CHIEF COMPLAINT: Acute liver failure

PRESENT ILLNESS: Ms. [**Known lastname 3761**] is a 52-year-old
female who was transferred to the [**Hospital1 190**] in hyperacute fulminant liver failure thought
to be secondary to either Bactrim reaction versus
acetaminophen toxicity. She was admitted to the medical
intensive care unit initially and became progressively
obtunded, with significant encephalopathy requiring
intubation and ventilatory support. Her liver function was
notable for transaminases with an ALT and AST of 9500 and
17,500 respectively and worsening hyperbilirubinemia. She
became progressively more coagulopathic, and it was thought
that she was most likely going to need orthotopic liver
transplantation for survival. Given the critical nature of
her illness, she was transferred to the transplant surgical
service and to the surgical intensive care unit for further
management. This management initially entailed aggressive
control and monitoring of intracranial pressures in
conjunction with the neurosurgical service. This required
placement of an intracranial bolt and aggressive volume
management with the use of hypertonic saline and mannitol.
She continued to receive aggressive cardiopulmonary support
with again, as noted, full ventilatory support and
vasopressor support for hypotension.

MEDICAL HISTORY: Anorexia Nervosa with multiple psychiatric and medical
admissions
PTSD
OCD
hypercholesterolemia
osteoporosis
Colostomy [**3-3**] constipation likely related to anorexia
GERD with delayed gastric emptying
persistent microhematuria
s/p cystourethrography on [**10-6**]

MEDICATION ON ADMISSION: Medications prior to hospitalization are unable to be confirmed
by pt during this hospitalization.  The pt's records indicate
she was on high doses of SSRI.

ALLERGIES: Bactrim

PHYSICAL EXAM: From MICU:
VS: 101/4 136/76 120 29 98%RA
Gen: lightly jaundiced, feeling generally unwell
HEENT: mild scleral icterus, OP clear, EOMI, Pupils 4 to 3mm
Neck: No JVD, no thyromegaly, no LAD
Cor: RRR no m/r/g, exagerated heart sounds
Pulm: diffuse rhonchi
Abd: ileostomy, +BS, NT
Extrem: 2+ edema,
Skin: some petchiae seen most prominently in distal extremities,
no rash
Neuro: intubated and sedated, tracking with her eyes but not
responding to commands, + asterixis, upgoing toes bilaterally,
5/5 strength

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: -Tob: denies
-EtOH: denies
-Illicits: None
-Living situation: Lives with husband
-Occupation: retired
Acute and subacute necrosis of liver,Hepatic encephalopathy,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Hyposmolality and/or hyponatremia,Iatrogenic cerebrovascular infarction or hemorrhage,Intracerebral hemorrhage,Acute pancreatitis,Aphasia,Pneumonia, organism unspecified,Cerebral edema,Acquired coagulation factor deficiency,Anorexia nervosa,Sulfonamides causing adverse effects in therapeutic use,Aromatic analgesics, not elsewhere classified, causing adverse effects in therapeutic use,Obsessive-compulsive disorders,Depressive disorder, not elsewhere classified,Hypoglycemia, unspecified,Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use,Esophageal reflux,Dyspepsia and other specified disorders of function of stomach,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Pressure ulcer, lower back,Dysphagia, unspecified,Anemia, unspecified,Ileostomy status,Osteoporosis, unspecified,Pure hypercholesterolemia
Acute necrosis of liver,Hepatic encephalopathy,Acute respiratry failure,Ac kidny fail, tubr necr,Hyposmolality,Iatrogen CV infarc/hmrhg,Intracerebral hemorrhage,Acute pancreatitis,Aphasia,Pneumonia, organism NOS,Cerebral edema,Acq coagul factor defic,Anorexia nervosa,Adv eff sulfonamides,Adv eff arom analgsc NEC,Obsessive-compulsive dis,Depressive disorder NEC,Hypoglycemia NOS,Drug dermatitis NOS,Adv eff penicillins,Esophageal reflux,Stomach function dis NEC,Abn react-procedure NEC,Pressure ulcer, low back,Dysphagia NOS,Anemia NOS,Ileostomy status,Osteoporosis NOS,Pure hypercholesterolem
Admission Date: [**2187-10-29**]        Discharge Date:

Date of Birth:  [**2135-10-28**]        Sex:  F

Service:  [**Last Name (un) **]


HISTORY OF PRESENT ILLNESS:  Ms. [**Known lastname 3761**] is a 52-year-old
female who was transferred to the [**Hospital1 190**] in hyperacute fulminant liver failure thought
to be secondary to either Bactrim reaction versus
acetaminophen toxicity. She was admitted to the medical
intensive care unit initially and became progressively
obtunded, with significant encephalopathy requiring
intubation and ventilatory support. Her liver function was
notable for transaminases with an ALT and AST of 9500 and
17,500 respectively and worsening hyperbilirubinemia. She
became progressively more coagulopathic, and it was thought
that she was most likely going to need orthotopic liver
transplantation for survival. Given the critical nature of
her illness, she was transferred to the transplant surgical
service and to the surgical intensive care unit for further
management. This management initially entailed aggressive
control and monitoring of intracranial pressures in
conjunction with the neurosurgical service. This required
placement of an intracranial bolt and aggressive volume
management with the use of hypertonic saline and mannitol.
She continued to receive aggressive cardiopulmonary support
with again, as noted, full ventilatory support and
vasopressor support for hypotension.

COURSE BY SYSTEMS:  Neurologically, as noted above the
patient required placement of an intracranial bolt for ICP
monitoring. Her ICPs had climbed into the high 30s. This was
managed with hyperventilation and usage of mannitol and
hypertonic saline. Over the course of the next 4-5 days as
her liver function improved, her intracranial pressures
decreased. Her sedation and paralytics were weaned. She had
removal of her intracranial bolt on [**2187-11-6**], and it
was noted on subsequent imaging that she had approximately a
4-cm, right frontal, intracranial hemorrhage. This was
followed serially with CT scans and there was no progression
of the bleeding. The bleeding was thought to be secondary to
her severe coagulopathy and thrombocytopenia in the setting
of her instrumentation. She was started on Keppra for seizure
prophylaxis to finish a 10-day course. On [**2187-11-12**],
the patient was extubated and her neurologic exam was notable
for response to voice and opening of her eyes. She was moving
her left upper extremity and her right lower extremity with
2/5 strength and had minimal movement in her right upper
extremity and left lower extremity, not following the
predicted neurologic pattern if this was a deficit associated
with her intracranial bleeding.

In terms of her respiratory status, it is noted that the
patient required full ventilatory support and was extubated
on [**2187-11-12**]. She initially did well, but, secondary
to what was thought to be pulmonary edema, required
reintubation on [**2187-11-13**] after failure of noninvasive
positive pressure ventilation. She had some degree of what
appeared to be an ARDS-type reaction or transfusion-
associated lung injury requiring high amounts of PEEP and
oxygenation during the initial days of her intensive care
unit stay. This resolved over the course of the next several
days with diuresis and supportive therapy.

In terms of her cardiovascular status, the patient initially
had blood pressure support with the use of vasopressors in
order to minimize her intravascular volume which was thought
to exacerbate her cerebral edema. The vasopressors were
weaned by ICU day 6, and there was no further requirement for
this. There were no significant dysrhythmias.

The patient, initially thought to most certainly require
liver transplantation, spontaneously improved in terms of her
liver function over the course of her 2 weeks in the
intensive care unit. This was evidenced by progressive
ability to metabolize her lactate, stabilization of her blood
sugars, and autocorrection of her coagulopathy. By the time
of her transfer, while she continued to have a
hyperbilirubinemia, her transaminases had completely
normalized. A Dobbhoff feeding tube was in place for post-
pyloric tube feedings. The patient's transaminases were
elevated; this was thought to be secondary to a possible mild
ischemic pancreatitis which might have developed during her
requirement for vasopressors. She otherwise did not seem to
be symptomatic for this and was tolerating tube feeds.
Therefore, this was not aggressively pursued.

In terms of her overall fluid status, her baseline weight is
37 kg. On the day of transfer, she weighed about 44 kg. This
volume overload was being managed with hemodialysis daily on
an as-needed basis. The patient's renal function, which had
been quite labile throughout her hospitalization, stabilized,
with creatinine in the 2.9-3.4 range. She makes approximately
500-700 mL of urine per day, but is dialysis-dependent. She
currently receives hemodialysis through a left femoral
hemodialysis catheter.

In terms of her ID issues, the patient was initially started
on vancomycin for prophylaxis against intracranial infection
with the bolt in place. She developed a leukocytosis, and the
thought was that she may have been developing pneumonia given
the persistent difficulty oxygenating her. She was started
empirically on Zosyn. Sputum cultures failed to evidence any
pneumonic process, and these antibiotics were discontinued.

In terms of hematologic issues, the patient developed what
appeared to be a DIC versus TTP picture, for which the
hematology service was following. She evidenced a consumptive
coagulopathy with significant destruction of platelets. Her
thrombocytopenia likely contributed to her intracranial
bleeding. The patient required special HLA-typed platelet
transfusions in order to maintain a platelet count above
100,000. She also developed a significant anemia without any
evidence of bleeding. This was thought to be secondary to
hemolysis in the face of an elevated indirect bilirubin and a
depressed haptoglobin. Her thrombocytopenia and anemia
resolved by [**11-11**], and she no longer
required any transfusion of any blood products.

At the present time, the patient is requiring intensive care
for management of respiratory failure and renal failure. She
is no longer in need of liver transplantation, and therefore,
given her primary medical issues, she will be transferred to
the medical intensive care unit. At the time of transfer, the
patient is receiving the following medications: Protonix 40
mg p.o. once daily; insulin sliding scale; fentanyl as
needed; heparin 5000 units subcu t.i.d.; Keppra 500 mg IV
q.12 hours.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 3762**]

Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D:  [**2187-11-13**] 18:23:57
T:  [**2187-11-13**] 19:19:38
Job#:  [**Job Number 3764**]


Admission Date:  [**2187-10-29**]              Discharge Date:   [**2187-11-23**]

Date of Birth:  [**2135-10-28**]             Sex:   F

Service: MEDICINE

Allergies:
Bactrim

Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Acute liver failure

Major Surgical or Invasive Procedure:
Intubation with extubation on [**2187-11-16**]
Hemodialysis
Intracranial bolt placement [**10-31**] and removal [**2187-11-5**]


History of Present Illness:
Pt is a 52F with OCD (stable recently, but h/o OD, anorexia and
alcohol use in past), ileostomy, GERD with delayed gastric
emptying, who presented to [**Hospital3 3765**] on [**10-28**] with nausea
and dizziness. There she was initially dx'd with dehydration,
ARF and UTI but then found to have ALT of 25,370 and of AST
11,490, total bili of 2.0, INR of 4.0, Cr of 3.0. She was
transferred to [**Hospital1 18**].
.
She had been having fevers for ~10 days. On [**10-23**] she went to her
PCP who diagnosed [**Name Initial (PRE) **] UTI (grew klebsiella) and was taking
Bactrim. She continued to have general malaise and fevers
despite bactrim and asa. On [**10-28**] she called her PCP who
recommended some tylenol. Per husbands report she took 650mg x2
before coming in to the ED on [**10-28**]. There she was initially dx'd
with dehydration, ARF and UTI. She was given home doses of
simvastatin and SSRIs, but then found to have ALT of 25,370 and
of AST 11,490, total bili of 2.0, INR of 4.0, Cr of 3.0. She was
transferred to [**Hospital1 18**]. On presentation initial vs were: 97.5 P89,
112/37 19 99%RA 37kg.
.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.


Past Medical History:
Anorexia Nervosa with multiple psychiatric and medical
admissions
PTSD
OCD
hypercholesterolemia
osteoporosis
Colostomy [**3-3**] constipation likely related to anorexia
GERD with delayed gastric emptying
persistent microhematuria
s/p cystourethrography on [**10-6**]


Social History:
-Tob: denies
-EtOH: denies
-Illicits: None
-Living situation: Lives with husband
-Occupation: retired


Family History:
Non-contributory

Physical Exam:
From MICU:
VS: 101/4 136/76 120 29 98%RA
Gen: lightly jaundiced, feeling generally unwell
HEENT: mild scleral icterus, OP clear, EOMI, Pupils 4 to 3mm
Neck: No JVD, no thyromegaly, no LAD
Cor: RRR no m/r/g, exagerated heart sounds
Pulm: diffuse rhonchi
Abd: ileostomy, +BS, NT
Extrem: 2+ edema,
Skin: some petchiae seen most prominently in distal extremities,
no rash
Neuro: intubated and sedated, tracking with her eyes but not
responding to commands, + asterixis, upgoing toes bilaterally,
5/5 strength


Pertinent Results:
[**2187-11-23**] 04:58AM BLOOD WBC-11.1* RBC-2.58* Hgb-7.8* Hct-22.9*
MCV-89 MCH-30.4 MCHC-34.3 RDW-15.7* Plt Ct-906*
[**2187-11-23**] 04:58AM BLOOD Neuts-70.3* Lymphs-14.2* Monos-3.8
Eos-11.0* Baso-0.7
[**2187-11-23**] 04:58AM BLOOD PT-12.9 PTT-26.7 INR(PT)-1.1
[**2187-11-23**] 04:58AM BLOOD Glucose-108* UreaN-49* Creat-1.5* Na-131*
K-3.2* Cl-107 HCO3-12* AnGap-15
[**2187-11-23**] 04:58AM BLOOD ALT-384* AST-243* LD(LDH)-290*
AlkPhos-439* TotBili-1.5
[**2187-11-23**] 04:58AM BLOOD Lipase-473*
[**2187-11-23**] 04:58AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.7
[**2187-11-13**] 03:14AM BLOOD calTIBC-244* Ferritn-894* TRF-188*
[**2187-10-31**] 07:43AM BLOOD TSH-1.8
[**2187-10-31**] 07:43AM BLOOD Free T4-1.5
[**2187-10-30**] 12:01AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE
.
[**2187-11-14**] TTE: The left atrium is normal in size. Left
ventricular wall thicknesses and cavity size are normal. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Hyperdynamic left ventricular function. Mild mitral
regurgitation.
.
[**2187-11-14**] CT head: IMPRESSION:
1. Widespread ground-glass attenuation likely represents
pulmonary edema as reported on serial chest radiographs, but
superimposed asymmetrical foci of consolidation in the lower
lobes and 2 small nodules raises the concern for coexisting
pulmonary infection.
2. Moderate bilateral pleural effusions and anasarca.
3. Over distention of endotracheal tube cuff.
.
[**2187-11-15**] Liver/Gallbladder US: No evidence of a distended
gallbladder to suggest cholecystitis. However, gallbladder is
not well visualized; likely contracted. No history of
cholecystectomy could be elicited from CareWeb. Dr. [**Last Name (STitle) 3766**] was
paged to discuss these findings at 1:45 p.m.
.
[**2187-11-18**] MRI Head:IMPRESSION:
1. No significant change in the large right frontal
intraparenchymal
hematoma, 3.8x3.4cm subacute in stage with surrounding edema,
peripheral
nodular hyperintense areas and mild mass effect on the frontal
[**Doctor Last Name 534**] of the
right lateral ventricle.
2. No new hemorrhage or acute infarction.
3. Patent major intracranial arteries without focal
flow-limiting stenosis, occlusion, or aneurysm more than 3 mm
within the resolution of MR angiogram.
4. Diminutive right distal vertebral artery, likely related to
hypoplasia or normal variant (effective PICA termination); left
fetal PCA.
5. Moderate amount of fluid in the mastoid air cells on both
sides and small amount in the left side of the sphenoid sinus.

Brief Hospital Course:
Pt is a 52F with OCD (stable recently, but h/o OD, anorexia and
alcohol use in past), ileostomy, GERD with delayed gastric
emptying, who presented to [**Hospital3 3765**] on [**10-28**] with nausea
and dizziness. There she was initially dx'd with dehydration,
ARF and UTI but then found to have ALT of 25,370 and of AST
11,490, total bili of 2.0, INR of 4.0, Cr of 3.0. She was
transferred to [**Hospital1 18**].
.
She had been having fevers for ~10 days. On [**10-23**] she went to her
PCP who diagnosed [**Name Initial (PRE) **] UTI (grew klebsiella) and was taking
Bactrim. She continued to have general malaise and fevers
despite bactrim and asa. On [**10-28**] she called her PCP who
recommended some tylenol. Per husbands report she took 650mg x2
before coming in to the ED on [**10-28**]. There she was initially dx'd
with dehydration, ARF and UTI. She was given home doses of
simvastatin and SSRIs, but then found to have ALT of 25,370 and
of AST 11,490, total bili of 2.0, INR of 4.0, Cr of 3.0. She was
transferred to [**Hospital1 18**]. On presentation initial vs were: 97.5 P89,
112/37 19 99%RA 37kg.
.
Initially the patient was treated in the MICU. She was thought
to be in hyperacute fulminant liver failure either secondary to
Bactrim reaction versus acetaminophen toxicity - tylenol level
peaked at 10.0 >24 hrs after last ingestion. She became
progressively obtunded, with significant encephalopathy
requiring intubation and ventilatory support. Her liver function
was notable for transaminases with an ALT and AST of 9500 and
17,500 respectively and worsening hyperbilirubinemia. She became
progressively more coagulopathic, and it was thought that she
was most likely going to need orthotopic liver transplantation
for survival. She was transfered to the SICU and transplant
team. Her liver function spontaneously improved over the course
of 2 weeks. This was evidenced by progressive ability to
metabolize her lactate, stabilization of her blood sugars, and
autocorrection of her coagulopathy.
.
During her stay in the SICU, she required respiratory
ventilation, vasopressors for hypotension and intracranial
pressure monitoring. The patient initially had blood pressure
support with the use of vasopressors in order to minimize her
intravascular volume which was thought to exacerbate her
cerebral edema. The vasopressors were weaned by ICU day 6, and
there was no further requirement for this.
.
Given the concern for hepatic encephalopathy and cerebral edema,
ICP was initiated. Hypertonic saline and mannitol were used for
aggressive volme managment. Her ICPs had climbed into the high
30s, which improved with treatment. Her sedation and paralytics
were weaned. She had removal of her intracranial bolt on [**11-6**], [**2187**], and it was noted on subsequent imaging that she had
approximately a 4-cm, right frontal, intracranial hemorrhage.
This was followed serially with CT scans and there was no
progression of the bleeding. The bleeding was thought to be
secondary to her severe coagulopathy and thrombocytopenia in the
setting of her instrumentation. She was started on Keppra for
seizureprophylaxis to finish a 10-day course.
.
In terms of her respiratory status, it is noted that the patient
required full ventilatory support with hypoxic respiratory
failure. She was found to have ARDS. She was extubated on
[**2187-11-12**]. She initially did well, but, secondary to what
was thought to be pulmonary edema, required reintubation on
[**2187-11-13**] after failure of noninvasive positive pressure
ventilation. She had some degree of what appeared to be an
ARDS-type reaction or transfusion-associated lung injury.
.
The patient also spiked fevers intermittenly starting [**11-7**]. She
was on Vancomycin fom [**2187-10-31**] for ppx with bold placement. Zosyn
was added for the concern for PNA when she spiked fevers and had
a leukocytosis. Pan cultures were negative. She then developed a
drug rash leading to the discontinuation of Vanc and Zosyn on
[**11-10**]. Cipro was started in lieu of Zosyn but was discontinued
on [**11-13**]
.
The patient was transferred to the floor on [**2187-11-18**] and did
well. Cr is gradually trending down. Keppra was stopped on [**11-21**]
[**3-3**] rise in LFT's. Since that time, LFT's continue to trend
down. The patient's outstanding issues include:
.
1 Intraparenchymal hemorrhage: s/p bolt removal with
thrombocytopenia and coagulopathy [**3-3**] liver failure. Stable on
MRI [**2187-11-18**]. Pt's aphasia likely [**3-3**] bleed. EEG from [**11-19**]
without epileptiform activity, consistent with encephalitis and
focal findings consistent with intraparenchymal bleed. Keppra
d/c'd [**11-21**] with rise in LFT's thought to possibly be [**3-3**] drug
rxn. She has had no evidence of seizure activity and is
currently off seizure prophylaxis. Pt's ability to communicate
and respond to commands seems to be improving daily. Pt failed
video swallow [**11-20**]. However, she was re-evaluated on [**11-23**]
prior to transfer and she was found to be safe to take teaspoon
trials of nectar thick liquids and pureed food. Will plan to
continue tube feeds for nutrition at this time. She has been
working with PT and OT at time of transfer. She will have neuro
follow up as below after discharge.
.
# ARF- Possibly [**3-3**] AIN from Bactrim/ tylenol possibly with ATN
component. Cr today continues to trend down at 1.5 prior to
transfer. Of note, nephrology thinks that her ongoing acidosis
is likely related to her liver pathology and does not think
bicarbonate should be used to correct this. At transfer, her
bicarb is 12. Renal team thinks that this should correct itself
as her kidneys recover. Her lytes should be monitored daily. We
recommend she continue on NS at 75 cc/hr for now.
- Continue IVF with NS at 75cc/hour
.
# Respiratory failure- stable since extubation [**11-16**].
.
# Hepatic failure- LFT's leveling off. Amylase and Lipase are
trending down so continuing TF. With pt's Eosinophilia, it seems
that drug allergy to keppra could very well have been causing
rise in LFTs seen on [**11-19**]. Lactulose is being continued [**Hospital1 **] PRN
to help clear her sensorium and assist with constipation. We
recommend the facility to which she is being discharged continue
to trend LFTs daily for now.  She will have outpatient
hepatology follow up as below.
- Trend LFTs Daily
.
# Fevers- currently resolved, afebrile since transfer to the
floor. S/p tx with zosyn. No infectious source found on bronch
or LP in MICU. Pt now without foley but incontinence also a risk
factor for UTI. However, pt currently afebrile with WBC 11.1.
.
# Thrombocytosis: Plt very slowly trending down at 906 at time
of transfer. Likely due to reactive physiology.
.
# Drug Rash: Drug rash per derm thought to be most likely [**3-3**]
Zosyn but Vanc or fluconazole also possible. Now pt with
exfoliation of whole body. Skin underneath intact.
.
# Anemia: Stable at 22.9 on day of discharge. iron/ TIBC ratio
17% indicating mild iron deficiency. Will continue iron
supplementation.
.
# Sacral decub: Pt with sacral decub developed in house. She was
seen on the day of discharge by wound care. Please see attached
note from wound care about recommended dressing. Pt should be
followed by wound care specialists as an outpatient.
.
FEN- TF at 30 cc/hr. We would recommend that pt continue IVF, NS
at 75cc/hour until she is better able to take in PO volume.
Also, she is currently cleared to take nectar thick liquids and
pureed foods in teaspoon trials.
Access- right PICC
PPX- lansoprazole, no anticoagulation with h/o intraparenchymal
bleed.
Code- Full

Medications on Admission:
Medications prior to hospitalization are unable to be confirmed
by pt during this hospitalization.  The pt's records indicate
she was on high doses of SSRI.

Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO BID (2
times a day) as needed.
3. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Last Name (STitle) **]: One (1)
PO DAILY (Daily).


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary diagnosis:
Hyperacute fulminant hepatic failure
Secondary diagnoses:
Acute Renal failure
Increased intracranial pressure s/p Bolt procedure
Intraparenchymal bleed
Aphasia
Dysphagia
OCD
Anemia
Drug rash


Discharge Condition:
Stable


Discharge Instructions:
You were admitted with liver failure. We are unsure of the exact
cause of your liver failure at this time but we think it was a
reaction to the tylenol and bactrim you had been taking. While
you were here you also had kidney failure. You recieved dialysis
for this but you no longer need this and your kidney function is
returning to normal. In addition, you had increased pressure in
your brain from your liver failure while you were here. This
required a bolt placement in your head to monitor your pressure.
 After this was removed, it was noticed that you had a bleed
into your brain. This bleed has been stable for 2 weeks. You
will need extensive physical and occupational therapy at rehab.
.
Please keep all your follow up appointments as below.
.
If you have any chest pain, shortness of breath, fever, chills,
nausea, vomitting, yellowing of your skin or eyes, blood in your
urine or any other concerning symptoms, please call your doctor
or return to the ED.

Followup Instructions:
Please follow up with neurology, Dr. [**Last Name (STitle) **] on Tues [**12-25**] at
2:30pm. Please call [**Telephone/Fax (1) 3767**] to make sure they have all of
your information at least 1 week before your appointment.
.
Please follow up in the liver center with Dr. [**Last Name (STitle) 696**] on [**11-28**] at 2:50pm. If you need to reschedule, please call
[**Telephone/Fax (1) 2422**].
.
Please follow up with nephrology, Dr. [**Last Name (STitle) **], on Tuesday
[**11-27**] at 8am. If you need to reschedule, call [**Telephone/Fax (1) 3768**].
.
Please call your previous outpatient psychiatrist to arrange
follow up withing 2 weeks.



Completed by:[**2187-11-23**]
{'Acute and subacute necrosis of liver,Hepatic encephalopathy,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Hyposmolality and/or hyponatremia,Iatrogenic cerebrovascular infarction or hemorrhage,Intracerebral hemorrhage,Acute pancreatitis,Aphasia,Pneumonia, organism unspecified,Cerebral edema,Acquired coagulation factor deficiency,Anorexia nervosa,Sulfonamides causing adverse effects in therapeutic use,Aromatic analgesics, not elsewhere classified, causing adverse effects in therapeutic use,Obsessive-compulsive disorders,Depressive disorder, not elsewhere classified,Hypoglycemia, unspecified,Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use,Esophageal reflux,Dyspepsia and other specified disorders of function of stomach,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Pressure ulcer, lower back,Dysphagia, unspecified,Anemia, unspecified,Ileostomy status,Osteoporosis, unspecified,Pure hypercholesterolemia'}


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: Acute liver failure

PRESENT ILLNESS: Ms. [**Known lastname 3761**] is a 52-year-old
female who was transferred to the [**Hospital1 190**] in hyperacute fulminant liver failure thought
to be secondary to either Bactrim reaction versus
acetaminophen toxicity. She was admitted to the medical
intensive care unit initially and became progressively
obtunded, with significant encephalopathy requiring
intubation and ventilatory support. Her liver function was
notable for transaminases with an ALT and AST of 9500 and
17,500 respectively and worsening hyperbilirubinemia. She
became progressively more coagulopathic, and it was thought
that she was most likely going to need orthotopic liver
transplantation for survival. Given the critical nature of
her illness, she was transferred to the transplant surgical
service and to the surgical intensive care unit for further
management. This management initially entailed aggressive
control and monitoring of intracranial pressures in
conjunction with the neurosurgical service. This required
placement of an intracranial bolt and aggressive volume
management with the use of hypertonic saline and mannitol.
She continued to receive aggressive cardiopulmonary support
with again, as noted, full ventilatory support and
vasopressor support for hypotension.

MEDICAL HISTORY: Anorexia Nervosa with multiple psychiatric and medical
admissions
PTSD
OCD
hypercholesterolemia
osteoporosis
Colostomy [**3-3**] constipation likely related to anorexia
GERD with delayed gastric emptying
persistent microhematuria
s/p cystourethrography on [**10-6**]

MEDICATION ON ADMISSION: Medications prior to hospitalization are unable to be confirmed
by pt during this hospitalization.  The pt's records indicate
she was on high doses of SSRI.

ALLERGIES: Bactrim

PHYSICAL EXAM: From MICU:
VS: 101/4 136/76 120 29 98%RA
Gen: lightly jaundiced, feeling generally unwell
HEENT: mild scleral icterus, OP clear, EOMI, Pupils 4 to 3mm
Neck: No JVD, no thyromegaly, no LAD
Cor: RRR no m/r/g, exagerated heart sounds
Pulm: diffuse rhonchi
Abd: ileostomy, +BS, NT
Extrem: 2+ edema,
Skin: some petchiae seen most prominently in distal extremities,
no rash
Neuro: intubated and sedated, tracking with her eyes but not
responding to commands, + asterixis, upgoing toes bilaterally,
5/5 strength

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: -Tob: denies
-EtOH: denies
-Illicits: None
-Living situation: Lives with husband
-Occupation: retired 

### Response:
{'Acute and subacute necrosis of liver,Hepatic encephalopathy,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Hyposmolality and/or hyponatremia,Iatrogenic cerebrovascular infarction or hemorrhage,Intracerebral hemorrhage,Acute pancreatitis,Aphasia,Pneumonia, organism unspecified,Cerebral edema,Acquired coagulation factor deficiency,Anorexia nervosa,Sulfonamides causing adverse effects in therapeutic use,Aromatic analgesics, not elsewhere classified, causing adverse effects in therapeutic use,Obsessive-compulsive disorders,Depressive disorder, not elsewhere classified,Hypoglycemia, unspecified,Dermatitis due to drugs and medicines taken internally,Penicillins causing adverse effects in therapeutic use,Esophageal reflux,Dyspepsia and other specified disorders of function of stomach,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Pressure ulcer, lower back,Dysphagia, unspecified,Anemia, unspecified,Ileostomy status,Osteoporosis, unspecified,Pure hypercholesterolemia'}
