CHIEF COMPLAINT: Shortness of breath.
Reason for MICU admission: severe septic shock and multiple
organ failure.

PRESENT ILLNESS: 58F with metastatic colon cancer, recent admission for N/V/abd
pain with subsequent establishment of hospice, presenting to ED
with confusion x few days day and shortness of breath.  She had
sudden onset of shortness of breath today, no chest pain;
persistent but unchanged abdominal pain.  No recent diarrhea,
constipation, N/V.  Husband notes patient taking increasing
doses of oxycontin (120 mg in 24 hour period - twice what is
prescribed - unclear if intentional).  No HA, fever, cough.

MEDICAL HISTORY: Metastatic colon cancer (brain/liver)
-[**2109-5-14**], colonoscopy due to anemia w/ fungating, friable and
infiltration mass (mets), at ascending colon w/ partial obs:
adenocarcinoma. Referred to Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1120**] for surgery.
-[**2109-5-23**], CCT, ACT: multiple bilateral pulmonary nodules, 7 mm.
Scattering smaller ones concern for mets; metastatic foci within
the liver also. 4.5 x 5 cm left hepatic lobe mets, 4.5 x 2.9 cm
& 4 cm x 3 cm right hepatic lobe mets
-[**6-10**] right palliative hemicolectomy
-[**2109-7-17**] FOLFOX started
-[**2109-8-28**] Avastin added
-[**2110-1-1**] Oxaloplatin held due to neuropathy
HTN
baseline Cr 0.9-1.2
celiac disease
OA - spine, right wrist
peripheral neuropathy from chemotherapy
recurrent vaginal abscesses
Asthma
Uterine fibroids
Iron deficiency anemia s/p transfusion during hospitalization in
[**11-12**]
VIN
lactose intolerance
hyponatremia
hypoalbuminemia with LE edema
Pul HTN
anterior wall abdominal hernia
postmenopausal bleeding s/p negative endometrial bx's

MEDICATION ON ADMISSION: Reglan 5 mg three times a day as needed for nausea
Oxycodone SR 30 mg Q12H

ALLERGIES: Lisinopril / Felodipine / Benadryl / Iodine / Latex /
Levofloxacin Hemihydrate / Augmentin / Sulfa (Sulfonamides) /
Clindamycin

PHYSICAL EXAM: On admission:
General: Somnolent though arousable, speech mostly confused when
awakened.
HEENT: Sclera mildly icteric, MM slightly dry
Neck: supple, JVD difficult to appreciate, no LAD appreciated.
Lungs: Bilaterally wheezy and rhonchorous, diminished at R base.
CV: Regular rate and rhythm, normal S1 + S2, distant beneath
breath sounds.  R port in place.
Abdomen:   Distended, bowel sounds present though ?hypoactive,
appears diffused tender throughout, ?slightly firm.  no
apparently rebound tenderness or guarding.  No clear ascites.
Ext: cool extrems on pressors, no clubbing, cyanosis.  2+ LE
edema, equal bilat.
Neuro: lethargic/somnolent, arousable, confused speech at times.
 Unable to perform further neuro exam.

FAMILY HISTORY: Mother and father with CAD and CVA, sister with DM2.

SOCIAL HISTORY: Never smoked, never drank.  Lived in [**State 4565**] 3 years ago.
Lives in [**Location 1468**] with husband.  [**Name (NI) **] is a grad student at [**Hospital1 3278**].
She was something of an activist.
Unspecified septicemia,Septic shock,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Acute and subacute necrosis of liver,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acidosis,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of brain and spinal cord,Other and unspecified coagulation defects,Severe sepsis,Other chronic pulmonary heart diseases,Asthma, unspecified type, unspecified,Celiac disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Leiomyoma of uterus, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Ventral, unspecified, hernia without mention of obstruction or gangrene,Thrombocytopenia, unspecified,Iron deficiency anemia, unspecified,Hypocalcemia,Flatulence, eructation, and gas pain,Personal history of malignant neoplasm of large intestine,Spondylosis of unspecified site, without mention of myelopathy,Osteoarthrosis, unspecified whether generalized or localized, forearm
Septicemia NOS,Septic shock,Acute respiratry failure,Ac kidny fail, tubr necr,Acute necrosis of liver,Meth sus pneum d/t Staph,Acidosis,Second malig neo liver,Sec mal neo brain/spine,Coagulat defect NEC/NOS,Severe sepsis,Chr pulmon heart dis NEC,Asthma NOS,Celiac disease,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Uterine leiomyoma NOS,Idio periph neurpthy NOS,Ventral hernia NOS,Thrombocytopenia NOS,Iron defic anemia NOS,Hypocalcemia,Flatul/eructat/gas pain,Hx of colonic malignancy,Spondylos NOS w/o myelop,Osteoarthros NOS-forearm
Admission Date:  [**2112-1-30**]              Discharge Date:   [**2112-2-8**]

Date of Birth:  [**2053-10-2**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril / Felodipine / Benadryl / Iodine / Latex /
Levofloxacin Hemihydrate / Augmentin / Sulfa (Sulfonamides) /
Clindamycin

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath.
Reason for MICU admission: severe septic shock and multiple
organ failure.

Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation.

History of Present Illness:
58F with metastatic colon cancer, recent admission for N/V/abd
pain with subsequent establishment of hospice, presenting to ED
with confusion x few days day and shortness of breath.  She had
sudden onset of shortness of breath today, no chest pain;
persistent but unchanged abdominal pain.  No recent diarrhea,
constipation, N/V.  Husband notes patient taking increasing
doses of oxycontin (120 mg in 24 hour period - twice what is
prescribed - unclear if intentional).  No HA, fever, cough.

In the ED, initial vs were: T97.7 rectal, P70, BP66/43 -> 93/53,
R13-20 O2 sats 80s on RA, 100% on 3L. Confused, sleepy.  Very
icteric on exam.  Bilateral coarse breath sounds.  Guaiac
positive.  2+ edema.  Patient was given ceftriaxone and
vancomycin; calcium gluconate, 1 gram, D50 and insulin,
kayexalate 60 g, and levophed gtt started for hypotension.  BPs
dipping into 70s even after 3L so levophed gtt started (running
through port).  BP in upper 90s.  Lab abnls included lactate 10,
severe metabolic acidosis (bicarb 8, pH 7.24), WBCs 18.8 with
17% bands, elevated coags with low plts, ARF, hyperkalemia to
7.4, transaminitis with hyperbilirubinemia. QRS 106 on ECG, no
peaked T waves.  Difficulty laying flat (dyspneic but not
de-satting).

On the floor, patient arrives altered, confused.  Denies pain or
discomfort.

Past Medical History:
Metastatic colon cancer (brain/liver)
-[**2109-5-14**], colonoscopy due to anemia w/ fungating, friable and
infiltration mass (mets), at ascending colon w/ partial obs:
adenocarcinoma. Referred to Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1120**] for surgery.
-[**2109-5-23**], CCT, ACT: multiple bilateral pulmonary nodules, 7 mm.
Scattering smaller ones concern for mets; metastatic foci within
the liver also. 4.5 x 5 cm left hepatic lobe mets, 4.5 x 2.9 cm
& 4 cm x 3 cm right hepatic lobe mets
-[**6-10**] right palliative hemicolectomy
-[**2109-7-17**] FOLFOX started
-[**2109-8-28**] Avastin added
-[**2110-1-1**] Oxaloplatin held due to neuropathy
HTN
baseline Cr 0.9-1.2
celiac disease
OA - spine, right wrist
peripheral neuropathy from chemotherapy
recurrent vaginal abscesses
Asthma
Uterine fibroids
Iron deficiency anemia s/p transfusion during hospitalization in
[**11-12**]
VIN
lactose intolerance
hyponatremia
hypoalbuminemia with LE edema
Pul HTN
anterior wall abdominal hernia
postmenopausal bleeding s/p negative endometrial bx's


Social History:
Never smoked, never drank.  Lived in [**State 4565**] 3 years ago.
Lives in [**Location 1468**] with husband.  [**Name (NI) **] is a grad student at [**Hospital1 3278**].
She was something of an activist.


Family History:
Mother and father with CAD and CVA, sister with DM2.


Physical Exam:
On admission:
General: Somnolent though arousable, speech mostly confused when
awakened.
HEENT: Sclera mildly icteric, MM slightly dry
Neck: supple, JVD difficult to appreciate, no LAD appreciated.
Lungs: Bilaterally wheezy and rhonchorous, diminished at R base.
CV: Regular rate and rhythm, normal S1 + S2, distant beneath
breath sounds.  R port in place.
Abdomen:   Distended, bowel sounds present though ?hypoactive,
appears diffused tender throughout, ?slightly firm.  no
apparently rebound tenderness or guarding.  No clear ascites.
Ext: cool extrems on pressors, no clubbing, cyanosis.  2+ LE
edema, equal bilat.
Neuro: lethargic/somnolent, arousable, confused speech at times.
 Unable to perform further neuro exam.


Pertinent Results:
137  102  73    AGap=34
------------- 73
7.4  8  4.1 &#8710;

K: Not Hemolyzed

Ck: 541  MB: 9  Trop-T: 0.10

Ca: 7.5 Mg: 3.6 P: 9.1 &#8710;

ALT: 448 AP: 1043 Tbili: 5.7 Alb: 2.5
AST: 1390 LDH: 9775 Lip: 36

     10.2
18.8 ----146 &#8710;
     34.7
Diff: N:75 Band:17 L:1 M:5 E:0 Bas:0 Metas: 1 Myelos: 1 Nrbc: 2


PT: 25.0  PTT: 39.0  INR: 2.4

Micro:
Blood cultures x 2 pending.

Images:
CXR: increased R sided pleural effusion.  concerning for opacity
in R lower lung fields.  Diffuse pulmonary nodules consistent
with known metastatic disease.

EKG: NSR at 75.  poor baseline.  LAD. slightly wide QRS (~100),
QTc 470, no peaked T waves.  Poor RWP.  Low voltage in
precordial and limb leads.   Compared to prior, voltage lower,
RWP worse.

ECHO: The left atrium and right atrium are normal in cavity
size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is a small pericardial
effusion

CT Torso: 1. Limited study without contrast with significant
progression of innumerable pulmonary and hepatic metastases with
massive enlargement of the liver causing volume loss in the
right lower lobe secondary to elevation of right hemidiaphragm.
2. Moderate abdominal and pelvic ascites with anasarca. No
significant pleural effusion noted.

Chest Xray: There is an endotracheal tube, right-sided central
venous catheter, and feeding tube which are unchanged in
position. The distal tip of the right- sided catheter is again
in the right atrium and could be pulled back a few centimeters
for more optimal placement. Diffuse opacities throughout both
lungs consistent with patient's extensive pulmonary metastases.
Superimposed consolidation cannot be entirely excluded. There is
a right-sided pleural effusion.


Brief Hospital Course:
58F with widely metastatic colon cancer, presenting with septic
shock and severe metabolic acidosis, ARF, hyperkalemia.

# Hypotension/Septic shock/MODS.  Patient presented with septic
shock, Leukocytosis/Bandemia and severe metabolic acidosis and
multiple organ dysfunction including pulmonary, cardiac, heme,
hepatic, renal failure.  While source of infection was
identified patient was covered broadly with Cefepime, Cipro,
Flagyl, and Vancomycin. Blood Cultures were negative throughout
hospitalization. Sputum culture only with MSSA. Urine Cultures
negative. UA positive covered with Cefepime. Levophed started
and titrated to maintain MAP of >60. During hospitalization pt
continued to reguire pressor support. Despite identification of
a MSSA pneumonia broad coverage was continued while discussion
regarding patients Code status was determined. Patient was made
CMO, antibiotics/pressors were stopped. Patient expired.

# Metabolic/lactic acidosis.  With severe systemic hypoperfusion
and hypotension in the setting of sepsis. Pt started on levophed
which was required throughout hospitalization to maintain
adequate perfusion. Lactate trended down during hospitalization
and acidosis stabilized with stabilization of blood pressure and
antibiotic treatment.

# ARF/hyperkalemia. Secondary to ATN int the setting of
hypotension/sepsis.  No known offending meds. During
hospitalization did not respond to fluids. Hyperkalemia without
ECG changes. Bicarb gtt started and DC'd with resolution of
metabolic acidosis. Dialysis was not initiated given the
patients very poor prognosis after long discussion with the
family. Throughout the hospitalization no meaningful return in
kidney function was attained.

# Coagulopathy/thrombocytopenia. Patient with increased INR and
decreased platelets during admission. Likely DIC given severity
of infection however Fibrinogen stable. During Admission
platelets improved/remained stable. INR continued to increase
during hospitalization. Patient had no active signs of bleeding.


# Transaminitis.  Likely shock liver. Liver enzymes were
followed during hospitalization and trended down after blood
pressure was controlled.

# Hypoxia and respiratory distress.  Evidence of pneumonia on
right.  Also with wheezes.  Respiratory distress reportedly
acute onset; would be at high risk for PE given malignancy,
however given patient's clinical status this was deferred.
Patient was intubated and vent settings were weaned throughout
the hospitalization to Pressure Support [**11-8**], until patient was
extubated when made CMO.

# ECG changes.  Lower voltage, poor RWP compared to prior.  No
clear elevation in JVD, not tachycardic, and sources other than
tamponade more likely playing a role in hypotension. TTE was
negative for pericardial effusion. On [**2-6**] EKG was performed for
hyperkalemia which should 1mm ST Elevation in V1-V2 and ST
Depression laterally. Enzymes were checked and were minimally
elevated. Repeat ECG with resolution in the height of ST
elevation in V1-V2. Given pt comorbidities these abnormalities
were not further evaluated.

Medications on Admission:
Reglan 5 mg three times a day as needed for nausea
Oxycodone SR 30 mg Q12H

Discharge Medications:
None.

Discharge Disposition:
Expired

Discharge Diagnosis:
Metastatic colon cancer with lethal multiple organ failure.

Discharge Condition:
Expired.

Discharge Instructions:
None.

Followup Instructions:
None.
{'Unspecified septicemia,Septic shock,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Acute and subacute necrosis of liver,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acidosis,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of brain and spinal cord,Other and unspecified coagulation defects,Severe sepsis,Other chronic pulmonary heart diseases,Asthma, unspecified type, unspecified,Celiac disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Leiomyoma of uterus, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Ventral, unspecified, hernia without mention of obstruction or gangrene,Thrombocytopenia, unspecified,Iron deficiency anemia, unspecified,Hypocalcemia,Flatulence, eructation, and gas pain,Personal history of malignant neoplasm of large intestine,Spondylosis of unspecified site, without mention of myelopathy,Osteoarthrosis, unspecified whether generalized or localized, forearm'}


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: Shortness of breath.
Reason for MICU admission: severe septic shock and multiple
organ failure.

PRESENT ILLNESS: 58F with metastatic colon cancer, recent admission for N/V/abd
pain with subsequent establishment of hospice, presenting to ED
with confusion x few days day and shortness of breath.  She had
sudden onset of shortness of breath today, no chest pain;
persistent but unchanged abdominal pain.  No recent diarrhea,
constipation, N/V.  Husband notes patient taking increasing
doses of oxycontin (120 mg in 24 hour period - twice what is
prescribed - unclear if intentional).  No HA, fever, cough.

MEDICAL HISTORY: Metastatic colon cancer (brain/liver)
-[**2109-5-14**], colonoscopy due to anemia w/ fungating, friable and
infiltration mass (mets), at ascending colon w/ partial obs:
adenocarcinoma. Referred to Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1120**] for surgery.
-[**2109-5-23**], CCT, ACT: multiple bilateral pulmonary nodules, 7 mm.
Scattering smaller ones concern for mets; metastatic foci within
the liver also. 4.5 x 5 cm left hepatic lobe mets, 4.5 x 2.9 cm
& 4 cm x 3 cm right hepatic lobe mets
-[**6-10**] right palliative hemicolectomy
-[**2109-7-17**] FOLFOX started
-[**2109-8-28**] Avastin added
-[**2110-1-1**] Oxaloplatin held due to neuropathy
HTN
baseline Cr 0.9-1.2
celiac disease
OA - spine, right wrist
peripheral neuropathy from chemotherapy
recurrent vaginal abscesses
Asthma
Uterine fibroids
Iron deficiency anemia s/p transfusion during hospitalization in
[**11-12**]
VIN
lactose intolerance
hyponatremia
hypoalbuminemia with LE edema
Pul HTN
anterior wall abdominal hernia
postmenopausal bleeding s/p negative endometrial bx's

MEDICATION ON ADMISSION: Reglan 5 mg three times a day as needed for nausea
Oxycodone SR 30 mg Q12H

ALLERGIES: Lisinopril / Felodipine / Benadryl / Iodine / Latex /
Levofloxacin Hemihydrate / Augmentin / Sulfa (Sulfonamides) /
Clindamycin

PHYSICAL EXAM: On admission:
General: Somnolent though arousable, speech mostly confused when
awakened.
HEENT: Sclera mildly icteric, MM slightly dry
Neck: supple, JVD difficult to appreciate, no LAD appreciated.
Lungs: Bilaterally wheezy and rhonchorous, diminished at R base.
CV: Regular rate and rhythm, normal S1 + S2, distant beneath
breath sounds.  R port in place.
Abdomen:   Distended, bowel sounds present though ?hypoactive,
appears diffused tender throughout, ?slightly firm.  no
apparently rebound tenderness or guarding.  No clear ascites.
Ext: cool extrems on pressors, no clubbing, cyanosis.  2+ LE
edema, equal bilat.
Neuro: lethargic/somnolent, arousable, confused speech at times.
 Unable to perform further neuro exam.

FAMILY HISTORY: Mother and father with CAD and CVA, sister with DM2.

SOCIAL HISTORY: Never smoked, never drank.  Lived in [**State 4565**] 3 years ago.
Lives in [**Location 1468**] with husband.  [**Name (NI) **] is a grad student at [**Hospital1 3278**].
She was something of an activist. 

### Response:
{'Unspecified septicemia,Septic shock,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Acute and subacute necrosis of liver,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acidosis,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of brain and spinal cord,Other and unspecified coagulation defects,Severe sepsis,Other chronic pulmonary heart diseases,Asthma, unspecified type, unspecified,Celiac disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Leiomyoma of uterus, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Ventral, unspecified, hernia without mention of obstruction or gangrene,Thrombocytopenia, unspecified,Iron deficiency anemia, unspecified,Hypocalcemia,Flatulence, eructation, and gas pain,Personal history of malignant neoplasm of large intestine,Spondylosis of unspecified site, without mention of myelopathy,Osteoarthrosis, unspecified whether generalized or localized, forearm'}
