CHIEF COMPLAINT: nausea, vomiting, hyperkalemia

PRESENT ILLNESS: 30 year old man with history of biliary atresia s/p liver
transplant at age 4 who presents from home with nausea and
vomiting for the last several days. He called the transplant
center on the day of admission and they checked outpatient labs
which were remarkable for K of 6.0. He was advised to come to
the ED.
.
In the ED, initial vitals were T 97.7, HR 79, BP 119/77, RR 22,
98%RA. K was 6.3. CBC and LFTs were consistent with priors.
Creatinine was 2.8 (c/w recent basline). EKG showed no
hyperkalemic changes. Abdomen was soft and no imaging was felt
to be necessary. Patient got 10U insulin, 1 amp D50, 15g
kayexalate, and repeat K was 4.9. He was admitted for treatment
of nausea, vomiting, and hyperkalemia. Liver fellow was
contact[**Name (NI) **] in [**Name (NI) **] and requested Prograf level be checked 12 hours
post last dose. Liver fellow agreed with admission to liver
service. Vitals at time of transfer were afebrile, HR 86, BP
133/86, RR 18, sat99%RA.
.
Of note, patient was seen in kidney clinic on [**5-31**] (Dr [**Last Name (STitle) **]
for follow-up of postinfectious glomerulonephritis. He had been
hospitalized several days before for symptoms of flank pain in
the setting of recent URI in [**Month (only) **]. Renal biopsy during that
admission was c/w post-infectious GN. He was discharged on
lisinopril 5 qday, Phoslo, sodium bicarb and tacrolimus.
Creatinine since that time has ranged from 2.1-2.9. Per notes
from the office visit, plan was to continue above meds and add
Lasix, uptitrating prn, for anasarca.
.
Currently, patient denies nausea. He says that he has been
having vomiting on and off for the last three days, and he has
been unable to hold any food down. He denies abdominal pain and
there is no history of diarrhea. For his symptoms, he says he
has been taking ibuprofen, 1 pill at a time, but he cannot
specify how frequently. It appears from his allergy list that
this has been a documented allergy for him in the past, and it
is unclear why he continues to take this medicine.

MEDICAL HISTORY: -biliary Atresia s/p liver transplant at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia

MEDICATION ON ADMISSION: alendronate 70mg qweek
-clcium acetate 667mg 2 capsule tid
-hydrocodone-acetaminophen 5-500 q6h prn
-lisinopril 5mg qday
-pantoprazole 40mg qday
-sucralfate 1g qid
-tacrolimus 0.5mg [**Hospital1 **]
-calcium carbonate-vitamin d3 600-400 [**Hospital1 **]
-sodium bicarbonate 650mg [**Hospital1 **]
-furosemide 80mg qday

ALLERGIES: Ibuprofen

PHYSICAL EXAM: VITALS: T 96.9, BP 112/68, HR 71, RR 18, sat96%RA
GENERAL: young man in no distress, speaking comfortably
HEENT: normocephalic, atraumatic, non-icteric sclera, PERRLA
NECK: supple
CARDIAC: RRR, normal s1/s2
LUNGS: decreased breath sounds at bases bilaterally
ABDOMEN: distended (?[**12-27**] anasarca?), non-tender, normal bowel
sounds
EXTREMITIES: [**12-28**]+ pitting edema to above the knees bilaterally

FAMILY HISTORY: NC

SOCIAL HISTORY: denies any tobacco, EtOH or illict drug use. Lives at home with
parents, engaged. Has one child with a prior girlfriend. Does
not work.
Spontaneous bacterial peritonitis,Acute kidney failure with lesion of tubular necrosis,Accidental puncture or laceration during a procedure, not elsewhere classified,Complications of transplanted liver,Unspecified pleural effusion,Other ascites,Pulmonary collapse,Aseptic necrosis of bone, other,Unspecified protein-calorie malnutrition,Acidosis,Urinary tract infection, site not specified,End stage renal disease,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Peritoneal adhesions (postoperative) (postinfection),Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other chronic pulmonary heart diseases,Anemia in chronic kidney disease,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol
Spontan bact peritonitis,Ac kidny fail, tubr necr,Accidental op laceration,Compl liver transplant,Pleural effusion NOS,Ascites NEC,Pulmonary collapse,Asept necrosis bone NEC,Protein-cal malnutr NOS,Acidosis,Urin tract infection NOS,End stage renal disease,Acc cut/hem in surgery,Peritoneal adhesions,Abn react-org transplant,Chr pulmon heart dis NEC,Anemia in chr kidney dis,Chrnc hpt C wo hpat coma,Cirrhosis of liver NOS
Admission Date:  [**2135-6-11**]              Discharge Date:   [**2135-8-2**]

Date of Birth:  [**2104-8-11**]             Sex:   M

Service: MEDICINE

Allergies:
Ibuprofen

Attending:[**Male First Name (un) 5282**]
Chief Complaint:
nausea, vomiting, hyperkalemia

Major Surgical or Invasive Procedure:
None


History of Present Illness:
30 year old man with history of biliary atresia s/p liver
transplant at age 4 who presents from home with nausea and
vomiting for the last several days. He called the transplant
center on the day of admission and they checked outpatient labs
which were remarkable for K of 6.0. He was advised to come to
the ED.
.
In the ED, initial vitals were T 97.7, HR 79, BP 119/77, RR 22,
98%RA. K was 6.3. CBC and LFTs were consistent with priors.
Creatinine was 2.8 (c/w recent basline). EKG showed no
hyperkalemic changes. Abdomen was soft and no imaging was felt
to be necessary. Patient got 10U insulin, 1 amp D50, 15g
kayexalate, and repeat K was 4.9. He was admitted for treatment
of nausea, vomiting, and hyperkalemia. Liver fellow was
contact[**Name (NI) **] in [**Name (NI) **] and requested Prograf level be checked 12 hours
post last dose. Liver fellow agreed with admission to liver
service. Vitals at time of transfer were afebrile, HR 86, BP
133/86, RR 18, sat99%RA.
.
Of note, patient was seen in kidney clinic on [**5-31**] (Dr [**Last Name (STitle) **]
for follow-up of postinfectious glomerulonephritis. He had been
hospitalized several days before for symptoms of flank pain in
the setting of recent URI in [**Month (only) **]. Renal biopsy during that
admission was c/w post-infectious GN. He was discharged on
lisinopril 5 qday, Phoslo, sodium bicarb and tacrolimus.
Creatinine since that time has ranged from 2.1-2.9. Per notes
from the office visit, plan was to continue above meds and add
Lasix, uptitrating prn, for anasarca.
.
Currently, patient denies nausea. He says that he has been
having vomiting on and off for the last three days, and he has
been unable to hold any food down. He denies abdominal pain and
there is no history of diarrhea. For his symptoms, he says he
has been taking ibuprofen, 1 pill at a time, but he cannot
specify how frequently. It appears from his allergy list that
this has been a documented allergy for him in the past, and it
is unclear why he continues to take this medicine.


Past Medical History:
-biliary Atresia s/p liver transplant at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia


Social History:
denies any tobacco, EtOH or illict drug use. Lives at home with
parents, engaged. Has one child with a prior girlfriend. Does
not work.

Family History:
NC

Physical Exam:
VITALS: T 96.9, BP 112/68, HR 71, RR 18, sat96%RA
GENERAL: young man in no distress, speaking comfortably
HEENT: normocephalic, atraumatic, non-icteric sclera, PERRLA
NECK: supple
CARDIAC: RRR, normal s1/s2
LUNGS: decreased breath sounds at bases bilaterally
ABDOMEN: distended (?[**12-27**] anasarca?), non-tender, normal bowel
sounds
EXTREMITIES: [**12-28**]+ pitting edema to above the knees bilaterally


Pertinent Results:
Labs on Admission ([**2135-6-11**]):
GLUCOSE-117* UREA N-83* CREAT-2.8* SODIUM-139 POTASSIUM-6.3*
CHLORIDE-111* TOTAL CO2-23 ANION GAP-11
ALT(SGPT)-42* AST(SGOT)-66* ALK PHOS-243* TOT BILI-0.8
LIPASE-68*
ALBUMIN-1.2* PHOSPHATE-4.8*
WBC-9.1 RBC-4.12* HGB-12.9* HCT-38.1* MCV-93 MCH-31.2 MCHC-33.7
RDW-13.7
 NEUTS-79.3* LYMPHS-14.0* MONOS-3.4 EOS-3.1 BASOS-0.3
PLT COUNT-157
PT-13.6* PTT-25.6 INR(PT)-1.2*
 tacroFK-6.7

[**2135-6-11**]
URINE  RBC->50 WBC-21-50* BACTERIA-MOD [**Month/Day/Year **]-NONE EPI-0
URINE  BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD

IMAGING:
[**2135-6-11**] CXR FINDINGS: No previous images. Bibasilar
opacifications, more prominent on the left, consistent with
pleural effusions and compensatory basilar atelectasis. The
upper lung zones are clear and there is no evidence of vascular
congestion.

[**2135-6-12**] CXR FINDINGS: In comparison with the study of [**6-11**],
allowing for differences in technique, there is probably little
change in the bilateral pleural effusions, slightly more
prominent on the left. Basilar atelectatic change is also seen
on the left.

[**2135-6-12**] PORTABLE ABDOMEN: No previous images. There is a
relative paucity of bowel gas presenting in a nonspecific
pattern. Although no dilatation of gas-filled loops is seen, the
possibility of a dilated fluid-filled bowel loops can certainly
not be excluded. If there is any serious clinical concern for
obstruction, CT would be necessary.

Findings of avascular necrosis are seen in the right femoral
head.

[**2135-8-2**] 06:58AM BLOOD WBC-8.1 RBC-2.86* Hgb-8.6* Hct-27.0*
MCV-94 MCH-30.0 MCHC-31.9 RDW-18.0* Plt Ct-181
[**2135-6-27**] 03:42PM URINE Eos-POSITIVE
[**2135-7-26**] 05:37AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.034
[**2135-8-2**] 06:58AM BLOOD Neuts-67.3 Lymphs-15.1* Monos-5.4
Eos-11.9* Baso-0.3
[**2135-7-29**] 05:40AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2135-8-2**] 06:58AM BLOOD PT-14.6* PTT-34.6 INR(PT)-1.3*
[**2135-8-2**] 06:58AM BLOOD Glucose-126* UreaN-42* Creat-3.3* Na-140
K-4.0 Cl-104 HCO3-26 AnGap-14
[**2135-8-2**] 06:58AM BLOOD ALT-36 AST-90* AlkPhos-468* TotBili-0.6
[**2135-8-1**] 06:20AM BLOOD GGT-79*
[**2135-8-2**] 06:58AM BLOOD Albumin-2.2* Calcium-9.3 Phos-5.2* Mg-2.3
[**2135-6-30**] 10:38AM BLOOD calTIBC-43* Ferritn-402* TRF-33*
[**2135-6-30**] 10:38AM BLOOD Triglyc-586* HDL-5 CHOL/HD-10.8
LDLmeas-<50
[**2135-7-27**] 05:26AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE
[**2135-7-20**] 02:12AM BLOOD HAV Ab-NEGATIVE
[**2135-8-2**] 09:04AM BLOOD tacroFK-5.5
[**2135-7-26**] 05:10AM BLOOD HCV Ab-NEGATIVE
[**2135-6-30**] 10:38AM BLOOD CA [**44**]-9 -Test
[**2135-6-30**] 10:38AM BLOOD VITAMIN D 25 HYDROXY-Test
[**2135-7-8**] 12:36PM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test
[**2135-7-8**] 12:36PM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Name
[**2135-7-31**] 07:05AM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND
[**2135-8-2**] 12:50PM BLOOD HISTOPLASMA ANTIBODY (BY CF AND ID)-PND
[**2135-8-2**] 12:50PM BLOOD SCHISTOSOMA ANTIBODIES-PND

Brief Hospital Course:
# Small bowel resection: Patient was admitted because of
hyperkalemia. On the night of admission he developed acute
abdomen and underwent emergent laparotomy. A 5cm area of
deserosalized tissues was found and a small bowel resection
performed. The post-op course was complicated by persistent
abdominal pain and intractable nausea and vomiting for ~2 weeks.
This subsequently resolved prior to the patient being transfered
to the hepatology service.

 #SBP: At about 2 weeks post-op the patient developed increased
abdominal pain. A diagnositic paracentesis was done that
revealed a WBC of [**Numeric Identifier 26452**] with 90% neutrophils. He was
subsequently transfered to the hepatology service. He was
started on ceftriaxone and albumin. He continued to have
abdominal pain and a repeat diagnostic paracentesis was done 2
days after initiation of treatment. This revealed a WBC of 5300
with 50% neutrophils indicating persistent infection despite
treatment. On [**7-12**] a diagnostic paracentesis was done that
showed a WBC of 3. Treatment with ceftriaxone was continued for
a total course of 2 weeks and he was then started on
ciprofloxacin for prophylaxis.

 # Hypoxemic respiratory failure: Patient was persistently
tachypneic to the mid 20s throughout his hospitalization. On the
morning of  [**7-15**] he was found to be tachypneic to 30s, using
accesory muscles and had cough blood tinged sputum.  His
respiratory status improved with diuresis and CXR showed
persistent left pleural effusion that was unchanged. An  ABG was
done once the patient was off O2 and it revealed A-a gradient of
48 (nl 10) which was consistent with significant shunting. That
afternoon the patient again developed respiratory distress and
was transferred to the MICU with increased work of breathing and
after failing a trial of NPPV, he was intubated on [**7-15**]. He has
numerous reasons for baseline multifactorial hypoxia with A-A
gradient. He has known shunting from hepatopulmonary syndrome,
and also has V/Q mismatch from a large, stable left pleural
effusion and ascites. The patient's baseline PaO2 low 70s. Given
the patient's increased work of breathing and minute
ventilation, there was concern for increased Vd/Vt suggestive of
either worsening V/Q mismatch from increased pulmonary edema or
increased shunting from a pulmonary emboli. His hepatopulmonary
syndrome, ascites, and left pleural effusion appeared stable,
contributing to decreased pulmonary reserve but likely not
contributing to acute decompensation. CXR on [**7-15**] revealed new R
sided effusion, new R sided parenchymal opacities, old L sided
effusion. In context of worsening clinical status and
leukocytosis, he was started on cefepime, vanco, cipro for
health care associated pneumonia. However, sputum subsequently
grew out rare oropharingeal flora and [**Last Name (LF) 23087**], [**First Name3 (LF) **] these
antibiotics were discontinued. Thus, it was concluded that CT
and CXR changes were likely due to increased pulmonary edema
likely secondary to acute on sub-acute renal failure and
oliguria in the setting of receiving volume. He was started on
CVVH on [**7-15**], with net negative fluid balance of approximately
negative 13L by [**7-21**]. His respiratory status improved,
ventilation settings were weaned, and he was successfully
extubated on [**7-21**]. He subsequently developed a low grade fever
and leukocytosis by [**7-22**] and was pancultured, with cultures
pending; an IR paracentesis was also scheduled. CXR from [**7-22**]
showed stable LLL atelectasis with layering of a moderate L
pleural effusion and improved right multifocal airspace
opacities and pulmonary edema (now mild). After transfer to the
floor, he was continued on dialysis.

# Renal failure: Prior to admission the patient was diagnosed
with post-infectious GN, Cr. of . His renal function continued
to improve slowly throughout admission. Once his Cr stabilized
at low 2s he was started on diuretics to treat his fluid
overload. His renal function subsequently worsened.  It was
thought that  this acute decompensation might have also had a
component of HRS and ATN. He was treated for HRS with minimal
improvement. He was started on CVVH on [**7-15**] to treat his fluid
overload as above. During his hospitalization he was evaluated
by the transplant nephrology team who concluded that his renal
failure was likely due to his post-infectious GN with a
component of ATN and so he initially did not qualify at the
moment for liver-kidney transplant.  However, Mr. [**Known lastname 40167**]
continued to require Hemodialysis at the end of his
hospitalization and ultimately was HLA typed and screened for
renal transplant.  At time of discharge, patient was listed for
both liver and renal transplant.

#Anemia: Patient was persistently anemic despite multiple blood
transfusions. Hemolytic workup was negative. His anemia was
thought to be due to renal failure.

#L pleural effusion: The patient was found to have a persistent
left pleural effusion and that was causing  mild left lower
collapse and contributing to his chronic respiratory distress.
He underwent  U/S guided thoracentesis by IR and a total 1.7 L
was taken out.  Fluid analysis showed that the fluid had a
similar composition to his ascites. The effusion  re-accumulated
after 2 days.  Pulmonary was consulted and they concluded that
this was due part to his ESLD  with a component of nephrotic
syndrome.

#Abdominal Pain: Patient had persistent abdominal pain
throughout admission. Initially it was thought to be due to
SBP(see above) but it persisted even after SBP was treated. He
received multiple abdominal CT that never revealed an acute
process.

# Pulmonary HTN: Patient had a TTE done as part of the
evaluation for liver re-transplantation. It revealed an EF 70%,
a hyperdynamic LV and pulmonary HTN. A right heart cath was
subsequently done to further characterize his pulmonary HTN.
This revealed PCWP of 22 mmHg, elevated right sided filling
pressure at 15 mmHg and moderate pulmonary HTN of PASP of 44
mmHg. He was diagnosed with type 1 pulmonary hypertension caused
by his ESLD and nephrotic syndrome.

#Sinus Tachycardia: Patient  was persistently in sinus
tachycardia to low 100s. His EKG revealed no abnormalities.
Right Heart Cath showed Pulmonary HTN.

# S/p Liver Transplant: Patient is s/p liver transplant at age 4
because of biliary atresia. His ESLD remained at baseline with a
MELD ranging in the mid 20s. He was re-evaluated and thought to
be a candidate for re-transplantation. He underwent complete
transplant workup while in the hospital and is currently listed
on the transplant list.

# Fever: Patient had a fever while on Vanc and Zosyn as well as
eosinophilia.  There was concern for drug fever and antibiotics
were discontinued.  Patient defervesced.  He continued to have
occasionaly low-grade fevers with no source identified.  He was
given Vancomycin HD protocol for possible HD line infection.  He
was discharged afebrile.
.
# Eosinophilia - Noted during the end of his admission.  Thought
likely secondary to antibiotics or other medication.  however,
other causes were not excluded.  Pending results for HISTOPLASMA
ANTIBODY (BY CF AND ID), SCHISTOSOMA ANTIBODIES, and
STRONGYLOIDES ANTIBODY,IGG were pending at discharge to be
followed up.

Medications on Admission:
alendronate 70mg qweek
-clcium acetate 667mg 2 capsule tid
-hydrocodone-acetaminophen 5-500 q6h prn
-lisinopril 5mg qday
-pantoprazole 40mg qday
-sucralfate 1g qid
-tacrolimus 0.5mg [**Hospital1 **]
-calcium carbonate-vitamin d3 600-400 [**Hospital1 **]
-sodium bicarbonate 650mg [**Hospital1 **]
-furosemide 80mg qday

Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QD ().
Disp:*30 Capsule(s)* Refills:*2*
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezes.
Disp:*1 inh* Refills:*2*
5. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO QID (4 times
a day) as needed for constipation: titrate to 3 bowel movements
per day.
Disp:*qs * Refills:*3*
6. Ivermectin 3 mg Tablet Sig: Four (4) Tablet PO daily () for 4
days: start [**2135-8-3**].
Disp:*16 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
Please draw a Quanteferon gold as ordered in Mr [**Known lastname 78898**]
electronic [**Medical Record Number 78899**]. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 511**] Home Therapies

Discharge Diagnosis:
Primary Diagnosis:
1. End Stage Liver Disease
2. End Stage Renal Failure, Hemodialysis dependent
3. Respiratory Failure
4. Peritonitis
5. s/p Small bowel resection
6. Avascular necrosis Left hip
7. Malnutrition


Discharge Condition:
Afebrile, vital signs stable. Tolerating PO and continuous tube
feeds, electrolytes within normal limits on HD.


Discharge Instructions:
You were admitted to [**Hospital1 **] on [**2135-6-11**] for
nausea, vomiting, and high potassium. We gave you fluids and
medications for nausea.  Due to your abdominal pain, you
required an operation to determine what was causing the pain.
During the operation a small portion of your bowel was removed
due to concern that there was a hole in the bowel wall causing
stool to leak into your abdomen. Because of this, you were
started on ciprofloxacin which you should continue. This is an
antibiotic which helps to prevent future infections in your
abdomen.

Additionally, during your admission, you had problems with your
breathing and were sent to the intensive care unit and required
a machine to breathe for you.  Additionally, you had problems
with your kidneys that required hemodialysis, which will
continue ([**Date Range 766**], Wednesday, and Fridays) once you leave the
hospital.  Your liver was determined to not be working properly
and you were listed for another liver transplant.  You also may
need a kidney transplant--and were evaluated in the hospital for
this as well.

You were also given a medication called ivermectin in case you
have a parasitic infection. You should continue this medication
for the next 4 days ([**8-3**], [**8-4**], [**8-5**] and [**8-6**]). In addition, you
should have a blood test drawn in the [**Hospital Unit Name **] early on
[**8-10**] PRIOR to your appointment with Dr [**Last Name (STitle) 497**] at 8:20
am.

In the meantime, you were started on tube feeds to support your
nutrition which you should continue until you are told
otherwise.

Please return to the ER or call your doctor if you experience
chest pain, shortness of breath, severe nausea/vomiting, bloody
stools, abdominal pain, fevers, chills, or any other symptoms
that are concerning to you.

You should NEVER take ibuprofen or any other nonsteroidal
anti-inflammatory medications for pain.

Followup Instructions:
Please follow up in Liver Clinic with Dr [**Last Name (STitle) 497**] on Wednesday,
[**8-10**] at 8:20am. Please have labs drawn early the same
morning prior to your appointment. Please call ([**Telephone/Fax (1) 1582**]
should you need to reschedule.
.
Please follow up in kidney clinic ([**Hospital Ward Name 23**] 7) with Dr. [**Last Name (STitle) **]
on Tuesday [**9-20**] at 3:00pm. Please call ([**Telephone/Fax (1) 10135**] should
you need to reschedule.
{'Spontaneous bacterial peritonitis,Acute kidney failure with lesion of tubular necrosis,Accidental puncture or laceration during a procedure, not elsewhere classified,Complications of transplanted liver,Unspecified pleural effusion,Other ascites,Pulmonary collapse,Aseptic necrosis of bone, other,Unspecified protein-calorie malnutrition,Acidosis,Urinary tract infection, site not specified,End stage renal disease,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Peritoneal adhesions (postoperative) (postinfection),Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other chronic pulmonary heart diseases,Anemia in chronic kidney disease,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol'}


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: nausea, vomiting, hyperkalemia

PRESENT ILLNESS: 30 year old man with history of biliary atresia s/p liver
transplant at age 4 who presents from home with nausea and
vomiting for the last several days. He called the transplant
center on the day of admission and they checked outpatient labs
which were remarkable for K of 6.0. He was advised to come to
the ED.
.
In the ED, initial vitals were T 97.7, HR 79, BP 119/77, RR 22,
98%RA. K was 6.3. CBC and LFTs were consistent with priors.
Creatinine was 2.8 (c/w recent basline). EKG showed no
hyperkalemic changes. Abdomen was soft and no imaging was felt
to be necessary. Patient got 10U insulin, 1 amp D50, 15g
kayexalate, and repeat K was 4.9. He was admitted for treatment
of nausea, vomiting, and hyperkalemia. Liver fellow was
contact[**Name (NI) **] in [**Name (NI) **] and requested Prograf level be checked 12 hours
post last dose. Liver fellow agreed with admission to liver
service. Vitals at time of transfer were afebrile, HR 86, BP
133/86, RR 18, sat99%RA.
.
Of note, patient was seen in kidney clinic on [**5-31**] (Dr [**Last Name (STitle) **]
for follow-up of postinfectious glomerulonephritis. He had been
hospitalized several days before for symptoms of flank pain in
the setting of recent URI in [**Month (only) **]. Renal biopsy during that
admission was c/w post-infectious GN. He was discharged on
lisinopril 5 qday, Phoslo, sodium bicarb and tacrolimus.
Creatinine since that time has ranged from 2.1-2.9. Per notes
from the office visit, plan was to continue above meds and add
Lasix, uptitrating prn, for anasarca.
.
Currently, patient denies nausea. He says that he has been
having vomiting on and off for the last three days, and he has
been unable to hold any food down. He denies abdominal pain and
there is no history of diarrhea. For his symptoms, he says he
has been taking ibuprofen, 1 pill at a time, but he cannot
specify how frequently. It appears from his allergy list that
this has been a documented allergy for him in the past, and it
is unclear why he continues to take this medicine.

MEDICAL HISTORY: -biliary Atresia s/p liver transplant at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia

MEDICATION ON ADMISSION: alendronate 70mg qweek
-clcium acetate 667mg 2 capsule tid
-hydrocodone-acetaminophen 5-500 q6h prn
-lisinopril 5mg qday
-pantoprazole 40mg qday
-sucralfate 1g qid
-tacrolimus 0.5mg [**Hospital1 **]
-calcium carbonate-vitamin d3 600-400 [**Hospital1 **]
-sodium bicarbonate 650mg [**Hospital1 **]
-furosemide 80mg qday

ALLERGIES: Ibuprofen

PHYSICAL EXAM: VITALS: T 96.9, BP 112/68, HR 71, RR 18, sat96%RA
GENERAL: young man in no distress, speaking comfortably
HEENT: normocephalic, atraumatic, non-icteric sclera, PERRLA
NECK: supple
CARDIAC: RRR, normal s1/s2
LUNGS: decreased breath sounds at bases bilaterally
ABDOMEN: distended (?[**12-27**] anasarca?), non-tender, normal bowel
sounds
EXTREMITIES: [**12-28**]+ pitting edema to above the knees bilaterally

FAMILY HISTORY: NC

SOCIAL HISTORY: denies any tobacco, EtOH or illict drug use. Lives at home with
parents, engaged. Has one child with a prior girlfriend. Does
not work. 

### Response:
{'Spontaneous bacterial peritonitis,Acute kidney failure with lesion of tubular necrosis,Accidental puncture or laceration during a procedure, not elsewhere classified,Complications of transplanted liver,Unspecified pleural effusion,Other ascites,Pulmonary collapse,Aseptic necrosis of bone, other,Unspecified protein-calorie malnutrition,Acidosis,Urinary tract infection, site not specified,End stage renal disease,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Peritoneal adhesions (postoperative) (postinfection),Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other chronic pulmonary heart diseases,Anemia in chronic kidney disease,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol'}
