CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: Ms. [**Known lastname 61295**] is a 57 year old female with HCV cirrhosis, s/p failed
liver transplant, admitted with altered mental status.
[**Name (NI) **] husband reports over the past few days, she has had
increasing become more somnolent.  She has been taking lactulose
4x daily, but is having only 2 BMs/day.  Denies fevers, chills,
dysuria, diarrhea, melena, hematemasis.  He did report
occasional BRBPR that is longstanding and of note patient had
normal colonoscopy with grade 1 varices noted on EGD.  She had
some complaints of abdominal pain per husband, but he was unable
to further clarify these symptoms.
.
In th ED, vitals were T 98.3, HR 93, BP 113/54, RR 14, O2 Sat
93% on RA.  An NGT was placed and she was given lactulose.  She
was given vanco/cipro/zosyn for conern of SBP.  She was given 4L
IVF.  Labs were notable for an ammonia of 266.  She was found to
have an INR of 3.6 and a lactate of 6.3.  Stox was negative.  CT
Head was negative.  Abdominal ultrasound showed patent portal
vein and not enough ascites to safely tap.  Abdominal CT showed
moderate ascites but no acute process (though oral contrast was
not given).

MEDICAL HISTORY: - Cirrhosis [**1-3**] Hep C; s/p OLT [**2172**] with recurrent hep C and
autoimmune hepatitis (seen on biopsy); s/p IFN/ribavirin in
past. Complicated by recurrent hepatic encephalopathy, SBP prior

MEDICATION ON ADMISSION: Mycophenolate mofetil 1000 mg qam, 500 mg qpm
Metoprolol 25 mg [**Hospital1 **]
Lactulose 60 TID
Pantoprazole 40 mg daily
Prednisone 10 mg daily
Rifaximin 400 mg TID
Tacrolimus 0.5 mg qpm
Folic acid
Insulin glargin 9 units qhs
Lasix 20 mg daily
MVI
Vitamin D
Lispro sliding scale

ALLERGIES: Sulfisoxazole

PHYSICAL EXAM: VS: HR 95, BP 112/66, RR 14, 100% on RA
Gen: moaning, eyes closed
HEENT: PERRL
CV: +2/6 systolic murmur
Pulm: clear to ausculatation
Abd: distended, NT, bowel sounds present, no difinitive ascites
Ext: 2+ bilateral pitting edema
Neuro: unable to cooperate, moving all extremities
.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with husband. [**Name (NI) 4906**] denies etoh, smoking, drug use.
Hepatic encephalopathy,Acute kidney failure, unspecified,Complications of transplanted liver,Other ascites,Hyperosmolality and/or hypernatremia,Urinary tract infection, site not specified,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Acute respiratory failure,Other and unspecified coagulation defects,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol,Cardiac arrest,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension
Hepatic encephalopathy,Acute kidney failure NOS,Compl liver transplant,Ascites NEC,Hyperosmolality,Urin tract infection NOS,Gastrointest hemorr NOS,Ac posthemorrhag anemia,Acute respiratry failure,Coagulat defect NEC/NOS,Chrnc hpt C wo hpat coma,Cirrhosis of liver NOS,Cardiac arrest,Thrombocytopenia NOS,DMII wo cmp nt st uncntr,Hypertension NOS
Admission Date:  [**2178-10-12**]              Discharge Date:   [**2178-10-20**]

Date of Birth:  [**2121-1-31**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfisoxazole

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:


History of Present Illness:
Ms. [**Known lastname 61295**] is a 57 year old female with HCV cirrhosis, s/p failed
liver transplant, admitted with altered mental status.
[**Name (NI) **] husband reports over the past few days, she has had
increasing become more somnolent.  She has been taking lactulose
4x daily, but is having only 2 BMs/day.  Denies fevers, chills,
dysuria, diarrhea, melena, hematemasis.  He did report
occasional BRBPR that is longstanding and of note patient had
normal colonoscopy with grade 1 varices noted on EGD.  She had
some complaints of abdominal pain per husband, but he was unable
to further clarify these symptoms.
.
In th ED, vitals were T 98.3, HR 93, BP 113/54, RR 14, O2 Sat
93% on RA.  An NGT was placed and she was given lactulose.  She
was given vanco/cipro/zosyn for conern of SBP.  She was given 4L
IVF.  Labs were notable for an ammonia of 266.  She was found to
have an INR of 3.6 and a lactate of 6.3.  Stox was negative.  CT
Head was negative.  Abdominal ultrasound showed patent portal
vein and not enough ascites to safely tap.  Abdominal CT showed
moderate ascites but no acute process (though oral contrast was
not given).


Past Medical History:
- Cirrhosis [**1-3**] Hep C; s/p OLT [**2172**] with recurrent hep C and
autoimmune hepatitis (seen on biopsy); s/p IFN/ribavirin in
past. Complicated by recurrent hepatic encephalopathy, SBP prior

to transplant per husband, GI bleeding (both BRBPR and melena,
last 3-4 months ago per husband, but per husband does not seem
that she has ever required blood transfusions etc).
- recurrent facial cellulitis of cheeks
- asthma
- DM
- HTN
- osteoporosis
- nephrolithiasis
- h/o C.diff
- zoster

Social History:
Lives with husband. [**Name (NI) 4906**] denies etoh, smoking, drug use.

Family History:
Noncontributory

Physical Exam:
VS: HR 95, BP 112/66, RR 14, 100% on RA
Gen: moaning, eyes closed
HEENT: PERRL
CV: +2/6 systolic murmur
Pulm: clear to ausculatation
Abd: distended, NT, bowel sounds present, no difinitive ascites
Ext: 2+ bilateral pitting edema
Neuro: unable to cooperate, moving all extremities
.

Pertinent Results:
139 | 106 | 26 /
---------------- 90
4.3 | 26 | 0.9 \
.
CK 59
.
.. \ 9.5 /
5.1 ----- 77
.. / 29.9 \
.
PT 34.4
PTT 54.5
INR 3.6
.
Ammonia 266
.
ALT 60
AST 96
AP 88
T. bili 7.2
D. bili 4.2
Alb 2.3
.
Stox - negative.
.
Micro:
Bl Cx x 2 - NGTD
Urine culture - pending
.
Lactate 6.3
.
Imaging:
CXR: no acute process
.
Liver ultrasound:
Patent portal vein with hepatopetal flow

CT pelvis.
IMPRESSION:
1. Cirrhotic transplant liver with moderate amount of ascites
and prominent
varices. Portal vein is patent.
2. Small right-sided pleural effusion.
3. Gastric and bowel wall thickening, most likely due to liver
disease/hypoalbuminemia. Evaluation is limited, as there was no
oral
contrast.
4. Multiple vertebral compression fractures, age indeterminate.
.


Brief Hospital Course:
On [**10-20**],  house officer was called for increasing O2
requirement.  On exam, patient complained of new abdominal pain.
 On exam, 02 sats low 90s on non-rebreather, other vital signs
stable.  She was found to have BRBPR.  ABG was done, showing pO2
65.  CBC and CXR performed.  CXR showed no acute process.
Transfer to the MICU was arragned.  Blood pressure became
inaudible, so she was taken emergently to the MICU.

In the MICU, patient began to have hematemesis followed shortly
by PEA arrest. ACLS protocol was begun.  She was transfused
multiple units pRBC via rapid infuser.  Also given several units
of FFP and platelets.  Pulse was restored after 30 minutes
following ACLS protocol.  She continued to have hematemesis and
[**Last Name (un) **] tube was placed by the liver attending and fellow.
She again went into PEA arrest and ACLS protocol was initiated.
During this time discussions were ongoing with the husband and
sister regarding her poor prognosis.  The patient expired that
night from presumed massive gastrointestinal hemorrhage.

Ms. [**Known lastname 61295**] is a 57 year old female with cirrhosis admitted for
hepatic encephalopathy in setting of UTI.
.
Hepatic encephalopathy.  Hepatic encephalopathy likely triggered
by UTI.  Patient treated with lactulose 30 q 2 hours for >24
hours until patient had significant improvement of mental
status.  She was given ceftriaxone for UTI.  Not enough ascites
to tap and there was low suspicion for SBP, so she did not get a
paracentesis or SBP treatment.  She was continued on rifaximin.
.
Cirrhosis S/p liver transplant.  Patient has HCV cirrhosis, s/p
transplant.  She had subequent liver failure secondary to HCV
verus autoimmune hepatitis.  She was listed for a second
transplant during this hospital stay.  She was continued on
mycophenolate and tacrolimus.  Cellcept was held per liver team
on hospital day 3.
.
UTI.  Patient found to have pansensitive klebsiella UTI and was
treated with 3 days of ceftriaxone, but was switched to cipro
due to concern for pancotypenia.
.
Pancytopenia.  Patient developed pancytopenia, requiring 4 units
of PRBCs, 4 units FFP, and 1 unit of cryoprecipitate.  She was
evaluated by hematology who felt it was likely a medication
effect (?dose of zosyn given in ED, ceftriaxone for UTI).  She
was monitored in the ICU.  There was no evidence of bleeding or
splenic vein thrombosis leading to splenic sequestration.  EBV,
Parvovirus, and CMV studies were sent for concern for an
infectious etiology of pancytopenia.

Coagulatopathy.  INR 2.5- 3 at baseline but rose to >7 during
hospitalization.  She was given 4 units of FFP.  Her INR
stabilized at 2.9.  Likely secondary to hepatic dysfunction.
She received two days of vitamin K.

Thrombocytopenia.  Stable.  Known to have splenomegaly.  HIT was
sent, but pending at present.
.
Renal failure. Cr rose from 1.1 to 1.7 in setting of aggressive
Lactulose regimen and getting a dose of lasix 40 IV on hospital
day 2.  He renal function later imprved with albumin and holding
lasix.

Hypernatremia.  Initially hypernatremic in setting of being NPO
for two days due to AMS and dehydration secondary to significant
diarrhea from Lactulose.  This improved when her mental status
improved and she was able to eat and drink.


Medications on Admission:
Mycophenolate mofetil 1000 mg qam, 500 mg qpm
Metoprolol 25 mg [**Hospital1 **]
Lactulose 60 TID
Pantoprazole 40 mg daily
Prednisone 10 mg daily
Rifaximin 400 mg TID
Tacrolimus 0.5 mg qpm
Folic acid
Insulin glargin 9 units qhs
Lasix 20 mg daily
MVI
Vitamin D
Lispro sliding scale

Discharge Disposition:
Expired

Discharge Diagnosis:
deceased

Discharge Condition:
deceased

Discharge Instructions:
deceased

Followup Instructions:
deceased
{'Hepatic encephalopathy,Acute kidney failure, unspecified,Complications of transplanted liver,Other ascites,Hyperosmolality and/or hypernatremia,Urinary tract infection, site not specified,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Acute respiratory failure,Other and unspecified coagulation defects,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol,Cardiac arrest,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: Ms. [**Known lastname 61295**] is a 57 year old female with HCV cirrhosis, s/p failed
liver transplant, admitted with altered mental status.
[**Name (NI) **] husband reports over the past few days, she has had
increasing become more somnolent.  She has been taking lactulose
4x daily, but is having only 2 BMs/day.  Denies fevers, chills,
dysuria, diarrhea, melena, hematemasis.  He did report
occasional BRBPR that is longstanding and of note patient had
normal colonoscopy with grade 1 varices noted on EGD.  She had
some complaints of abdominal pain per husband, but he was unable
to further clarify these symptoms.
.
In th ED, vitals were T 98.3, HR 93, BP 113/54, RR 14, O2 Sat
93% on RA.  An NGT was placed and she was given lactulose.  She
was given vanco/cipro/zosyn for conern of SBP.  She was given 4L
IVF.  Labs were notable for an ammonia of 266.  She was found to
have an INR of 3.6 and a lactate of 6.3.  Stox was negative.  CT
Head was negative.  Abdominal ultrasound showed patent portal
vein and not enough ascites to safely tap.  Abdominal CT showed
moderate ascites but no acute process (though oral contrast was
not given).

MEDICAL HISTORY: - Cirrhosis [**1-3**] Hep C; s/p OLT [**2172**] with recurrent hep C and
autoimmune hepatitis (seen on biopsy); s/p IFN/ribavirin in
past. Complicated by recurrent hepatic encephalopathy, SBP prior

MEDICATION ON ADMISSION: Mycophenolate mofetil 1000 mg qam, 500 mg qpm
Metoprolol 25 mg [**Hospital1 **]
Lactulose 60 TID
Pantoprazole 40 mg daily
Prednisone 10 mg daily
Rifaximin 400 mg TID
Tacrolimus 0.5 mg qpm
Folic acid
Insulin glargin 9 units qhs
Lasix 20 mg daily
MVI
Vitamin D
Lispro sliding scale

ALLERGIES: Sulfisoxazole

PHYSICAL EXAM: VS: HR 95, BP 112/66, RR 14, 100% on RA
Gen: moaning, eyes closed
HEENT: PERRL
CV: +2/6 systolic murmur
Pulm: clear to ausculatation
Abd: distended, NT, bowel sounds present, no difinitive ascites
Ext: 2+ bilateral pitting edema
Neuro: unable to cooperate, moving all extremities
.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with husband. [**Name (NI) 4906**] denies etoh, smoking, drug use. 

### Response:
{'Hepatic encephalopathy,Acute kidney failure, unspecified,Complications of transplanted liver,Other ascites,Hyperosmolality and/or hypernatremia,Urinary tract infection, site not specified,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Acute respiratory failure,Other and unspecified coagulation defects,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol,Cardiac arrest,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}
