CHIEF COMPLAINT: lethargy

PRESENT ILLNESS: 86 yo female with PMHx of CAD, HTN, TIAs, hyperparathyroidism
on Unasyn at [**Hospital 100**] rehab for acute cholecystitis (no surgery,
cooling down w/ abx), presents with lethary. Patient denies
chest pain or abdominal pain. Patient is able to answer
questions but slow response.
.
In the ED patient was found to be thrombocytopenic and have
elevated WBC, she was also found to be hypercalcemic and was
given IVF. She underwent CTA to rule out PE as patient reporting
some dyspnea and was found to have PE in the R pulmonary artery
and left upper lobe branch. Patient was given vanc/levo/flagyl
for cholecystitis as felt unasyn could be contributing to
thrombocytopenia. She was seen by surgery in the ED who
recommended previous plan to hold off on any type of surgery
until patient more stable.

MEDICAL HISTORY: 1. CAD, NSTEMI '[**10**], treated with PCI and stent of LCx. Most
recent echo [**4-25**] shows LVEF 65% to 70%
2. HTN
3. Type 2 diabetes
4. ?TIA many years ago - from record, but pt does not recall
5. DVT in '[**11**] (LLE) and again in '[**15**] (LUE - no line; thought to

MEDICATION ON ADMISSION: Docusate Sodium 100 mg PO BID
Compazine
Senna 8.6 mg Tablet PO BID
Acetaminophen 325 mg 1-2 Tablets PO Q4-6H prn
Metoprolol Tartrate 25 mg PO TID
Nifedipine 10 mg PO Q8H
Simvastatin 20 mg PO DAILY
Ondansetron 4 mg IV Q8H:PRN
HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3-4H:PRN
Triamterene-Hydrochlorothiazide 37.5-25 mg Capsule Sig: 1-1.5
Caps PO DAILY
Ampicillin-Sulbactam 1-0.5 g q8 until [**2116-6-3**]
Coumadin 1mg qhs
Rosiglitazone 1 mg PO DAILY
Metformin 500mg daily

ALLERGIES: Heparin Agents

PHYSICAL EXAM: Upon arrival to MICU:
T 97.8 HR 96 BP 126/104 RR 24 O2Sat 100% on NRB
Gen: NAD
Heent: [**Last Name (un) **], EOMI, sclera anicteric, OP clear
Lungs: CTA b/l
Cardiac: Irregularly Irregular, no murmurs
Abdomen: obese soft, NT +BS
Ext: no edema
Neuro: Awake and alert

FAMILY HISTORY: Father w/ HTN
No history of clots in the family.

SOCIAL HISTORY: From [**Hospital 100**] Rehab facility, she is a retired epidemiologist. Pt
moved to US in [**2102**].
Tob: none currently, remote 20 pk yr hx.
EtOH: no history of alcohol abuse.
Other pulmonary embolism and infarction,Defibrination syndrome,Atrial fibrillation,Acute cholecystitis,Chronic kidney disease, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Hypercalcemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Secondary hyperparathyroidism (of renal origin),Leukocytosis, unspecified,Anemia, unspecified
Pulm embol/infarct NEC,Defibrination syndrome,Atrial fibrillation,Acute cholecystitis,Chronic kidney dis NOS,Crnry athrscl natve vssl,Status-post ptca,Hypercalcemia,Hy kid NOS w cr kid I-IV,Sec hyperparathyrd-renal,Leukocytosis NOS,Anemia NOS
Admission Date:  [**2116-5-28**]              Discharge Date:   [**2116-5-30**]

Date of Birth:  [**2035-12-31**]             Sex:   F

Service: MEDICINE

Allergies:
Heparin Agents

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
lethargy

Major Surgical or Invasive Procedure:
none

History of Present Illness:
 86 yo female with PMHx of CAD, HTN, TIAs, hyperparathyroidism
on Unasyn at [**Hospital 100**] rehab for acute cholecystitis (no surgery,
cooling down w/ abx), presents with lethary. Patient denies
chest pain or abdominal pain. Patient is able to answer
questions but slow response.
.
In the ED patient was found to be thrombocytopenic and have
elevated WBC, she was also found to be hypercalcemic and was
given IVF. She underwent CTA to rule out PE as patient reporting
some dyspnea and was found to have PE in the R pulmonary artery
and left upper lobe branch. Patient was given vanc/levo/flagyl
for cholecystitis as felt unasyn could be contributing to
thrombocytopenia. She was seen by surgery in the ED who
recommended previous plan to hold off on any type of surgery
until patient more stable.


Past Medical History:

1. CAD, NSTEMI '[**10**], treated with PCI and stent of LCx. Most
recent echo [**4-25**] shows LVEF 65% to 70%
2. HTN
3. Type 2 diabetes
4. ?TIA many years ago - from record, but pt does not recall
5. DVT in '[**11**] (LLE) and again in '[**15**] (LUE - no line; thought to

be [**2-21**] anatomical variant, but did not r/o hypercoagulable
state), now on warfarin
6. Obesity
7. Lower Back Pain
8. Hyperparathyroidism
9. s/p TAH
10. h/o arthritis
11. CKD with Cr 1.0-1.2
12. Lipoma (abdomen)
13. s/p appy
14. Acute Cholecystitis (being treated with Unasyn)
15. H/O hip fracture
16. gall bladder mass
.


Social History:
From [**Hospital 100**] Rehab facility, she is a retired epidemiologist. Pt
moved to US in [**2102**].
Tob: none currently, remote 20 pk yr hx.
EtOH: no history of alcohol abuse.


Family History:
Father w/ HTN
No history of clots in the family.


Physical Exam:
Upon arrival to MICU:
T 97.8 HR 96 BP 126/104 RR 24 O2Sat 100% on NRB
Gen: NAD
Heent: [**Last Name (un) **], EOMI, sclera anicteric, OP clear
Lungs: CTA b/l
Cardiac: Irregularly Irregular, no murmurs
Abdomen: obese soft, NT +BS
Ext: no edema
Neuro: Awake and alert


Pertinent Results:
[**2116-5-28**] 01:15PM   WBC-18.0* RBC-3.63* HGB-10.6* HCT-30.4*
MCV-84 MCH-29.3 MCHC-35.0 RDW-17.7*
[**2116-5-28**] 01:15PM   PLT SMR-VERY LOW PLT COUNT-58*# LPLT-1+
[**2116-5-28**] 01:15PM   NEUTS-86* BANDS-1 LYMPHS-4* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-2* MYELOS-0 NUC RBCS-1*
[**2116-5-28**] 01:15PM   GLUCOSE-257* UREA N-46* CREAT-1.2* SODIUM-137
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
[**2116-5-28**] 01:15PM   ALT(SGPT)-8 AST(SGOT)-23 LD(LDH)-673*
CK(CPK)-59 ALK PHOS-480* AMYLASE-80 TOT BILI-1.9*
[**2116-5-28**] 01:15PM   LIPASE-134*
[**2116-5-28**] 01:15PM   ALBUMIN-3.2* CALCIUM-13.2* PHOSPHATE-2.7
MAGNESIUM-1.7
[**2116-5-28**] 01:15PM   PT-32.4* PTT-35.5* INR(PT)-3.5*

Micro:

Imaging:
[**2116-5-28**] - lower ext ultrasound -  1. Intraluminal thrombus
extending from the left common femoral vein to the popliteal
vein, nonocclusive.
2. Intraluminal thrombus extending from the right superficial
vein distally and possibly to the popliteal vein, also
nonocclusive.

[**2116-5-28**] - CTA chest -
1. Bilateral pulmonary emboli, greatest within the distal right
main pulmonary artery extending into the right upper and right
lower lobes. Small pulmonary embolus within the arteries to the
left upper lobe. Ground-glass opacity and small right pleural
effusion distal to the major portion of pulmonary embolism could
reflect small pulmonary infarction.
2. Prominent, ectatic thoracic aorta.
3. Small intra-aortic thrombus, unchanged by imaging compared to
a CT from [**2116-5-14**].

[**2116-5-29**] - U/S liver - Persistent areas of thickening within the
gallbladder wall, and soft tissue within the lumen, with an
enlarged periportal lymph node. These findings are concerning
for gallbladder carcinoma.


Brief Hospital Course:
80 y/o female with recent diagnosis of acute cholecystitis who
present from [**Hospital **] rehab with dyspnea found to have PE on CTA
and thrombocytopenia.
.
1. PE/DVT and thrombocytopenia: The patient presented with
multiple thrombi in lungs and legs.  She was found to have HIT
type 1 which was thought to be the main driver of the clotting.
Complicating her treatment was her simultaneous DIC which was
felt to be driven by her likely (although never biopsy proven)
locally advanced gallbladder cancer.  The patient was treated
with empiric antibiotics directed at acute cholecystitis but
further imaging was not consistent with active infection or
gallbladder inflammation.  The patient was felt to have both DIC
and HIT as she had a significantly positive PF4 antibody and
evidence of hemolysis and a consumptive coagulopathy.  In
discussions with the patient's family, given that the underlying
DIC cause (i.e. gallbladder cancer) was not treatable and
therapies for the HIT driven thromboembolic disease would put
her at significant risk for bleeding, comfort was made the prime
goal of care.  Over the course of the next day, her consumptive
coagulopathy progressed with resulting oliguria and depressed
mental status.  The patient's condition continued to deteriorate
and she expired in the early morning of [**2116-5-30**].  The family
(son and daughter-in-law) was [**Date Range 653**].  The family declined
autopsy.
.
2. Hypercalcemia - Patient with elevated calcium, appears to
have elevated CA at baseline. Most likely secondary to
hyperparathyroidism as this has been noted in OMR worsened by
the thiazide diuretic.
.
3. Diabetes - BS elevated, will cover patient with RISS
.
4. CAD - Patient with history of fixed defect on stress-MIBI.
- Will hold ASA given thrombocytopenia
- Continue BBlocker and statin once po
.
5. PPx - supratheraputic INR, tylenol, bowel regimin
.
FEN - NPO
.
Code - DNI/DNR, later changed to CMO following extensive
discussions with her next of [**Doctor First Name **] [**Doctor First Name 1975**] [**Known lastname 8024**] and his
wife.
.
Dispo: expired

Medications on Admission:
Docusate Sodium 100 mg PO BID
Compazine
Senna 8.6 mg Tablet PO BID
Acetaminophen 325 mg 1-2 Tablets PO Q4-6H prn
Metoprolol Tartrate 25 mg PO TID
Nifedipine 10 mg PO Q8H
Simvastatin 20 mg PO DAILY
Ondansetron 4 mg IV Q8H:PRN
HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3-4H:PRN
Triamterene-Hydrochlorothiazide 37.5-25 mg Capsule Sig: 1-1.5
Caps PO DAILY
Ampicillin-Sulbactam 1-0.5 g q8 until [**2116-6-3**]
Coumadin 1mg qhs
Rosiglitazone 1 mg PO DAILY
Metformin 500mg daily


Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
Primary:
pulmonary embolism
disseminated intravascular coagulation
heparin induced thrombocytopenia type 1
gall bladder cancer

Secondary:
coronary artery disease
hypertension
Type 2 diabetes mellitus
Deep venous thrombosis
Obesity
Primary Hyperparathyroidism
osteoarthritis
Chronic kidney disease
hip fracture treated with nail placement.


Discharge Condition:
expired

Discharge Instructions:
NA

Followup Instructions:
NA
{'Other pulmonary embolism and infarction,Defibrination syndrome,Atrial fibrillation,Acute cholecystitis,Chronic kidney disease, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Hypercalcemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Secondary hyperparathyroidism (of renal origin),Leukocytosis, unspecified,Anemia, unspecified'}


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: lethargy

PRESENT ILLNESS: 86 yo female with PMHx of CAD, HTN, TIAs, hyperparathyroidism
on Unasyn at [**Hospital 100**] rehab for acute cholecystitis (no surgery,
cooling down w/ abx), presents with lethary. Patient denies
chest pain or abdominal pain. Patient is able to answer
questions but slow response.
.
In the ED patient was found to be thrombocytopenic and have
elevated WBC, she was also found to be hypercalcemic and was
given IVF. She underwent CTA to rule out PE as patient reporting
some dyspnea and was found to have PE in the R pulmonary artery
and left upper lobe branch. Patient was given vanc/levo/flagyl
for cholecystitis as felt unasyn could be contributing to
thrombocytopenia. She was seen by surgery in the ED who
recommended previous plan to hold off on any type of surgery
until patient more stable.

MEDICAL HISTORY: 1. CAD, NSTEMI '[**10**], treated with PCI and stent of LCx. Most
recent echo [**4-25**] shows LVEF 65% to 70%
2. HTN
3. Type 2 diabetes
4. ?TIA many years ago - from record, but pt does not recall
5. DVT in '[**11**] (LLE) and again in '[**15**] (LUE - no line; thought to

MEDICATION ON ADMISSION: Docusate Sodium 100 mg PO BID
Compazine
Senna 8.6 mg Tablet PO BID
Acetaminophen 325 mg 1-2 Tablets PO Q4-6H prn
Metoprolol Tartrate 25 mg PO TID
Nifedipine 10 mg PO Q8H
Simvastatin 20 mg PO DAILY
Ondansetron 4 mg IV Q8H:PRN
HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3-4H:PRN
Triamterene-Hydrochlorothiazide 37.5-25 mg Capsule Sig: 1-1.5
Caps PO DAILY
Ampicillin-Sulbactam 1-0.5 g q8 until [**2116-6-3**]
Coumadin 1mg qhs
Rosiglitazone 1 mg PO DAILY
Metformin 500mg daily

ALLERGIES: Heparin Agents

PHYSICAL EXAM: Upon arrival to MICU:
T 97.8 HR 96 BP 126/104 RR 24 O2Sat 100% on NRB
Gen: NAD
Heent: [**Last Name (un) **], EOMI, sclera anicteric, OP clear
Lungs: CTA b/l
Cardiac: Irregularly Irregular, no murmurs
Abdomen: obese soft, NT +BS
Ext: no edema
Neuro: Awake and alert

FAMILY HISTORY: Father w/ HTN
No history of clots in the family.

SOCIAL HISTORY: From [**Hospital 100**] Rehab facility, she is a retired epidemiologist. Pt
moved to US in [**2102**].
Tob: none currently, remote 20 pk yr hx.
EtOH: no history of alcohol abuse. 

### Response:
{'Other pulmonary embolism and infarction,Defibrination syndrome,Atrial fibrillation,Acute cholecystitis,Chronic kidney disease, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Hypercalcemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Secondary hyperparathyroidism (of renal origin),Leukocytosis, unspecified,Anemia, unspecified'}
