CHIEF COMPLAINT: Worsening Liver Disease

PRESENT ILLNESS: 54 year-old M with DM, CRI, and bipolar disorder who is
transferred from [**Hospital3 3583**] for worsened liver dysfunction.
He was admitted to [**Hospital3 3583**] on [**3-31**] with SOB and weakness.
He was found to have fever and was started on ceftriaxone, with
unknown source. His LFTs began to increase on [**4-2**] (bili
1.6->15.9). MRCP and CT Abdomen did not show intrahepatic or
extrahepatic bile duct dilation. Small liver lesions found were
likely hemangiomas; the spleen was moderately enlarged. Out of
concern for drug-induced transaminitis, ceftriaxone was switched
to levoflox on [**4-6**]. This was stopped on [**4-8**] due to continued
increase in LFTs. His depakote was stopped, with psychiatry
consultation, but then restarted on transfer. After consultation
with Dr. [**Last Name (STitle) 497**], the patient was transferred for possible liver
biopsy.

MEDICAL HISTORY: DM - insulin-dependent, c/b neuropathy
CRI - now on HD M,W,F
CHF - suspected diastolic dysfunction, EF 60% with LVH
HTN
bipolar disorder - on depakote
sleep apnea
BPH - with h/o urinary retention
hypothyroidism
anemia

MEDICATION ON ADMISSION: Medications at Home:
insulin 50 NPH QAM / 18 NPH QPM, humalog SSI
ASA 81 mg Qday
depakote 50 mg QHS
vitamin C
finasteride 5 mg QDay
lasix 420 mg [**Hospital1 **]
nifedipine 90 mg QDay
propranolol 120 mg Q12H
renagel 1600 PO Q8H
flomax 0.4 mg Qday
synthroid 50 mcg PO QDay
labetalol 200 mg Q12H
lisinopril 10 mg Qday
MVI
aranesp 100 mcg
FeSO4
Metolazone 2.5 mg QDay
.
.
Medications on Transfer:
finasteride 5 mg QD
robitussin 200 mg Q4H prn cough
haldol 5 mg [**Hospital1 **] prn
Insulin NPH 50 SC QAM, 18 SC QPM
ISMN 30 QDayy
lisinopril 20 mg QDay
reglan 10 mg ORN
MVI QDay
procardia 90 mg QDay
oxybutynin 5 mg Q6H prn
propranolol LA 120 mg [**Hospital1 **]
ranitidine 150 mg prn
sevelamer 1600 mg TID with meals
albuterol Q4H prn
atroven prn
epgen 20,000 TIW
depakote 1000 mg QHS

ALLERGIES: Penicillins / Seroquel / Ceftriaxone

PHYSICAL EXAM: Vitals: T: 1007. BP: 116/53 P: 90 RR: 27 SaO2: 97% on 2L NC wt
128 kg
General: Awake, alert, tremulous, jaundiced, in NAD.
HEENT: PERRL, EOMI, sclera icteric. MMM, OP without lesions
Neck: supple, unable to appreciate JVP
Pulm: CTAB
Cardiac: RRR, nl S1/S2, no M/R/G appreciated
Abdomen: soft, protuberant, NT/ND, + BS, no hepatomegaly noted.

FAMILY HISTORY: No history of liver disease, pancreatic Ca.

SOCIAL HISTORY: Lives with his wife and teenage daughter. [**Name (NI) **] used to work as an
accountant, but is now on disability. He denies tobacco or EtOH
use. No h/o IVDA.
Acute and subacute necrosis of liver,Diastolic heart failure, unspecified,Chronic kidney disease, unspecified,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Anemia, unspecified
Acute necrosis of liver,Diastolc hrt failure NOS,Chronic kidney dis NOS,DMI neuro nt st uncntrld,Neuropathy in diabetes,Anemia NOS
Admission Date:  [**2122-4-11**]              Discharge Date:   [**2122-4-17**]

Date of Birth:  [**2067-7-22**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Seroquel / Ceftriaxone

Attending:[**Known firstname 943**]
Chief Complaint:
Worsening Liver Disease

Major Surgical or Invasive Procedure:
none


History of Present Illness:
54 year-old M with DM, CRI, and bipolar disorder who is
transferred from [**Hospital3 3583**] for worsened liver dysfunction.
He was admitted to [**Hospital3 3583**] on [**3-31**] with SOB and weakness.
He was found to have fever and was started on ceftriaxone, with
unknown source. His LFTs began to increase on [**4-2**] (bili
1.6->15.9). MRCP and CT Abdomen did not show intrahepatic or
extrahepatic bile duct dilation. Small liver lesions found were
likely hemangiomas; the spleen was moderately enlarged. Out of
concern for drug-induced transaminitis, ceftriaxone was switched
to levoflox on [**4-6**]. This was stopped on [**4-8**] due to continued
increase in LFTs. His depakote was stopped, with psychiatry
consultation, but then restarted on transfer. After consultation
with Dr. [**Last Name (STitle) 497**], the patient was transferred for possible liver
biopsy.

During his hospital stay he presented in renal failure and a
tunneled dialysis catheter was placed [**4-2**] for three times
weekly HD. His SOB was attributed to CHF, uremia, and anemia. He
was mildy hypoxic, requiring 2L of NC; ABG 7.33/60/87. This was
thought to be due to a history of sleep apnea, although he had
never been on CPAP in the past. He also had hematuria, seen by
urology, that was attributed to foley trauma.

ROS: He complains of pruritus. He also notes nausea and poor
appetite, without vomiting. No changes in color of stools or
urine. Pt denies recent weight loss or gain. Reports dry cough.
No shortness of breath. Denied chest pain or tightness,
palpitations. Denied diarrhea, constipation, or abdominal pain.
No melena or BRBPR. No dysuria. He was dialyzed 2L today. No
history of blood transfusions, IVDA, liver disease.


Past Medical History:
DM - insulin-dependent, c/b neuropathy
CRI - now on HD M,W,F
CHF - suspected diastolic dysfunction, EF 60% with LVH
HTN
bipolar disorder - on depakote
sleep apnea
BPH - with h/o urinary retention
hypothyroidism
anemia

Social History:
Lives with his wife and teenage daughter. [**Name (NI) **] used to work as an
accountant, but is now on disability. He denies tobacco or EtOH
use. No h/o IVDA.

Family History:
No history of liver disease, pancreatic Ca.

Physical Exam:
Vitals: T: 1007. BP: 116/53 P: 90 RR: 27 SaO2: 97% on 2L NC wt
128 kg
General: Awake, alert, tremulous, jaundiced, in NAD.
HEENT: PERRL, EOMI, sclera icteric. MMM, OP without lesions
Neck: supple, unable to appreciate JVP
Pulm: CTAB
Cardiac: RRR, nl S1/S2, no M/R/G appreciated
Abdomen: soft, protuberant, NT/ND, + BS, no hepatomegaly noted.

Ext: No edema b/t, warm.
Skin: confluent macular rash to abdomen, chest, arms, back. R
SCL tunneled line with small ecchymosis.
Neurologic: Alert & Oriented x 3. Able to relate history without
difficulty. tremulous, unable to determine asterixis.


Pertinent Results:
[**2122-4-14**] Liver U/S: This is an extremely limited study due to
patient's size and inherent noise with limited acoustic windows.
The liver appears normal in size. There are no grossly evident
focal lesions seen. There is no evidence of ascites, but the
spleen appears mildly enlarged at 13.4 cm. The portal vein and
right and left branches are patent with forward flow. Hepatic
veins are visualized in left middle and right trunks and are
fully patent as is the cava. Hepatic arteries are also patent.
The pancreas cannot be adequately imaged. Limited views of both
kidneys show normal size and no evidence of hydronephrosis. No
gallstones or bile duct dilatation is noted.
CONCLUSION: Technically limited study with no gross liver
lesions or ascites seen. Patent portal and hepatic venous
vasculature. Mild splenomegaly.

[**2122-4-15**] Renal U/S: FINDINGS: The left and right kidneys are
unchanged in size or appearance when compared to the prior
study. No renal mass lesions, stones, or hydronephrosis is
noted. No perirenal fluid collections are noted. Right kidney
measures 12.2 cm in length. The left kidney measures
approximately 13.2 cm in length. Doppler studies are performed
which reveal patent arterial and venous flow to the right kidney
with peak systolic velocity of approximately 30 cm/sec. Patent
arterial and venous flow is also noted in the left kidney with
peak systolic velocities of approximately 25 cm/sec.
IMPRESSION: No hydronephrosis in left or right kidneys, patent
arterial flow to both kidneys.

CXR: IMPRESSION:
Low lung volumes. Bibasilar opacities likely represent
atelectasis, but early basilar pneumonia is not excluded and
followup radiographs may be helpful in this regard. If clinical
suspicion for infection persists, followup radiograph with
improved inspiratory level may be helpful to fully exclude early
basilar pneumonia.

PERTINENT LABS:
LFTs:
[**2122-4-11**] 10:21PM BLOOD ALT-396* AST-185* LD(LDH)-407*
AlkPhos-1071* Amylase-101* TotBili-15.2* DirBili-12.0*
IndBili-3.2
[**2122-4-12**] 06:44AM BLOOD ALT-361* AST-188* LD(LDH)-819*
AlkPhos-1060* Amylase-145* TotBili-15.0*
[**2122-4-13**] 05:03AM BLOOD ALT-258* AST-53* LD(LDH)-263*
AlkPhos-967* Amylase-113* TotBili-13.6*
[**2122-4-14**] 05:07AM BLOOD ALT-177* AST-36 LD(LDH)-254* AlkPhos-887*
TotBili-9.0*
[**2122-4-15**] 05:17AM BLOOD ALT-142* AST-38 LD(LDH)-300* AlkPhos-875*
TotBili-6.8*
[**2122-4-16**] 05:25AM BLOOD ALT-118* AST-42* AlkPhos-824*
TotBili-5.2*
[**2122-4-17**] 05:33AM BLOOD ALT-95* AST-39 AlkPhos-774* TotBili-5.4*

Labs on discharge: [**2122-4-17**]
Glucose-89 UreaN-64* Creat-10.3*# Na-131* K-5.1 Cl-92* HCO3-25
Calcium-9.5 Phos-7.3*# Mg-2.6

PT-10.8 PTT-36.1* INR(PT)-0.9

WBC-7.0 RBC-3.06* Hgb-9.7* Hct-29.8* MCV-98 MCH-31.6 MCHC-32.4
RDW-19.8* Plt Ct-430
[**2122-4-13**] 05:03AM BLOOD Neuts-61.0 Lymphs-3.0* Monos-17.0*
Eos-14.0* Baso-5.0*

[**2122-4-11**] 10:21PM BLOOD TSH-0.90
[**2122-4-13**] 11:09AM BLOOD PTH-34
[**2122-4-11**] 10:21PM BLOOD Valproa-17*
[**2122-4-15**] 07:00PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE

Brief Hospital Course:
54 year-old M with DM, CRI, and bipolar disorder who is
transferred from OSH for worsened liver dysfunction for liver
biopsy.  Active issues include:

# Liver dysfunction: Etiology for liver disease remained unclear
but as LFTs improved significantly, it was ultimately attributed
to reaction to ceftriaxone with perhap underlying chronic liver
disease such as NASH/NAFLD (given history of splenomegaly).
Valproic acid may also cause chronic hepatocellular necrosis.
Hepatitis serologies negative, [**Doctor First Name **]/AMA negative. His depakote
was stopped. Liver biopsy was not necessary as LFT's improved
rapidly.
- Patient will f/u with Dr. [**Last Name (STitle) 497**]

# Bipolar: Psychiatry was consulted to help manage patient's
psych regimen after depakote was stopped. He was started on 5 mg
Abilify and titrated to 10 mg daily. Depakote was not restarted
given that it may have been chronically causing liver disease
and is also hepatically cleared. Patient had been managed by his
PCP regarding his psych meds, but has a new outpatient
psychiatrist (Dr. [**Last Name (STitle) 29004**] in [**Location (un) 22287**])scheduled (first appointment 3
weeks post discharge). He was also started on Lamictal 25 mg
daily given that it may be less hepatotoxic than depakote. Post
discharge, he will need:
- LFT's checked by PCP within [**Name Initial (PRE) **] week of starting lamictal
- Patient and wife alerted of risk for [**Name (NI) **] [**Name (NI) **].
- Lamictal 25 mg X 2 weeks and then if tolerating, can double
the dose.

# Low-grade Fever: Patient intially had low grade temp with mild
leukocytosis. This was felt to be inflammatory from
drug-reaction and less likely to be infectious.  For remainder
of hospital course, he remained afebrile and had no sources for
infection.

# CHF: patient has history of diastolic dysfunction. He
continued lisinopril, B-blocker, and imdur.

# Rash: Upon tranfser, patient was noted to have rash over
abdomen and extremities. The rash appeared to be drug-related
and possibly from ceftriaxone (has allergy to PCN). By
discharge, the rash had improved significantly.

# ESRD on HD: Patient initiated dialysis at OSH and upon
transfer to continued HD initiation.  Renal was following and
patient was set up with outpatient HD. He was discharged on
sevelamer and lanthanum. He will need outpatient work-up for
fistula. His lasix and metolazone were stopped.

# Anemia: patient received 2 units pRBCs at OSH and his anemia
was from chronic kidney disease. He had epogen at HD and
remained hemodynamically stable during this admission.

# HTN: He continued nifedipine, propranolol, lisinopril

# DM: Patient continued NPH and humalog SSI

# Prophylaxis: H2 blocker, SC heparin, bowel regimen
# FEN: low Na cardiac renal diabetic diet; albumin 1.8 at OSH.
# Contact: wife, [**Name (NI) 5627**] (HCP), [**Telephone/Fax (1) 72633**]
# Access: 20g, and R SCL HD catheter ([**4-2**])
# Code Status: Full


Medications on Admission:
Medications at Home:
insulin 50 NPH QAM / 18 NPH QPM, humalog SSI
ASA 81 mg Qday
depakote 50 mg QHS
vitamin C
finasteride 5 mg QDay
lasix 420 mg [**Hospital1 **]
nifedipine 90 mg QDay
propranolol 120 mg Q12H
renagel 1600 PO Q8H
flomax 0.4 mg Qday
synthroid 50 mcg PO QDay
labetalol 200 mg Q12H
lisinopril 10 mg Qday
MVI
aranesp 100 mcg
FeSO4
Metolazone 2.5 mg QDay
.
.
Medications on Transfer:
finasteride 5 mg QD
robitussin 200 mg Q4H prn cough
haldol 5 mg [**Hospital1 **] prn
Insulin NPH 50 SC QAM, 18 SC QPM
ISMN 30 QDayy
lisinopril 20 mg QDay
reglan 10 mg ORN
MVI QDay
procardia 90 mg QDay
oxybutynin 5 mg Q6H prn
propranolol LA 120 mg [**Hospital1 **]
ranitidine 150 mg prn
sevelamer 1600 mg TID with meals
albuterol Q4H prn
atroven prn
epgen 20,000 TIW
depakote 1000 mg QHS


Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for 1 months.
Disp:*qs qs* Refills:*0*
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
7. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. Propranolol 120 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO twice a day.
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*2*
12. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
13. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
14. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as
directed  Subcutaneous twice a day: 50 units QAM; 18 units QPM.

15. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
16. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
17. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
acute liver failure
chronic renal failure
bipolar disorder

Secondary:
congestive heart failure


Discharge Condition:
stable, pain free


Discharge Instructions:
You had liver failure felt possibly due to ceftriaxone. You are
also now on hemodialysis for your kidney failure.

You have been started on new medications. Please take all
medications as prescribed.
1) Abilify 10 mg in evenings
2) Lamictal 25 mg daily: You should take this dose for 2 weeks
and then you may need adjustments from your psychiatrist. Please
ask your primary doctor to check your liver function tests.

Please note that the lamictal can cause a very serious rash
leading to very serious complications including death in some
patients. If you develop ANY symptoms of a rash you must see a
doctor immediately.

Your Lasix and metolazone have been stopped now that you are on
dialysis.

Please attend all follow-up appointments.

Please call your doctor or go to the hospital if you have any
fever, chills, nausea, worsening yellow skin or eyes, mental
status changes, pain, or any other concerning symptoms.

Followup Instructions:
You have an appointment with [**Known firstname **] [**Last Name (NamePattern1) 8507**], MD
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2122-5-22**] 1:00.

You have an appointment with your primary doctor: Dr. [**First Name (STitle) **], on
Thursday, [**2122-4-23**] at 1:30 PM. [**Telephone/Fax (1) 72634**]. Please ask Dr.
[**First Name (STitle) **] to check your liver function tests while on the new psych
meds.

You have an appointment with Dr. [**Last Name (STitle) 29004**], your new psychiatrist on
[**2122-5-14**] at 11 AM. Please call his office to confirm and try to
get an earlier appointment.
{'Acute and subacute necrosis of liver,Diastolic heart failure, unspecified,Chronic kidney disease, unspecified,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,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: Worsening Liver Disease

PRESENT ILLNESS: 54 year-old M with DM, CRI, and bipolar disorder who is
transferred from [**Hospital3 3583**] for worsened liver dysfunction.
He was admitted to [**Hospital3 3583**] on [**3-31**] with SOB and weakness.
He was found to have fever and was started on ceftriaxone, with
unknown source. His LFTs began to increase on [**4-2**] (bili
1.6->15.9). MRCP and CT Abdomen did not show intrahepatic or
extrahepatic bile duct dilation. Small liver lesions found were
likely hemangiomas; the spleen was moderately enlarged. Out of
concern for drug-induced transaminitis, ceftriaxone was switched
to levoflox on [**4-6**]. This was stopped on [**4-8**] due to continued
increase in LFTs. His depakote was stopped, with psychiatry
consultation, but then restarted on transfer. After consultation
with Dr. [**Last Name (STitle) 497**], the patient was transferred for possible liver
biopsy.

MEDICAL HISTORY: DM - insulin-dependent, c/b neuropathy
CRI - now on HD M,W,F
CHF - suspected diastolic dysfunction, EF 60% with LVH
HTN
bipolar disorder - on depakote
sleep apnea
BPH - with h/o urinary retention
hypothyroidism
anemia

MEDICATION ON ADMISSION: Medications at Home:
insulin 50 NPH QAM / 18 NPH QPM, humalog SSI
ASA 81 mg Qday
depakote 50 mg QHS
vitamin C
finasteride 5 mg QDay
lasix 420 mg [**Hospital1 **]
nifedipine 90 mg QDay
propranolol 120 mg Q12H
renagel 1600 PO Q8H
flomax 0.4 mg Qday
synthroid 50 mcg PO QDay
labetalol 200 mg Q12H
lisinopril 10 mg Qday
MVI
aranesp 100 mcg
FeSO4
Metolazone 2.5 mg QDay
.
.
Medications on Transfer:
finasteride 5 mg QD
robitussin 200 mg Q4H prn cough
haldol 5 mg [**Hospital1 **] prn
Insulin NPH 50 SC QAM, 18 SC QPM
ISMN 30 QDayy
lisinopril 20 mg QDay
reglan 10 mg ORN
MVI QDay
procardia 90 mg QDay
oxybutynin 5 mg Q6H prn
propranolol LA 120 mg [**Hospital1 **]
ranitidine 150 mg prn
sevelamer 1600 mg TID with meals
albuterol Q4H prn
atroven prn
epgen 20,000 TIW
depakote 1000 mg QHS

ALLERGIES: Penicillins / Seroquel / Ceftriaxone

PHYSICAL EXAM: Vitals: T: 1007. BP: 116/53 P: 90 RR: 27 SaO2: 97% on 2L NC wt
128 kg
General: Awake, alert, tremulous, jaundiced, in NAD.
HEENT: PERRL, EOMI, sclera icteric. MMM, OP without lesions
Neck: supple, unable to appreciate JVP
Pulm: CTAB
Cardiac: RRR, nl S1/S2, no M/R/G appreciated
Abdomen: soft, protuberant, NT/ND, + BS, no hepatomegaly noted.

FAMILY HISTORY: No history of liver disease, pancreatic Ca.

SOCIAL HISTORY: Lives with his wife and teenage daughter. [**Name (NI) **] used to work as an
accountant, but is now on disability. He denies tobacco or EtOH
use. No h/o IVDA. 

### Response:
{'Acute and subacute necrosis of liver,Diastolic heart failure, unspecified,Chronic kidney disease, unspecified,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Anemia, unspecified'}
