CHIEF COMPLAINT: liver failure

PRESENT ILLNESS: This is a 60 y/o female with a hx of EtOH abuse who was
transferred from [**Hospital3 26615**] Hospital on [**2145-3-19**] with
decompensated liver failure.  She originally presented to the
OSH with severe jaundice and mental status changes.  Initially
at the OSH, her labs were significant for an elevated WBC at
14,800 with 18% bands. Her total bilirubin was 13.0, with a
direct bilirubin of 8.1, Alkphos 310, AST 246, ALT 262. Amylase
and Lipase were normal. Albumin was 1.8 and INR was 1.8.
.
Due to the concern for sepsis, she was treated initially for
acute cholecystitis with Ampicillin/Sulbactam and Ceftriaxone.
US of the gallbladder revealed sludge and multiple calculi. The
liver was found to have a fatty infiltrate. A CT showed no
evidence of obstruction, ascites or neoplasm but confirmed a
fatty liver. An alternative diagnosis of ETOH hepatitis was
considered. Pentoxiphylline was started. The pt's LFTS trended
down while the Bilirubin [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 35952**] to 14.6 upon transfer. The
patient was also found to have [**Last Name (NamePattern1) **] with a creatinine of 3.3 on
presentation, which improved to 1.7 upon transfer. [**Last Name (NamePattern1) **] was
presumed to be due to hypotension and ATN. Pt was also
hyponatremic on admission to 120, improved to 130 on transfer.
Cultures on transfer had shown no growth to date. BP meds were
held at the OSH due to borderline hypotension and bradycardia.
THe patient was transiently on low dose Dopamine. The patient
was also treated with a Detox protocoll for ETOH withdrawal and
Lactulose for elevated Ammonia and presumed chronic liver
disease. On the day of transfer the patient had acutely
worsening MS changes likely secondary to BZD and/or ETOH
withdrawal and was intubated for airway protection.
.
Since her admission here to the SICU at [**Hospital1 18**], the patient was
changed to Vancomycin and Zosyn for antibiotic coverage. Blood
cultures and Urine cultures were drawn and are NTD. The patient
was maintained intubated and Lactulose and Rifaximin was given
for hepatic encephalopathy. THe patient developed a
hypernatremia. She was maintained on Dopamin gtt and was found
to have intermittent spurts of SVT and cardiology was consulted
who recommended a change to neosynephrine which was done.
Hepatology was consulted and recommended further workup for
liver failure.  This has included hepatitis serologies.  She was
hep A Ab positive. Remaining hep serologies were negative.  [**Doctor First Name **],
AMA and smooth antibodies were negative.  CMV and EBV have been
sent and are pending.
.
Of note to further assess the patient's mental status, a head CT
was obtained it did not show any acute process.  Despite being
off the propofol it continues to be difficult to arouse the
patient.  To protect her airway she continues to be intubated.
The patient has now been transferred to the MICU for further
mgmt of her medical condition.

MEDICAL HISTORY: PMH:
EtOH cirrhosis?
h/o SVT, followed by Dr. [**Last Name (STitle) 77919**], on Sotalol and Diltizem
Generalized anxiety
Macrocytosis
h/o rheumatic fever

MEDICATION ON ADMISSION: Medications at home:
Diltiazem xt 300 Qdaily
Sotalol 120 Qdaily
Vit D 400 Qdaily
MVA
Glucosamine
.
Medications on transfer from OSH:
Pentoxifylline 400 [**Hospital1 **]
Folic acid Qdaily
Mva Qdaily
Librium 25mg q6hr
Thiamine 100 Qdaily
Lactulose 30mg q4hr
Unasyn 3g qDaily
Ceftriaxone 1mg Qdaily
Dopamine gtt
.
Medications on transfer from SICU:
Insulin SC (per Insulin Flowsheet)
Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP >90, <140

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 97.8 BP  112/57 HR 75
RR 26 PSV 12/5 FiO2 40% O2 sat 98-100%
Orthostatics
Gen: overweight Caucasian female in NAD, lying in bed, who does
not respond to command
HEENT: NC/AT, PERRLA, scleral icterus
NECK: no LAD, no JVD, no carotid bruit
COR: S1S2, regular rhythm, no m/r/g
PULM: CTA b/l anteriorly, no RRW
ABD: + bowel sounds, soft, nd, nt
Skin: jaundiced,
EXT: 2 + pitting edema
Neuro: does not follow commands.

FAMILY HISTORY: Father died of brain tumor at age 67
Mother died of H.flu infection at age 71

SOCIAL HISTORY: married for 40yrs, has two grown children, works in sales at a
nursery, smoked for at least 20yrs between 1pack and 1 1/2packs
a day. She quit about 5 yrs ago. Drinks about [**2-14**]
scotches/highballs a day and has been doing so for "many years".
Unspecified septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Portal vein thrombosis,Alcohol withdrawal,Hyperosmolality and/or hypernatremia,Septic shock,Hepatic encephalopathy,Severe sepsis,Other specified cardiac dysrhythmias,Acute alcoholic hepatitis
Septicemia NOS,Acute respiratry failure,Acute kidney failure NOS,Portal vein thrombosis,Alcohol withdrawal,Hyperosmolality,Septic shock,Hepatic encephalopathy,Severe sepsis,Cardiac dysrhythmias NEC,Ac alcoholic hepatitis
Admission Date:  [**2145-3-22**]              Discharge Date:   [**2145-3-30**]

Date of Birth:  [**2085-3-23**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 338**]
Chief Complaint:
liver failure

Major Surgical or Invasive Procedure:
central venous line placement
arterial line placement
intubation

History of Present Illness:
This is a 60 y/o female with a hx of EtOH abuse who was
transferred from [**Hospital3 26615**] Hospital on [**2145-3-19**] with
decompensated liver failure.  She originally presented to the
OSH with severe jaundice and mental status changes.  Initially
at the OSH, her labs were significant for an elevated WBC at
14,800 with 18% bands. Her total bilirubin was 13.0, with a
direct bilirubin of 8.1, Alkphos 310, AST 246, ALT 262. Amylase
and Lipase were normal. Albumin was 1.8 and INR was 1.8.
.
Due to the concern for sepsis, she was treated initially for
acute cholecystitis with Ampicillin/Sulbactam and Ceftriaxone.
US of the gallbladder revealed sludge and multiple calculi. The
liver was found to have a fatty infiltrate. A CT showed no
evidence of obstruction, ascites or neoplasm but confirmed a
fatty liver. An alternative diagnosis of ETOH hepatitis was
considered. Pentoxiphylline was started. The pt's LFTS trended
down while the Bilirubin [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 35952**] to 14.6 upon transfer. The
patient was also found to have [**Last Name (NamePattern1) **] with a creatinine of 3.3 on
presentation, which improved to 1.7 upon transfer. [**Last Name (NamePattern1) **] was
presumed to be due to hypotension and ATN. Pt was also
hyponatremic on admission to 120, improved to 130 on transfer.
Cultures on transfer had shown no growth to date. BP meds were
held at the OSH due to borderline hypotension and bradycardia.
THe patient was transiently on low dose Dopamine. The patient
was also treated with a Detox protocoll for ETOH withdrawal and
Lactulose for elevated Ammonia and presumed chronic liver
disease. On the day of transfer the patient had acutely
worsening MS changes likely secondary to BZD and/or ETOH
withdrawal and was intubated for airway protection.
.
Since her admission here to the SICU at [**Hospital1 18**], the patient was
changed to Vancomycin and Zosyn for antibiotic coverage. Blood
cultures and Urine cultures were drawn and are NTD. The patient
was maintained intubated and Lactulose and Rifaximin was given
for hepatic encephalopathy. THe patient developed a
hypernatremia. She was maintained on Dopamin gtt and was found
to have intermittent spurts of SVT and cardiology was consulted
who recommended a change to neosynephrine which was done.
Hepatology was consulted and recommended further workup for
liver failure.  This has included hepatitis serologies.  She was
hep A Ab positive. Remaining hep serologies were negative.  [**Doctor First Name **],
AMA and smooth antibodies were negative.  CMV and EBV have been
sent and are pending.
.
Of note to further assess the patient's mental status, a head CT
was obtained it did not show any acute process.  Despite being
off the propofol it continues to be difficult to arouse the
patient.  To protect her airway she continues to be intubated.
The patient has now been transferred to the MICU for further
mgmt of her medical condition.


Past Medical History:
PMH:
EtOH cirrhosis?
h/o SVT, followed by Dr. [**Last Name (STitle) 77919**], on Sotalol and Diltizem
Generalized anxiety
Macrocytosis
h/o rheumatic fever


Social History:
married for 40yrs, has two grown children, works in sales at a
nursery, smoked for at least 20yrs between 1pack and 1 1/2packs
a day. She quit about 5 yrs ago. Drinks about [**2-14**]
scotches/highballs a day and has been doing so for "many years".



Family History:
Father died of brain tumor at age 67
Mother died of H.flu infection at age 71


Physical Exam:
VS T 97.8 BP  112/57 HR 75
RR 26 PSV 12/5 FiO2 40% O2 sat 98-100%
Orthostatics
Gen: overweight Caucasian female in NAD, lying in bed, who does
not respond to command
HEENT: NC/AT, PERRLA, scleral icterus
NECK: no LAD, no JVD, no carotid bruit
COR: S1S2, regular rhythm, no m/r/g
PULM: CTA b/l anteriorly, no RRW
ABD: + bowel sounds, soft, nd, nt
Skin: jaundiced,
EXT: 2 + pitting edema
Neuro: does not follow commands.

Pertinent Results:
[**2145-3-22**] 11:51PM   GLUCOSE-129* UREA N-15 CREAT-1.4* SODIUM-149*
POTASSIUM-4.9 CHLORIDE-118* TOTAL CO2-14* ANION GAP-22*
[**2145-3-22**] 11:51PM   estGFR-Using this
[**2145-3-22**] 11:51PM   ALT(SGPT)-215* AST(SGOT)-226* LD(LDH)-1600*
CK(CPK)-559* ALK PHOS-292* AMYLASE-50 TOT BILI-12.9*
[**2145-3-22**] 11:51PM   LIPASE-36
[**2145-3-22**] 11:51PM   CK-MB-8 cTropnT-0.02*
[**2145-3-22**] 11:51PM   ALBUMIN-2.0* CALCIUM-7.7* PHOSPHATE-1.4*
MAGNESIUM-1.6
[**2145-3-22**] 11:51PM   HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE
[**2145-3-22**] 11:51PM   HCV Ab-NEGATIVE
[**2145-3-22**] 11:51PM   WBC-15.1* RBC-2.44* HGB-11.2* HCT-33.5*
MCV-138* MCH-45.9* MCHC-33.4 RDW-17.1*
[**2145-3-22**] 11:51PM   NEUTS-86.3* LYMPHS-9.1* MONOS-4.3 EOS-0.2
BASOS-0.2
[**2145-3-22**] 11:51PM   PLT COUNT-292
[**2145-3-22**] 11:51PM   PT-17.4* PTT-45.9* INR(PT)-1.6*
[**2145-3-22**] 11:51PM   FIBRINOGE-144*
.
Studies:
Liver duplex [**3-23**]:
1.Diffusely echogenic liver consistent with extensive fatty
infiltration.
2.Patent SMV with reversed flow in the splenic vein.
3.Portal vein without detectable flow, presumed to be secondary
to thrombosis.
.
CXR [**3-23**]: Portable AP chest radiograph was reviewed with no
prior studies available for comparison. The ET tube tip is 4 cm
above the carina. The NG tube tip passes below the diaphragm
most likely terminating in the stomach. The cardiomediastinal
silhouette is unremarkable. Linear opacity at the left base is
consistent with atelectasis. The rest of the lungs are normal.
There is no appreciable pleural effusion. There is no
pneumothorax
.

Brief Hospital Course:
Hospital Course: 59 yo with ETOH cirrhosis, who presents with
altered MS [**First Name (Titles) **] [**Last Name (Titles) **].
.
# Altered mental status: On admission the patient's altered
mental appeared to be multifactorial. The differential diagnosis
included hepatic encephalopathy, alcohol withdrawl, benzo
withdrawl, and infection.  The patient had a negative CT head
and a negative MR head. An EEG demonstrated findings consistent
with widespread encephalopathy. Ammonia was elevated in the 80s.
TSH was normal. She was placed on broad spectrum antibiotics
(initially vancomycin and zosyn) and continued on lactulose and
rifaximin. Despite aggressive treatment, as described below, the
patient's condition continued to decline. She continued to be
encephalopathic. On discussion with her family, including her
daughter/HCP, the patient was made [**Name (NI) 3225**] and died after aggressive
life support measures were withdrawn.
.
# Acute Hepatitis: On admission the patient had markedly
elevated LFTs and total bilirubin. This was felt to likely be
due to ETOH. the hepatology service followed the patient
throughout the admission. She was placed on pentoxifylline and,
lactulose and rifaximin. Transplant surgery followed but given
the patient's instability made her a poor candidate acutely. The
patient remained encephalopathic throughout her hospitalization.
.
# Shock: The patient met SIRS criteria and had an elevated white
count but no clear source of infection. The patient required
neosynephrine and intermittent fluid boluses to maintain her
blood pressure. Initially the patient was placed on vancomycin
and zosyn alone. However, doxycycline was later added. As
multiple cultures eventually grew out yeast, caspofungin was
also added. Despite this broad coverage the patient continued to
have a pressor requirement and her white count continued to
rise. As above, the patient was ultimately made comfort measures
only.
.
# Respiratory failure: This was due to altered mental status.
The patient was continued on ventilatory support and could not
be weaned due to her encephlopathy as above. Ventilatory support
was withdrawn with the changing of her code status to [**Name (NI) 3225**].
.
# SVT: The patient had episodes of A fib with RVR requiring
DCCV. The patient intermittently required diltiazem and esmolol
drips to control her heart rate as well.
.
# [**Name (NI) **]: The patient intially had renal failure, likely pre-renal
in the setting of hypotension. This resolved with pressor
support and fluids as above.
.
# PPX: The patient was maintained on pneumoboots and an H2
blocker thorughout the admission.
.
# FEN: The patient was supported with tube feeds throughout the
admission.
.
# Code: Initially the patient was full code but her code status
was changed to [**Name (NI) 3225**] upon discussions with her daughter/healthcare
proxy [**Name (NI) 1022**].


Medications on Admission:
Medications at home:
Diltiazem xt 300 Qdaily
Sotalol 120 Qdaily
Vit D 400 Qdaily
MVA
Glucosamine
.
Medications on transfer from OSH:
Pentoxifylline 400 [**Hospital1 **]
Folic acid Qdaily
Mva Qdaily
Librium 25mg q6hr
Thiamine 100 Qdaily
Lactulose 30mg q4hr
Unasyn 3g qDaily
Ceftriaxone 1mg Qdaily
Dopamine gtt
.
Medications on transfer from SICU:
Insulin SC (per Insulin Flowsheet)
Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP >90, <140

Albumin 25% (12.5g / 50mL) 25 gm IV Q6H
Piperacillin-Tazobactam Na 2.25 g IV Q8H
Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Chlordiazepoxide HCl 10 mg PO Q8H:PRN etoh withdrawal
Propofol 20-100 mcg/kg/min IV DRIP TITRATE TO sedation
Famotidine 20 mg PO BID
Rifaximin 600 mg PO BID
Folic Acid/Multivitamin/Thiamine-1000mL D5W Continuous at 50
ml/hr Heparin 5000 UNIT SC BID
Vancomycin 1000 mg IV PRN <15


Discharge Medications:
Patient died during the admission.

Discharge Disposition:
Expired

Discharge Diagnosis:
Patient died during the admission.

Discharge Condition:
Patient died during the admission.

Discharge Instructions:
Patient died during the admission.

Followup Instructions:
Patient died during the admission.
{'Unspecified septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Portal vein thrombosis,Alcohol withdrawal,Hyperosmolality and/or hypernatremia,Septic shock,Hepatic encephalopathy,Severe sepsis,Other specified cardiac dysrhythmias,Acute alcoholic hepatitis'}


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: liver failure

PRESENT ILLNESS: This is a 60 y/o female with a hx of EtOH abuse who was
transferred from [**Hospital3 26615**] Hospital on [**2145-3-19**] with
decompensated liver failure.  She originally presented to the
OSH with severe jaundice and mental status changes.  Initially
at the OSH, her labs were significant for an elevated WBC at
14,800 with 18% bands. Her total bilirubin was 13.0, with a
direct bilirubin of 8.1, Alkphos 310, AST 246, ALT 262. Amylase
and Lipase were normal. Albumin was 1.8 and INR was 1.8.
.
Due to the concern for sepsis, she was treated initially for
acute cholecystitis with Ampicillin/Sulbactam and Ceftriaxone.
US of the gallbladder revealed sludge and multiple calculi. The
liver was found to have a fatty infiltrate. A CT showed no
evidence of obstruction, ascites or neoplasm but confirmed a
fatty liver. An alternative diagnosis of ETOH hepatitis was
considered. Pentoxiphylline was started. The pt's LFTS trended
down while the Bilirubin [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 35952**] to 14.6 upon transfer. The
patient was also found to have [**Last Name (NamePattern1) **] with a creatinine of 3.3 on
presentation, which improved to 1.7 upon transfer. [**Last Name (NamePattern1) **] was
presumed to be due to hypotension and ATN. Pt was also
hyponatremic on admission to 120, improved to 130 on transfer.
Cultures on transfer had shown no growth to date. BP meds were
held at the OSH due to borderline hypotension and bradycardia.
THe patient was transiently on low dose Dopamine. The patient
was also treated with a Detox protocoll for ETOH withdrawal and
Lactulose for elevated Ammonia and presumed chronic liver
disease. On the day of transfer the patient had acutely
worsening MS changes likely secondary to BZD and/or ETOH
withdrawal and was intubated for airway protection.
.
Since her admission here to the SICU at [**Hospital1 18**], the patient was
changed to Vancomycin and Zosyn for antibiotic coverage. Blood
cultures and Urine cultures were drawn and are NTD. The patient
was maintained intubated and Lactulose and Rifaximin was given
for hepatic encephalopathy. THe patient developed a
hypernatremia. She was maintained on Dopamin gtt and was found
to have intermittent spurts of SVT and cardiology was consulted
who recommended a change to neosynephrine which was done.
Hepatology was consulted and recommended further workup for
liver failure.  This has included hepatitis serologies.  She was
hep A Ab positive. Remaining hep serologies were negative.  [**Doctor First Name **],
AMA and smooth antibodies were negative.  CMV and EBV have been
sent and are pending.
.
Of note to further assess the patient's mental status, a head CT
was obtained it did not show any acute process.  Despite being
off the propofol it continues to be difficult to arouse the
patient.  To protect her airway she continues to be intubated.
The patient has now been transferred to the MICU for further
mgmt of her medical condition.

MEDICAL HISTORY: PMH:
EtOH cirrhosis?
h/o SVT, followed by Dr. [**Last Name (STitle) 77919**], on Sotalol and Diltizem
Generalized anxiety
Macrocytosis
h/o rheumatic fever

MEDICATION ON ADMISSION: Medications at home:
Diltiazem xt 300 Qdaily
Sotalol 120 Qdaily
Vit D 400 Qdaily
MVA
Glucosamine
.
Medications on transfer from OSH:
Pentoxifylline 400 [**Hospital1 **]
Folic acid Qdaily
Mva Qdaily
Librium 25mg q6hr
Thiamine 100 Qdaily
Lactulose 30mg q4hr
Unasyn 3g qDaily
Ceftriaxone 1mg Qdaily
Dopamine gtt
.
Medications on transfer from SICU:
Insulin SC (per Insulin Flowsheet)
Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO SBP >90, <140

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 97.8 BP  112/57 HR 75
RR 26 PSV 12/5 FiO2 40% O2 sat 98-100%
Orthostatics
Gen: overweight Caucasian female in NAD, lying in bed, who does
not respond to command
HEENT: NC/AT, PERRLA, scleral icterus
NECK: no LAD, no JVD, no carotid bruit
COR: S1S2, regular rhythm, no m/r/g
PULM: CTA b/l anteriorly, no RRW
ABD: + bowel sounds, soft, nd, nt
Skin: jaundiced,
EXT: 2 + pitting edema
Neuro: does not follow commands.

FAMILY HISTORY: Father died of brain tumor at age 67
Mother died of H.flu infection at age 71

SOCIAL HISTORY: married for 40yrs, has two grown children, works in sales at a
nursery, smoked for at least 20yrs between 1pack and 1 1/2packs
a day. She quit about 5 yrs ago. Drinks about [**2-14**]
scotches/highballs a day and has been doing so for "many years". 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Portal vein thrombosis,Alcohol withdrawal,Hyperosmolality and/or hypernatremia,Septic shock,Hepatic encephalopathy,Severe sepsis,Other specified cardiac dysrhythmias,Acute alcoholic hepatitis'}
