CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 74-year-old
gentleman with a history of type 2 diabetes, coronary artery
disease (status post myocardial infarction), and
cerebrovascular accident who originally presented on [**6-11**]
from [**Hospital 1562**] Hospital with painless jaundice and a 55-pounds
weight over the past year here for endoscopic retrograde
cholangiopancreatography.

MEDICAL HISTORY: (Past medical history is significant
for)
1.  Coronary artery disease; status post myocardial
infarction.  A catheterization performed in [**2162-5-23**]
showed no significant coronary artery disease.
2.  An echocardiogram performed in [**2162-5-23**] showed
diastolic dysfunction without systolic dysfunction and left
atrial enlargement.
3.  Non-insulin-dependent diabetes mellitus.
4.  Cerebrovascular accident with a right facial droop.
5.  Left hydronephrosis; chronic ?
6.  Mild spinal stenosis at L4-L5.
7.  Left anterior temporal lobe small arachnoid cyst.

MEDICATION ON ADMISSION: Spironolactone.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Family history was not significant for
gastrointestinal problems or [**Name2 (NI) 499**] cancer.

SOCIAL HISTORY: Alcohol once per month.  Tobacco times 20
years; quit four years ago.  No intravenous drug abuse.  One
to two cups of coffee once per day.  A retired truck driver.
Malignant neoplasm of extrahepatic bile ducts,Hyperpotassemia,Cholangitis,Hydronephrosis,Cirrhosis of liver without mention of alcohol,Acute kidney failure with lesion of tubular necrosis,Unspecified septicemia
Mal neo extrahepat ducts,Hyperpotassemia,Cholangitis,Hydronephrosis,Cirrhosis of liver NOS,Ac kidny fail, tubr necr,Septicemia NOS
Admission Date:  [**2164-6-14**]       Discharge Date:  [**2164-6-18**]

Date of Birth:   [**2090-2-27**]       Sex:  M

Service:  MICU

HISTORY OF PRESENT ILLNESS:  The patient is a 74-year-old
gentleman with a history of type 2 diabetes, coronary artery
disease (status post myocardial infarction), and
cerebrovascular accident who originally presented on [**6-11**]
from [**Hospital 1562**] Hospital with painless jaundice and a 55-pounds
weight over the past year here for endoscopic retrograde
cholangiopancreatography.

The patient noticed gradual jaundice since [**2164-5-25**].  No
abdominal pain, nausea, vomiting, fevers, or chills.
Positive dark urine, and light stools, pruritus, and fatigue.

An abdominal computed tomography on [**2164-5-31**] from the
outside hospital was reported to have shown moderate ascites,
a large liver and spleen, and dilation of the biliary tree,
with a question of intrahepatic malignancy.

An abdominal ultrasound at the outside hospital on [**2164-6-1**] showed splenomegaly, ascites, gallbladder wall
thickening, and dilated ducts in the liver.

A magnetic resonance imaging on [**2164-6-2**] at the outside
hospital showed dilation of the biliary tree and a 4-cm
lesion in the left lobe of the liver.

Endoscopic retrograde cholangiopancreatography on [**6-11**]
performed at [**Hospital1 69**] showed an
intraductal mass, and plastic stent placed.  The mass was
brushed and cells were sent to cytology which were positive
for adenocarcinoma.

Additionally, the patient was found to have an increased
creatinine while admitted.  Creatinine in [**2163-12-24**]
was noted to be 0.9.  Then on [**6-5**], creatinine was noted
to be 2 after a computed tomography scan at the outside
hospital.  On admission to the hospital on [**6-11**],
creatinine was noted to be 8.1.   The patient was treated
multiple times with Kayexalate for a high potassium.  A
paracentesis was performed on [**6-13**] which showed no
evidence of spontaneous bacterial peritonitis.

On [**6-14**], a Quinton catheter was placed in the right
femoral vein, and the patient underwent hemodialysis.  During
the course of hemodialysis the patient became hypotensive in
the 80s/40s, and was subsequently volume resuscitated with
2.2 liters of fluids.  His blood pressure did not increase,
and the patient began to experience shortness of breath.  The
patient was originally saturating 96% on room air but then
desaturated to 93% on 2 liters of oxygen and then 95% on 4
liters of oxygen.  Additionally, the patient was wheezing.
Thus, the patient was transferred to the Medical Intensive
Care Unit.

An arterial blood gas was taken and showed a pH of 7.41, a
PCO2 of 28, and a PO2 of 72.  Once the patient was
transferred to the Medical Intensive Care Unit, his blood
pressures dropped to the 60s.  A right internal jugular was
placed, and the patient was started on Levophed.  Fresh
frozen plasma was given prior to line placement as the
patient's INR was 1.7.  Additionally, the patient was started
on ampicillin, gentamicin, and Flagyl for presume
cholangitis.

PAST MEDICAL HISTORY:  (Past medical history is significant
for)
1.  Coronary artery disease; status post myocardial
infarction.  A catheterization performed in [**2162-5-23**]
showed no significant coronary artery disease.
2.  An echocardiogram performed in [**2162-5-23**] showed
diastolic dysfunction without systolic dysfunction and left
atrial enlargement.
3.  Non-insulin-dependent diabetes mellitus.
4.  Cerebrovascular accident with a right facial droop.
5.  Left hydronephrosis; chronic ?
6.  Mild spinal stenosis at L4-L5.
7.  Left anterior temporal lobe small arachnoid cyst.

MEDICATIONS ON ADMISSION:  Spironolactone.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  Alcohol once per month.  Tobacco times 20
years; quit four years ago.  No intravenous drug abuse.  One
to two cups of coffee once per day.  A retired truck driver.

FAMILY HISTORY:  Family history was not significant for
gastrointestinal problems or [**Name2 (NI) 499**] cancer.

PHYSICAL EXAMINATION ON PRESENTATION:   Physical examination
on admission to the Medical Intensive Care Unit revealed
vital signs of 93/29, heart rate was 83, respiratory rate was
10, and oxygen saturation was 96% oxygen saturation on 4
liters nasal cannula.  Temperature was 95.8 (hypothermic).
In general, the patient was markedly jaundiced and
appropriately conversational.  Head, eyes, ears, nose, and
throat examination revealed normocephalic and atraumatic.
Pupils were equal, round, and reactive to light.  Scleral
icterus.  A jaundiced oropharynx.  Spider angiomas on the
face.  Chest examination revealed crackles at the bases
bilaterally/anteriorly.  Mild expiratory wheezes.
Cardiovascular examination revealed a regular rate and
rhythm.  A [**1-26**] holosystolic murmur heard at the left fifth
intercostal space midclavicular line.  The abdomen was soft
and nontender.  Distended.  Positive fluid wave.  Unable to
assess organ size.  A right femoral Quinton catheter.
Extremity examination revealed no edema.  Dorsalis pedis
pulses were 2+ bilaterally.  Positive asterixis bilaterally.

PERTINENT LABORATORY VALUES ON PRESENTATION:  Laboratories on
admission to the Medical Intensive Care Unit revealed white
blood cell count was 7 (down from 10.2), hematocrit was 28.6,
and platelets were 90.  Prothrombin time was 15.9, partial
thromboplastin time was 37.1, and INR was 1.7.  Urinalysis
revealed brown/cloudy.  Specific gravity was 1.016, large
blood, 100 protein, moderate bilirubin, trace leukocytes,
greater than 50 red blood cells, 6 to 10 white blood cells,
few bacteria, and amorphous crystals.  Sodium was 137,
potassium was 4.5, chloride was 100, bicarbonate was 16,
blood urea nitrogen was 86, creatinine was 7.9, and blood
glucose was 105.  Lipase was 72 and amylase was 25.  Calcium
was 7.8, phosphate was 6.9, and magnesium was 2.1.  Albumin
was 3.  ALT was 47, AST was 82, total bilirubin was 27.2, and
alkaline phosphatase was 145.  Microscopic examination from
ascites taken from [**6-13**] revealed no growth, no
polymorphonuclear leukocytes, no organisms seen on Gram
stain, 55 white blood cells, and 3045 red blood cells.
Cytology from ascites taken from [**6-13**] was negative for
malignant cells.  Brush on endoscopic retrograde
cholangiopancreatography taken from [**6-11**] was positive for
malignancy cells adenocarcinoma.  Urine cultures from [**6-12**]
and [**6-13**] revealed no growth.

PERTINENT RADIOLOGY/IMAGING PERFORMED AT [**Hospital1 **]:

1.  Endoscopic retrograde cholangiopancreatography performed
on [**6-11**] revealed intraductal mass, stent placed.

2.  Abdominal ultrasound on [**6-12**] revealed sludge in the
gallbladder, negative [**Doctor Last Name **] sign, liver shrunken with
increased echogenicity, enlarged spleen, and portal vein was
patent.

3.  Magnetic resonance imaging of the abdomen performed on
[**6-11**] (although limited by the patient's claustrophobia),
revealed massive ascites, left greater than right small
bilateral pleural effusions, liver nodularity (consistent
with cirrhosis), 3.6-cm X 4.8-cm mass with increased signal
in segment 4A liver, spleen mildly enlarged, varices along
the stomach (portal hypertension), gallbladder with no stones
and no ductal dilatation.

4.  A chest x-ray on [**6-14**] revealed right internal jugular
in place and pulmonary edema.  No infiltrate.  No
pneumothorax.

HOSPITAL COURSE BY ISSUE/SYSTEM:   In summary, the patient is
a 74-year-old gentleman with diabetes, coronary artery
disease, and cerebrovascular accident who presented with
painless jaundice and a 55-pound weight loss, status post
endoscopic retrograde cholangiopancreatography with stent,
now with cirrhosis and acute renal failure and probable
cholangiocarcinoma.  The patient was transferred to the
Medical Intensive Care Unit with hypotension and shortness of
breath.

 1.  HYPOTENSION ISSUES:  Hypotension was treated with
pressors (Levophed).  The patient was weaned off Levophed
with gentle fluid boluses.  Mean arterial pressure remained
in the 50s to 60s, and the patient mentated well throughout
his hospital course in the Medical Intensive Care Unit.
Hypotension was most likely secondary to sepsis.

 2.  PULMONARY ISSUES:  The patient remained stable on 4
liters nasal cannula and was saturating well.  The patient's
pulmonary status was monitored closely while receiving fluid
boluses for blood pressure so as to prevent a flare of
pulmonary edema.  Albuterol nebulizers were given for
wheezing.

Shortness of breath differential diagnoses  included
cirrhosis, renal failure, ascites (atelectasis), possible
congestive heart failure or fluid overload.

 3.  CORONARY ARTERY DISEASE/CONGESTIVE HEART FAILURE ISSUES:
No aspirin was given at this time as the patient was
coagulopathic with an increased INR.  No beta blocker were
given during this time as the patient was hypotensive.  Mild
congestive heart failure was seen on chest x-ray on [**6-11**].

The patient received an echocardiogram on [**6-15**] which
revealed an ejection fraction of 75% to 80%; although the
patient was on Levophed at the time of this echocardiogram.
Findings included left atrium was mildly dilated, left
ventricular wall thickness and cavity size were normal,
hyperdynamic, right ventricular size and motion were normal,
aortic valve leaflets were thickened, no regurgitation,
trivial tricuspid regurgitation, and borderline pulmonary
artery systolic hypertension.  No effusions.

 4.  GASTROENTEROLOGY ISSUES:  Intraductal mass was positive
for adenocarcinoma by cytology.  Palliative care for this
patient.  The patient's treatment options and prognosis were
discussed at length with the patient and his family.

Total bilirubin and liver function tests were checked daily
to assess for obstruction.  If these values were to increase
significantly, could possibly replace stent with a more
permanent stent via endoscopic retrograde
cholangiopancreatography to relieve obstruction.  Total
bilirubin tended to decrease throughout his hospital stay.
The patient also has cirrhosis of unclear etiology.

 5.  RENAL ISSUES:  Acute renal failure; question as to
etiology - acute tubular necrosis; status post contrast for
computed tomography versus hepatorenal syndrome.

The patient received three days of hemodialysis.  No fluid
was removed in hemodialysis.  Renal consultation team is
following the patient.  Fractional excretion of sodium was
1%.

 6.  INFECTIOUS DISEASE ISSUES:  The patient was originally
started on ampicillin, gentamicin, and Flagyl for presumed
cholangitis causing a septic picture with increased white
blood cells, hypotension, and hypothermia.  This antibiotic
regimen was changed to vancomycin, ceftazidime, and Flagyl so
as to provide more protection for the kidneys.

Cultures were negative or pending to date.  Blood cultures
from [**6-15**] were pending.  Urine cultures from [**6-12**] and
[**6-13**] showed no growth.  Ascites from [**6-13**] showed no
growth.

 7.  HEMATOLOGIC ISSUES:  The patient remained coagulopathic
secondary to liver disease.  The patient was oozing from
intravenous site.  Thus, the patient was given three days of
subcutaneous vitamin K to correct for the increased INR.

The patient received two units of packed red blood cells
while in the Medical Intensive Care Unit for a hematocrit of
less than 30.  The patient also received one unit of fresh
frozen plasma prior to internal jugular central vein line
placement on [**6-14**].

 8.  FLUIDS/ELECTROLYTES/NUTRITION ISSUES:  The patient
received fluid boluses for a decreased blood pressure; yet
remained saturating well on 4 liters nasal cannula oxygen and
had no complaints of chest discomfort.  Electrolytes were
repleted as needed.  The patient was given a full diet upon
his request.

 9.  ACCESS ISSUES:  The patient has a right internal jugular
central line which was placed on [**6-15**], and a right femoral
Quinton catheter which was placed on [**6-14**], as well as two
peripheral intravenous lines.

10.  CODE STATUS:  The patient's code status was changed from
full code to do not resuscitate/do not intubate.  The patient
and the patient's family expressed a wish to not be started
on pressors if the patient's blood pressure were to fall.

11.  SOCIAL ISSUES:  Multiple family meetings were held with
the patient and his family.  His son [**Doctor Last Name **] is the main
contact person.  Additionally, the patient's brother flew in
from [**Name (NI) **] and was able to meet with the patient and spend
time with him.

DISCHARGE DISPOSITION:  Currently, the patient is in the
Medical Intensive Care Unit awaiting a private bed on the
floor.  The patient will most likely either be discharged to
the floor in a private bed or go home soon with some kind of
hospice care or visiting nurse assistance; pending Social
Work evaluation and discussions with the family and the
patient.

CONDITION AT DISCHARGE:  Condition on discharge was fair.

DISCHARGE STATUS:  The patient was to be discharged pending a
private room on the floor, or the patient and his family wish
for care at home.

DISCHARGE DIAGNOSES:
1.  Cirrhosis.
2.  Probably cholangiocarcinoma.
3.  Acute renal failure.
4.  Diabetes.
5.  Coronary artery disease/congestive heart failure.

MEDICATIONS ON DISCHARGE:  Have yet to be decided.  The
patient will most likely go home with antibiotics for
presumed cholangitis and other comfort medications.

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient was to follow up with his primary care doctor
if needed.
2.  The patient was also to follow up with Social Work for
home hospice care if desired.






                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 21075**]

Dictated By:[**Last Name (NamePattern1) 9789**]
MEDQUIST36

D:  [**2164-6-17**]  22:36
T:  [**2164-6-17**]  22:51
JOB#:  [**Job Number 51753**]

cc:[**Last Name (NamePattern4) 51754**]
{'Malignant neoplasm of extrahepatic bile ducts,Hyperpotassemia,Cholangitis,Hydronephrosis,Cirrhosis of liver without mention of alcohol,Acute kidney failure with lesion of tubular necrosis,Unspecified septicemia'}


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: 

PRESENT ILLNESS: The patient is a 74-year-old
gentleman with a history of type 2 diabetes, coronary artery
disease (status post myocardial infarction), and
cerebrovascular accident who originally presented on [**6-11**]
from [**Hospital 1562**] Hospital with painless jaundice and a 55-pounds
weight over the past year here for endoscopic retrograde
cholangiopancreatography.

MEDICAL HISTORY: (Past medical history is significant
for)
1.  Coronary artery disease; status post myocardial
infarction.  A catheterization performed in [**2162-5-23**]
showed no significant coronary artery disease.
2.  An echocardiogram performed in [**2162-5-23**] showed
diastolic dysfunction without systolic dysfunction and left
atrial enlargement.
3.  Non-insulin-dependent diabetes mellitus.
4.  Cerebrovascular accident with a right facial droop.
5.  Left hydronephrosis; chronic ?
6.  Mild spinal stenosis at L4-L5.
7.  Left anterior temporal lobe small arachnoid cyst.

MEDICATION ON ADMISSION: Spironolactone.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Family history was not significant for
gastrointestinal problems or [**Name2 (NI) 499**] cancer.

SOCIAL HISTORY: Alcohol once per month.  Tobacco times 20
years; quit four years ago.  No intravenous drug abuse.  One
to two cups of coffee once per day.  A retired truck driver. 

### Response:
{'Malignant neoplasm of extrahepatic bile ducts,Hyperpotassemia,Cholangitis,Hydronephrosis,Cirrhosis of liver without mention of alcohol,Acute kidney failure with lesion of tubular necrosis,Unspecified septicemia'}
