CHIEF COMPLAINT: s/p TACE

PRESENT ILLNESS: This 60-year-old gentleman with h/o chronic HCV and cirrhosis
who has been followed with regular u/s and MRIs and recently
found to have two less than 1 cm nodules that subsequently
progressed to numerous nodules. He was referred to [**Hospital1 18**] and
underwent targeted liver biopsy, which confirmed HCC in three of
the five nodules, making him no longer transplant eligible.
Today he underwent his first chemoembolization.
For his HCV, he had been treated with ribavirin and interferon,
without response.  He is followed closely for this and was
diagnosed with varices in the past but recent endoscopy did not
show any varices.  He has no histopry of encephalopathy, ascites
or GI bleed.
Pt underwent chemoembolization today and during procedure became
very uncomfortable with epigastric abd pain [**8-25**], requiring
dilaudid, toradol.  His BP was increased to SBP 200s, and
required also hydralazine.  At this time, the patient is feeling
better, his pain has decreased to [**2159-12-19**].  He denies any
associated n/v/fever, chills, rigors, lightheadedness,
palpitations.
ROS: pt denies HA, weight chamges, fatigue, cough, SOB, CP,
dysuria, constipation.  Full ten point ROS was otehrwise
negative.

MEDICAL HISTORY: 1.  HCV cirrhosis complicated by portal hypertension, esophageal
varices, hepatoma.
2.  Diabetes.
3.  COPD.
4.  Orbit repair

MEDICATION ON ADMISSION: NADOLOL -  (Prescribed by Other Provider) - 40 mg Tablet - 3
Tablet(s) by mouth once a day

ALLERGIES: Influenza Vaccine,Trival [**2159**]

PHYSICAL EXAM: Exam on admission:
 VS  T current   96.6  BP 120/84       HR 52     RR 16     O2sat
95%RA

FAMILY HISTORY: Family History:  His mother was diagnosed with breast cancer at
the age of 84. He has never been in contact with his father.

SOCIAL HISTORY: Social History:  Half-pack-per-day smoker.  No ETOH, no IVDA,
occasional marijuana use. lives with his wife and dog.  He has
three grown children.  He works as a postal clerk.
Encounter for antineoplastic chemotherapy,Chronic hepatitis C with hepatic coma,Toxic encephalopathy,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Malignant neoplasm of liver, primary,Hyperosmolality and/or hypernatremia,Portal hypertension,Other and unspecified coagulation defects,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Chronic airway obstruction, not elsewhere classified,Disorders of phosphorus metabolism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tobacco use disorder,Dermatophytosis of groin and perianal area
Antineoplastic chemo enc,Chrnc hpt C w hepat Coma,Toxic encephalopathy,Food/vomit pneumonitis,Acute respiratry failure,Mal neo liver, primary,Hyperosmolality,Portal hypertension,Coagulat defect NEC/NOS,Esoph varice oth dis NOS,Chr airway obstruct NEC,Dis phosphorus metabol,DMII wo cmp nt st uncntr,Tobacco use disorder,Dermatophytosis of groin
Admission Date:  [**2162-2-15**]              Discharge Date:   [**2162-3-6**]

Date of Birth:  [**2101-7-7**]             Sex:   M

Service: MEDICINE

Allergies:
Influenza Vaccine,Trival [**2159**]

Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
s/p TACE

Major Surgical or Invasive Procedure:
Transarterial chemoembolization [**2162-2-15**]
mechanical intubation

History of Present Illness:
This 60-year-old gentleman with h/o chronic HCV and cirrhosis
who has been followed with regular u/s and MRIs and recently
found to have two less than 1 cm nodules that subsequently
progressed to numerous nodules. He was referred to [**Hospital1 18**] and
underwent targeted liver biopsy, which confirmed HCC in three of
the five nodules, making him no longer transplant eligible.
Today he underwent his first chemoembolization.
For his HCV, he had been treated with ribavirin and interferon,
without response.  He is followed closely for this and was
diagnosed with varices in the past but recent endoscopy did not
show any varices.  He has no histopry of encephalopathy, ascites
or GI bleed.
Pt underwent chemoembolization today and during procedure became
very uncomfortable with epigastric abd pain [**8-25**], requiring
dilaudid, toradol.  His BP was increased to SBP 200s, and
required also hydralazine.  At this time, the patient is feeling
better, his pain has decreased to [**2159-12-19**].  He denies any
associated n/v/fever, chills, rigors, lightheadedness,
palpitations.
ROS: pt denies HA, weight chamges, fatigue, cough, SOB, CP,
dysuria, constipation.  Full ten point ROS was otehrwise
negative.

Past Medical History:
1.  HCV cirrhosis complicated by portal hypertension, esophageal
varices, hepatoma.
2.  Diabetes.
3.  COPD.
4.  Orbit repair


Social History:
Social History:  Half-pack-per-day smoker.  No ETOH, no IVDA,
occasional marijuana use. lives with his wife and dog.  He has
three grown children.  He works as a postal clerk.


Family History:
Family History:  His mother was diagnosed with breast cancer at
the age of 84. He has never been in contact with his father.


Physical Exam:
Exam on admission:
 VS  T current   96.6  BP 120/84       HR 52     RR 16     O2sat
95%RA

Gen:  In NAD.
HEENT:  PERRL, EOMI.  No scleral icterus.  No conjunctival
injection.   Mucous membranes moist.  No oral ulcers.
Neck:  Supple, no LAD, no JVP elevation.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi.  Normal
respiratory effort.
CV:  RRR, no murmurs, rubs, gallops.
Abdomen:  soft, NT, ND, NABS, no HSM. well healed surgical scars
at the umbilicus and right upper quadrant
Extremities:  warm and well perfused, no cyanosis, clubbing,
trace pedal edema B.  R leg immobilizer in place, adequate B
pulses peripherally, no bruits in R femoral puncture site
Neurological:  alert and oriented X 3, CN II-XII intact.
Skin:  No rashes or ulcers.
Psychiatric:  Appropriate.
GU:  deferred.

Discharge exam:

PHYSICAL EXAM:
VS: 97.3  112/55  63  18  94%RA
General: no acute distress, jaundiced, a+ox3
HEENT: +scleral icterus, MMM
Neck: supple, unable to assess JVP, no LAD
Lungs: CTA, no wheezes or rales appreciated
CV: Regular rate and rhythm, no murmurs appreciated
Abdomen: soft, mild distended, bowel sounds present, no rebound
tenderness or guarding, no ascites
Ext: warm, well perfused, 2+ pulses, 1+edema, scrotal edema

Pertinent Results:
MRI performed on [**2161-11-24**] showed at least four hepatic lesions
up to 1 cm in size, two of which have slightly increased and
demonstrate washout and two with borderline  washout; all
concerning for HCC.  Several additional nodules which are
subcentimeter in size, are also concerning for HCC but too small
for definitive imaging  diagnosis.
.
ADMISSION LABS:
[**2162-2-15**] 08:14AM   WBC-4.1 RBC-4.31* HGB-13.8* HCT-43.9
MCV-102*# MCH-32.0 MCHC-31.4# RDW-14.8
[**2162-2-15**] 08:14AM   PLT COUNT-100*
[**2162-2-15**] 08:14AM   PT-12.8* PTT-36.5 INR(PT)-1.2*
[**2162-2-15**] 08:14AM   GRAN CT-2140*
[**2162-2-15**] 08:14AM   ALBUMIN-3.0* CALCIUM-8.5
[**2162-2-15**] 08:14AM   ALT(SGPT)-45* AST(SGOT)-70* ALK PHOS-129 TOT
BILI-1.8*
[**2162-2-15**] 08:14AM   UREA N-7 CREAT-0.8 SODIUM-142 POTASSIUM-3.5
CHLORIDE-106
[**2162-2-15**] 08:14AM   AFP-11.6*
[**2162-3-6**] 05:20AM BLOOD WBC-6.3 RBC-3.07* Hgb-11.0* Hct-35.6*
MCV-116* MCH-35.8* MCHC-30.9* RDW-19.1* Plt Ct-95*
[**2162-3-6**] 05:20AM BLOOD PT-21.2* PTT-53.3* INR(PT)-2.0*
[**2162-3-6**] 05:20AM BLOOD Glucose-84 UreaN-11 Creat-0.7 Na-135
K-4.0 Cl-102 HCO3-33* AnGap-4*
[**2162-3-6**] 05:20AM BLOOD ALT-85* AST-167* LD(LDH)-499*
AlkPhos-199* TotBili-8.6*
[**2162-3-6**] 05:20AM BLOOD Albumin-2.0* Calcium-7.8* Phos-2.6*
Mg-1.9

SINGLE FRONTAL VIEW OF THE CHEST

REASON FOR EXAM: Status post TACE treatment, complicating by
pneumonia and
hepatic coma. New oxygen requirement.

Comparison is made with prior study, [**2-24**].

Right lower lobe opacity has markedly increased, a combination
of pleural
effusion and adjacent consolidation. Left lower lobe opacities
have
increased, could be due to atelectasis or pneumonia. There is no

pneumothorax. Cardiac size is normal. Right PICC tip is in the
lower SVC.

LIMITED ABDOMINAL ULTRASOUND

DATE: [**2162-2-26**].

COMPARISON: Liver ultrasound [**2162-2-18**], CT abdomen and
pelvis [**2162-2-20**], chemoembolization [**2162-2-15**].

CLINICAL INDICATION: 60-year-old man with hepatitis C status
post TACE
procedure, elevated and rising bilirubin of unclear etiology.
Question
obstruction.

TECHNIQUE: Multiple son[**Name (NI) 493**] grayscale images of the abdomen
were obtained
with select images supplemented with color Doppler and spectral
waveform
analysis.

FINDINGS:

The liver demonstrates coarsened echotexture consistent with
known cirrhosis.
Echogenic foci within the right hepatic lobe are consistent with
sequelae of
recent TACE procedure. This examination was not tailored to
evaluate for
liver lesions. The gallbladder is nondistended and demonstrates
diffuse
gallbladder wall thickening measuring up to 3 mm, stable from
prior CT
examination. There is no intra- or extra-hepatic biliary
dilation with the
common hepatic duct measuring 4 mm.

The main portal vein is patent, but demonstrates persistent
hepatofugal flow.
Visualized portions of the pancreas are within normal limits
with the
pancreatic head, uncinate process and tail non-visualized
secondary to
shadowing from overlying bowel gas. There is a small amount of
ascites seen
in the right lower quadrant and perihepatic locations. The
spleen measures
approximately 13.2 cm. Representative images of the kidneys
demonstrate no
hydronephrosis.


IMPRESSION:
1. No evidence of biliary obstruction. Circumferential
gallbladder wall
thickening, stable from recent CT, which likely relates to
underlying liver
disease.

2. Sequelae of recent TACE. Coarsened, heterogeneous liver
consistent with
cirrhosis with stable reversal of flow in the patent main portal
vein.

3. Small amount of perihepatic and right lower quadrant ascites.


The study and the report were reviewed by the staff radiologist.


Radiology Report MR HEAD W & W/O CONTRAST Study Date of [**2162-2-24**]
8:44 PM


[**Last Name (LF) 2437**],[**First Name3 (LF) **] [**First Name3 (LF) **] [**Hospital Unit Name 153**] [**2162-2-24**] 8:44 PM
MR HEAD W & W/O CONTRAST   Clip # [**Clip Number (Radiology) 91738**]
Reason: evaluate for cause of obtunded state



[**Hospital 93**] MEDICAL CONDITION:
   60 year old man with HCC who is obtunded s/p TACE
REASON FOR THIS EXAMINATION:
   evaluate for cause of obtunded state
CONTRAINDICATIONS FOR IV CONTRAST:
   None.



Final Report
INDICATION: Altered mental status, status post chemoembolization
procedure.

COMPARISON: CT head from [**2162-2-22**].

TECHNIQUE: MRI of the head was obtained before and after
administration of
contrast per department protocol.

FINDINGS: There is no evidence of hemorrhage, infarction, edema,
mass, or
mass effect. Ventricles and sulci are age appropriate. Few
scattered
T2/FLAIR hyperintensities are seen in the periventricular white
matter, which
are nonspecific and may represent small vessel ischemic disease.
Visualized
orbits, paranasal sinuses are unremarkable. There is minimal
fluid signal in
bilateral mastoid air cells. The post-contrast images are
degraded by motion.

IMPRESSION:

Post-contrast images are markedly degraded by motion artifact.
There are
several nonspecific FLAIR signal abnormalities may represent
small vessel
ischemic disease. This limited study is otherwise normal.


Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of
[**2162-2-20**] 4:11 PM


[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] 11R [**2162-2-20**] 4:11 PM
CT ABD & PELVIS WITH CONTRAST   Clip # [**Clip Number (Radiology) 91739**]
Reason: ? infarct or infection
Contrast: OMNIPAQUE Amt: 130



[**Hospital 93**] MEDICAL CONDITION:
   60 year old man with hepatic encephalopathy post TACE
REASON FOR THIS EXAMINATION:
   ? infarct or infection
CONTRAINDICATIONS FOR IV CONTRAST:
   post TACE



Final Report
INDICATION: 60-year-old male with hepatic encephalopathy status
post TACE.
Question liver infarct or abscess.

COMPARISON: CT dated [**2162-2-16**] and MR dated [**2161-11-24**].

TECHNIQUE: MDCT images were acquired from the lung bases through
the pubic
symphysis following administration of intravenous contrast with
multiplanar
reformations.

CT ABDOMEN: An enteric tube is in place with tip extending to
the stomach.

There is a small right pleural effusion with compressive
atelectasis. Mild
dependent atelectasis is present on the left. The heart is
normal in size
without pericardial effusion. Multivessel coronary arterial
disease is
present. A 1-cm saccular enhancing structure at the
gastroesophageal junction
(300A, 27 and 2, 8) likely represents a paraesophageal varix.

A small perihepatic ascites is present. The liver is shrunken
and nodular,
consistent with cirrhosis. The portal veins are attenuated but
appear patent.
The patient is status post TACE with hyperdense Ethiodol
accumulating in known
lesions in segments V, VI and VII. The remainder of the liver
demonstrates no
evidence of infarct. Two subcentimeter hypodense lesions are
seen within
liver, segments [**Doctor First Name 690**] (2, 14) and IVb (2, 21), too small to fully
characterize.
Additional lesions demonstrated on preceding MRI are not evident
on current
single phase exam. The gallbladder demonstrates circumferential
mural edema,
likely reflecting underlying liver disease.

The spleen is enlarged to 17 cm and associated with prominent
splenorenal and
gastrosplenic varices. The pancreas and adrenal glands are
unremarkable.
Bilateral kidneys enhance symmetrically without hydronephrosis
or hydroureter.
A 2-cm lower pole exophytic left renal cyst is present.
Additional
subcentimeter renal hypodensities are too small to fully
characterize. The
small and large bowel loops are normal in caliber.

Scattered tiny retroperitoneal and mesenteric lymph nodes do not
meet size
criteria for adenopathy. Moderate atherosclerotic calcifications
are seen in
the infrarenal aorta extending into common iliac arteries.

CT PELVIS: The bladder is partially collapsed, containing a
Foley catheter
and probably post-instrumentation air. The prostate appears
unremarkable. A
rectal tube is in place. There is no inguinal or pelvic sidewall
adenopathy.
Trace free fluid is in the pelvis.

BONE WINDOW: No focal concerning lesion. Remote right posterior
rib
fractures are seen in ribs 9 and 10. A hemangioma is noted in L4
vertebral
body.

IMPRESSION:
1. No evidence of intra-abdominal or intrapelvic abscess.
2. Cirrhosis, splenomegaly, varices, and small ascites,
consistent with
portal hypertension.
3. TACE treated liver, without evidence of infarct.
4. Two subcentimeter hypoattenuating liver lesions within
segments [**Doctor First Name 690**] and
IVb, too small to fully characterize. Additional known liver
lesions are
better depicted on preceding MRI dated [**2161-11-24**].
5. Small right pleural effusion with compressive atelectasis.
6. Bilateral renal cysts, some of which are too small to fully
characterize.
7. Remote right ninth and tenth chronic appearing posterior rib
fractures.



Brief Hospital Course:
REASON FOR HOSPITAL ADMISSION
60 y/o M with recently diagnosed multifocal HCC, s/p selective
segment VI + right lobar TACE [**2162-2-15**].
.
HOSPITAL COURSE:
# hepatic encephalopathy:  s/p selective segment VI and right
lobar TACE [**2-15**] for hepatic carcinoma.  He became hypertensive at
the the end of the procedure, thought to be due to pain with BP
up to SBP 200, controlled with dilaudid, toradol for pain and
hydralazine. Slowly became obtunded and altered following the
procedure. His bilirubin and LFTs trended up. non-contrast CT of
liver done showed ethidiol in most of R hepatic lobe and
additional mass, no extravasation.  Pt with persistent
nausea/vomiting/pain post procedure and marked increase in
transaminases and bilirubin and developed encephalopathy and
hypoxia, see below. Pt was transferred to the [**Hospital Unit Name 153**] for
unresponsiveness. C/f infection given pt was febrile to 101 on
[**2-21**]. Source of infection unclear. [**Name2 (NI) **] evidence of abscess or
liver infarct on [**2162-2-20**] CT ab/pelvis. RUQ u/s was negative. No
ascites to tap. BCx and Ucx are no growth to date. CXR x 2
concernign for RLL opacification. Head CT w & w/o was neg [**2-18**].
Pt started on vanc/ctx/flagyl initially, then broadened to
vanc/zosyn. Amonia level was 177. Pt was unresponsive to sternal
rub, off sedation. EEG did not show signs of epileptic activity.
Head CT stable without evidence of bleed. MRI head was performed
which showed only nonspecific signal abnormalities likely from
small vessel ischemic disease, nothing acute. RUQ u/s with
doppler obtained but did not suggest significant hepatic artery
or portal vein obstruction. Tube feeds were started via NG.
After 3 days in the [**Hospital Unit Name 153**] with aggressive lactulose therapy and
rifaxamin transaminases and bili were trending down, and pt
regained consciousness. Amonium level went down to 70. It was
felt this had been a toxic-metabolic encephalopathy likely [**12-17**]
elevated ammonium levels. He was extubated and slowly
re-oriented, making jokes with his family. Subsequently
bilirubin went up to 10.8 and pt developed severe jaundice. Pt
did not complain of RUQ pain at this time but given elevated
bili RUQ u/s obtained without evidence of obstruction. While on
the hepatology floor Tbili stabilized 7-8 range.  He was started
on ursodiol 600 mg [**Hospital1 **].

# Hypoxia: Patient developed new O2 requirement on the floo
following the TACE procedure with O2 sat down to 86% on RA ->
92% on 3L shovel mask. Given hepatic encephalopathy/coma,
patient had increasing difficulty clearing his secretions and
developed diffuse rhonchi on exam. c/f aspiration pneumonia as
he also had a fever to 101.2. Vanc/zosyn initiated, pt
transferred to the [**Hospital Unit Name 153**] and was intubated. After 3 days in the
[**Name (NI) 153**] pt was extubated and regained significant neurologic
function. Hypoxia resolved.  A 13 days course of vanc/zosyn for
HAP was finished on [**3-6**].

# Volume overload:  Likely combiniation of hepatic failure and
IVF.  Patient started on spironolactone and furosemide.
.
# Coagulopathy: Pt with INR 3.3, thrombocytopenia, fibrinogen
64, concern for DIC. Most likely secondary to hepatic
decompensation and poor synthetic function. No schistocytes on
smear. Pt was given IV vitamin K and this remained stable.
.
# Hypernatremia: Likely secondary to decreased free water intake
given mental status, as well as hypovolemia from diarrhea ([**12-17**]
lactulose for hepatic encephalopathy). While intubated pt
without access to free water. Pt was given slow rate D5W with
careful monitoring of electrolytes. No issues after resolution
and patient taking PO.

# Fever: Source unclear, although concern for respiratory
process given new hypoxia and O2 requirement in the context of
high risk for aspiration. Blood/urine cultures unrevealing.
Vanc/zosyn was continued for 13 day course for possible HAP.

# Hepatocellular carcinoma s/p TACE: s/p selective segment VI
and right lobar TACE. Patient had marked increase in
transaminases and bili with development of hepatic
encephalopathy as above. Per oncologist, prognosis for HCC alone
would be about 1year.

# Thrombocytopenia: baseline 100s due to portal hypertension.
PLTs in the 50s while in the [**Hospital Unit Name 153**]. Pt without signs of active
bleeding and it was felt appropriate to monitor; no transfusions
were given. Remained stable while on the floor.

# DM2: Initially getting D5W for hypernatremia. Post extubation
pt began taking PO. Insulin sliding scale was continued.
.
# Portal HTN: controlled on home nadolol
.
# Communication: wife [**Name (NI) 2048**]: cell [**Telephone/Fax (1) 91740**], H [**Telephone/Fax (1) 91741**]
.
Pt was maintained as FULL CODE throughout the course of this
hospitalization.
.

TRANSITIONAL ISSUES:

# Patient will need LFT monitoring including Tbili for the next
5 days to evaluate stability.  If stable at this point no need
to continue to check unless otherwise indicated.

# Patient will need Chem7 monitoring for the next 5 days to
evaluate for hypokalemia or worsening renal function. If stable
at this point no need to continue to check.

Medications on Admission:
NADOLOL -  (Prescribed by Other Provider) - 40 mg Tablet - 3
Tablet(s) by mouth once a day


Discharge Medications:
1. nadolol 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
3. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
4. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
5. insulin lispro 100 unit/mL Solution Sig: as directed units
Subcutaneous four times a day: per insulin sliding scale.
6. spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical twice
a day as needed for [**Female First Name (un) **]: apply to groin area.
9. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital 38**] Rehab, [**Location (un) 38**], MA

Discharge Diagnosis:
Hepatoma s/p chemoembolization
Hepatic Coma/Encephalopathy
Pneumonia
HCV cirrhosis
Diabetes


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname **],

You were admitted for transarterial chemoembolization of your
liver cancer. Unfortunately, the procedure was complicated by
injury to the normal liver cells as well as the cancer cells
which led you to have decompensation requiring intubation. You
were also found to have a pneumonia, for which you were treated
with IV antibiotics. You were extubated several days later and
have remain stable on room air. We have continued to treat you
with diuretics as well as lactulose and rifaximin. We also had
the nutritionist meet with you and your family to help you with
your caloric intake and dietary choices. We wish you a fast
recovery and hope you make it home soon.

The following changes have been made to your medications:
START Simethicone 80 mg up to 4 times a day as needed for gas
(take separate from other meds by at least 1 hr)
START Insulin glargine 12 units at bedtime
START Insulin lispro per sliding scale
START Spironolactone 150 mg daily
START Furosemide 40 mg daily
START Lactulose 30 mL TID (can increase or decrease but titrate
to [**1-17**] bowel movements daily)
START Miconazole powder to groin as needed for rash
START Rifaxamin 550 mg twice a day
START Ranitidine 150 mg twice a day
START Ursodiol 600 mg twice a day

Followup Instructions:
You have the following appointments:

Department: LIVER CENTER
When: THURSDAY [**2162-3-18**] at 1:40 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: RADIOLOGY
When: FRIDAY [**2162-4-2**] at 1:40 PM
With: XMR [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2162-4-16**] at 2:30 PM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Encounter for antineoplastic chemotherapy,Chronic hepatitis C with hepatic coma,Toxic encephalopathy,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Malignant neoplasm of liver, primary,Hyperosmolality and/or hypernatremia,Portal hypertension,Other and unspecified coagulation defects,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Chronic airway obstruction, not elsewhere classified,Disorders of phosphorus metabolism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tobacco use disorder,Dermatophytosis of groin and perianal area'}


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: s/p TACE

PRESENT ILLNESS: This 60-year-old gentleman with h/o chronic HCV and cirrhosis
who has been followed with regular u/s and MRIs and recently
found to have two less than 1 cm nodules that subsequently
progressed to numerous nodules. He was referred to [**Hospital1 18**] and
underwent targeted liver biopsy, which confirmed HCC in three of
the five nodules, making him no longer transplant eligible.
Today he underwent his first chemoembolization.
For his HCV, he had been treated with ribavirin and interferon,
without response.  He is followed closely for this and was
diagnosed with varices in the past but recent endoscopy did not
show any varices.  He has no histopry of encephalopathy, ascites
or GI bleed.
Pt underwent chemoembolization today and during procedure became
very uncomfortable with epigastric abd pain [**8-25**], requiring
dilaudid, toradol.  His BP was increased to SBP 200s, and
required also hydralazine.  At this time, the patient is feeling
better, his pain has decreased to [**2159-12-19**].  He denies any
associated n/v/fever, chills, rigors, lightheadedness,
palpitations.
ROS: pt denies HA, weight chamges, fatigue, cough, SOB, CP,
dysuria, constipation.  Full ten point ROS was otehrwise
negative.

MEDICAL HISTORY: 1.  HCV cirrhosis complicated by portal hypertension, esophageal
varices, hepatoma.
2.  Diabetes.
3.  COPD.
4.  Orbit repair

MEDICATION ON ADMISSION: NADOLOL -  (Prescribed by Other Provider) - 40 mg Tablet - 3
Tablet(s) by mouth once a day

ALLERGIES: Influenza Vaccine,Trival [**2159**]

PHYSICAL EXAM: Exam on admission:
 VS  T current   96.6  BP 120/84       HR 52     RR 16     O2sat
95%RA

FAMILY HISTORY: Family History:  His mother was diagnosed with breast cancer at
the age of 84. He has never been in contact with his father.

SOCIAL HISTORY: Social History:  Half-pack-per-day smoker.  No ETOH, no IVDA,
occasional marijuana use. lives with his wife and dog.  He has
three grown children.  He works as a postal clerk. 

### Response:
{'Encounter for antineoplastic chemotherapy,Chronic hepatitis C with hepatic coma,Toxic encephalopathy,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Malignant neoplasm of liver, primary,Hyperosmolality and/or hypernatremia,Portal hypertension,Other and unspecified coagulation defects,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Chronic airway obstruction, not elsewhere classified,Disorders of phosphorus metabolism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tobacco use disorder,Dermatophytosis of groin and perianal area'}
