CHIEF COMPLAINT: hypotension, altered mental status

PRESENT ILLNESS: Ms. [**Known lastname 63057**] is an 82 year old woman with pancreatic Ca, gastric
outlet obstruction and questionable biliary obstruction, s/p
plastic stent in CBD placed by GI several months ago. She was
transferred from [**Hospital3 **] for ERCP today with bacteremia and
septic picture.
She had ERCP today - GI could not cannulate ampula due to mass,
placed  duodenal stent. IR wants to confirm biliary obstruction
+ assess the anatomy before potential PTC tomorrow.  She is
admitted to the [**Hospital Unit Name 153**] for hypotension and altered mental status.
.
Patient was admitted to [**Hospital6 33**] from a nursing home
on [**2158-2-26**] with intractable nausea and vomiting and coffee
ground emesis.
She was to have ERCP as above today to look at possible
dudodenal obstruction with potential palliative stenting.
.
During the procedure GI doctors made aware by physicians at
[**Hospital3 **] that patient had blood cultures growing GNR's.
.
On seeing the patient, she is unable to provide much history.
She has received about 2 liters of normal saline for blood
pressure in 80's to 90's.  Throughout ERCP blood pressure had
been in this range.

MEDICAL HISTORY: 1. Metastatic pancreatic carcinoma diagnosed in [**Month (only) **] of
[**2156**]-CT scan at [**Hospital3 **] done weeks ago showed mets to liver,
lungs, and obstruction of portal, splenic veins
2. GI bleeding--recent, [**2-16**] at [**Hospital3 **], EGD revealed
erosive esophagitis and dudoenal inflammation raising concern
for duodenal outlet obstruction.
3. diabetes mellitus
4. formerly hypertension
5. Orthostatic hypotension

MEDICATION ON ADMISSION: 1. midodrine
2. lipitor
3. protonix
4. glyburide
5. reglan
6. potassium

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:
VS:  Temp: 98     BP: 90  /55    HR:80  RR:16    98%2l ncO2sat

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Resides in skilled nursing facility. No smoking, occasional
alcohol, no drug use.
Septicemia due to escherichia coli [E. coli],Cholangitis,Malignant neoplasm of other specified sites of pancreas,Acquired hypertrophic pyloric stenosis,Atrial fibrillation,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of liver, secondary,Sepsis,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
E coli septicemia,Cholangitis,Malig neo pancreas NEC,Acq pyloric stenosis,Atrial fibrillation,Secondary malig neo bone,Second malig neo liver,Sepsis,Hypertension NOS,DMII wo cmp nt st uncntr
Admission Date:  [**2158-3-1**]              Discharge Date:   [**2158-3-7**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
hypotension, altered mental status

Major Surgical or Invasive Procedure:
ERCP, and biliary stent placement by IR

History of Present Illness:
Ms. [**Known lastname 63057**] is an 82 year old woman with pancreatic Ca, gastric
outlet obstruction and questionable biliary obstruction, s/p
plastic stent in CBD placed by GI several months ago. She was
transferred from [**Hospital3 **] for ERCP today with bacteremia and
septic picture.
She had ERCP today - GI could not cannulate ampula due to mass,
placed  duodenal stent. IR wants to confirm biliary obstruction
+ assess the anatomy before potential PTC tomorrow.  She is
admitted to the [**Hospital Unit Name 153**] for hypotension and altered mental status.
.
Patient was admitted to [**Hospital6 33**] from a nursing home
on [**2158-2-26**] with intractable nausea and vomiting and coffee
ground emesis.
She was to have ERCP as above today to look at possible
dudodenal obstruction with potential palliative stenting.
.
During the procedure GI doctors made aware by physicians at
[**Hospital3 **] that patient had blood cultures growing GNR's.
.
On seeing the patient, she is unable to provide much history.
She has received about 2 liters of normal saline for blood
pressure in 80's to 90's.  Throughout ERCP blood pressure had
been in this range.


Past Medical History:
1. Metastatic pancreatic carcinoma diagnosed in [**Month (only) **] of
[**2156**]-CT scan at [**Hospital3 **] done weeks ago showed mets to liver,
lungs, and obstruction of portal, splenic veins
2. GI bleeding--recent, [**2-16**] at [**Hospital3 **], EGD revealed
erosive esophagitis and dudoenal inflammation raising concern
for duodenal outlet obstruction.
3. diabetes mellitus
4. formerly hypertension
5. Orthostatic hypotension

Social History:
Resides in skilled nursing facility. No smoking, occasional
alcohol, no drug use.

Family History:
non-contributory

Physical Exam:
Admission:
VS:  Temp: 98     BP: 90  /55    HR:80  RR:16    98%2l ncO2sat

general: pleasant, comfortable but delirious
HEENT: PERLLA, EOMI, scleral icterus, no sinus tenderness,
MMdry, op without lesions, no supraclavicular or cervical
lymphadenopathy, no jvd, no carotid bruits
lungs: crackles at bases
heart: RR, S1 and S2 wnl
abdomen: distended, hypoactive b/s, soft, nt
extremities: 2+edema, non-tender
skin/nails: jaundiced
neuro: AAOx3.  Cn II-XII intact.
rectal:deferred

Pertinent Results:
[**2158-3-1**] 02:25PM BLOOD WBC-22.8* RBC-3.08* Hgb-8.7* Hct-26.3*
MCV-85 MCH-28.3 MCHC-33.2 RDW-15.1 Plt Ct-64*
[**2158-3-1**] 09:46PM BLOOD WBC-25.0* RBC-3.48* Hgb-9.3* Hct-28.8*
MCV-83 MCH-26.7* MCHC-32.2 RDW-15.0 Plt Ct-62*
[**2158-3-2**] 06:18AM BLOOD WBC-26.6* RBC-3.70* Hgb-9.9* Hct-31.0*
MCV-84 MCH-26.8* MCHC-32.0 RDW-15.0 Plt Ct-71*
[**2158-3-3**] 04:14AM BLOOD WBC-15.8* RBC-3.14* Hgb-8.6* Hct-26.6*
MCV-85 MCH-27.5 MCHC-32.5 RDW-15.4 Plt Ct-57*
[**2158-3-1**] 02:25PM BLOOD PT-21.0* PTT-48.4* INR(PT)-2.0*
[**2158-3-1**] 09:46PM BLOOD PT-21.3* PTT-42.8* INR(PT)-2.1*
[**2158-3-2**] 06:18AM BLOOD PT-21.6* PTT-34.9 INR(PT)-2.1*
[**2158-3-2**] 05:47PM BLOOD PT-14.6* PTT-27.5 INR(PT)-1.3*
[**2158-3-3**] 04:14AM BLOOD PT-15.8* PTT-29.1 INR(PT)-1.4*
[**2158-3-1**] 02:25PM BLOOD Glucose-150* UreaN-20 Creat-0.9 Na-133
K-2.9* Cl-102 HCO3-16* AnGap-18
[**2158-3-1**] 09:46PM BLOOD Glucose-161* UreaN-25* Creat-0.9 Na-146*
K-3.4 Cl-113* HCO3-19* AnGap-17
[**2158-3-2**] 06:18AM BLOOD Glucose-130* UreaN-28* Creat-0.9 Na-131*
K->10.0 Cl-126* HCO3-17*
[**2158-3-2**] 09:32AM BLOOD Glucose-140* UreaN-31* Creat-1.0 Na-142
K-3.8 Cl-111* HCO3-17* AnGap-18
[**2158-3-2**] 05:34PM BLOOD Glucose-121* UreaN-33* Creat-1.0 Na-143
K-3.3 Cl-113* HCO3-18* AnGap-15
[**2158-3-3**] 04:14AM BLOOD Glucose-118* UreaN-33* Creat-0.9 Na-141
K-3.5 Cl-114* HCO3-19* AnGap-12
[**2158-3-1**] 02:25PM BLOOD ALT-67* AST-99* LD(LDH)-307* AlkPhos-242*
Amylase-114* TotBili-3.2* DirBili-2.8* IndBili-0.4
[**2158-3-1**] 09:46PM BLOOD ALT-96* AST-136* LD(LDH)-328*
AlkPhos-250* TotBili-3.5*
[**2158-3-2**] 06:18AM BLOOD ALT-89* AST-110* TotBili-2.4*
[**2158-3-1**] 09:46PM BLOOD Albumin-2.0* Calcium-7.2* Phos-3.4
Mg-1.1*
[**2158-3-2**] 06:18AM BLOOD Calcium-7.1* Phos-3.2 Mg-2.3
[**2158-3-2**] 09:32AM BLOOD Calcium-7.6* Phos-3.2 Mg-2.3
[**2158-3-2**] 05:34PM BLOOD Calcium-7.8* Phos-3.2 Mg-2.3
[**2158-3-3**] 04:14AM BLOOD Calcium-7.7* Phos-2.2* Mg-2.2
[**2158-3-1**] 09:46PM BLOOD Cortsol-40.8*
[**2158-3-1**] 10:36PM BLOOD Cortsol-58.9*
[**2158-3-1**] 11:40PM BLOOD Cortsol-75.1*
[**2158-3-1**] 05:25PM BLOOD Type-ART pO2-70* pCO2-29* pH-7.42
calHCO3-19* Base XS--3
[**2158-3-1**] CXR: 1. Right IJ terminates in the lower SVC. No
pneumothorax.
2. Small right pleural effusion and bibasilar atelectasis.
3. Multiple small nodular opacities in both lungs, suspicious
for metastasis. CT may be helpful for further evaluation.
.
[**2158-3-1**] CT abd/pelvis: 1. Extrahepatic biliary ductal dilation
measuring 9 mm in diameter. Pneumobilia.
2. Large pancreatic mass with hepatic, splenic, and likely
osseous metastases. Common bile duct and duodenal stent.
.
[**2158-3-1**] ERCP: Three spot fluoroscopic images were obtained
without a radiologist present. The initial scout image
demonstrates a plastic biliary stent overlying the right upper
quadrant as well as surgical clips at the level of the cystic
duct and gallbladder. A guide wire is seen within the duodenum.
The final image demonstrates an enteral Wallstent traversing the
duodenum with proximal end within the antrum.
.
[**2158-3-2**] PTBD: 1. Percutaneous cholangiogram demonstrated mildly
distended intrahepatic biliary ducts and severely distended
proximal common bile duct with a large filling defect occupying
most of the common bile duct and extending to the ampulla. The
in situ plastic stent previously placed by gastroenterology was
demonstrated within the filling defect in the common bile duct.
A plastic stent was partially obstructed.
2. 10 mm by 94 mm Wallstent was placed across the narrow common
bile duct extending from the bifurcation of the common bile duct
to the duodenum. Post deployment balloon dilatation of the stent
with mm balloon catheter was performed.
3. An external internal biliary drain was left in place
extending from the peripheral branch of the right intrahepatic
biliary duct into the duodenum. The biliary drain was capped for
internal drainage.
.
EKG: no acute changes


Brief Hospital Course:
# Pancreatic cancer: Ms. [**Known lastname 63057**] has extensive metastatic
pancreatic cancer ith gastric outlet obstruction, duodenal
obstruction and possible biliary obstruction. She is now s/p
stent placement by IR, with drain in place. It drained to her GI
tract. The IR team felt that at some point in the coming weeks,
her internal stents will become blocked from her disease so they
left the external drain in-place.  It can remained plugged until
she develops itching or any signs that the stents are clogged.
She should have LFT's checked twice a week and if starting to
rise, her drain should be unplugged.

# Hypotension:  This was likely secondary to cholangitis/sepsis:
with rising LFTs's, tbili, and she has a known biliary
obstruction from pancreatic cancer. Her blood cultures from the
OSH grew pan-sensitive E Coli. She was initially treated with
Zosyn, and admitted to the [**Hospital Unit Name 153**] after hypotension in the ERCP
suite. During that procedure, one stent was placed, but was not
sufficient to remove the obstruction. Overnight she was treated
with IV fluids for hypotension after a central line was placed.
She was also briefly on levophed to maintain a MAP > 55. THe
following day she had a second stent placement, by IR, and has
an external/internal drain in place, draining into the GI tract.
After the cultures returned as pan-sensitive E Coli, she was
switched from Zosyn to Levaquin, started [**2158-3-2**]. Surveillance
blood cultures were drawn [**3-1**], [**3-2**], and [**3-3**], and are all
NGTD. Her LFTs were followed, and are trending down. She will
complete a 14 day course of the levoquin.  The day of discharge
([**2158-3-7**]) was day #[**6-16**].

# Afib: Intially during her stay Ms. [**Known lastname 63057**] was going in and out
of Afib. She has no known h/o Afib. However, her EKGs showed
irregular rhythm at times, and appeared to have P waves at times
as well. She cannot be anticoagulated given recent GIB. She was
started a low dose beta blocker for HR control

# Recent GI bleeding: Ms [**Known lastname 63057**] had recent GIB at OSH, which now
appears to be stabilized. We maintained a type and screen,
treated her with IV ppi, and followed Q12hr hct. She had a
hematocrit drop following her procedure fomr 31 to 27, but then
stabalized.  She is being discharged with a hct of 33.

# Diabetes: She was on an insulin sliding scale.

# coaulopathy: secondary to sepsis vs. liver failure vs. dic.
DIC labs negative. Followed INR, gave FFP for her IR procedure.

# Code:DNR/DNI--had extensive discussions with [**Doctor First Name 553**] and [**Doctor First Name 2147**]
as well as sister [**Name (NI) **].  They serve as next of [**Doctor First Name **] and health
care proxies.

# Communication: [**Doctor First Name **] [**Telephone/Fax (1) 63058**] is sister, [**Name (NI) **].

Medications on Admission:
1. midodrine
2. lipitor
3. protonix
4. glyburide
5. reglan
6. potassium


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Rehabilitation & Nursing Center - [**Location (un) **]

Discharge Diagnosis:
Cholangitis
Sepsis

Discharge Condition:
Fair


Discharge Instructions:
--Please take all medications as prescribed.  You need to finish
a course of antibiotices for the infection you had.
--Please return to the hospital for any increasing abdominal
pain, fevers, or chills.
--If the patient develops itching or has rising LFT's this would
likely indicate that the internal stents in her biliary tract
are blocked and her external drain should be unplugged.

Followup Instructions:
--Please see you primary care doctor (Dr. [**Last Name (STitle) 39408**] within the
next 2-4 weeks.
{'Septicemia due to escherichia coli [E. coli],Cholangitis,Malignant neoplasm of other specified sites of pancreas,Acquired hypertrophic pyloric stenosis,Atrial fibrillation,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of liver, secondary,Sepsis,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: hypotension, altered mental status

PRESENT ILLNESS: Ms. [**Known lastname 63057**] is an 82 year old woman with pancreatic Ca, gastric
outlet obstruction and questionable biliary obstruction, s/p
plastic stent in CBD placed by GI several months ago. She was
transferred from [**Hospital3 **] for ERCP today with bacteremia and
septic picture.
She had ERCP today - GI could not cannulate ampula due to mass,
placed  duodenal stent. IR wants to confirm biliary obstruction
+ assess the anatomy before potential PTC tomorrow.  She is
admitted to the [**Hospital Unit Name 153**] for hypotension and altered mental status.
.
Patient was admitted to [**Hospital6 33**] from a nursing home
on [**2158-2-26**] with intractable nausea and vomiting and coffee
ground emesis.
She was to have ERCP as above today to look at possible
dudodenal obstruction with potential palliative stenting.
.
During the procedure GI doctors made aware by physicians at
[**Hospital3 **] that patient had blood cultures growing GNR's.
.
On seeing the patient, she is unable to provide much history.
She has received about 2 liters of normal saline for blood
pressure in 80's to 90's.  Throughout ERCP blood pressure had
been in this range.

MEDICAL HISTORY: 1. Metastatic pancreatic carcinoma diagnosed in [**Month (only) **] of
[**2156**]-CT scan at [**Hospital3 **] done weeks ago showed mets to liver,
lungs, and obstruction of portal, splenic veins
2. GI bleeding--recent, [**2-16**] at [**Hospital3 **], EGD revealed
erosive esophagitis and dudoenal inflammation raising concern
for duodenal outlet obstruction.
3. diabetes mellitus
4. formerly hypertension
5. Orthostatic hypotension

MEDICATION ON ADMISSION: 1. midodrine
2. lipitor
3. protonix
4. glyburide
5. reglan
6. potassium

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:
VS:  Temp: 98     BP: 90  /55    HR:80  RR:16    98%2l ncO2sat

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Resides in skilled nursing facility. No smoking, occasional
alcohol, no drug use. 

### Response:
{'Septicemia due to escherichia coli [E. coli],Cholangitis,Malignant neoplasm of other specified sites of pancreas,Acquired hypertrophic pyloric stenosis,Atrial fibrillation,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of liver, secondary,Sepsis,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
