acute rejection one month ago, treated with prednisone taper.

Patient is re-admitted today for concern of continually elevated
LFTs for the past few weeks.  He underwent ERCP four days ago
([**2187-8-17**]) which showed mismatch in the caliber of the native and
transplanted bile ducts; a stent was placed across the
anastomosis.  Also noted on ERCP were multiple areas of
stricturing and dilation of the intrahepatic biliary system with
small bile leaks "concerning for cholangitis".

Since that time the patient reports he has not been feeling
well,
with poor appetite, low PO intake, subjective fevers/chills, and
fatigue.  He reports a temperature at home of 100.2 today, and
he
states that he has felt quite thirsty and has been drinking a
lot
of water.  His blood sugars have been poorly controlled in the
high 200s recently.

He denies abdominal pain, nausea/vomiting, changes in his normal
bowel or bladder habits, or other symptoms on ROS.


Past Medical History:
Liver transplant [**2187-4-26**] secondary to Hepatitis E
mild liver rejection [**2187-7-11**] treated with steroids
Tonsillectomy
Hernia Repair
Alcohol Abuse
Tobacco Use

Social History:
Divorced, 3 children.  Owns own auto repair and sale business.
Smoked 1 ppd for 20+ years, discontinued with onset of jaundice.
 H/o alcohol abuse.  Recently drank a couple glasses of wine or
beer with dinner discontinued with onset of jaundice.  Remote
history of vicodin and percocet abuse.  Remote history of
marijuana and cocaine use. Remote history of using supplements
from GNC. No IVDU, risky sexual behavior or tattoos.  No sick
contacts.  [**Name (NI) **] foreign travel.


Family History:
No liver disease.

Physical Exam:
VS  98.6  98  149/101  20  100RA
Gen: NAD
HEENT: sclerae anicteric
CV: RRR
Chest: CTAB
Abd: S/NT/ND, well-healed liver txp scar
Ext: WWP, no C/C/E
Skin: trace jaundice


Pertinent Results:
[**2187-8-21**] 08:20PM BLOOD WBC-15.2* RBC-3.34* Hgb-10.4* Hct-33.2*
MCV-99* MCH-31.2 MCHC-31.5 RDW-15.4 Plt Ct-344
[**2187-8-21**] 08:20PM BLOOD PT-10.5 PTT-21.6* INR(PT)-0.9
[**2187-8-21**] 08:20PM BLOOD Glucose-124* UreaN-40* Creat-2.3* Na-137
K-3.9 Cl-103 HCO3-20* AnGap-18
[**2187-8-21**] 08:20PM BLOOD ALT-77* AST-196* LD(LDH)-275*
AlkPhos-953* TotBili-5.6*
[**2187-8-21**] 08:20PM BLOOD Albumin-4.2 Calcium-10.7* Phos-2.8 Mg-1.6
[**2187-8-22**] 05:25AM BLOOD tacroFK-10.5

Brief Hospital Course:
On [**2187-8-21**] he presented with rising LFTs and general malaise. He
was admitted to Transplant Surgery Service and was given IV
hydration for rising creatinine. CT scan demonstrated no
evidence for hepatic abscess and interval resolution of
subhepatic fluid collection. Blood cultures on [**8-22**] were
positive for pansensitive E.coli. Vanco and zosyn were started.
This was later changed to IV meropenum, micafungin, flagyl were
started.  On [**8-27**], ERCP was performd noting focal areas of
biliary leaks and native and donor CBD mismatch followed by
stenting. Findings were suggestive of ischemia.

On [**8-30**], liver duplex revealed 2 hypoechoic lesions within the
right hepatic lobe concerning for abscesses or bilomas with
interval development of intrahepatic biliary ductal dilatation.
Extrahepatic bile ducts could not be assessed. CT showed
biliomas. Broadspectrum antibiotics were continued (flagyl,
cipro, fluc). WBC count continued to increase as high as 35
without fevers. Panculturing was done. Cultures remained
negative. LFTs especially alk phos continued to rise as high as
1800 and t.bili up to 75. He became very jaundiced and pruritic.
Ursodiol was started. In addition to worsening liver function,
he developed ARF on CRF. This increased his acidosis and
pruritus. Phosphate binders were used to lower the phosphate.
Intermittent IV fluid and bicarb were administered for acidosis
and increasing creatinine. Nephrology followed closely agreeing
with Transplant Surgery that a kidney transplant was necessary.
Given progression of liver and kidney dysfunction, he was
relisted for a liver and kidney transplant.

He remained hospitalized while awaiting re-transplant. During
this time, he continued to have poor appetite and inconsistent
caloric intake necessitating TPN then post pyloric tube feeds.
Anemia was treated with ~ weekly PRBC. Of note, stool was guaiac
positive, but EGD did not reveal active bleed, just portal
hypertensive gastropathy. Colonostopy [**10-22**] was done showing
Grade 2 internal hemorrhoids. Hemolysis w/u was negative. On
[**10-17**], blood cultures were sent via the picc line. These were

During this wait time, he remained on low dose prograf,
prednisone. On [**2187-10-23**], a liver and kidney became available.
Donor was HBV core positive. Donation was accepted and he was
taken to the OR by Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Induction immunosuppression was administered (cellcept
and solumedrol)as well as HBIG during the anhepatic phase.
Please refer to operative notes for complete details. Two 19
[**Doctor Last Name 406**] drains were placed in the abdomen -one behind the right
lobe of the liver and one behind the porta hepatis. A 3rd drain
was place near the kidney which made urine.

Postop, he was transferred to the SICU for management. Urine
output increased and creatinine trended down. LFTs initially
increased then trended down. Sedation was weaned off and he was
extubated. Initially, he was very agitated due to pruritus. This
was treated with vistaril, benadryl, and ursodiol. Agitation
resolved. Diet was advanced. He was transferred out of the SICU
on postop day 3. Hepatitis B immune globulin (5000units per
dose)was administered for 5 days postop as well as on postop day
7 and 14. This will continue per protocol at home. HBSAb titers
remained >450 and HBSAg was negative. Daily Lamivudine was
started per protocol for HBV prophylaxis.

On [**10-27**], he was hypotensive when oob. Hct dropped to 18. He was
transferred back to the SICU where an EGD revealed a few
serpigenous shallow non-bleeding ulcers were found in the
duodenal bulb. One visible vessel was noted in the duodenal
bulb. The vessel was clipped x1 and injected with 4 ml of
epinephrine at the base. CMV viral load was negative. IV
protonix drip was given. The drip was subsequently changed to
[**Hospital1 **] protonix. Feeding tube was not replaced. Once stable, he
returned to the med-[**Doctor First Name **] unit where he continued to make
progress with his diet, activity and understanding of
medications.

The lateral JP was removed. The medial JP appeared bilious. On
[**11-3**], ERCP was done showing the common bile duct, common hepatic
duct, right and left hepatic ducts, and biliary radicles were
filled with contrast and well visualized. The course and caliber
of the structures were normal with no evidence of extravasation.
No stricture was seen at the native and donor duct anastomosis.
Intra-procedure discussion with Dr. [**First Name (STitle) **] occured. Given
findings- decison made not to place biliary stent.  LFTs
improved postop ercp. Ursodiol continued. Recommendations
included repeat ERCP in 8 weeks with f/u HIDA post ERCP.

The medial JP appeared bilious and averaged 130-200cc/day. The
renal JP output continued to average 150-200cc of clear yellow
fluid. The renal JP fluid was sent for creatinine that was 1.1.

PT worked with him extensively noting progress with strength,
balance and endurance. He was declared safe for discharge home
with a cane. Nutrition followed noting kcal intake of 2000kcals.
He was able to take in supplements tid.

On [**11-9**], he was feeling well with LFTs trending down (ast 12,
alt 14, alk phos 183 and tbili 1.9. Creatinine was 1.2.
Immunosuppression consisted of cellcept 1gram [**Hospital1 **], steroids were
tapered to 20mg qd and prograf 2mg [**Hospital1 **] as trough levels
stabilized at 9.2.

He was discharged to home with VNA services. He demonstrated
good understanding of his meds. He was taught how to empty and
record JP outputs. VNA was to administered scheduled HBIG doses.


Of note, he should have f/u of his TSH which was low (0.085 and
0.6) with T4 4.4/4.7 and T3 68/73.

He was discharged home on broad spectrum antibiotics (flagyl,
Linezolid and cipro)which were to continue until follow-up. Of
note, cipro interacts with fluconazole causing prolonged QT
interval. QT interval was acceptable. Weekly outpatient ekg/QT
interval f/u should occur as long as he is on cipro and
fluconazole.
ekg [**11-14**] to check qt interval

Medications on Admission:
- Prograf 2.5mg PO BID
 - Cellcept 500mg PO QID
 - Prednisone 20mg PO qAM
 - Valcyte 450mg PO qAM
 - Fluconazole 400mg PO qAM
 - Protonix 40mg PO BID
 - Colace 100mg PO BID
 - Ursodiol 300mg PO TID
 - Ferrous Sulfate 325mg PO BID
 - Caltrate / Vit D 600/400mg PO BID
 - Metoprolol 50mg PO TID
 - Dapsone 100mg PO daily
 - Ambien 5mg PO qHS prn sleep
 - ISS


Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*2*
3. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
follow transplant clinic taper.
Disp:*120 Tablet(s)* Refills:*2*
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
Disp:*63 Tablet(s)* Refills:*0*
12. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
Disp:*120 Capsule(s)* Refills:*2*
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
14. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED).
Disp:*2 bottles* Refills:*2*
15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*42 Tablet(s)* Refills:*0*
16. Hepatitis B Immun Glob-Maltose >312 unit/mL (5 mL) Solution
Sig: Five (5) ML Intramuscular ONCE (Once) for 2 doses: give IM
on [**11-13**] and [**11-20**].


Discharge Disposition:
Home With Service

Facility:
VNA Care [**Location (un) 511**]

Discharge Diagnosis:
biliary ischemia s/p liver transplant
ARF on CRF
malnutrition
VRE, rectal swab
UTI
DM
Duodenal ulcer
GI bleed
anemia


Discharge Condition:
good


Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
jaundice, abdominal distension, increased drain output, incision
redness/bleeding/drainage, decreased urine output, weight gain
of 3 pounds in a day, leg edema or blood sugars persistently
>200 or too low


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-11-15**]
8:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-11-22**]
8:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2187-11-29**]
10:00



Completed by:[**2187-11-9**]
{'Complications of transplanted liver,End stage renal disease,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction,Bacteremia,Acidosis,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Peritoneal adhesions (postoperative) (postinfection),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified disorders of stomach and duodenum,Unspecified pruritic disorder,Anemia, unspecified'}


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: elevated LFTs noted on outpatient follow-up

PRESENT ILLNESS: 46M with fulminant hepatic failure c/b HRS likely secondary
to Hepatitis E, s/p ABO mismatch OLTx with splenectomy [**4-/2187**]
complicated by bleeding requiring exploratory laparotomy and
washout, splenic fluid collection requiring drainage x 2 and
decubitus ulcers.  Notably had a recent episode of biopsy-proven
acute rejection one month ago, treated with prednisone taper.

MEDICAL HISTORY: Liver transplant [**2187-4-26**] secondary to Hepatitis E
mild liver rejection [**2187-7-11**] treated with steroids
Tonsillectomy
Hernia Repair
Alcohol Abuse
Tobacco Use

MEDICATION ON ADMISSION: - Prograf 2.5mg PO BID
 - Cellcept 500mg PO QID
 - Prednisone 20mg PO qAM
 - Valcyte 450mg PO qAM
 - Fluconazole 400mg PO qAM
 - Protonix 40mg PO BID
 - Colace 100mg PO BID
 - Ursodiol 300mg PO TID
 - Ferrous Sulfate 325mg PO BID
 - Caltrate / Vit D 600/400mg PO BID
 - Metoprolol 50mg PO TID
 - Dapsone 100mg PO daily
 - Ambien 5mg PO qHS prn sleep
 - ISS

ALLERGIES: Azithromycin

PHYSICAL EXAM: VS  98.6  98  149/101  20  100RA
Gen: NAD
HEENT: sclerae anicteric
CV: RRR
Chest: CTAB
Abd: S/NT/ND, well-healed liver txp scar
Ext: WWP, no C/C/E
Skin: trace jaundice

FAMILY HISTORY: No liver disease.

SOCIAL HISTORY: Divorced, 3 children.  Owns own auto repair and sale business.
Smoked 1 ppd for 20+ years, discontinued with onset of jaundice.
 H/o alcohol abuse.  Recently drank a couple glasses of wine or
beer with dinner discontinued with onset of jaundice.  Remote
history of vicodin and percocet abuse.  Remote history of
marijuana and cocaine use. Remote history of using supplements
from GNC. No IVDU, risky sexual behavior or tattoos.  No sick
contacts.  [**Name (NI) **] foreign travel. 

### Response:
{'Complications of transplanted liver,End stage renal disease,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute duodenal ulcer without mention of hemorrhage or perforation, without mention of obstruction,Bacteremia,Acidosis,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Peritoneal adhesions (postoperative) (postinfection),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified disorders of stomach and duodenum,Unspecified pruritic disorder,Anemia, unspecified'}
