CHIEF COMPLAINT: RLQ pain

PRESENT ILLNESS: HPI: 74 y/o M with a PMHx of PVD, mild COPD, etoh/tob abuse, who
presented to [**Hospital1 18**] with 1d of RLQ abdominal pain and worsening
SOB. No N/V, +1 episode of nonbloody stools today. +chills, no
fever.
.
In the ED, he had a RUQ U/S that showed concern for cholangitis.
He was given CTX 1g IV x1, Flagyl 500mg IV x1. He was transfused
1u pRBC and transferred to the MICU for further management. Labs
clotted and unable to be processed. Patient became hypotensiove
requiring pressors. Smear was reviewed by heme-path and it was
concerning for clostridium perfringens and started on broad
Vanc, [**Last Name (un) **], [**Doctor Last Name **] & Clinda.

MEDICAL HISTORY: 1) PVD
2) COPD FEV1 2.19L (85% pred) in [**2182**]
3) tob abuse
4) hyperlipidemia
5) Leukoplakia

MEDICATION ON ADMISSION: HCTZ 12.5 qD
Zocor 20 qD
ASA 81 qD
.
Allergies: NKDA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps

FAMILY HISTORY: Father died at 92. Mother died of ? stomach cancer.

SOCIAL HISTORY: He lives in [**Location (un) 538**] with his son. [**Name (NI) **] is widowed.
ETOH:  +4 etoh drinks/day.
TOB:  1ppd
Septicemia due to escherichia coli [E. coli],Acute kidney failure with lesion of tubular necrosis,Cholangitis,Calculus of gallbladder and bile duct without cholecystitis, with obstruction,Mechanical complication due to other implant and internal device, not elsewhere classified,Acute respiratory failure,Septic shock,Thrombocytopenia, unspecified,Chronic airway obstruction, not elsewhere classified,Acidosis,Acute and subacute necrosis of liver,Severe sepsis,Anticoagulants causing adverse effects in therapeutic use,Accidents occurring in residential institution,Benign neoplasm of other and unspecified site in the digestive system,Acute alcoholic intoxication in alcoholism, continuous,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Atherosclerosis of native arteries of the extremities, unspecified,Tobacco use disorder,Other specified dermatoses,Diverticulosis of colon (without mention of hemorrhage),Other specified disorders of skin,Adult failure to thrive
E coli septicemia,Ac kidny fail, tubr necr,Cholangitis,Gall&bil cal w/o ch w ob,Malfunc oth device/graft,Acute respiratry failure,Septic shock,Thrombocytopenia NOS,Chr airway obstruct NEC,Acidosis,Acute necrosis of liver,Severe sepsis,Adv eff anticoagulants,Accid in resident instit,Ben neo GI tract NEC/NOS,Ac alcohol intox-contin,Abn react-procedure NEC,Athscl extrm ntv art NOS,Tobacco use disorder,Other specf dermatoses,Dvrtclo colon w/o hmrhg,Skin disorders NEC,Failure to thrive-adult
Admission Date:  [**2189-11-25**]              Discharge Date:   [**2189-12-24**]

Date of Birth:  [**2115-2-3**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
RLQ pain

Major Surgical or Invasive Procedure:
ERCP (2 times)
Endotracheal Intubation and Mechanical Ventilation
Insertion of tunneled hemodialysis catheter
Hemodialysis


History of Present Illness:
HPI: 74 y/o M with a PMHx of PVD, mild COPD, etoh/tob abuse, who
presented to [**Hospital1 18**] with 1d of RLQ abdominal pain and worsening
SOB. No N/V, +1 episode of nonbloody stools today. +chills, no
fever.
.
In the ED, he had a RUQ U/S that showed concern for cholangitis.
He was given CTX 1g IV x1, Flagyl 500mg IV x1. He was transfused
1u pRBC and transferred to the MICU for further management. Labs
clotted and unable to be processed. Patient became hypotensiove
requiring pressors. Smear was reviewed by heme-path and it was
concerning for clostridium perfringens and started on broad
Vanc, [**Last Name (un) **], [**Doctor Last Name **] & Clinda.

Past Medical History:
1) PVD
2) COPD FEV1 2.19L (85% pred) in [**2182**]
3) tob abuse
4) hyperlipidemia
5) Leukoplakia


Social History:
He lives in [**Location (un) 538**] with his son. [**Name (NI) **] is widowed.
ETOH:  +4 etoh drinks/day.
TOB:  1ppd


Family History:
Father died at 92. Mother died of ? stomach cancer.


Physical Exam:
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps


Pertinent Results:
OSH Imaging:
CT abd/pelvis [**11-24**]: Prominent CBD (11 mm) and pancreatic duct
(7 mm) with probable 7 mm distal CBD stone at level of
pancreatic head. Given dilation of both the CBD and panc. duct,
consideration should be given to distal obstruction (stone,
stenosis/stricture, pancreatic
head mass). Aorta is heavily calcified. No evidence of free air,
SBO or pneumotosis. No intra-abdominal abscess of fluid
collection. Sigmoid diverticulosis without diverticulitis.
Gallstones as seen on US.
.
CXR [**11-24**]: There is no acute cardiopulmonary process. The lungs
are clear and pleural surfaces are smooth with no effusion or
pneumothorax. Cardiomediastinal silhouette is normal.
.
RUQ U/S [**11-24**]:
1. Cholelithiasis without cholecystitis. Son[**Name (NI) 493**] [**Name2 (NI) 515**]
sign was not able to be elicited, though the patient just
received pain medication.
2. Prominent common bile duct, however, it can be traced in
nearly its entirety with no evidence of CBD stones.
.
Admission Labs:
[**2189-11-24**] 09:30PM   WBC-25.7*# HCT-16*#
[**2189-11-24**] 09:30PM   NEUTS-85* BANDS-4 LYMPHS-9* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-4*
[**2189-11-24**] 09:30PM   PLT SMR-VERY HIGH PLT COUNT-603*#
[**2189-11-24**] 09:30PM   ALT(SGPT)-1400* AST(SGOT)-2600* LD(LDH)-9000*
CK(CPK)-450* ALK PHOS-100 TOT BILI-6.8*
[**2189-11-24**] 09:30PM   GGT-500*
[**2189-11-24**] 09:30PM   CREAT-4.5*#
[**2189-11-24**] 09:36PM   LACTATE-7.3*
.
Pertinent Labs:
HIT positive
Serotonin releasing assay - negative
[**2189-12-12**] 03:54AM BLOOD calTIBC-220* Ferritn-1715* TRF-169*
[**2189-12-8**] 05:54AM BLOOD VitB12-1377* Folate-12.0
[**2189-12-8**] 05:54AM BLOOD TSH-4.5*
.
Discharge Labs:
[**2189-12-23**] 07:45AM BLOOD WBC-10.3 RBC-3.49* Hgb-10.8* Hct-33.2*
MCV-95 MCH-30.9 MCHC-32.5 RDW-17.3* Plt Ct-310
[**2189-12-23**] 07:45AM BLOOD Plt Ct-310
[**2189-12-23**] 07:45AM BLOOD Glucose-111* UreaN-42* Creat-9.2*# Na-143
K-4.5 Cl-104
[**2189-12-23**] 07:45AM BLOOD Calcium-10.2 Phos-2.7 Mg-2.1
[**2189-12-22**] 06:05AM BLOOD ALT-17 AST-14 LD(LDH)-260* AlkPhos-89
TotBili-1.1
.
Imaging:
LIVER OR GALLBLADDER US (SINGLE ORGAN)  [**2189-11-24**]
1. Cholelithiasis without cholecystitis. Son[**Name (NI) 493**] [**Name2 (NI) 515**]
sign was not able to be elicited, though the patient had just
received pain medication.
2. Dilated common bile duct and pancreatic duct; however, the
CBD can be traced quite distally to the region of the pancreatic
head, with no evidence of CBD calculus.
.
CT ABDOMEN W/O CONTRAST  [**2189-11-25**]
1. Dilatation of the CBD and pancreatic duct, raising the
possibility of distal obstruction at the ampullary level due to
stone, stricture/stenosis, ampullary or pancreatic head mass.
Evaluation for mass is significantly limited due to lack of IV
contrast. There is a 7 mm hypoattenuating structure within the
distal CBD, proximal to the ampulla, which is likely a stone.
Given the patient's clinical scenario of RUQ pain, marked
leukocytosis and sepsis, cholangitis is a consideration and ERCP
should be considered.
2. Cholelithiasis.
3. Extensive vascular calcification throughout the aorta. No
evidence of free air, pneumatosis, or bowel pathology.
4. Sigmoid diverticulosis without diverticulitis.
NOTE ADDED IN ATTENDING REVIEW: Though there is an apparent
calculus in the distalmost CBD, as mentioned above, the duct
does not appear to taper to it and, in fact, remains dilated to
the ampullary level. There is also a suggestion of abnormal
rounded soft tissue in the region of the ampulla (2:38;
301b:29), protruding into the 2nd portion of the duodenum. While
this could represent edema surrounding an impacted calculus
(given the other calculi), an ampullary carcinoma is a distinct
consideration and an additional reason for ERCP with
brushings/biopsy, if feasible.
.
Portable TTE (Complete) Done [**2189-12-1**]
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Trace aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
Pathology Reports:
AMPULLARY BIOPSY [**2189-11-25**]
DIAGNOSIS: Ampullary body biopsy: Fragments of adenoma with
low-grade dysplasia.
AMPULLARY BIOPSY [**2189-12-16**]
DIAGNOSIS: Ampulla (major papilla), biopsy:
1.  Fragments of adenoma.
2.  Adjacent duodenal mucosa with chronic active enteritis and
focal ulceration.
3.  Multiple levels are examined.

Brief Hospital Course:
# Septic [**Name (NI) 21020**]
Pt was found to have an ampullary mass and stricture leading to
cholangitis thought due to clostridium perfringens. He initially
required 2 pressors and his extremities were cyanotic. He was
initially treated with meropenem, penicillin, cipro, vancomycin,
metronidazole and clindamycin. Once his blood grew out gram
negative and gram positive rods, the antibiotics were tappered
to meropenem, cipro and vanc with renal dosing.  He was started
on empiric treatment with hydrocortisone for 5 days. His
pressors were weaned in the first 2-3 days and he seemed to be
improving.  He subsequently was treated for a 14d course of
cipro and meropenem to treat c. perfringens and GNR per d/w ID.
He intermittently had hypotensive episodes and intermittent
fevers requiring volume resuscitation in the MICU.  We also
intermittently treated with vanco although this was not
supported by cx data.  Repeat cxs were NGTD. Ultimately, given
that he was afebrile and there were no positive culture data,
all antibiotics were stopped.  On the floor his blood pressure
was noted to be increased and he was started on Metoprolol and
Amlodipine for control.
.
# Respiratory Failure
Pt was intubated in setting of severe sepsis. He had no known
previous lung disease. Pt was slow to wake up given sedation on
board in setting of renal and liver failure.  Sedation was
weened off and given in boluses rather than drips.  He then
developed ARDS with increased dead space.  This was presumed to
be [**2-27**] infection, PE, COPD.  LENIs were negative for DVT.
Calculated dead space was 76% with increased esophageal balloon
pressure of [**1-18**].  He was treated with solumedrol and
prednisone taper for ? bronchoconstriction.  He was initially
treated with anticoagulation for possible PE and started on
CVVHD to take fluid off.  With improvement, anticoagulation was
stopped.  By discharge, he was satting high 90s on room air.
.
# Thrombocytopenia: He developed low platelets in setting of his
infection.  HIT antibody was intially positive with optical
density of 1.55.  Per heme/onc, serotonin release assay was sent
and patient was started on argatroban.  All heparin
products/coated-lines were removed.  Platelets recovered and
serotonin release assay returned negative. Pt does not have HIT
and thus anticoagulation was stopped.
.
# MS: His mental status while intubated was intially poor, and
it was difficult to arouse. This was felt to be secondary to
sedation (he was on fentanyl, propofol, midazolam, ativan, and
haldol during his ICU course); however, when he did not wake up
after sedation weaned, neurology was consulted for further
evaluation. EEG was unremarkable and patient's mental status
subsequently improved. After extubation, his sedation was weaned
and required only haldol 2.5 mg [**Hospital1 **] for agitation. He was able
to follow commands and oriented to self.  On the floor his
mental status continued to improve off haldol and is now
oriented x3.
.
# ARF: His ARF was likely due to ATN in setting of septic [**Hospital1 **]
and profound hypotension. He was initially anuric on admission.
He did not respond to furosemide bolus and was started on HD by
renal consult. As above, he required CVVH for fluid removal for
pulmonary edema.  On the floor he was continued on Mon, Wed, Fri
hemodialysis.  A tunneled line was placed.  By discharge he was
ogliuric.  The nephrology team expect recovery of his kidney
function.
.
# Metabolic Acidosis: He initially had lactic acidosis secondary
to sepsis, which resolved.
.
# EtOH Abuse:  Pt was given thiamine and placed on a CIWA scale
for the first 72 hours.
.
# Ampullary Mass:  Patient had an ERCP and was found to have a
large ampullary mass with pathology c/w adenoma.  A second ERCP
with biopsy was performed, which also showed adenoma.  He will
follow-up with gastroenterology (Dr. [**Last Name (STitle) **] and surgery (Dr.
[**Last Name (STitle) 468**] to decided on ampullectomy endoscopically versus
surgically.
.
# HTN:  Patient had elevated BP on the medical floor.
Metoprolol was titrated up and he was started on amlodipine.
His SBP goal is 120-140 to allow for adequate renal perfusion.
If his SBP is persistently <120, he will need to discontinue his
amlodipine.  ACEI/ARBs were advoided due to his renal function.

.
# FEN: Pt was initially on TPN, then tube feeds.  He was
repeatedly evaluated by speech and swallow and has no graduated
to soft diet with thin liquids.
.
# Access: tunneled dialysis line
.
# Code: FULL CODE
.
# DISPO:  Rehabilitation center

Medications on Admission:
HCTZ 12.5 qD
Zocor 20 qD
ASA 81 qD
.
Allergies: NKDA


Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day): Hold for SBP < 90 or HR < 55.
9. Megestrol 40 mg/mL Suspension Sig: One (1)  PO BID (2 times a
day).
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).


Discharge Disposition:
Extended Care

Facility:
Normandy Senior Care Center - [**Location (un) **]

Discharge Diagnosis:
Primary diagnoses
Cholangitis
Ampullary intestinal adenoma
Acute renal failure requiring hemodialysis
Acute respiratory distress syndrome
.
Secondary diagnoses:
Hypertension
Chronic obstructive pulmonary disease
Alcohol abuse


Discharge Condition:
Vital signs stable, abdominal pain resolved, tolerating PO diet.


Discharge Instructions:
You were admitted for abdominal pain and were found to have a
mass in your intestines and an infection of your gall bladder
duct.  You were treated with an endoscopy procedure to stent
open the blockage of your gallbladder duct.  You also received
antiobiotics.  You also had kidney failure that required
dialysis.  You will need to continue dialysis as an outpatient,
at least temporarily.
.
If you notice worsening abdominal pain, fevers, chills, or any
other concerning symptoms, please contact your primary care
physician or report to the emergency room.
.
Please take all medications as prescribed.

Followup Instructions:
Please keep the following appointments:
.
You have an appointment with your primary care doctor,
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on [**2190-2-25**] at 10:50 AM.  Please call
Phone:[**Telephone/Fax (1) 250**] to change the appointment or with any
questions or concerns.
.
You also have follow up with gastroenterology regarding your
ampullary intestinal adenoma.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2190-1-7**] 10:30
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2190-3-4**] 9:00
.
You also have an appointment with Surgery with Dr. [**Last Name (STitle) 468**] to
determine if your a surgical candidate for the removal of your
adenoma.
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2190-2-1**]
10:00
.
You also have an appointment with Nephrology with Dr. [**Last Name (STitle) 4883**].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2190-1-12**] 9:00
{'Septicemia due to escherichia coli [E. coli],Acute kidney failure with lesion of tubular necrosis,Cholangitis,Calculus of gallbladder and bile duct without cholecystitis, with obstruction,Mechanical complication due to other implant and internal device, not elsewhere classified,Acute respiratory failure,Septic shock,Thrombocytopenia, unspecified,Chronic airway obstruction, not elsewhere classified,Acidosis,Acute and subacute necrosis of liver,Severe sepsis,Anticoagulants causing adverse effects in therapeutic use,Accidents occurring in residential institution,Benign neoplasm of other and unspecified site in the digestive system,Acute alcoholic intoxication in alcoholism, continuous,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Atherosclerosis of native arteries of the extremities, unspecified,Tobacco use disorder,Other specified dermatoses,Diverticulosis of colon (without mention of hemorrhage),Other specified disorders of skin,Adult failure to thrive'}


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: RLQ pain

PRESENT ILLNESS: HPI: 74 y/o M with a PMHx of PVD, mild COPD, etoh/tob abuse, who
presented to [**Hospital1 18**] with 1d of RLQ abdominal pain and worsening
SOB. No N/V, +1 episode of nonbloody stools today. +chills, no
fever.
.
In the ED, he had a RUQ U/S that showed concern for cholangitis.
He was given CTX 1g IV x1, Flagyl 500mg IV x1. He was transfused
1u pRBC and transferred to the MICU for further management. Labs
clotted and unable to be processed. Patient became hypotensiove
requiring pressors. Smear was reviewed by heme-path and it was
concerning for clostridium perfringens and started on broad
Vanc, [**Last Name (un) **], [**Doctor Last Name **] & Clinda.

MEDICAL HISTORY: 1) PVD
2) COPD FEV1 2.19L (85% pred) in [**2182**]
3) tob abuse
4) hyperlipidemia
5) Leukoplakia

MEDICATION ON ADMISSION: HCTZ 12.5 qD
Zocor 20 qD
ASA 81 qD
.
Allergies: NKDA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps

FAMILY HISTORY: Father died at 92. Mother died of ? stomach cancer.

SOCIAL HISTORY: He lives in [**Location (un) 538**] with his son. [**Name (NI) **] is widowed.
ETOH:  +4 etoh drinks/day.
TOB:  1ppd 

### Response:
{'Septicemia due to escherichia coli [E. coli],Acute kidney failure with lesion of tubular necrosis,Cholangitis,Calculus of gallbladder and bile duct without cholecystitis, with obstruction,Mechanical complication due to other implant and internal device, not elsewhere classified,Acute respiratory failure,Septic shock,Thrombocytopenia, unspecified,Chronic airway obstruction, not elsewhere classified,Acidosis,Acute and subacute necrosis of liver,Severe sepsis,Anticoagulants causing adverse effects in therapeutic use,Accidents occurring in residential institution,Benign neoplasm of other and unspecified site in the digestive system,Acute alcoholic intoxication in alcoholism, continuous,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Atherosclerosis of native arteries of the extremities, unspecified,Tobacco use disorder,Other specified dermatoses,Diverticulosis of colon (without mention of hemorrhage),Other specified disorders of skin,Adult failure to thrive'}
