CHIEF COMPLAINT: Confusion/lethargy

PRESENT ILLNESS: This is a 61 yom with Hep C cirrhosis genotype I with grade II
varices and hepatic encephalopathy on lactulose/rifaximin with
calculated MELD score of 22 as of [**2174-8-11**].  He is currently
on the liver Tx list with workup complete.  He was recently
admitted on [**6-/2174**] for volume overload now presenting with
confusion and lethargy.  Most of the history is obtained from
his daughter who reports an acute decompensation yesterday with
increaed confusion.  He has been taking lactulose 6x/day in
addition to miralax but has not had any BM for 2 days.  He
denies any increase in ascites, fevers, CP, SOB, abd pain, or
increased swelling of his extremities.  His daughter does note
an increase in his jaundice.  He denies any blood in his stool
or melena.
.
On the floor, pt is interactive but slow to respond and appears
to be searching for words.  He appears frustrated by his
confusion.

MEDICAL HISTORY: 1. HCV cirrhosis: genotype I
-grade II varices no h/o variceal bleeding
-hepatic encephalopathy on lactulose/rifaximin (admitted [**Month (only) **]
[**2173**] and [**2174-6-27**])
2. IDDM
3. Hemorrhoids

MEDICATION ON ADMISSION: Calcium plus D3
clotrimazole 10mg troche 5x daily
Vitmain D2 [**Numeric Identifier 1871**] U q week
lasix 20mg po bid
levemir 5U nightly
humalog up to 20U daily as needed
lactulose 30ml po 6x daily
nadolol 20mg po daily
omeprazole 20mg po daily
polyethylene glycol 3350 17g powder daily when no BM
rifaximin 550mg po bid
spironalactone 50mg po daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
Vitals: 97.3   130/80   55  18  100% RA
General:  Pleasant AA male in NAD.  He is oriented to person,
place and year, but not month.
HEENT: OP dry, EOM intact.  Scleral icterus present
Neck: Supple
Heart: RRR no m/r/g
Lungs: CTAB
Abdomen: Soft, NT, ND, no palpable liver
Extremities: Trace edema bilaterally in the LE
Neurological: A/o x2.5.  asterixis present

FAMILY HISTORY: Mom with DM.

SOCIAL HISTORY: Married, has 3 daughters. [**Name (NI) **] works as an engineer at Teradyne
(on short-term disability). He denies any alcohol use or tobacco
use. Remote history of IVDA.
Chronic hepatitis C with hepatic coma,Hepatorenal syndrome,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Unspecified septicemia,Severe sepsis,Septic shock,Hyposmolality and/or hyponatremia,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Nontraumatic compartment syndrome of abdomen,Other and unspecified coagulation defects,Hemorrhage complicating a procedure,Epistaxis,Cirrhosis of liver without mention of alcohol,Thrombocytopenia, unspecified,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Awaiting organ transplant status,Long-term (current) use of insulin,Hip joint replacement,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Chrnc hpt C w hepat Coma,Hepatorenal syndrome,Ac kidny fail, tubr necr,Acute respiratry failure,Septicemia NOS,Severe sepsis,Septic shock,Hyposmolality,Esoph varice oth dis NOS,Nontrauma comp syn-abd,Coagulat defect NEC/NOS,Hemorrhage complic proc,Epistaxis,Cirrhosis of liver NOS,Thrombocytopenia NOS,Chr pulmon heart dis NEC,DMII wo cmp nt st uncntr,Await organ transplnt st,Long-term use of insulin,Joint replaced hip,Abn react-surg proc NEC
Admission Date:  [**2174-8-18**]              Discharge Date:   [**2174-8-29**]

Date of Birth:  [**2112-11-24**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Confusion/lethargy

Major Surgical or Invasive Procedure:
[**2174-8-24**]: Esophagogastroduodenoscopy
[**2174-8-25**]: Visceral angiography, intracranial angiography with
embolization
[**2174-8-25**]: Exploratory laparotomy, decompressive laparotomy
[**2174-8-25**]: Abdominal washout
[**2174-8-27**]: Abdominal washout

History of Present Illness:
This is a 61 yom with Hep C cirrhosis genotype I with grade II
varices and hepatic encephalopathy on lactulose/rifaximin with
calculated MELD score of 22 as of [**2174-8-11**].  He is currently
on the liver Tx list with workup complete.  He was recently
admitted on [**6-/2174**] for volume overload now presenting with
confusion and lethargy.  Most of the history is obtained from
his daughter who reports an acute decompensation yesterday with
increaed confusion.  He has been taking lactulose 6x/day in
addition to miralax but has not had any BM for 2 days.  He
denies any increase in ascites, fevers, CP, SOB, abd pain, or
increased swelling of his extremities.  His daughter does note
an increase in his jaundice.  He denies any blood in his stool
or melena.
.
On the floor, pt is interactive but slow to respond and appears
to be searching for words.  He appears frustrated by his
confusion.

Past Medical History:
1. HCV cirrhosis: genotype I
-grade II varices no h/o variceal bleeding
-hepatic encephalopathy on lactulose/rifaximin (admitted [**Month (only) **]
[**2173**] and [**2174-6-27**])
2. IDDM
3. Hemorrhoids

Past Surgical History:
R hip replacement x 2, remote appendectomy.

Social History:
Married, has 3 daughters. [**Name (NI) **] works as an engineer at Teradyne
(on short-term disability). He denies any alcohol use or tobacco
use. Remote history of IVDA.


Family History:
Mom with DM.

Physical Exam:
ADMISSION EXAM
Vitals: 97.3   130/80   55  18  100% RA
General:  Pleasant AA male in NAD.  He is oriented to person,
place and year, but not month.
HEENT: OP dry, EOM intact.  Scleral icterus present
Neck: Supple
Heart: RRR no m/r/g
Lungs: CTAB
Abdomen: Soft, NT, ND, no palpable liver
Extremities: Trace edema bilaterally in the LE
Neurological: A/o x2.5.  asterixis present

DISCHARGE EXAM
Expired

Pertinent Results:
ADMISSION LABS:

[**2174-8-18**] 04:40PM BLOOD WBC-4.9 RBC-2.69* Hgb-8.9* Hct-27.4*
MCV-102* MCH-33.2* MCHC-32.6 RDW-18.4* Plt Ct-42*
[**2174-8-18**] 04:40PM BLOOD Neuts-56.7 Lymphs-31.4 Monos-11.2*
Eos-0.2 Baso-0.4
[**2174-8-18**] 04:40PM BLOOD PT-30.3* PTT-62.3* INR(PT)-3.0*
[**2174-8-18**] 04:40PM BLOOD Glucose-177* UreaN-15 Creat-1.1 Na-117*
K-5.0 Cl-87* HCO3-25 AnGap-10
[**2174-8-18**] 04:40PM BLOOD ALT-182* AST-492* LD(LDH)-630*
AlkPhos-218* TotBili-8.2*
[**2174-8-18**] 04:40PM BLOOD Albumin-1.9* Calcium-9.2 Phos-2.9 Mg-1.7
Iron-130

CT abdomen/pelvis [**2174-8-24**]:
1. No intra-abdominal hemorrhage.
2. Sequelae of portal hypertension including varices and
moderate perihepatic simple ascites.
3. Severe degenerative changes of the left hip.

Visceral arteriography [**2174-8-25**]:
1. Normal celiac artery angiogram with selective catheterization
of the gastroduodenal artery and left gastric artery.
2. Normal superior mesenteric artery angiogram.
3. No active arterial extravasation from the visceral aortic
branches.

TTE [**2174-8-26**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). There is a mild resting left
ventricular outflow tract obstruction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2174-7-4**], the
LV cavity is slightly smaller, there is some turbulence in the
LVOT with a mild functional outflow tract gradient.

TTE [**2174-8-28**]:
The left atrium and right atrium are normal in cavity size. Left
ventricular systolic function is hyperdynamic (EF>75%). No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. There is no mitral valve prolapse. No
mass or vegetation is seen on the mitral valve. Physiologic
mitral regurgitation is seen (within normal limits). Tricuspid
regurgitation is present but cannot be quantified. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. No interval change in comparison to [**2174-8-26**].

Brief Hospital Course:
61-year-old African-American pleasant male with genotype 1
hepatitis C-induced cirrhosis who is on the liver transplant
list presenting with confusion/lethargy [**12-29**] to encephalopathy
and/or hyponatremia.
.
Pertaining to his hospital course [**2174-8-18**] to [**2174-8-24**]:
.
# Hep C cirrhosis with HE:  Pt is on the liver transplant list
with Meld of 28 on admission. Family had noted an increase in
confusion over past few days prior to admission in setting of
not having BMs despite taking his lactulose and miralax.
Patient was given frequent lactulose with miralax and started
stooling adequately. Mental status and asterixis was waxing and
[**Doctor Last Name 688**] throughout his hospital stay.   He was also continued on
rifaximin and nadolol. His infectious workup was negative. His
lasix was initially held given hyponatremia.
.
# Hyponatremia:  Pt with Na+ of 117 on admisssion.  He has
chronically low sodium, however his baseline was 125. His renal
ultrasound was normal. Renal was consulted and after he did not
respond to fluid restriction, he was started on one dose of
tolvaptan, however did not respond and this was discontinued.
After starting the tolvaptan his urinary output decreased and
there was concern for HRS. He was about to be challenged with a
volume challenge when he was no longer holding his pressures and
required transfer to the unit.
.
# DM - Pt was given 5U of glargine nightly (takes levamir at
home). He was also maintained on insulin sliding scale while in
the hospital.
.
On [**8-24**]- the patient became oliguric, and developed hypotension
despite fluid bolus and hypothermia and was felt that he could
have sepsis of unknown origin and he was transferred to the
SICU.

Pertaining to his hospital course [**2174-8-24**] to [**2174-8-29**]:
.
On [**2174-8-24**], the patient was transferred to the SICU on the
transplant surgery service for hypothermia (T 93) and
hypotension (SBP 80).  Blood and urine cultures were repeated,
which showed no growth.  Blood was also negative for fungemia.
He was transfused 2u PRBC for hct 24.7, after which hct 22.1.
Rectal exam revealed positive occult blood without gross blood.
Nasogastric lavage revealed coffee grounds fluid which did not
clear significantly after 1L lavage.  He was further transfused
and started on octreotide and pantoprazole gtts.  He was
intubated and EGD found no obvious source of bleeding.
Bronchoscopy found no obvious bleed.  He developed epistaxis,
for which ENT was consulted, and his nasopharynx was packed.
.
On [**2174-8-25**], he was taken to IR.  Arteriography of the celiac
and superior mesenteric arteries revealed no obvious UGI bleed.
Bilateral inferior maxillary arteries were embolized for his
continued epistaxis.  At the end of the procedure, his abdomen
was distended and he was increasingly difficult to ventilate.
He was brought emergently to the operating room for
decompressive laparotomy, which revealed no intraperitoneal
bleed or hematoma.  He was left with an open abdomen and
returned to the SICU.  He developed worsening hypotension,
requiring norepinephrine gtt, and his abdomen was re-explored,
revealing some blood, but insufficient to explain his
transfusion requirements.  Bloodwork (low haptoglobin, high LDH)
suggested hemolysis with no clear aetiology.
.
On [**2174-8-26**], hypothermia resolved and CVVH was started for
worsening renal function.  He continued to have a mild ooze from
his nose and mouth and was transfused for hct <30.
.
On [**2174-8-27**], he underwent abdominal washout at the bedside,
which was unrevealing.  There was again no obvious source of
bleeding.  The bowel appeared less edematous and the Ioban
dressing was replaced.  Post-operatively, he required additional
vasopressors, and vasopressin gtt was added.  For sedation,
propofol gtt was changed to fentanyl and midazolam gtts.
Cortisol stimulation test was equivocal.
.
On [**2174-8-28**], he remained hypotensive and continued to bleed
from JP, NGT, left ear, and mouth. Refractory hypotension to
pressors, some response to volume. Bedside ECHO showed
hyperdynamic empty LV and hypodynamic strained RV with PAP in
the 60's. started nitric oxide with improved BP, PaO2.  Switched
to meropenem and Micafungin for broad empiric coverage. brief
episode of Afib with RVR. Spontaneous conversion to SR.
Delisted from liver transplant list on account of his critical
illness.  Overnight, his hypotension worsened, requiring up to
three vasopressors, though these were weaned to one by morning.
.
On [**2174-8-29**], in the morning, he received 2 units PRBCs for a
hematocrit of 26.1, with response in hematocrit to 30.6, but
subsequent continued decline to 29.1.  He received 1 unit of
frozen plasma with no subsequent change in INR.  In the early
afternoon, per the patient's family's request, the patient was
rendered comfort measures only, and he died at 14:20.

Medications on Admission:
Calcium plus D3
clotrimazole 10mg troche 5x daily
Vitmain D2 [**Numeric Identifier 1871**] U q week
lasix 20mg po bid
levemir 5U nightly
humalog up to 20U daily as needed
lactulose 30ml po 6x daily
nadolol 20mg po daily
omeprazole 20mg po daily
polyethylene glycol 3350 17g powder daily when no BM
rifaximin 550mg po bid
spironalactone 50mg po daily


Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
Expired.

Discharge Condition:
Expired.

Discharge Instructions:
He who has gone, so we but cherish his memory.

Followup Instructions:
None.


Completed by:[**2174-8-30**]
{'Chronic hepatitis C with hepatic coma,Hepatorenal syndrome,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Unspecified septicemia,Severe sepsis,Septic shock,Hyposmolality and/or hyponatremia,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Nontraumatic compartment syndrome of abdomen,Other and unspecified coagulation defects,Hemorrhage complicating a procedure,Epistaxis,Cirrhosis of liver without mention of alcohol,Thrombocytopenia, unspecified,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Awaiting organ transplant status,Long-term (current) use of insulin,Hip joint replacement,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: Confusion/lethargy

PRESENT ILLNESS: This is a 61 yom with Hep C cirrhosis genotype I with grade II
varices and hepatic encephalopathy on lactulose/rifaximin with
calculated MELD score of 22 as of [**2174-8-11**].  He is currently
on the liver Tx list with workup complete.  He was recently
admitted on [**6-/2174**] for volume overload now presenting with
confusion and lethargy.  Most of the history is obtained from
his daughter who reports an acute decompensation yesterday with
increaed confusion.  He has been taking lactulose 6x/day in
addition to miralax but has not had any BM for 2 days.  He
denies any increase in ascites, fevers, CP, SOB, abd pain, or
increased swelling of his extremities.  His daughter does note
an increase in his jaundice.  He denies any blood in his stool
or melena.
.
On the floor, pt is interactive but slow to respond and appears
to be searching for words.  He appears frustrated by his
confusion.

MEDICAL HISTORY: 1. HCV cirrhosis: genotype I
-grade II varices no h/o variceal bleeding
-hepatic encephalopathy on lactulose/rifaximin (admitted [**Month (only) **]
[**2173**] and [**2174-6-27**])
2. IDDM
3. Hemorrhoids

MEDICATION ON ADMISSION: Calcium plus D3
clotrimazole 10mg troche 5x daily
Vitmain D2 [**Numeric Identifier 1871**] U q week
lasix 20mg po bid
levemir 5U nightly
humalog up to 20U daily as needed
lactulose 30ml po 6x daily
nadolol 20mg po daily
omeprazole 20mg po daily
polyethylene glycol 3350 17g powder daily when no BM
rifaximin 550mg po bid
spironalactone 50mg po daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
Vitals: 97.3   130/80   55  18  100% RA
General:  Pleasant AA male in NAD.  He is oriented to person,
place and year, but not month.
HEENT: OP dry, EOM intact.  Scleral icterus present
Neck: Supple
Heart: RRR no m/r/g
Lungs: CTAB
Abdomen: Soft, NT, ND, no palpable liver
Extremities: Trace edema bilaterally in the LE
Neurological: A/o x2.5.  asterixis present

FAMILY HISTORY: Mom with DM.

SOCIAL HISTORY: Married, has 3 daughters. [**Name (NI) **] works as an engineer at Teradyne
(on short-term disability). He denies any alcohol use or tobacco
use. Remote history of IVDA. 

### Response:
{'Chronic hepatitis C with hepatic coma,Hepatorenal syndrome,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Unspecified septicemia,Severe sepsis,Septic shock,Hyposmolality and/or hyponatremia,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Nontraumatic compartment syndrome of abdomen,Other and unspecified coagulation defects,Hemorrhage complicating a procedure,Epistaxis,Cirrhosis of liver without mention of alcohol,Thrombocytopenia, unspecified,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Awaiting organ transplant status,Long-term (current) use of insulin,Hip joint replacement,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
