CHIEF COMPLAINT: Chills

PRESENT ILLNESS: A 53 year old lady with metastatic breast CA 9 weeks s/p Chemo
presented to the ED after experiencing chills the evening prior
to admission after starting the day's TPN.  She then later
developed a fever to 101.9 and was recommended to come to the ED
by the oncologist on call.
.
In the ED, initial vs were: 101.4 165 82/43 18 97%RA Patient was
given 5-6 L NS; Vancomycin, Zosyn, Fluconazole and a femoral
line was placed.  She also received Toradol for pain control.
Given her hypotension, she was started on Norepinephrine,
Dopamine and Phenylephrine and Dexamethasone for blood pressure
support.  Her respiratory and mental statuses remained
uncompromised.
.
Of note, the patient had a R hickman placed 2 weeks prior to
initate TPN.  She is also 1 day s/p therapeutic paracentesis
with "many" bottles of fluid removed.
.
On the floor, the patient appears pale and mildy uncomfortable
and reports generalized pain.  She denies dyspnea, chest pain,
line pain or abdominal pain, and reports that her belly is
softer after paracentesis. She denies any cough, sinus pain,
congestion.  She is not chilled at this time. The patient
reports chronic constipation with 5 episodes of non-bloody
diarrhea the day prior to admission; all secondary to an
obstructive colonic mass.

MEDICAL HISTORY: -Metastatic Breast Cancer

MEDICATION ON ADMISSION: Senna 8.6 mg PO BID PRN
Colace 100mg PO BID
Megestrol 40mg/mL PO daily
Caltrate-600 Plus Vitamin D3 600-400 mg-unit PO BID
Fentanyl 100 mcg/hr Patch Q72hr
Oxycodone 20-30mg PO Q3prn Pain

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 99.3  BP: 101/46 P: 154 R: 17 O2: 95% RA
General: Alert, oriented, mildly uncomfortable
HEENT: Pale conjunctive, dry mucous membranes.
Neck: supple, JVP not elevated, no LAD
Lungs: Occasional wheezes, otherwise clear to auscultation
bilaterally
CV: S1 & S2 rapid without appreciable murmur, difficult given
rate.  Hickman on R Subclavian with mild erythema surrounding
line insertion.
Abdomen:  tight and distended, nontender, bowel sounds present.
No masses palpable. No hepatosplenomegaly, but difficult given
tight abdomen.
GU: foley & R femoral line in place
Ext: warm, well perfused, 2+ pulses, no edema

FAMILY HISTORY: Father - died at age 63 from CVA
Mother - Glaucoma

SOCIAL HISTORY: Lives with her husband and 2 daughters. Former [**Company 378**] consultant,
business owner.  5pkyr history, quit
Other and unspecified infection due to central venous catheter,Bacteremia,Shock, unspecified,Malignant neoplasm of liver, secondary,Other ascites,Acidosis,Malignant pleural effusion,Thrombocytopenia, unspecified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of malignant neoplasm of breast,Anemia, unspecified,Neoplasm related pain (acute) (chronic),Nausea alone
Oth/uns inf-cen ven cath,Bacteremia,Shock NOS,Second malig neo liver,Ascites NEC,Acidosis,Malignant pleural effusn,Thrombocytopenia NOS,Oth gram negatv bacteria,Abn react-procedure NEC,Hx of breast malignancy,Anemia NOS,Neoplasm related pain,Nausea alone
Admission Date:  [**2180-11-18**]              Discharge Date:   [**2180-11-22**]

Date of Birth:  [**2127-9-23**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
Chills

Major Surgical or Invasive Procedure:
None

History of Present Illness:
A 53 year old lady with metastatic breast CA 9 weeks s/p Chemo
presented to the ED after experiencing chills the evening prior
to admission after starting the day's TPN.  She then later
developed a fever to 101.9 and was recommended to come to the ED
by the oncologist on call.
.
In the ED, initial vs were: 101.4 165 82/43 18 97%RA Patient was
given 5-6 L NS; Vancomycin, Zosyn, Fluconazole and a femoral
line was placed.  She also received Toradol for pain control.
Given her hypotension, she was started on Norepinephrine,
Dopamine and Phenylephrine and Dexamethasone for blood pressure
support.  Her respiratory and mental statuses remained
uncompromised.
.
Of note, the patient had a R hickman placed 2 weeks prior to
initate TPN.  She is also 1 day s/p therapeutic paracentesis
with "many" bottles of fluid removed.
.
On the floor, the patient appears pale and mildy uncomfortable
and reports generalized pain.  She denies dyspnea, chest pain,
line pain or abdominal pain, and reports that her belly is
softer after paracentesis. She denies any cough, sinus pain,
congestion.  She is not chilled at this time. The patient
reports chronic constipation with 5 episodes of non-bloody
diarrhea the day prior to admission; all secondary to an
obstructive colonic mass.

Past Medical History:
-Metastatic Breast Cancer

Oncologic History:
- [**8-3**] - initially diagnosed after finding breast lump
- [**8-3**] - s/p partial mastectomy and lymph node dissection in
[**8-3**] with negative nodes and clean margins
- [**12-3**] - s/p radiation therapy
- initially declined chemotherapy in [**2176**]
- [**3-5**] - found to have breast cancer metastatic to liver with
associated ascites
- [**Date range (1) 66166**] - received 5 cycles taxotere and cytoxan; 6th cycle
taxotere only due to bladder irritation related to cytoxan;
excellent response to chemotherapy
- [**8-5**] - started on xeloda for maintenance
- [**5-6**] - progression of hepatic and peritoneal disease, started
on doxil
- [**7-6**] - started clinical trial with cisplatin and PARP
inhibitor for metastatic triple negative breast cancer;
unfortunately she had to withdraw from the study due to
thrombocytopenia
- [**10-6**] - started weekly taxotere

Social History:
Lives with her husband and 2 daughters. Former [**Company 378**] consultant,
business owner.  5pkyr history, quit

Family History:
Father - died at age 63 from CVA
Mother - Glaucoma

Physical Exam:
Vitals: T: 99.3  BP: 101/46 P: 154 R: 17 O2: 95% RA
General: Alert, oriented, mildly uncomfortable
HEENT: Pale conjunctive, dry mucous membranes.
Neck: supple, JVP not elevated, no LAD
Lungs: Occasional wheezes, otherwise clear to auscultation
bilaterally
CV: S1 & S2 rapid without appreciable murmur, difficult given
rate.  Hickman on R Subclavian with mild erythema surrounding
line insertion.
Abdomen:  tight and distended, nontender, bowel sounds present.
No masses palpable. No hepatosplenomegaly, but difficult given
tight abdomen.
GU: foley & R femoral line in place
Ext: warm, well perfused, 2+ pulses, no edema

At discharge:
VSS, afebrile
Gen: in chair, NAD
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, tender to deep palpation in the RUQ and mid
periumbilical area, no rebound or guarding, mildly distended. NL
BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-31**]+
reflexes,equal BL. Normal coordination. Gait assessment deferred

PSYCH: Listens and responds to questions appropriately, pleasant


Pertinent Results:
[**2180-11-18**] 08:44PM   LACTATE-7.6*
[**2180-11-18**] 08:20PM   GLUCOSE-211* UREA N-36* CREAT-1.1 SODIUM-137
POTASSIUM-3.0* CHLORIDE-98 TOTAL CO2-21* ANION GAP-21*
[**2180-11-18**] 08:20PM   ALT(SGPT)-20 AST(SGOT)-33 LD(LDH)-527*
CK(CPK)-43 ALK PHOS-753* TOT BILI-0.7
[**2180-11-18**] 08:20PM   LIPASE-8 GGT-72*
[**2180-11-18**] 08:20PM   CK-MB-1 cTropnT-<0.01
[**2180-11-18**] 08:20PM   CALCIUM-7.6* PHOSPHATE-2.5* MAGNESIUM-1.7
[**2180-11-18**] 08:20PM   WBC-13.6* RBC-2.79* HGB-9.1* HCT-26.4* MCV-95
MCH-32.6* MCHC-34.4 RDW-17.2*
[**2180-11-18**] 08:20PM   NEUTS-95* BANDS-1 LYMPHS-4* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2180-11-18**] 08:20PM   HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL ENVELOP-1+
[**2180-11-18**] 08:20PM   PLT COUNT-86*
[**2180-11-17**] 02:00PM   WBC-14.7*# RBC-2.68* HGB-8.7* HCT-25.5*
MCV-95 MCH-32.3* MCHC-33.9 RDW-16.7*
[**2180-11-17**] 02:00PM   PLT SMR-LOW PLT COUNT-94*#
[**2180-11-17**] 02:00PM   PT-14.9* PTT-35.0 INR(PT)-1.3*
[**2180-11-17**] 02:00PM   GRAN CT-[**Numeric Identifier 16227**]*
[**2180-11-21**] 07:35AM BLOOD WBC-25.4* RBC-3.12* Hgb-9.6* Hct-27.6*
MCV-89 MCH-30.7 MCHC-34.7 RDW-17.4* Plt Ct-24*
[**2180-11-20**] 03:02AM BLOOD Neuts-93* Bands-2 Lymphs-1* Monos-2 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-1*
[**2180-11-20**] 03:02AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Schisto-OCCASIONAL Bite-OCCASIONAL
[**2180-11-21**] 06:15PM BLOOD Plt Ct-61*#
[**2180-11-21**] 07:35AM BLOOD Glucose-185* UreaN-23* Creat-0.6 Na-137
K-2.9* Cl-107 HCO3-22 AnGap-11
[**2180-11-21**] 07:35AM BLOOD ALT-22 AST-24 AlkPhos-169* TotBili-0.6
[**2180-11-21**] 07:35AM BLOOD Calcium-6.9* Phos-1.6* Mg-2.1
[**2180-11-20**] 05:39AM BLOOD Type-ART pH-7.43
.
CT CHEST/ABDOMEN AND PELVIS [**2180-11-19**]


IMPRESSION:
1. Progression of metastatic disease involving the left pelvic
serosal
implant as well as right abdominal omental caking.
2. Worsening large bowel obstruction, with transition point in
the sigmoid
colon at the region of serosal implant.
3. Decrease in omental caking within the left mid and left
anterior abdomen.
4. Interval decrease in size of hepatic lesion.

Using son[**Name (NI) 493**] guidance, an appropriate spot for paracentesis
was selected in the right lower quadrant, and the skin was
marked. The skin was prepped and draped in the usual sterile
fashion. 1% buffered local lidocaine was administered. A 5
French [**Last Name (un) 11097**] catheter was inserted into the peritoneal cavity and
2.8 liters of brown fluid was removed

Abdominal ultrasound:
1. Liver vessels patent.
2. Distended gallbladder with small amount of pericholecystic
fluid.
3. Liver lesion seen on recent CT are not demonstrated well on
this study,
due to difference in technique, and the patient unable to
cooperate

Labs at discharge:
WBC   RBC   Hgb  Hct  MCV MCH  MCHC RDW  Plt Ct
25.4* 3.19* 9.7* 29.0* 91 30.6 33.5 17.3* 69*

PT 13.11   PTT 31.5     INR 1.1

Glucose UreaN Creat Na  K    Cl  HCO3 AnGap
  153*    19   0.6 139 3.2* 110*  22   10

Albumin Calcium Phos Mg
  2.1*   6.7*   2.0* 2.0

Blood Culture, Routine (Final [**2180-11-22**]):
      CITROBACTER FREUNDII COMPLEX.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 66167**]
         [**2180-11-18**].
      ENTEROBACTER GERGOVIAE.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
286-0135K
         [**2180-11-18**].

[**2180-11-19**] 11:30 am BLOOD CULTURE

   Blood Culture, Routine (Pending)










Brief Hospital Course:
A 53 year old lady with metastatic breast CA currently between
chemo cycles presenting with sepsis of indeterminate source.
.
1) Septic Shock: Mrs. [**Known lastname 1022**] [**Last Name (NamePattern1) 66168**] hypotensive, tachycardic
with leukocytosis on multiple pressors with likely sources
including Hickman catheter infection (Bacterial or fungal given
TPN); secondary or spontaneous bacterial peritonitis given
recent tap, without fluid to be sent.  Initially received vanc,
zosyn, fluconazole.  Received crystalloid and blood fluid
rescussiation.  Levophed and dopamine were needed for pressor
support, and were successfully weaned.  It was decided to
administer stress dose hydrocortisone given chronic
dexamethasone.  The indwelling port was thought to be the nidus
of her infection.  Initial cultures eventually grew out
citrobacter and enterobacter.  The patient defervesced and was
transferred to the floor, where she continued to improve.  Her
primary oncologist had a discussion regarding removal of Hickman
catheter, and given the direction of care towards comfort, it
was decided not to remove the port but to treat through it.  The
patient received a gentamicin lock at the time of discharge for
additional anti-microbial therapy.
.
2) Metabolic/Lactic Acidosis: The patient's lactate was elevated
initially from hypoperfusion which improved with blood pressure
and fluid support.
.
3) Anemia, thrombocytopenia: At recent baseline.  Patient showed
good response to blood transfusion.
.
4) Metastatic Breast Ca: The patient has chronic/constant pain
but otherwise no active issues.  She also has an obstructive
bowel mass preventing any PO intake.  Fentanyl Tp and Oxycodone
home regimen were used for pain control.
.

Medications on Admission:
Senna 8.6 mg PO BID PRN
Colace 100mg PO BID
Megestrol 40mg/mL PO daily
Caltrate-600 Plus Vitamin D3 600-400 mg-unit PO BID
Fentanyl 100 mcg/hr Patch Q72hr
Oxycodone 20-30mg PO Q3prn Pain

Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Morphine Concentrate 20 mg/mL Solution Sig: [**5-17**] ml PO q1-2
as needed for pain, shortness of breath.
Disp:*1 bottle* Refills:*2*
4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) patch
Transdermal once a day.
Disp:*10 patches* Refills:*0*
5. Ciprofloxacin 500 mg/5 mL Suspension, Microcapsule Recon Sig:
Five (5) Suspension, Microcapsule Recon PO every twelve (12)
hours for 14 days.
Disp:*140 Suspension, Microcapsule Recon(s)* Refills:*0*
6. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**12-31**] Tablet, Rapid
Dissolves PO every eight (8) hours.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 3005**] Hospice

Discharge Diagnosis:
Primary
Gram Negative Bacteremia
.
Secondary
Breast Cancer


Discharge Condition:
stable, afebrile


Discharge Instructions:
You were admitted to the hospital because you were having
fevers. You were found to have an infection in your blood stream
which was treated with antibiotics. You were found to have a low
platelet numbers so you received a platelet infusion.
.
We are discharging you on an antibiotic called ciprofloxacin.
Please take 5mL of this liquid medication twice daily for 14
days.
.
Please return to the hospital or call your doctor if you
experience any nausea, diarrhea, headache, fever, chills,
constipation, light headedness, blurry vision, abdominal pain,
bleeding, changes in your bowel movements of any other symptoms
that are concerning to you.


Followup Instructions:
MD follow up needed
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2180-11-27**] 12:00
Provider: [**Name10 (NameIs) 17246**] [**Name11 (NameIs) **], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2180-11-28**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4285**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2180-12-1**] 11:00
{'Other and unspecified infection due to central venous catheter,Bacteremia,Shock, unspecified,Malignant neoplasm of liver, secondary,Other ascites,Acidosis,Malignant pleural effusion,Thrombocytopenia, unspecified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of malignant neoplasm of breast,Anemia, unspecified,Neoplasm related pain (acute) (chronic),Nausea alone'}


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: Chills

PRESENT ILLNESS: A 53 year old lady with metastatic breast CA 9 weeks s/p Chemo
presented to the ED after experiencing chills the evening prior
to admission after starting the day's TPN.  She then later
developed a fever to 101.9 and was recommended to come to the ED
by the oncologist on call.
.
In the ED, initial vs were: 101.4 165 82/43 18 97%RA Patient was
given 5-6 L NS; Vancomycin, Zosyn, Fluconazole and a femoral
line was placed.  She also received Toradol for pain control.
Given her hypotension, she was started on Norepinephrine,
Dopamine and Phenylephrine and Dexamethasone for blood pressure
support.  Her respiratory and mental statuses remained
uncompromised.
.
Of note, the patient had a R hickman placed 2 weeks prior to
initate TPN.  She is also 1 day s/p therapeutic paracentesis
with "many" bottles of fluid removed.
.
On the floor, the patient appears pale and mildy uncomfortable
and reports generalized pain.  She denies dyspnea, chest pain,
line pain or abdominal pain, and reports that her belly is
softer after paracentesis. She denies any cough, sinus pain,
congestion.  She is not chilled at this time. The patient
reports chronic constipation with 5 episodes of non-bloody
diarrhea the day prior to admission; all secondary to an
obstructive colonic mass.

MEDICAL HISTORY: -Metastatic Breast Cancer

MEDICATION ON ADMISSION: Senna 8.6 mg PO BID PRN
Colace 100mg PO BID
Megestrol 40mg/mL PO daily
Caltrate-600 Plus Vitamin D3 600-400 mg-unit PO BID
Fentanyl 100 mcg/hr Patch Q72hr
Oxycodone 20-30mg PO Q3prn Pain

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 99.3  BP: 101/46 P: 154 R: 17 O2: 95% RA
General: Alert, oriented, mildly uncomfortable
HEENT: Pale conjunctive, dry mucous membranes.
Neck: supple, JVP not elevated, no LAD
Lungs: Occasional wheezes, otherwise clear to auscultation
bilaterally
CV: S1 & S2 rapid without appreciable murmur, difficult given
rate.  Hickman on R Subclavian with mild erythema surrounding
line insertion.
Abdomen:  tight and distended, nontender, bowel sounds present.
No masses palpable. No hepatosplenomegaly, but difficult given
tight abdomen.
GU: foley & R femoral line in place
Ext: warm, well perfused, 2+ pulses, no edema

FAMILY HISTORY: Father - died at age 63 from CVA
Mother - Glaucoma

SOCIAL HISTORY: Lives with her husband and 2 daughters. Former [**Company 378**] consultant,
business owner.  5pkyr history, quit 

### Response:
{'Other and unspecified infection due to central venous catheter,Bacteremia,Shock, unspecified,Malignant neoplasm of liver, secondary,Other ascites,Acidosis,Malignant pleural effusion,Thrombocytopenia, unspecified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of malignant neoplasm of breast,Anemia, unspecified,Neoplasm related pain (acute) (chronic),Nausea alone'}
