CHIEF COMPLAINT: fever, somnolence

PRESENT ILLNESS: 57 yo F c PBC c/b cirrhosis, HCC s/p segmentectomies x 2 ([**2-14**],
[**6-17**]) and recurrence s/p TACE of R, L hepatic arteries ([**7-19**],
[**8-19**]) c/b biliary ischemia and hepatic abscesses growing
separate pansensitive and ciprofloxacin-resistant <i>Pseudomonas
aeruginosa</i> s/p surgical drain placement in [**2122-11-10**] and
indefinite inititation of home IV meropenem.  Interval imaging
showed decrease in abscess size in [**Month (only) 404**]; her last imaging was
a CT scan on [**2123-1-18**] and showed no change in abscess size since
[**Month (only) 404**] and showed intrahepatic biliary dilatation, as well as
ill-defined opacity in caudate lobe worrisome for tumor
recurrence.  Her AFP was documented as 4.2 at that time and she
was scheduled for ERCP for stent placement.  ERCP was performed
[**2123-1-26**] and revealed no evidence of extrahepatic biliary
stricturing, diffuse stenosis of intrahepatic ducts with no
lesion appropriate for stent placement.
.
Since the ERCP, patient has noted increased somnolence and
fatigue; she has been falling asleep during conversations and
has trouble going up and down stairs.  On day prior to
admission, she was noted to have temperature on VNA assessment
of 100.0 and was noted to have WBC count of 2.5 on lab draw.
Patient said that her skin felt warm but she denied feeling
feverish, chills, or night sweats.  Patient endorses increased
abdominal distention and LE edema over last two weeks; she is
unclear as to whether she has gained weight recently.  Stable,
chronic, non-radiating RUQ pain well controlled with oxycodone
prn.  Patient was admitted from clinic today after detailing
these complaints for management of suspected infection and
possible hepatic encephalopathy.
.
Currently, patient is resting comfortably in the hospital bed
and is lucid, oriented x 3, and without acute complaints.
.
ROS: See HPI.  Patient complains of mild HA, nasal congestion x
2 days with no associated sinus congestion or SOB.  Mild cough x
2 days slightly productive of sputum.  Altered taste and poor
appetite.    Denies CP, N/V/D/C, dysuria.

MEDICAL HISTORY: ONCOLOGIC HISTORY
1. [**2-14**]: Resection of segment VII HCC
2. [**6-17**]: Resection of segment VI HCC
3. [**6-18**]: Multifocal HCC in both the left lobe and remainder of
right lobe. Underwent TACE of the right hepatic lobe on [**2122-7-30**]

MEDICATION ON ADMISSION: calcitonin 200u spray 1 hs
questran 4g qday
folic acid 1 mg qd
lasix 40 mg qd
meropenem 1g IV q8h
mesalamine 1.2g tid
mesalamine enema qd
oxycodone 5-10 mg q8-12h prn pain
compazine 5mg q12-24h prn nausea
spironolactone 100 mg qd
ursodiol 500 mg [**Hospital1 **]
Vit C 500 qd-tid
Ca/Vit D 500/200 [**Hospital1 **]
MVI
cranberry extract 500 qd

ALLERGIES: Codeine / Demerol / Penicillins / Erythromycin Base

PHYSICAL EXAM: Vitals - T: 97.1 BP: 90/60 HR: 101 RR: 16 02 sat: 99% RA
Wt: 61.7 kg
GENERAL: NAD, AAOx3
HEENT: NCAT, OP clear, MM dry
CARDIAC: RRR s mrg
LUNG: CTA with diminished BS at bases bilaterally
ABDOMEN: mildly distended, S, mild TTP R side > L side without
rebound, guarding, or rigidity, no appreciable fluid wave or
shifting dullness
EXT: WWP, [**12-12**]+ pitting edema to knees bilaterally, 2+ pulses
NEURO:
DERM: Spider angiomata on trunk.
PSYCH: Appropriate affect, intact thought processes and content.

FAMILY HISTORY: Significant for primary biliary cirrhosis in one of her sisters.

SOCIAL HISTORY: She is a dentist who works with her husband in a mutually owned
dental practice in [**Location (un) 686**]. She smoked tobacco between the
ages 12 and 19 and does not drink alcohol.
Malignant neoplasm of liver, primary,Abscess of liver,Bacteremia,Hyposmolality and/or hyponatremia,Ulcerative colitis, unspecified,Jaundice, unspecified, not of newborn,Biliary cirrhosis,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Altered mental status,Osteoporosis, unspecified,Hypocalcemia
Mal neo liver, primary,Abscess of liver,Bacteremia,Hyposmolality,Ulceratve colitis unspcf,Jaundice NOS,Biliary cirrhosis,Pseudomonas infect NOS,Altered mental status,Osteoporosis NOS,Hypocalcemia
Admission Date:  [**2123-2-2**]              Discharge Date:   [**2123-2-10**]

Date of Birth:  [**2065-2-1**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine / Demerol / Penicillins / Erythromycin Base

Attending:[**First Name3 (LF) 8388**]
Chief Complaint:
fever, somnolence

Major Surgical or Invasive Procedure:
Double lumen Power PICC placed [**2-9**]


History of Present Illness:
57 yo F c PBC c/b cirrhosis, HCC s/p segmentectomies x 2 ([**2-14**],
[**6-17**]) and recurrence s/p TACE of R, L hepatic arteries ([**7-19**],
[**8-19**]) c/b biliary ischemia and hepatic abscesses growing
separate pansensitive and ciprofloxacin-resistant <i>Pseudomonas
aeruginosa</i> s/p surgical drain placement in [**2122-11-10**] and
indefinite inititation of home IV meropenem.  Interval imaging
showed decrease in abscess size in [**Month (only) 404**]; her last imaging was
a CT scan on [**2123-1-18**] and showed no change in abscess size since
[**Month (only) 404**] and showed intrahepatic biliary dilatation, as well as
ill-defined opacity in caudate lobe worrisome for tumor
recurrence.  Her AFP was documented as 4.2 at that time and she
was scheduled for ERCP for stent placement.  ERCP was performed
[**2123-1-26**] and revealed no evidence of extrahepatic biliary
stricturing, diffuse stenosis of intrahepatic ducts with no
lesion appropriate for stent placement.
.
Since the ERCP, patient has noted increased somnolence and
fatigue; she has been falling asleep during conversations and
has trouble going up and down stairs.  On day prior to
admission, she was noted to have temperature on VNA assessment
of 100.0 and was noted to have WBC count of 2.5 on lab draw.
Patient said that her skin felt warm but she denied feeling
feverish, chills, or night sweats.  Patient endorses increased
abdominal distention and LE edema over last two weeks; she is
unclear as to whether she has gained weight recently.  Stable,
chronic, non-radiating RUQ pain well controlled with oxycodone
prn.  Patient was admitted from clinic today after detailing
these complaints for management of suspected infection and
possible hepatic encephalopathy.
.
Currently, patient is resting comfortably in the hospital bed
and is lucid, oriented x 3, and without acute complaints.
.
ROS: See HPI.  Patient complains of mild HA, nasal congestion x
2 days with no associated sinus congestion or SOB.  Mild cough x
2 days slightly productive of sputum.  Altered taste and poor
appetite.    Denies CP, N/V/D/C, dysuria.

Past Medical History:
ONCOLOGIC HISTORY
1. [**2-14**]: Resection of segment VII HCC
2. [**6-17**]: Resection of segment VI HCC
3. [**6-18**]: Multifocal HCC in both the left lobe and remainder of
right lobe. Underwent TACE of the right hepatic lobe on [**2122-7-30**]

4. [**2122-9-8**]: TACE of the left hepatic lobe
.
PAST MEDICAL HISTORY:
1. Primary biliary cirrhosis diagnosed in [**2096**]. EGD on [**2122-4-10**] demonstrated normal esophagus without esophageal or gastric
varices.
2. Ulcerative colitis x10 years.
3. Frequent urinary tract infections.
4. HCC s/p segmentectomy

Social History:
She is a dentist who works with her husband in a mutually owned
dental practice in [**Location (un) 686**]. She smoked tobacco between the
ages 12 and 19 and does not drink alcohol.


Family History:
Significant for primary biliary cirrhosis in one of her sisters.


Physical Exam:
Vitals - T: 97.1 BP: 90/60 HR: 101 RR: 16 02 sat: 99% RA
Wt: 61.7 kg
GENERAL: NAD, AAOx3
HEENT: NCAT, OP clear, MM dry
CARDIAC: RRR s mrg
LUNG: CTA with diminished BS at bases bilaterally
ABDOMEN: mildly distended, S, mild TTP R side > L side without
rebound, guarding, or rigidity, no appreciable fluid wave or
shifting dullness
EXT: WWP, [**12-12**]+ pitting edema to knees bilaterally, 2+ pulses
NEURO:
DERM: Spider angiomata on trunk.
PSYCH: Appropriate affect, intact thought processes and content.

Pertinent Results:
Labs on admission [**2122-2-2**]:
[**2123-2-2**] 07:34PM URINE  HOURS-RANDOM UREA N-339 CREAT-48
SODIUM-LESS THAN  POTASSIUM-27 CHLORIDE-11
[**2123-2-2**] 07:34PM URINE  OSMOLAL-223
[**2123-2-2**] 04:46PM   GLUCOSE-104* UREA N-25* CREAT-0.8 SODIUM-121*
POTASSIUM-4.1 CHLORIDE-88* TOTAL CO2-27 ANION GAP-10
[**2123-2-2**] 04:46PM   ALT(SGPT)-78* AST(SGOT)-117* ALK PHOS-174*
TOT BILI-18.6* DIR BILI-14.2* INDIR BIL-4.4
[**2123-2-2**] 04:46PM   ALBUMIN-2.6* CALCIUM-8.3* PHOSPHATE-3.2
MAGNESIUM-2.0
[**2123-2-2**] 04:46PM   OSMOLAL-265*
[**2123-2-2**] 04:46PM   WBC-3.1* RBC-3.85* HGB-11.9* HCT-35.3* MCV-92
MCH-30.8 MCHC-33.7 RDW-15.8*
[**2123-2-2**] 04:46PM   NEUTS-63 BANDS-1 LYMPHS-14* MONOS-20* EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2123-2-2**] 04:46PM   PLT SMR-VERY LOW PLT COUNT-59*
[**2123-2-2**] 04:46PM   PT-17.8* PTT-32.8 INR(PT)-1.6*
.
CT [**2123-1-18**]:
1. Clamped right-sided transhepatic pigtail catheter in place
with no
appreciable change in size of two hepatic abscesses within
segments VII and VIII since [**2122-12-18**].
2. Ill-defined low-attenuating area in caudate lobe concerning
for tumor recurrence as suspected on prior CT, is better
depicted on multiphasic study of [**2122-11-16**].
3. Interval increase in size of a moderate right pleural
effusion.
4. Cirrhosis with intrahepatic biliary dilatation. Unchanged
perigastric and perisplenic varices as well as splenomegaly with
mass effect on left kidney.
.
ERCP [**2123-1-26**]:
Cannulation of the biliary duct was obtained and contrast medium
was injected, revealing a normal-appearing CBD, cystic duct and
gallbladder. Diffuse narrowing of the intrahepatic ducts is
present, consistent with cirrhosis. An area of contrast
extravasation at the right posterior intrahepatic duct
apparently corresponds to a prior drain site seen on a previous
CT examination.
.
Blood cultures [**Date range (1) 28561**] positive for
 PSEUDOMONAS AERUGINOSA.    FINAL SENSITIVITIES.
         Cefepime & CEFTAZIDIME sensitivity testing confirmed by
Microscan.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------  =>64 R
CEFTAZIDIME-----------    16 I
CIPROFLOXACIN---------     1 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------  =>16 R
PIPERACILLIN/TAZO-----    64 S
TOBRAMYCIN------------   <=1 S

.
RUQ U/S [**2123-2-3**]:
Nodular cirrhotic liver with a dominant 2.6-cm mass in the
caudate lobe and several smaller suspicious nodules scattered
elsewhere.
Doppler assessment is normal. There is no residual fluid
collection seen
following prior drainage. Gallstones and splenomegaly also
noted.
.
ECHO [**2-4**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). There is no ventricular septal defect. 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 masses or vegetations are seen on
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve. The
estimated pulmonary artery systolic pressure is normal. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: no obvious vegetations
.
CT abd/pelvis [**2-7**]:
IMPRESSION:
1. Removal of the right transhepatic drainage catheter with
reaccumulation of
fluid posterior to the right hepatic lobe.

2. New areas of low attenuation in both hepatic lobes, the
largest in the
left hepatic lobe measures 2.7 cm, concerning for new hepatic
abscesses.

3. Caudate lobe mass consistent with growing hepatocellular
carcinoma.
Multiple treated HCC as before.
.


Brief Hospital Course:
This is a 58 year female with history of PBC complicated by
cirrhosis, HCC s/p surgical resection, HCC recurrence s/p TACE
complicated by biliary ischemia and hepatic abscesses s/p
surgical drain placement and IV abx who presented with
somnolence as well as fevers and was found to be hyponatremic
with recurrent hepatic abscesses and blood cultures positive for
MDR Pseudomonas.
.
#. MDR Pseudomonas bacteremia, hepatic abscesses: The patient's
blood cultures were positive for MDR Pseudomonas from [**Date range (1) 28561**]
likely secondary to recurrent hepatic abscesses which were
discovered on a CT scan.  The Pseudomonas was cefepime/meropenem
resistant, ceftazidime intermediate resistance, and cipro/zosyn
sensitive.  A TTE was negative for any vegetations.  The
infectious disease consult service followed the patient closely
throughout her admission.  Her old PICC line was discontinued
and she was started on cipro monotherapy given her documented
allergy to penicillin.  A new double lumen power PICC was placed
on [**2-9**] after the patient had been blood culture negative and
afebrile for several days.  She was also desensitized to
penicillin per MICU protocol and started on Zosyn prior to
discharge.  Zosyn/Cipro will be continued indefinitely with the
[**Hospital **] clinic following surveillance labs.  Interventional radiology
was consulted for hepatic abscess drainage, but felt that the
abscesses were small enough where antibiotic penetration would
be possible without drainage.
.
#. HCC: A CT abdomen/pelvis performed on [**2-7**] demonstrated
progression of her known HCC as well as recurrent hepatic
abscesses with no significant ascites.  Her MELD score was 22 on
discharge, but the patient is not a transplant candidate.  She
was treated with lactulose, lasix, aldactone, cholestyramine,
ursodiol, and oxycodone with only minor modifcations in dosing
when compared to her previous home regimen.
.
#. AMS/somnolence: Likely secondary to hyponatremia (Na=121 on
admission) along with a component of hepatic encephalopathy.
Mental status improved to baseline and patient was alert and
oriented times 3 on discharge after sodium correction with fluid
restrcition and administration of lactulose.
.
#. Ulcerative colitis: Remained stable.  The patient's home
mesalamine regimen was continued.
.
#. CODE: The patient's code status was established as DNR/DNI
this admission following a conversation with the patient and her
family concerning her poor prognosis given her worsening liver
failure secondary to treatment refractory, progressive HCC.
.
#. DISPO: Home with hospice services and IV Cipro/Zosyn

Medications on Admission:
calcitonin 200u spray 1 hs
questran 4g qday
folic acid 1 mg qd
lasix 40 mg qd
meropenem 1g IV q8h
mesalamine 1.2g tid
mesalamine enema qd
oxycodone 5-10 mg q8-12h prn pain
compazine 5mg q12-24h prn nausea
spironolactone 100 mg qd
ursodiol 500 mg [**Hospital1 **]
Vit C 500 qd-tid
Ca/Vit D 500/200 [**Hospital1 **]
MVI
cranberry extract 500 qd

Discharge Medications:
1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) spray Nasal HS (at bedtime).
2. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
5. Mesalamine 4 gram/60 mL Enema Sig: One (1) enema Rectal HS
(at bedtime).
6. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Ascorbic Acid 250 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO BID (2 times a day).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
Disp:*1 bottle* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Spironolactone 100 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
14. Oxycodone 5 mg Tablet Sig: [**12-12**] to 1 Tablet PO every four (4)
hours as needed for pain.
15. Ciprofloxacin 400 mg/40 mL Solution Sig: Four Hundred (400)
mg Intravenous twice a day.
Disp:*QS * Refills:*2*
16. Zosyn 4.5 gram Recon Soln Sig: 4.5 grams Intravenous every
eight (8) hours.
Disp:*QS * Refills:*2*
17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*QS ML(s)* Refills:*0*
18. Compazine 5 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for nausea.
19. Oxycodone 5 mg/5 mL Solution Sig: 2.5 mL PO every six (6)
hours as needed for pain.
Disp:*2 bottle* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Hepatic abscesses
Multi drug resistant Pseudomonas bacteremia
Primary Biliary Cirrhosis
Hepatocellular Carcinoma

Secondary diagnoses:
- Ulcerative Colitis


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


Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital for
evaluation of fevers and fatigue.  You were found to have
recurrent liver abscesses and your blood was infected with an
antibiotic resistant bacteria called Pseudomonas.  Your old PICC
was removed as a result of the infection and a new one was
placed several days later for continued long term IV antibiotic
treatment.  You were desensitized to pencillin and will be
started on an extended course of Zosyn (a stronger penicillin
related antibiotic) and Cipro.  It appears that the abscesses
are too small to be drained at this time and should respond to
your antibiotic regimen.  Unfortunately, it also appears as
though your known liver cancer continues to progress despite all
the treatments you have received.
.
The following changes have been made to your home medication
regimen:
- You will be on Zosyn 4.5 grams IV every 8 hours indefinitely
- You will be on ciprofloxaxin 400mg IV twice daily indefinitely
- Your home furosemide dose has been decreased to 20mg daily
- Your home spironolactone dose has been decreased to 50mg daily
- You will be started on lactulose which should be titrated to
help ensure daily bowel movements
.
Please follow-up with your scheduled appointments listed below.

Followup Instructions:
Please follow-up with your scheduled appointments listed below:
.
1. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 16976**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2123-3-1**] 9:30
.
2. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2123-3-1**] 11:40
.
3. Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2123-5-28**] 2:30
{'Malignant neoplasm of liver, primary,Abscess of liver,Bacteremia,Hyposmolality and/or hyponatremia,Ulcerative colitis, unspecified,Jaundice, unspecified, not of newborn,Biliary cirrhosis,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Altered mental status,Osteoporosis, unspecified,Hypocalcemia'}


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: fever, somnolence

PRESENT ILLNESS: 57 yo F c PBC c/b cirrhosis, HCC s/p segmentectomies x 2 ([**2-14**],
[**6-17**]) and recurrence s/p TACE of R, L hepatic arteries ([**7-19**],
[**8-19**]) c/b biliary ischemia and hepatic abscesses growing
separate pansensitive and ciprofloxacin-resistant <i>Pseudomonas
aeruginosa</i> s/p surgical drain placement in [**2122-11-10**] and
indefinite inititation of home IV meropenem.  Interval imaging
showed decrease in abscess size in [**Month (only) 404**]; her last imaging was
a CT scan on [**2123-1-18**] and showed no change in abscess size since
[**Month (only) 404**] and showed intrahepatic biliary dilatation, as well as
ill-defined opacity in caudate lobe worrisome for tumor
recurrence.  Her AFP was documented as 4.2 at that time and she
was scheduled for ERCP for stent placement.  ERCP was performed
[**2123-1-26**] and revealed no evidence of extrahepatic biliary
stricturing, diffuse stenosis of intrahepatic ducts with no
lesion appropriate for stent placement.
.
Since the ERCP, patient has noted increased somnolence and
fatigue; she has been falling asleep during conversations and
has trouble going up and down stairs.  On day prior to
admission, she was noted to have temperature on VNA assessment
of 100.0 and was noted to have WBC count of 2.5 on lab draw.
Patient said that her skin felt warm but she denied feeling
feverish, chills, or night sweats.  Patient endorses increased
abdominal distention and LE edema over last two weeks; she is
unclear as to whether she has gained weight recently.  Stable,
chronic, non-radiating RUQ pain well controlled with oxycodone
prn.  Patient was admitted from clinic today after detailing
these complaints for management of suspected infection and
possible hepatic encephalopathy.
.
Currently, patient is resting comfortably in the hospital bed
and is lucid, oriented x 3, and without acute complaints.
.
ROS: See HPI.  Patient complains of mild HA, nasal congestion x
2 days with no associated sinus congestion or SOB.  Mild cough x
2 days slightly productive of sputum.  Altered taste and poor
appetite.    Denies CP, N/V/D/C, dysuria.

MEDICAL HISTORY: ONCOLOGIC HISTORY
1. [**2-14**]: Resection of segment VII HCC
2. [**6-17**]: Resection of segment VI HCC
3. [**6-18**]: Multifocal HCC in both the left lobe and remainder of
right lobe. Underwent TACE of the right hepatic lobe on [**2122-7-30**]

MEDICATION ON ADMISSION: calcitonin 200u spray 1 hs
questran 4g qday
folic acid 1 mg qd
lasix 40 mg qd
meropenem 1g IV q8h
mesalamine 1.2g tid
mesalamine enema qd
oxycodone 5-10 mg q8-12h prn pain
compazine 5mg q12-24h prn nausea
spironolactone 100 mg qd
ursodiol 500 mg [**Hospital1 **]
Vit C 500 qd-tid
Ca/Vit D 500/200 [**Hospital1 **]
MVI
cranberry extract 500 qd

ALLERGIES: Codeine / Demerol / Penicillins / Erythromycin Base

PHYSICAL EXAM: Vitals - T: 97.1 BP: 90/60 HR: 101 RR: 16 02 sat: 99% RA
Wt: 61.7 kg
GENERAL: NAD, AAOx3
HEENT: NCAT, OP clear, MM dry
CARDIAC: RRR s mrg
LUNG: CTA with diminished BS at bases bilaterally
ABDOMEN: mildly distended, S, mild TTP R side > L side without
rebound, guarding, or rigidity, no appreciable fluid wave or
shifting dullness
EXT: WWP, [**12-12**]+ pitting edema to knees bilaterally, 2+ pulses
NEURO:
DERM: Spider angiomata on trunk.
PSYCH: Appropriate affect, intact thought processes and content.

FAMILY HISTORY: Significant for primary biliary cirrhosis in one of her sisters.

SOCIAL HISTORY: She is a dentist who works with her husband in a mutually owned
dental practice in [**Location (un) 686**]. She smoked tobacco between the
ages 12 and 19 and does not drink alcohol. 

### Response:
{'Malignant neoplasm of liver, primary,Abscess of liver,Bacteremia,Hyposmolality and/or hyponatremia,Ulcerative colitis, unspecified,Jaundice, unspecified, not of newborn,Biliary cirrhosis,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Altered mental status,Osteoporosis, unspecified,Hypocalcemia'}
