CHIEF COMPLAINT: biliary sepsis

PRESENT ILLNESS: Mr. [**Known lastname 7518**] is 87M with history of Alzheimer's disease who
initially presented to [**Hospital3 **] on 8.18 with complaints
of N/V, abdominal pain, and RUQ discomfort.  The patient reports
that day before presentation he developed abdominal cramping
pain.  Reports that the pain started after he ate breakfast;
initially thought that his pain was due to eating.  Reports that
the pain was primarily on the R side of abdomen, reports that it
self resolved.  However, as per the patient's family, his
primary reason for going to the hospital was because he was
having nausea and vomit; cream colored vomitus, no blood or
[**Hospital3 **].

MEDICAL HISTORY: Alzheimer's disease
prostate cancer
pulmonary fibrosis
diabetes
hyperlipidemia
gastric ulcers

MEDICATION ON ADMISSION: MEDICATIONS FROM [**Hospital3 **]
Heparin 5000 SQ Q8H
Phenylephrine drip
Cipro 200 IV Q12H
Flagyl 500 IV Q6H
Tylenol 1000 Q6H PRN
Dilaudid 0.5 mg IV Q6H PRN
Atropine 1mg IV PRN
Milk of Magnesia QD PRN
Nitrostat 0.4 mg SL PRN
Duonebs Q6H PRN
D51/2NS + 40 meq KCl

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMITTING EXAM
Vitals: 71 113/42  13  98% RA (phenylephrine dc'd x>3h)
General: Alert, oriented to person only, NAD, laying comfortably
in bed, some delayed speech, slight Parkinsonian facies
Skin: notable for slight jaundice
HEENT: slight scleral icterus, MMM, oropharynx clear, EOMI,
PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, + systolic murmur,
no rubs, gallops
Lungs: crackles bilateral bases, otherwise clear to auscultation
no wheezes, rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: denies

SOCIAL HISTORY: The patient reports that he lives with his wife.
Calculus of bile duct without mention of cholecystitis, without mention of obstruction,Unspecified septicemia,Sepsis,Cholangitis,Acute cholecystitis,Alzheimer's disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Postinflammatory pulmonary fibrosis,Diverticulosis of small intestine (without mention of hemorrhage),Malignant neoplasm of prostate,Dementia in conditions classified elsewhere without behavioral disturbance,Abnormal coagulation profile
Choledocholithiasis NOS,Septicemia NOS,Sepsis,Cholangitis,Acute cholecystitis,Alzheimer's disease,DMII wo cmp nt st uncntr,Hyperlipidemia NEC/NOS,Postinflam pulm fibrosis,Dvrtclo sml int w/o hmrg,Malign neopl prostate,Dementia w/o behav dist,Abnrml coagultion prfile
Admission Date:  [**2185-9-25**]              Discharge Date:   [**2185-9-26**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
biliary sepsis

Major Surgical or Invasive Procedure:
ERCP ([**2185-9-25**])


History of Present Illness:
Mr. [**Known lastname 7518**] is 87M with history of Alzheimer's disease who
initially presented to [**Hospital3 **] on 8.18 with complaints
of N/V, abdominal pain, and RUQ discomfort.  The patient reports
that day before presentation he developed abdominal cramping
pain.  Reports that the pain started after he ate breakfast;
initially thought that his pain was due to eating.  Reports that
the pain was primarily on the R side of abdomen, reports that it
self resolved.  However, as per the patient's family, his
primary reason for going to the hospital was because he was
having nausea and vomit; cream colored vomitus, no blood or
[**Hospital3 **].

As [**First Name8 (NamePattern2) **] [**Hospital1 **] outside records, patient was recently hospitalized
08.08-08.12 with epigastric pain.  He underwent nuclear stress
testing and EGD  and was diagnosed with gastric ulcers, which
were cauterized. He was discharge to an [**Hospital3 **] facility
on an oral PPI. He was also noted to have nonsustaned vtach in
teh steting of negative nuclear stress test with plan to start a
low dose beta blocker.

As per the patient's family, prior to that admission, he
presented to OSH with abdominal pain, bloating, and increased
belching was noted to have elevated LFTs. As per the family, the
patient was treated for sepsis which was thought to be from a
pulmonary source.

Of note, the patient's daughter reports that he is more altered
than his baseline; reports that this mental status has been off
for the last two weeks.

While at [**Hospital1 **], labs were notable for a total bili of 2.0, with
transaminases in the 900s.  CT showed evidence of distended
gallbladder and e/o GB stones; no biliary dilation was noted.
As per report, the patient had temperature of [**Age over 90 **] yesterday, and
overnight developed hypotension and started on neo 20 mcg,
prompting him for transfer to [**Hospital1 18**] for ERCP.  While at [**Hospital1 **],
the patient received Vancomycin, Cipro/Flagyl.  The plan is to
transfer him back to [**Hospital1 **] tomorrow post procedure for
laparascopic cholecystectomy.

On arrival to the MICU, patient's VS: 99/46 HR 79 17 97% on RA.
The patient reports feeling well, no acute complaints.  Denies
having any current abdominal pain.  Denies any nausea or vomit.
Denies any light headedness or dizziness.  Reports feeling very
comfortable.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.


Past Medical History:
Alzheimer's disease
prostate cancer
pulmonary fibrosis
diabetes
hyperlipidemia
gastric ulcers

Medications:
HOME MEDS (as [**First Name8 (NamePattern2) **] [**Hospital1 **] d/c summary, 8.13)
Januvia 100 mg by mouth daily
Lipitor 40 mg by mouth each bedtime
Ferrous sulfate 325 mg by mouth daily
Multivitamin 1 tab by mouth daily
Niaspar thousand milligrams by mouth daily
Prilosec 20 mg by mouth twice daily
Carafate 1 g by mouth 4 times a day
Tylenol 650 mg by mouth every 6 when necessary
Colace 100 mg by mouth daily when necessary
Lopressor 12.5 mg by mouth twice a day(to be held for systolic
blood pressure
less than 100, heart rate less than 50).

MEDS ON TRANSFER
Heparin 5000 SQ Q8H
Phenylephrine drip
Cipro 200 IV Q12H
Flagyl 500 IV Q6H
Tylenol 1000 Q6H PRN
Dilaudid 0.5 mg IV Q6H PRN
Atropine 1mg IV PRN
Milk of Magnesia QD PRN
Nitrostat 0.4 mg SL PRN
Duonebs Q6H PRN
D51/2NS + 40 meq KCl


Social History:
The patient reports that he lives with his wife.

Family History:
denies

Physical Exam:
ADMITTING EXAM
Vitals: 71 113/42  13  98% RA (phenylephrine dc'd x>3h)
General: Alert, oriented to person only, NAD, laying comfortably
in bed, some delayed speech, slight Parkinsonian facies
Skin: notable for slight jaundice
HEENT: slight scleral icterus, MMM, oropharynx clear, EOMI,
PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, + systolic murmur,
no rubs, gallops
Lungs: crackles bilateral bases, otherwise clear to auscultation
no wheezes, rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

DISCHARGE EXAM
98.1  127/57  70    17   96% ra
General: Alert, oriented, NAD, laying comfortably in bed, some
delayed speech, slight Parkinsonian facies
Skin: notable for slight jaundice
HEENT: slight scleral icterus, MMM, oropharynx clear, EOMI,
PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, + systolic murmur,
no rubs, gallops
Lungs: crackles bilateral bases, otherwise clear to auscultation
no wheezes, rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.


Pertinent Results:
[**2185-9-25**] 12:21PM   GLUCOSE-94 UREA N-15 CREAT-1.0 SODIUM-137
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-26 ANION GAP-9
[**2185-9-25**] 12:21PM   ALT(SGPT)-903* AST(SGOT)-1133* LD(LDH)-320*
ALK PHOS-333* TOT BILI-2.0*
[**2185-9-25**] 12:21PM   ALBUMIN-2.9* CALCIUM-7.4* PHOSPHATE-2.0*
MAGNESIUM-1.4*
[**2185-9-25**] 12:21PM   WBC-22.3* RBC-3.23* HGB-9.6* HCT-28.5* MCV-88
MCH-29.8 MCHC-33.8 RDW-15.0
[**2185-9-25**] 12:21PM   PLT COUNT-161
[**2185-9-25**] 12:21PM   PT-20.3* PTT-48.8* INR(PT)-1.9*

CXR 8.19
Cardiac silhouette is mildly enlarged without
evidence of vascular congestion.  There is prominence of
interstitial
markings, especially at the bases and in the retrocardiac
region.  This is
consistent with the clinical diagnosis of pulmonary fibrosis.
Although not
optimally seen, in the retrocardiac region there is suggestion
of some
bronchiectatic change.

No acute focal pneumonia is appreciated, though this would be
difficult to
exclude in the appropriate clinical setting.

ERCP 8.19
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
One round black stone was extracted successfully using a
balloon. Occlusion cholangiogram revealed no other filling
defects in the biliary tree.
The PD stent was removed with a snare.

Impression: A large periampullary diverticulum was seen causing
distortion of the papilla.
Cannulation of the biliary duct was performed with a
sphincterotome using a free-hand technique. Biliary cannulation
was initially difficult due to the large diverticulum. A PD 5Fr
x 4cm straigth stent was placed in the pancreatic duct to
facilitate cannulation. Biliary cannulation was then successful
Cholangiogram revealed a single 6 mm round stone was seen in the
lower common [**Month/Day/Year **] duct. There was mild post-obstructive
dilation.
Successful biliary sphincterotomy was performed
Successful balloon extraction of a single round black stone from
the CBD.
There was no evidence of additional stones, and the [**Month/Day/Year **] duct
was draining clear [**Last Name (LF) **], [**First Name3 (LF) **] the decision was made not to place a
biliary stent.
The PD stent was then removed
Otherwise normal ERCP to 3rd portion of duodenum.
NOTE: endoscopic images could not be permanently stored in
GCARE.


Recommendations: NPO overnight with aggressive IV hydration with
LR at 200 cc/hr
Cholecystectomy with Dr. [**Last Name (STitle) **] tomorrow or Tuesday depending
on clinical course.
Continue antibiotics for cholecystitis.

Additional notes: FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. Specimens taken for
pathology: none.

MICRO: none

Brief Hospital Course:
MICU COURSE:
87 year old male hx Alzheimer's disease, prostate cancer,
pulmonary fibrosis, presented to OSH with epigastric pain, found
to have choledocholethiasis, transferred here sepsis with
cholangitis picture.

# Choledocholethiasis with cholangitis: Had elevated LFTs,
bilirubin, rising white count and febrile concerning for
infection.  Patient underwent ERCP on 8.19 with stone removal
and sphincterotomy.  Patient was continued on antibiotics from
[**Hospital3 4107**] (IV Vanc, ciprofloxacin, flagyl) as well as IVF
to maintain appropriate urine output.  He was kept NPO.  Patient
was stable after procedure and transferred 8.20 to [**Hospital1 **] for
planned cholecystectomy.

# Sepsis: patient became hypotensive, febrile, with elevated
white count on day of transfer.  Likely [**3-10**] to
choledocholethiasis that has progressed to cholangitis.  Patient
was initially on phenylephrine drip from [**Hospital1 **].  His pressure
were responsive to fluids and the drip was dc'd within an hour
of arrival.  His pressures remained stable throughout his stay
here.  He was continued on broad coverage abx. given biliary
sepsis and concern from gram negative and enterococcus.

# Pulmonary fibrosis: his respiratory status remained stable on
room air.  He was continued on duonebs PRN as per outside
hospital administration record.

# Chest pain: Patient developed positional chest pain after
ERCP.  EKG was unchanged. Was positional, likely
musculoskeletal, and improved with toradol.

Chronic Issues

# Nonsustained Vtach on prior hospitalization: he was apparently
started on lopressor on previous hospitalization for concern for
nonsustained V-tach.  Patient's lopressor was held in the
context of his hypotension.

# Dementia: has significant Alzheimer's dementia at baseline.
Per family, they feel he is at his baseline mental status.

# Diabetes: on januvia per OSH records.  We did finger sticks
and covered him with ISS as needed.

TRANSITIONAL ISSUES

   Patient will need cholecystectomy in [**Hospital1 **].  Patient's
antibiotic regimen will need to be tailored to culture results.
Further management of chronic issues as [**First Name8 (NamePattern2) **] [**Hospital1 **] team.
   Of note, on day of discharge from [**Hospital1 18**] ICU, [**Hospital3 4107**]
staff and his attending surgeon, Dr. [**Last Name (STitle) **] requested that pt
be transferred to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], as it is the policy of [**Hospital1 **] that if a patient has been out of house for >24h, he
must be readmitted through the ED.  Dr. [**Last Name (STitle) **] of the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
was informed of the impending transfer over the phone.

Medications on Admission:
MEDICATIONS FROM [**Hospital3 **]
Heparin 5000 SQ Q8H
Phenylephrine drip
Cipro 200 IV Q12H
Flagyl 500 IV Q6H
Tylenol 1000 Q6H PRN
Dilaudid 0.5 mg IV Q6H PRN
Atropine 1mg IV PRN
Milk of Magnesia QD PRN
Nitrostat 0.4 mg SL PRN
Duonebs Q6H PRN
D51/2NS + 40 meq KCl



Discharge Medications:
MEDICATIONS ON DISCHARGE
Duonebs Q6H PRN
Cipro 200 IV Q12H
Flagyl 500 IV Q6H
Vancomycin 1000 mg IV Q12H
Heparin 5000 SQ Q8H
Tylenol IV PRN


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 **] TCU

Discharge Diagnosis:
Primary: Cholangitis

Secondary: Choledocholithiasis
           Sepsis
           Pulmonary Fibrosis


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure to take care of you at [**Hospital1 18**].  You were
transferred here from [**Hospital3 4107**] for an ERCP.  You were
found to have gallstones and sludge, which were removed.  You
were treated with IV antibiotics and fluids.  You tolerated the
procedure well.  You are being transferred back to [**Hospital1 **] for a cholecystectomy.

Any changes to your medications upon discharge will be addressed
by the [**Hospital3 **] physicians.

Followup Instructions:
Follow-up will be arranged for you by your team assuming your
care at [**Hospital3 **].



Completed by:[**2185-9-26**]
{"Calculus of bile duct without mention of cholecystitis, without mention of obstruction,Unspecified septicemia,Sepsis,Cholangitis,Acute cholecystitis,Alzheimer's disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Postinflammatory pulmonary fibrosis,Diverticulosis of small intestine (without mention of hemorrhage),Malignant neoplasm of prostate,Dementia in conditions classified elsewhere without behavioral disturbance,Abnormal coagulation profile"}


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: biliary sepsis

PRESENT ILLNESS: Mr. [**Known lastname 7518**] is 87M with history of Alzheimer's disease who
initially presented to [**Hospital3 **] on 8.18 with complaints
of N/V, abdominal pain, and RUQ discomfort.  The patient reports
that day before presentation he developed abdominal cramping
pain.  Reports that the pain started after he ate breakfast;
initially thought that his pain was due to eating.  Reports that
the pain was primarily on the R side of abdomen, reports that it
self resolved.  However, as per the patient's family, his
primary reason for going to the hospital was because he was
having nausea and vomit; cream colored vomitus, no blood or
[**Hospital3 **].

MEDICAL HISTORY: Alzheimer's disease
prostate cancer
pulmonary fibrosis
diabetes
hyperlipidemia
gastric ulcers

MEDICATION ON ADMISSION: MEDICATIONS FROM [**Hospital3 **]
Heparin 5000 SQ Q8H
Phenylephrine drip
Cipro 200 IV Q12H
Flagyl 500 IV Q6H
Tylenol 1000 Q6H PRN
Dilaudid 0.5 mg IV Q6H PRN
Atropine 1mg IV PRN
Milk of Magnesia QD PRN
Nitrostat 0.4 mg SL PRN
Duonebs Q6H PRN
D51/2NS + 40 meq KCl

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMITTING EXAM
Vitals: 71 113/42  13  98% RA (phenylephrine dc'd x>3h)
General: Alert, oriented to person only, NAD, laying comfortably
in bed, some delayed speech, slight Parkinsonian facies
Skin: notable for slight jaundice
HEENT: slight scleral icterus, MMM, oropharynx clear, EOMI,
PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, + systolic murmur,
no rubs, gallops
Lungs: crackles bilateral bases, otherwise clear to auscultation
no wheezes, rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: denies

SOCIAL HISTORY: The patient reports that he lives with his wife. 

### Response:
{"Calculus of bile duct without mention of cholecystitis, without mention of obstruction,Unspecified septicemia,Sepsis,Cholangitis,Acute cholecystitis,Alzheimer's disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Postinflammatory pulmonary fibrosis,Diverticulosis of small intestine (without mention of hemorrhage),Malignant neoplasm of prostate,Dementia in conditions classified elsewhere without behavioral disturbance,Abnormal coagulation profile"}
