CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 57 year-old male with a
history of Klatskin tumor status post cholecystectomy and
biliary drainage on continuous chemotherapy who presented to
an outside hospital with shortness of breath described as
being unable to get breath in. The patient denies that he had
chest pain but this was potentially reported at the outside
hospital. EKG at the outside hospital was read as having
acute changes. Troponin was 0.4 and a concern was raised for
acute coronary syndrome.

MEDICAL HISTORY: 1.  Biliary duct adenocarcinoma with positive lymph nodes,
unresectable diagnosis [**2136-1-31**]. Status post exploratory
laparotomy and cholecystectomy in [**2136-3-2**] with biliary
drainage.
2.  Diabetes mellitus.
3.  Hypertension.
4.  Multiple back surgeries for disc problems.

MEDICATION ON ADMISSION: 

ALLERGIES: Zestril leads to unknown reaction. Versed leads to
seizure.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Other pulmonary embolism and infarction,Malignant neoplasm of extrahepatic bile ducts,Obstruction of bile duct,Hyposmolality and/or hyponatremia,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Abnormal coagulation profile
Pulm embol/infarct NEC,Mal neo extrahepat ducts,Obstruction of bile duct,Hyposmolality,Thrombocytopenia NOS,DMII wo cmp nt st uncntr,Hypertension NOS,Abnrml coagultion prfile
Admission Date:  [**2136-6-18**]       Discharge Date:  [**2136-6-27**]

Date of Birth:   [**2078-11-24**]       Sex:  M

Service:  [**Doctor Last Name **]

HISTORY OF PRESENT ILLNESS: This is a 57 year-old male with a
history of Klatskin tumor status post cholecystectomy and
biliary drainage on continuous chemotherapy who presented to
an outside hospital with shortness of breath described as
being unable to get breath in. The patient denies that he had
chest pain but this was potentially reported at the outside
hospital. EKG at the outside hospital was read as having
acute changes. Troponin was 0.4 and a concern was raised for
acute coronary syndrome.

The patient was then transferred to the [**Hospital1 190**] for further evaluation.

PAST MEDICAL HISTORY:
1.  Biliary duct adenocarcinoma with positive lymph nodes,
unresectable diagnosis [**2136-1-31**]. Status post exploratory
laparotomy and cholecystectomy in [**2136-3-2**] with biliary
drainage.
2.  Diabetes mellitus.
3.  Hypertension.
4.  Multiple back surgeries for disc problems.

ALLERGIES: Zestril leads to unknown reaction. Versed leads to
seizure.

MEDICATIONS:
1.  Protonix 40 mg po q day.
2.  Oxycodone 5 mg po q day six hours prn.
3.  OxyContin 40 mg po q eight hours.
4.  NPH 12 units.
5.  Chemotherapy of unknown [**Doctor Last Name 360**].
6.  Augmentin one po bid.

PHYSICAL EXAMINATION: On presentation at [**Hospital1 346**] vital signs 98.0 F, blood pressure
124/69, heart rate 112, O2 saturation 96% on nonrebreather,
respiratory rate ranged from 27 to 36.  General exam - alert
and oriented times 3, tachypneic. HEENT - pupils are equal,
round and reactive to light. Extraocular muscles are intact.
Oropharynx mucous membranes moist, neck is supple.
Cardiovascular - tachycardic with a grade II/VI slow murmur
at the right upper sternal base. Respiratory - crackles
bilaterally with an increase in right base to half way up.
Abdomen with biliary drains intact and soft though
protuberant with diffuse abdominal pain and no rebound.
Extremities - 3+ pitting edema to the knees. Neurologically -
cranial nerves II through XII are grossly intact. Strength is
[**6-3**].

ADMISSION LABORATORY DATA: White blood cell count 16.5,
hematocrit 27.4, platelet count 74, INR 1.7, sodium 133,
potassium 4.8, chloride 97, bicarb 23, BUN 25, creatinine
1.0, glucose 103, CK 32, Troponin 4.8.

EKG revealed normal sinus rhythm at a rate of 105 with a Q in
III and flipped T wave in lead III which was old. There was T
wave inversion in lead aVF and ST elevation in V1 and V2 with
T wave flattening in V3 and V6. T wave changes were new since
[**2136-4-30**].

ABG 7.47, Pco2 31, Po2 77 at 100% nonrebreather mask.

Echocardiogram revealed no focal wall motion abnormalities
with some right heart strain and a PA pressure of 58.

Head CT scan was negative for hemorrhage or mass affect or
masses.

ASSESSMENT:  Given the EKG changes and echocardiographic
changes the patient was felt to have a pulmonary embolus.

A CT angiogram was performed which revealed thrombi in the
right tree and multiple bilateral thrombi, left basilar
atelectasis and a right effusion and ground glass appearance
in the upper lobes.

Chest x-ray revealed a moderate right pleural effusion but no
consolidation. Given the potential for hemodynamic
instability the patient was initially admitted to the
medical Intensive Care Unit for close observation. The
patient did well in the Medical Intensive Care Unit and was
called out to the floor the following day.

Upon presentation to the floor the patient denied chest pain,
headache, nausea, vomiting and decreasing shortness of
breath. He continued abdominal pain with no black or bloody
stools and no dysuria.

The patient was received on the following medications:
1.  Heparin.
2.  Morphine Sulfate.
3.  Oxycodone.
4.  OxyContin.
5.  Augmentin.
6.  Levaquin.
7.  Flagyl.

Levaquin and Flagyl were added for a rising white count and
the presence of abdominal pain.

COURSE ON THE GENERAL MEDICAL SERVICE:
1.  Pulmonary - For multiple bilateral pulmonary emboli the
patient was continued on Heparin and was started on Coumadin
therapy. His O2 saturation gradually improved over the course
of the hospitalization. He had no further complications of
his pulmonary emboli or its treatment.

2.  Oncologic - The patient's oncologist was contact[**Name (NI) **] by the
Medical Intensive Care Unit team who reported that the
patient did not need further chemotherapy at this time. The
[**Doctor Last Name 360**] being used was unable to be determined. The oncologist
was contact[**Name (NI) **] but unsuccessfully by the floor team.

3.  Infectious Disease - The patient was started on Levaquin
and Flagyl as described above for rising white count and
abdominal tenderness. The patient remained afebrile despite a
rising white blood cell count blood cultures were negative.
The patient was discontinued on Levaquin, Flagyl and
Augmentin by the floor team. He was followed clinically with
no further increase in temperature though white count
continued to rise. To evaluate for this the patient was
maintained on continuous biliary drainage and received a
cholangiogram at this hospital. The results of which are
pending at this time.

4.  Ascites - The patient was felt to have tense ascites and
could benefit from a paracentesis for comfort reasons. This
was performed on [**2136-6-20**] with the removal of approximately
4.6 liters of fluid. Analysis of the fluid reveals white
blood cells [**Pager number **], red blood cells [**Pager number **], 54% polys, 1
lymphocytes, 36 monos and 9 macrophages, amylase 7, total
bilirubin 1.9, albumin 0.9. This was felt to be consistent
with a transient state and the patient was encouraged to
consume a low salt diet. He was started on Lasix and
Aldactone. Over the remaining course of the hospitalization
the fluid did slowly re-accumulate.

5.  Cardiovascular - Though the Troponin was elevated, the
patient had no symptoms consistent with acute coronary
syndrome. He was watched closely and had no further chest
pain and no further work up of this problem ensued.

6.  Diabetes mellitus - The patient was continued on regular
sliding scale insulin.

7.  Prophylaxis - The patient was continued on Protonix and
was maintained on Heparin as described above.

DISPOSITION AND CODE STATUS: Extensive conversation took
place between the house officers and the palliative care
team, the patient and his family, the patient expressed in
his wishes that he not be placed on any machines and should
be DNR / DNI. He expressed concerned that DNR / DNI status
would prohibit further treatment which could be of benefit to
him. It was extensively explained to him that DNR / DNI
status does not preclude treatment of other medical problems
such as paracentesis or pulmonary emboli. The patient was
relieved to hear this and the family agreed that the patient
should be made DNR / DNI. The beginnings of Hospice care were
discussed as well and the patient elected to pursue further
management with Hospice at the time of his discharge.

At this point the patient is deemed prepared for transfer to
the [**Hospital 47**] [**Hospital 1281**] Hospital if a bed is available. At that
hospital upon his discharge he should be referred for hospice
care with the [**Hospital3 1280**] Hospice upon discharge from
[**Hospital 47**] [**Hospital 1281**] Hospital. The palliative care team at this
hospital spoke with [**First Name4 (NamePattern1) 3788**] [**Last Name (NamePattern1) **] from that hospice
institution.

ADDITIONAL RELEVANT LABORATORY TESTS: There was a culture
done on [**2136-6-21**] biliary fluid which is pending. Gram stain
of the [**2136-6-20**] peritoneal fluid was negative.  [**2136-6-19**]
blood culture no growth to date at the time of this
dictation. The [**2136-6-19**] blood culture second bottle also
negative to date. There was a [**2136-6-19**] culture of biliary
fluid which grew enterococci species which were not treated.
Given the lack of symptoms suggesting a clinical infection.

The patient also had a hepatic ultrasound to evaluate for
Chiari syndrome and this was negative.

FINAL DIAGNOSIS:
1.  Pulmonary embolus.
2.  Klatskin tumor.
3.  Ascites.
4.  Diabetes mellitus.
5.  Anemia.

DISCHARGE INSTRUCTIONS: The patient is deemed prepared for
transfer to the [**Location (un) 47**] [**Hospital3 1280**] Hospital for continued
management. He should follow up with his primary care
physician and his oncologist, Dr. [**Last Name (STitle) 38218**]. Dr.[**Name (NI) 38221**]
phone number is [**Telephone/Fax (1) 38222**].

DISCHARGE MEDICATIONS:
1.  Lovenox.
2.  Regular sliding scale insulin.
3.  Oxycodone sustained released 100 mg po q eight hours.
4.  Bisacodyl 10 mg po prn [**Hospital1 **].
5.  Trazodone 50 mg po q HS prn.
6.  Protonix 40 mg po q day.
7.  Oxycodone 5 mg po four to six hours prn breakthrough
pain.
8.  Coumadin 5 mg po q HS.
9.  Lasix 40 mg po q day.
10. Spirolactone 100 mg po q day.
11. Ampicillin 1 gram IV q six hours times two doses status
post cholangiography.
12. Gentamycin 80 mg IV q eight hours times two doses status
post cholangiography.



                         DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAK




Dictated By:[**Name8 (MD) 2665**]
MEDQUIST36

D:  [**2136-6-22**]  10:58
T:  [**2136-6-22**]  12:21
JOB#:  [**Job Number 38223**]


Name:  [**Known lastname 158**], [**Known firstname 3834**]                         Unit No:  [**Numeric Identifier 6901**]

Admission Date:  [**2136-6-18**]     Discharge Date:  [**2136-6-27**]

Date of Birth:   [**2078-11-24**]     Sex:  M


DISCHARGE SUMMARY ADDENDUM:  This addendum is to detail the
events from [**2136-6-22**] onward.

1. Pulmonary embolism - Upon returning from his
patient was noted to have a transient desaturation in his
oxygen level. He received an arterial blood gas, chest X-ray
and EKG all of which pointed to a repeat pulmonary embolus as
the cause. Over the remaining 24 hours his oxygen was weaned
down to 5 liters by nasal cannula where he had been after the
transfer from the Intensive Care Unit.  He has since been
stable on 5 liters by nasal cannula.
On [**2136-6-26**] because of difficulties managing his Heparin
drip he was started on Lovenox. There were difficulties
managing his INR as well with a supratherapeutic INR that
required vitamin K to reverse. He was restarted on Coumadin
2.5 mg po q HS on [**2136-6-26**].

2.  Infectious Disease - He was seen by interventional
radiology to manipulate his biliary drains which were
implicated in his high white blood cell count. They reported
the following:  obstructive left biliary tree most likely
secondary to tumor extension to the left duct. Balloon
dilatation of the mid and distal left hepatic duct was
performed. Exchange of the previous 8 French biliary drainage
catheters for a new 8 French biliary drainage catheter with
post cholangiograms demonstrating optimal placement of the
proximal side holes. Both tubes were placed to internal
drainage.

His liver function tests and clinical exam was followed after
this and he remained stable. However the white blood cell
count which had been rising continued to stay elevated.
Clinically the patient remained afebrile and was hence not
treated with any antibiotics. Bile consistently grew multiple
organisms which again were not treated as the patient
remained clinically well appearing.

3.  Gastrointestinal / Ascites - The patient's ascites
re-accumulated and was drained again on [**2136-6-24**]. The
analysis again was not consistent with infection. He was
started on Lasix and Spironolactone to prevent reaccumulation
and these doses were increased to Lasix 80 mg and
Spironolactone 200 mg.

4.  Hyponatremia - The patient became hyponatremic. This was
attributed to his ascites. He was treated with a 1.0 liter
per day fluid restriction.

5.  Hematologic - Thrombocytopenia - The patient's platelet
count was noted to be declining to as low as 80,000.  It was
felt that this may be from disseminated intravascular
coagulation. A DIC panel was checked and was negative. Other
possibilities included Heparin induced thrombocytopenia
however the patient's platelet count remained stable in the
80,000 range and had no clinical signs of bleeding. It was
determined that Heparin will be continued while HIT antibody
is pending. Given the fact that Lovenox has less incidence of
Heparin induced thrombocytopenia, he was felt to be safe for
discharge on Lovenox in the interim while becoming
therapeutic on Coumadin.

6.  Disposition - On [**2136-6-26**] the patient's affect seemed
more sad and the patient became less interested in his care.
It was felt the patient may be becoming more accepting of his
diagnosis and interested in going home. The patient had been
a DNR / DNI status. Since transfer from the Medical Intensive
Care Unit a discussion took place between the patient's
family, the palliative care team and the house officer on [**2136-6-26**]. During this conversation the patient made it clear
that he wishes to be discharged to home with Hospice care. He
does wish to continue Lovenox and Coumadin to treat his
pulmonary embolus and hypercoagulable state.

At this time he is being prepared for discharge to home with
visiting nurses and Hospice care.

DISCHARGE INSTRUCTIONS: He should continue to follow with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6902**]. He should have a
Coumadin level check q OD while adjusting Coumadin and fax to
Dr. [**Last Name (STitle) 6902**]. Fax number [**Telephone/Fax (1) 6903**] who will adjust the
patient's Coumadin dose. He will continue on Lovenox until he
is therapeutic on his Coumadin.

DISCHARGE MEDICATIONS:
1.  Docusate Sodium liquid 100 mg po bid.
2.  Bisacodyl 10 mg po / pr [**Hospital1 **] prn.
3.  Pantoprazole 40 mg po q day.
4.  Furosemide 80 mg po q day.
5.  Spironolactone 200 mg po q day.
6.  Sodium Chloride nasal spray one to two sprays qid prn.
7.  Oxycodone sustained release 80 mg po eight hours.
8.  Oxycodone 10 mg po q four to six hours prn.
9.  Warfarin 2.5 mg po q HS.
10. Enoxaparin Sodium 60 mg subcutaneous q 12 hours.
11. Morphine Sulfate elixir prn.

FINAL DIAGNOSIS:
1.  Klatskin tumor.
2.  Pulmonary embolus.
3.  Hypoxia.
4.  Ascites.
5.  Hyponatremia.
6.  Thrombocytopenia.




                          Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6904**] [**MD Number(4) 6905**]

Dictated By:[**Name8 (MD) 292**]

MEDQUIST36

D:  [**2136-6-26**]  17:35
T:  [**2136-6-27**]  10:56
JOB#:  [**Job Number 6906**]

cc:[**Hospital3 6907**]
{'Other pulmonary embolism and infarction,Malignant neoplasm of extrahepatic bile ducts,Obstruction of bile duct,Hyposmolality and/or hyponatremia,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,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: 

PRESENT ILLNESS: This is a 57 year-old male with a
history of Klatskin tumor status post cholecystectomy and
biliary drainage on continuous chemotherapy who presented to
an outside hospital with shortness of breath described as
being unable to get breath in. The patient denies that he had
chest pain but this was potentially reported at the outside
hospital. EKG at the outside hospital was read as having
acute changes. Troponin was 0.4 and a concern was raised for
acute coronary syndrome.

MEDICAL HISTORY: 1.  Biliary duct adenocarcinoma with positive lymph nodes,
unresectable diagnosis [**2136-1-31**]. Status post exploratory
laparotomy and cholecystectomy in [**2136-3-2**] with biliary
drainage.
2.  Diabetes mellitus.
3.  Hypertension.
4.  Multiple back surgeries for disc problems.

MEDICATION ON ADMISSION: 

ALLERGIES: Zestril leads to unknown reaction. Versed leads to
seizure.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Other pulmonary embolism and infarction,Malignant neoplasm of extrahepatic bile ducts,Obstruction of bile duct,Hyposmolality and/or hyponatremia,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Abnormal coagulation profile'}
