CHIEF COMPLAINT: CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
Intubation

PRESENT ILLNESS: HPI: 54 yo M with h/o HCV, hepatocellular ca, cirrhosis, ascites
who has been living in a nursing home transitioning to hospice.
Plan was for patient to go back to [**Country 4812**] where he would
likely die soon. Instructions were that he wanted to remain full
code in hopes that he would be able to make it back to [**Country 4812**].
On DOA pt was noted to have MS changes and was sent to ED. On
arrival he was noted to have sBP in 60's and was started on
levophed and bolused with IVF. Lactate was 10.6. ECG showed
peaked t waves and K was 6.8. An NG tube was placed to give him
kayexalate and coffee ground material was aspirated. He was
given IV protonix, vanco, levofloxacin, flagyl and albumin in
the ED. LFT's were c/w cholangitis and RUQ U/S showed no
significant change from prior exam. Surgery was consulted but
felt that pt was not a surgical candidate given comorbidities
and overall dismal prognosis. This was communicated to the
patients friends who accompanied him in the [**Name (NI) **], but they felt
uncomfortable changing his code status. His brother is flying to
[**Name (NI) 86**] from [**Country 4812**] and the wish was expressed that the patient
be supported fully, including intubation if necessary, until his
brother arrives tomorrow ([**6-17**]).

MEDICAL HISTORY: Past Medical History:
-Hepatitis C (unclear how he got it); HIV negative
-Etoh abuse; stopped Febr 06
-s/p R-humerus fracture (ORIF - [**2180-1-5**])
-R ankle arthritis
-hepatocellular ca, diagnosed [**4-9**]; non-surgical; plans on going
back to [**Country 4812**] in [**Month (only) 116**]
-esophagitis [**4-9**]
-portal vein thrombosis
-chronic LLE swelling

MEDICATION ON ADMISSION: Meds on admission:
Nystatin 5 mL p.o. q.i.d.
Protonix 40 mg p.o.daily,
Lasix 40 mg p.o. daily,
spironolactone 50 mg p.o. daily,
bisacodyl p.r.n.
lactulose 30 mL t.i.d.
levofloxacin 500 mg p.o. once daily
lorazepam 0.5 mg p.o. q.4-6h. p.r.n.
Colace 100 mg p.o. b.i.d.
ibuprofen 800 mg p.o. q.8h. as needed,
morphine sustained release tablets 30 mg p.o. b.i.d.
oxycodone 5 mg p.o. q.2-4h. p.r.n.
Zofran 8 mg p.o. q.8h. p.r.n. nausea

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: T 95.8 HR 109 BP 97/50 RR 26  sO2 95% on 4L NC, CVP 12,
MAP 61
GEN: ill-appearing male w/ NG tube in place, uncomfortable and
breathing rapidly. Understands simple english
SKIN: cool, dry
HEENT: mmm w/ dried blood at gumline, scleral icterus, arcus
senilus
NECK: prominent venous pulsations, no LAD; no carotid bruits;
neck supple
LUNGS: bilateral rales by anterior exam; no wheezes or rhonchi
HEART: tachycardic, could not appreciate murmur
ABDOMEN: faint bowel sounds, soft, tender at RUQ, distended,
liver
palpable (about 1cm under costal margin)
EXTREMITIES: edema 1+R, 2+L (chronic); marked asterixis
NEURO: alert, intermittently answering questions. oriented to
place - names [**Hospital3 **]

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: He emigrated from [**Country 4812**] in [**2162**] and lived in [**Country 2784**] a few
years before moving to USA about 10 years ago. He was formerly
an artist educated in [**Country 4812**] but left during political unrest.
He is single and currently unemployed. He used to live at the
[**Company 3596**], currently lives at a NH. He has a sister that lives in
town. He was never married and has no children. He denies
excessive drinking but does admit to getting drunk on the
weekends. He drinks beer regularly and whiskey on the weekends
until [**Month (only) 956**]. No IVDU. No smoking.
Unspecified septicemia,Malignant neoplasm of liver, primary,Portal vein thrombosis,Acute kidney failure, unspecified,Hyperpotassemia,Septic shock,Cirrhosis of liver without mention of alcohol,Acute respiratory failure,Cholangitis,Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Unspecified viral hepatitis C with hepatic coma,Hemorrhage of gastrointestinal tract, unspecified,Other and unspecified coagulation defects,Severe sepsis
Septicemia NOS,Mal neo liver, primary,Portal vein thrombosis,Acute kidney failure NOS,Hyperpotassemia,Septic shock,Cirrhosis of liver NOS,Acute respiratry failure,Cholangitis,Subendo infarct, initial,Pneumonia, organism NOS,Hpt C w hepatic coma NOS,Gastrointest hemorr NOS,Coagulat defect NEC/NOS,Severe sepsis
Admission Date:  [**2181-6-16**]              Discharge Date:   [**2181-6-21**]

Date of Birth:  [**2127-3-18**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
HPI: 54 yo M with h/o HCV, hepatocellular ca, cirrhosis, ascites
who has been living in a nursing home transitioning to hospice.
Plan was for patient to go back to [**Country 4812**] where he would
likely die soon. Instructions were that he wanted to remain full
code in hopes that he would be able to make it back to [**Country 4812**].
On DOA pt was noted to have MS changes and was sent to ED. On
arrival he was noted to have sBP in 60's and was started on
levophed and bolused with IVF. Lactate was 10.6. ECG showed
peaked t waves and K was 6.8. An NG tube was placed to give him
kayexalate and coffee ground material was aspirated. He was
given IV protonix, vanco, levofloxacin, flagyl and albumin in
the ED. LFT's were c/w cholangitis and RUQ U/S showed no
significant change from prior exam. Surgery was consulted but
felt that pt was not a surgical candidate given comorbidities
and overall dismal prognosis. This was communicated to the
patients friends who accompanied him in the [**Name (NI) **], but they felt
uncomfortable changing his code status. His brother is flying to
[**Name (NI) 86**] from [**Country 4812**] and the wish was expressed that the patient
be supported fully, including intubation if necessary, until his
brother arrives tomorrow ([**6-17**]).

Past Medical History:
Past Medical History:
-Hepatitis C (unclear how he got it); HIV negative
-Etoh abuse; stopped Febr 06
-s/p R-humerus fracture (ORIF - [**2180-1-5**])
-R ankle arthritis
-hepatocellular ca, diagnosed [**4-9**]; non-surgical; plans on going
back to [**Country 4812**] in [**Month (only) 116**]
-esophagitis [**4-9**]
-portal vein thrombosis
-chronic LLE swelling


Social History:
He emigrated from [**Country 4812**] in [**2162**] and lived in [**Country 2784**] a few
years before moving to USA about 10 years ago. He was formerly
an artist educated in [**Country 4812**] but left during political unrest.
He is single and currently unemployed. He used to live at the
[**Company 3596**], currently lives at a NH. He has a sister that lives in
town. He was never married and has no children. He denies
excessive drinking but does admit to getting drunk on the
weekends. He drinks beer regularly and whiskey on the weekends
until [**Month (only) 956**]. No IVDU. No smoking.

Family History:
noncontributory



Physical Exam:
VITALS: T 95.8 HR 109 BP 97/50 RR 26  sO2 95% on 4L NC, CVP 12,
MAP 61
GEN: ill-appearing male w/ NG tube in place, uncomfortable and
breathing rapidly. Understands simple english
SKIN: cool, dry
HEENT: mmm w/ dried blood at gumline, scleral icterus, arcus
senilus
NECK: prominent venous pulsations, no LAD; no carotid bruits;
neck supple
LUNGS: bilateral rales by anterior exam; no wheezes or rhonchi
HEART: tachycardic, could not appreciate murmur
ABDOMEN: faint bowel sounds, soft, tender at RUQ, distended,
liver
palpable (about 1cm under costal margin)
EXTREMITIES: edema 1+R, 2+L (chronic); marked asterixis
NEURO: alert, intermittently answering questions. oriented to
place - names [**Hospital3 **]

Pertinent Results:
Labs:
Notable for lactate 10.6, WBC 13.3, K 6.8, T. bili 18.5, INR 2.1
.
Studies:
CXR ([**2181-6-16**]) 6:49 p.m.: There are multiple new ill-defined
patchy opacities throughout both lungs, perihilar haze, and an
effaced right diaphragmatic border.  This is secondary to
multifocal pneumonia, asymmetric pulmonary edema, or
combination. A small right pleural effusion is also present.
The cardiac size continues to be normal, and the mediastinal
contours are normal. An NG tube is located in
the stomach. IMPRESSION:  Multifocal pneumonia, asymmetric
pulmonary edema, or combination.
.
CXR (5/13/06)7:57 p.m.: In the one hour interval, a right
internal jugular central venous catheter has been placed with
the tip projecting over the cavoatrial junction. There is no
evidence for pneumothorax.  Opacification of both lungs appears
to be worsening. IMPRESSION: Worsening bilateral opacification
with new central venous line provjecting over cavoatrial
junction.
.
RUQ U/S ([**2181-6-16**]) - prelim read:
1. Portal vein thrombosis with apparent cavernous
transformation.  Unchanged compared to prior examination of [**4-17**], [**2181**].
2. Heterogeneous right liver lobe lesions consistent with HCC.
3. Minimal amount of ascites.
4. Gallbladder wall thickening with no evidence of acute
cholecystitis.

Brief Hospital Course:
A/P: 54 yo M with h/o HCV, hepatocellular ca, cirrhosis, ascites
who presents with sepsis, hyperkalemia and ARF.
.
# septic shock: The patient was admitted with concern for septic
shock of a cholagitis or lung origin.  BP remained low.
Pressers were eventually weaned down and off for a short period
of time and then eventually were restarted.
.
# hypotension: Pt's BP at presentation was 70s/palp.
Differentials include sepsis, 3rd space fluid shift resulting
from hypoalbuminemia; less likely from GI bleed.  BP increased
over subsequent days and pressors were decreased.
.
# hypoxemia: Pt was initially hypoxemic - this then resolved.
.
# MS changes: The pt was unresponsive off sedation, likely due
to hepatic encephalopathy but intracranial process is another
possibility.
.
# GI bleed: Pt reported to have coffee-ground material from NG
aspirate.  Pt has known cirrhosis and portal vein thrombosis
which has likely resulted in the development of porto-caval
anastomosis and varices.  Of note, pt had EGD in [**4-9**] which did
not show any evidence of varices.
.
# ARF: Creatinine was 4.2 at presentation; baseline <1.0.  This
improved with hydration.
.
# ?ST depression: there was no CE elevation
.
# coagulopathy: INR elevated to 2.1 - likely due to liver
failure. Pt got vitamin K but coagulopathy worsened.
Eventually, he began bleeding profusely and could not be
resucitated effectively and care was withdrawn (see below).
.
# HCC: Pt has a large liver mass and elevated alpha-fetoprotein.
Patient is not a candidate for surgery or transplant due to the
size of his mass, and the presence of cirrhosis and portal
venous involvement. Not a candidate for chemotherapy given poor
performance status. This was the underlying cause of his
worsening status over this hospital stay.
.
The patient was treated supportively.  Though his ARF improved,
his mental status did not, nor did his liver function.  On the
final day of hospitalization he developed bleeding from the ETT,
line site, and HCT dropped.  He became tachycardic, hypotensive,
and remained unresponsive.  His brother was notified of his
status change and, despite efforts to resuscitate his blood
volume, he remianed hypotensive.  His brother was [**Name (NI) 653**] and
agreed with withdrawal of resuscitative measures and focus on
comfort.  The ETT was withdrawn and the patient developed
cardiopulmonary failure within 15 minutes.  He died at 11:05 pm
on [**2181-6-21**].

Medications on Admission:
Meds on admission:
Nystatin 5 mL p.o. q.i.d.
Protonix 40 mg p.o.daily,
Lasix 40 mg p.o. daily,
spironolactone 50 mg p.o. daily,
bisacodyl p.r.n.
lactulose 30 mL t.i.d.
levofloxacin 500 mg p.o. once daily
lorazepam 0.5 mg p.o. q.4-6h. p.r.n.
Colace 100 mg p.o. b.i.d.
ibuprofen 800 mg p.o. q.8h. as needed,
morphine sustained release tablets 30 mg p.o. b.i.d.
oxycodone 5 mg p.o. q.2-4h. p.r.n.
Zofran 8 mg p.o. q.8h. p.r.n. nausea

Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
Deceased

Discharge Condition:
Deceased

Discharge Instructions:
Deceased

Followup Instructions:
Deceased


Completed by:[**2181-6-22**]
{'Unspecified septicemia,Malignant neoplasm of liver, primary,Portal vein thrombosis,Acute kidney failure, unspecified,Hyperpotassemia,Septic shock,Cirrhosis of liver without mention of alcohol,Acute respiratory failure,Cholangitis,Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Unspecified viral hepatitis C with hepatic coma,Hemorrhage of gastrointestinal tract, unspecified,Other and unspecified coagulation defects,Severe sepsis'}


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: CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
Intubation

PRESENT ILLNESS: HPI: 54 yo M with h/o HCV, hepatocellular ca, cirrhosis, ascites
who has been living in a nursing home transitioning to hospice.
Plan was for patient to go back to [**Country 4812**] where he would
likely die soon. Instructions were that he wanted to remain full
code in hopes that he would be able to make it back to [**Country 4812**].
On DOA pt was noted to have MS changes and was sent to ED. On
arrival he was noted to have sBP in 60's and was started on
levophed and bolused with IVF. Lactate was 10.6. ECG showed
peaked t waves and K was 6.8. An NG tube was placed to give him
kayexalate and coffee ground material was aspirated. He was
given IV protonix, vanco, levofloxacin, flagyl and albumin in
the ED. LFT's were c/w cholangitis and RUQ U/S showed no
significant change from prior exam. Surgery was consulted but
felt that pt was not a surgical candidate given comorbidities
and overall dismal prognosis. This was communicated to the
patients friends who accompanied him in the [**Name (NI) **], but they felt
uncomfortable changing his code status. His brother is flying to
[**Name (NI) 86**] from [**Country 4812**] and the wish was expressed that the patient
be supported fully, including intubation if necessary, until his
brother arrives tomorrow ([**6-17**]).

MEDICAL HISTORY: Past Medical History:
-Hepatitis C (unclear how he got it); HIV negative
-Etoh abuse; stopped Febr 06
-s/p R-humerus fracture (ORIF - [**2180-1-5**])
-R ankle arthritis
-hepatocellular ca, diagnosed [**4-9**]; non-surgical; plans on going
back to [**Country 4812**] in [**Month (only) 116**]
-esophagitis [**4-9**]
-portal vein thrombosis
-chronic LLE swelling

MEDICATION ON ADMISSION: Meds on admission:
Nystatin 5 mL p.o. q.i.d.
Protonix 40 mg p.o.daily,
Lasix 40 mg p.o. daily,
spironolactone 50 mg p.o. daily,
bisacodyl p.r.n.
lactulose 30 mL t.i.d.
levofloxacin 500 mg p.o. once daily
lorazepam 0.5 mg p.o. q.4-6h. p.r.n.
Colace 100 mg p.o. b.i.d.
ibuprofen 800 mg p.o. q.8h. as needed,
morphine sustained release tablets 30 mg p.o. b.i.d.
oxycodone 5 mg p.o. q.2-4h. p.r.n.
Zofran 8 mg p.o. q.8h. p.r.n. nausea

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: T 95.8 HR 109 BP 97/50 RR 26  sO2 95% on 4L NC, CVP 12,
MAP 61
GEN: ill-appearing male w/ NG tube in place, uncomfortable and
breathing rapidly. Understands simple english
SKIN: cool, dry
HEENT: mmm w/ dried blood at gumline, scleral icterus, arcus
senilus
NECK: prominent venous pulsations, no LAD; no carotid bruits;
neck supple
LUNGS: bilateral rales by anterior exam; no wheezes or rhonchi
HEART: tachycardic, could not appreciate murmur
ABDOMEN: faint bowel sounds, soft, tender at RUQ, distended,
liver
palpable (about 1cm under costal margin)
EXTREMITIES: edema 1+R, 2+L (chronic); marked asterixis
NEURO: alert, intermittently answering questions. oriented to
place - names [**Hospital3 **]

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: He emigrated from [**Country 4812**] in [**2162**] and lived in [**Country 2784**] a few
years before moving to USA about 10 years ago. He was formerly
an artist educated in [**Country 4812**] but left during political unrest.
He is single and currently unemployed. He used to live at the
[**Company 3596**], currently lives at a NH. He has a sister that lives in
town. He was never married and has no children. He denies
excessive drinking but does admit to getting drunk on the
weekends. He drinks beer regularly and whiskey on the weekends
until [**Month (only) 956**]. No IVDU. No smoking. 

### Response:
{'Unspecified septicemia,Malignant neoplasm of liver, primary,Portal vein thrombosis,Acute kidney failure, unspecified,Hyperpotassemia,Septic shock,Cirrhosis of liver without mention of alcohol,Acute respiratory failure,Cholangitis,Subendocardial infarction, initial episode of care,Pneumonia, organism unspecified,Unspecified viral hepatitis C with hepatic coma,Hemorrhage of gastrointestinal tract, unspecified,Other and unspecified coagulation defects,Severe sepsis'}
