CHIEF COMPLAINT: abdominal pain and fever

PRESENT ILLNESS: Mr. [**Known lastname 57978**] is a 31 y/o man with a history metastatic, poorly
differentiated adenocarcinoma  with squamous differentiation,
likely gallbladder primary who presents with abdominal pain and
fevers.

MEDICAL HISTORY: 1.  Metastatic GB cancer as above, with mets to liver,
retroperitoneal lymph nodes.  With metal stent in CBD.
Complications of esophageal varices, s/p multiple bandings (most
recently [**2168-1-21**]).  On Gemcitabine/Cisplatin, most recent chemo
[**2168-2-4**]
2.  Malaria in past
3. s/p Appendectomy
4. H. Pylori, treated
5. UTI [**2163**]
6.  HBV, low viral load, with varices in lower 1/3 esophagus

MEDICATION ON ADMISSION: Ciprofloxacin 500 mg po qd
Aldactone 50 mg po qd
Dilaudid 16 mg po q6-8h prn
Neurontin 300 mg po tid

ALLERGIES: Bactrim

PHYSICAL EXAM: PE: VS: 98.9 HR 99 BP 106/48 RR 25 %Sat 99 CVP 9 ScvO2 77
Gen:  Tired, jaundiced, flat affect otherwise NAD
HEENT:  Mild icterus bilateral, O/P dry
Neck: Supple, no cervical LAD, RIJ in place
Chest:  Decreased breath sounds on right halfway up and crackles
left base
Cor:  Tachy no rubs/m/g
Abd:  Distended, bandage on right side, generalized TN on deep
palp
Ext:  1+ pitting edema to knee
Neuro:  A+O x 3, grossly non-focal

FAMILY HISTORY: DM in both parents, no cad, cancer.  10 siblings, none with
cancer

SOCIAL HISTORY: Originially from [**Country **], moved to [**Location (un) **] 5 years ago, worked at
[**7-4**] (not currently). Denies tobacco/etoh (for many
months)/drugs. Living with his brothers
Other septicemia due to gram-negative organisms,Acute and subacute bacterial endocarditis,Malignant neoplasm of liver, secondary,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Malignant neoplasm of gallbladder,Sepsis,Other and unspecified noninfectious gastroenteritis and colitis,Lipodystrophy,Portal hypertension,Iron deficiency anemia, unspecified
Gram-neg septicemia NEC,Ac/subac bact endocard,Second malig neo liver,Mal neo lymph intra-abd,Hpt B chrn wo cm wo dlta,Malig neo gallbladder,Sepsis,Noninf gastroenterit NEC,Lipodystrophy,Portal hypertension,Iron defic anemia NOS
Admission Date:  [**2168-4-27**]              Discharge Date:   [**2168-5-7**]

Date of Birth:  [**2137-3-18**]             Sex:   M

Service: MEDICINE

Allergies:
Bactrim

Attending:[**First Name3 (LF) 32198**]
Chief Complaint:
abdominal pain and fever

Major Surgical or Invasive Procedure:
paracentesis

History of Present Illness:
Mr. [**Known lastname 57978**] is a 31 y/o man with a history metastatic, poorly
differentiated adenocarcinoma  with squamous differentiation,
likely gallbladder primary who presents with abdominal pain and
fevers.

Was recently admitted to the OMED service [**Date range (1) 10649**]/[**2167**] for
hematemesis. Had EGD which showed non-bleeding duodenal masses
likely malignant in nature. They were not intervened upon. The
plan was to start him on xeloda as an outpatient.  He had a
paracentesis with removal of 2.5L fluid on [**2168-4-11**] and then
was seen in Heme/[**Hospital **] clinic on [**4-15**]  when the ascites fluid had
reaccumulated.  There was a long family meeting at that time and
the decision was made to NOT proceed with Xeloda chemotherapy,
and to focus on pain control, however the patient??????s code remains
full.

He has had diffuse abdominal pain since [**4-15**] and then on the
evening prior to admission developed fevers and nausea with
non-bloody vomiting today. He complains of diarrhea x 2 days
after taking Fleet??????s enema. Pain generalized, dull [**8-3**]. No
radiations.  He otherwise describes some mild dysuria and left
inguinal/scrotal pain associated with walking. Denies SOB or
cough, sinus pressure or pain, dysphagia, chest pain. No sick
contacts, no travel history.

In the ED,  VS T103; HR 122 BP 175/87 18  99%RA.  WBC was 19.1.
Lactate was 4.2.  He was enrolled in sepsis protocol.  A central
venous line was placed and paracentesis was performed removing
1L of ascites.  Ascites fluid showed WBC 385 ( 20PMNs, 40L,
18Mono, 5meso, 17mac); RBC 2340; tpro 0.7; glu 153; LD 57; [**Doctor First Name **]
75; alb <1. He was given Vancomycin 1g , Flagyl 500iv x 1,
Unasyn 3 g, Dilaudid 8 mg and 8L NS with repeat WBC 26 with 10%
bands . RUQ U/S showed no obstruction. CT abdomen showed diffuse
colitis new from CT scan 2 days prior . Surgery was consulted
and felt that the patient was not a surgical candidate,
recommended antibiotic treatment. Admitted to the [**Hospital Unit Name 153**] for
further workup and management.


Past Medical History:
1.  Metastatic GB cancer as above, with mets to liver,
retroperitoneal lymph nodes.  With metal stent in CBD.
Complications of esophageal varices, s/p multiple bandings (most
recently [**2168-1-21**]).  On Gemcitabine/Cisplatin, most recent chemo
[**2168-2-4**]
2.  Malaria in past
3. s/p Appendectomy
4. H. Pylori, treated
5. UTI [**2163**]
6.  HBV, low viral load, with varices in lower 1/3 esophagus


Social History:
Originially from [**Country **], moved to [**Location (un) **] 5 years ago, worked at
[**7-4**] (not currently). Denies tobacco/etoh (for many
months)/drugs. Living with his brothers

Family History:
DM in both parents, no cad, cancer.  10 siblings, none with
cancer

Physical Exam:
PE: VS: 98.9 HR 99 BP 106/48 RR 25 %Sat 99 CVP 9 ScvO2 77
Gen:  Tired, jaundiced, flat affect otherwise NAD
HEENT:  Mild icterus bilateral, O/P dry
Neck: Supple, no cervical LAD, RIJ in place
Chest:  Decreased breath sounds on right halfway up and crackles
left base
Cor:  Tachy no rubs/m/g
Abd:  Distended, bandage on right side, generalized TN on deep
palp
Ext:  1+ pitting edema to knee
Neuro:  A+O x 3, grossly non-focal

Pertinent Results:
CXR: Right effusion, cannot rule-out PNA

CT Chest/Abdomen [**2168-4-25**]: 1) Interval progression of disease with
new pulmonary nodules and increased size and number of multiple
hepatic metastasis when compared to prior studies from
[**2167-11-20**] as well as [**2168-2-26**]. 2) Occlusion of the portal vein
as well as the superior mesenteric vein at its confluence with
the splenic vein. 3) Increased intraabdominal ascites when
compared to [**2168-2-26**]. 4) The lesion within the gallbladder
fundus that measured 3.0 x 2.5 cm on [**2168-2-26**], measures 2.7 x
2.5 cm.

RUQ U/S [**4-27**]:
1.	Ascites and right pleural effusion.
2.	Gallbladder with sludge, not distended. There is some minimal
gallbladder
wall edema, though to be expected in the setting of high fluid
states.

CT Abdomen [**4-27**]: Thickened Colon. No perforation.  Unchanged
pancreas. Unchanged bilateral pleural effusions.

Brief Hospital Course:
31 yo M with metastatic gallbladder cancer who presented to the
ED with fever, abdominal pain and sepsis; found to have
enterococcal bacteremia and endocarditis

.

1. Entercoccal bacteremia, endocarditis

He met criteria for sepsis by fever, tachycardia, elevated white
count, and elevated lactate.  He has had early
intervention/aggressive volume resuscitation and broad spectrum
abx.  His infectious work up to date significant for pan-colitis
on CT with c. diff negative, clean UA, clear CXR, and [**1-27**]
bottles bloood cultures on [**4-27**] with gram + cocci/enterococcus,
and paracentesis with no evidence of SBP. RUQ US with no
evidence of cholecystitis.

He clinically improved and remained stable; continued broad
spectrum abx with Linezolid to cover for potential MRSA or VRE,
levo for SBP prophylaxis, and po flagyl for empiric c. diff
coverage.

Ultimately, he was maintained on Penicillin and gentamycin for
treatment of his enterococcal bacteremia with TTE evidence of
endocarditis - had valvular thickening and inferior wall
hypokinesis. TEE was considered, but was deemed too risky in the
setting of known esophageal varices. Plan is for 4-6 weeks of
these antibiotics.

2. cholestasis/liver failure

Complicated by recurrent ascites and h/o esophageal varices s/p
repeat banding
- EGD in [**2-27**] with grade I varices
- s/p paracentesis on admission with no evidence of SBP

His ascites, peripheral edema was manged with lasix/aldactone,
and repeat
paracentesis. His nadolol was continued for secondary variceal
bleeding prophylaxis.

.

3. Metastatic cholangiocarcinoma of the GB

 With mets to liver and lungs, retroperitoneal lymph nodes. With
metal stent in CBD.  Discussion was held with Dr. [**Last Name (STitle) 27538**],
patient, and family.  It was discussed that these is no further
role for chemotherapy, and also code status was discussed.

.

5. Microcytic, hypochromic anemia

History of past GI bleeding from esophageal varices. These have
been
monitored by repeated EGD with banding. GI was involved in his
care during
this hospitalization; no further EGD or banding done at this
time. Last EGD
in [**2-27**] with Grade I varices.

6. Pan-colitis

Seen by abdominal CT; was c. diff negative x 3. Diarrhea only
once, thereafter resolved and clincally stable. Tolerated po
diet well.
.


Medications on Admission:
Ciprofloxacin 500 mg po qd
Aldactone 50 mg po qd
Dilaudid 16 mg po q6-8h prn
Neurontin 300 mg po tid

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).

7. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Nadolol 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Fentanyl 100 mcg/hr Patch 72HR Sig: 2.5 patches Transdermal
Q72H (every 72 hours): total dose of 250mcg patch q72h.
13. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: Four
(4) MU Injection Q4H (every 4 hours) for 4 weeks.
14. Gentamicin in Normal Saline 100 mg/50 mL Piggyback Sig: One
Hundred (100) mg Intravenous  Q8H (every 8 hours) for 4 weeks.
15. Hydromorphone HCl 4 mg/mL Syringe Sig: Four (4) mg Injection
Q3-4H () as needed.
16. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg
Injection Q6H (every 6 hours) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
1. metastatic cholangiocarcinoma
2. enterococcal bacteremia/endocarditis
3. liver metastases/failure/coagulopathy/h/o variceal bleeding
4. anemia
5. ascites, s/p paracentesis
6. pan-colitis, c. diff negative x 3


Discharge Condition:
stable

Discharge Instructions:
Call your doctor for any worsening abdominal pain,
nausea/vomiting,
blood in your stool, or any fevers.

Followup Instructions:
Keep your follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 150**].


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 32201**]
{'Other septicemia due to gram-negative organisms,Acute and subacute bacterial endocarditis,Malignant neoplasm of liver, secondary,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Malignant neoplasm of gallbladder,Sepsis,Other and unspecified noninfectious gastroenteritis and colitis,Lipodystrophy,Portal hypertension,Iron deficiency 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: abdominal pain and fever

PRESENT ILLNESS: Mr. [**Known lastname 57978**] is a 31 y/o man with a history metastatic, poorly
differentiated adenocarcinoma  with squamous differentiation,
likely gallbladder primary who presents with abdominal pain and
fevers.

MEDICAL HISTORY: 1.  Metastatic GB cancer as above, with mets to liver,
retroperitoneal lymph nodes.  With metal stent in CBD.
Complications of esophageal varices, s/p multiple bandings (most
recently [**2168-1-21**]).  On Gemcitabine/Cisplatin, most recent chemo
[**2168-2-4**]
2.  Malaria in past
3. s/p Appendectomy
4. H. Pylori, treated
5. UTI [**2163**]
6.  HBV, low viral load, with varices in lower 1/3 esophagus

MEDICATION ON ADMISSION: Ciprofloxacin 500 mg po qd
Aldactone 50 mg po qd
Dilaudid 16 mg po q6-8h prn
Neurontin 300 mg po tid

ALLERGIES: Bactrim

PHYSICAL EXAM: PE: VS: 98.9 HR 99 BP 106/48 RR 25 %Sat 99 CVP 9 ScvO2 77
Gen:  Tired, jaundiced, flat affect otherwise NAD
HEENT:  Mild icterus bilateral, O/P dry
Neck: Supple, no cervical LAD, RIJ in place
Chest:  Decreased breath sounds on right halfway up and crackles
left base
Cor:  Tachy no rubs/m/g
Abd:  Distended, bandage on right side, generalized TN on deep
palp
Ext:  1+ pitting edema to knee
Neuro:  A+O x 3, grossly non-focal

FAMILY HISTORY: DM in both parents, no cad, cancer.  10 siblings, none with
cancer

SOCIAL HISTORY: Originially from [**Country **], moved to [**Location (un) **] 5 years ago, worked at
[**7-4**] (not currently). Denies tobacco/etoh (for many
months)/drugs. Living with his brothers 

### Response:
{'Other septicemia due to gram-negative organisms,Acute and subacute bacterial endocarditis,Malignant neoplasm of liver, secondary,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Malignant neoplasm of gallbladder,Sepsis,Other and unspecified noninfectious gastroenteritis and colitis,Lipodystrophy,Portal hypertension,Iron deficiency anemia, unspecified'}
