CHIEF COMPLAINT: Fever and Hypotension

PRESENT ILLNESS: Oncology History:
Patient was originally diagnosed with Breast cancer in [**2113**]. At
time of diagnosis she had a T1N0M0, ER+, PR-, her-2/NEU- lesion
treated with lumpectomy and XRT. The patient had received
Tamoxifen since [**2113-12-25**] without additional adjuvant
chemotherapy and without known progression of disease to date as
per patient's report. The patient's Tamoxifen was discontinued
upon diagnosis of second primary malignancy.
In late [**2117-11-24**], the patient presented with abdominal
pain. A CT at that time revealed a mass in the pancreas
w/extension to the Left adrenal and kidney with biopsy revealing
mucinous adenocarcinoma. The patient is now s/p distal
pancreatectomy, splenectomy, L adrenalectomy, L nephrectomy, and
omentectomy for this lesion. She began treatment with XRT/xeloda
and was then discovered to have metastatic disease for which
gemcitabine/cisplatin were initiated. Most recently the patient
has been receiving irinotecan and xeloda in [**2118-8-25**] in
the setting of rising CA19-9 which has been followed by good
response with a drop in her CA19-9 from 1549 to 439. Her last
dose of Irinotecan was [**9-14**].  The patient was nearing
completion of her second cycle of xeloda with her last dose
taken on Tuesday [**9-27**]. She was to complete her cycle
Wednesday night but was told to hold further doses given her
symptoms for which she presented. Her next scheduled cycle was
to begin Wednesday, [**2118-10-5**], but may be postponed
given current symptoms.
.
The patient was reported to be in her USOH until Sunday
afternoon when she developed onset of diarrhea. She was visiting
friends in [**Name (NI) **] at the time and previously reported she felt well.
She reports small hiking but denies insect bites, tick bites,
rashes, drinking stream or [**Doctor Last Name **] water. The patient continued to
have diarrhea and called her Oncologist on Tuesday for her
ongoing symptoms. She was instructed at this time to hold her
xeloda. The patient reported additionally decreased p.o. intake
over the prior 48h. On the evening of presentation, the patient
went to a hotel room to lie down. The patient was found by her
partner to be somnolent. She was arousable but reported to be
sleepy and unable to verbalize response. The patient was taken
to [**Hospital1 18**] by taxi, with assistance. On the way to the hospital,
she reports one episode of non-bloody, non-bilous vomiting. She
denied on admission any ongoing fevers/chills, rashes,
headaches, visual changes, chest pain, sob, cough, or abdominal
pain. She denied any sick contacts.
.
In ED her vitals were as follows: 102.1, 105, 79/52, 18, 96% RA.
Patient was noted to have altered MS, was confused and
somnolent. She received cefepime 2g, vancomycin 1g,
hydrocortisone 100mg, and levofloxacin 500mg iv x1. The
patient's elevated INR was reversed w/ 1 U FFP for possible LP.
However, the patient's MS improved w/3L NS with improvement in
her blood pressure and an LP was not performed.
.
Interval History: Since admission to the MICU, the patient was
noted to have episode of hypotension with SBP's in the 60's to
70's for which she received 2 500cc NS boluses. Patient
continued to be hypotensive overnight and was additionally
bolused another 500CC NS as well as 500CC LR. Patient was noted
to have ongoing diarrhea and one episode of non-bilious,
non-bloody vomiting overnight as well with dinner. She tolerated
breakfast on the am of trasnfer to floor, but reports ongoing
fatigue. She additionally reports some F/C this am but denies
any additional N/V, abdominal pain. She denies any HA, neck
stiffness, photophobia. She reports her mental clarity to be
much improved since admission.
.
Allergies: Sulfas - patient reports adverse reaction to sulfa
containing eye drops previously

MEDICAL HISTORY: PMHx:
- Breast Ca, T1N0M0, ER+, PR-, her-2/NEU-, s/p lumpectomy and
XRT, on Tamoxifen since [**12-25**], which was stopped with
initiation of chemotherapy
- Pancreatic Ca, as above
- HTN
- DVT - [**7-29**] - diagnosed asymptomatically by abd CT
- Migraines

MEDICATION ON ADMISSION: Medications - outpatient:
pancrease 1 capsule orally before meals
coumadin 5 mg po qd
xanax 0.25 mg [**12-26**] tab po qid prn anxiety
propranolol 40 mg po bid
prochlorperazine 10 mg po qid prn nausea
capecitabine (xeloda) 500 mg 4 tabs qam, 3 tabs qpm x 14 days.
loperamide 2 mg po prn diarrhea
tylenol prn
erythropoetin 20,000u sq qwk.
.
Meds on transfer to floor from MICU:
RISS
Lorazepam 0.5-1 mg IV Q4H:PRN
Acetaminophen 325-650 mg PO Q4-6H:PRN
Pangestyme-EC 2 CAP PO TID W/MEALS
Cefepime 2 gm IV Q12H, Day 2
Cholestyramine 4 gm PO BID
Vancomycin HCl 1000 mg IV Q 12H D 2
Epoetin Alfa 8000 UNIT SC

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: Physical Exam
Vitals: Tc:97.7___ Tmx:101 ([**2118-9-28**] 21:00)____  BP:120/59___
HR:94_____
RR:15____  O2 Sat: 99% on RA
Rectal Tube: 2835cc over last 24 hours
.
Gen: Patient is a middle aged female, appears chronically ill
but not greatly malnourished, in NAD
HEENT: NCAT, EOMI, PERRL. OP: MMM, no lesions
Neck: No LAD, No JVD. Supple
Chest: Mildy decreased BS at left base, otherwise CTA A+P
Cor: mildly tachycardic, no M/R/G
Abd: firm but not rigid, mild/mod tenderness diffusely but
greater in LLQ without rebound or guarding. +NABS with
occasional borborygymi
Extrem: No C/C/E
Access: left chest port, + Foley, + rectal tube

FAMILY HISTORY: Mother deceased brain tumor age 54
Father deceased [**Name2 (NI) 499**] ca age 64

SOCIAL HISTORY: Patient is currently retired. Previously employed as a
superintendent for school district in [**State 4565**]. Patient denies
etoh/tobacco/ivdu. Patient with male partner of 25 years,
previously married with 2 children from previous marriage.
Travel history as above to NH recently. Previously received her
care with [**Doctor Last Name 21721**] in CA, referred to Dr. [**First Name (STitle) **] for 2nd opinion,
the reason for which she is currently in [**Location (un) 86**].
Unspecified septicemia,Hypovolemia,Malignant neoplasm of other specified sites of pancreas,Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of breast,Unspecified essential hypertension,Diarrhea,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use
Septicemia NOS,Hypovolemia,Malig neo pancreas NEC,SIRS-noninf w/o ac or ds,Long-term use anticoagul,Hx of breast malignancy,Hypertension NOS,Diarrhea,Adv eff antineoplastic
Admission Date:  [**2118-9-29**]              Discharge Date:   [**2118-10-6**]

Date of Birth:  [**2055-1-4**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
Fever and Hypotension

Major Surgical or Invasive Procedure:
1. None


History of Present Illness:
Oncology History:
Patient was originally diagnosed with Breast cancer in [**2113**]. At
time of diagnosis she had a T1N0M0, ER+, PR-, her-2/NEU- lesion
treated with lumpectomy and XRT. The patient had received
Tamoxifen since [**2113-12-25**] without additional adjuvant
chemotherapy and without known progression of disease to date as
per patient's report. The patient's Tamoxifen was discontinued
upon diagnosis of second primary malignancy.
In late [**2117-11-24**], the patient presented with abdominal
pain. A CT at that time revealed a mass in the pancreas
w/extension to the Left adrenal and kidney with biopsy revealing
mucinous adenocarcinoma. The patient is now s/p distal
pancreatectomy, splenectomy, L adrenalectomy, L nephrectomy, and
omentectomy for this lesion. She began treatment with XRT/xeloda
and was then discovered to have metastatic disease for which
gemcitabine/cisplatin were initiated. Most recently the patient
has been receiving irinotecan and xeloda in [**2118-8-25**] in
the setting of rising CA19-9 which has been followed by good
response with a drop in her CA19-9 from 1549 to 439. Her last
dose of Irinotecan was [**9-14**].  The patient was nearing
completion of her second cycle of xeloda with her last dose
taken on Tuesday [**9-27**]. She was to complete her cycle
Wednesday night but was told to hold further doses given her
symptoms for which she presented. Her next scheduled cycle was
to begin Wednesday, [**2118-10-5**], but may be postponed
given current symptoms.
.
The patient was reported to be in her USOH until Sunday
afternoon when she developed onset of diarrhea. She was visiting
friends in [**Name (NI) **] at the time and previously reported she felt well.
She reports small hiking but denies insect bites, tick bites,
rashes, drinking stream or [**Doctor Last Name **] water. The patient continued to
have diarrhea and called her Oncologist on Tuesday for her
ongoing symptoms. She was instructed at this time to hold her
xeloda. The patient reported additionally decreased p.o. intake
over the prior 48h. On the evening of presentation, the patient
went to a hotel room to lie down. The patient was found by her
partner to be somnolent. She was arousable but reported to be
sleepy and unable to verbalize response. The patient was taken
to [**Hospital1 18**] by taxi, with assistance. On the way to the hospital,
she reports one episode of non-bloody, non-bilous vomiting. She
denied on admission any ongoing fevers/chills, rashes,
headaches, visual changes, chest pain, sob, cough, or abdominal
pain. She denied any sick contacts.
.
In ED her vitals were as follows: 102.1, 105, 79/52, 18, 96% RA.
Patient was noted to have altered MS, was confused and
somnolent. She received cefepime 2g, vancomycin 1g,
hydrocortisone 100mg, and levofloxacin 500mg iv x1. The
patient's elevated INR was reversed w/ 1 U FFP for possible LP.
However, the patient's MS improved w/3L NS with improvement in
her blood pressure and an LP was not performed.
.
Interval History: Since admission to the MICU, the patient was
noted to have episode of hypotension with SBP's in the 60's to
70's for which she received 2 500cc NS boluses. Patient
continued to be hypotensive overnight and was additionally
bolused another 500CC NS as well as 500CC LR. Patient was noted
to have ongoing diarrhea and one episode of non-bilious,
non-bloody vomiting overnight as well with dinner. She tolerated
breakfast on the am of trasnfer to floor, but reports ongoing
fatigue. She additionally reports some F/C this am but denies
any additional N/V, abdominal pain. She denies any HA, neck
stiffness, photophobia. She reports her mental clarity to be
much improved since admission.
.
Allergies: Sulfas - patient reports adverse reaction to sulfa
containing eye drops previously

Past Medical History:
PMHx:
- Breast Ca, T1N0M0, ER+, PR-, her-2/NEU-, s/p lumpectomy and
XRT, on Tamoxifen since [**12-25**], which was stopped with
initiation of chemotherapy
- Pancreatic Ca, as above
- HTN
- DVT - [**7-29**] - diagnosed asymptomatically by abd CT
- Migraines

Social History:
Patient is currently retired. Previously employed as a
superintendent for school district in [**State 4565**]. Patient denies
etoh/tobacco/ivdu. Patient with male partner of 25 years,
previously married with 2 children from previous marriage.
Travel history as above to NH recently. Previously received her
care with [**Doctor Last Name 21721**] in CA, referred to Dr. [**First Name (STitle) **] for 2nd opinion,
the reason for which she is currently in [**Location (un) 86**].

Family History:
Mother deceased brain tumor age 54
Father deceased [**Name2 (NI) 499**] ca age 64

Physical Exam:
Physical Exam
Vitals: Tc:97.7___ Tmx:101 ([**2118-9-28**] 21:00)____  BP:120/59___
HR:94_____
RR:15____  O2 Sat: 99% on RA
Rectal Tube: 2835cc over last 24 hours
.
Gen: Patient is a middle aged female, appears chronically ill
but not greatly malnourished, in NAD
HEENT: NCAT, EOMI, PERRL. OP: MMM, no lesions
Neck: No LAD, No JVD. Supple
Chest: Mildy decreased BS at left base, otherwise CTA A+P
Cor: mildly tachycardic, no M/R/G
Abd: firm but not rigid, mild/mod tenderness diffusely but
greater in LLQ without rebound or guarding. +NABS with
occasional borborygymi
Extrem: No C/C/E
Access: left chest port, + Foley, + rectal tube

Pertinent Results:
Admission Labs: [**2118-9-29**]:
.
[**2118-9-29**] 01:25AM   PLT COUNT-271
[**2118-9-29**] 01:25AM   PT-21.8* PTT-27.6 INR(PT)-3.4
[**2118-9-29**] 01:25AM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-OCCASIONAL
TEARDROP-OCCASIONAL HOW-JOL-OCCASIONAL
[**2118-9-29**] 01:25AM   NEUTS-33* BANDS-8* LYMPHS-28 MONOS-24* EOS-2
BASOS-0 ATYPS-1* METAS-2* MYELOS-0 NUC RBCS-2* OTHER-2*
[**2118-9-29**] 01:25AM   WBC-1.7* RBC-3.37* HGB-11.5* HCT-33.8*
MCV-100* MCH-34.0* MCHC-33.9 RDW-20.1*
[**2118-9-29**] 01:25AM   ALBUMIN-3.8 CALCIUM-8.5 PHOSPHATE-1.4*
MAGNESIUM-1.4*
[**2118-9-29**] 01:25AM   LIPASE-9
[**2118-9-29**] 01:25AM   ALT(SGPT)-10 AST(SGOT)-13 ALK PHOS-68
AMYLASE-15 TOT BILI-1.7*
[**2118-9-29**] 01:25AM   GLUCOSE-155* UREA N-19 CREAT-1.3* SODIUM-130*
POTASSIUM-3.4 CHLORIDE-98 TOTAL CO2-20* ANION GAP-15
[**2118-9-29**] 01:43AM   LACTATE-1.8
[**2118-9-29**] 02:20AM URINE  GRANULAR-[**6-3**]* HYALINE-[**2-26**]*
[**2118-9-29**] 02:20AM URINE  RBC-[**2-26**]* WBC-[**2-26**] BACTERIA-FEW YEAST-NONE
EPI-[**2-26**]
[**2118-9-29**] 02:20AM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG
[**2118-9-29**] 02:20AM URINE  TYPE-RANDOM COLOR-Amber APPEAR-Hazy SP
[**Last Name (un) 155**]-1.026
[**2118-9-29**] 08:14AM URINE  RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2118-9-29**] 08:14AM URINE  BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2118-9-29**] 08:14AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2118-9-29**] 08:14AM   PT-24.6* PTT-29.1 INR(PT)-4.4
[**2118-9-29**] 08:14AM   PLT SMR-NORMAL PLT COUNT-241
[**2118-9-29**] 08:14AM   HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
SCHISTOCY-1+ BURR-OCCASIONAL HOW-JOL-1+
[**2118-9-29**] 08:14AM   NEUTS-39* BANDS-14* LYMPHS-25 MONOS-17* EOS-0
BASOS-0 ATYPS-3* METAS-2* MYELOS-0 NUC RBCS-2*
[**2118-9-29**] 08:14AM   WBC-1.9* RBC-2.90* HGB-9.5* HCT-28.8*
MCV-100* MCH-32.7* MCHC-32.8 RDW-19.7*
[**2118-9-29**] 08:14AM   CALCIUM-7.6* PHOSPHATE-1.8* MAGNESIUM-1.9
[**2118-9-29**] 08:14AM   GLUCOSE-169* UREA N-16 CREAT-0.8 SODIUM-135
POTASSIUM-3.3 CHLORIDE-109* TOTAL CO2-16* ANION GAP-13
Additional Pertinent Labs/Studies:
.
[**2118-10-4**] ABG - pO2-92 pCO2-22* pH-7.40 calHCO3-14* Base XS--8
[**2118-9-29**] Venous Lactate-1.8
[**2118-10-2**] Venous Lactate-1.2
[**2118-10-4**] Venous Lactate-1.4
.
Trends:
WBC: 8.9 <- 5.1 <- 4.9 <- 3.2 <- 1.5 <- 2.4 <- 1.9 <- 1.7
ANC: 2950 ([**2118-10-4**]) <- 1369 <- 1290 <- 590 ([**2118-10-1**])
HCT: 26.2 <- 27.4 <- 29.6 <- 31.0 <- 25.8 <- 26.2 <- 28.8 <-
33.8
INR: 6.3 <- 4.8 <- 4.2 <- 6.0 <- 3.1 <- 4.2 <- 4.4 <- 3.4
.
Microbiology:
[**2118-9-29**] Blood cx - No growth
[**2118-10-1**] Blood cx - No growth
[**2118-10-2**] Blood cx - No growth
[**2118-10-3**] Blood cx - No growth
.
[**2118-9-29**] Stool cx - No salmonella, shigella, or campylobacter
found. FEW CHARCOT-[**Location (un) **] CRYSTALS PRESENT. FEW
POLYMORPHONUCLEAR LEUKOCYTES. NO OVA AND PARASITES SEEN. C. Diff
negative
[**2118-9-30**] Stool cx - MODERATE POLYMORPHONUCLEAR LEUKOCYTES. NO
OVA AND PARASITES SEEN.
[**2118-10-1**]: Stool: Negative for C. Diff
[**2118-10-2**]: Stool: Negative for C. Diff
[**2118-10-4**]: Stool cxs - No growth to date
[**2118-10-5**]: Stool cxs - No groeth to date
.
[**2118-9-29**]: Urine cx - No growth
[**2118-10-3**]: urine cx - No growth
.
Radiology:
[**2118-9-29**]: Chest Pa/Lat: CHEST AP:  Surgical clips are visualized
over the right lateral upper chest. The right costophrenic angle
has been excluded from the study.  A left-sided Port-A-Cath is
visualized with its tip in the proximal SVC.  The heart size,
mediastinal and hilar contours are unremarkable.  The lungs are
clear. There are no pleural effusions.  The pulmonary
vasculature is normal.
IMPRESSION:  No acute cardiopulmonary process.
.
[**2118-9-29**]: CT Head: FINDINGS:  There is no intracranial mass
effect, hydrocephalus, shift of normally midline structures or
major vascular territorial infarction. The density values of the
brain parenchyma are within normal limits.  Surrounding soft
tissue and osseous structures are unremarkable.
IMPRESSION:  No mass effect or hemorrhage.
.
[**2118-9-30**]: Port-a-cath Flow Study: 1. Flow study through the port
was suggestive of either a fibrin sheath, or less likely, a
small catheter leak. 2. Good flow was obtained on aspiration of
the port at the end of the examination.
.
[**2118-10-4**]: CT Abdomen + Pelvis:
The lung bases are clear. Patient has prior distal
pancreatectomy, splenectomy and radical left nephrectomy. In the
left upper quadrant posteriorly, there is ill-defined area of
soft tissue density located just posterior to the surgical clips
to the left and slightly inferior to the celiac artery axis
origin.  This area of tissue density measures up to 2.8 cm AP x
1.6 cm transverse.  This could represent postoperative
thickening but correlation with any prior imaging is advised to
exclude the possibility of local recurrence. The remaining
portion of the proximal pancreatic body, neck and head appear
normal. No intra or extrahepatic biliary dilatation. The liver
is normal in size. Multiple sub cm ovoid hypoattenuating areas
mainly in the left lobe ,these may represent small cysts but are
too small to characterise on CT and should be correlated with
prior imaging or interval follow up as small hypovascular
metastases cannot be excluded. The gallbladder and right adrenal
gland are normal. The remaining right kidney is normal in size,
1.5 cm fluid attenuating cyst in the upper pole cortex. The
abdominal aorta is normal in caliber.  No intra-abdominal
ascites. In the lateral mid abdominal mesentry, there is a 9 mm
area of nodularity just anterior to and separate from the
descending [**Month/Day/Year 499**] (series 3 image 48) and a 5
mm area of nodularity more superiorly (series 3, image 43).
There is no abnormal large or small bowel loop dilatation.  Many
of the small bowel loops are mildly prominent, measuring up to 3
cm in diameter and the [**Month/Day/Year 499**] is fluid filled throughout which
may be due to a current episode of
enteritis.
.
Pelvis: A small 2 cm fluid attenuating locule in the posterior
inferior pelvis.  The uterus is normal in size.  No pelvic mass
lesions or lymphadenopathy. No concerning bone lesions
demonstrated on bone window setting.
.
CONCLUSION: 1)Fluid filled non-thickened non-distended [**Month/Day/Year 499**]
.This may be related to current episode of enteritis depending
on current clinical correlation. 2) No definite evidence of
metastatic disease. There are a number of findings which require
correlation with prior postoperative imaging if available or
otherwise interval follow.These include an ill- defined area of
thickening of the posterior operative site in the left upper
quadrant, two sub cm areas of nodularity in the left abdominal
mesentery and sub cm hypodensities mainly in the left lobe of
the liver.
Discharge Labs:
.
[**2118-10-6**] 07:25AM BLOOD WBC-5.8 RBC-2.90* Hgb-9.5* Hct-28.9*
MCV-100* MCH-32.6* MCHC-32.7 RDW-20.8* Plt Ct-458*
[**2118-10-6**] 07:25AM BLOOD Neuts-46* Bands-6* Lymphs-16* Monos-23*
Eos-2 Baso-0 Atyps-0 Metas-5* Myelos-2* NRBC-41*
[**2118-10-6**] 07:25AM BLOOD Hypochr-OCCASIONAL Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Target-OCCASIONAL
Schisto-1+ How-Jol-OCCASIONAL Acantho-2+
[**2118-10-6**] 07:25AM BLOOD Fibrinogen - Pending
[**2118-10-6**] 07:25AM BLOOD Glucose-98 UreaN-3* Creat-0.7 Na-134
K-3.8 Cl-108 HCO3-15* AnGap-15
[**2118-10-6**] 07:25AM BLOOD Calcium-7.5* Phos-2.0* Mg-2.0

Brief Hospital Course:
Patient is a 63 year old female with pancreatic Cancer, recently
receiving treatment with her 2nd cycle of xeloda and irinotecan
who presents to hospital with fever, hypotension, and altered
mental status.
.
#. Hypotension/Diarrhea - On presentation, the patient's
presentation was assessed to meet criteria for SIRS with a
septic like picture on presentation. The patient was febrile,
hypotensive with altered mental status in the setting of an ANC
of 590. While in the ED, the patient had cultures drawn, and was
initially treated with Cefepime, Vancomycin, Levofloxacin, and
Hydrocortisone. Upon transfer to the MICU, the patient was
maintained on therapy with cefepime and vancomycin  for
treatment of febrile neutropenia. The patient had received 3L NS
hydration initially and was given FFP with intention to reverse
the patient's elevated INR (patient on coumadin for DVT) for
possible LP. However, after hydration the patient's mental
status was noted to significantly improve and an LP was not
attempted at this time. The patient had a lactate of 1.8 with
good response in blood pressure with hydration. Overnight in the
ICU on the day of admission the patient had two episodes of
hypotension, with systolics in the 60's to 70's range
necessitating 2NS and 2LR boluses, again with good response. It
was the impression of the treating attending oncologist that the
patient's presentation and diarrhea was consistent with
chemotherapy induced diarrhea rather than an infectious
diarrhea. For this reason, the patient was started on
anti-motility agents including lomotil and questran. However,
these agents had little effect initially as the patient
continued to have high volume diarrhea. In the 24 hours after
admission, the patient was assessed to have a GI output of about
2800cc. The patient upon transfer to the floor had a rectal tube
and foley in place. However, given that the patient had an ANC <
1000 at that time, the decision was made that invasive catheters
should likely be removed. As the patient has been largely
incontinent of stool, it has been difficult objectively to
quantify exact GI output. The patient reported that over the
course of her hospital stay, she has not felt that there has
been great improvement to date in the quantity of stool produced
,although she has reported increased continence. However, the
day prior to discharge to receiving hospital, the patient
endorses two to three liquid green bowel movements that she
reports she was not even aware of until they had passed. The
patient has not required fluid bolusing since trasnfer to the
floor, but has been receiving constant IV hydration with NS with
20mEq KCl requiring electrolyte repletion q12hr. The patient
continues to have a significant non-gap acidosis secondary to
diarrhea with serum bicarbonate levels of 11 to 14 over the last
three days prior to discharge. However, an ABG performed on
[**2118-10-4**] as follows: pO2-92 pCO2-22* pH-7.40 calHCO3-14* Base
XS--8 revealed that the patient is not acidemic and adequately
compensating for her bicarbonate loss. As the patient has had a
normal serum pH she has not been receiving oral or IV
bicarbonate but continues to receive hydration and volume
repletion with NS at 125 to 175 cc/hr. As the patient continues
to have significant GI output, she will require ongoing
hydration and additionally should receive electrolyte panels
with repletion q12hrs until no longer needed. In an attempt to
decrease the patient's GI output, in addition to lomotil and
questran which were initiated on admission, the patient has
serially been given Kaopectate and the day prior to discharge
was started on Octreotide and Metamucil to help bulk her very
liquidy green stool. The patient has now been afebrile > 48
hours, and is currently receiving still cefepime 2gm IV q8hr,
now Day 8 (started [**2118-9-29**]) and Flagyl which was initiated in
place of Vancomycin (now Day 4, initiated [**2118-10-3**]). As the
patient has been afebrile for > 48 hours consideration may be
made towards discontinuing these medications but will be left to
the discretion of the receiving hospital. The patient has had
multiple stool and blood cultures sent during this admission
(see pertinent results) which have demonstrated mild to moderate
Leukocytes in the stool but cultures, O+P and C. Diff have been
negative multiple times. As the patient reported some mild LLQ
tenderness a CT of the abdomen was obtained to detect any occult
abscess or other infectious process. CT results demonstrated
soft tissue density a the site of the patient's known prior
pancreatic mass but revealed no abnormal large or small bowel
loop dilatation. CT demonstrated many of the small bowel loops
to be mildly prominent, measuring up to 3 cm in diameter and
revealed the [**Month/Day/Year 499**] to be fluid filled throughout, thought to be
related to the patient's ongoing enteritis. In the pelvis CT
additionally revealed a small 2 cm fluid attenuating locule in
the posterior inferior pelvis. The patient is now being
transferred to receiving hospital for ongoing management of
patient's diarrhea and electroylte abnormalities.
.
#. DVT - The patient on admission was being treated with 2.5mg
po qhs of coumadin qhs for known DVT diagnosed in 08-[**2117**]. The
patient's INR on presentation was 3.4 which was partially
reversed with 1U FFP in anticipation of possible LP. However, as
above, given reversal of somnolence with volume rescucitation
alone, an LP was not performed. The patient's coumadin was held
throughout her stay as she continued to have a supratherapeutic
INR without coumadin, thought likely to be secondary to her poor
PO intake as well as extinguishing gut flora with antibiotics.
The patient's INR was 6.0 on [**2118-10-2**] for which she received
2.5mg PO Vitamin K with good effect, and reduction of her INR to
4.2 the next day. The patient in error however was given a dose
of 2.5mg coumadin x1 despite a holding order the following day.
Her INR was again elevated to 6.3 the day prior to discharge. As
the patient's INR was greater than 5, but without any evidence
of any ongoing bleeding, the patient's coumadin continues to be
held and an addiitional 2.5mg PO Vitamin K was administered. The
patient's INR the am of discharge was found to be 7.0. The
patient was given 5mg Vitamin K SC this am with concern that
previous PO doses are not being well absorbed given the patients
rapid GI transit time. Of additional note, the patient has been
noted previously and again this am to have occasional
schistocytes on peripheral blood smear. A fibrinogen level
checked previously was 543 on [**2118-10-3**] and repeat fibrinogen am
of discharge, [**2118-10-6**] was 418, not consistent with DIC.  The
patient should continue to have her INR carefully monitored at
the receiving hospital with consideration towards additional
Vitamin K SC/IV for reversal of INR > 5.0 or FFP with any signs
of bleeding.
.
#. Access - In the ICU on admission, the patient's port was
noted to be not functioning properly. A flow study was performed
which demonstrated fluid flow proximal to the catheter tip
suggestive likely of a fibrin sheath vs. a possible catheter
leak. The port was used once on the floor prior to the results
of the flow study being revealed and the patient reported some
burning at the port entry site with the infusion of some fluids
with potassium. Therefore, the port has not been used again
during this hospital course and the port should not be used any
longer. The patient's port likely will have to be removed given
it is not functional. Plans were to be made to have the port
removed now that the patient has been afebrile > 48hours and
hemodynamically stable. Upon transfer to the receiving hospital,
plans will need to continue to be initiated towards port removal
or alternatively attempts could be made to have an attempted
snare by interventional radiology for removal of a fibrin sheath
if present. The patient is aware the port is not functional and
aware it will likely need to be removed.
.
#. Pancreatic Ca: As discussed in H+P, the patient is currently
s/p distal pancreatectomy, left adrenal/nephrectomy, ometectomy
treated additionally with XRT and Xeloda, follwed by
gemcitabine/cisplatin, and most recently treated with
xeloda/irinotecan s/p two 3-week cycles. The patient was
travelling to [**Location (un) 86**] for second opinion regarding treatment
options when she developed severe diarrhea and hypotension.
Given the patient's apparent chemo toxicity, chemo was held
currently until patient is medically stable to continue.
Impression of Oncologist seeing patient at [**Hospital1 18**] is that of the
two agents, the Xeloda may be more responsible for the treatment
response to date and the irinotecan her current GI toxicity.
Given this, considerations towards additional chemo included
Xeloda alone, possibly with the addition of low dose irinotecan
if tumor markers began to rise again. Alternatively, patient
could additioanlly receive FOLFOX or taxotere as well. The
patient is being discharged to receiving hospital currently with
plans towards continuing management of diarrhea, electrolyte
abnormalities as outlined above and will continue treatment
planning with regards to her pancreatic Ca with her oncologist.

.
#. HTN - Given patient's admission for hypotension, her
outpatient regimen of propranolol was held during her hospital
course. Upon resolution of large GI output and decreased need
for IV volume sresuscitation, consideration could be made
towards reinitiating patient's antihypertesnive regimen.
.
#. FEN- patient was kept on a low fat, lactose free BRAT diet
with supplemental pancrease given. Patient's PO intake was not
optimal during hospital course, but continues to improve with
resolution of her symptoms.
.
#. Communication: Patient's significant other, [**Name (NI) **] may be
reached at [**Telephone/Fax (1) 62493**].; He is very supportive and intimately
involved in the patient's care.

Medications on Admission:
Medications - outpatient:
pancrease 1 capsule orally before meals
coumadin 5 mg po qd
xanax 0.25 mg [**12-26**] tab po qid prn anxiety
propranolol 40 mg po bid
prochlorperazine 10 mg po qid prn nausea
capecitabine (xeloda) 500 mg 4 tabs qam, 3 tabs qpm x 14 days.
loperamide 2 mg po prn diarrhea
tylenol prn
erythropoetin 20,000u sq qwk.
.
Meds on transfer to floor from MICU:
RISS
Lorazepam 0.5-1 mg IV Q4H:PRN
Acetaminophen 325-650 mg PO Q4-6H:PRN
Pangestyme-EC 2 CAP PO TID W/MEALS
Cefepime 2 gm IV Q12H, Day 2
Cholestyramine 4 gm PO BID
Vancomycin HCl 1000 mg IV Q 12H D 2
Epoetin Alfa 8000 UNIT SC

Discharge Medications:
1. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 (8000) unit
Injection QMOWEFR (Monday -Wednesday-Friday).
4. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID
(2 times a day).
5. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two
(2) Packet PO BID (2 times a day).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q6 ().
7. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
8. Bismuth Subsalicylate 262 mg Tablet, Chewable Sig: One (1)
Tablet PO Q3H (every 3 hours) as needed for diarrhea.
9. Psyllium     Packet Sig: One (1) Packet PO TID (3 times a
day).
10. Lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q4H
(every 4 hours) as needed.
11. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous  Q8H
(every 8 hours).
12. Octreotide Acetate 50 mcg/mL Solution Sig: Fifty (50) mcg
Injection Q8H (every 8 hours).


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary:
SIRS
Hypotension
Chemotherapy related diarrhea
Pancreatic Cancer
.
Secondary:
Breast Cancer
Hypertension
DVT - [**7-/2118**]
Migraines


Discharge Condition:
1. Fair. Patient is being transferred to receiving hospital in
[**State 4565**] for ongoing management. Patient is currently
afebrile, normotensive, with ongoing large liquid bowel
movements and requiring frequent electrolyte repletion.

Discharge Instructions:
1. Please take all medications as prescribed unless instructed
otherwise by receiving hospital
.
2. Please continue outpatient follow up with your oncologist in
[**State 4565**] and continue to contact Dr. [**First Name (STitle) **] at [**Hospital1 18**] as
desired for ongoing treatment options.
.
3. Upon discharge from receiving hosptial, please return to
hospital for any signs or symptoms of increasing diarrhea,
dizziness, fever, intractable nausea/vomiting, bleeding or any
other concerning symptoms.

Followup Instructions:
1. Please continue treatment under the supervision and care of
receiving hospital in [**State 4565**]
.
2. Please call your oncologist upon discharge for ongoing care
and treatment plans
{'Unspecified septicemia,Hypovolemia,Malignant neoplasm of other specified sites of pancreas,Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of breast,Unspecified essential hypertension,Diarrhea,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use'}


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 and Hypotension

PRESENT ILLNESS: Oncology History:
Patient was originally diagnosed with Breast cancer in [**2113**]. At
time of diagnosis she had a T1N0M0, ER+, PR-, her-2/NEU- lesion
treated with lumpectomy and XRT. The patient had received
Tamoxifen since [**2113-12-25**] without additional adjuvant
chemotherapy and without known progression of disease to date as
per patient's report. The patient's Tamoxifen was discontinued
upon diagnosis of second primary malignancy.
In late [**2117-11-24**], the patient presented with abdominal
pain. A CT at that time revealed a mass in the pancreas
w/extension to the Left adrenal and kidney with biopsy revealing
mucinous adenocarcinoma. The patient is now s/p distal
pancreatectomy, splenectomy, L adrenalectomy, L nephrectomy, and
omentectomy for this lesion. She began treatment with XRT/xeloda
and was then discovered to have metastatic disease for which
gemcitabine/cisplatin were initiated. Most recently the patient
has been receiving irinotecan and xeloda in [**2118-8-25**] in
the setting of rising CA19-9 which has been followed by good
response with a drop in her CA19-9 from 1549 to 439. Her last
dose of Irinotecan was [**9-14**].  The patient was nearing
completion of her second cycle of xeloda with her last dose
taken on Tuesday [**9-27**]. She was to complete her cycle
Wednesday night but was told to hold further doses given her
symptoms for which she presented. Her next scheduled cycle was
to begin Wednesday, [**2118-10-5**], but may be postponed
given current symptoms.
.
The patient was reported to be in her USOH until Sunday
afternoon when she developed onset of diarrhea. She was visiting
friends in [**Name (NI) **] at the time and previously reported she felt well.
She reports small hiking but denies insect bites, tick bites,
rashes, drinking stream or [**Doctor Last Name **] water. The patient continued to
have diarrhea and called her Oncologist on Tuesday for her
ongoing symptoms. She was instructed at this time to hold her
xeloda. The patient reported additionally decreased p.o. intake
over the prior 48h. On the evening of presentation, the patient
went to a hotel room to lie down. The patient was found by her
partner to be somnolent. She was arousable but reported to be
sleepy and unable to verbalize response. The patient was taken
to [**Hospital1 18**] by taxi, with assistance. On the way to the hospital,
she reports one episode of non-bloody, non-bilous vomiting. She
denied on admission any ongoing fevers/chills, rashes,
headaches, visual changes, chest pain, sob, cough, or abdominal
pain. She denied any sick contacts.
.
In ED her vitals were as follows: 102.1, 105, 79/52, 18, 96% RA.
Patient was noted to have altered MS, was confused and
somnolent. She received cefepime 2g, vancomycin 1g,
hydrocortisone 100mg, and levofloxacin 500mg iv x1. The
patient's elevated INR was reversed w/ 1 U FFP for possible LP.
However, the patient's MS improved w/3L NS with improvement in
her blood pressure and an LP was not performed.
.
Interval History: Since admission to the MICU, the patient was
noted to have episode of hypotension with SBP's in the 60's to
70's for which she received 2 500cc NS boluses. Patient
continued to be hypotensive overnight and was additionally
bolused another 500CC NS as well as 500CC LR. Patient was noted
to have ongoing diarrhea and one episode of non-bilious,
non-bloody vomiting overnight as well with dinner. She tolerated
breakfast on the am of trasnfer to floor, but reports ongoing
fatigue. She additionally reports some F/C this am but denies
any additional N/V, abdominal pain. She denies any HA, neck
stiffness, photophobia. She reports her mental clarity to be
much improved since admission.
.
Allergies: Sulfas - patient reports adverse reaction to sulfa
containing eye drops previously

MEDICAL HISTORY: PMHx:
- Breast Ca, T1N0M0, ER+, PR-, her-2/NEU-, s/p lumpectomy and
XRT, on Tamoxifen since [**12-25**], which was stopped with
initiation of chemotherapy
- Pancreatic Ca, as above
- HTN
- DVT - [**7-29**] - diagnosed asymptomatically by abd CT
- Migraines

MEDICATION ON ADMISSION: Medications - outpatient:
pancrease 1 capsule orally before meals
coumadin 5 mg po qd
xanax 0.25 mg [**12-26**] tab po qid prn anxiety
propranolol 40 mg po bid
prochlorperazine 10 mg po qid prn nausea
capecitabine (xeloda) 500 mg 4 tabs qam, 3 tabs qpm x 14 days.
loperamide 2 mg po prn diarrhea
tylenol prn
erythropoetin 20,000u sq qwk.
.
Meds on transfer to floor from MICU:
RISS
Lorazepam 0.5-1 mg IV Q4H:PRN
Acetaminophen 325-650 mg PO Q4-6H:PRN
Pangestyme-EC 2 CAP PO TID W/MEALS
Cefepime 2 gm IV Q12H, Day 2
Cholestyramine 4 gm PO BID
Vancomycin HCl 1000 mg IV Q 12H D 2
Epoetin Alfa 8000 UNIT SC

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: Physical Exam
Vitals: Tc:97.7___ Tmx:101 ([**2118-9-28**] 21:00)____  BP:120/59___
HR:94_____
RR:15____  O2 Sat: 99% on RA
Rectal Tube: 2835cc over last 24 hours
.
Gen: Patient is a middle aged female, appears chronically ill
but not greatly malnourished, in NAD
HEENT: NCAT, EOMI, PERRL. OP: MMM, no lesions
Neck: No LAD, No JVD. Supple
Chest: Mildy decreased BS at left base, otherwise CTA A+P
Cor: mildly tachycardic, no M/R/G
Abd: firm but not rigid, mild/mod tenderness diffusely but
greater in LLQ without rebound or guarding. +NABS with
occasional borborygymi
Extrem: No C/C/E
Access: left chest port, + Foley, + rectal tube

FAMILY HISTORY: Mother deceased brain tumor age 54
Father deceased [**Name2 (NI) 499**] ca age 64

SOCIAL HISTORY: Patient is currently retired. Previously employed as a
superintendent for school district in [**State 4565**]. Patient denies
etoh/tobacco/ivdu. Patient with male partner of 25 years,
previously married with 2 children from previous marriage.
Travel history as above to NH recently. Previously received her
care with [**Doctor Last Name 21721**] in CA, referred to Dr. [**First Name (STitle) **] for 2nd opinion,
the reason for which she is currently in [**Location (un) 86**]. 

### Response:
{'Unspecified septicemia,Hypovolemia,Malignant neoplasm of other specified sites of pancreas,Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of breast,Unspecified essential hypertension,Diarrhea,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use'}
