CHIEF COMPLAINT: Fever, chills, increased abdominal girth.

PRESENT ILLNESS: 73 YO M with fatigue, increased abdominal girth, decreased PO
intake and chills with low grade temps to 100. Re-initiated oral
chemotherapy on [**4-13**] and is status post 5L paracentesis 4 days
prior to admission. Dr [**Last Name (STitle) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10919**] are onc team.
Complained of intermittent diffuse abd cramps. Initial VS in ED:
98.1 102 93/66 16 100% Lactate 2.7. Mild tachycardia. BP in 90s.
Family reports pt runs in 110s. Mild diffusely tender abd.
Guaiac + brown stool. 2PIVs placed initially. CXR unremarkable.
Paracentesis done, transudative, did not look like SBP, cultures
sent. UA with no infection. CT scan abdomen with ?gasrtric
obstruction. Has history of duodenal stent in the past. Surgery
evaluated and did not feel that this was clinical gastric outlet
syndrome, though with more metastatic disease in abd, most
likely leading to more ascites. Over the night in the ED his BP
decreased to 80s. Initially he received 500 cc bolus with
increase to 88. LIJ was placed...post-CXR fine. CVP 3. Got add'l
500cc NS with increase to SBP 100, HR 105, satting fine on 2L
NC. Basically admitted for hypotension, potential infection with
unclear source.

MEDICAL HISTORY: -Cholangiocarcinoma
-Diabetes mellitus II (oral meds)
-Atrial fibrillation (on amiodorone)
-Chronic left ventricular systolic heart failure (last EF
40-45%)
-CAD, known 3VD with s/p BMS to LAD in [**8-18**]
-H/o pneumonia and effusion which was tapped in [**State 108**]
-Mass encircling the biliary stent which was biopsied and found
to be cholangiocarcinoma, s/p biliary stent c/b infection s/p
stent removal [**2171-9-11**]
-[**2171-11-4**] ERCP with 10mm x 60mm biliary covered Wallstent
in the common bile duct within the previously placed uncovered
metal stent 8mm x 60mm.
-Chronic renal failure
-Depression
-Hyperlipidemia
-Prior MI by EKG
-Hypertension
-Anemia

MEDICATION ON ADMISSION: 1. Amiodarone 100mg daily
2. Ursodiol 300 mg Capsule [**Hospital1 **]
3. Clopidogrel 75 mg Tablet daily
4. Bicarbonate 1300 [**Hospital1 **] every other day
5. Aspirin 325 mg Tablet daily
6. Digoxin 0.0625mg daily
7. Docusate Sodium 100 mg Capsule [**Hospital1 **]
8. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]
9. Omeprazole 20 mg Capsule daily
10. Spironolactone 50 mg Tablet daily.
11. Lasix 40 mg Tablet daily
12. Glipizide 2.5 mg Tab daily
13. Nephrocaps daily

ALLERGIES: Epinephrine / Keflex

PHYSICAL EXAM: Vitals: T:98.6  BP:85/52  P:114  R: 17 SaO2:100%
General: Thin elderly man, fatigued, pleasant, NAD
HEENT: NCAT, MM dry, no scleral icterus
Neck: supple, LIJ in place. JVP visible at 7cm.
Pulmonary: Decreased BS at bases bilaterally. No crackles,
wheezes.
Cardiac: Regular, tachycardic.
Abdomen: + ascites, soft, distended.  Well healed scar in RUQ. +
palpable mass vs liver edge.  Non-tender.  No rebound or
guarding.
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout. No nystagmus, dysarthria, intention or
action tremor. 2+ biceps, triceps, brachioradialis, patellar
reflexes and 2+ ankle jerks bilaterally. Plantar response was
flexor bilaterally.

FAMILY HISTORY: His father had [**Name2 (NI) 499**] cancer in his 50s. There are no other
family members with any GI cancers, liver problems. His mother
died at age [**Age over 90 **]. He has six children, who are healthy.

SOCIAL HISTORY: Italian but speaks some English. He is a retired truck driver.
He denies smoking or illicit drug use. He lives with his wife;
daughter is nearby. Drank about one glass of wine per night with
dinner for many years but has not had any alcohol in the last
several months.  Daughter [**Name (NI) **] is HCP ([**Telephone/Fax (1) 79023**])
Other septicemia due to gram-negative organisms,Malignant neoplasm of extrahepatic bile ducts,Hyposmolality and/or hyponatremia,Other ascites,Acquired hypertrophic pyloric stenosis,Malignant neoplasm of liver, secondary,Chronic systolic heart failure,Atrial fibrillation,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Cirrhosis of liver without mention of alcohol,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia
Gram-neg septicemia NEC,Mal neo extrahepat ducts,Hyposmolality,Ascites NEC,Acq pyloric stenosis,Second malig neo liver,Chr systolic hrt failure,Atrial fibrillation,Thrombocytopenia NOS,DMII wo cmp nt st uncntr,Hy kid NOS w cr kid I-IV,Cirrhosis of liver NOS,Crnry athrscl natve vssl,Status-post ptca,Chronic kidney dis NOS,Hyperlipidemia NEC/NOS
Admission Date:  [**2172-4-17**]              Discharge Date:   [**2172-4-22**]

Date of Birth:  [**2098-5-11**]             Sex:   M

Service: MEDICINE

Allergies:
Epinephrine / Keflex

Attending:[**First Name3 (LF) 4616**]
Chief Complaint:
Fever, chills, increased abdominal girth.

Major Surgical or Invasive Procedure:
Diagnostic paracentesis.
Therapeutic paracentesis with removal of 4L.
Central venous line placement and removal.

History of Present Illness:
73 YO M with fatigue, increased abdominal girth, decreased PO
intake and chills with low grade temps to 100. Re-initiated oral
chemotherapy on [**4-13**] and is status post 5L paracentesis 4 days
prior to admission. Dr [**Last Name (STitle) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10919**] are onc team.
Complained of intermittent diffuse abd cramps. Initial VS in ED:
98.1 102 93/66 16 100% Lactate 2.7. Mild tachycardia. BP in 90s.
Family reports pt runs in 110s. Mild diffusely tender abd.
Guaiac + brown stool. 2PIVs placed initially. CXR unremarkable.
Paracentesis done, transudative, did not look like SBP, cultures
sent. UA with no infection. CT scan abdomen with ?gasrtric
obstruction. Has history of duodenal stent in the past. Surgery
evaluated and did not feel that this was clinical gastric outlet
syndrome, though with more metastatic disease in abd, most
likely leading to more ascites. Over the night in the ED his BP
decreased to 80s. Initially he received 500 cc bolus with
increase to 88. LIJ was placed...post-CXR fine. CVP 3. Got add'l
500cc NS with increase to SBP 100, HR 105, satting fine on 2L
NC. Basically admitted for hypotension, potential infection with
unclear source.

Got zosyn and vanco, question of allergy to keflex, though has
tolerated in the past. VS at time of transfer 105 83/49 99% 2L
16-18. Received add'l fluid bolus prior to transfer, received
total of 3L NS in ED.

On arrival to [**Name (NI) 153**] pt's BP in high 80s, low 90s, borderline
tachycardia. Complaining of fatigue, increased abdominal girth,
decreased appetite. Currently denies abdominal pain. Reports
decreased PO intake since chemo on Monday with increasing
abdominal girth, lower extremity edema. No diarrhea, no nausea
or vomiting, no change in stool.  No dizziness/orthostasis.
Shaking chills at home.  Currently no abdominal pain, responded
to low dose morphine.

Past Medical History:
-Cholangiocarcinoma
-Diabetes mellitus II (oral meds)
-Atrial fibrillation (on amiodorone)
-Chronic left ventricular systolic heart failure (last EF
40-45%)
-CAD, known 3VD with s/p BMS to LAD in [**8-18**]
-H/o pneumonia and effusion which was tapped in [**State 108**]
-Mass encircling the biliary stent which was biopsied and found
to be cholangiocarcinoma, s/p biliary stent c/b infection s/p
stent removal [**2171-9-11**]
-[**2171-11-4**] ERCP with 10mm x 60mm biliary covered Wallstent
in the common bile duct within the previously placed uncovered
metal stent 8mm x 60mm.
-Chronic renal failure
-Depression
-Hyperlipidemia
-Prior MI by EKG
-Hypertension
-Anemia

Social History:
Italian but speaks some English. He is a retired truck driver.
He denies smoking or illicit drug use. He lives with his wife;
daughter is nearby. Drank about one glass of wine per night with
dinner for many years but has not had any alcohol in the last
several months.  Daughter [**Name (NI) **] is HCP ([**Telephone/Fax (1) 79023**])

Family History:
His father had [**Name2 (NI) 499**] cancer in his 50s. There are no other
family members with any GI cancers, liver problems. His mother
died at age [**Age over 90 **]. He has six children, who are healthy.


Physical Exam:
Vitals: T:98.6  BP:85/52  P:114  R: 17 SaO2:100%
General: Thin elderly man, fatigued, pleasant, NAD
HEENT: NCAT, MM dry, no scleral icterus
Neck: supple, LIJ in place. JVP visible at 7cm.
Pulmonary: Decreased BS at bases bilaterally. No crackles,
wheezes.
Cardiac: Regular, tachycardic.
Abdomen: + ascites, soft, distended.  Well healed scar in RUQ. +
palpable mass vs liver edge.  Non-tender.  No rebound or
guarding.
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout. No nystagmus, dysarthria, intention or
action tremor. 2+ biceps, triceps, brachioradialis, patellar
reflexes and 2+ ankle jerks bilaterally. Plantar response was
flexor bilaterally.

Pertinent Results:
Labs at Admission:

[**2172-4-17**] 12:00AM BLOOD WBC-10.4 RBC-3.49* Hgb-11.8* Hct-34.5*
MCV-99* MCH-33.9* MCHC-34.3 RDW-16.1* Plt Ct-267
[**2172-4-17**] 12:00AM BLOOD Neuts-92.3* Lymphs-6.0* Monos-1.5*
Eos-0.1 Baso-0.1
[**2172-4-17**] 08:24AM BLOOD PT-14.7* PTT-31.8 INR(PT)-1.3*
[**2172-4-17**] 12:00AM BLOOD Glucose-141* UreaN-21* Creat-1.1 Na-131*
K-4.8 Cl-98 HCO3-23 AnGap-15
[**2172-4-17**] 12:00AM BLOOD ALT-24 AST-26 AlkPhos-454* TotBili-1.8*
[**2172-4-17**] 12:00AM BLOOD Lipase-127*
[**2172-4-17**] 12:00AM BLOOD TotProt-6.1* Albumin-2.8* Globuln-3.3
[**2172-4-17**] 10:30AM BLOOD Albumin-2.2* Calcium-7.3* Phos-3.2 Mg-1.7
[**2172-4-17**] 12:12AM BLOOD Lactate-2.7*
[**2172-4-17**] 04:32AM BLOOD Lactate-2.1*
[**2172-4-17**] 09:18AM BLOOD Lactate-1.3

  BASIC COAGULATION          Plt
[**2172-4-22**] 06:50AM          193
[**2172-4-21**] 05:45AM          153
[**2172-4-20**] 12:00AM          163
[**2172-4-19**] 05:35AM          121*
[**2172-4-18**] 07:34PM          109*
[**2172-4-18**] 11:03AM          107*
[**2172-4-18**] 03:29AM        LOW 93*1
[**2172-4-17**] 03:47PM          139*
[**2172-4-17**] 08:24AM          171
[**2172-4-17**] 12:00AM          267

HIT Ab - pending

Microbiology:
Blood culture ([**4-17**]): Klebsiella pneumoniae, pansensitive
Peritoneal fluid culture ([**4-17**] and [**4-21**]): no growth to date
(NGTD)
Peritoneal cytology ([**4-17**]): NEGATIVE FOR MALIGNANT CELLS.
Urine culture ([**4-17**]): no growth
Surveillance blood cultures:
BCx x 2 [**4-17**] - NGTD
BCx [**4-18**] - NGTD
Cath tip [**4-20**] - NGTD

Imaging Studies:

CT abdomen/pelvis ([**4-17**]):
  CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: In the visualized
thorax, there is a new small right pleural effusion with
associated relaxation atelectasis. The heart is top normal in
size. There are coronary artery calcifications. There is no
pericardial effusion.
  In the abdomen, there is increased, now massive ascites. Again
seen is a
common biliary ductal stent terminating in the third portion of
the duodenum. There has been interval placement of a duodenal
stent; however, the stomach is distended but the antrum
collaped. A new duodenal stent is seen.
  Multiple enlarged hypodensities within the liver are
concerning for metastatic disease, progressed from prior. The
spleen, adrenals and pancreas appear normal. The kidneys
symmetrically take up and excrete contrast. Multiple
retroperitoneal and mesenteric nodes are again seen, but none
reach size criteria for pathologic enlargement. No peritoneal
implants are specifically identifiable.
  CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: There is a right
fluid-containing inguinal hernia (series 2, image 95). The
urinary bladder, distal ureters, rectum, sigmoid [**Month/Day (4) 499**] and
prostate are unremarkable.
  MUSCULOSKELETAL: Again noted is sclerosis of L3. Degenerative
changes are seen at multiple levels of the spine and severe
degenerative changes are seen in the hip.

IMPRESSION:
1. Interval placement of duodenal stent.
2. Progressed metastatic disease in the liver with associated
massive ascites.
3. Fluid-filled right inguinal hernia.
4. Unchanged sclerotic L3 vertebral body lesion concerning for
metastasis.

CXR PA and LAT ([**4-17**]):
CHEST, TWO VIEWS: Heart size, hilar and mediastinal contours are
normal. Low lung volumes limit assessment. There is mild
bibasilar atelectasis. There is no consolidation, effusion or
pneumothorax. Pulmonary vasculature is normal. There is a
distended gastric bubble. Two stents are seen in the right upper
abdomen.

IMPRESSION: No pneumonia.

Duplex doppler ultrasound liver ([**4-17**]):
RIGHT UPPER QUADRANT ULTRASOUND: The liver again demonstrates a
coarsened
echotexture, although without focal masses definitively
identified. Mild-
moderate intra-hepatic biliary ductal dilatation is unchanged.
Stents are
noted in the common bile duct and duodenum. There is a moderate
amount of
ascites.
DOPPLER ULTRASOUND: Color and Doppler ultrasound was used to
evaluate the
hepatic vasculature. The main portal vein demonstrates normal
hepatopetal
flow, with normal velocity of approximately 20 cm/sec. The left,
right
posterior, and right anterior portal veins demonstrate normal
wall-to-wall
flow with appropriate directionality. The right, middle, and
left hepatic
veins are patent with wall-to-wall flow and normal waveforms.
The main
hepatic artery demonstrates a brisk upstroke and antegrade
diastolic flow.
IMPRESSION:
1. Stable appearance of heterogeneous liver with mild-moderate
intrahepatic
biliary ductal dilatation consistent with cholangiocarcinoma.
2. Moderate ascites.
3. Patent hepatic vasculature.


Brief Hospital Course:
A 73 yo man with metastatic inoperable cholangiocarcinoma with
history of gastric outlet obstruction s/p stenting presented
with hypotension, fever/chills, increased ascites and poor po
intake.

# Hypotension/Klebsiella Bacteremia/Fever:  In the ED he
received 3-3.5L IVF with persistent hypotension and lactic
acidosis so he was admitted to the MICU due to concern for
sepsis. Reassuringly the lactate improved from 2.7-->2.1-->1.3
with IVF. He was continued on empiric antibiotics which had been
started in the ED with Zosyn for possible GI source for sepsis.
Blood cultures from ED grew out GNR which speciated as
klebsiella that were pan sensitive. Meanwhile, he was bolused
with fluids prn to maintain MAP >60 in addition to which he
received albumin to increase oncotic pressure.  A diagnostic
paracentesis showed transudative fluid without evidence of SBP,
his CXR showed no evidence of infection, and his UA was negative
so no source was identified.  He was converted to oral cipro to
complete a fourteen day course which he will finish as an
outpatient.  Throughout the rest of his hospitalization he
remained afebrile.

# Poor PO intake: His slowly advance his diet as tolerated.
Nutrition service made specific recommendations for dietary
supplements.  Surgery was consulted for a possible G or J tube
placement but his CT scan was without obstruction, however he
stated that he felt his ascites was hindering his po intake and
given his recent infection surgical options were not further
pursued.  He was started on marinol 2.5 mg qam daily to help
improve his appetite and underwent a therapeutic paracentesis on
[**4-21**] during which 4 L were removed.  He was asked to discuss his
nutritional status further with his oncologist as an outpatient.

# Cholangiocarcinoma: The patient has a history of inoperable
cholangiocarcinoma s/p biliary stent and duodenal stent. His
primary oncologist here is Dr. [**Last Name (STitle) **], however he has been seeing
an oncologist at [**Hospital3 417**] Hospital, Dr. [**First Name (STitle) **], more
recently for local care.  He has been undergoing treatent with
xeloda and last received this on [**4-13**].  We continued his home
ursodiol.  At discharge the family wanted to follow up with Dr.
[**First Name (STitle) **] during the next week and the daughter stated she would
make the appoitnment.

# Ascites: This was felt to be secondary to portal hypertension
from diffuse metastases in liver parenchyma. Doppler ultrasound
of the liver during this admission did not show evidence of
portal venous thrombosis; there was moderate ascites noted.
Diagnostic paracentesis, as above, was consistent with
transudate. Culture from the peritoneal fluid was negative.  As
above a therapeutic paracentesis was preformed on [**4-21**] during
which 4 L were removed.  His lasix and aldactone were held
during his inpatient stay and restarted at his home doses at
discharge.

# Thrombocytopenia: The patient initially had large drop in his
platlet cound (> 50%) so there was concern for HIT, however he
did not develop evidence of clotting.  Heparin was stopped,
however his platlets began to improve even during his last day
on heparin.  HIT Ab was sent and is pending, but he has a low
likelihood of HIT.  He had other reasons for thrombocytopenia
including bacteremia and zosyn.

# Hyponatremia:  The patient was slightly hyponatremic during
his hospitalization.  This was thought toe be secondary to
hypervolemic hyponatremia due to his liver disease.

# Coronary artery disease: He remained asymptomatic during his
hospitalization and he was continued on his home ASA and Plavix.

# Atrial fibrillation: He is not anticoagulated as an oupatient;
he is on a BB, digoxin and amiodarone at home. His ventricular
rate was well-controlled with fluid resuscitation. We continued
his home digoxin and amiodorone, and held his metoprolol in the
setting of hypotension, however this was restarted when he was
moved out from the MICU.

# Guaiac positive stool: Hematocrit was initially slightly above
baseline, appeared hemo-concentrated, and dropped from 34 to 28
after hydration. Serial hematocrits showed stability in the high
20-low 30s, which is his baseline. He did not require
transfusion.

# Diabetes mellitus. We held his glipizide and started humalog
sliding scale insulin during his hospitalization.  His glipizide
was restarted at discharge.

# Code status: Full

Medications on Admission:
1. Amiodarone 100mg daily
2. Ursodiol 300 mg Capsule [**Hospital1 **]
3. Clopidogrel 75 mg Tablet daily
4. Bicarbonate 1300 [**Hospital1 **] every other day
5. Aspirin 325 mg Tablet daily
6. Digoxin 0.0625mg daily
7. Docusate Sodium 100 mg Capsule [**Hospital1 **]
8. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]
9. Omeprazole 20 mg Capsule daily
10. Spironolactone 50 mg Tablet daily.
11. Lasix 40 mg Tablet daily
12. Glipizide 2.5 mg Tab daily
13. Nephrocaps daily

Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Ascorbic Acid 250 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Glipizide 2.5 mg Tablet Extended Rel 24 hr (2) Sig: 0.5
Tablet Extended Rel 24 hr (2) PO once a day.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO
every other day.
13. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO QAM (once
a day (in the morning)).
Disp:*30 Capsule(s)* Refills:*2*
14. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
15. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
16. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day.


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Primary -
Klebsiella pneumoniae bacteremia
Ascites
Poor nutritional status
Thrombocytopenia
Hyponatremia

Secondary -
Cholangiocarcinoma
History of coronary artery disease
Atrial fibrillation
Diabetes type II


Discharge Condition:
Stable, afebrile


Discharge Instructions:
You were admitted to the hospital due to fevers and were found
to have bacteria in your blood.  You were treated with
antibiotics with improvement.  You underwent both a diagnostic,
then later a therapeutic paracentesis.  There was no evidence of
infection in your abdomen.  You will need to finish a course of
oral antibiotics.

Due to your poor oral intake you were started on a medication to
improve your appetite.  It is very important that you receive
adequate nutrition.  Please discuss this with your primary
oncologist.

Medication changes:
1.  You will need to complete 8 more days of antibiotic
treatment with ciprofloxacin 750 mg twice daily.
2.  You were started on Dronabinol 2.5 mg daily in the morning
to help increase your appetitie.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

Call your primary doctor, or go to the emergency room if you
experience fevers, chills, dizziness, shortness of breath,
abdominal pain, blood in your stool, or dark black stool.

Followup Instructions:
As we discussed, please follow up with your oncologist, Dr.
[**First Name (STitle) **] at [**Hospital3 417**] Hospital within the next week.

Please keep your previously scheduled appointment:

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2172-7-17**] 1:00



Completed by:[**2172-4-22**]
{'Other septicemia due to gram-negative organisms,Malignant neoplasm of extrahepatic bile ducts,Hyposmolality and/or hyponatremia,Other ascites,Acquired hypertrophic pyloric stenosis,Malignant neoplasm of liver, secondary,Chronic systolic heart failure,Atrial fibrillation,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Cirrhosis of liver without mention of alcohol,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia'}


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: Fever, chills, increased abdominal girth.

PRESENT ILLNESS: 73 YO M with fatigue, increased abdominal girth, decreased PO
intake and chills with low grade temps to 100. Re-initiated oral
chemotherapy on [**4-13**] and is status post 5L paracentesis 4 days
prior to admission. Dr [**Last Name (STitle) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10919**] are onc team.
Complained of intermittent diffuse abd cramps. Initial VS in ED:
98.1 102 93/66 16 100% Lactate 2.7. Mild tachycardia. BP in 90s.
Family reports pt runs in 110s. Mild diffusely tender abd.
Guaiac + brown stool. 2PIVs placed initially. CXR unremarkable.
Paracentesis done, transudative, did not look like SBP, cultures
sent. UA with no infection. CT scan abdomen with ?gasrtric
obstruction. Has history of duodenal stent in the past. Surgery
evaluated and did not feel that this was clinical gastric outlet
syndrome, though with more metastatic disease in abd, most
likely leading to more ascites. Over the night in the ED his BP
decreased to 80s. Initially he received 500 cc bolus with
increase to 88. LIJ was placed...post-CXR fine. CVP 3. Got add'l
500cc NS with increase to SBP 100, HR 105, satting fine on 2L
NC. Basically admitted for hypotension, potential infection with
unclear source.

MEDICAL HISTORY: -Cholangiocarcinoma
-Diabetes mellitus II (oral meds)
-Atrial fibrillation (on amiodorone)
-Chronic left ventricular systolic heart failure (last EF
40-45%)
-CAD, known 3VD with s/p BMS to LAD in [**8-18**]
-H/o pneumonia and effusion which was tapped in [**State 108**]
-Mass encircling the biliary stent which was biopsied and found
to be cholangiocarcinoma, s/p biliary stent c/b infection s/p
stent removal [**2171-9-11**]
-[**2171-11-4**] ERCP with 10mm x 60mm biliary covered Wallstent
in the common bile duct within the previously placed uncovered
metal stent 8mm x 60mm.
-Chronic renal failure
-Depression
-Hyperlipidemia
-Prior MI by EKG
-Hypertension
-Anemia

MEDICATION ON ADMISSION: 1. Amiodarone 100mg daily
2. Ursodiol 300 mg Capsule [**Hospital1 **]
3. Clopidogrel 75 mg Tablet daily
4. Bicarbonate 1300 [**Hospital1 **] every other day
5. Aspirin 325 mg Tablet daily
6. Digoxin 0.0625mg daily
7. Docusate Sodium 100 mg Capsule [**Hospital1 **]
8. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]
9. Omeprazole 20 mg Capsule daily
10. Spironolactone 50 mg Tablet daily.
11. Lasix 40 mg Tablet daily
12. Glipizide 2.5 mg Tab daily
13. Nephrocaps daily

ALLERGIES: Epinephrine / Keflex

PHYSICAL EXAM: Vitals: T:98.6  BP:85/52  P:114  R: 17 SaO2:100%
General: Thin elderly man, fatigued, pleasant, NAD
HEENT: NCAT, MM dry, no scleral icterus
Neck: supple, LIJ in place. JVP visible at 7cm.
Pulmonary: Decreased BS at bases bilaterally. No crackles,
wheezes.
Cardiac: Regular, tachycardic.
Abdomen: + ascites, soft, distended.  Well healed scar in RUQ. +
palpable mass vs liver edge.  Non-tender.  No rebound or
guarding.
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout. No nystagmus, dysarthria, intention or
action tremor. 2+ biceps, triceps, brachioradialis, patellar
reflexes and 2+ ankle jerks bilaterally. Plantar response was
flexor bilaterally.

FAMILY HISTORY: His father had [**Name2 (NI) 499**] cancer in his 50s. There are no other
family members with any GI cancers, liver problems. His mother
died at age [**Age over 90 **]. He has six children, who are healthy.

SOCIAL HISTORY: Italian but speaks some English. He is a retired truck driver.
He denies smoking or illicit drug use. He lives with his wife;
daughter is nearby. Drank about one glass of wine per night with
dinner for many years but has not had any alcohol in the last
several months.  Daughter [**Name (NI) **] is HCP ([**Telephone/Fax (1) 79023**]) 

### Response:
{'Other septicemia due to gram-negative organisms,Malignant neoplasm of extrahepatic bile ducts,Hyposmolality and/or hyponatremia,Other ascites,Acquired hypertrophic pyloric stenosis,Malignant neoplasm of liver, secondary,Chronic systolic heart failure,Atrial fibrillation,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Cirrhosis of liver without mention of alcohol,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia'}
