CHIEF COMPLAINT: right-sided hepatic hydrothorax
Hepatitis C
HIV

PRESENT ILLNESS: 43 year old woman with hepatitis C cirrhosis (complicated by
ascites, encephalopathy, portal hypertensive gastropathy, grade
1 varices, hepatic hydrothorax, elevated AFP without focal liver
lesions) and HIV who presents with increased shortness of breath
.
She has recently experienced increasingly rapid reaccumulation
of her hepatic hydrothorax, requiring 3 weekly thoracenteses
since [**2179-5-23**]. She was admitted to [**Hospital 794**] Hospital
yesterday with SOB and increased O2 requirement. They did a 2
liter thoracentesis and admitted her because her Cr was up to
1.5 from 1.0, K 5.9 and her WBC is up to 20 from 7.8. She
received IVF and albumin for ARF but this continued to worsen
and her Cr was 1.9 prior to transfer. In term of her presumed
infection they are unsure of the source and unfortunately they
didnt send the fluid from the [**Female First Name (un) 576**] for cell count or culture
but did a paracentesis to evaluate for SBP. She was given
ciprofloxacin IV initially but this was later broadened to
cefotaxime and vancomycin.
.
On arrival to the floor, she states she is feeling well but is
still having baseline mild abdominal pain.
.
ROS: (+) baseline abdominal pain. Nausea, vomiting at OSH in the
setting of narcotic medications.
Denies fever, chills, headache, sore throat, cough, shortness of
breath, chest pain, dysuria, hematuria.

MEDICAL HISTORY: Hepatic hydrothorax
HIV: (CD4 303, VL ND [**2179-4-28**])
- diagnosed [**2157**], presumed from IVDU versus sexual transmission

MEDICATION ON ADMISSION: Ciprofloxacin 250mg qday (SBP ppx)
Lactulose 30ml tid
Raltegravir 400mg [**Hospital1 **]
Clotrimazole 10mg qid
Ascorbic Acid 1000mg qhs
Spironolactone 100mg daily
Furosemide 40mg daily
Tolvaptan 30mg daily
Emtricitabine-Tenofovir 200-300 mg daily
Caltrate-600 Plus Vitamin D3 600-400 mg-unit [**Hospital1 **]

ALLERGIES: ATRIPLA / Morphine / Percocet

PHYSICAL EXAM: VS - Temp 97.9F, BP 108/66, HR 88, R 18, O2-sat 100% RA
GENERAL - Well-appearing woman in NAD, comfortable, appropriate,
AO x3
HEENT - EOMI, sclerae mildly icteric, MMM, OP clear
NECK - Soft, supple, LAD
LUNGS - CTA on left, decreased BS [**11-21**] of the way up on right, no
wheezing/rales, respirations unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, TTP RUQ, mild ascites with palpable fluid
wave, no masses, no rebound/guarding
EXTREMITIES - WWP, 2+ edema up to knees bilaterally, +DP/PT
pulses,
SKIN - no rashes or lesions, spider angiomas across upper chest

FAMILY HISTORY: Mother alive & well but suffers from high blood pressure and
hyperlipidemia. Father died in [**2173**] from Parkinson's disease and
had h/o MI.

SOCIAL HISTORY: The patient lives with her mother and does not work due to
disability. She has a 20 year old daughter. She very
occasionally used to smoke tobacco and last smoked two years
ago. The patient reported that she stopped consuming alcohol ~3
years ago. History of other substance use includes IVDU (stopped
[**2156**]), cocaine and mushrooms, no current use.
Acute hepatitis C with hepatic coma,Hepatorenal syndrome,Septicemia due to gram-negative organism, unspecified,Peritonitis (acute) generalized,Acute kidney failure with lesion of tubular necrosis,Acute edema of lung, unspecified,Pneumonia, organism unspecified,Acute gastrojejunal ulcer with hemorrhage, without mention of obstruction,Acute and subacute necrosis of liver,End stage renal disease,Complications of transplanted liver,Other specified forms of effusion, except tuberculous,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other ascites,Acquired coagulation factor deficiency,Hematoma complicating a procedure,Acute graft-versus-host disease,Jaundice, unspecified, not of newborn,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Cachexia,Delirium due to conditions classified elsewhere,Candidiasis of mouth,Other and unspecified infection due to central venous catheter,Cirrhosis of liver without mention of alcohol,Asymptomatic human immunodeficiency virus [HIV] infection status,Opioid type dependence, in remission,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Urinary complications, not elsewhere classified,Other convulsions,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Hpt C acute w hepat Coma,Hepatorenal syndrome,Gram-neg septicemia NOS,Peritonitis (acute) gen,Ac kidny fail, tubr necr,Acute lung edema NOS,Pneumonia, organism NOS,Ac marginal ulcer w hem,Acute necrosis of liver,End stage renal disease,Compl liver transplant,Effusion NEC exc tb,Esoph varice oth dis NOS,Hyp kid NOS w cr kid V,Ascites NEC,Acq coagul factor defic,Hematoma complic proc,Ac graft-versus-host dis,Jaundice NOS,Protein-cal malnutr NOS,Urin tract infection NOS,Cachexia,Delirium d/t other cond,Thrush,Oth/uns inf-cen ven cath,Cirrhosis of liver NOS,Asymp hiv infectn status,Opioid dependence-remiss,Abn react-org transplant,Surg compl-urinary tract,Convulsions NEC,Oth gram negatv bacteria,Abn react-procedure NEC
Admission Date:  [**2179-7-28**]              Discharge Date:   [**2179-11-24**]

Date of Birth:  [**2136-1-30**]             Sex:   F

Service: SURGERY

Allergies:
ATRIPLA / Morphine / Percocet

Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
right-sided hepatic hydrothorax
Hepatitis C
HIV

Major Surgical or Invasive Procedure:
[**2179-8-17**]: liver transplant
[**2179-9-29**]: Combined liver and kidney ransplant
[**2179-10-6**]: transplant kidney biopsy
tunnelled HD line (now removed)
picc line
nasointestinal tube placement (multiple reinsertions)
Paracentesis
Thoracentesis
[**2179-11-4**]: percutaneous liver biopsy
ureteral stent removal [**2179-11-6**]
[**2179-11-18**]: Transjugular liver biopsy

History of Present Illness:
43 year old woman with hepatitis C cirrhosis (complicated by
ascites, encephalopathy, portal hypertensive gastropathy, grade
1 varices, hepatic hydrothorax, elevated AFP without focal liver
lesions) and HIV who presents with increased shortness of breath
.
She has recently experienced increasingly rapid reaccumulation
of her hepatic hydrothorax, requiring 3 weekly thoracenteses
since [**2179-5-23**]. She was admitted to [**Hospital 794**] Hospital
yesterday with SOB and increased O2 requirement. They did a 2
liter thoracentesis and admitted her because her Cr was up to
1.5 from 1.0, K 5.9 and her WBC is up to 20 from 7.8. She
received IVF and albumin for ARF but this continued to worsen
and her Cr was 1.9 prior to transfer. In term of her presumed
infection they are unsure of the source and unfortunately they
didnt send the fluid from the [**Female First Name (un) 576**] for cell count or culture
but did a paracentesis to evaluate for SBP. She was given
ciprofloxacin IV initially but this was later broadened to
cefotaxime and vancomycin.
.
On arrival to the floor, she states she is feeling well but is
still having baseline mild abdominal pain.
.
ROS: (+) baseline abdominal pain. Nausea, vomiting at OSH in the
setting of narcotic medications.
Denies fever, chills, headache, sore throat, cough, shortness of
breath, chest pain, dysuria, hematuria.


Past Medical History:
Hepatic hydrothorax
HIV: (CD4 303, VL ND [**2179-4-28**])
- diagnosed [**2157**], presumed from IVDU versus sexual transmission

from husband, who was long-term IV drug user
Hepatitis C cirrhosis
- diagnosed [**2176**]
- complicated by ascites, encephalopathy, portal hypertensive
gastropathy, grade 1 varices, hepatic hydrothorax, elevated AFP
without focal liver lesions
h/o necrotizing fascitis [**2163**] (complication of dog bite)
Pulmonary nodule, noted [**3-/2178**], 0.7cm
PSH:
- Liver transplant [**2179-8-17**]
- Liver/kidney transplant [**2179-9-29**].
- [**2179-10-7**] Exploratory retroperitoneal exploration
and revision ureteral anastomosis, evacuation of hematoma,
removal of packing.


Social History:
The patient lives with her mother and does not work due to
disability. She has a 20 year old daughter. She very
occasionally used to smoke tobacco and last smoked two years
ago. The patient reported that she stopped consuming alcohol ~3
years ago. History of other substance use includes IVDU (stopped
[**2156**]), cocaine and mushrooms, no current use.


Family History:
Mother alive & well but suffers from high blood pressure and
hyperlipidemia. Father died in [**2173**] from Parkinson's disease and
had h/o MI.

Physical Exam:
VS - Temp 97.9F, BP 108/66, HR 88, R 18, O2-sat 100% RA
GENERAL - Well-appearing woman in NAD, comfortable, appropriate,
AO x3
HEENT - EOMI, sclerae mildly icteric, MMM, OP clear
NECK - Soft, supple, LAD
LUNGS - CTA on left, decreased BS [**11-21**] of the way up on right, no
wheezing/rales, respirations unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, TTP RUQ, mild ascites with palpable fluid
wave, no masses, no rebound/guarding
EXTREMITIES - WWP, 2+ edema up to knees bilaterally, +DP/PT
pulses,
SKIN - no rashes or lesions, spider angiomas across upper chest

NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength
grossly intact, no asterixis
.


Pertinent Results:
On Admission: [**2179-7-28**]
WBC-13.9*# RBC-2.29* Hgb-8.2* Hct-26.1* MCV-114* MCH-35.6*
MCHC-31.3 RDW-18.1* Plt Ct-55*
PT-22.8* PTT-48.0* INR(PT)-2.1*
Glucose-85 UreaN-42* Creat-1.6* Na-126* K-4.0 Cl-99 HCO3-20*
AnGap-11
ALT-69* AST-125* LD(LDH)-268* AlkPhos-154* TotBili-9.1*
Albumin-2.7* Calcium-7.6* Phos-3.0 Mg-2.3
At time of liver transplant: [**2179-8-17**]
PT-31.4* PTT-76.1* INR(PT)-3.4*
Glucose-318* UreaN-39* Creat-1.9*# Na-143 K-3.9 Cl-103 HCO3-19*
AnGap-25*
ALT-463* AST-896* CK(CPK)-217* AlkPhos-44 Amylase-59
TotBili-5.4*
DirBili-2.1* IndBili-3.3
At time of combined liver/kidney transplant [**2179-9-29**]
Glucose-75 UreaN-43* Creat-1.5* Na-136 K-4.8 Cl-99 HCO3-26
AnGap-16
ALT-162* AST-268* AlkPhos-1156* TotBili-20.9*
HBsAg-NEGATIVE HBcAb-NEGATIVE HBsAb-POSITIVE
At time of discharge to rehab: [**2179-11-24**]
WBC-4.7 RBC-3.73*# Hgb-11.1*# Hct-33.5*# MCV-90# MCH-29.8
MCHC-33.2 RDW-26.4* Plt Ct-338
PT-15.0* PTT-42.8* INR(PT)-1.3*
Glucose-114* UreaN-47* Creat-0.9 Na-133 K-3.9 Cl-99 HCO3-23
AnGap-15
ALT-34 AST-77* AlkPhos-1104* TotBili-17.2*
Albumin-2.3* Calcium-7.9* Phos-4.6* Mg-1.8
Cyclspr-214

Brief Hospital Course:
43F with history of Hep C cirrhosis (complicated by ascites,
encephalopathy, portal hypertensive gastropathy, grade 1
varices, hepatic hydrothorax, elevated AFP) and HIV (CD4 303 in
early [**2179-4-20**])who transferred from [**Hospital 794**] Hospital with SOB
[**12-22**] recurrent hepatic hydrothorax, ARF, and leukocytosis [**12-22**] to
now known SBP. She requiring weekly or biweekly thoracenteses
since [**Month (only) 205**]. MELD score in 40s-50s and awaiting transplant.

She was admitted to the medicine service s/p thoracentesis at
the OSH, and was not in respiratory distress on arrival.
Diagnostic paracentesis was done and showed SBP, requiring 5-day
treatment course with Ceftriaxone.  Due to increasing
respiratory distress, a thoracentesis was done for 3.3L on [**7-29**],
transudative fluid on analysis.  Her post-[**Female First Name (un) 576**] course was
complicated by re-expansion pulmonary edema and tachypnea,
requiring transfer to the SICU for a day.  Repeat CXRs from that
point showed only bilateral effusions without recurrence of the
hydrothorax.  There was a question of new consolidation on the
post-ICU CXR and an 8-day treatment for hospital-acquired
pneumonia was started with Cefepime/Flagyl/Vancomycin.  As her
liver function began to decline precipitously, the decision was
made to leave her antibiotics on-board to prevent any infections
that may prevent her from undergoing surgery while waiting for a
transplant to arrive.

She experienced ARF likely secondary to hepatorenal syndrome.
MELD steadily increased, to a peak of >50. HAART was
discontinued due to worsening renal function. Dialysis was
started.  Nutritional status was poor. Anemia was treated with
transfusions every few days.

On [**2179-8-16**] an ECD liver donor was available and she underwent
liver transplant with Roux-en-Y hepaticojejunostomy.  Intra-op
course was complicated by hypothermia ([**12-22**] to CVVH), persistent
coagulopathy, prolonged time to HA reperfusion (90 min), delayed
graft function. Over the first 24 hours post-op, she continued
to be coagulopathic with a falling hematocrit along with rising
LFTs (1550/[**2168**], TB 10.9). Liver duplex was normal.

On [**2179-8-18**] she required exploration, hematoma evacuation. Liver
appeared hyperemic but viable with good pulse in the hepatic
artery. Hepaticojej was intact. LFTs continued to rise
(2800/3000, TB 17) and lactate remained elevated. She was
relisted for primary graft non-function on postop day 2.

By POD 6 she was extubated. LFTs were steadily improving
(ALT/AST 170/664, TB13.5) therefore she was delisted from the
transplant list. TBili began to rise from POD 7 reaching 60.8 by
POD 12. Liver duplex demonstrated parvus tardus arterial
waveforms which later resolved.

WBC rose to 17. Blood cultures were sent. On [**8-24**], blood
cultures were positive for enterococcus faecalis vanco
sensitive. Daptomycin and Zosyn were started and continued for
16 days. Rectal swab also isolated VRE.  Zosyn was stopped after
~ 6 days subsequent blood cultures were negative.

On POD [**8-30**]: hematocrit and platelets fell precipitously. This
was thought to be passenger leukocyte syndrome, treated with
transfusion of ABO-O PRBCs and ABO-B plasma, platelets,
Rituxamab,and switch to cyclosporin from prograf for possible
HUS.

Liver bx (POD 12)showed prominent ballooning degeneration with
moderate to severe cholestasis, cholangiolar proliferation and
associated mixed inflammation most suggestive of a severe
preservation/reperfusion injury. At this time, she was
relisted for liver transplant (MELD 52) as well as a kidney
transplant.

She experienced an UGIB on POD 20 secondary to bleeding ulcer at
J-J anastomosis. This was clipped endoscopically and  6 units of
PRBCs were given over the next 2 days. She rebled on POD 25. The
ulcer was unable to be re-clipped endoscopically. Only 1U of
PRBCs was needed.

She steadily improved and was transferred out of the SICU after
29 days. T bili decreased slowly and plateaued at 20. She
remained relatively stable while awaiting re-transplant while
dialysis dependent.

On [**2179-9-29**], liver/kidney donor became available. She underwent
standard criteria liver transplant with RNY hepaticojejunostomy
with iliac artery supraceliac conduit to the donor common
hepatic artery ?????? uneventful intra-op course. She also received a
cadaveric renal transplant. Of note, pre-transplant, T and
B-cell crossmatches were positive. After the liver was
re-perfused for approximately 1 hour. Repeat crossmatch
demonstrated a negative T-cell crossmatch and a positive B-cell
crossmatch

Post-operatively, liver began functioning immediately but the
kidney wasn't functioning. The crossmatch was repeated, and
initially unclear, but ultimately determined to be negative. No
ATG was given as she was felt to be too sick at baseline. She
was extubated on [**9-30**] and continued on CVVH. She transferred
out of the SICU.

On [**10-4**], she seized and transferred back to the SICU. Head CT
showed new bifrontal white matter hypodensities with no
significant mass effect. Neurology was consulted and Keppra
started. Recs were to obtain a head MRI. This was done
demonstrating multiple subcortical white matter lesions in both
cerebral hemispheres showing fast diffusion. Differentials
considered were post-transplant lymphoproliferative disorder,
infection, and posterior reversible encephalopathy syndrome.

On [**10-5**], HCT dropped from 30 to 22 after renal bx for delayed
graft function (DGF).
She developed R flank pain with increasing abdominal distension.
CT of abdomen showed massive 28 x 17 x 15-cm right
retroperitoneal heterogeneous hematoma, extending from the right
liver tip inferiorly to the right pelvis; appeared to surround
the transplanted right kidney and displaces the native right
kidney medially. She was taken emergently to the OR by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] who performed retroperitoneal exploration and evacuation
of hematoma. Upon entering the retroperitoneum, a massive amount
of old and fresh blood was encountered. The kidney looked
marginally viable and dusky and soft. The retroperitoneum was
packed with laparotomy sponges and she was temporarily closured.
She transferred to the SICU for correction of the coagulopathy
with 8U PRBCs overnight along with appropriate factors.

On [**10-6**], she returned to the OR for retroperitoneal exploration
with revision of ureteral anastamosis.  A massive amount of
fresh blood & clot was evacuated. Upon exposure of the operative
field, the ureter was noted to be dilated. Ureterotomy was made
and with difficulty, a ureteral stent was advanced across the UV
anastomosis; ureterotomy closed. Ureter detached from it??????s
anastomosis to the peritoneum and was then anastomosed to the
bladder over a double-J stent. Retroperitoneum was packed and
hemostasis achieved. Drains were placed and retroperitoneum
closed.

She was extubated 2 days later. Urine output was brisk.
Creatinine decreased. Dialysis was stopped.

Remainder of hospital course by systems:
Neuro:
??????Extensive work-up negative including CSF for JCV, HSV, EBV,
Cryptococcal Ag, HIV VL, bacterial/viral/fungal cx, cytology
??????Negative serum Aspergillus Ag, Cryptococal Ag, Toxo, RPR
??????Ultrasensitive JCV PCR (Dr. [**Last Name (STitle) 2340**]??????s lab) negative
??????Ddx: PML vs CI-related leukoencepholpathy
??????Fk switched to [**Last Name (un) **] and MMF lowered to 250 daily 2 days after
seizure
??????Repeat MRI [**2179-10-16**] (11 days after seizure): decrease in the R
frontal lesion; resolution of the hyperintense signal in the
previously noted lesions
??????No further seizures; maintained on Keppra
??????Brain bx put on hold given improvement brain lesions.
??????Repeatimaging held given ARF
??????Non-con MRI [**2179-11-11**] (POD 43): continued improvement in frontal
lesion; all others resolved (c/w PRES)

GI:
??????AP/TB steadily rose to 450/19 by POD 15
??????Duplex ([**10-11**]): dramatic change in echotexture with radiating
echogenic bands distributed along portal pathways concerning for
vascular compromise
??????CTA ([**10-11**]): short segment HA stricture
??????Angio ([**10-12**], POD 16): focal narrowing in the HA just distal to
the GDA stump; successful stenting
??????AP (1500) continued to rise despite ursodiol, TB fell
??????Bx ([**10-17**], POD 21): Mild portal mixed inflammation with occ
lobular apoptotic hepatocytes c/w early recurrent Hep C without
increased fibrosis, foci of bile duct damage
??????Tube cholangiogram: patent anastomosis but failed to visualize
the L ducts
??????MRCP ([**11-1**], POD 26): no biliary dilatation
??????Liver bx ([**11-3**], POD 28) ?????? AP/TB 1700/7: scattered lobular
apoptotic hepatocytes and associated minimal lobular mononuclear
inflammation c/w with recurrent Hep C; no increase in fibrosis;
interval resolution of portal inflammation and bile duct damage
??????Duplex ([**11-13**], POD 47): Parvus tardus wave forms
??????Tube Cholangiogram ([**11-14**], POD 48): patent but attenuated
intrahepatic ducts
??????Angio ([**11-15**], POD 49):patent stent.
.Continued ASA/plavix

GU:
??????Following revision of ureteral anastomosis, kidney began
working and HD was held
??????Foley was ultimately removed and I/O??????s NR [**12-22**] to incontinence;
followed weights
??????[**2179-10-24**] (POD 25/18): Cr rose to 1.6 (from baseline 0.9-1)
??????Vanco 30, [**Last Name (un) 1380**] 20
??????Foley placed, oliguric
??????Cr 2.0 on POD 27/20
??????HD [**10-28**] - [**11-6**] intermittent
??????Renal bx [**2179-10-28**] (POD 29/22): widespread interstitial edema and
mild diffuse interstitial fibrosis and tubular atrophy; ATN
??????Kidney function improved over the following 3 weeks and HD was
held
-Ureteral stent found to be out of position and in bladder,
removed by urology

ID:
??????[**10-11**] Bactermia: VSE
??????[**10-11**] UTI: Enterobacter ([**Last Name (un) **] Amikacin, Cefepime, [**Last Name (un) **],
Nitrofurantoin)
??????[**10-27**] RP Swab (from re-exploration): VSE
??????[**11-8**] UTI: Resistant Enterobacter ([**Last Name (un) **] to only Amikacin &
[**Last Name (un) **])
-Last day of antibiotics [**2179-11-22**]


Medications on Admission:
Ciprofloxacin 250mg qday (SBP ppx)
Lactulose 30ml tid
Raltegravir 400mg [**Hospital1 **]
Clotrimazole 10mg qid
Ascorbic Acid 1000mg qhs
Spironolactone 100mg daily
Furosemide 40mg daily
Tolvaptan 30mg daily
Emtricitabine-Tenofovir 200-300 mg daily
Caltrate-600 Plus Vitamin D3 600-400 mg-unit [**Hospital1 **]

Discharge Medications:
1. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. epoetin alfa 4,000 unit/mL Solution Sig: One (1) ml Injection
MWF (Monday-Wednesday-Friday).
3. benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID
(4 times a day) as needed for tooth pain.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: no more than 2 grams per day.
5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO QHS (once a day (at bedtime)) as needed for anxiety.

9. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): check TSH in 5 weeks.
10. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): frontal brain lesion.
12. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for sbp <110 or HR <60.
14. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO Q72H (every 72 hours): last [**2179-11-22**].
15. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
17. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): see taper schedule.
18. cyclosporine modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours): (Neoral)
trough level every Monday and Thursday am.
19. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hepatic artery stent.
20. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): hepatic artery stent.
21. hydromorphone 2 mg Tablet Sig: 0.25-0.5 Tablet PO Q6H (every
6 hours) as needed for pain.
22. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Two (2) ml
Injection Q8H (every 8 hours) as needed for nausea.
23. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
24. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-21**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
25. insulin lispro 100 unit/mL Solution Sig: follow printed
sliding scale  Subcutaneous ASDIR (AS DIRECTED).
26. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
27. dextrose 50% in water (D50W)     Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.

28. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
HIV
Spontaneous bacterial peritonitis
Hepatorenal syndrome
Recurrent hepatic hydrothorax
Liver transplant, failure with re-transplant of Liver with roux
en y HJ/kidney
recurrent Hepatitis C cirrhosis
hematoma
ureteral anastomosis breakdown
UTI, enterobacter cloacae
malnutrition
hypothyroid
depression
incision wound
brain lesions, likely calcineurin inhibitor effect vs PML


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Fall risk


Discharge Instructions:
You will transfer to [**Hospital 100**] Rehab
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you experience
any of the following: fever, chills, nausea, vomiting, inability
to take any of your medications, feeding tube clogs, increased
jaundice, increased abdominal distension, incision redness/wound
drainage, decreased urine output, weight gain of 3 pounds in a
day
You will have labs drawn every Monday and Thursday with results
to [**Hospital1 18**] Transplant Office [**Telephone/Fax (1) 673**]


Followup Instructions:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] MD, [**Telephone/Fax (1) 673**], [**Hospital **] Medical Office Building [**First Name8 (NamePattern2) 10357**] [**Location (un) 86**]; Date/Time Monday [**2179-11-29**] @ 9:30 AM.



Completed by:[**2179-11-24**]
{'Acute hepatitis C with hepatic coma,Hepatorenal syndrome,Septicemia due to gram-negative organism, unspecified,Peritonitis (acute) generalized,Acute kidney failure with lesion of tubular necrosis,Acute edema of lung, unspecified,Pneumonia, organism unspecified,Acute gastrojejunal ulcer with hemorrhage, without mention of obstruction,Acute and subacute necrosis of liver,End stage renal disease,Complications of transplanted liver,Other specified forms of effusion, except tuberculous,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other ascites,Acquired coagulation factor deficiency,Hematoma complicating a procedure,Acute graft-versus-host disease,Jaundice, unspecified, not of newborn,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Cachexia,Delirium due to conditions classified elsewhere,Candidiasis of mouth,Other and unspecified infection due to central venous catheter,Cirrhosis of liver without mention of alcohol,Asymptomatic human immunodeficiency virus [HIV] infection status,Opioid type dependence, in remission,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Urinary complications, not elsewhere classified,Other convulsions,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: right-sided hepatic hydrothorax
Hepatitis C
HIV

PRESENT ILLNESS: 43 year old woman with hepatitis C cirrhosis (complicated by
ascites, encephalopathy, portal hypertensive gastropathy, grade
1 varices, hepatic hydrothorax, elevated AFP without focal liver
lesions) and HIV who presents with increased shortness of breath
.
She has recently experienced increasingly rapid reaccumulation
of her hepatic hydrothorax, requiring 3 weekly thoracenteses
since [**2179-5-23**]. She was admitted to [**Hospital 794**] Hospital
yesterday with SOB and increased O2 requirement. They did a 2
liter thoracentesis and admitted her because her Cr was up to
1.5 from 1.0, K 5.9 and her WBC is up to 20 from 7.8. She
received IVF and albumin for ARF but this continued to worsen
and her Cr was 1.9 prior to transfer. In term of her presumed
infection they are unsure of the source and unfortunately they
didnt send the fluid from the [**Female First Name (un) 576**] for cell count or culture
but did a paracentesis to evaluate for SBP. She was given
ciprofloxacin IV initially but this was later broadened to
cefotaxime and vancomycin.
.
On arrival to the floor, she states she is feeling well but is
still having baseline mild abdominal pain.
.
ROS: (+) baseline abdominal pain. Nausea, vomiting at OSH in the
setting of narcotic medications.
Denies fever, chills, headache, sore throat, cough, shortness of
breath, chest pain, dysuria, hematuria.

MEDICAL HISTORY: Hepatic hydrothorax
HIV: (CD4 303, VL ND [**2179-4-28**])
- diagnosed [**2157**], presumed from IVDU versus sexual transmission

MEDICATION ON ADMISSION: Ciprofloxacin 250mg qday (SBP ppx)
Lactulose 30ml tid
Raltegravir 400mg [**Hospital1 **]
Clotrimazole 10mg qid
Ascorbic Acid 1000mg qhs
Spironolactone 100mg daily
Furosemide 40mg daily
Tolvaptan 30mg daily
Emtricitabine-Tenofovir 200-300 mg daily
Caltrate-600 Plus Vitamin D3 600-400 mg-unit [**Hospital1 **]

ALLERGIES: ATRIPLA / Morphine / Percocet

PHYSICAL EXAM: VS - Temp 97.9F, BP 108/66, HR 88, R 18, O2-sat 100% RA
GENERAL - Well-appearing woman in NAD, comfortable, appropriate,
AO x3
HEENT - EOMI, sclerae mildly icteric, MMM, OP clear
NECK - Soft, supple, LAD
LUNGS - CTA on left, decreased BS [**11-21**] of the way up on right, no
wheezing/rales, respirations unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, TTP RUQ, mild ascites with palpable fluid
wave, no masses, no rebound/guarding
EXTREMITIES - WWP, 2+ edema up to knees bilaterally, +DP/PT
pulses,
SKIN - no rashes or lesions, spider angiomas across upper chest

FAMILY HISTORY: Mother alive & well but suffers from high blood pressure and
hyperlipidemia. Father died in [**2173**] from Parkinson's disease and
had h/o MI.

SOCIAL HISTORY: The patient lives with her mother and does not work due to
disability. She has a 20 year old daughter. She very
occasionally used to smoke tobacco and last smoked two years
ago. The patient reported that she stopped consuming alcohol ~3
years ago. History of other substance use includes IVDU (stopped
[**2156**]), cocaine and mushrooms, no current use. 

### Response:
{'Acute hepatitis C with hepatic coma,Hepatorenal syndrome,Septicemia due to gram-negative organism, unspecified,Peritonitis (acute) generalized,Acute kidney failure with lesion of tubular necrosis,Acute edema of lung, unspecified,Pneumonia, organism unspecified,Acute gastrojejunal ulcer with hemorrhage, without mention of obstruction,Acute and subacute necrosis of liver,End stage renal disease,Complications of transplanted liver,Other specified forms of effusion, except tuberculous,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other ascites,Acquired coagulation factor deficiency,Hematoma complicating a procedure,Acute graft-versus-host disease,Jaundice, unspecified, not of newborn,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Cachexia,Delirium due to conditions classified elsewhere,Candidiasis of mouth,Other and unspecified infection due to central venous catheter,Cirrhosis of liver without mention of alcohol,Asymptomatic human immunodeficiency virus [HIV] infection status,Opioid type dependence, in remission,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Urinary complications, not elsewhere classified,Other convulsions,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
