CHIEF COMPLAINT: cholangitis

PRESENT ILLNESS: 83M with COPD, Waldenstrom's presented to OSH on [**2-26**] with
abdominal pain and distension as well as LE edema.

MEDICAL HISTORY: COPD with "severe bullous disease"
Waldenstrom's macroglobulinemia
Paget's disease
Temporal arteritis
s/p cholecystectomy [**72**] years ago
h/o PUD
s/p gastrectomy, s/p hand surgery

MEDICATION ON ADMISSION: Medications at home:
Lasix 20 mg daily
Fosamax 70 mg qweek
Spiriva daily
Albuterol inhalations prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T36.9C P 82 BP 95/46 CVP 15 PA 67/32 RR 27 O2 96% on FiO2 50%
General Elderly man in no acute distress
HEENT Sclera anicteric, conjunctiva pink, ET and NGT in place
Neck No JVD
Pulm Lungs with few crackles at left base and decreased breath
sounds right base
CV Regular rate S1 S2 no m/r/g
Abd Soft, mild discomfort right abdomen without rigidity or
guarding, no masses appreciated
Extrem Legs warm with tr bilateral pitting edema
Neuro Alert awake and communicative via head movements and hand
gestures
Derm No jaundice
Lines/tubes/drains R PA line, foley

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Lives alone but daughter lives in downstairs apt. Former 60 pack
year h/o smoking. Occ EtoH.
Other septicemia due to gram-negative organisms,Cholangitis,Septic shock,Other pulmonary insufficiency, not elsewhere classified,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Disseminated candidiasis,Defibrination syndrome,Primary pulmonary hypertension,Subendocardial infarction, initial episode of care,Calculus of bile duct without mention of cholecystitis, without mention of obstruction,Severe sepsis,Encounter for palliative care,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Infection with microorganisms resistant to penicillins,Anemia, unspecified,Hypocalcemia
Gram-neg septicemia NEC,Cholangitis,Septic shock,Other pulmonary insuff,Gastrointest hemorr NOS,Acute kidney failure NOS,Disseminated candidiasis,Defibrination syndrome,Prim pulm hypertension,Subendo infarct, initial,Choledocholithiasis NOS,Severe sepsis,Encountr palliative care,Chr airway obstruct NEC,Crnry athrscl natve vssl,Inf mcrg rstn pncllins,Anemia NOS,Hypocalcemia
Admission Date:  [**2145-3-12**]              Discharge Date:   [**2145-3-18**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
cholangitis

Major Surgical or Invasive Procedure:
endotracheal intubation
central line placement
ERCP

History of Present Illness:
83M with COPD, Waldenstrom's presented to OSH on [**2-26**] with
abdominal pain and distension as well as LE edema.

His hospital course was notable for hypoxia and hypotension on
[**2-28**] in the setting of blood transfusion, with Klebsiella
pneumoniae in [**5-14**] blood culture bottles. He was noted to have
guiac positive stools. He was empirically treated with
levofloxacin and flagyl. He did experience an elevation of his
cardiac enzymes thought c/w NSTEMI vs demand ischemia; this was
medically treated with beta blocker/ASA/statin. A RUQ ultrasound
was obtained on [**2-27**] which showed dilatation of the CBD with
stones.

ERCP was delayed until [**3-11**] as he was not felt to be stable
enough for the procedure prior to that time. At ERCP, the CBD
was cannulated with pancreatogram showing distal filling defects
c/w stones. He became hypotensive to the 70's and hypoxic to the
70's during the procedure. Subsequently he was intubated and
transferred to the CCU. His antibiotics were changed to
vancomycin and Zosyn per the OSH ID consultant's
recommendations.

He was transferred to [**Hospital1 18**] on [**3-12**] for ERCP and further
management of his biliary sepsis. Current vent settings AC
400x20, PEEP 5, FiO2 0.5.

Currently c/o mild right sided abd pain.

Past Medical History:
COPD with "severe bullous disease"
Waldenstrom's macroglobulinemia
Paget's disease
Temporal arteritis
s/p cholecystectomy [**72**] years ago
h/o PUD
s/p gastrectomy, s/p hand surgery

Social History:
Lives alone but daughter lives in downstairs apt. Former 60 pack
year h/o smoking. Occ EtoH.

Family History:
noncontributory

Physical Exam:
T36.9C P 82 BP 95/46 CVP 15 PA 67/32 RR 27 O2 96% on FiO2 50%
General Elderly man in no acute distress
HEENT Sclera anicteric, conjunctiva pink, ET and NGT in place
Neck No JVD
Pulm Lungs with few crackles at left base and decreased breath
sounds right base
CV Regular rate S1 S2 no m/r/g
Abd Soft, mild discomfort right abdomen without rigidity or
guarding, no masses appreciated
Extrem Legs warm with tr bilateral pitting edema
Neuro Alert awake and communicative via head movements and hand
gestures
Derm No jaundice
Lines/tubes/drains R PA line, foley

Pertinent Results:
[**Hospital1 18**] labs
[**3-12**]
Chem 146/3.5/116/19/19/1.5<104 Ca 6.5 Mag 2.2 Phos 3.0 Alb
pending
CK 41 MB pending Tropn pending
ALT 29 AST 67 ALKP 167 Tbil 0.8 [**Doctor First Name **] 130 Lip 39
pro-BNP pending
CBC 5.5>8.9/28.7<176 N 83.1 L 11.9 M 4.6 E 0.2 Baso 0.1
INR 1.7 PTT 18.8
ABG 7.28/43/89/21/-6 on PSV 31x390 PEEP 5
lactate 0.8
.
[**Hospital3 **] labs (select)
[**3-12**]
WBC 6.9, Hb/Hct 8.9/28.8, Plts 162
Na 145 K 3.9 Cl 114 Co2 19 Bun 19 Cr 1.7 (Cr 1.3 on [**3-11**].4 on
[**2-26**])
Mg 1.9 Phos 2.1
PT 1.9, PTT 37.8
ALT 47, AST 126, ALKP 205, Tbil 0.6, Dbil 0.2,
amylase 131, lipase 73, alb 2.8, tprot 7.1
ABG 7.29/42/92/21 on FiO2 0.5
[**2-28**] CK 241 MB 8.6 Tropn 7.41 (peaks, on [**3-12**] CK 48 MB 2.6 Tropn
0.06)
[**2-27**] lactate 0.9
[**3-12**] UA 1.013 5.0 leuk- nitr- blood 3+, [**3-16**] wbc, 50-100 rbc
.
.
MICRO
[**Hospital1 18**]
[**3-16**] catheter tip cx negative
[**3-13**] sputum >25 polys cx with MRSA
2/1,2/4,2/5,[**3-17**] blood cx NGTD
[**3-12**] blood a line *** [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) **] ***
[**3-12**] urine cx negative
.
[**Hospital3 **]
[**3-12**] sputum >25 polys, "many" GPCs on gram MRSA
[**3-12**] urine cx NGTD
[**3-12**] blood cx [**3-13**] NGTD
[**3-10**] blood cx [**2-10**] GPC in clusters
[**3-7**] blood cx NGTD
[**3-6**] C diff negative
[**3-3**] blood cx no growth
[**2-28**] sputum no polys, few bacteria on gram, rare growth oral
flora
***** [**2-28**] blood cx [**5-14**] Klebsiella pneumoniae *****
S to augmentin, unasyn, cefazolin, cipro, gent, levo, zosyn,
bactrim; I to amp, tetracycline
[**2-27**] urine cx <10k skin flora
[**2-27**] strep pneumoniae urinary antigen negative, legionella
urinary antigen negative
.
[**3-13**] ERCP report
Impression: 1. Short Billroth II segment
2. The major papilla was noted to be bulging.
3. Successful cannulation of the biliary duct was performed with
a sphincterotome using a free-hand technique.
4. Cholangiogram showed multiple large filling defects
consistent with stones in the CBD.
5. Successful placement of a 7cm by 7Fr Cotton [**Doctor Last Name **] biliary
stent, with draiange of dark, infected looking bile.
.
[**3-15**] TTE
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF >55%) The
right ventricular cavity is moderately dilated with moderate
global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Right ventricular cavity enlargement with free wall
hypokinesis. Pulmonary artery systolic hypertension. Normal left
ventricular cavity size and systolic function.
This constellation of findings is suggestive of a primary
pulmoanry process (COPD, pulmonary embolism, etc.).
.
[**3-18**] CXR
Minimal interval improvement in pulmonary edema is noted with
unchanged left retrocardiac atelectasis and bilateral pleural
effusions. Borderline cardiomegaly is stable.
IMPRESSION: Slight improvement in pulmonary edema still
accompanied by large bilateral pleural effusions. Left
retrocardiac atelectasis.
Most likely underlying emphysema.

Brief Hospital Course:
1. Biliary sepsis with Klebsiella bacteremia
The patient was transferred to [**Hospital1 18**] on [**3-12**] for planned ERCP. He
was continued on vancomycin and zosyn for coverage of the
Klebsiella and MRSA isolated at the OSH. His dopamine was weaned
off, but by [**3-13**] he again required pressor support despite
aggressive fluid resuscitation so he was started on levophed. He
underwent the planned ERCP on [**3-13**] with stenting of the biliary
duct and drainage of dark bile. Subsequent to the ERCP he
required additional ventilatory support and addition of
vasopressin for additional blood pressure support. He was
started on Xigris on [**3-14**] which was initially complicated by some
hematuria and heme positive stools. Xigris was discontinued by
[**3-15**] in anticipation of central line change.

By [**3-17**] he developed grossly bloody stools. Labs on [**3-18**] showed
evidence of low level DIC. After discussion with the family
regarding the patient's extremely poor prognosis in setting of
respiratory failure, candidemia, cholangitis, and transfusion
dependent GI bleed the decision was made to make the patient
CMO. He was extubated and pressors were discontinued. He died at
6:18pm on [**2145-3-18**].

2. Candidemia (non-albicans)
The patient's blood culture drawn on [**3-12**] from the arterial line
placed at the OSH grew C. [**Month/Day (4) 29361**]. He was empirically started
on caspofungin on [**3-16**] when this positive result returned.
Opthalmology exam showed no evidence of fungal retinitis.

3. Respiratory failure, ARDS
The patient remained ventilatory dependent during his
hospitalization with P/F ratios less than 200 and bilateral
infiltrates c/w ARDS.

4. Gastrointestinal bleeding
GI bleeding as above. The GI service was consulted and offered
to perform EGD to evaluate for source of bleeding. The family
declined the procedure given the patient's extremely poor
prognosis by the time gross GI bleeding had developed.

5. Acute renal failure
The patient's creatinine remained essentially stable at 1.8
above his recent baseline, with elevation thought likely due to
ATN in setting of hypotension.

6. COPD
We continued the patient on his bronchodilators.

7. CAD
By report he had a NSTEMI versus demand ischemia at the OSH
prior to transfer. His troponin was mildly elevated at admission
but remained flat on serial check. EKG showed diffuse T wave
inversions. Echocardiogram showed RV free wall HK c/w prior
infarct.

8. Pulmonary hypertension
The patient underwent a brief trial of sildenafil to assess
whether this would improve cardiac output, but BP did not
tolerate the trial.

Medications on Admission:
Medications at home:
Lasix 20 mg daily
Fosamax 70 mg qweek
Spiriva daily
Albuterol inhalations prn

Medications on Tx:
levofloxacin/Flagyl ([**Date range (2) 95072**])
Vancomycin 1g IV daily
Zosyn 2.25g IV q6
Dopamine
Lipitor 20mg QHS
Combivent q6
Nexium 40 daily

Discharge Medications:
n/a

Discharge Disposition:
Expired

Discharge Diagnosis:
primary
1. cholangitis
2. septic shock
3. ARDS
4. gastrointestinal bleeding
5. acute renal failure
6. fungemia
7. coagulopathy suspected DIC
secondary
1. pulmonary hypertension
2. CAD s/p NSTEMI

Discharge Condition:
deceased

Discharge Instructions:
n/a

Followup Instructions:
n/a

                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Other septicemia due to gram-negative organisms,Cholangitis,Septic shock,Other pulmonary insufficiency, not elsewhere classified,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Disseminated candidiasis,Defibrination syndrome,Primary pulmonary hypertension,Subendocardial infarction, initial episode of care,Calculus of bile duct without mention of cholecystitis, without mention of obstruction,Severe sepsis,Encounter for palliative care,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Infection with microorganisms resistant to penicillins,Anemia, unspecified,Hypocalcemia'}


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: cholangitis

PRESENT ILLNESS: 83M with COPD, Waldenstrom's presented to OSH on [**2-26**] with
abdominal pain and distension as well as LE edema.

MEDICAL HISTORY: COPD with "severe bullous disease"
Waldenstrom's macroglobulinemia
Paget's disease
Temporal arteritis
s/p cholecystectomy [**72**] years ago
h/o PUD
s/p gastrectomy, s/p hand surgery

MEDICATION ON ADMISSION: Medications at home:
Lasix 20 mg daily
Fosamax 70 mg qweek
Spiriva daily
Albuterol inhalations prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T36.9C P 82 BP 95/46 CVP 15 PA 67/32 RR 27 O2 96% on FiO2 50%
General Elderly man in no acute distress
HEENT Sclera anicteric, conjunctiva pink, ET and NGT in place
Neck No JVD
Pulm Lungs with few crackles at left base and decreased breath
sounds right base
CV Regular rate S1 S2 no m/r/g
Abd Soft, mild discomfort right abdomen without rigidity or
guarding, no masses appreciated
Extrem Legs warm with tr bilateral pitting edema
Neuro Alert awake and communicative via head movements and hand
gestures
Derm No jaundice
Lines/tubes/drains R PA line, foley

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Lives alone but daughter lives in downstairs apt. Former 60 pack
year h/o smoking. Occ EtoH. 

### Response:
{'Other septicemia due to gram-negative organisms,Cholangitis,Septic shock,Other pulmonary insufficiency, not elsewhere classified,Hemorrhage of gastrointestinal tract, unspecified,Acute kidney failure, unspecified,Disseminated candidiasis,Defibrination syndrome,Primary pulmonary hypertension,Subendocardial infarction, initial episode of care,Calculus of bile duct without mention of cholecystitis, without mention of obstruction,Severe sepsis,Encounter for palliative care,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Infection with microorganisms resistant to penicillins,Anemia, unspecified,Hypocalcemia'}
