CHIEF COMPLAINT: Altered Mental Status

PRESENT ILLNESS: Ms. [**Known lastname 65453**] is a 44 y/o female with a hx of UGIB [**1-10**] duodenal
ulcers and EtOH liver disease who was transferred from [**Hospital1 1562**]
hosptial due to altered mental status.
.
As per her sister, she was recently admitted to [**Name (NI) 1562**]
hospital for an upper Gi bleed. She was discharged to [**Location (un) 3244**]
detox facility for a couple of days. When she came home from
detox, she was mildly confused.  over the next few [**Last Name (un) 32460**] she
become progressively more confused and had significant decrease
in her functional status.  Also having frequent diarrhea. Her
sister took her to her PCP who promptly sent her to the ED.  In
the ED at [**Hospital1 1562**] (per report) it was thought her mental status
may be related to her liver disease and she was transferred to
[**Hospital1 18**].
.
In the ED, initial VS: 98.0 90 113/50 18 98%. She had a head CT
which was negative for an acute process. There was no ascitic
fluid that was visulized therefore could not perform a
diagnostic tap. She was given lactulose and ceftriaxone. ? given
narcan with improvement of mental status.
.
Overnight, Cr was found to be 5.1 with BUN of 15.  WBC 22. U/A
suggestive of UTI. She was given 100g albumin for HRS and
ceftriaxone for UTI, ? SBP. This morning on rounds, she was
thought to be acutely confused, and transfer to the MICU
transfer was requested for altered mental status and possible
endoscopy.  On evaluation this morning, she was confused and
unable to give a history. She denied having any discomfort. She
oriented to self but not to place and time.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.

MEDICAL HISTORY: Alcohol abuse

MEDICATION ON ADMISSION: Oxycodone 5mg
Vitamin B12
Ondansetron 4mg
Pantoprazole 40mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS - 98.1 132/74  96  20  99/ra
GENERAL - NAD, drowsy, confused
HEENT - scleral icterus
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, mild
expiratory wheezing, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, distended but soft/NT, no masses or HSM, no
rebound/guarding
EXTREMITIES - several punctures in volar arms with surround
erythmea, ? injection drug sites vs. prior IVs.  bilateral LE 3+
edema
NEURO - AAOx1, mild left facial droop, speech fluent, no
pronator drift
.
Discharge Exam:
Afebrile, HD stable, on RA
GENERAL: Well appearing 51yo M. Comfortable, appropriate and in
good humor. Mildly Jaundiced.
HEENT: Sclera icteric though improved. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, III/VI systolic murmur with best heard at LUSB.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Normoactive BS. Distended but Soft, non-tender to
palpation, Tympanic to percussion, No HSM or tenderness.
EXTREMITIES: WWP, trace LLE (reduced from baseline).
NEURO: A and O x 3; approrpiately mentating; motor and sensory
grossly intact

FAMILY HISTORY: No pertinent family history, including PSC, liver disease, or
other gastrointestinal disease. (Has identical twin brother
without above conditions). Grandfather with diabetes.

SOCIAL HISTORY: Lives with his eldest of 2 sons. [**Name (NI) **] lots of family support
(mother, sisters, [**Name2 (NI) 12232**]) - requires 24 hour care at home. Not
currently employed, on SSI.
- Smoking: quit > 16 yrs ago, 25 pack year history
- EtOH: history of abuse, last drink > 22 yrs ago
- Drugs: history of polysubstance abuse including cocaine,
crack, barbiturates, amphetamines, and marijuana. None for 20
years.
Hepatic encephalopathy,Acute kidney failure with lesion of tubular necrosis,Pneumonitis due to inhalation of food or vomitus,Acidosis,Other B-complex deficiencies,Disorders of phosphorus metabolism,Blood in stool,Acute alcoholic hepatitis,Benign neoplasm of rectum and anal canal,Anemia, unspecified,Chronic kidney disease, unspecified,Internal hemorrhoids without mention of complication,Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Other and unspecified alcohol dependence, continuous
Hepatic encephalopathy,Ac kidny fail, tubr necr,Food/vomit pneumonitis,Acidosis,B-complex defic NEC,Dis phosphorus metabol,Blood in stool,Ac alcoholic hepatitis,Benign neopl rectum/anus,Anemia NOS,Chronic kidney dis NOS,Int hemorrhoid w/o compl,Peptic ulcer NOS,Alcoh dep NEC/NOS-contin
Admission Date:  [**2103-11-12**]              Discharge Date:   [**2103-11-25**]

Date of Birth:  [**2059-4-15**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Altered Mental Status

Major Surgical or Invasive Procedure:
Sigmoidoscopy


History of Present Illness:
Ms. [**Known lastname 65453**] is a 44 y/o female with a hx of UGIB [**1-10**] duodenal
ulcers and EtOH liver disease who was transferred from [**Hospital1 1562**]
hosptial due to altered mental status.
.
As per her sister, she was recently admitted to [**Name (NI) 1562**]
hospital for an upper Gi bleed. She was discharged to [**Location (un) 3244**]
detox facility for a couple of days. When she came home from
detox, she was mildly confused.  over the next few [**Last Name (un) 32460**] she
become progressively more confused and had significant decrease
in her functional status.  Also having frequent diarrhea. Her
sister took her to her PCP who promptly sent her to the ED.  In
the ED at [**Hospital1 1562**] (per report) it was thought her mental status
may be related to her liver disease and she was transferred to
[**Hospital1 18**].
.
In the ED, initial VS: 98.0 90 113/50 18 98%. She had a head CT
which was negative for an acute process. There was no ascitic
fluid that was visulized therefore could not perform a
diagnostic tap. She was given lactulose and ceftriaxone. ? given
narcan with improvement of mental status.
.
Overnight, Cr was found to be 5.1 with BUN of 15.  WBC 22. U/A
suggestive of UTI. She was given 100g albumin for HRS and
ceftriaxone for UTI, ? SBP. This morning on rounds, she was
thought to be acutely confused, and transfer to the MICU
transfer was requested for altered mental status and possible
endoscopy.  On evaluation this morning, she was confused and
unable to give a history. She denied having any discomfort. She
oriented to self but not to place and time.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.

Past Medical History:
Alcohol abuse

Social History:
Lives with his eldest of 2 sons. [**Name (NI) **] lots of family support
(mother, sisters, [**Name2 (NI) 12232**]) - requires 24 hour care at home. Not
currently employed, on SSI.
- Smoking: quit > 16 yrs ago, 25 pack year history
- EtOH: history of abuse, last drink > 22 yrs ago
- Drugs: history of polysubstance abuse including cocaine,
crack, barbiturates, amphetamines, and marijuana. None for 20
years.


Family History:
No pertinent family history, including PSC, liver disease, or
other gastrointestinal disease. (Has identical twin brother
without above conditions). Grandfather with diabetes.

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.1 132/74  96  20  99/ra
GENERAL - NAD, drowsy, confused
HEENT - scleral icterus
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, mild
expiratory wheezing, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, distended but soft/NT, no masses or HSM, no
rebound/guarding
EXTREMITIES - several punctures in volar arms with surround
erythmea, ? injection drug sites vs. prior IVs.  bilateral LE 3+
edema
NEURO - AAOx1, mild left facial droop, speech fluent, no
pronator drift
.
Discharge Exam:
Afebrile, HD stable, on RA
GENERAL: Well appearing 51yo M. Comfortable, appropriate and in
good humor. Mildly Jaundiced.
HEENT: Sclera icteric though improved. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, III/VI systolic murmur with best heard at LUSB.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Normoactive BS. Distended but Soft, non-tender to
palpation, Tympanic to percussion, No HSM or tenderness.
EXTREMITIES: WWP, trace LLE (reduced from baseline).
NEURO: A and O x 3; approrpiately mentating; motor and sensory
grossly intact


Pertinent Results:
ADMISSION LABS:
[**2103-11-12**] 05:40PM BLOOD WBC-22.4* RBC-3.18* Hgb-10.4* Hct-33.0*
MCV-104* MCH-32.9* MCHC-31.7 RDW-19.2* Plt Ct-387
[**2103-11-12**] 05:40PM BLOOD Neuts-74* Bands-0 Lymphs-16* Monos-5
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-1*
[**2103-11-12**] 05:40PM BLOOD PT-19.3* PTT-44.8* INR(PT)-1.8*
[**2103-11-12**] 05:40PM BLOOD Glucose-81 UreaN-15 Creat-5.2* Na-131*
K-3.2* Cl-97 HCO3-16* AnGap-21*
[**2103-11-12**] 05:40PM BLOOD ALT-52* AST-150* AlkPhos-265*
TotBili-4.8* DirBili-4.0* IndBili-0.8
[**2103-11-12**] 05:40PM BLOOD Lipase-23
[**2103-11-12**] 05:40PM BLOOD Albumin-2.3* Calcium-8.5 Phos-3.6 Mg-2.2
[**2103-11-14**] 02:37PM BLOOD Ammonia-147*
[**2103-11-13**] 06:20AM BLOOD Osmolal-288
[**2103-11-13**] 06:20AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE
[**2103-11-12**] 05:40PM BLOOD HCG-<5
[**2103-11-12**] 05:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2103-11-13**] 06:20AM BLOOD HCV Ab-NEGATIVE
[**2103-11-13**] 03:06AM BLOOD Type-ART pO2-90 pCO2-26* pH-7.42
calTCO2-17* Base XS--5 Intubat-NOT INTUBA
[**2103-11-12**] 05:51PM BLOOD Glucose-77 Lactate-1.7 Na-132*
K-3.2*[**2103-11-13**] 03:06AM BLOOD Hgb-10.2* calcHCT-31 O2 Sat-96
COHgb-1 MetHgb-0
[**2103-11-13**] 03:06AM BLOOD freeCa-1.14
.
Discharge Labs:
[**2103-11-24**] 07:15AM BLOOD WBC-26.7* RBC-2.46* Hgb-7.8* Hct-25.5*
MCV-104* MCH-31.6 MCHC-30.6* RDW-18.4* Plt Ct-490*
[**2103-11-24**] 07:15AM BLOOD PT-22.1* INR(PT)-2.1*
[**2103-11-24**] 07:15AM BLOOD Glucose-92 UreaN-36* Creat-1.3* Na-136
K-4.3 Cl-105 HCO3-17* AnGap-18
[**2103-11-24**] 07:15AM BLOOD ALT-25 AST-88* AlkPhos-151* TotBili-3.5*
[**2103-11-24**] 07:15AM BLOOD Albumin-2.7* Calcium-8.1* Phos-5.5*
Mg-1.7
.
MICRO:
BCx negative x4
UCx negative x2
C.DIFF NEGATIVE
.
IMAGING:
[**11-12**] CT HEAD  TECHNIQUE: Axial MDCT images were acquired of the
head without contrast and reformatted into coronal and sagittal
planes.
FINDINGS:
The exam is somewhat limited by patient motion, although repeat
scans were
performed. There is no intracranial hemorrhage, extra-axial
collection, or
mass effect. The ventricles and sulci are normal in size and
configuration.  [**Doctor Last Name **] matter/white matter differentiation is
preserved. The orbits are normal appearing. The soft tissues are
unremarkable. There is an air-fluid level within the left
maxillary sinus, and mucosal thickening of ethmoid air cells.
The frontal sinuses are clear. An air-fluid level is seen in the
sphenoid sinus with aerosolized debris. The mastoid air cells
and middle ear cavities are clear. There is no osseous
abnormality.
IMPRESSION:
1. No acute intracranial process.
2. Air-fluid levels in multiple paranasal sinuses.
.
[**11-12**] LIVER ULTRASOUND:  FINDINGS: The liver is diffusely coarse
and echogenic consistent with history of liver disease. No focal
lesions are seen. The gallbladder appears normal. The common
bile duct is mildly dilated measuring up to 8 mm. No definite
stone is seen within the common bile duct. To and fro flow is
seen within the main portal vein. There is no ascites. The right
kidney measures 13.9 cm in the long axis and is normal in
appearance without hydronephrosis or stones.
IMPRESSION:
1. Diffusely echogenic liver consistent with history of
alcoholic hepatitis.
2. To and fro flow within the main portal vein without portal
vein
thrombosis.
3. Common bile duct measures up to 8 mm and is thus dilated.
MRCP/ERCP could better evaluate for an obstructing cause.
.
[**11-13**] RENAL ULTRASOUND: The right kidney measures 12.1 cm. The
left kidney measures 12.5 cm. There is no hydronephrosis, stones
or masses. The bladder is only minimally distended and cannot be
assessed. Small portion of a urinary catheter is seen.
IMPRESSION: Normal renal son[**Name (NI) **]
.
[**11-16**] HIDA SCAN: RADIOPHARMACEUTICAL DATA: 4.2 mCi Tc-[**Age over 90 **]m DISIDA
([**2103-11-16**]); HISTORY: Common duct dilation, leukocytosis, and
right upper quadrant pain. Evaluate for biliary pathology.
METHODS: Following the intravenous injection of tracer, serial
one-minute images of tracer uptake into the hepatobiliary system
were obtained for 75 minutes. A delayed static image was
obtained at 5.5 hours. Images of the injection site were also
acquired.
INTERPRETATION: Serial images over the abdomen show poor uptake
of tracer into the hepatic parenchyma in a homogeneous pattern.
At 15 minutes, the small bowel is visualized, although no tracer
uptake is seen within the gallbladder throughout the first 75
minutes. The patient returned to the nuclear medicine suite
after 5.5 hours for additional imaging, which revealed tracer
activity within the gallbladder.
IMPRESSION:
1. Diffusely poor tracer uptake throughout the liver is
consistent with poor hepatocellular function.
2. Tracer activity within the gallbladder on delayed images
excludes the
diagnosis of acute cholecystitis.
2. Excretion of tracer into the small bowel excludes the
diagnosis of complete biliary obstruction.
.
[**11-17**] CXR HISTORY: Alcoholic hepatitis. Aspiration event.
IMPRESSION: AP chest compared to [**11-13**]:
Consolidation in the perihilar left lung and in the right upper
lung extending to the apex is readily explained by massive
aspiration. A smaller region of consolidation may be present in
the right lung projecting behind the lower pole of the right
hilus. Mild cardiomegaly and mediastinal vascular engorgement
have increased suggesting cardiac decompensation. Dr. [**Last Name (STitle) **]
was paged.
.
CXR [**2103-11-18**] Bilateral upper lobe consolidation is slightly more
pronounced today than yesterday. Whether this is due to
progression of pneumonia or deposition of early edema in a
region of pre-existing pneumonia is difficult to say since the
mediastinal veins are dilated in the supine position. Heart size
is top normal, and there may be mild pulmonary vascular
engorgement, but no clear edema elsewhere. There is no
appreciable pleural effusion. Nasogastric tube passes into the
stomach and out of view
.
Sigmoidoscopy [**2103-11-23**]
- Polyp at 8cm in the rectum
- Polyps at the ranging distance from 18 cm to 28 cm in the
distal sigmoid colon
- Grade 2 internal hemorrhoids
- Otherwise normal sigmoidoscopy to splenic flexure
- Recommendations: Patient will need colonoscopy for removal of
polyps when her alcoholic hepatitis improves and her INR is less
than 1.5.


Brief Hospital Course:
Ms. [**Known lastname 65453**] is a 44 year old female with a history of upper GI
bleed (UGIB) secondary to duodenal ulcers and alcoholic liver
disease who was transferred from [**Hospital 1562**] hospital due to
altered mental status.
.
ACTIVE PROBLEMS BY ISSUES:
.
# Alcoholic Hepatitis: Hepatic encephalopathy, jaundice, LFTs
with alcoholic picture, viral studies were negative.  She has
signficant synthetic dysfunction as well with a discriminant
function of 51 on admission. Steroids were deferred initially
for possible acute hepatitis since her LFTs and bilirubin were
improving in the MICU with fluids. Hepatitis B and C virus
serologies negative. On floor tube feeds were started to augment
nutrition and improve hepatitis. NGT was accidentally self
removed. Nutrition reconsulted and felt she could take adequate
caloric intake to treat alcoholic hepatitis and so NGT was not
replaced. Discriminant function 36 on discharge but patient
clinically much improved, walking around floor, jaundice
improving, POing well with downtrending T.Bili <4 on discharge.
Patient discharged in improved condition agreement with plan to
abstain from alcohol completely. She was discharged home with
outpatient alcohol rehabilitation.
.
# Encephalopathy: The patient was transferred to the MICU for
altered mental status (AMS); likely due to hepatic
encephalopathy.  A lumbar puncture was attempted, but
unsuccessful.  She received Narcan in the ED to which there was
a questionable improvement in her mental status.  She was given
lactulose and rifaxamin, aiming for 4 bowel movements/day and
was also started on empiric antibiotic coverage since she had a
leukocytosis with the AMS including acyclovir, vancomycin,
ampillicin, and ceftriaxone.  The patient then had a right upper
quadrant ultrasound that showed dilated common bile duct, so she
underwent a HIDA scan which ruled out cholangitis as a cause of
her AMS and leukocytosis.  At that point, ampicillin was
discontinued and the patient was continued on vanc/acyclovir,
flagyl/ceftriaxone was added for intra abdominal pathology.
Antibiotics were changed to Vanc/Zosyn after she developed PNA.
The patient also has a drinking history and was started on
thiamine. As the patient's mental status slowly improved, the
acyclovir was stopped, as the concern for encephalitis lessened.
On arrival to the floor her mental status continued to improve
with lactulose and Rifaximin. He encephalopathy was attributed
to alcoholic hepatitis and continued to improve throughot
duration of stay.
.
# Acute Renal Failure: The patient was found to be in ARF
(baseline creatinine is around 0.9) and presented with creat
5.2. FeNa of 0.22 consistent with prerenal etiology and muddy
brown casts were found in the urine sediment suggesting acute
tubular necrosis (ATN). With significant liver dysfunction
hepatorenal syndrome (HRS) was of concern. Renal consulted but
thought that the etiology was pure ATN. She underwent a renal
ultrasound which was normal and an albumin challenge which ruled
out hepatorenal syndrome. Creatinine continued to improve after
albumin was given and with improvement in hepatitis.
.
# Aspiration pneumonia:  She developed aspiration pneumonia on
[**11-17**] with a rising leukocytosis.  She was fed with a
[**Last Name (un) **]-gastric tube and continued on vanc/zosyn. She completed an
HCAP course with Vanc/Zosyn and she remained on RA throughout
duration of floor stay.
.
# Leukoctosis: Patient with profound leukocytosis which
uptrended initially and remained elevated. Initial concern was
for HCAP which was adequately treated. C.Diff returned negative
multiple times. Leukocytosis remained elevated despite HCAP
treatment and so WBCs thought most likely related to alcoholic
hepatitis rather than infectious etiology. Cultures negative
otherwise in work up.
.
# Upper GI bleed (UGIB): Presented with bright red blood per
rectum (BRBPR), and a Hematocrit trending down 33 -> 30.  Upon
further questioning, she reported that she was having her
menses.  Her hematocrit remained stable and she did not recieve
any blood transfusions. This was initially stable until 2 days
prior to discharged when on the floor she began having GIB.
Patient again felt this was menses though rectal exam with
internal hemorrhoids. Flex Sig was completed given concern for
rectal bleed which showed grade 2 hemorrhoids and multiple
recto-sigmoid polyps. Polyps were not removed because of
elevated INR and tenuous Alc Hep. Repeat colonoscopy deferred to
outpatient after improvement in hepatitis and coagulopathy.
.
# Anion Gap Acidosis: She is noted to have a gap of 18 upon
admission labs. Her lactate was within normal limits, no osmolar
gap. Given BUN unlikely to be uremia, but possible contribution
of acute renal failure. Also possible alcoholic/starvation
ketosis. Gap closed and remained stable after transfer to floor
from MICU.
.
# Sodium imbalance: She likely had hypervolemic hyponatremia due
to liver dysfunction.  She was maintained on a fluid restricted
diet.  She later developed hypernatremia while she was on tube
feeds only for aspiration.  This was treated with free water
flushes through the NG tube. After hepatitis and HCAP
improved/resolved her Na remained stable requiring no further
intervention.
.
# Macrocytic Anemia: With significant alcohol use she is likely
either folate or B12 deficient.
.
# Peptic ulcer disease (PUD): she has a history of duodenal
ulcers and was continued on pantoprazole.
.
TRANSITIONAL ISSUES:
- Colonoscopy needs to be completed as an outpatient with
removal of colonic polyps after INR improves
- Patient counseled extensively on the importance of alcohol
abstainence and she is agreeable with plan. Should continue
reinforcing abstinence
- Consider Baclofen for alcohol abuse prophylaxis

Medications on Admission:
Oxycodone 5mg
Vitamin B12
Ondansetron 4mg
Pantoprazole 40mg daily


Discharge Medications:
1. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as
needed) as needed for rectal irritation.
Disp:*1 tube* Refills:*0*
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a
day.
Disp:*1800 ML(s)* Refills:*1*
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every twelve (12) hours as needed for nausea.



Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
hepatic encephalopathy
acute kidney injury


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Ms. [**Known lastname 65453**],
.
You were admitted to the hospital because you were more confused
than your baseline and there was concern that you had bleeding
from your intestines.  We did not find that there was any
significant bleeding in your intestines and the levels of your
blood stayed steady.  You do have a hemorrhoid which bleeds a
little bit when you have bowel movements. Flex Sigmoidoscopy
performed showed polyps in your sigmoid colon which should be
followed up after you are discharged.
.
For your confusion, we think that it relates to your liver
disease.  When your liver disease progresses, a condition called
cirrhosis, your body builds up toxic substances.  You were
treated with lactulose to make you have bowel movements which
will remove these toxic substances.
.
Finally, you developed a pneumonia because when you swallow the
food sometimes goes into your lungs.  This is called aspiration.
 You have to eat very slowly to help the food go into your
stomach not your lungs.
.
The following changes were made to your medications:
- START Folic Acid 1mg Daily
- START Thiamine 100 mg DAILY
- START Vitamin D 400 UNIT DAILY
- START Hydrocortisone cream: apply rectally as needed for
irritation
- CONTINUE Pantoprazole
- START Lactulose 30 mL Twice daily
- START Rifaximin 550 mg twice daily
.
It is also very important that you keep all of the follow-up
appointments listed below.
.
It is also very important that you have a colonoscopy to
evaluate polyps in your colon.
.
It was a pleasure taking care of you in the hospital!

Followup Instructions:
Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 682**]
Appointment: Wednesday [**2103-12-5**] 10:45am


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
{'Hepatic encephalopathy,Acute kidney failure with lesion of tubular necrosis,Pneumonitis due to inhalation of food or vomitus,Acidosis,Other B-complex deficiencies,Disorders of phosphorus metabolism,Blood in stool,Acute alcoholic hepatitis,Benign neoplasm of rectum and anal canal,Anemia, unspecified,Chronic kidney disease, unspecified,Internal hemorrhoids without mention of complication,Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Other and unspecified alcohol dependence, continuous'}


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: Altered Mental Status

PRESENT ILLNESS: Ms. [**Known lastname 65453**] is a 44 y/o female with a hx of UGIB [**1-10**] duodenal
ulcers and EtOH liver disease who was transferred from [**Hospital1 1562**]
hosptial due to altered mental status.
.
As per her sister, she was recently admitted to [**Name (NI) 1562**]
hospital for an upper Gi bleed. She was discharged to [**Location (un) 3244**]
detox facility for a couple of days. When she came home from
detox, she was mildly confused.  over the next few [**Last Name (un) 32460**] she
become progressively more confused and had significant decrease
in her functional status.  Also having frequent diarrhea. Her
sister took her to her PCP who promptly sent her to the ED.  In
the ED at [**Hospital1 1562**] (per report) it was thought her mental status
may be related to her liver disease and she was transferred to
[**Hospital1 18**].
.
In the ED, initial VS: 98.0 90 113/50 18 98%. She had a head CT
which was negative for an acute process. There was no ascitic
fluid that was visulized therefore could not perform a
diagnostic tap. She was given lactulose and ceftriaxone. ? given
narcan with improvement of mental status.
.
Overnight, Cr was found to be 5.1 with BUN of 15.  WBC 22. U/A
suggestive of UTI. She was given 100g albumin for HRS and
ceftriaxone for UTI, ? SBP. This morning on rounds, she was
thought to be acutely confused, and transfer to the MICU
transfer was requested for altered mental status and possible
endoscopy.  On evaluation this morning, she was confused and
unable to give a history. She denied having any discomfort. She
oriented to self but not to place and time.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.

MEDICAL HISTORY: Alcohol abuse

MEDICATION ON ADMISSION: Oxycodone 5mg
Vitamin B12
Ondansetron 4mg
Pantoprazole 40mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS - 98.1 132/74  96  20  99/ra
GENERAL - NAD, drowsy, confused
HEENT - scleral icterus
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, mild
expiratory wheezing, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, distended but soft/NT, no masses or HSM, no
rebound/guarding
EXTREMITIES - several punctures in volar arms with surround
erythmea, ? injection drug sites vs. prior IVs.  bilateral LE 3+
edema
NEURO - AAOx1, mild left facial droop, speech fluent, no
pronator drift
.
Discharge Exam:
Afebrile, HD stable, on RA
GENERAL: Well appearing 51yo M. Comfortable, appropriate and in
good humor. Mildly Jaundiced.
HEENT: Sclera icteric though improved. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: RRR, III/VI systolic murmur with best heard at LUSB.
LUNGS: Resp were unlabored, no accessory muscle use, moving air
well and symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Normoactive BS. Distended but Soft, non-tender to
palpation, Tympanic to percussion, No HSM or tenderness.
EXTREMITIES: WWP, trace LLE (reduced from baseline).
NEURO: A and O x 3; approrpiately mentating; motor and sensory
grossly intact

FAMILY HISTORY: No pertinent family history, including PSC, liver disease, or
other gastrointestinal disease. (Has identical twin brother
without above conditions). Grandfather with diabetes.

SOCIAL HISTORY: Lives with his eldest of 2 sons. [**Name (NI) **] lots of family support
(mother, sisters, [**Name2 (NI) 12232**]) - requires 24 hour care at home. Not
currently employed, on SSI.
- Smoking: quit > 16 yrs ago, 25 pack year history
- EtOH: history of abuse, last drink > 22 yrs ago
- Drugs: history of polysubstance abuse including cocaine,
crack, barbiturates, amphetamines, and marijuana. None for 20
years. 

### Response:
{'Hepatic encephalopathy,Acute kidney failure with lesion of tubular necrosis,Pneumonitis due to inhalation of food or vomitus,Acidosis,Other B-complex deficiencies,Disorders of phosphorus metabolism,Blood in stool,Acute alcoholic hepatitis,Benign neoplasm of rectum and anal canal,Anemia, unspecified,Chronic kidney disease, unspecified,Internal hemorrhoids without mention of complication,Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Other and unspecified alcohol dependence, continuous'}
