CHIEF COMPLAINT: admitted from rehab with worsening renal failure

PRESENT ILLNESS: 60 y.o. M with diabetes, EtOH-induced cirrhosis, portal
hypertension with esophageal varices, listed for combined
liver-kidney transplant, encephalopathic at baseline, most
recently admitted [**Date range (1) 38382**] for edema, now re-admitted from
[**Hospital **] clinic with worsening renal failure in the setting of
continuing diuresis with 80 PO lasix and 25 PO spironolactone
daily. Per progress note, patient also had labile blood sugars,
and has developed C Diff colitis being treated with PO
vancomycin.
.
On interview, patient says he is very tired. He says he has been
feeling better after discharge until about 6 days ago when he
developed severe diarrhea. He says he has been sleeping poorly
because of multiple night time stools. He also reports that
while he initially felt that the swelling in his legs and
abdomen was improving, that over the past few days he feels like
his abdominal swelling has returned. Denies SOB, abd pain, or
fevers. His previous L-sided leg pain of unknown etiology has
improved. He got up for a brief walk with PT x 1, and has
otherwise been bedbound.

MEDICAL HISTORY: -alcoholic cirrhosis
-diabetes
-hypertension
-mild pulmonary artery hypertension
-CRI (Baseline Cr. 2.0 up to 2.4)
-vitamin B12 deficiency
-rectal adenoma
-herniated lumbar disk
-gastritis
-hyperkalemia

MEDICATION ON ADMISSION: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Iodine / Heparin Agents

PHYSICAL EXAM: VS: 96.2 110/62 92 16 94% on RA
General: elderly man in NAD, lying in bed, appears sleepy but
easy to arouse, speaking in full sentences
HEENT: EOMI, MMM, OP clear, sclera slightly icteric
Heart: RRR, 2/6 systolic murmur heard throughout the precordium

FAMILY HISTORY: -F: Committed suicide at age 34
-M: Colon CA, doing well

SOCIAL HISTORY: - Pt lives at [**Hospital 38380**] rehab, previously lived alone at [**Location (un) **]
with the support of his sons. [**Name (NI) **] has 9 siblings. Previous
occupation was working in Maintenance at a school. He has had
occupational exposure to benzene working on ships.
- Quit smoking Tob 16years ago, smoked 2ppd x 25years.
- Denies current ETOH use x11 years, used to drink 1pint ETOH
daily x25years, started drinking at age 12.
Acute and subacute necrosis of liver,Alcoholic cirrhosis of liver,Hepatorenal syndrome,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Hyperpotassemia,Acute kidney failure with lesion of tubular necrosis,Unspecified protein-calorie malnutrition,Pressure ulcer, lower back,Other and unspecified alcohol dependence, in remission,Unspecified essential hypertension,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pain in limb,Long-term (current) use of insulin,Anticoagulants causing adverse effects in therapeutic use,Abnormal involuntary movements,Polyuria,Unspecified hereditary and idiopathic peripheral neuropathy
Acute necrosis of liver,Alcohol cirrhosis liver,Hepatorenal syndrome,Int inf clstrdium dfcile,Urin tract infection NOS,CHF NOS,Hyperpotassemia,Ac kidny fail, tubr necr,Protein-cal malnutr NOS,Pressure ulcer, low back,Alcoh dep NEC/NOS-remiss,Hypertension NOS,Esoph varice oth dis NOS,DMII wo cmp nt st uncntr,Pain in limb,Long-term use of insulin,Adv eff anticoagulants,Abn involun movement NEC,Polyuria,Idio periph neurpthy NOS
Admission Date:  [**2180-2-11**]              Discharge Date:   [**2180-4-7**]

Date of Birth:  [**2119-2-13**]             Sex:   M

Service: SURGERY

Allergies:
Iodine / Heparin Agents

Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
admitted from rehab with worsening renal failure

Major Surgical or Invasive Procedure:
Tunneled HD cath placed by IR on [**2180-2-17**]
liver and kidney transplant [**2180-3-8**]
post pyloric feeding tube, later d/c'd


History of Present Illness:
60 y.o. M with diabetes, EtOH-induced cirrhosis, portal
hypertension with esophageal varices, listed for combined
liver-kidney transplant, encephalopathic at baseline, most
recently admitted [**Date range (1) 38382**] for edema, now re-admitted from
[**Hospital **] clinic with worsening renal failure in the setting of
continuing diuresis with 80 PO lasix and 25 PO spironolactone
daily. Per progress note, patient also had labile blood sugars,
and has developed C Diff colitis being treated with PO
vancomycin.
.
On interview, patient says he is very tired. He says he has been
feeling better after discharge until about 6 days ago when he
developed severe diarrhea. He says he has been sleeping poorly
because of multiple night time stools. He also reports that
while he initially felt that the swelling in his legs and
abdomen was improving, that over the past few days he feels like
his abdominal swelling has returned. Denies SOB, abd pain, or
fevers. His previous L-sided leg pain of unknown etiology has
improved. He got up for a brief walk with PT x 1, and has
otherwise been bedbound.


Past Medical History:
-alcoholic cirrhosis
-diabetes
-hypertension
-mild pulmonary artery hypertension
-CRI (Baseline Cr. 2.0 up to 2.4)
-vitamin B12 deficiency
-rectal adenoma
-herniated lumbar disk
-gastritis
-hyperkalemia


Social History:
- Pt lives at [**Hospital 38380**] rehab, previously lived alone at [**Location (un) **]
with the support of his sons. [**Name (NI) **] has 9 siblings. Previous
occupation was working in Maintenance at a school. He has had
occupational exposure to benzene working on ships.
- Quit smoking Tob 16years ago, smoked 2ppd x 25years.
- Denies current ETOH use x11 years, used to drink 1pint ETOH
daily x25years, started drinking at age 12.


Family History:
-F: Committed suicide at age 34
-M: Colon CA, doing well

Physical Exam:
VS: 96.2 110/62 92 16 94% on RA
General: elderly man in NAD, lying in bed, appears sleepy but
easy to arouse, speaking in full sentences
HEENT: EOMI, MMM, OP clear, sclera slightly icteric
Heart: RRR, 2/6 systolic murmur heard throughout the precordium

Chest: CTA B/L, no w/r/r
Abd: firm, distended, + BS, no fluid wave, nontender on
palpation.
Ext: + 3 edema to hips BL.
Skin overlying both lower extremities is dry and cracked with
several healing ulcers. Pulses are 1+ bilaterally, skin dry with
multiple healing ulcers.
Neuro: CN II-XII grossly intact. Speech clear. Mild asterixis.
Moving
all extremities without difficulty. Mental status, alert and
oriented x 3.


Pertinent Results:
On Admission: [**2180-2-11**]
GLUCOSE-244* UREA N-136* CREAT-4.6*# SODIUM-133 POTASSIUM-5.1
CHLORIDE-101 TOTAL CO2-18* ANION GAP-19
WBC-9.1 RBC-3.05* HGB-10.4* HCT-31.0* MCV-102* MCH-34.0*
MCHC-33.4
RDW-18.2* PLT COUNT-81*
PT-15.7* PTT-40.0* INR(PT)-1.4*
ALBUMIN-2.4* CALCIUM-8.1* PHOSPHATE-7.4*# MAGNESIUM-2.6
ALT(SGPT)-38 AST(SGOT)-40 LD(LDH)-201 ALK PHOS-312* TOT
BILI-2.0*
On Discharge:[**2180-3-23**]
Glucose-145* UreaN-22* Creat-0.7 Na-136 K-4.9 Cl-105 HCO3-24
AnGap-12
WBC-9.6 RBC-3.69* Hgb-11.6* Hct-33.6* MCV-91 MCH-31.3 MCHC-34.5
RDW-20.2* Plt Ct-111*
PT-14.5* PTT-33.8 INR(PT)-1.3*
ALT-38 AST-19 AlkPhos-135* TotBili-1.3
Albumin-2.9* Calcium-8.1* Phos-1.8* Mg-1.4*

[**2180-4-3**] 04:40AM BLOOD WBC-7.7 RBC-3.62* Hgb-11.8* Hct-32.9*
MCV-91 MCH-32.5* MCHC-35.9* RDW-20.8* Plt Ct-96*
[**2180-3-24**] 02:45AM BLOOD Neuts-84.8* Lymphs-11.6* Monos-2.4
Eos-0.9 Baso-0.3
[**2180-3-24**] 02:45AM BLOOD Anisocy-2+ Macrocy-2+
[**2180-4-3**] 04:40AM BLOOD Plt Smr-LOW Plt Ct-96*
[**2180-3-18**] 04:45PM BLOOD K-6.9*
[**2180-4-3**] 04:40AM BLOOD Glucose-165* UreaN-39* Creat-1.1 Na-137
K-4.3 Cl-105 HCO3-24 AnGap-12
[**2180-4-2**] 07:15AM BLOOD estGFR-Using this
[**2180-4-3**] 04:40AM BLOOD ALT-18 AST-20 AlkPhos-113 TotBili-1.0
[**2180-3-9**] 12:25AM BLOOD ALT-261* AST-346* AlkPhos-91 Amylase-23
TotBili-5.3* DirBili-3.8* IndBili-1.5
[**2180-4-3**] 04:40AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.5*
[**2180-3-12**] 04:06AM BLOOD VitB12-1702*
[**2180-2-26**] 05:30AM BLOOD %HbA1c-6.9* [Hgb]-DONE [A1c]-DONE
[**2180-3-26**] 02:40PM BLOOD Osmolal-288
[**2180-2-17**] 11:51AM BLOOD Osmolal-342*
[**2180-3-23**] 01:48PM BLOOD TSH-2.8
[**2180-3-23**] 01:48PM BLOOD T4-5.7 T3-82
[**2180-2-18**] 04:45PM BLOOD PTH-68*
[**2180-3-23**] 01:48PM BLOOD Cortsol-16.4
[**2180-2-19**] 04:20PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2180-2-17**] 06:00PM BLOOD HBsAb-POSITIVE HBcAb-NEGATIVE
[**2180-4-3**] 04:40AM BLOOD FK506-9.3
[**2180-2-19**] 04:20PM BLOOD HCV Ab-NEGATIVE
[**2180-2-17**] 06:00PM BLOOD HCV Ab-NEGATIVE
[**2180-3-28**] 11:15AM BLOOD RENIN-Test

Brief Hospital Course:
Presented with baseline Cr of 1.6-1.8 . Worsening renal failure
made him more resistant to his diuretics, leading to
re-accumulation of his ascites. - Abdominal U/S showed
moderate-to-large amount of ascites. There was no evidence of
SBP on tap. Patient was encephalopathic at baseline and he
continued on Lactulose and rifaximin. Urine cx + for e coli
completed 7 days of cipro on [**2-24**].
He started on HD and c/o CP when on dialysis. EKG without
significant ST-T changes. Underwent persantine MIBI which did
not show any e/o ischemia, no [**Male First Name (un) 4746**] abnormality was noted.
Tube feeds were given. He experienced hyperglycemia and insulin
was adjusted by [**Last Name (un) **].

On [**3-8**] he was taken to the OR by Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and [**Name5 (PTitle) **]
[**Doctor Last Name **] for liver and kidney transplant from a 16 y.o. brain dead
donor involved in MVC. Of note, he is HIT + therefore, heparin
was not used. The portal vein was found to be small but
otherwise normal in appearance. The liver was reperfused after
the portal vein had been freed of any clot but reperfused
somewhat sluggishly. After the arterial anastomosis, the liver
pinked up appropriately. Please see OP report for further
details. Two [**Doctor Last Name 406**] drains were placed; The medial drain under
the biliary anastomosis and the lateral drain at the
suprahepatic cava. A JP drain was placed near the renal
transplant.

On POD 1,fluid boluses, blood products and albumin were given
for hypotension. He was extubated. On [**3-9**] he spiked a temp to
102.2. He was coughing and raising thick yellow sputum. There
was concern for aspiration pneumonia. WBC was 4.1.  A CXR
revealed LLL collapse.  Nebs were given. O2 sats were in high
90's and abg's were good. Periop IV vanco and levo were
continued and flagyl was added. An insulin gtt was initially
used for hyperglycemia then glargine was started. Glucoses
improved. A U/A had rbc>50, wbc 20-50 and no epi's. A urine cx
subsequently was positive for 10-100,000 col of E.coli. Flagyl
and levo were changed to meropenum. Meropenum was given for a 7
day course.

On POD 2 he appeared tremulous, confused and at times appeared
to be hallucinating. An U/S revealed normal Doppler evaluation
of transplanted liver, but the left hepatic vein was not
assessed. Creatinine and LFTs trended down. He was started on
prograf. On [**3-11**] a head CT was done for confusion and tremors.
This showed no acute intracranial hemorrhage or mass effect.
Neurology was consulted and recommended toxic metabolic and
infectious workup including an MRI as well as avoidance of
dopamine blocking agents. MRI was not done due to significant
tremors.  There was concern for leukoencephalopathy from prograf
although prograf levels were low at 4.9.  The left femoral HD
line was removed. A post pyloric feeding tube was inserted and
feedings were initially held given concern for aspiration. Lasix
was given for volume excess with good response. Creat decreased
to 1.6.

On POD 4 neuro exam was improved. He required aggressive
pulmonary toilet. Fluid boluses were given for tachycardia and
tube feedings were initiated. A bedside swallow eval was done to
r/o aspiration. Aspiration could not be r/o and he remained npo.
On [**3-14**] a video swallow showed evidence of premature spillover.
Penetration and aspiration after the swallow was noted with thin
liquids. Residue in valleculae greater than piriform sinuses
also noted. Speech and swallow recommended nectar thick liquids
and ground consistency and tube feedings. Tube feedings
continued for insufficient po caloric intake.

Tremors lessened. He became more alert and oriented. Diet was
advanced. Prograf level increased to 21.8 on pod 7. Tremor was
more pronounced with higher prograf levels. Over several days,
Prograf dosage was decreased with levels dropping to 12.4. The
JPs were removed. Urine output averaged [**2-12**] liter/day. Low dose
lopressor was given for tachycardia in 90s then stopped when bps
were on the low side.

Potassium started to trend up on pod 9. He was placed on a 2gram
potassium diet. Tube feedings were switched to Nutren Renal at
45cc/hour. Treatment with insulin/dextrose, iv normal saline and
kayexalate was given on [**3-18**] for K of 6.9. Over the day this
decreased to 5.5.

On pod 12([**3-20**]) he became tachycardic into the 120s with bp of
72/50 while sitting in chair. An ekg was negative. He responded
to  2 liters of  IV NS with HR decreasing to 100 and BP
increasing to 112/70. Other vital signs, chem 7 and cbc were
normal. Blood and urine cultures were sent.

On POD 13, he again required volume for tachycardia,but HR
persisted in 110-117 range. IV fluid was stopped. Weight
increased 5 kg from previous day. IV fluid replacments were
given to keep I/Os even. Polyuria persisted with concern for
SIADH. A head CT was negative for pathology. IV fluid was
tapered off. A renal scan was done to differentiate whether
native kidneys were functioning. Findings demonstrated evidence
of ATN in both native kidneys with normal transplant kidney
function. Serum renin and aldosterone levels were sent on [**3-28**].

Prograf level was a little high at 14.9 on pod 20. Potassium was
persistently elevated. He continued on telemetry without ectopy.
Heart rate decreased to the 80-90 range. Tube feedings were
stopped given Kcal intake of 2313.

He experienced neuropathy in both feet with slight right foot
drop. Neurontin was increased with some improvement. Neurology
evaluated and recommended increase of neurontin if symptoms
persisted.

On POD 23, the patient fell in the bathroom, secondary to
dizziness.  A hip x-ray was negative for fracture or
dislocation.  The dizziness subsided with rest.

By POD 24, the patient's urine output decreased, possibly due to
the florinef that was started, and his ins and outs became
roughly even.  He still complained of occasional dizzness and
SOB when walking.  On POD 26, a VA scan was ordered to rule
pulmonary embolus.  The results of this scan did not suggest a
PE.

Below is a summary of events and pertinent studies performed
throughout this patient's course:

STUDIES:
[**3-10**] Liver US: P
[**3-9**] Liver US: patent vessels, increased velocities in portal
vein distal to anastamosis. did not see L hepatic vein or CBD,
no intrahepatic duct dil.
[**3-9**] CXR: LLL collapse
[**3-6**] HIDA: Normal visualization of gallbladder
[**3-1**] RUQ US: Cirrhotic liver; no focal lesions identified.
Large ascites. Distended, nontender sludge-filled gallbladder.
Patent portal vein demonstrating hepatofugal flow.
2/13 Persantine MIBI: Normal pharmacologic stress myocardial
perfusion with normal left ventricular wall motion and cavity
size.  Compared with the study of [**2178-7-22**], no significant
change. EF 64%
2/12 Stress Test: Technically adequate dipyridamole
pharmacologic stress test without symptoms, evidence of ischemia
by ECG, or significant arrhythmia. Nuclear report sent
separately.
[**3-11**] Head CT: nml
.
MICRO:
[**3-8**] UrCx: EColi intermediate senisitivity to cipro, sensi to
meropenem
[**3-9**] BlCx: Negative, UrCx: EColi sensi to meropenem
[**3-11**] Bld Cx: Pnd
[**3-12**] Sputum Cx: OROPHARYNGEAL FLORA
[**3-13**] R tunnelled line cath tip Cx: Negative
[**3-14**] C. diff/stool Cx: Negative
[**3-20**] Blood and Urine Cult: Neg
.
[**3-15**] transfer to floor
[**3-16**] EEG: more consistent w/ encephalopathy, no seizures,
?attribute to compazine
[**3-17**] meropenem d/c'd end of [**2180-3-16**] (7 days total), TF Nutren
Renal Full strength 45cc/hr cont, dobhoff d/c'd, TFs stopped
[**3-18**] CVL d/c'd, K elevated to 6.9 (no EKG changes)-->rec'd 1LNS
bolus, Kayexalate 30 x1, D50 + insulin 10U IV x2 w/ improvement
to K 5.7
[**3-20**] Dobhoff post-pyloric via IR, bactrim restarted, JP d/c'd
[**3-23**] hypotensive, tachy, rec'd NS x2L, elevated BG - rec'd
insulin
[**3-24**] Renal scan shows ATN in both native kidneys but nl fxn of
txp.   Feeding tube repositioned - in duodenal-jejunal jxn.
[**3-25**] Head CT negative
[**3-27**] Neurology c/s - peripheral neuropathy [**2-11**] DM, liver dz,
poor nutrition, Rx.  Rec: cont gabapentin, can incr to 300 TID
if needed.
Renal recs: goal FK [**6-16**].  Pharm recs FK <10 [**2-11**] hyperk+.
[**Last Name (un) **] recs: decr pm SS [**2-11**] d/c'ing TFs.
[**3-28**]: Start florinef.
[**3-31**]: s/p fall - pelvic x-ray no evidence of fracture
[**4-3**]: VQ scan - no evidence of PE.

The patient is being discharged on POD 26 to an acute rehab
center.  He should continue to have regular blood draws to
monitor both his chemistries and his tacrolimus levels.  His
magnesium has consistently needed repletion and most likely will
continue to need repletion.  His potassium is now improved, but
should be checked, along with his creatinine, in case of
recurrence of ATN and subsequent hyperkalemia.  The patient is
ambulating with the assistance of a walker, and tolerating a
regular diet.




Medications on Admission:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID
4. Ferrous Sulfate 325 (65) mg One (1) Tablet PO DAILY
5. Phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY
6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a

7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
10. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
12. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO BID
13. Epoetin Alfa 3,000 unit/mL Solution Sig: 3000 (3000) U
Injection QMOWEFR (Monday -Wednesday-Friday).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U

Injection TID (3 times a day): while patient immobile.
15. INSULIN
Please continue lantus at 14 U nightly as well as sliding scale

insulin per the attached regimen.


Discharge Medications:
1. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO once a day: 17.5mg
qd x 10 days then follow taper.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
4. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
5. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Sodium Chloride 0.9%  Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift


Discharge Disposition:
Extended Care

Discharge Diagnosis:
s/p combined liver and kidney transplant [**2180-3-8**]
ESLD
HIT +
ESRD/ESLD
DM
Anemia
Malnutrition
Encephalopathy
Polyuria with dehyration
neuropathy


Discharge Condition:
good


Discharge Instructions:
Call Transplant office [**Telephone/Fax (1) 673**] if fevers, chills, nausea,
vomiting, inability to take medications, abdominal pain,
incision redness/bleeding/drainage, jaundice, or any questions.
Labs every Monday & Thursday for cbc, chem10, lfts, and trough
prograf level. Fax to [**Telephone/Fax (1) 697**] attn: [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], RN

Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2180-3-30**] 9:00
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2180-4-6**] 10:00
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2180-4-13**] 9:20





Name:  [**Known lastname 2706**],[**Known firstname **] W                   Unit No:   [**Numeric Identifier 6966**]

Admission Date:  [**2180-2-11**]              Discharge Date:   [**2180-4-7**]

Date of Birth:  [**2119-2-13**]             Sex:   M

Service: SURGERY

Allergies:
Iodine / Heparin Agents

Attending:[**First Name3 (LF) 2648**]
Addendum:
The patient experienced a drop in oxygen saturation when
ambulating with physical therapy and was kept in-house for
further work-up.  As both his CXR and VQ scan were normal, a
pulmonary embolus was less likely to be the cause and a cardiac
etiology was pursued.  Results are as follows:

The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is unusually
small. Right ventricular systolic function is normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.

Compared with the prior study (images reviewed) of [**2180-1-28**],
biventricular cavity size is now smaller consistent with volume
depletion.
Seen by Pulmonology on [**2180-4-5**] for evaluation of Oxygen
desaturation with activity. Consistent with pulmonary
hypertension, or may be hepatopulmonary shunt. Patient will be
followed up by pulmonary, appointment has been made.

Discharge Disposition:
Extended Care

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

Completed by:[**2180-4-7**]
{'Acute and subacute necrosis of liver,Alcoholic cirrhosis of liver,Hepatorenal syndrome,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Hyperpotassemia,Acute kidney failure with lesion of tubular necrosis,Unspecified protein-calorie malnutrition,Pressure ulcer, lower back,Other and unspecified alcohol dependence, in remission,Unspecified essential hypertension,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pain in limb,Long-term (current) use of insulin,Anticoagulants causing adverse effects in therapeutic use,Abnormal involuntary movements,Polyuria,Unspecified hereditary and idiopathic peripheral neuropathy'}


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: admitted from rehab with worsening renal failure

PRESENT ILLNESS: 60 y.o. M with diabetes, EtOH-induced cirrhosis, portal
hypertension with esophageal varices, listed for combined
liver-kidney transplant, encephalopathic at baseline, most
recently admitted [**Date range (1) 38382**] for edema, now re-admitted from
[**Hospital **] clinic with worsening renal failure in the setting of
continuing diuresis with 80 PO lasix and 25 PO spironolactone
daily. Per progress note, patient also had labile blood sugars,
and has developed C Diff colitis being treated with PO
vancomycin.
.
On interview, patient says he is very tired. He says he has been
feeling better after discharge until about 6 days ago when he
developed severe diarrhea. He says he has been sleeping poorly
because of multiple night time stools. He also reports that
while he initially felt that the swelling in his legs and
abdomen was improving, that over the past few days he feels like
his abdominal swelling has returned. Denies SOB, abd pain, or
fevers. His previous L-sided leg pain of unknown etiology has
improved. He got up for a brief walk with PT x 1, and has
otherwise been bedbound.

MEDICAL HISTORY: -alcoholic cirrhosis
-diabetes
-hypertension
-mild pulmonary artery hypertension
-CRI (Baseline Cr. 2.0 up to 2.4)
-vitamin B12 deficiency
-rectal adenoma
-herniated lumbar disk
-gastritis
-hyperkalemia

MEDICATION ON ADMISSION: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Iodine / Heparin Agents

PHYSICAL EXAM: VS: 96.2 110/62 92 16 94% on RA
General: elderly man in NAD, lying in bed, appears sleepy but
easy to arouse, speaking in full sentences
HEENT: EOMI, MMM, OP clear, sclera slightly icteric
Heart: RRR, 2/6 systolic murmur heard throughout the precordium

FAMILY HISTORY: -F: Committed suicide at age 34
-M: Colon CA, doing well

SOCIAL HISTORY: - Pt lives at [**Hospital 38380**] rehab, previously lived alone at [**Location (un) **]
with the support of his sons. [**Name (NI) **] has 9 siblings. Previous
occupation was working in Maintenance at a school. He has had
occupational exposure to benzene working on ships.
- Quit smoking Tob 16years ago, smoked 2ppd x 25years.
- Denies current ETOH use x11 years, used to drink 1pint ETOH
daily x25years, started drinking at age 12. 

### Response:
{'Acute and subacute necrosis of liver,Alcoholic cirrhosis of liver,Hepatorenal syndrome,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Hyperpotassemia,Acute kidney failure with lesion of tubular necrosis,Unspecified protein-calorie malnutrition,Pressure ulcer, lower back,Other and unspecified alcohol dependence, in remission,Unspecified essential hypertension,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pain in limb,Long-term (current) use of insulin,Anticoagulants causing adverse effects in therapeutic use,Abnormal involuntary movements,Polyuria,Unspecified hereditary and idiopathic peripheral neuropathy'}
