CHIEF COMPLAINT: Direct admission from clinic for hyponatremia

PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname **] is a 53-year-old male with cirrhosis due to
hepatitis C, who has decompensated with ascites, encephalopathy,
esophageal variceal bleed, hepatic hydrothorax listed for a
[**Known lastname **] who presents from clinic with worsening hyponatremia
on diuretics and tolvaptan.
.
Patient was recently discharged on [**2157-8-15**] after admission for
abdominal pain/nausea/vomiting, which resolved. On that
admission, he had hyponatremia which improved when diuretics
were held. Upon discharge, lasix 40mg daily and aldactone 300mg
daily were restarted. He was also discharged home on tolvaptan
30mg daily.
.
Sodium on discharge was 130. Current sodium is 126. As per
outpatient clinic [**Date Range **] coordinator, reports from VNA (who
has fired patient) that patient may be drinking and may be
driving. Patient denies. Also per report, patient very sleepy
this AM. Concern that this is secondary to trazodone at night.
.
On the floor, patient is asymptomatic.
.
ROS was otherwise essentially negative. The pt denied recent
unintended weight loss, fevers, night sweats, headaches,
dizziness or vertigo, changes in hearing or vision, including
amaurosis fugax, neck stiffness, lymphadenopathy, hematemesis,
coffee-ground emesis, dysphagia, odynophagia, heartburn, nausea,
vomiting, diarrhea, constipation, steatorrhea, melena,
hematochezia, cough, hemoptysis, wheezing, shortness of breath,
chest pain, palpitations, dyspnea on exertion, increasing lower
extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg
pain while walking, joint pain.
Does endorse restless legs at night.

MEDICAL HISTORY: 1. Hep C cirrhosis, followed by Dr. [**Last Name (STitle) 497**], complicated by
esophageal variceal hemorrhage, ascites, portal vein thrombosis,

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

ALLERGIES: Motrin

PHYSICAL EXAM: Vitals: T: 96.3, BP: 148/85, P: 109,  RR: 18, SaO2: 98% RA
General: Awake, alert, NAD.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no
oropharyngeal lesions
Neck: supple, no JVD, mild thyromegaly
Pulmonary: CTAB, with decreased AE in right base, no wheezes,
rhonchi or rales
Cardiac: RRR, nl S1/S2, no m/r/g
Abdomen: soft, mildly distended, no fluid wave/fluid level, NT,
mild caput medusa
Extremities: 1+ LE symmetric edema, chronic venous stasis
changes, 2+ DP/radial pulses
Skin: spider angiomata on upper chest, no palmar erythema
Neurologic: No asterixis. Alert, oriented x 3. Cranial nerves
II-XII intact. Normal bulk, strength and tone throughout. No
abnormal movements noted.

FAMILY HISTORY: Mother and father with DM

SOCIAL HISTORY: Denies substance abuse currently. Quit alcohol and drugs x 24
years ago, though concerns from VNA that he is ?drinking alcohol
again. Listed for [**Date Range **]. Lives alone in [**Location (un) 3610**]. Because
patient frequently rehospitalized, desire for more social
support. Brother, [**Name (NI) **], has agreed to take patient in at cottage
on his property. Brother and his wife not around during the day,
so talk of the mother in her 80's taking care of pt during the
day. Of note, patient has been fired by VNA.
Other disorders of neurohypophysis,Portal vein thrombosis,Acute kidney failure, unspecified,Unspecified viral hepatitis C with hepatic coma,Bacteremia,Other specified forms of effusion, except tuberculous,Unspecified protein-calorie malnutrition,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Pulmonary collapse,Acidosis,Body Mass Index between 19-24, adult,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, in remission,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Leukocytopenia, unspecified,Thrombocytopenia, unspecified,Other disorders of plasma protein metabolism,Other specified disorders of stomach and duodenum,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Anemia, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified
Neurohypophysis dis NEC,Portal vein thrombosis,Acute kidney failure NOS,Hpt C w hepatic coma NOS,Bacteremia,Effusion NEC exc tb,Protein-cal malnutr NOS,Esoph varice oth dis NOS,Pulmonary collapse,Acidosis,BMI between 19-24,adult,Klebsiella pneumoniae,Alcohol cirrhosis liver,Alcoh dep NEC/NOS-remiss,DMII wo cmp nt st uncntr,Leukocytopenia NOS,Thrombocytopenia NOS,Dis plas protein met NEC,Gastroduodenal dis NEC,Cholelithiasis NOS,Anemia NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS
Admission Date:  [**2157-8-17**]              Discharge Date:   [**2157-9-4**]

Date of Birth:  [**2104-3-11**]             Sex:   M

Service: MEDICINE

Allergies:
Motrin

Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
Direct admission from clinic for hyponatremia

Major Surgical or Invasive Procedure:
Dobhoff (nasogastric) tube placement


History of Present Illness:
Mr. [**Known firstname **] [**Known lastname **] is a 53-year-old male with cirrhosis due to
hepatitis C, who has decompensated with ascites, encephalopathy,
esophageal variceal bleed, hepatic hydrothorax listed for a
[**Known lastname **] who presents from clinic with worsening hyponatremia
on diuretics and tolvaptan.
.
Patient was recently discharged on [**2157-8-15**] after admission for
abdominal pain/nausea/vomiting, which resolved. On that
admission, he had hyponatremia which improved when diuretics
were held. Upon discharge, lasix 40mg daily and aldactone 300mg
daily were restarted. He was also discharged home on tolvaptan
30mg daily.
.
Sodium on discharge was 130. Current sodium is 126. As per
outpatient clinic [**Date Range **] coordinator, reports from VNA (who
has fired patient) that patient may be drinking and may be
driving. Patient denies. Also per report, patient very sleepy
this AM. Concern that this is secondary to trazodone at night.
.
On the floor, patient is asymptomatic.
.
ROS was otherwise essentially negative. The pt denied recent
unintended weight loss, fevers, night sweats, headaches,
dizziness or vertigo, changes in hearing or vision, including
amaurosis fugax, neck stiffness, lymphadenopathy, hematemesis,
coffee-ground emesis, dysphagia, odynophagia, heartburn, nausea,
vomiting, diarrhea, constipation, steatorrhea, melena,
hematochezia, cough, hemoptysis, wheezing, shortness of breath,
chest pain, palpitations, dyspnea on exertion, increasing lower
extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg
pain while walking, joint pain.
Does endorse restless legs at night.


Past Medical History:
1. Hep C cirrhosis, followed by Dr. [**Last Name (STitle) 497**], complicated by
esophageal variceal hemorrhage, ascites, portal vein thrombosis,

hepatic hydrothorax, episodes of encephalopathy. Last EGD on
[**2157-5-17**] showed grade I varices, portal gastropathy
2. Type II DM
3. Inguinal and umbilical hernia repair
4. history of SMV thrombus, which is patent on recent MRI

Social History:
Denies substance abuse currently. Quit alcohol and drugs x 24
years ago, though concerns from VNA that he is ?drinking alcohol
again. Listed for [**Date Range **]. Lives alone in [**Location (un) 3610**]. Because
patient frequently rehospitalized, desire for more social
support. Brother, [**Name (NI) **], has agreed to take patient in at cottage
on his property. Brother and his wife not around during the day,
so talk of the mother in her 80's taking care of pt during the
day. Of note, patient has been fired by VNA.


Family History:
Mother and father with DM


Physical Exam:
Vitals: T: 96.3, BP: 148/85, P: 109,  RR: 18, SaO2: 98% RA
General: Awake, alert, NAD.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no
oropharyngeal lesions
Neck: supple, no JVD, mild thyromegaly
Pulmonary: CTAB, with decreased AE in right base, no wheezes,
rhonchi or rales
Cardiac: RRR, nl S1/S2, no m/r/g
Abdomen: soft, mildly distended, no fluid wave/fluid level, NT,
mild caput medusa
Extremities: 1+ LE symmetric edema, chronic venous stasis
changes, 2+ DP/radial pulses
Skin: spider angiomata on upper chest, no palmar erythema
Neurologic: No asterixis. Alert, oriented x 3. Cranial nerves
II-XII intact. Normal bulk, strength and tone throughout. No
abnormal movements noted.


Pertinent Results:
[**2157-8-17**] 03:20PM BLOOD WBC-5.4 RBC-4.12* Hgb-11.9* Hct-36.4*
MCV-88 MCH-28.8 MCHC-32.7 RDW-19.0* Plt Ct-57*
[**2157-8-22**] 06:45AM BLOOD WBC-4.5 RBC-3.83* Hgb-11.0* Hct-33.9*
MCV-88 MCH-28.6 MCHC-32.4 RDW-19.1* Plt Ct-35*
[**2157-8-26**] 07:45AM BLOOD WBC-3.9* RBC-3.67* Hgb-11.0* Hct-31.9*
MCV-87 MCH-30.1 MCHC-34.6 RDW-19.5* Plt Ct-31*
[**2157-8-28**] 05:55AM BLOOD WBC-18.1*# RBC-4.72 Hgb-13.7* Hct-43.1
MCV-91 MCH-29.0 MCHC-31.8 RDW-19.5* Plt Ct-88*#
[**2157-8-28**] 04:53PM BLOOD WBC-14.4* RBC-4.20* Hgb-12.5* Hct-36.8*
MCV-88 MCH-29.7 MCHC-33.9 RDW-19.5* Plt Ct-52*
[**2157-8-29**] 03:19AM BLOOD WBC-7.0# RBC-3.37* Hgb-10.2* Hct-28.7*
MCV-85 MCH-30.2 MCHC-35.4* RDW-19.6* Plt Ct-26*
[**2157-8-31**] 06:15AM BLOOD WBC-1.8* RBC-3.17* Hgb-9.7* Hct-27.7*
MCV-87 MCH-30.5 MCHC-35.0 RDW-19.4* Plt Ct-22*
[**2157-9-2**] 06:30AM BLOOD WBC-2.4*# RBC-2.96* Hgb-9.1* Hct-26.8*
MCV-91 MCH-30.6 MCHC-33.8 RDW-19.2* Plt Ct-15*
[**2157-9-3**] 05:17AM BLOOD WBC-2.1* RBC-2.67* Hgb-8.1* Hct-23.8*
MCV-89 MCH-30.2 MCHC-33.8 RDW-19.2* Plt Ct-20*
.
[**2157-8-17**] 03:20PM BLOOD PT-17.5* INR(PT)-1.6*
[**2157-8-23**] 06:15AM BLOOD PT-17.2* PTT-32.2 INR(PT)-1.5*
[**2157-8-26**] 09:10AM BLOOD PT-18.1* PTT-33.4 INR(PT)-1.6*
[**2157-8-29**] 03:19AM BLOOD PT-20.9* PTT-70.5* INR(PT)-1.9*
[**2157-9-1**] 06:05AM BLOOD PT-19.3* PTT-150* INR(PT)-1.8*
[**2157-9-3**] 05:17AM BLOOD PT-18.0* PTT-32.1 INR(PT)-1.6*
.

[**2157-8-17**] 03:20PM BLOOD UreaN-16 Creat-0.8 Na-131* K-3.9 Cl-98
HCO3-25 AnGap-12
[**2157-8-19**] 05:25AM BLOOD Glucose-222* UreaN-19 Creat-0.9 Na-127*
K-3.7 Cl-98 HCO3-21* AnGap-12
[**2157-8-22**] 06:45AM BLOOD Glucose-246* UreaN-20 Creat-0.9 Na-131*
K-4.0 Cl-102 HCO3-24 AnGap-9
[**2157-8-25**] 06:35AM BLOOD Glucose-302* UreaN-26* Creat-1.2 Na-134
K-3.2* Cl-104 HCO3-19* AnGap-14
[**2157-8-28**] 04:53PM BLOOD Glucose-358* UreaN-52* Creat-2.5* Na-139
K-3.5 Cl-108 HCO3-12* AnGap-23*
[**2157-8-30**] 06:15AM BLOOD Glucose-141* UreaN-52* Creat-1.5* Na-130*
K-3.2* Cl-99 HCO3-22 AnGap-12
[**2157-9-3**] 05:17AM BLOOD Glucose-313* UreaN-24* Creat-0.7 Na-139
K-3.8 Cl-109* HCO3-25 AnGap-9
.
[**2157-8-18**] 06:30AM BLOOD ALT-33 AST-44* LD(LDH)-246 AlkPhos-73
TotBili-2.3*
[**2157-8-28**] 05:55AM BLOOD ALT-37 AST-46* LD(LDH)-300* AlkPhos-89
TotBili-3.4*
[**2157-8-31**] 06:15AM BLOOD ALT-22 AST-34 LD(LDH)-163 AlkPhos-54
TotBili-3.0*
[**2157-9-3**] 05:17AM BLOOD ALT-18 AST-28 LD(LDH)-195 AlkPhos-54
TotBili-1.6*
.
[**2157-8-17**] 03:20PM BLOOD Albumin-2.6* Calcium-8.7 Phos-2.6* Mg-1.9
[**2157-8-24**] 06:05AM BLOOD Albumin-2.5* Calcium-7.9* Phos-3.4 Mg-1.7
[**2157-8-27**] 06:10AM BLOOD Albumin-2.4* Calcium-8.0* Phos-2.7 Mg-1.8
[**2157-8-30**] 06:15AM BLOOD Albumin-2.7* Calcium-8.3* Phos-2.4*
Mg-2.0
[**2157-9-2**] 06:30AM BLOOD Albumin-3.2* Calcium-8.0* Phos-0.9*
Mg-2.0
[**2157-9-3**] 05:17AM BLOOD Albumin-3.1* Calcium-8.1* Phos-2.1*
Mg-1.8
.
[**2157-8-18**] 06:30AM BLOOD calTIBC-244* Ferritn-79 TRF-188*
.
[**2157-9-2**] 06:30AM BLOOD %HbA1c-6.8* eAG-148*
.
[**2157-8-17**] 03:20PM BLOOD Ethanol-NEG
.
[**2157-8-28**] 08:22AM BLOOD Type-ART pO2-110* pCO2-19* pH-7.26*
calTCO2-9* Base XS--16
[**2157-8-28**] 08:25PM BLOOD Type-ART pO2-95 pCO2-25* pH-7.45
calTCO2-18* Base XS--4
.
[**2157-8-28**] 08:22AM BLOOD Lactate-8.9*
[**2157-8-29**] 09:32AM BLOOD Lactate-1.1
.
[**2157-8-18**] 01:43AM URINE Hours-RANDOM UreaN-921 Creat-138 Na-14
K-44 Cl-16
[**2157-8-29**] 09:57AM URINE Hours-RANDOM UreaN-630 Creat-132 Na-LESS
THAN  K-23 Cl-21
[**2157-8-17**] 03:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG marijua-NEG
.
[**2157-8-26**] 10:59AM PLEURAL WBC-210* RBC-340* Polys-15* Lymphs-23*
Monos-0 Meso-2* Macro-60*
[**2157-8-26**] 10:59AM PLEURAL TotProt-0.3 LD(LDH)-44 TotBili-0.1
Albumin-LESS THAN  Cholest-0
.
MICROBIOLOGY:
[**2157-8-28**] 5:55 am BLOOD CULTURE      Source: Venipuncture.

                            **FINAL REPORT [**2157-8-31**]**

   Blood Culture, Routine (Final [**2157-8-30**]):
      KLEBSIELLA PNEUMONIAE.    FINAL SENSITIVITIES.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
.
Blood and urine cultures ([**2157-8-28**] - discharge) - no growth to
date
.
C. diff toxin ([**9-1**] and [**9-2**]) - negative x2
.
IMAGING
CXR ([**8-22**])
There is a moderate right-sided pleural effusion that is
increased in size
compared to the prior exam. The right upper lung and left lung
are clear
without infiltrate.
.
CXR ([**8-24**])
IMPRESSION: AP chest compared to [**7-20**] through [**8-22**]:

The large right pleural effusion has increased in volume
substantially, now
displacing the mediastinum to the left and producing severe
atelectasis of
much of the right lung. Detail in the left lung is obscured by
respiratory
motion, but there appears to be atelectasis at the base. Heart
is probably
not changed in size but difficult to assess because of
displacement.

Nasogastric tube ends in the upper stomach but would need to be
advanced at
least 6 cm to move all the side ports beyond the
gastroesophageal junction.

Although hepatic hydrothorax is one explanation for the
dramatically enlarging
right pleural effusion, empyema is another.
.
CXR ([**8-29**])
IMPRESSION: Stable moderate right pleural effusion. Increasing
retrocardiac
opacity, likely atelectasis.
.
Doppler abd U/S ([**8-28**])
IMPRESSION:
1. Nonvisualization of the main portal vein, which was occluded
on prior
studies. The left portal vein may have been visualized.
2. Patency of the right hepatic vein, left hepatic vein, main
hepatic artery
and IVC.
3. Extensive varices. Trace abdominal ascites.
4. Gallbladder edema and stones. Gallbladder edema likely
secondary to
hepatic dysfunction.
5. Right pleural effusion.
6. Cirrhosis and splenomegaly.
.
LABS ON DISCHARGE
.
Na+ 130, Cr 0.7, Glucose 340, Phos 1.8
T. bili 17, Alb 2.8, MELD 24
WBC 2.4, Hct 24.5, Plat 24
INR 1.7

Brief Hospital Course:
53 yo man with hep C cirrhosis (c/b ascites, encephalopathy,
esophageal variceal bleed, hepatic hydrothorax), initially
presenting with hyponatremia and lethargy, with hospitalization
complicated by acute episodes of encephalopathy secondary to
sedating meds, Klebsiella bacteremia and new portal venous
thrombosis.
.
#. Encephalopathy [**1-18**] Klebsiella bacteremia: On [**8-28**], the
patient became very sleepy and was difficult to arouse in the
morning.  He had been acutely encephalopathic previously likely
secondary to compazine, treated with lactulose with good effect.
 He was transferred to the intensive care unit with a
pan-sensitive Klebsiella and antibiotics were narrowed from
piperacillin-tazobactam to ceftriaxone.   He then developed
leukopenia, which we attributed to administration of Zosyn,
given the time course of the WBC decline.  The patient was never
febrile and was, in fact, hypertensive on transfer from floor to
SICU.  He continued to improve clinically and a PICC line was
placed for continued treatment for bacteremia with ceftriaxone
for 2 weeks from his last clear culture on [**8-30**], to end on [**9-13**].

.
#. New portal vein thrombosis and hematologic complications:
Abdominal U/S with dopplers was performed upon transfer to the
ICU as part of the work-up during his decompensation and
revealed a portal vein thrombosis.  It was confirmed with
Radiology that this was a new thrombus, as they believed the
previous read indicating the presence of a thrombus in an U/S
study done on [**2157-7-26**] was incorrect. He was started on a
heparin gtt initially and it was noticed that his platelets
counts had been steadily decreasing since the day of transfer
from 88 to a nadir of 15.  The drip was stopped and at this time
and the hematology service was consulted.  It was decided not to
send a HIT panel, given his low "4T" score of 3, a measurement
of the likelihood that heparin was responsible for the decline.
It was also recommended to not restart anticoagulation given the
low platelets.  We weighed the risks and benefits of restarting
anticoagulation and ultimately decided not to.  Platelet count
should be followed up as an outpatient and anticoagulation
therapy should be considered when platelets are stable between
25 and 40 for at least one week.
.
#. Hyponatremia: On admission, sodium was 125.  We held his
diuretics and started him on a fluid restriction.  His
tolvaptan, which he had been taking for 3 months, was then
discontinued, as it did not appear to be having a beneficial
effect on his sodium.  He stabilized around 130, and now has
continued to trend up toward the normal range, as he abides by
his fluid restriction and has been getting tube feeds.  Sodium
on discharge was 130.  He should be kept on a 1.5L fluid
restriction to help control his sodium.
.
#. Anemia: The patient's hematocrit had a discrete drop from
[**8-28**] to [**8-29**] (36 to 28)during this hospitalization, before
eventually stabilizing.  He did not have any signs of acute GI
bleeding and an EGD revealed friable gastric mucosa, likely
attributable to portal gastropathy secondary to portal
hypertension.
.
#. Acute renal failure: Upon becoming septic, the patient had a
creatinine bump from 1.0 to 2.5.  This improved with albumin
administration and gradually trended down to baseline as the
patient's clinical status improved.
.
#. Diabetes Mellitus: His blood glucose readings were
consistently high and he failed uptitration of oral
hypoglycemics (glipizide and metformin) to help control them,
along with an insulin sliding scale.  On uptitration of
metformin, he developed this septic picture with lactic
acidosis, raising the suspicion that metformin was somehow
involved.  Tolvaptan can also cause hyperglycemia, but the
discontinuation of this medication did not seem to help much.
While on his tube feeds, fingerstick readings continued to
climb, ranging between 300 and 500 and the patient was started
on long-acting Lantus in the evenings.  He will be monitored on
an insulin sliding scale and Lantus at the long-term acute care
facility and will need to be taught how to administer these
injections upon discharge back home.
.
#. Right pleural effusion / hepatic hydrothorax: Patient had
intermittent desaturations, but was mostly comfortable on room
air and the effusion looked to be stable, after a thoracentesis
took off 3.3L on [**8-26**].  He may have reaccumulated in the setting
of being off diuretics, but his respiratory status is stable on
discharge.
.
#. Social issues: Social work and case management has been
working with Mr. [**Known lastname **] and his family/friends to work out a
schedule to keep an eye of him for 24 hours a day.  A family
meeting was held during his admission, where we discussed issues
that will need to be addressed at home, with respect to
nutritional status/tube feeds, constant supervision, and
medication compliance.  He will be discharged to an LTAC
facility before going home and this schedule of care still needs
to be worked out among the caretakers at home.
.
#. Nutritional status: A Dobhoff tube was successfully placed
under EGD guidance and secured to the duodenum.  This will
prevent the tube from coming out with retching and vomiting, as
the patient managed to do on 2 separate occassions.  He is on
tube feeds now at his goal rate, per nutrition recommendations,
to supplement his diet.  He developed mild re-feeding syndrome
with low phosphorus level that we supplemented.  He should also
continue to have Ensure supplements with all meals as well as
phosphate repletion based on his laboratory results.  Continuing
to supplement his nutrition will be very important in preparing
him for a good outcome from liver [**Known lastname **] in the future.
.
#. Depression - During his hospitalization, Mr. [**Known lastname **] expressed
suicidality with a plan and the Psychiatry was consulted to
evaluate him.  They recommended starting him on a low-dose
antidepressant and Citalopram 10mg was started.  He was kept on
precautions with a 1:1 sitter for 2 days until he was able to
contract for his safety.
.
#. Hepatitis C cirrhosis: He was continued on lactulose and
rifaximin.  His abdomen was distended for much of this
admission, but a paracentesis was unsuccessful and ultrasound
proved that there was minimal ascites.  His hepatic hydrothoraz
is stable and not causing any respiratory difficulties.  He did
not have any GI bleeds during the hospitaliation.  He will be
following up with Dr. [**Last Name (STitle) 497**] to discuss the options of moving to
[**State 108**] to get on their [**State **] list.
.
==========================================================
Issues for follow-up
.
1) Portal vein thrombosis - If patient's platelet count is
stable between 25-40 for 1 week, he can safely be started on
anticoagulation therapy.
.
2) Thrombocytopenia - Please check bloodwork every 5 days,
starting on [**2157-9-9**] (CBC, Chemistry 10, ALT, AST, total
bilirubin, PT/INR).  These results should be reported to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] or [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 673**].
.
3) Hyponatremia - Patient should be continued on a 1.5L fluid
restriction along with lab draws every 5 days, to be reported to
his outpatient [**Telephone/Fax (1) **] hepatologist, Dr. [**Last Name (STitle) 497**].
.
4) Depression - Patient needs to be screened for depression
regularly, as he expressed suicidality during this admission and
is now on an SSRI.
.
5) Diabetes mellitus - Maintain patient on an insulin sliding
scale with PM Lantus, with fingersticks 4 times a day.  Patient
should also be taught how to administer insulin, for preparation
on discharge to home.


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

2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO four
times a day.
6. Tolvaptan 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QWED (every Wednesday).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

11. Metformin 1,000 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
12. Spironolactone 100 mg Tablet Sig: Three (3) Tablet PO once a
day.
13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO QHS

Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*6 Tablet(s)* Refills:*0*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO QHS (once a day (at
bedtime)).
8. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1)  Intravenous Q24H (every 24 hours) for 10 days:
Antibiotic course to end on [**9-13**].
9. Citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Insulin
Start Lantus 36 units QHS with finger sticks QID and humalog
sliding scale as attached in paperwork.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Primary diagnoses:
Klebsiella bacteremia
Portal vein thrombosis
Hyponatremia
Hypoalbuminemia
Acute renal failure
Depression
Lactic acidosis
Diabetes Mellitus II
Leukopenia
Thrombocytopenia

Secondary diagnoses:
Alcoholic cirrhosis


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


Discharge Instructions:
It was a pleasure treating you at [**Hospital3 **] Medical Center.
You were admitted from the clinic with increasing sleepiness,
low sodium level in your blood, and nutrition issues.  We did
not give you any sedating medications and you were more awake
and less confused.  In order to increase your sodium levels, we
stopped your diuretics, restricted the amount of fluids you
could drink, and discontinued your "tolvaptan" medication.  We
started tube feedings to help with your nutrition.  We also had
a family meeting to discuss how you would be cared for at home.

.
During your hospitalization, you became very sleepy and we had
to send you to the Intensive Care unit.  We found that you had
an infection in your blood, which we have been treating properly
with antibiotics.  Another imaging test of your abdomen showed
us that you had a new clot in your "portal vein" of your liver.
However, your platelet count was too low for us to start you on
blood thinners safely.  Therefore, we felt that since you were
feeling much better, we would not treat this clot for now.
.
Your blood sugars were also very high and we were not able to
control them with your previous diabetes medications, glipizide
and metformin.  We started a long-acting insulin called
"glargine" or "Lantus" that should help control your blood
sugars a little better.  You will also need to take short-acting
insulin during the day, depending on your glucose level from
your fingersticks 4 times a day.

You also felt depressed and suicidal during your
hospitalization, but this resolved. We started you on an
anti-depressant medication called citalopram. CALL 911
IMMEDIATELY IF YOU ARE EVER FEELING LIKE YOU WANT TO HURT
YOURSELF OR ANYONE ELSE.

The following changes have been made to your medications:
START Lantus 36 units every evening before bed with a Humalog
insulin sliding scale.
START Ceftriaxone IV 1g daily until [**9-13**]
START Citalopram 10mg daily for depression
STOP Tolvaptan
STOP Lasix 40mg daily
STOP Spironolactone 100mg 3 tabs daily
STOP Glipizide 5mg daily
STOP Metformin 1g daily
STOP Trazodone 25mg every night

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 497**] in the [**Last Name (STitle) **] center
[**Telephone/Fax (1) 673**] this week. Your facility can call to make this
appointment or Dr. [**Last Name (STitle) 497**]/[**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] will contact you with this
appointment.

Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2157-11-2**] 10:00
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2157-11-2**] 10:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2157-11-2**]
10:30
{"Other disorders of neurohypophysis,Portal vein thrombosis,Acute kidney failure, unspecified,Unspecified viral hepatitis C with hepatic coma,Bacteremia,Other specified forms of effusion, except tuberculous,Unspecified protein-calorie malnutrition,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Pulmonary collapse,Acidosis,Body Mass Index between 19-24, adult,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, in remission,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Leukocytopenia, unspecified,Thrombocytopenia, unspecified,Other disorders of plasma protein metabolism,Other specified disorders of stomach and duodenum,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Anemia, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified"}


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: Direct admission from clinic for hyponatremia

PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname **] is a 53-year-old male with cirrhosis due to
hepatitis C, who has decompensated with ascites, encephalopathy,
esophageal variceal bleed, hepatic hydrothorax listed for a
[**Known lastname **] who presents from clinic with worsening hyponatremia
on diuretics and tolvaptan.
.
Patient was recently discharged on [**2157-8-15**] after admission for
abdominal pain/nausea/vomiting, which resolved. On that
admission, he had hyponatremia which improved when diuretics
were held. Upon discharge, lasix 40mg daily and aldactone 300mg
daily were restarted. He was also discharged home on tolvaptan
30mg daily.
.
Sodium on discharge was 130. Current sodium is 126. As per
outpatient clinic [**Date Range **] coordinator, reports from VNA (who
has fired patient) that patient may be drinking and may be
driving. Patient denies. Also per report, patient very sleepy
this AM. Concern that this is secondary to trazodone at night.
.
On the floor, patient is asymptomatic.
.
ROS was otherwise essentially negative. The pt denied recent
unintended weight loss, fevers, night sweats, headaches,
dizziness or vertigo, changes in hearing or vision, including
amaurosis fugax, neck stiffness, lymphadenopathy, hematemesis,
coffee-ground emesis, dysphagia, odynophagia, heartburn, nausea,
vomiting, diarrhea, constipation, steatorrhea, melena,
hematochezia, cough, hemoptysis, wheezing, shortness of breath,
chest pain, palpitations, dyspnea on exertion, increasing lower
extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg
pain while walking, joint pain.
Does endorse restless legs at night.

MEDICAL HISTORY: 1. Hep C cirrhosis, followed by Dr. [**Last Name (STitle) 497**], complicated by
esophageal variceal hemorrhage, ascites, portal vein thrombosis,

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

ALLERGIES: Motrin

PHYSICAL EXAM: Vitals: T: 96.3, BP: 148/85, P: 109,  RR: 18, SaO2: 98% RA
General: Awake, alert, NAD.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no
oropharyngeal lesions
Neck: supple, no JVD, mild thyromegaly
Pulmonary: CTAB, with decreased AE in right base, no wheezes,
rhonchi or rales
Cardiac: RRR, nl S1/S2, no m/r/g
Abdomen: soft, mildly distended, no fluid wave/fluid level, NT,
mild caput medusa
Extremities: 1+ LE symmetric edema, chronic venous stasis
changes, 2+ DP/radial pulses
Skin: spider angiomata on upper chest, no palmar erythema
Neurologic: No asterixis. Alert, oriented x 3. Cranial nerves
II-XII intact. Normal bulk, strength and tone throughout. No
abnormal movements noted.

FAMILY HISTORY: Mother and father with DM

SOCIAL HISTORY: Denies substance abuse currently. Quit alcohol and drugs x 24
years ago, though concerns from VNA that he is ?drinking alcohol
again. Listed for [**Date Range **]. Lives alone in [**Location (un) 3610**]. Because
patient frequently rehospitalized, desire for more social
support. Brother, [**Name (NI) **], has agreed to take patient in at cottage
on his property. Brother and his wife not around during the day,
so talk of the mother in her 80's taking care of pt during the
day. Of note, patient has been fired by VNA. 

### Response:
{"Other disorders of neurohypophysis,Portal vein thrombosis,Acute kidney failure, unspecified,Unspecified viral hepatitis C with hepatic coma,Bacteremia,Other specified forms of effusion, except tuberculous,Unspecified protein-calorie malnutrition,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Pulmonary collapse,Acidosis,Body Mass Index between 19-24, adult,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, in remission,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Leukocytopenia, unspecified,Thrombocytopenia, unspecified,Other disorders of plasma protein metabolism,Other specified disorders of stomach and duodenum,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Anemia, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified"}
