CHIEF COMPLAINT: Fever, Chills

PRESENT ILLNESS: The pt is an 84M with stage two metastastic pancreatic cancer
with palliative CBD stent placement who presents with fevers and
chills for 1 day. He does not endorse feeling particularly short
of breath although he admits now that he feels better with
oxygen. He measured his temperature at home to be ~100.6. He
also notes continued abdominal bloating that he has had for
months, although he feels it is actually slightly better now. He
does not have any focal abdominal tenderness. He states he had
dysuria about 1-2 weeks ago but this stopped a few days ago.
.
In the ED CXR showed a right-sided PNA. His UA was floridly
positive. After discussion with the ID fellow, he was treated
with Levo and clinda due to allergies to PCN and Flagyl. His SBP
was mostly in the 120s initially. His LFTs were found to be
markedly abnormal, and he was sent for RUQ US that showed air in
the gallbladder, indicating patency of the CBD stent; sludge and
stones in the GB; and thickening of the CBD wall that may
represent infiltration of tumor. Upon return from US, his SBP
dropped to the high 70s but responded to the 90s-100s with an
additional 1L of IVF. He received a total of ~2L IVF in the ED.
He was admitted to the MICU for further fluids and monitoring.

MEDICAL HISTORY: Past Onc Hx: He was Diagnosed with pancreatic ca in [**7-27**] after
an episode of cholangitis and sepsis. He had ERCP w/ stenting
and PTC placed. He is s/p biliary stent ([**10-27**]). His disease was
felt to be unresectable due to the confluence of the splenic
vein and lack of fat planes for resection. He was treated w/
palliative, weekly Gemcitabine x 3 from [**2153-11-27**] to [**2153-12-11**]. His
postchemo course was c/b prolonged periods of neutropenia fevers
and infections such as klebsiella bacteremia. He underwent
cyberknife therapy in [**3-28**]. PET [**1-29**] was notable for a FDG-avid
infiltrating mass originating in pancreatic head that extends to
porta hepatitis and which abuts, but does not appear to extend
beyond, the site of fiducial markers. No evidence of remote
FDG-avid metastatic disease. Ca19-9 on [**2154-2-8**] - 126 from 11 in
[**8-28**].
.
Other PMH:
CRI (1.6-2)
GERD
Lumbar stenosis s/p repair
COPD
Peripheral [**Month/Year (2) 1106**] disease
Prostatectomy for early stage prostate CA
Hernia repair
Hypertension
CVA- TIA [**2146**] years ago, no residual deficits
chronic constipation
rheumatic fever as a child

MEDICATION ON ADMISSION: 1. Nexium 40 mg qd
2. Atorvastatin 5 mg QOD (recently stopped)
3. Toprol XL 25 mg qd
4. Ecotrin 325 mg qd
5. Docusate Sodium 100 mg [**Hospital1 **]
6. Senna 8.6 mg Tablet [**Hospital1 **]
7. Hexavitamin qd
8. Simethicone 80 mg qid prn
9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Three (3) Cap PO TID W/MEALS
10. Claritin 10 mg prn
11. erythromycin 250 mg tid (recently stopped)

ALLERGIES: Penicillins / Ultracet / Codeine / Flagyl

PHYSICAL EXAM: VS: 98.3, 108/52, 91, 96% 4L NC
Gen: NAD, pleasant elderly man appearing younger than stated age

FAMILY HISTORY: non-contirbutory

SOCIAL HISTORY: Lives in [**Location 3307**] with wife of 12 [**Name2 (NI) 1686**]. Retired president of
insurance company. The patient is a 100-pack year smoker but
quit 25 [**Name2 (NI) 1686**] ago. He used to drink alcohol socially, but
currently not drinking at all. No children. He is an only child.
Wife is very supportive.
Septicemia due to gram-negative organism, unspecified,Cholangitis,Paralytic ileus,Malignant neoplasm of other specified sites of pancreas,Chronic airway obstruction, not elsewhere classified,Sepsis,Anemia in neoplastic disease,Esophageal reflux,Peripheral vascular disease, unspecified,Unspecified essential hypertension
Gram-neg septicemia NOS,Cholangitis,Paralytic ileus,Malig neo pancreas NEC,Chr airway obstruct NEC,Sepsis,Anemia in neoplastic dis,Esophageal reflux,Periph vascular dis NOS,Hypertension NOS
Admission Date:  [**2155-4-7**]              Discharge Date:   [**2155-4-17**]


Service: MEDICINE

Allergies:
Penicillins / Ultracet / Codeine / Flagyl

Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Fever, Chills

Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangiopancreatography

History of Present Illness:
The pt is an 84M with stage two metastastic pancreatic cancer
with palliative CBD stent placement who presents with fevers and
chills for 1 day. He does not endorse feeling particularly short
of breath although he admits now that he feels better with
oxygen. He measured his temperature at home to be ~100.6. He
also notes continued abdominal bloating that he has had for
months, although he feels it is actually slightly better now. He
does not have any focal abdominal tenderness. He states he had
dysuria about 1-2 weeks ago but this stopped a few days ago.
.
In the ED CXR showed a right-sided PNA. His UA was floridly
positive. After discussion with the ID fellow, he was treated
with Levo and clinda due to allergies to PCN and Flagyl. His SBP
was mostly in the 120s initially. His LFTs were found to be
markedly abnormal, and he was sent for RUQ US that showed air in
the gallbladder, indicating patency of the CBD stent; sludge and
stones in the GB; and thickening of the CBD wall that may
represent infiltration of tumor. Upon return from US, his SBP
dropped to the high 70s but responded to the 90s-100s with an
additional 1L of IVF. He received a total of ~2L IVF in the ED.
He was admitted to the MICU for further fluids and monitoring.

Past Medical History:
Past Onc Hx: He was Diagnosed with pancreatic ca in [**7-27**] after
an episode of cholangitis and sepsis. He had ERCP w/ stenting
and PTC placed. He is s/p biliary stent ([**10-27**]). His disease was
felt to be unresectable due to the confluence of the splenic
vein and lack of fat planes for resection. He was treated w/
palliative, weekly Gemcitabine x 3 from [**2153-11-27**] to [**2153-12-11**]. His
postchemo course was c/b prolonged periods of neutropenia fevers
and infections such as klebsiella bacteremia. He underwent
cyberknife therapy in [**3-28**]. PET [**1-29**] was notable for a FDG-avid
infiltrating mass originating in pancreatic head that extends to
porta hepatitis and which abuts, but does not appear to extend
beyond, the site of fiducial markers. No evidence of remote
FDG-avid metastatic disease. Ca19-9 on [**2154-2-8**] - 126 from 11 in
[**8-28**].
.
Other PMH:
CRI (1.6-2)
GERD
Lumbar stenosis s/p repair
COPD
Peripheral [**Month/Year (2) 1106**] disease
Prostatectomy for early stage prostate CA
Hernia repair
Hypertension
CVA- TIA [**2146**] years ago, no residual deficits
chronic constipation
rheumatic fever as a child


Social History:
Lives in [**Location 3307**] with wife of 12 [**Name2 (NI) 1686**]. Retired president of
insurance company. The patient is a 100-pack year smoker but
quit 25 [**Name2 (NI) 1686**] ago. He used to drink alcohol socially, but
currently not drinking at all. No children. He is an only child.
Wife is very supportive.


Family History:
non-contirbutory

Physical Exam:
VS: 98.3, 108/52, 91, 96% 4L NC
Gen: NAD, pleasant elderly man appearing younger than stated age

HEENT: PERRL, EOMI, anicteric, MM dry, OP clear
Neck: no LAD, supple, no JVD
Lungs: CTAB
CV: RRR, nl S1S2, I/VI HSM LUSB
Abd: +BS, soft, nontender, distended, tympanitic
Ext: no c/c/e, 2+ DP pulses b/l
Neuro: AAOx3, CN II-XII intact, sensory/motor grossly intact


Pertinent Results:
[**2155-4-6**] LIVER OR GALLBLADDER US:
1. Air in the biliary system indicating patency of the common
bile duct stent.  2. Sludge and stones in the gallbladder, with
focus of air in the gallbladder also suggesting patency with the
biliary system.  3. Unchanged appearance since [**2155-3-14**] CT
scan of thickening of the common bile duct, which itself is
normal caliber.
.
[**2155-4-6**] CXR: No evidence of acute cardiopulmonary process.
.
[**2155-4-6**] ECG: Sinus rhythm. Low limb lead voltage. Delayed
precordial R wave progression. Compared to the previous tracing
of [**2153-7-28**] the rate has slowed and there is variation in
precordial lead placement. Otherwise, no diagnostic interim
change.
.
[**2155-4-8**] CXR: Compared with 4/16, the CHF/fluid overload has
almost completely cleared.
.
[**2155-4-9**] CXR: No evidence of lung consolidation.
.
[**2155-4-12**] ABDOMEN (SUPINE & ERECT): Non-specific bowel gas pattern
which includes dilated loops of small bowel. However air and
stool are seen in the colon. If there is persistent pain,
followup radiographs or cross-sectional imaging is recommended.
.
[**2155-4-15**] CXR: Small bilateral pleural effusions with no evidence
of pulmonary edema.
.
[**2155-4-15**] ABDOMEN (SUPINE & ERECT): Mildly distended gas-filled
loops of large bowel with multiple air-fluid levels, which
likely represents ileus. the appearance is improved when
compared to the prior study.
.
[**2155-4-8**] ERCP: A metal stent was found in the major papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome through the metal stent seen in good position at
the ampulla. Contrast medium was injected resulting in complete
opacification. Filling defects in the stent within the CBD were
noted. The intrahepatic ducts were normal.Biliary debris and
purulent bile was extracted successfully using sweeps with a
balloon catheter. The stent allowed passage of a fully inflated
12mm balloon.
Occlusion cholangiogram performed at the end of the procedure
revealed no overgrowth or ingrowth of tumor into the stent.
.

[**2155-4-17**] 08:10AM BLOOD WBC-9.4 RBC-3.27* Hgb-9.9* Hct-29.4*
MCV-90 MCH-30.1 MCHC-33.5 RDW-16.1* Plt Ct-211
[**2155-4-6**] 08:00PM BLOOD WBC-4.4 RBC-3.43* Hgb-9.9* Hct-28.9*
MCV-84 MCH-28.8 MCHC-34.3 RDW-15.8* Plt Ct-110*
[**2155-4-17**] 08:10AM BLOOD Plt Ct-211
[**2155-4-12**] 07:10AM BLOOD Plt Ct-65*
[**2155-4-12**] 07:10AM BLOOD PT-15.5* PTT-29.2 INR(PT)-1.4*
[**2155-4-9**] 05:11AM BLOOD Plt Ct-59*
[**2155-4-7**] 12:44AM BLOOD Plt Ct-80*
[**2155-4-17**] 08:10AM BLOOD Glucose-110* UreaN-21* Creat-1.3* Na-131*
K-4.4 Cl-93* HCO3-29 AnGap-13
[**2155-4-6**] 08:00PM BLOOD Glucose-171* UreaN-24* Creat-1.3* Na-129*
K-3.8 Cl-94* HCO3-21* AnGap-18
[**2155-4-17**] 08:10AM BLOOD ALT-48* AST-28 AlkPhos-357* TotBili-1.3
[**2155-4-13**] 07:08AM BLOOD ALT-120* AST-54* AlkPhos-541*
TotBili-2.3*
[**2155-4-11**] 07:50AM BLOOD ALT-165* AST-62* AlkPhos-548*
TotBili-2.5*
[**2155-4-6**] 08:00PM BLOOD ALT-779* AST-565* AlkPhos-515* Amylase-27
TotBili-2.3*
[**2155-4-14**] 07:20AM BLOOD Lipase-37
[**2155-4-14**] 07:20AM BLOOD calTIBC-182* Ferritn-649* TRF-140*
[**2155-4-7**] 08:35PM BLOOD Lactate-6.1*
HIT AB: negative

Brief Hospital Course:
#Biliary Sepsis/GNR bacteremia:  underwent ERCP which showed
biliary debris and purulent bile which was extracted
successfully.  Blood cultures grew E. Coli, Morganella, and C.
perfringens.  Treated with 14 day course of [**Month/Day/Year 621**] (initially
Vanc/Gent/[**Last Name (un) **]-->CTX-->Cefpodox/Cipro on discharge).
.
#COPD: started on Advair and Albuterol prn.
.
#Thrombocytopenia: Resolved, HIT negative.  Likely [**1-24**] sepsis.
.
#Narcotic Induced ileus: resolved with aggressive bowel
regimine.
.
#Anemia of Chronic Disease: HCT stable, no indication for
transfusion.
.
#Mild hypoxia: developed mild hypoxia (high 80s/low 90s).  ABG
without C02 retention, CTA without PE.  Likely from volume
overload from resuscitation.  Improved after diuresis.

Medications on Admission:
1. Nexium 40 mg qd
2. Atorvastatin 5 mg QOD (recently stopped)
3. Toprol XL 25 mg qd
4. Ecotrin 325 mg qd
5. Docusate Sodium 100 mg [**Hospital1 **]
6. Senna 8.6 mg Tablet [**Hospital1 **]
7. Hexavitamin qd
8. Simethicone 80 mg qid prn
9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Three (3) Cap PO TID W/MEALS
10. Claritin 10 mg prn
11. erythromycin 250 mg tid (recently stopped)

Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
2. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Three (3) Cap PO TID W/MEALS (3 TIMES
A DAY WITH MEALS).
4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
8. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable
PO QID (4 times a day).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Atorvastatin 10 mg Tablet Sig: .5 Tablet PO every other day.

11. Ecotrin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
13. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inhalation
Inhalation every 4-6 hours.
Disp:*1 inhaler* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
CareGroup

Discharge Diagnosis:
1.  Biliary Sepsis/GNR bacteremia
2.  Pancreatic CA
3.  COPD
4.  Hypertension
5.  Thrombocytopenia, resolved
6.  Narcotic Induced ileus, resolved
7.  Anemia of Chronic Disease


Discharge Condition:
stable


Discharge Instructions:
Please return to the Emergency Room should you develop any
fevers, chills, sweats, nausea, vomiting, abdominal pain,
shortness of breath or any other complaints.

Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2155-4-30**] 10:00

Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2155-5-12**]
10:00

Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7721**] [**Name11 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Date/Time:[**2156-1-19**]
10:00
{'Septicemia due to gram-negative organism, unspecified,Cholangitis,Paralytic ileus,Malignant neoplasm of other specified sites of pancreas,Chronic airway obstruction, not elsewhere classified,Sepsis,Anemia in neoplastic disease,Esophageal reflux,Peripheral vascular disease, unspecified,Unspecified essential hypertension'}


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: Fever, Chills

PRESENT ILLNESS: The pt is an 84M with stage two metastastic pancreatic cancer
with palliative CBD stent placement who presents with fevers and
chills for 1 day. He does not endorse feeling particularly short
of breath although he admits now that he feels better with
oxygen. He measured his temperature at home to be ~100.6. He
also notes continued abdominal bloating that he has had for
months, although he feels it is actually slightly better now. He
does not have any focal abdominal tenderness. He states he had
dysuria about 1-2 weeks ago but this stopped a few days ago.
.
In the ED CXR showed a right-sided PNA. His UA was floridly
positive. After discussion with the ID fellow, he was treated
with Levo and clinda due to allergies to PCN and Flagyl. His SBP
was mostly in the 120s initially. His LFTs were found to be
markedly abnormal, and he was sent for RUQ US that showed air in
the gallbladder, indicating patency of the CBD stent; sludge and
stones in the GB; and thickening of the CBD wall that may
represent infiltration of tumor. Upon return from US, his SBP
dropped to the high 70s but responded to the 90s-100s with an
additional 1L of IVF. He received a total of ~2L IVF in the ED.
He was admitted to the MICU for further fluids and monitoring.

MEDICAL HISTORY: Past Onc Hx: He was Diagnosed with pancreatic ca in [**7-27**] after
an episode of cholangitis and sepsis. He had ERCP w/ stenting
and PTC placed. He is s/p biliary stent ([**10-27**]). His disease was
felt to be unresectable due to the confluence of the splenic
vein and lack of fat planes for resection. He was treated w/
palliative, weekly Gemcitabine x 3 from [**2153-11-27**] to [**2153-12-11**]. His
postchemo course was c/b prolonged periods of neutropenia fevers
and infections such as klebsiella bacteremia. He underwent
cyberknife therapy in [**3-28**]. PET [**1-29**] was notable for a FDG-avid
infiltrating mass originating in pancreatic head that extends to
porta hepatitis and which abuts, but does not appear to extend
beyond, the site of fiducial markers. No evidence of remote
FDG-avid metastatic disease. Ca19-9 on [**2154-2-8**] - 126 from 11 in
[**8-28**].
.
Other PMH:
CRI (1.6-2)
GERD
Lumbar stenosis s/p repair
COPD
Peripheral [**Month/Year (2) 1106**] disease
Prostatectomy for early stage prostate CA
Hernia repair
Hypertension
CVA- TIA [**2146**] years ago, no residual deficits
chronic constipation
rheumatic fever as a child

MEDICATION ON ADMISSION: 1. Nexium 40 mg qd
2. Atorvastatin 5 mg QOD (recently stopped)
3. Toprol XL 25 mg qd
4. Ecotrin 325 mg qd
5. Docusate Sodium 100 mg [**Hospital1 **]
6. Senna 8.6 mg Tablet [**Hospital1 **]
7. Hexavitamin qd
8. Simethicone 80 mg qid prn
9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Three (3) Cap PO TID W/MEALS
10. Claritin 10 mg prn
11. erythromycin 250 mg tid (recently stopped)

ALLERGIES: Penicillins / Ultracet / Codeine / Flagyl

PHYSICAL EXAM: VS: 98.3, 108/52, 91, 96% 4L NC
Gen: NAD, pleasant elderly man appearing younger than stated age

FAMILY HISTORY: non-contirbutory

SOCIAL HISTORY: Lives in [**Location 3307**] with wife of 12 [**Name2 (NI) 1686**]. Retired president of
insurance company. The patient is a 100-pack year smoker but
quit 25 [**Name2 (NI) 1686**] ago. He used to drink alcohol socially, but
currently not drinking at all. No children. He is an only child.
Wife is very supportive. 

### Response:
{'Septicemia due to gram-negative organism, unspecified,Cholangitis,Paralytic ileus,Malignant neoplasm of other specified sites of pancreas,Chronic airway obstruction, not elsewhere classified,Sepsis,Anemia in neoplastic disease,Esophageal reflux,Peripheral vascular disease, unspecified,Unspecified essential hypertension'}
