CHIEF COMPLAINT: Liver failure

PRESENT ILLNESS: 45M with a one month history of jaundice and progressive liver
failure.  Pt states that he first starting noticing that he had
low energy last summer.  He is the owner of an auto repair and
sales business and noted that he was having to sleep all day on
his days off starig last summer which was unusual for him.  The
first week of [**Month (only) 956**], he went to the dentist and was referred
to his PCP because they notes jaundice.  His PCP did basic liver
function test and referred him to a hepatologist who
subsequently referred him for liver biopsy that was performed on
[**2187-4-9**].  The patient was not scheduled to follow-up with his
hepatologist until [**4-30**], however, his father suggested that he
see another hepatologist sooner.  The patient then was seen at
Brown.  He has been followed daily since last Friday and was
transferred to [**Hospital1 18**] today in the setting of worsening renal
failure on top of liver failure.

MEDICAL HISTORY: Tonsillectomy
Hernia Repair
Alcohol Abuse
Tobacco Use

MEDICATION ON ADMISSION: None

ALLERGIES: Azithromycin

PHYSICAL EXAM: 97.3  75  152/91  18  O2 99%
nad, a&o
scleral icterus
neck supple
lungs clear
cor RRR
abd soft, distended, non-tender, nonrigid, exam positive for
shifting dullness
skin jaundiced
ext no edema

FAMILY HISTORY: No liver disease.

SOCIAL HISTORY: Divorced, 3 children.  Owns own auto repair and sale business.
Smoked 1 ppd for 20+ years, discontinued with onset of jaundice.
 H/o alcohol abuse.  Recently drank a couple glasses of wine or
beer with dinner discontinued with onset of jaundice.  Remote
history of vicodin and percocet abuse.  Remote history of
marijuana and cocaine use.  Ate raw oysters the Saunday before
he was found to be jaundiced. Remote history of using
supplements from GNC.  No IVDU, risky sexual behavior or
tattoos.  No sick contacts.  [**Name (NI) **] foreign travel.
Acute and subacute necrosis of liver,Hepatic encephalopathy,Hemorrhage complicating a procedure,Acute kidney failure with lesion of tubular necrosis,Unspecified protein-calorie malnutrition,Hyposmolality and/or hyponatremia,Critical illness myopathy,Unspecified pleural effusion,Pressure ulcer, lower back,Thrombocytopenia, unspecified,Other specified disorders of biliary tract
Acute necrosis of liver,Hepatic encephalopathy,Hemorrhage complic proc,Ac kidny fail, tubr necr,Protein-cal malnutr NOS,Hyposmolality,Critical illness myopthy,Pleural effusion NOS,Pressure ulcer, low back,Thrombocytopenia NOS,Dis of biliary tract NEC
Admission Date:  [**2187-4-18**]              Discharge Date:   [**2187-5-29**]

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

Service: SURGERY

Allergies:
Azithromycin

Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Liver failure

Major Surgical or Invasive Procedure:
[**2187-4-26**] Cadaveric liver transplant with splenectomy
using ABO incompatible liver.
[**2187-4-27**] ex lap, wash out,
plasmapheresis
hemodialysis
[**2187-5-7**] IR drainage of splenic fossa
[**2187-5-11**] transjugular biopsy
[**2187-5-14**] ERCP
[**2187-5-18**] collection drain placed in splenic fossa
[**2187-5-18**] hepatic artery angio
[**2187-5-21**] liver biopsy
ercp


History of Present Illness:
45M with a one month history of jaundice and progressive liver
failure.  Pt states that he first starting noticing that he had
low energy last summer.  He is the owner of an auto repair and
sales business and noted that he was having to sleep all day on
his days off starig last summer which was unusual for him.  The
first week of [**Month (only) 956**], he went to the dentist and was referred
to his PCP because they notes jaundice.  His PCP did basic liver
function test and referred him to a hepatologist who
subsequently referred him for liver biopsy that was performed on
[**2187-4-9**].  The patient was not scheduled to follow-up with his
hepatologist until [**4-30**], however, his father suggested that he
see another hepatologist sooner.  The patient then was seen at
Brown.  He has been followed daily since last Friday and was
transferred to [**Hospital1 18**] today in the setting of worsening renal
failure on top of liver failure.

The patient has a history of heavy drinking.  He last drank in
[**Month (only) 956**] when his liver failure was diagnosed.  At that point,
he drank [**3-6**] glasses of wine perday.  He admits that he used to
drink to excess and that he would consistently drink close to a
6pack of beer a day.  He also has a remote history of cocaine
and marijuana use.  He smoked 1ppd until this diagnosis.  He
denies any foreign travel.  He has no sick contacts.  [**Name (NI) **] did eat
raw oysters the Sunday before he saw his dentist, though no one
else who dined with him got sick.  Pt also used to abuse
percocet and vicodin in combination with alcohol.  He states
that he stopped doing this when he learned that this could be
bad for the liver several years ago.

In the ED, vitals 96.9 134/97 83 14 100% RA.  The patient's labs
were significant for transaminases in the thousands, Tbili of 50
and a Cr of 3.0.  Ammonia level 101.  RUQ ultrasound performed.

On arrival to the ICU, vitals 97.2 73 150/93 15 99% RA.  Pt
states that he was some abdominal pain, constipation, and
reflux.  ROS positive for mild headache, shortness of breath for
the last 2-3 days, orthopnea since Monday, reflux, lower
abdominal pain and distention, constipation, pale stools, [**Location (un) 2452**]
urine, dry, itchy skin and worsening short term memory.

Past Medical History:
Tonsillectomy
Hernia Repair
Alcohol Abuse
Tobacco Use

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

Family History:
No liver disease.

Physical Exam:
97.3  75  152/91  18  O2 99%
nad, a&o
scleral icterus
neck supple
lungs clear
cor RRR
abd soft, distended, non-tender, nonrigid, exam positive for
shifting dullness
skin jaundiced
ext no edema

RUQ U/S gallbladder wall thickening likely secondary to
hepatitis with small amount of ascites. no intra or extra
hepatic bile duct dilatation or other son[**Name (NI) 493**] findings to
suggest acute cholecystitis. no hydronephrosis.

Pertinent Results:
[**2187-4-18**] 03:10PM   WBC-11.8* RBC-5.13 HGB-16.6 HCT-47.2 MCV-92
MCH-32.4* MCHC-35.3* RDW-20.4* NEUTS-72.2* LYMPHS-20.3 MONOS-6.0
EOS-1.0 BASOS-0.5

[**2187-4-18**] 03:10PM   GLUCOSE-120* UREA N-52* CREAT-3.0* SODIUM-138
POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-20* ANION GAP-22*

[**2187-4-18**] 03:19PM   LACTATE-2.7*

[**2187-4-18**] 03:10PM   TOT PROT-4.8* ALBUMIN-3.7 GLOBULIN-1.1*
CALCIUM-9.7 PHOSPHATE-4.8* MAGNESIUM-3.0*

[**2187-4-18**] 03:54PM   PT-28.5* PTT-44.0* INR(PT)-2.9*

[**2187-4-18**] 03:10PM   ACETMNPHN-NEG
[**2187-4-18**] 03:10PM   ETHANOL-NEG


Brief Hospital Course:
45y.o. M with hepatic failure of uncertain etiology and renal
failure transferred to [**Hospital1 18**] MICU for further work-up and
evaluation. Initially liver failure was of unknown etiology.
Autoimmune panels were negative.  Biopsy was consistent with
viral hepatitis vs toxin or drug injury.  He did consume raw
oysters the Sunday prior to the onset of jaundice. Slit lamp
eval for [**Last Name (un) 80544**]-[**Last Name (un) 23070**] rings was negative. Hepatitis E IgM
came back positive. There was also some thought that Zithromax
may have contributed to acute liver failure as he had taken this
prior to admission. A liver transplant evaluation was done. He
was listed as status 1.

He developed worsening hepatic function with consequent
encephalopathy. Ultimately, on [**4-23**], a right frontal bolt was
placed to monitor ICP pressures. On [**4-24**], the bolt was
repositioned. Hepatorenal syndrome developed. On [**2187-4-26**] an ABO
incompatible liver offer was available. His family consented to
transplant offer. Prior to transplant, he received
plasmapheresis. On [**2187-4-26**], he underwent cadaveric liver
transplant with splenectomy using an ABO incompatible liver.
Surgeons were Drs [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to
operative notes. He received multiple blood products to maintain
hemodynamic stability. On [**4-27**], JP started pouring out blood.
He was taken back to the OR for exploration,washout, control of
hemorrhage and abdominal closure. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**].
Postop, he returned to the SICU.

Hemodialysis was initiated on [**4-28**] for ATN on HRS and
discontinued as renal function improved. On [**4-29**] the bolt was
removed after receiving platelets and head CT was negative for
bleed. On [**5-2**], he was extubated.

Plasmapheresis continued based on anti-A titers for 5 treatments
postop. Liver u/s on [**5-4**] showed small perihepatic fluid; nl flow
and waveforms. On [**5-12**] liver U/S showed normal vasculature with
trace perihepatic fluid. LFTs started to trend up and a
transjugular biopsy was performed on [**5-11**] showing moderate
cholestasis and no rejection.

A total of 7 doses of ATG (125mg x5 and 75mg x2 due to lower wbc
counts)were given. Steroids were tapered per protocol. Prograf
was started on postop day 1 and titrated per trough levels.
Cellcept 1 gram was given [**Hospital1 **] until around postop day 26/16 when
he complained of nausea. Dose was divided into 500mg qid with
decreased complaints of nausea.

On [**5-4**] neurology was consulted for confusion. CT of head/neck
was wnl. He was following commands, but was disoriented,
confused and weak. He appeared encephalopathic with waxing and
[**Doctor Last Name 688**] mental status likely related to hepatic and renal
insufficiency. Given elevated wbc there was concern for
underlying infection. Weakness was likely from ICU
stay/myopathy. He also developed hyponatremia requiring free
water boluses. Flagyl was added for empiric c.diff. Several
stools were negative for c.diff and flagyl was stopped after 5
days. Speech evaluated at the bedside and recommended npo status
due to signs of aspiration. TPN was initiated then switched to
tube feeds. A post pyloric feeding tube was inserted for feeds
on [**5-2**].

An abd CT on [**5-6**] revealed a LUQ fluid collection in splenic bed.
A # 6 drain was placed into this LUQ collection on [**5-7**]. Vanco
and zosyn were started on [**5-6**] and continued thru [**5-10**]. Repeat Abd
CT on [**5-11**] showed unchanged splenic bed collection, bowel wall
thickening resolution, no obstruction, and b/l pleural effusions
with b/l atelectasis vs pneumonia. On [**5-16**], he was transfered
out of the SICU.

LFTS started to increase with a steady trend up of the alk phos
as high as 1400. Liver duplex was normal. CTA was done on [**5-17**]
which was a suboptimal exam of the distal hepatic artery, but
the proximal to mid hepatic artery was patent. Hepatic Artery
Angio was then done showing a patent hepatic artery anastamosis
with an irregular pattern of donor artery, normal parenchyma
enhancement. A biopsy was then performed on [**5-21**] revealing
moderate to severe cholestasis with foci of associated
hepatocellular necrosis. There was no cellular rejection noted.
On [**5-14**], ERCP was done showing no leak or stricture. There was
concern that cholestasis was due to either bactrim or
fluconazole. Both of these were stopped on [**5-19**]. Ursodiol was
also started. Gradually, LFTs improved with alk phos dropping
into the 600 range. On [**5-25**], a pentamidine treatment (bactrim
replacement) was attempted, but he was unable to complete
treatment due to nausea. He did receive a complete Pentamidine
treatment on [**5-28**].

He experienced several days of nausea with some vomiting. KUB on
[**5-22**] was negatie for ileus or obstruction. It was discovered
that the feeding tube had dislodged and was coiled in his
esophagus. This was removed and remained out. Nausea resolved
and he was able to take in a sufficient kcal count to warrent
cessation of the tube feeds.

On [**5-24**], a repeat abdominal CT was done to evaluate the splenic
bed collection given concern for drain culture that grew coag
neg staph. Drain fluid amylase was 10,840. CT showed splenic bed
collection gone with drain in place. A new infrahepatic
collection measuring 5x7cm was seen near the porta, but was
ammenable to drainage only thru a trans liver approach. Becausea
of this, CT drainage was not done. He was afebrile and WBC was
stable. In fact the wbc decreased.

Mental status improved allowing for medication teaching. He
worked with PT extensively. [**Hospital 38439**] rehab was recommended,
but he became independent with ambulation. He was declared safe
to discharge to home.

He had developed a sacral deep tissue injury while in the SICU
that initially measured 4cm x 1.5cm x .5 cm. This was treated
with commercial cleanser then duoderm gel followed by Mepilex
dressing q 72. Wound bed appeared clean with some fibrin making
the wound non-stageable. Size improved to 3cmx 1cmx 0.5cm. The
pigtail drain in the slenic bed was left in place with an
average output of 10cc.  Abdomen was soft, non-distended and
transplant incision was intact without erythema/drainage.

VNA Care NE ([**Telephone/Fax (1) 80193**]was arranged. His parents were very
involved and he was discharged home to stay with them initially.
At time of discharge, vital signs were stable.

Medications on Admission:
None

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
9. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): started [**5-26**].
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): prevents fungal mouth infection.
Disp:*600 ML(s)* Refills:*1*
13. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale  Subcutaneous three times a day.
Disp:*1 bottle* Refills:*1*
14. syringes
Insulin low dose syringes qid for humalog sliding scale insulin
25 gauge
supply 1 box
Refill 1
15. One Touch Ultra System Kit     Kit Sig: One (1) kit
Miscellaneous three times a day.
Disp:*1 kit* Refills:*0*
16. One Touch UltraSoft Lancets     Misc Sig: One (1)
Miscellaneous four times a day.
Disp:*1 box* Refills:*1*
17. One Touch Ultra Test     Strip Sig: One (1)  In [**Last Name (un) 5153**] four
times a day.
Disp:*1 box* Refills:*1*
18. NovaSource Renal     Liquid Sig: Eight (8) ounces PO three
times a day.
Disp:*42 cans* Refills:*2*


Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
acute liver failure
Hepatitis E
ABO incompatible liver transplantsplenectomy
cholestasis, medication related
Abdominal fluid collection near splenic bed
abdominal fluid collection near porta, undrained
malnutrition
sacral decrubitus

Discharge Condition:
good


Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications or
eat, jaundice, abdominal distension, incision/drain site
redness/drainage or any concerns
Empty abdominal drain and record output. Bring record of output
to next appointment in Transplant Office.
Labs every Monday and Thursday


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-6-4**]
10:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-6-11**]
9:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2187-6-11**]
10:00



Completed by:[**2187-5-31**]
{'Acute and subacute necrosis of liver,Hepatic encephalopathy,Hemorrhage complicating a procedure,Acute kidney failure with lesion of tubular necrosis,Unspecified protein-calorie malnutrition,Hyposmolality and/or hyponatremia,Critical illness myopathy,Unspecified pleural effusion,Pressure ulcer, lower back,Thrombocytopenia, unspecified,Other specified disorders of biliary tract'}


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: Liver failure

PRESENT ILLNESS: 45M with a one month history of jaundice and progressive liver
failure.  Pt states that he first starting noticing that he had
low energy last summer.  He is the owner of an auto repair and
sales business and noted that he was having to sleep all day on
his days off starig last summer which was unusual for him.  The
first week of [**Month (only) 956**], he went to the dentist and was referred
to his PCP because they notes jaundice.  His PCP did basic liver
function test and referred him to a hepatologist who
subsequently referred him for liver biopsy that was performed on
[**2187-4-9**].  The patient was not scheduled to follow-up with his
hepatologist until [**4-30**], however, his father suggested that he
see another hepatologist sooner.  The patient then was seen at
Brown.  He has been followed daily since last Friday and was
transferred to [**Hospital1 18**] today in the setting of worsening renal
failure on top of liver failure.

MEDICAL HISTORY: Tonsillectomy
Hernia Repair
Alcohol Abuse
Tobacco Use

MEDICATION ON ADMISSION: None

ALLERGIES: Azithromycin

PHYSICAL EXAM: 97.3  75  152/91  18  O2 99%
nad, a&o
scleral icterus
neck supple
lungs clear
cor RRR
abd soft, distended, non-tender, nonrigid, exam positive for
shifting dullness
skin jaundiced
ext no edema

FAMILY HISTORY: No liver disease.

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

### Response:
{'Acute and subacute necrosis of liver,Hepatic encephalopathy,Hemorrhage complicating a procedure,Acute kidney failure with lesion of tubular necrosis,Unspecified protein-calorie malnutrition,Hyposmolality and/or hyponatremia,Critical illness myopathy,Unspecified pleural effusion,Pressure ulcer, lower back,Thrombocytopenia, unspecified,Other specified disorders of biliary tract'}
