CHIEF COMPLAINT: Sepsis

PRESENT ILLNESS: 75 yo female with h/o DVT/PE, h/o necrotizing fasciitis, COPD,
hyperlipidemia presented to ED on Sunday after experience
several days of "GERD like" sharp pain from chest to abdomen and
tachypnea, found to have negative workup for cardiac etiology of
pain and no evidence of PE, but with positive [**Doctor Last Name 515**] sign.
Found to have acute cholecystitis and underwent subsequent lap
chole 4 days ago Op report remarks that gallbladder was
thickened with purulent material and hydrops fluid, course
subsequently complicated by bile leak confirmed on HIDA scan and
presence of large biloma in gallbladder fossa confirmed on CT
scan. Transferred to [**Hospital1 18**] for intervention in setting of sepsis
including fever to 101.8, tachycardia, tachypnea, WBC 19.1, and
diffuse abdominal tenderness. Also diagnosed with bilateral pna
and ileus at [**Location (un) **].

MEDICAL HISTORY: Past Medical History:
Necrotizing fasicitis right groin and pelvic area
DVT/PE after necrotizing fasicitis of right groin six years ago
previously on warfarin but since stopped
MVP
Chronic constipation
Non obstructive CAD: cath in [**2101**] with proximal calcification in
left coronary arteries. 30-40% stenosis in prox LAD, mild osteal
circ narrowing, 40% prox RCA stenosis. EF 50-55% with apical
hypokinesis. Echo in [**2103-5-13**] normal LV fxn, mod MR with mild
MVP, and trace TR
Hyperlipidemia
Osteoporosis
COPD

MEDICATION ON ADMISSION: Medications:
Torpol XL 50'
Lisinopril 10'
Pravachol 40'
Asa 81'
Xanax 0.25 mg prn anxiety
Allergies:
Pencillin
Sulfa
Latex

ALLERGIES: Penicillins / Sulfa(Sulfonamide Antibiotics) / latex

PHYSICAL EXAM: T 98.6 HR 100  BP 75/40 - 107/59 RR 12  O2 96% NC  wt 60.4 kg
General: Alert, oriented, no acute distress aside from pain
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP <8, no LAD
CV: tachycardic, normal S1 + S2, ? MVP click, no murmurs, rubs,
gallops
Lungs: Crackles R>L, very bronchial breath sounds on right with
+ egophony
Abdomen: + BS, diffusely tender
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

FAMILY HISTORY: Mother died from CAD at age 71. Father died from COPD and CAD at
age 74.

SOCIAL HISTORY: Married, stopped smoking in [**2086**]. 30-40 pack year. Social
drinking. No drug use
Other digestive system complications,Unspecified septicemia,Sepsis,Chronic diastolic heart failure,Pulmonary collapse,Cholangitis,Personal history of venous thrombosis and embolism,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Other and unspecified hyperlipidemia,Chronic airway obstruction, not elsewhere classified,Osteoporosis, unspecified,Personal history of tobacco use,Calculus of bile duct without mention of cholecystitis, without mention of obstruction,Diverticulosis of small intestine (without mention of hemorrhage),Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Malnutrition of moderate degree,Do not resuscitate status,Hypopotassemia,Constipation, unspecified
Oth digestv system comp,Septicemia NOS,Sepsis,Chr diastolic hrt fail,Pulmonary collapse,Cholangitis,Hx-ven thrombosis/embols,Crnry athrscl natve vssl,Mitral valve disorder,Hyperlipidemia NEC/NOS,Chr airway obstruct NEC,Osteoporosis NOS,History of tobacco use,Choledocholithiasis NOS,Dvrtclo sml int w/o hmrg,Abn reac-organ rem NEC,Elev transaminase/ldh,Malnutrition mod degree,Do not resusctate status,Hypopotassemia,Constipation NOS
Admission Date:  [**2104-6-19**]              Discharge Date:   [**2104-6-25**]

Date of Birth:  [**2028-9-6**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics) / latex

Attending:[**Last Name (un) 7835**]
Chief Complaint:
Sepsis

Major Surgical or Invasive Procedure:
ERCP with sphincterotomy, stent placement
Ultrasound guided percutaneous drainage of biloma

History of Present Illness:
75 yo female with h/o DVT/PE, h/o necrotizing fasciitis, COPD,
hyperlipidemia presented to ED on Sunday after experience
several days of "GERD like" sharp pain from chest to abdomen and
tachypnea, found to have negative workup for cardiac etiology of
pain and no evidence of PE, but with positive [**Doctor Last Name 515**] sign.
Found to have acute cholecystitis and underwent subsequent lap
chole 4 days ago Op report remarks that gallbladder was
thickened with purulent material and hydrops fluid, course
subsequently complicated by bile leak confirmed on HIDA scan and
presence of large biloma in gallbladder fossa confirmed on CT
scan. Transferred to [**Hospital1 18**] for intervention in setting of sepsis
including fever to 101.8, tachycardia, tachypnea, WBC 19.1, and
diffuse abdominal tenderness. Also diagnosed with bilateral pna
and ileus at [**Location (un) **].

At OSH, pt on levofloxacin and flagy. Given phenergan, zofran,
lopressor, fluids as needed. Had push-pull with lasix and IV
fluids for volume overload versus hypotension. Last set of labs
on [**6-19**] show WBC 19.1 (90% polys, 3% bands), Hgb 12.2/35.8,
platelet 183, Ma 134, K 3.6, Cl 94, Bicarb 30, BUN 10, Cr 0.6,
lactate 1.1, BNP 157, trop 0.01
On arrival here, VS afebrile HR 115 pt states she has diffuse
abdominal pain, unable to localize pain, alert and oriented x3.
Per family, very active at baseline. Just returned from [**State 108**]
few weeks ago.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.


Past Medical History:
Past Medical History:
Necrotizing fasicitis right groin and pelvic area
DVT/PE after necrotizing fasicitis of right groin six years ago
previously on warfarin but since stopped
MVP
Chronic constipation
Non obstructive CAD: cath in [**2101**] with proximal calcification in
left coronary arteries. 30-40% stenosis in prox LAD, mild osteal
circ narrowing, 40% prox RCA stenosis. EF 50-55% with apical
hypokinesis. Echo in [**2103-5-13**] normal LV fxn, mod MR with mild
MVP, and trace TR
Hyperlipidemia
Osteoporosis
COPD


Social History:
Married, stopped smoking in [**2086**]. 30-40 pack year. Social
drinking. No drug use


Family History:
Mother died from CAD at age 71. Father died from COPD and CAD at
age 74.


Physical Exam:
T 98.6 HR 100  BP 75/40 - 107/59 RR 12  O2 96% NC  wt 60.4 kg
General: Alert, oriented, no acute distress aside from pain
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP <8, no LAD
CV: tachycardic, normal S1 + S2, ? MVP click, no murmurs, rubs,
gallops
Lungs: Crackles R>L, very bronchial breath sounds on right with
+ egophony
Abdomen: + BS, diffusely tender
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.


Pertinent Results:
ADMISSION LABS ([**2104-6-19**]):
WBC-23.4* RBC-3.54* Hgb-11.1* Hct-33.5* MCV-95 MCH-31.3
MCHC-33.1 RDW-11.8 Plt Ct-310
PT-14.4* PTT-22.5* INR(PT)-1.3*
Glucose-126* UreaN-10 Creat-0.6 Na-133 K-3.9 Cl-95* HCO3-28
AnGap-14
ALT-42* AST-24 AlkPhos-160* TotBili-1.0
Calcium-8.6 Phos-3.6 Mg-2.2

ECG ([**2104-6-19**]): Sinus tachycardia. Right bundle-branch block.
There are tiny R waves in the lateral leads consistent with
possible myocardial infarction. Non-specific ST-T wave changes.
No previous tracing available for comparison.

ERCP ([**2104-6-20**]): Major papilla was found within a large
diverticulum.
Cannulation of the biliary duct was successful and deep after a
guidewire was placed. A single 5 mm stone was seen at the distal
biliary tree. Large extravasation was noted at the ducts of
Luschka. Otherwise, normal biliary tree. A sphincterotomy was
performed in the 12 o'clock position using a sphincterotome over
an existing guidewire. The stone was extracted successfully
using a balloon. A 7cm by 10FR Plastic stent biliary stent was
placed successfully.

ULTRASOUND ([**2104-6-20**]): Successful percutaneous drainage of a
biloma in the gallbladder fossa. Sample of the drained bile was
sent for microbiological analysis.

CXR ([**2104-6-20**]): Low lung volumes with mild pulmonary interstitial
abnormality, which could represent edema or chronic thickening.
Comparison with prior radiographs is recommended to aid in this
differentiation.

KUB ([**2104-6-21**]): There is a catheter projecting over the right
upper abdomen. There is air seen throughout the colon, and there
are few air-filled loops of small bowel which are non-enlarged.
Air and stool seen within the rectum. Air within the stomach.
There is a nonspecific bowel gas pattern without definite signs
for bowel obstruction. There is no free intra-abdominal gas seen
on the left side down decubitus films.


Brief Hospital Course:
1. Sepsis: Hypotensive on admission with concern for sepsis.
Started on broad specturm antibiotics with levofloxaxin,
metronidazole and vancomycin. Underwent bedside drainage of her
biloma and ERCP with sphincterotomy, stone extraction, and
biliary stent placement. Antibiotics were narrowed to
cipro/metronidazole as CXR here did not show evidence of
pneumonia.  Blood cultures from OSH as well as here were
negative to date of discharge.  She will complete 10 days of
antibiotics (to complete through [**2104-6-29**]), which will be
transitioned to po upon discharge.

2. Biloma: Underwent drainage with IR at bedside the evening of
admission. Bile cultures were without growth.  Biliary drainage
decreased to about [**10-27**] ml/day over last 3 days of admission,
so this was removed prior to discharge.

3. Hypoxia: At the OSH there was concern for pneumonia. Imaging
here showed low lung volumes with mild pulmonary interstitial
abnormality, which could represent edema or chronic thickening.
Oxygen was weaned.

4. Nausea: After initial concern for ileus or obstruction, KUB
was obtained. When this showed no evidence of obstruction, diet
was advanced slowly.

5. Transaminitis: Pt had mild transaminitis, found due to lower
abdominal cramping which was later thought to be due to
constipation, this was downtrending at discharge with no WBC or
focal exam findings.

6. Coronary artery disease: Non obstructive disease. Continued
aspirin and pravastatin. Metoprolol was initially held then
restarted; lisinopril also held and restarted just prior to
discharge.

7. Hyperlipidemia: Continued pravastatin

8. Malnutrition, moderate: Nutrition consulted.

9. Right IV infiltration: Noted after IV vancomycin
administration. Improved with arm elevation.

10. Anxiety: Continued alprazolam.

11. Constipation: started on colace as well as prn miralax.

TRANSITIONAL ISSUES:
- Patient was DNR ok to intubate throughout this admission
- Complete 10 days of antibiotics Cipro and Flagyl through
[**2104-6-29**]
- Change dressing at previous biliary drain site daily
- follow up ERCP in 4 weeks as scheduled

Medications on Admission:
Medications:
Torpol XL 50'
Lisinopril 10'
Pravachol 40'
Asa 81'
Xanax 0.25 mg prn anxiety
Allergies:
Pencillin
Sulfa
Latex


Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6
hours) as needed for SOB.
4. ipratropium bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed for SOB.
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
6. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for dyspepsia.
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heartburn.
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for anxiety.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
12. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 4 days.
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: through [**2104-6-29**].
14. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
15. Zofran 8 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours as needed for nausea.
16. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.


Discharge Disposition:
Extended Care

Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57850**] Healthcare Center - [**Location (un) **]

Discharge Diagnosis:
1. Sepsis secondary to acute cholecystitis
2. Bile leak
3. Pleural effusion and hypoxia
4. Chronic diastolic CHF
5. Malnutrition
6. Right IV infiltration
7. Anxiety
8. Hypokalemia

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

Discharge Instructions:
You were admitted with cholangitis. To treat this you underwent
ERCP with sphincterotomy and extraction of a 5mm stone in
addition to drainage of fluid and placement of a catheter, which
was removed prior to discharge.
you will continue antibiotics to complete 10 days, Cipro and
Flagyl (through [**2104-6-29**])

Followup Instructions:
Department: ENDO SUITES
When: FRIDAY [**2104-7-18**] at 10:00 AM

Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2104-7-18**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST     Best Parking: Main Garage
.
Follow up with your PCP once discharged from Rehab facility
{'Other digestive system complications,Unspecified septicemia,Sepsis,Chronic diastolic heart failure,Pulmonary collapse,Cholangitis,Personal history of venous thrombosis and embolism,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Other and unspecified hyperlipidemia,Chronic airway obstruction, not elsewhere classified,Osteoporosis, unspecified,Personal history of tobacco use,Calculus of bile duct without mention of cholecystitis, without mention of obstruction,Diverticulosis of small intestine (without mention of hemorrhage),Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Malnutrition of moderate degree,Do not resuscitate status,Hypopotassemia,Constipation, 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: Sepsis

PRESENT ILLNESS: 75 yo female with h/o DVT/PE, h/o necrotizing fasciitis, COPD,
hyperlipidemia presented to ED on Sunday after experience
several days of "GERD like" sharp pain from chest to abdomen and
tachypnea, found to have negative workup for cardiac etiology of
pain and no evidence of PE, but with positive [**Doctor Last Name 515**] sign.
Found to have acute cholecystitis and underwent subsequent lap
chole 4 days ago Op report remarks that gallbladder was
thickened with purulent material and hydrops fluid, course
subsequently complicated by bile leak confirmed on HIDA scan and
presence of large biloma in gallbladder fossa confirmed on CT
scan. Transferred to [**Hospital1 18**] for intervention in setting of sepsis
including fever to 101.8, tachycardia, tachypnea, WBC 19.1, and
diffuse abdominal tenderness. Also diagnosed with bilateral pna
and ileus at [**Location (un) **].

MEDICAL HISTORY: Past Medical History:
Necrotizing fasicitis right groin and pelvic area
DVT/PE after necrotizing fasicitis of right groin six years ago
previously on warfarin but since stopped
MVP
Chronic constipation
Non obstructive CAD: cath in [**2101**] with proximal calcification in
left coronary arteries. 30-40% stenosis in prox LAD, mild osteal
circ narrowing, 40% prox RCA stenosis. EF 50-55% with apical
hypokinesis. Echo in [**2103-5-13**] normal LV fxn, mod MR with mild
MVP, and trace TR
Hyperlipidemia
Osteoporosis
COPD

MEDICATION ON ADMISSION: Medications:
Torpol XL 50'
Lisinopril 10'
Pravachol 40'
Asa 81'
Xanax 0.25 mg prn anxiety
Allergies:
Pencillin
Sulfa
Latex

ALLERGIES: Penicillins / Sulfa(Sulfonamide Antibiotics) / latex

PHYSICAL EXAM: T 98.6 HR 100  BP 75/40 - 107/59 RR 12  O2 96% NC  wt 60.4 kg
General: Alert, oriented, no acute distress aside from pain
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP <8, no LAD
CV: tachycardic, normal S1 + S2, ? MVP click, no murmurs, rubs,
gallops
Lungs: Crackles R>L, very bronchial breath sounds on right with
+ egophony
Abdomen: + BS, diffusely tender
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

FAMILY HISTORY: Mother died from CAD at age 71. Father died from COPD and CAD at
age 74.

SOCIAL HISTORY: Married, stopped smoking in [**2086**]. 30-40 pack year. Social
drinking. No drug use 

### Response:
{'Other digestive system complications,Unspecified septicemia,Sepsis,Chronic diastolic heart failure,Pulmonary collapse,Cholangitis,Personal history of venous thrombosis and embolism,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Other and unspecified hyperlipidemia,Chronic airway obstruction, not elsewhere classified,Osteoporosis, unspecified,Personal history of tobacco use,Calculus of bile duct without mention of cholecystitis, without mention of obstruction,Diverticulosis of small intestine (without mention of hemorrhage),Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Malnutrition of moderate degree,Do not resuscitate status,Hypopotassemia,Constipation, unspecified'}
