CHIEF COMPLAINT: Sepsis

PRESENT ILLNESS: This is a very unfortunate 31 yo male who had an initial
diagnosis of metastatic poorly differentiated carcinoma
w/lesions in the gallbladder, biliary tree, and hepatic
metastasis in [**2167-8-26**]. Initial workup demonstrated an
abnormal pancreatic drainage, which
likely lead to the development of his malignancy. Onc felt
gallbladder was primary site.
.
Patient was treated initially w/ 5 cycles of gemcitabine and
cisplatin (last dose [**2168-1-26**]), requiring dose reductions due to
cytopenias. Imaging from [**2-/2168**] showed increased disease. The
patient was switched to Xeloda in [**2168-2-23**] x1, complicated by
ascites and sbp. [**2168-4-24**] CT showed new pulmonary nodules,
increased size and number of multiple hepatic metastasis with
occlusion of the portal vein as well as the superior mesenteric
vein due to lymphadenopathy and worsening ascites. Over his
chemotherapy course, he had evidence of progressive portal
hypertension, esophageal varices, requiring multiple banding and
at least three admissions for upper GI bleeds and hyponatremia.
.
Last admit was [**2168-5-7**] for sepsis and positive blood cultures
w/enterococcus. TEE showed thickening of the aortic valve and
endocarditis. Patient sent to rehab on penicillin and gentamicin
were for four weeks. Onc team has tried to switch patient to
palliative care, but family wants all atempts at treatment and
in fact got a second opinion at [**Hospital1 4601**].  Per onc notes,
[**Hospital1 **] staff have talked to family multiple times about
patients terminal status and expressed that he is atively dying.
 Family wants "more chemotherapy, Liver transplant"
.
At [**Hospital1 **], pain progressed and patient placed on PCA pump. He
has required weekely large volume paracentesis of [**3-30**] liters for
relief.  Over the past week patient has become more obtunded and
had a Na of less than 120.  He also developed worsening renal
failure with a Cr over 5 concerning for hepatorenal syndrome.
.
In the ED, found to be lethargic.  Had diarrhea today for first
time.  Hypotensive to 90/60, responded quickly to 500 cc IVF.
Blood cultures from [**Hospital1 **] were positive for GNR and GPC in
clusters.  He had Cipro and Vanco dosed prior to arrival at ED.
Put on vanc, levo, flagyl, ceftriaxone in the ED.  In the ED got
cx, FFP and paracentesis (diagnostic only).  Started on 1U prbc.
 Abdominal US done, per radiology there is so much tumor they
cannot assess liver or portal vein.  Lab data concerning for wbc
of 33, lactate of 9, INR 2.5, greatly elevated LFTs, Cr of 5.4,
albumin 1.9.
.

MEDICAL HISTORY: Past Medical History:
1. Metastatic GB cancer as above, with mets to liver,
retroperitoneal lymph nodes. With metal stent in CBD.
Complications of esophageal varices, s/p multiple bandings (most

MEDICATION ON ADMISSION: Meds at rehab: Fentanyl patch; Prevacid; Mg Oxide; remeron;
nadolol; Dilauded PCA; cipro; vanco;

ALLERGIES: Bactrim

PHYSICAL EXAM: PE:  98.0 112/60  72  16  100% RA
Gen: Lethargic, cachectic, arousable
HEENT: +scleral icterus, jaundice, mmd, neck supple
CV: rrr 1/6 murmer rusb
Pulm: ant clear, dull at bases
Abd:  + caput madusa, huge ascites w/fluid wave, tender
throughout, more over RUQ. hypoactive bs
Ext: 4+ edema to knees, thin throughout. PICC in place,
non-tender.
Rectal: (Per ED) red blod from visible hemorrhoids mixed w/brown
stool.

FAMILY HISTORY: DM in both parents, no cad, cancer.  10 siblings, none with
cancer

SOCIAL HISTORY: Originially from [**Country **], moved to [**Location (un) **] 5 years ago, worked at
[**7-4**] (not currently). Denies tobacco/etoh (for many
months)/drugs. Lived with his brothers until last admit, at
rehab since then.  Per report, brother is POA.
Unspecified septicemia,Acute kidney failure, unspecified,Malignant neoplasm of liver, secondary,Malignant neoplasm of gallbladder,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Esophageal varices in diseases classified elsewhere, with bleeding,Acute and subacute bacterial endocarditis,Hepatorenal syndrome,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction
Septicemia NOS,Acute kidney failure NOS,Second malig neo liver,Malig neo gallbladder,Mal neo lymph intra-abd,Bleed esoph var oth dis,Ac/subac bact endocard,Hepatorenal syndrome,SIRS-noninf w ac org dys
Admission Date:  [**2168-6-1**]              Discharge Date:   [**2168-6-2**]

Date of Birth:  [**2137-3-18**]             Sex:   M

Service: MEDICINE

Allergies:
Bactrim

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Sepsis

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is a very unfortunate 31 yo male who had an initial
diagnosis of metastatic poorly differentiated carcinoma
w/lesions in the gallbladder, biliary tree, and hepatic
metastasis in [**2167-8-26**]. Initial workup demonstrated an
abnormal pancreatic drainage, which
likely lead to the development of his malignancy. Onc felt
gallbladder was primary site.
.
Patient was treated initially w/ 5 cycles of gemcitabine and
cisplatin (last dose [**2168-1-26**]), requiring dose reductions due to
cytopenias. Imaging from [**2-/2168**] showed increased disease. The
patient was switched to Xeloda in [**2168-2-23**] x1, complicated by
ascites and sbp. [**2168-4-24**] CT showed new pulmonary nodules,
increased size and number of multiple hepatic metastasis with
occlusion of the portal vein as well as the superior mesenteric
vein due to lymphadenopathy and worsening ascites. Over his
chemotherapy course, he had evidence of progressive portal
hypertension, esophageal varices, requiring multiple banding and
at least three admissions for upper GI bleeds and hyponatremia.
.
Last admit was [**2168-5-7**] for sepsis and positive blood cultures
w/enterococcus. TEE showed thickening of the aortic valve and
endocarditis. Patient sent to rehab on penicillin and gentamicin
were for four weeks. Onc team has tried to switch patient to
palliative care, but family wants all atempts at treatment and
in fact got a second opinion at [**Hospital1 4601**].  Per onc notes,
[**Hospital1 **] staff have talked to family multiple times about
patients terminal status and expressed that he is atively dying.
 Family wants "more chemotherapy, Liver transplant"
.
At [**Hospital1 **], pain progressed and patient placed on PCA pump. He
has required weekely large volume paracentesis of [**3-30**] liters for
relief.  Over the past week patient has become more obtunded and
had a Na of less than 120.  He also developed worsening renal
failure with a Cr over 5 concerning for hepatorenal syndrome.
.
In the ED, found to be lethargic.  Had diarrhea today for first
time.  Hypotensive to 90/60, responded quickly to 500 cc IVF.
Blood cultures from [**Hospital1 **] were positive for GNR and GPC in
clusters.  He had Cipro and Vanco dosed prior to arrival at ED.
Put on vanc, levo, flagyl, ceftriaxone in the ED.  In the ED got
cx, FFP and paracentesis (diagnostic only).  Started on 1U prbc.
 Abdominal US done, per radiology there is so much tumor they
cannot assess liver or portal vein.  Lab data concerning for wbc
of 33, lactate of 9, INR 2.5, greatly elevated LFTs, Cr of 5.4,
albumin 1.9.
.


Past Medical History:
Past Medical History:
1. Metastatic GB cancer as above, with mets to liver,
retroperitoneal lymph nodes. With metal stent in CBD.
Complications of esophageal varices, s/p multiple bandings (most

recently [**2168-1-21**]). On Gemcitabine/Cisplatin, last dose [**2168-2-4**].
Most recently received Xeloda x1 [**2-27**].
2. Malaria in past
3. s/p Appendectomy
4. H. Pylori, treated
5. UTI [**2163**]
6. HBV, low viral load, with varices in lower 1/3 esophagus


Social History:
Originially from [**Country **], moved to [**Location (un) **] 5 years ago, worked at
[**7-4**] (not currently). Denies tobacco/etoh (for many
months)/drugs. Lived with his brothers until last admit, at
rehab since then.  Per report, brother is POA.


Family History:
DM in both parents, no cad, cancer.  10 siblings, none with
cancer

Physical Exam:
PE:  98.0 112/60  72  16  100% RA
Gen: Lethargic, cachectic, arousable
HEENT: +scleral icterus, jaundice, mmd, neck supple
CV: rrr 1/6 murmer rusb
Pulm: ant clear, dull at bases
Abd:  + caput madusa, huge ascites w/fluid wave, tender
throughout, more over RUQ. hypoactive bs
Ext: 4+ edema to knees, thin throughout. PICC in place,
non-tender.
Rectal: (Per ED) red blod from visible hemorrhoids mixed w/brown
stool.


Pertinent Results:
CBC:
[**2168-6-1**] 05:20PM BLOOD WBC-33.6*# RBC-3.66* Hgb-8.4* Hct-27.8*
MCV-76* MCH-23.0* MCHC-30.3* RDW-17.9* Plt Ct-165
[**2168-6-2**] 04:30AM BLOOD WBC-26.6* RBC-4.23* Hgb-10.6*# Hct-33.1*
MCV-78* MCH-25.0* MCHC-32.0 RDW-17.7* Plt Ct-125*
[**2168-6-1**] 05:20PM BLOOD Neuts-85* Bands-9* Lymphs-1* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2168-6-1**] 05:20PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-1+ Target-1+
[**2168-6-2**] 04:30AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Burr-2+ Tear
Dr[**Last Name (STitle) 833**]
[**Name (STitle) 2591**]:
[**2168-6-2**] 04:30AM BLOOD Plt Ct-125*
[**2168-6-2**] 04:30AM BLOOD PT-20.6* PTT-39.2* INR(PT)-2.8
[**2168-6-1**] 05:20PM BLOOD PT-18.9* PTT-60.4* INR(PT)-2.4
Chemistries:
[**2168-6-1**] 05:20PM BLOOD Glucose-92 UreaN-68* Creat-5.4*# Na-121*
K-5.6* Cl-86* HCO3-15* AnGap-26*
[**2168-6-2**] 04:30AM BLOOD Glucose-60* UreaN-71* Creat-5.4* Na-122*
K-6.4* Cl-92* HCO3-10* AnGap-26*
Calcium-7.7* Phos-7.2*# Mg-1.7
[**2168-6-2**] 04:30AM BLOOD Calcium-8.1* Phos-8.5* Mg-1.9
[**2168-6-1**] 05:49PM BLOOD Lactate-9.0*
LFTs:
[**2168-6-1**] 05:20PM BLOOD ALT-412* AST-1140* AlkPhos-463*
Amylase-90 TotBili-5.3*
[**2168-6-2**] 04:30AM BLOOD ALT-376* AST-967* LD(LDH)-949*
AlkPhos-464* TotBili-6.2*
[**2168-6-1**] 05:20PM BLOOD Albumin-1.9*

CXR:Left pleural effusion and left lower lobe atelectasis,
improved
since the last examination.
.
RUQ US:Heterogeneous and nodular liver consistent with
metastatic disease.  No definite intrahepatic biliary ductal
dilatation.  Large ascites.


Brief Hospital Course:
1.  Sepsis:  This 31 yo M with poorly differentiated metastatic
GB carcinoma presents with progressive liver failure, acute
renal failure, active GI bleeding, SBP, bacteremia, possible
endocarditis, and profound 3rd spacing.  At presentation he was
in Sepsis with a lactate of 9, the etiology was thought to be
secondary to peritonitis (~400 polys in peritoneal fluid) from
erosions of mets into bowel.  Pt also had diarrhea concerning
for C. diff given recent ABX and severe leukocytosis.  Recent
endocarditis and new bacteremia make it likely patient may have
endocarditis again.  PICC line does not appear infected however
may be source.  On admission his Hypotension was initially
treated with fluid boluses.   He was continued on Vanco dosed by
levels given severe renal failure, ceftaz, levo, and flagyl. IV
hydration was held overnight given the concern for severe third
spacing into his abdomen.  The morning after admission he was
hypotensive and appeared moribund.  He was treated with IV
fluids with no improvement.  His electrolytes were markedly
abnormal.  Several family meetings were held to discuss
prognosis and it was explained that he was extremely ill and
prognosis was extremely poor.  The family and medical team
agreed that CPR was not medically indicated with advanced
carcinoma and organ failurs.  All agreed that comfort was most
important goal.  Care then shifted to primary goal of comfort.
He was started on a PCA for pain control.  He was comfortable
throughout the day.  He developed increased hypotension and
bradycardia.  He passed away at 6:45 PM.  The family members
were present.

2. Renal failure: This was felt to be secondary to hepatorenal
syndrome.  His medications were all renally dosed.  His
electrolytes were markedly abnormal
.
3. GIB:  BRBPR likely secondary to known varices and tumor
eroding through stomach.  Received FFP and 2 units prbc's upon
admission.  His HCT was followed during his admission.

4. Liver failure/possible biliary obstruction: U/S done in the
ED unable to asses portal vein or ducts given extensive tumor
burden as per radiology.  LFTs much worse than prior.  Felt that
he might have portal vein thrombosis.
.
5. Hypervolemic Hyponatremia secondary to liver failure/ascites.
Urine lytes were sent.  He was bolused as needed for
hypotension.
.
6. Pain: He was treated with a Dilaudid PCA which was titrated
up to control his pain.
.
7. Social Work:  Palliative care and social work were involved
to help with end of life issues.
.
8. Communication: There was continual communication with the
patient and his family.  His Brother is the HCP.
.

Medications on Admission:
Meds at rehab: Fentanyl patch; Prevacid; Mg Oxide; remeron;
nadolol; Dilauded PCA; cipro; vanco;


Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
Deceased

Discharge Condition:
Deceased

Discharge Instructions:
none

Followup Instructions:
none

                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
{'Unspecified septicemia,Acute kidney failure, unspecified,Malignant neoplasm of liver, secondary,Malignant neoplasm of gallbladder,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Esophageal varices in diseases classified elsewhere, with bleeding,Acute and subacute bacterial endocarditis,Hepatorenal syndrome,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction'}


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: Sepsis

PRESENT ILLNESS: This is a very unfortunate 31 yo male who had an initial
diagnosis of metastatic poorly differentiated carcinoma
w/lesions in the gallbladder, biliary tree, and hepatic
metastasis in [**2167-8-26**]. Initial workup demonstrated an
abnormal pancreatic drainage, which
likely lead to the development of his malignancy. Onc felt
gallbladder was primary site.
.
Patient was treated initially w/ 5 cycles of gemcitabine and
cisplatin (last dose [**2168-1-26**]), requiring dose reductions due to
cytopenias. Imaging from [**2-/2168**] showed increased disease. The
patient was switched to Xeloda in [**2168-2-23**] x1, complicated by
ascites and sbp. [**2168-4-24**] CT showed new pulmonary nodules,
increased size and number of multiple hepatic metastasis with
occlusion of the portal vein as well as the superior mesenteric
vein due to lymphadenopathy and worsening ascites. Over his
chemotherapy course, he had evidence of progressive portal
hypertension, esophageal varices, requiring multiple banding and
at least three admissions for upper GI bleeds and hyponatremia.
.
Last admit was [**2168-5-7**] for sepsis and positive blood cultures
w/enterococcus. TEE showed thickening of the aortic valve and
endocarditis. Patient sent to rehab on penicillin and gentamicin
were for four weeks. Onc team has tried to switch patient to
palliative care, but family wants all atempts at treatment and
in fact got a second opinion at [**Hospital1 4601**].  Per onc notes,
[**Hospital1 **] staff have talked to family multiple times about
patients terminal status and expressed that he is atively dying.
 Family wants "more chemotherapy, Liver transplant"
.
At [**Hospital1 **], pain progressed and patient placed on PCA pump. He
has required weekely large volume paracentesis of [**3-30**] liters for
relief.  Over the past week patient has become more obtunded and
had a Na of less than 120.  He also developed worsening renal
failure with a Cr over 5 concerning for hepatorenal syndrome.
.
In the ED, found to be lethargic.  Had diarrhea today for first
time.  Hypotensive to 90/60, responded quickly to 500 cc IVF.
Blood cultures from [**Hospital1 **] were positive for GNR and GPC in
clusters.  He had Cipro and Vanco dosed prior to arrival at ED.
Put on vanc, levo, flagyl, ceftriaxone in the ED.  In the ED got
cx, FFP and paracentesis (diagnostic only).  Started on 1U prbc.
 Abdominal US done, per radiology there is so much tumor they
cannot assess liver or portal vein.  Lab data concerning for wbc
of 33, lactate of 9, INR 2.5, greatly elevated LFTs, Cr of 5.4,
albumin 1.9.
.

MEDICAL HISTORY: Past Medical History:
1. Metastatic GB cancer as above, with mets to liver,
retroperitoneal lymph nodes. With metal stent in CBD.
Complications of esophageal varices, s/p multiple bandings (most

MEDICATION ON ADMISSION: Meds at rehab: Fentanyl patch; Prevacid; Mg Oxide; remeron;
nadolol; Dilauded PCA; cipro; vanco;

ALLERGIES: Bactrim

PHYSICAL EXAM: PE:  98.0 112/60  72  16  100% RA
Gen: Lethargic, cachectic, arousable
HEENT: +scleral icterus, jaundice, mmd, neck supple
CV: rrr 1/6 murmer rusb
Pulm: ant clear, dull at bases
Abd:  + caput madusa, huge ascites w/fluid wave, tender
throughout, more over RUQ. hypoactive bs
Ext: 4+ edema to knees, thin throughout. PICC in place,
non-tender.
Rectal: (Per ED) red blod from visible hemorrhoids mixed w/brown
stool.

FAMILY HISTORY: DM in both parents, no cad, cancer.  10 siblings, none with
cancer

SOCIAL HISTORY: Originially from [**Country **], moved to [**Location (un) **] 5 years ago, worked at
[**7-4**] (not currently). Denies tobacco/etoh (for many
months)/drugs. Lived with his brothers until last admit, at
rehab since then.  Per report, brother is POA. 

### Response:
{'Unspecified septicemia,Acute kidney failure, unspecified,Malignant neoplasm of liver, secondary,Malignant neoplasm of gallbladder,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Esophageal varices in diseases classified elsewhere, with bleeding,Acute and subacute bacterial endocarditis,Hepatorenal syndrome,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction'}
