CHIEF COMPLAINT: Fever, tachycardia

PRESENT ILLNESS: This is a 31 yo male with biliary atresia s/p liver [**Last Name (un) **]
in [**2110**], s/p small bowel resection [**8-/2135**], recent staph
bacteremia [**12-27**] infected HD line who was transferred from OSH for
fevers and tachycardia. At home, patient complained of two weeks
of fatigue, productive cough, progressive lower extremity edema,
and fevers/chills.  At a VNA visit he was noted to be
tachycardic and taken to an OSH.
.
At OSH, he was febrile and noted to be in SVT, which broke with
adenosine. He was started on levofloxacin for suspected LLL PNA
on CXR. This was broadened empirically to vanc/pip-tazo given
concern for SBP, as well. Patient was transferred to [**Hospital1 18**] ICU.

MEDICAL HISTORY: -biliary Atresia s/p liver [**Hospital1 **] 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
-small bowel resection

MEDICATION ON ADMISSION: OxycoDONE 2.5 mg Q4H:PRN pain
Oseltamivir Phosphate 75 mg PO BID
Sarna Lotion 1 Appl TP TID:PRN itching
DiphenhydrAMINE 25 mg Q6H:PRN itching
Ipratropium Bromide 1 NEB IH Q6H SOB
Ondansetron 4 mg IV Q8H:PRN nausea
Acetaminophen 325-650 mg PO/NG Q6H:PRN fevers, pain
Tacrolimus 0.5 mg PO Q12H
Pantoprazole 40 mg PO Q24H
Lactulose 30 mL PO/NG TID

ALLERGIES: Ibuprofen

PHYSICAL EXAM: PHYSICAL EXAM:
Vitals - T: 101.1 (current) BP: 136/92 HR: 110 RR: 22 02 sat:
94% 3L
GENERAL: Tachypneic, diaphoretic, mild resp distress, alert and
cooperative
HEENT: NCAT, no scleral icterus, MM dry, no JVD
CARDIAC: +S1/S2, no M/R/G, slightly tachycardic, regular rhythm

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.
Awaiting organ transplant status,Biliary cirrhosis,Euthyroid sick syndrome,Other disorders of plasma protein metabolism,Asthma, unspecified type, unspecified,Nephrotic syndrome with unspecified pathological lesion in kidney,Anemia of other chronic disease,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Obstruction of bile duct,Other ascites,Portal hypertension,Unspecified pleural effusion,Aseptic necrosis of head and neck of femur,Liver replaced by transplant,Chronic kidney disease, unspecified
Await organ transplnt st,Biliary cirrhosis,Euthyroid sick syndrome,Dis plas protein met NEC,Asthma NOS,Nephrotic syndrome NOS,Anemia-other chronic dis,Acute kidney failure NOS,Pneumonia, organism NOS,Obstruction of bile duct,Ascites NEC,Portal hypertension,Pleural effusion NOS,Aseptic necrosis femur,Liver transplant status,Chronic kidney dis NOS
Admission Date:  [**2135-9-27**]              Discharge Date:   [**2135-10-7**]

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

Service: MEDICINE

Allergies:
Ibuprofen

Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Fever, tachycardia

Major Surgical or Invasive Procedure:
Temporary hemodialysis catheter placement
Tunnelled hemodialysis catheter placement
[**Last Name (un) 1372**] intestinal tube placement


History of Present Illness:
This is a 31 yo male with biliary atresia s/p liver [**Last Name (un) **]
in [**2110**], s/p small bowel resection [**8-/2135**], recent staph
bacteremia [**12-27**] infected HD line who was transferred from OSH for
fevers and tachycardia. At home, patient complained of two weeks
of fatigue, productive cough, progressive lower extremity edema,
and fevers/chills.  At a VNA visit he was noted to be
tachycardic and taken to an OSH.
.
At OSH, he was febrile and noted to be in SVT, which broke with
adenosine. He was started on levofloxacin for suspected LLL PNA
on CXR. This was broadened empirically to vanc/pip-tazo given
concern for SBP, as well. Patient was transferred to [**Hospital1 18**] ICU.

.
In the ICU, all cell lines of his CBC were trending down, hct
drop from 27 to 19, given 2U PRBC with appropriate increase to
26. No clear source of blood loss. He also c/o
myalgias/arthralgias, with multiple sick contacts, so flu swab
was sent. This came back positive, so he was started on
oseltamivir. Diagnostic para was negative for SBP and CXR did
not show PNA, so vanc/pip-tazo were stopped. His vitals have
shown mild tachycardia from the 90s to low 100s, current BP
136/90.
.
Currently, patient c/o fevers, chills, night sweats, myalgias,
arthralgias, dyspnea, cough productive of greenish sputum, and
hematuria. He denies CP, sore throat, n/v/d, abd pain, melena,
hematochezia, dysuria, frequency, urgency.


Past Medical History:
-biliary Atresia s/p liver [**Hospital1 **] 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
-small bowel resection


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:
PHYSICAL EXAM:
Vitals - T: 101.1 (current) BP: 136/92 HR: 110 RR: 22 02 sat:
94% 3L
GENERAL: Tachypneic, diaphoretic, mild resp distress, alert and
cooperative
HEENT: NCAT, no scleral icterus, MM dry, no JVD
CARDIAC: +S1/S2, no M/R/G, slightly tachycardic, regular rhythm

LUNG: Rhonchi throughout right lung, exp wheezing on left, good
air mvmt
ABDOMEN: NABS, several abdominal scars, soft, distended, no TTP.
Dependent flank edema.
EXT: 2+ LE edema, WWP.


Pertinent Results:
*** CBC
[**2135-9-27**] WBC-7.8 RBC-2.99* Hgb-9.1* Hct-26.9* MCV-90 MCH-30.3
MCHC-33.8 RDW-16.6* Plt Ct-169#
[**2135-10-7**] WBC-9.6 RBC-3.40* Hgb-9.8* Hct-29.5* MCV-87 MCH-28.9
MCHC-33.2 RDW-16.7* Plt Ct-187
[**2135-9-27**] Neuts-84.2* Lymphs-7.2* Monos-3.4 Eos-4.8* Baso-0.4
[**2135-9-27**] PT-16.0* PTT-35.2* INR(PT)-1.4*
.
*** Chemistries
[**2135-9-27**] Glucose-87 UreaN-23* Creat-2.5* Na-137 K-4.2 Cl-109*
HCO3-21* AnGap-11
[**2135-9-28**] Glucose-105 UreaN-24* Creat-2.5* Na-136 K-4.0 Cl-110*
HCO3-19* AnGap-11
[**2135-9-28**] Glucose-98 UreaN-28* Creat-2.6* Na-136 K-4.1 Cl-110*
HCO3-20* AnGap-10
[**2135-9-29**] Glucose-80 UreaN-30* Creat-2.8* Na-138 K-4.1 Cl-112*
HCO3-20* AnGap-10
[**2135-9-30**] Glucose-78 UreaN-38* Creat-3.6* Na-137 K-3.8 Cl-111*
HCO3-17* AnGap-13
[**2135-10-1**] Glucose-95 UreaN-45* Creat-4.2* Na-137 K-3.8 Cl-110*
HCO3-17* AnGap-14
[**2135-10-2**] Glucose-82 UreaN-52* Creat-5.5*# Na-135 K-3.9 Cl-110*
HCO3-16* AnGap-13
[**2135-10-3**] Glucose-80 UreaN-57* Creat-6.6*# Na-138 K-4.3 Cl-110*
HCO3-15* AnGap-17
[**2135-10-4**] Glucose-83 UreaN-66* Creat-7.6* Na-139 K-4.6 Cl-111*
HCO3-15* AnGap-18
[**2135-10-5**] Glucose-92 UreaN-51* Creat-6.9* Na-140 K-3.8 Cl-108
HCO3-20* AnGap-16
[**2135-10-6**] Glucose-98 UreaN-35* Creat-5.7*# Na-141 K-3.7 Cl-107
HCO3-26 AnGap-12
[**2135-10-7**] Glucose-139* UreaN-22* Creat-4.3*# Na-140 K-3.8 Cl-105
HCO3-28 AnGap-11
.
*** Liver Function Tests:
[**2135-9-27**] ALT-33 AST-79* LD(LDH)-399* CK(CPK)-310* AlkPhos-371*
TotBili-0.4
[**2135-9-28**] ALT-25 AST-63* LD(LDH)-319* CK(CPK)-305* AlkPhos-265*
TotBili-0.6
[**2135-9-28**] LD(LDH)-364*
[**2135-9-29**] ALT-20 AST-62* LD(LDH)-403* AlkPhos-267* TotBili-1.0
[**2135-9-30**] ALT-18 AST-68* LD(LDH)-504* AlkPhos-336* TotBili-0.5
[**2135-9-30**] CK(CPK)-387*
[**2135-10-1**] ALT-15 AST-56* LD(LDH)-442* AlkPhos-329* TotBili-0.6
[**2135-10-2**] ALT-14 AST-56* LD(LDH)-469* AlkPhos-321* TotBili-0.5
[**2135-10-4**] ALT-12 AST-48* AlkPhos-310* TotBili-0.5
[**2135-10-5**] ALT-13 AST-39 AlkPhos-275* TotBili-0.5
[**2135-10-6**] ALT-10 AST-40 AlkPhos-301* TotBili-0.5
[**2135-10-7**] ALT-14 AST-48* AlkPhos-327* TotBili-0.4
[**2135-9-30**] Lipase-119*
.
*** Albumin, Calcium, Phosphorus, Magnesium
[**2135-9-27**] Albumin-1.1* Calcium-6.3* Phos-3.2 Mg-0.8*
[**2135-9-28**] Calcium-6.0* Phos-3.2 Mg-1.4*
[**2135-9-28**] Calcium-6.5* Phos-3.7 Mg-1.8
[**2135-9-29**] Calcium-6.7* Phos-4.3 Mg-1.8
[**2135-9-30**] Albumin-1.5* Calcium-6.8* Phos-4.3 Mg-1.7
[**2135-10-1**] Calcium-7.3* Phos-4.4 Mg-1.7
[**2135-10-2**] Calcium-7.4* Phos-4.4 Mg-1.7
[**2135-10-3**] Calcium-7.3* Phos-4.6* Mg-1.8
[**2135-10-4**] Albumin-1.2* Calcium-7.2* Phos-5.0* Mg-1.9
[**2135-10-5**] Calcium-7.2* Phos-4.4 Mg-1.8
[**2135-10-6**] Albumin-1.1* Calcium-7.0* Phos-4.0 Mg-1.7 Iron-22*
[**2135-10-7**] Calcium-6.9* Phos-3.1 Mg-1.7
.
*** Other Lab Tests:
[**2135-10-6**] calTIBC-55* Ferritn-1367* TRF-42*
[**2135-9-28**] TSH-0.18*
[**2135-9-30**] Free T4-0.48*
[**2135-10-4**] T3-50*
[**2135-10-7**] C3-70* C4-26
[**2135-10-6**] Vanco-21.5*
.
*** Serum tacrolimus level:
[**2135-9-28**] tacroFK-2.2*
[**2135-9-29**] tacroFK-3.5*
[**2135-9-30**] tacroFK-5.5
[**2135-10-1**] tacroFK-11.5
[**2135-10-2**] tacroFK-8.6
[**2135-10-3**] tacroFK-10.2
[**2135-10-4**] tacroFK-8.7
[**2135-10-5**] tacroFK-6.9
[**2135-10-6**] tacroFK-8.8
[**2135-10-7**] tacroFK-5.0
.
*** Urine
[**2135-9-28**] 11:44AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018
[**2135-9-28**] 11:44AM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2135-9-28**] 11:44AM URINE RBC->50 WBC-[**10-14**]* Bacteri-FEW [**Month/Year (2) **]-MANY
Epi-0
[**2135-9-28**] 11:44AM URINE Hours-RANDOM UreaN-339 Creat-73 Na-58
URINE CULTURE (Final [**2135-9-29**]):    NO GROWTH.
.
[**2135-10-2**] 11:10AM URINE Color-Brown Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2135-10-2**] 11:10AM URINE Blood-LG Nitrite-NEG Protein->300
Glucose-NEG Ketone-15 Bilirub-MOD Urobiln-0.2 pH-5.5 Leuks-NEG
[**2135-10-2**] 11:10AM URINE RBC->50 WBC-[**1-27**] Bacteri-MANY [**Month/Day (1) **]-NONE
Epi-[**1-27**]
[**2135-10-2**] 11:10AM URINE Hours-RANDOM UreaN-195 Creat-157 Na-32
K-63
[**2135-10-2**] 11:10AM URINE Osmolal-295
URINE CULTURE (Final [**2135-10-2**]):
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
      AND/OR GENITAL CONTAMINATION.
.
*** Peritoneal Fluid.

[**2135-9-28**] 08:10AM ASCITES WBC-25* RBC-50* Polys-1* Lymphs-7*
Monos-0 Eos-3* Macroph-89*
   GRAM STAIN (Final [**2135-9-28**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
      This is a concentrated smear made by cytospin method,
please refer to
      hematology for a quantitative white blood cell count..

   FLUID CULTURE (Final [**2135-10-1**]):    NO GROWTH.

   ANAEROBIC CULTURE (Final [**2135-10-4**]):    NO GROWTH.
Transthoracic Echcardiogram:
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>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.

No vegetation identified (but cannot exclude).
.
Abdominal Ultrasound:
INDINGS: Postsurgical anatomy and inability of patient to
cooperate with
breathing instructions limits this examination.

No evidence of focal lesions. Echogenic linear structures are
seen in the
liver, likely due to pneumobilia. Limited views of the pancreas,
due to
overlapping bowel gas. Gallbladder not seen, likely surgically
absent. There
is no intrahepatic biliary duct dilatation.

IVC, right main and left hepatic vein are patent.

The main portal vein and right portal vein are patent and show
normal
hepatopetal flow. Flow was seen in the splenic veins, however,
difficult to
obtain splenic vein waveform. The SMV was not imaged. The left
portal vein
is not definitely identified.

The right hepatic artery, main hepatic artery, are patent with
normal
waveforms. The left hepatic artery was not seen.

Ascites is seen in the left lower quadrant.

IMPRESSION:

1. Main and right portal veins have appropriate flow and
directionality; the
left portal vein difficult to visualize, and unable to assess.

2. Left hepatic artery not clearly visualized; remainder of the
arteries and
veins of the liver appear patent.

3. Gallbladder not seen, likely surgically removed.

4. Trace ascites.
.
Renal U/S:
Both kidneys are echogenic throughout with poor corticomedullary
differentiation. They are of a good size, measuring 11.3 cm
longitudinally on
the left, and 11.7 cm longitudinally on the right. No
hydronephrosis or focal
abnormality is seen in relation to either kidney.

Both main renal veins and main renal arteries are patent. There
are normal
resistive indices on both sides varying from 0.59 to 0.66.

Views of the urinary bladder are unremarkable.

Incidental note is made of a small amount of ascites.

CONCLUSION:. The kidneys are of increased echogenicity
bilaterally with poor
corticomedullary differentiation, in keeping with chronic renal
disease, from
the patient's known post-infectious glomerulonephritis. There is
no
hydronephrosis. There is good perfusion of the kidneys.


Brief Hospital Course:
#. Multifocal Pneumonia.  On arrival to the floor, patient had
significant rhonchi bilaterally, and had an oxygen saturation of
94% on 3L of oxygen by nasal cannula.  Serial blood cultures
were negative and an echocardiogram demonstrated no vegetations
suggestive of endocarditis.  A repeat chest x-ray was obtained
which demonstrated multifocal opacities sugeestive f pneumonia.
He was restarted in IV vancomycin, piperacillin-tazobactam, and
levofloxacin for treatment of multifocal pneumonia in the
setting of influenza, in a immunosupressed patient.  Antibiotics
were dosed renally and adjusted to match his changing renal
function.  His respiratory symptoms and pulmonary exam improved
with treatment and he was successfully weaned from supplemental
oxygen.  Per the recommendation of infectious disease, he was
treated for a total of 8 days of antibiotics with complete
resolution of symptoms.
.
#. H1N1 Influenza.  On admission, his influenza swab tested
positive for H1N1 swine like influenza.  He was treated with
five days of oseltamivir 150mg PO bid and kept on droplet
precautions.  He defervesced on hospital day 4, and droplet
precautions were removed, and droplet precautions were removed
24 hours later, with the completion of antiviral therapy.
.
#. Acute on Chronic Renal Failure.  On admission, serum
creatinine was 2.5, which was increased over his baseline of 1.9
at his last discharge.  Urinalysis was X, and FeNa was 1.46%.
He was given IV fluid boluses and his creatinine did not
decrease.  He later was treated with IV albumin, with no
improvement of his renal function.  His serum creatinine
subsequently began to increase to a peak of 7.6, with a
concomitant  decrease in urine output.  [**Month/Day/Year 1326**] nephrology
was consulted, and a urinalysis, urine chemistries were
repeated.  Urinalysis was significant for muddy brown casts, and
acute tubular necrosis was diagnosed.  A temporary hemodialysis
catheter was placed on [**2135-10-3**], and hemodialysis was initiated
on [**2135-10-4**].  The temporary catheter was exchanged for a
tunneled catheter on [**2135-10-6**].  By discharge, serum creatinine
had improved to 4.3, but he was still oliguric with under 100cc
of urine output per day.  He was relisted for kidney [**Date Range **],
and follow-up will be arranged with [**Date Range **] nephrology.
Infectious disease was consulted regarding infectious causes of
renal failure, and recommended CMV, HIV, BK virus, HBV and HCV
viral load tests, which were pending at the time of discharge.
.
#. Chronic liver disease s/p liver [**Date Range **].  On admission,
patient had a mild transamititis with an ALT and AST of 33 and
79, an elevated alkaline phosphatase of 371, low albumin of 1.1
and an INR of 1.4, all of which were at his baseline.  An
ultrasound guided paracentesis was performed, revealing mild
ascites, but paratoneal fluid analysis demonstrated no SBP.
Patient was continued on his home doses of tacrolimus 0.5mg PO
bid and lactulose 30ml PO tid.  Daily serum tacrolimus levels
were drawn, and doses were held as his renal function worsened.
On the day of discharge, his serum tacrolimus level had
decreased to 5.0, and he was restarted on tacrolimus 0.5mg
daily.  Serum tacro levels will be drawn at [**Date Range 2286**] on [**2135-10-11**]
and faxed to the liver [**Date Range **] center.  MELD on discharge was
23. Follow-up was arranged with the liver [**Date Range **] center on
[**2135-10-19**].
.
#. Hyperthyroidism.  On admission, serum TSH was low at 0.18.
Free T4 was low at 0.4 and T3 low at 50.  This was thought to be
due to sick euthyroid and was on uncertain significance in a
patient with acute illness.  Repeat TSH levels are recommended
4-6 weeks after discharge.


Medications on Admission:
OxycoDONE 2.5 mg Q4H:PRN pain
Oseltamivir Phosphate 75 mg PO BID
Sarna Lotion 1 Appl TP TID:PRN itching
DiphenhydrAMINE 25 mg Q6H:PRN itching
Ipratropium Bromide 1 NEB IH Q6H SOB
Ondansetron 4 mg IV Q8H:PRN nausea
Acetaminophen 325-650 mg PO/NG Q6H:PRN fevers, pain
Tacrolimus 0.5 mg PO Q12H
Pantoprazole 40 mg PO Q24H
Lactulose 30 mL PO/NG TID

Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*1 bottle* Refills:*2*
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*1 bottle* Refills:*2*
5. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO once a day.

6. Outpatient Lab Work
Please draw serum tacrolimus level with [**Date Range 2286**] next tuesday
[**2135-10-11**] and fax the result to Dr. [**Last Name (STitle) 497**] at the liver [**Last Name (STitle) **]
center.


Discharge Disposition:
Home With Service

Facility:
vna southeastern [**State **]

Discharge Diagnosis:
Acute on Chronic Renal Failure
H1N1 Influenza
Multifocal Pneumonia
s/p liver [**State **]


Discharge Condition:
Stable, alert and oriented to person, place and time.


Discharge Instructions:
You were admitted for high heart rate and fevers.  Laboratory
testing revealed you had H1N1 swine like influenza.  A chest
x-ray showed pneumonia.  Fluid was taken from your abdomen and
demonstrated no infection.  You were treated with antiviral
medications for your flu.  You were treated with intravenous
antibiotics for your pneumonia.  Your kidney function
deteriorated and hemodialysis was initiated.  With hemodialysis,
your laboratory values improved. While here your blood level of
thyroid stimulating hormone (TSH) was low.  This is not
surprising in the case of an acute illness, but your primary
doctor may want to recheck you TSH valcue is 4-6 weeks.

Please make the following changes in your medications:
Please CHANGE your dose of tacrolimus to 0.5mg by mouth daily
Please STOP taking lasix
Please START Pantoprazole 40mg by mouth daily

You will require hemodialysis for the forseeable future.  Your
first hemodialysis session will be on [**2135-10-8**].

Please adhere to your follow-up appointments. They are important
for managing your long-term health.
.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.


Followup Instructions:
Please follow up with the following appointments:

Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2135-10-8**]
7:30
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2135-10-19**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **],[**MD Number(3) 13795**]:[**Telephone/Fax (1) 37766**]
Date/Time:[**2135-10-26**] 9:00

Please make an appointment with your primary care doctor within
the next two weeks.
{'Awaiting organ transplant status,Biliary cirrhosis,Euthyroid sick syndrome,Other disorders of plasma protein metabolism,Asthma, unspecified type, unspecified,Nephrotic syndrome with unspecified pathological lesion in kidney,Anemia of other chronic disease,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Obstruction of bile duct,Other ascites,Portal hypertension,Unspecified pleural effusion,Aseptic necrosis of head and neck of femur,Liver replaced by transplant,Chronic kidney disease, unspecified'}


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, tachycardia

PRESENT ILLNESS: This is a 31 yo male with biliary atresia s/p liver [**Last Name (un) **]
in [**2110**], s/p small bowel resection [**8-/2135**], recent staph
bacteremia [**12-27**] infected HD line who was transferred from OSH for
fevers and tachycardia. At home, patient complained of two weeks
of fatigue, productive cough, progressive lower extremity edema,
and fevers/chills.  At a VNA visit he was noted to be
tachycardic and taken to an OSH.
.
At OSH, he was febrile and noted to be in SVT, which broke with
adenosine. He was started on levofloxacin for suspected LLL PNA
on CXR. This was broadened empirically to vanc/pip-tazo given
concern for SBP, as well. Patient was transferred to [**Hospital1 18**] ICU.

MEDICAL HISTORY: -biliary Atresia s/p liver [**Hospital1 **] 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
-small bowel resection

MEDICATION ON ADMISSION: OxycoDONE 2.5 mg Q4H:PRN pain
Oseltamivir Phosphate 75 mg PO BID
Sarna Lotion 1 Appl TP TID:PRN itching
DiphenhydrAMINE 25 mg Q6H:PRN itching
Ipratropium Bromide 1 NEB IH Q6H SOB
Ondansetron 4 mg IV Q8H:PRN nausea
Acetaminophen 325-650 mg PO/NG Q6H:PRN fevers, pain
Tacrolimus 0.5 mg PO Q12H
Pantoprazole 40 mg PO Q24H
Lactulose 30 mL PO/NG TID

ALLERGIES: Ibuprofen

PHYSICAL EXAM: PHYSICAL EXAM:
Vitals - T: 101.1 (current) BP: 136/92 HR: 110 RR: 22 02 sat:
94% 3L
GENERAL: Tachypneic, diaphoretic, mild resp distress, alert and
cooperative
HEENT: NCAT, no scleral icterus, MM dry, no JVD
CARDIAC: +S1/S2, no M/R/G, slightly tachycardic, regular rhythm

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:
{'Awaiting organ transplant status,Biliary cirrhosis,Euthyroid sick syndrome,Other disorders of plasma protein metabolism,Asthma, unspecified type, unspecified,Nephrotic syndrome with unspecified pathological lesion in kidney,Anemia of other chronic disease,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Obstruction of bile duct,Other ascites,Portal hypertension,Unspecified pleural effusion,Aseptic necrosis of head and neck of femur,Liver replaced by transplant,Chronic kidney disease, unspecified'}
