CHIEF COMPLAINT: abdominal pain, fever

PRESENT ILLNESS: 63M with PVD, EtOH and cocaine abuse, admitted to [**Hospital **]
Hospital on [**2117-2-22**] with septic shock and E.coli bacteremia, now
transferred to [**Hospital1 18**] for further workup and potential ERCP.
.
He presented on [**2-22**] with lethargy, disorientation, and fever to
105 with abdominal pain after his roommate called EMS.  Blood
cultures grew E.coli bacteremia and he developed septic shock
and was admitted to the ICU.  He was intubated and required both
vasopressin and norepinephrine.  Started on meropenem (and later
changed to irtapenem).  He had perc CCY tube placed on [**2-24**].
Pressors were weaned off.  He also had NSTEMI in setting of his
sepsis with peak troponin 37.88 on [**2-24**].  Echo showed EF 25-30%
with severe global LV HK.  There was also concern for worsening
RLE ischemia on pressors vs. true graft thrombosis.  On [**3-1**] he
went to the OR for RLE AKA and cholecystectomy.  Procedure
notable for somewhat difficult to remove gallbladder with some
resultant bleeding in gallbladder fossa.  No intraop
cholangiogram per procedure notes.  He was extubated on [**2117-3-1**].
 Post op noted to have increasing amylase (to 551) and lipase
(to 288).  Also developed fever to 100.8.  Could not get MRCP
due to shrapnel in eye (though wife does not know anything about
this), so being transferred to [**Hospital1 18**] for ERCP to evaluate these
new changes.
.
Speaking with patient's wife, she notes a change in mental
status since extubation.  Extubated on [**3-1**] and she reports that
he recognized her and other family members that night.  However,
the following day and yesterday he has been confused about where
he is and who friends and family were.  Also slurring speech
worse (has some slur at baseline).  No noted weakness in
UEs/LEs.  Has baseline facial asymmetry since MVA.
.
In the [**Hospital Unit Name 153**], patient appears comfortable.  Delerious and
disoriented but calm.  Denies pain of any type.  ROS as below.

MEDICAL HISTORY: - Severe PVD s/p multiple bypass surgeries of LEs (L femoral to
above knee bypass [**2115**], R external iliac to superficial femoral
artery bypass [**2115**] and R common iliac to above knee [**Doctor Last Name **] bypass
[**2116**]) and carotids (L CEA [**2115**]).
- HTN
- Hyperlipidemia
- Polysubstance abuse including EtOH and cocaine, ?others
- ?COPD
- Motorcycle accident resulting in need for reconstructive
surgery of L jaw.

MEDICATION ON ADMISSION: Medications at home:
Atenolol 25 mg daily per notes (not clear that he was actually
taking any)
.
Medications at transfer:
Ertapenem 1 gram daily
Metoprolol 5 mg IV Q6H
Protonix 40 mg daily
Albuterol nebs Q2H prn
Morphine 2-4 mg prn
Haldol 4 mg Q8H prn agitation
Heparin SC
NS at 75 cc/hr

ALLERGIES: Penicillins / Aspirin / Codeine

PHYSICAL EXAM: General: Alert but somewhat lethargic at times, no distress.
HEENT: Sclera anicteric, PERRL, MMM, appears to have some thrush
on posterior tongue. Poor dentition with most teeth missing.
Neck: supple, JVP not elevated, no LAD.  L CEA scar.  Denies
posterior neck TTP.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, but very poor effort.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  All incisions C/D/I.  RUQ port incision had been
draining small amount serous fluid, no purulence or bleeding.
Old healed RLQ scar from bypass.  +BS.  Soft, appears to be
diffusely tender, non-distended, no rebound tenderness or
guarding, no organomegaly.
Ext: warm, well perfused.  2+ L DP and PT pulses.  No edema.
s/p R AKA, wrapped.
Neuro: Alert.  Oriented to person only.  Facial asymmetry with
?droop of L lower face, though appears c/w past trauma and
asymmetric tooth loss.  Initially ?very mild L ptosis and
inability to raise L eyebrow, but able to do so later in exam.
Difficulties with cooperating and following commands (won't
smile).  Tongue does show some deviation to R.  EOMs not able to
be completely tested but will move in all directions.  PERRL.
Denies sensory deficits.  Extremity strength testing also
difficult.  Of LLE, [**5-12**] in dorsi/plantar flexing, but will not
move rest of muscle groups.  Of bilateral UEs, can get [**5-12**] elbow
flexion and [**5-12**] elbow extension on R, weaker on L vs. not fully
participating.  [**4-11**]+/5 intrinsic hand muscles.  Difficulty with
testing proximal UE muscle groups.  Unable to look for pronator
drift or asterixis due to lack of patient participation.  Tone
appears normal.

FAMILY HISTORY: Mother had [**Name2 (NI) 499**] cancer.

SOCIAL HISTORY: Married though is estranged from wife (lives with a few
roommates) mainly related to EtOH abuse.  Very heavy drinker.
Smoking history of approx 1 PPD per wife.  Cocaine positive on
tox, wife does not know much abuse illicit drug use history.
Subendocardial infarction, initial episode of care,Obstruction of bile duct,Acute pancreatitis,Bacteremia,Drug-induced delirium,Candidiasis of mouth,Chronic hepatitis C without mention of hepatic coma,Above knee amputation status,Coronary atherosclerosis of native coronary artery,Atherosclerosis of unspecified bypass graft of the extremities,Unspecified essential hypertension,Other and unspecified alcohol dependence, continuous,Tobacco use disorder,Chronic airway obstruction, not elsewhere classified,Esophageal reflux,Essential thrombocythemia
Subendo infarct, initial,Obstruction of bile duct,Acute pancreatitis,Bacteremia,Drug-induced delirium,Thrush,Chrnc hpt C wo hpat coma,Status amput above knee,Crnry athrscl natve vssl,Athscl extrm bps gft NOS,Hypertension NOS,Alcoh dep NEC/NOS-contin,Tobacco use disorder,Chr airway obstruct NEC,Esophageal reflux,Essntial thrombocythemia
Admission Date:  [**2117-3-4**]              Discharge Date:   [**2117-3-10**]

Date of Birth:  [**2053-12-5**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Aspirin / Codeine

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
abdominal pain, fever

Major Surgical or Invasive Procedure:
ERCP [**3-5**]
at OSH:  percutaneous biliary tube placement, cholecystectomy,
Rt sided AKA

History of Present Illness:
63M with PVD, EtOH and cocaine abuse, admitted to [**Hospital **]
Hospital on [**2117-2-22**] with septic shock and E.coli bacteremia, now
transferred to [**Hospital1 18**] for further workup and potential ERCP.
.
He presented on [**2-22**] with lethargy, disorientation, and fever to
105 with abdominal pain after his roommate called EMS.  Blood
cultures grew E.coli bacteremia and he developed septic shock
and was admitted to the ICU.  He was intubated and required both
vasopressin and norepinephrine.  Started on meropenem (and later
changed to irtapenem).  He had perc CCY tube placed on [**2-24**].
Pressors were weaned off.  He also had NSTEMI in setting of his
sepsis with peak troponin 37.88 on [**2-24**].  Echo showed EF 25-30%
with severe global LV HK.  There was also concern for worsening
RLE ischemia on pressors vs. true graft thrombosis.  On [**3-1**] he
went to the OR for RLE AKA and cholecystectomy.  Procedure
notable for somewhat difficult to remove gallbladder with some
resultant bleeding in gallbladder fossa.  No intraop
cholangiogram per procedure notes.  He was extubated on [**2117-3-1**].
 Post op noted to have increasing amylase (to 551) and lipase
(to 288).  Also developed fever to 100.8.  Could not get MRCP
due to shrapnel in eye (though wife does not know anything about
this), so being transferred to [**Hospital1 18**] for ERCP to evaluate these
new changes.
.
Speaking with patient's wife, she notes a change in mental
status since extubation.  Extubated on [**3-1**] and she reports that
he recognized her and other family members that night.  However,
the following day and yesterday he has been confused about where
he is and who friends and family were.  Also slurring speech
worse (has some slur at baseline).  No noted weakness in
UEs/LEs.  Has baseline facial asymmetry since MVA.
.
In the [**Hospital Unit Name 153**], patient appears comfortable.  Delerious and
disoriented but calm.  Denies pain of any type.  ROS as below.


Past Medical History:
- Severe PVD s/p multiple bypass surgeries of LEs (L femoral to
above knee bypass [**2115**], R external iliac to superficial femoral
artery bypass [**2115**] and R common iliac to above knee [**Doctor Last Name **] bypass
[**2116**]) and carotids (L CEA [**2115**]).
- HTN
- Hyperlipidemia
- Polysubstance abuse including EtOH and cocaine, ?others
- ?COPD
- Motorcycle accident resulting in need for reconstructive
surgery of L jaw.

Social History:
Married though is estranged from wife (lives with a few
roommates) mainly related to EtOH abuse.  Very heavy drinker.
Smoking history of approx 1 PPD per wife.  Cocaine positive on
tox, wife does not know much abuse illicit drug use history.


Family History:
Mother had [**Name2 (NI) 499**] cancer.

Physical Exam:
General: Alert but somewhat lethargic at times, no distress.
HEENT: Sclera anicteric, PERRL, MMM, appears to have some thrush
on posterior tongue. Poor dentition with most teeth missing.
Neck: supple, JVP not elevated, no LAD.  L CEA scar.  Denies
posterior neck TTP.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, but very poor effort.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  All incisions C/D/I.  RUQ port incision had been
draining small amount serous fluid, no purulence or bleeding.
Old healed RLQ scar from bypass.  +BS.  Soft, appears to be
diffusely tender, non-distended, no rebound tenderness or
guarding, no organomegaly.
Ext: warm, well perfused.  2+ L DP and PT pulses.  No edema.
s/p R AKA, wrapped.
Neuro: Alert.  Oriented to person only.  Facial asymmetry with
?droop of L lower face, though appears c/w past trauma and
asymmetric tooth loss.  Initially ?very mild L ptosis and
inability to raise L eyebrow, but able to do so later in exam.
Difficulties with cooperating and following commands (won't
smile).  Tongue does show some deviation to R.  EOMs not able to
be completely tested but will move in all directions.  PERRL.
Denies sensory deficits.  Extremity strength testing also
difficult.  Of LLE, [**5-12**] in dorsi/plantar flexing, but will not
move rest of muscle groups.  Of bilateral UEs, can get [**5-12**] elbow
flexion and [**5-12**] elbow extension on R, weaker on L vs. not fully
participating.  [**4-11**]+/5 intrinsic hand muscles.  Difficulty with
testing proximal UE muscle groups.  Unable to look for pronator
drift or asterixis due to lack of patient participation.  Tone
appears normal.

Pertinent Results:
[**2117-3-4**] 09:18PM   GLUCOSE-96 UREA N-20 CREAT-0.5 SODIUM-138
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-14
[**2117-3-4**] 09:18PM   estGFR-Using this
[**2117-3-4**] 09:18PM   ALT(SGPT)-192* AST(SGOT)-92* LD(LDH)-211
CK(CPK)-130 ALK PHOS-263* AMYLASE-516* TOT BILI-0.7
[**2117-3-4**] 09:18PM   LIPASE-241*
[**2117-3-4**] 09:18PM   CK-MB-2 cTropnT-0.16*
[**2117-3-4**] 09:18PM   IRON-65
[**2117-3-4**] 09:18PM   ALBUMIN-3.4* CALCIUM-8.9 PHOSPHATE-4.1
MAGNESIUM-2.0
[**2117-3-4**] 09:18PM   calTIBC-313 FERRITIN-314 TRF-241
[**2117-3-4**] 09:18PM   VIT B12-GREATER TH FOLATE-15.8
[**2117-3-4**] 09:18PM   TRIGLYCER-131
[**2117-3-4**] 09:18PM   TSH-1.7
[**2117-3-4**] 09:18PM   HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE
[**2117-3-4**] 09:18PM   HCV Ab-POSITIVE*
[**2117-3-4**] 09:18PM   WBC-11.9* RBC-4.06* HGB-11.2* HCT-33.5*
MCV-83 MCH-27.7 MCHC-33.5 RDW-14.8
[**2117-3-4**] 09:18PM   NEUTS-69.4 LYMPHS-22.2 MONOS-5.4 EOS-2.3
BASOS-0.7
[**2117-3-4**] 09:18PM   PLT COUNT-647*
[**2117-3-4**] 09:18PM   PT-12.9 PTT-23.6 INR(PT)-1.1

on dishcarge from the [**Hospital1 **], pt.s platelet count was 1,049,000.
This is felt to be a reactive thrombocytosis due to the combined
effects of: multiple recent surgeries, and also possibly post
alcohol abuse thrombocytopenia recovery.  ESR and CRP were
checked and are elevated supporting this etiology.  This will
need to be monitored - please check weekly CBC.  If platelet
count is continuing to rise, pt. will need evaluation by
hematology to rule out underlying ET or PV by peripheral smear
review and or bone marrow biopsy.  Here thre were no stigmata or
symptoms of thrombotic complication of this thrombocytosis
(uncommon in reactive thrombocytosis) and aspirin 325 mg was
started for combined effect of platelet inhibition and secondary
prevention given known cad and nstemi suffered at outside
hospital prior to admission here.

ERCP Report


major papilla s/p sphincterotomy, PD stent in place PD stent
(later removed)

CCY clips Dilated PD Distal CBD

No cystic duct leak Balloon sweep
Date: Friday, [**2117-3-5**] Endoscopist(s): [**Name6 (MD) **] [**Name8 (MD) 19087**], MD (attending)
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (fellow)

Patient: [**Known firstname **] [**Last Name (NamePattern1) 86101**]
 Ref.Phys.: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4427**], MD
    Assisting Nurse(s)/
Other Personnel: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 52485**], RN
Birth Date: [**2053-12-5**] (63 years) Instrument: TJF-160VF
([**Telephone/Fax (5) 86102**] Indications: A level 4 consult was performed
Elevated LFTs s/p complicated cholecystectomy, and abnormal CT
scan showing a dilated CBD and fluid in the gallbladder fossa.
Rule out retained CBD stone and/or bile leak.

Medications: Cetacaine topical spray
Monitored anesthesia care

Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered MAC
anesthesia. The patient was placed in the supine position and an
endoscope was introduced through the mouth and advanced under
direct visualization until the third part of the duodenum was
reached. Careful visualization was performed. The procedure was
not difficult. The quality of the preparation was good. The
patient tolerated the procedure well. There were no
complications.
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation:  Cannulation of the pancreatic duct was performed
with a sphincterotome after a guidewire was placed in order to
place a PD stent to facilitate biliary cannulation. Contrast
medium was injected resulting in partial opacification.
Cannulation of the biliary duct was performed with a
sphincterotome after a guidewire was placed. Contrast medium was
injected resulting in complete opacification.

Biliary Tree: A mild dilation was seen at the main duct with the
CBD measuring 9-10 mm. These findings are compatible with benign
papillary stenosis. No stones were seen in the CBD. There was no
extravasation of contrast seen from the cystic duct stump or
from any ducts of Luschka. A sphincterotomy was performed in the
12 o'clock position using a sphincterotome over an existing
guidewire. A small amount of biliary sludge was extracted from
the CBD successfully using a 9-12mm Rx balloon catheter.
Pancreas: A mild dilation of approximately 5mm was seen at the
distal main pancreatic duct. A 4cm by 5FR pancreatic stent was
placed successfully to aid in biliary cannulation. The plastic
pancreatic duct stent was removed successfully with a snare.
Impression: Normal major papilla.
Cannulation of the pancreatic duct was performed with a
sphincterotome after a guidewire was placed in order to place a
PD stent to facilitate biliary cannulation. Contrast medium was
injected resulting in partial opacification.
A mild dilation of approximately 5mm was seen at the distal main
pancreatic duct.
A 4cm by 5FR pancreatic stent was placed successfully to aid in
biliary cannulation.
Cannulation of the biliary duct was performed with a
sphincterotome after a guidewire was placed. Contrast medium was
injected resulting in complete opacification.
A mild dilation was seen at the main duct with the CBD measuring
9-10 mm. These findings are compatible with benign papillary
stenosis.
No stones were seen in the CBD.
There was no extravasation of contrast seen from the cystic duct
stump or from any ducts of Luschka.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
A small amount of biliary sludge was extracted from the CBD
successfully using a 9-12mm Rx balloon catheter.
The plastic pancreatic duct stent was removed successfully with
a snare.

Recommendations: Return to the ICU.
NPO overnight with aggressive IV fluid hydration with LR at 200
cc/hr if he can tolerate the rate.

Recommend MRCP to evaluate his dilated pancreatic duct.
Additional notes: The procedure was performed by Dr. [**Last Name (STitle) **] and
the GI fellow.

Thank you Dr. [**Last Name (STitle) 4427**] for allowing me to participate in the care
of Mr. [**Last Name (Titles) 86101**].

_________________________________
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD (attending)
_________________________________
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (fellow)
Case documentation started on [**2117-3-5**] 3:22:40 PM
Patient: [**Known firstname **] [**Last Name (NamePattern1) 86101**] ([**Numeric Identifier **])


Brief Hospital Course:
63M with PVD, EtOH abuse, presents with septic shock from
presumed biliary source, now transferred to [**Hospital1 18**] for
consideration of ERCP and further management of abnormal LFTs
and lipase.
.
# Elevated lipase and abnormal LFTs.  ERCP done, report above.
LFTs and lipase imrproved.  Pt. found to have hcv - ab positive
and viral load of:

[**2117-3-5**] 5:41 am IMMUNOLOGY
      CHEM S# [**Serial Number 24032**]D QUANTITATION BEYOND 850,000 IU/ML ADDED
[**3-5**].

                            **FINAL REPORT [**2117-3-8**]**

   HCV VIRAL LOAD (Final [**2117-3-8**]):
      13,800,000 IU/mL.
      Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
      Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
      Limit of detection: 18 IU/mL.
      If HCV genotype on patient's sample is desired, please
contact
      laboratory at ext. [**7-/3125**] within two weeks.

Clinically, he had no abdominal pain, n/v, jaundice, fevers.  He
tolerated resumption of a regular diet without difficulty once
his ileus resolved with holding of large narcotic doses given in
the ICU.
.
# Septic shock/bacteremia.  Shock resolved and normotensive with
no evidence of poor perfusion; note - pt. had undergone rt. leg
BKA prior to admission for ischemia of the rt. LE when pressors
given at outside hospital, and, our CT here demonstrated
thrombosis of his prior bypass grafts (likely old) - he
maintained good perfusion of the Lt. LE and remaining rt LE
without any evidence of diminished perfusion (warm, good
capillary refil, no pallor or dusky appearance, no pain other
than some tenderness at the rt. BKA incision site).  Treatment
for bacteremia continued with meropenem, and course was
completed on [**2117-3-9**].  His cultures obtained here remained
negative.
.
# Altered mental status consistent with delerium.  Likely due to
combined effects of illness and narcotic medications.   This
resolved slowly, with holding of nacotics.  He required some
parenteral haldol for agitation while in the intensive care
unit.  His mental status continues to clear at time of
discharge, but wife indicates he is not at his baseline.
.
# NSTEMI.  Very elevated trops (and CKs) in setting of
hypotension/sepsis, though patient with bad PVD (thus likely
CAD) and may have had more classic thrombotic infarct.  ECG with
inferior Q waves and poor transition - present on ECGs early
this admission though unclear exactly how old.  Was on heparin
early this admit, now off.  After ERCP, aspirin was started -
his aspirin allergy is GERD only, so a PPI was added for
prophylaxis and protection.  Beta blockers were continued.  He
should be considered for statin and ace inhibitor as an
outpatient in follow up with a cardiologist.
.
# RLE ischemia/PVD.  Now s/p AKA as above.  Unclear if was graft
or arterial thrombus formation vs. global effects of pressors.
CT abdomen obtained and seemed to show graft thrombosis.
Antiplatelet [**Doctor Last Name 360**] as above.  Vascular was consulted and
provided recs here.
- Post op followup as indicated in the discharge instructions.
.
# Polysubstance abuse.  EtOH and cocaine known.  Folate, MVI,
thiamine started.
No evidence for withdrawal.
.
# Thrombocytosis.  From recent infection and acute stressors
most likely.
- Continue to monitor as indicated in discharge instructions.
.
Communication: Patient, wife [**Name (NI) **] [**Telephone/Fax (1) 86103**]

Medications on Admission:
Medications at home:
Atenolol 25 mg daily per notes (not clear that he was actually
taking any)
.
Medications at transfer:
Ertapenem 1 gram daily
Metoprolol 5 mg IV Q6H
Protonix 40 mg daily
Albuterol nebs Q2H prn
Morphine 2-4 mg prn
Haldol 4 mg Q8H prn agitation
Heparin SC
NS at 75 cc/hr


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours) as needed for nausea.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gram PO DAILY (Daily) as needed for constipation.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for sob/wheeze.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: maximum of 2 grams per day.
12. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]

Discharge Diagnosis:
Delerium
CAD, PVD
Likely reactive thrombocytosis
Ileus (resolved)
E Coli bacteremia (two week course of abx. therapy completed,
surveillance cultures no growth to date)
s/p open ccy
s/p rt LE BKA amputation
Deconditioning
HCV infection, chronic
Ongoing polysubstance abuse and tobacco use (alcohol, cocaine)

Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)

Discharge Instructions:
See below

Followup Instructions:
Primary MD: ([**Doctor First Name **] J. [**Doctor Last Name **] [**Telephone/Fax (1) 86104**]), [**Hospital **] Hospital,
Dr. [**Last Name (STitle) 86105**] (surgery at [**Hospital **] hospital), will also need
hepatologist and cardiology outpatient care established through
primary MD as outpatient given CAD, HCV infection
{'Subendocardial infarction, initial episode of care,Obstruction of bile duct,Acute pancreatitis,Bacteremia,Drug-induced delirium,Candidiasis of mouth,Chronic hepatitis C without mention of hepatic coma,Above knee amputation status,Coronary atherosclerosis of native coronary artery,Atherosclerosis of unspecified bypass graft of the extremities,Unspecified essential hypertension,Other and unspecified alcohol dependence, continuous,Tobacco use disorder,Chronic airway obstruction, not elsewhere classified,Esophageal reflux,Essential thrombocythemia'}


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, fever

PRESENT ILLNESS: 63M with PVD, EtOH and cocaine abuse, admitted to [**Hospital **]
Hospital on [**2117-2-22**] with septic shock and E.coli bacteremia, now
transferred to [**Hospital1 18**] for further workup and potential ERCP.
.
He presented on [**2-22**] with lethargy, disorientation, and fever to
105 with abdominal pain after his roommate called EMS.  Blood
cultures grew E.coli bacteremia and he developed septic shock
and was admitted to the ICU.  He was intubated and required both
vasopressin and norepinephrine.  Started on meropenem (and later
changed to irtapenem).  He had perc CCY tube placed on [**2-24**].
Pressors were weaned off.  He also had NSTEMI in setting of his
sepsis with peak troponin 37.88 on [**2-24**].  Echo showed EF 25-30%
with severe global LV HK.  There was also concern for worsening
RLE ischemia on pressors vs. true graft thrombosis.  On [**3-1**] he
went to the OR for RLE AKA and cholecystectomy.  Procedure
notable for somewhat difficult to remove gallbladder with some
resultant bleeding in gallbladder fossa.  No intraop
cholangiogram per procedure notes.  He was extubated on [**2117-3-1**].
 Post op noted to have increasing amylase (to 551) and lipase
(to 288).  Also developed fever to 100.8.  Could not get MRCP
due to shrapnel in eye (though wife does not know anything about
this), so being transferred to [**Hospital1 18**] for ERCP to evaluate these
new changes.
.
Speaking with patient's wife, she notes a change in mental
status since extubation.  Extubated on [**3-1**] and she reports that
he recognized her and other family members that night.  However,
the following day and yesterday he has been confused about where
he is and who friends and family were.  Also slurring speech
worse (has some slur at baseline).  No noted weakness in
UEs/LEs.  Has baseline facial asymmetry since MVA.
.
In the [**Hospital Unit Name 153**], patient appears comfortable.  Delerious and
disoriented but calm.  Denies pain of any type.  ROS as below.

MEDICAL HISTORY: - Severe PVD s/p multiple bypass surgeries of LEs (L femoral to
above knee bypass [**2115**], R external iliac to superficial femoral
artery bypass [**2115**] and R common iliac to above knee [**Doctor Last Name **] bypass
[**2116**]) and carotids (L CEA [**2115**]).
- HTN
- Hyperlipidemia
- Polysubstance abuse including EtOH and cocaine, ?others
- ?COPD
- Motorcycle accident resulting in need for reconstructive
surgery of L jaw.

MEDICATION ON ADMISSION: Medications at home:
Atenolol 25 mg daily per notes (not clear that he was actually
taking any)
.
Medications at transfer:
Ertapenem 1 gram daily
Metoprolol 5 mg IV Q6H
Protonix 40 mg daily
Albuterol nebs Q2H prn
Morphine 2-4 mg prn
Haldol 4 mg Q8H prn agitation
Heparin SC
NS at 75 cc/hr

ALLERGIES: Penicillins / Aspirin / Codeine

PHYSICAL EXAM: General: Alert but somewhat lethargic at times, no distress.
HEENT: Sclera anicteric, PERRL, MMM, appears to have some thrush
on posterior tongue. Poor dentition with most teeth missing.
Neck: supple, JVP not elevated, no LAD.  L CEA scar.  Denies
posterior neck TTP.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, but very poor effort.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  All incisions C/D/I.  RUQ port incision had been
draining small amount serous fluid, no purulence or bleeding.
Old healed RLQ scar from bypass.  +BS.  Soft, appears to be
diffusely tender, non-distended, no rebound tenderness or
guarding, no organomegaly.
Ext: warm, well perfused.  2+ L DP and PT pulses.  No edema.
s/p R AKA, wrapped.
Neuro: Alert.  Oriented to person only.  Facial asymmetry with
?droop of L lower face, though appears c/w past trauma and
asymmetric tooth loss.  Initially ?very mild L ptosis and
inability to raise L eyebrow, but able to do so later in exam.
Difficulties with cooperating and following commands (won't
smile).  Tongue does show some deviation to R.  EOMs not able to
be completely tested but will move in all directions.  PERRL.
Denies sensory deficits.  Extremity strength testing also
difficult.  Of LLE, [**5-12**] in dorsi/plantar flexing, but will not
move rest of muscle groups.  Of bilateral UEs, can get [**5-12**] elbow
flexion and [**5-12**] elbow extension on R, weaker on L vs. not fully
participating.  [**4-11**]+/5 intrinsic hand muscles.  Difficulty with
testing proximal UE muscle groups.  Unable to look for pronator
drift or asterixis due to lack of patient participation.  Tone
appears normal.

FAMILY HISTORY: Mother had [**Name2 (NI) 499**] cancer.

SOCIAL HISTORY: Married though is estranged from wife (lives with a few
roommates) mainly related to EtOH abuse.  Very heavy drinker.
Smoking history of approx 1 PPD per wife.  Cocaine positive on
tox, wife does not know much abuse illicit drug use history. 

### Response:
{'Subendocardial infarction, initial episode of care,Obstruction of bile duct,Acute pancreatitis,Bacteremia,Drug-induced delirium,Candidiasis of mouth,Chronic hepatitis C without mention of hepatic coma,Above knee amputation status,Coronary atherosclerosis of native coronary artery,Atherosclerosis of unspecified bypass graft of the extremities,Unspecified essential hypertension,Other and unspecified alcohol dependence, continuous,Tobacco use disorder,Chronic airway obstruction, not elsewhere classified,Esophageal reflux,Essential thrombocythemia'}
