CHIEF COMPLAINT: Septic shock

PRESENT ILLNESS: Mr. [**Known lastname **] is a 59 year old man with history of likely pancreatic
malignancy who was transferred from [**Hospital **] Hospital with
abdominal pain and rising bilirubin for ERCP evaluation. At
[**Hospital1 **], he had worsening abdominal pain, and he was noted to
have a rising bilirubin. ERCP/stenting cannot be performed at
[**Last Name (LF) **], [**First Name3 (LF) **] he was transferred here for urgent evaluation and
stenting.

MEDICAL HISTORY: Pancreatic mass s/p stent placement ([**4-/2143**])
Type 2 Diabetes, on insulin
CVA
Chronic renal insufficiency - baseline 1.5
s/p pacemaker placement for bradycardia
Hypertension
CAD s/p MI
Gout
COPD/OSA
Chronic LBP
Arthritis
History of venous stasis ulcers, recent cellulitis

MEDICATION ON ADMISSION: - Omeprazole 20mg PO daily
- ASA 81mg PO daily
- Furosemide 40mg daily
- Metoprolol 12.5mg PO BID
- Captopril 25mg PO TID
- Fluoxetine 40mg PO daily
- Colchicine 0.6mg daily
- Lantus 50mg SQ Qam
- Regular Insulin Sliding Scale
- Dilaudid 2-4mg IV Q3H PRN severe pain
- Dilaudid 4mg PO Q3H PRN pain
- Heparin SubQ DVT prophylaxis
- Colace 100mg PO BID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: T99.9F, BP 167/90, HR 130, RR 21, Sat 100%
VENT: A/C, FiO2 100%, TV 550, Rate 14, PEEP 5
GEN: Sedated, intubated, jaundiced
HEENT: Scleral icterus, PERRL
NECK: Unable to appreciate JVP
RESP: CTA bilaterally anteriorly
CV: Tachycardic, no murmurs
ABD: Obese, distended, decreased bowel sounds; opens eyes and
becomes agitated with palpation and shaking the bed
EXT: Trace edema bilaterally, lower extremities with 2+ DP
pulses, dry skin
SKIN: Jaundiced
RECTAL: Guaiac + in ED

FAMILY HISTORY: Unable to obtain

SOCIAL HISTORY: Unemployed, previously worked as a mechanic. Lives at [**First Name8 (NamePattern2) 2048**]
[**Last Name (NamePattern1) **] house. H/o tobacco x 4-5 years, alcohol and
polysubstance abuse, but currently sober. Per previous notes,
wheelchair bound and very little ambulation.
Other septicemia due to gram-negative organisms,Acute kidney failure, unspecified,Cholangitis,Malignant neoplasm of head of pancreas,Acute respiratory failure,Septic shock,Other and unspecified coagulation defects,Encounter for palliative care,Unspecified disorder of kidney and ureter,Old myocardial infarction,Lack of housing,Lumbago,Other chronic pain,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Chronic kidney disease, unspecified,Severe sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled
Gram-neg septicemia NEC,Acute kidney failure NOS,Cholangitis,Mal neo pancreas head,Acute respiratry failure,Septic shock,Coagulat defect NEC/NOS,Encountr palliative care,Renal & ureteral dis NOS,Old myocardial infarct,Lack of housing,Lumbago,Chronic pain NEC,Chr airway obstruct NEC,Crnry athrscl natve vssl,Chronic kidney dis NOS,Severe sepsis,Hy kid NOS w cr kid I-IV,DMII wo cmp uncntrld
Admission Date:  [**2143-11-22**]              Discharge Date:   [**2143-12-6**]

Date of Birth:  [**2084-5-30**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Septic shock

Major Surgical or Invasive Procedure:
mechanical ventilation

History of Present Illness:
Mr. [**Known lastname **] is a 59 year old man with history of likely pancreatic
malignancy who was transferred from [**Hospital **] Hospital with
abdominal pain and rising bilirubin for ERCP evaluation. At
[**Hospital1 **], he had worsening abdominal pain, and he was noted to
have a rising bilirubin. ERCP/stenting cannot be performed at
[**Last Name (LF) **], [**First Name3 (LF) **] he was transferred here for urgent evaluation and
stenting.

In the ED, he was given vancomycin and piperacillin-tazobactam.
He was seen by surgery, who reiterated that he is not a surgical
candidate. On arrival he was confused, and his mental status
deteriorated, and he was intubated. He received a total of 7L
normal saline. Dopamine was started for BP 58/38 (which
decreased to 46/25), and norepinephrine was added after a right
IJ triple lumen was placed. A foley was placed and he was sent
to the ICU. He received a total of 7L normal saline in the ED.

In the ICU, he was seen by the ERCP team, who emergently
performed an ERCP, discovering a blocked CBD stent with frank
pus and placed a new stent within the blocked stent.

Past Medical History:
Pancreatic mass s/p stent placement ([**4-/2143**])
Type 2 Diabetes, on insulin
CVA
Chronic renal insufficiency - baseline 1.5
s/p pacemaker placement for bradycardia
Hypertension
CAD s/p MI
Gout
COPD/OSA
Chronic LBP
Arthritis
History of venous stasis ulcers, recent cellulitis

Social History:
Unemployed, previously worked as a mechanic. Lives at [**First Name8 (NamePattern2) 2048**]
[**Last Name (NamePattern1) **] house. H/o tobacco x 4-5 years, alcohol and
polysubstance abuse, but currently sober. Per previous notes,
wheelchair bound and very little ambulation.


Family History:
Unable to obtain

Physical Exam:
VITALS: T99.9F, BP 167/90, HR 130, RR 21, Sat 100%
VENT: A/C, FiO2 100%, TV 550, Rate 14, PEEP 5
GEN: Sedated, intubated, jaundiced
HEENT: Scleral icterus, PERRL
NECK: Unable to appreciate JVP
RESP: CTA bilaterally anteriorly
CV: Tachycardic, no murmurs
ABD: Obese, distended, decreased bowel sounds; opens eyes and
becomes agitated with palpation and shaking the bed
EXT: Trace edema bilaterally, lower extremities with 2+ DP
pulses, dry skin
SKIN: Jaundiced
RECTAL: Guaiac + in ED


Pertinent Results:
[**2143-11-22**] 03:50PM   WBC-12.7*# RBC-4.12* HGB-12.2* HCT-37.7*
MCV-92 MCH-29.7 MCHC-32.4 RDW-16.2*
[**2143-11-22**] 03:50PM   NEUTS-69 BANDS-15* LYMPHS-6* MONOS-4 EOS-1
BASOS-0 ATYPS-0 METAS-5* MYELOS-0
[**2143-11-22**] 03:50PM   GLUCOSE-108* UREA N-31* CREAT-2.2*#
SODIUM-125* POTASSIUM-4.3 CHLORIDE-85* TOTAL CO2-17* ANION
GAP-27*
[**2143-11-22**] 03:50PM   ALT(SGPT)-58* AST(SGOT)-117* LD(LDH)-256*
CK(CPK)-410* ALK PHOS-689* AMYLASE-10 TOT BILI-13.1*
[**2143-11-22**] 03:50PM   cTropnT-0.02*
[**2143-12-5**] 02:50AM BLOOD WBC-9.5 RBC-2.59* Hgb-8.0* Hct-24.8*
MCV-96 MCH-30.9 MCHC-32.3 RDW-19.3* Plt Ct-281
[**2143-12-6**] 02:12PM BLOOD PT-18.5* PTT-46.2* INR(PT)-1.7*
[**2143-12-5**] 02:50AM BLOOD Glucose-149* UreaN-32* Creat-2.6* Na-140
K-3.8 Cl-101 HCO3-26 AnGap-17
[**2143-12-6**] 02:31AM BLOOD ALT-26 AST-59* LD(LDH)-197 CK(CPK)-22*
AlkPhos-371* Amylase-14 TotBili-6.8*
[**2143-12-6**] 02:31AM BLOOD Lipase-36
[**2143-12-6**] 02:31AM BLOOD Albumin-2.3* Calcium-9.1 Phos-3.9 Mg-2.3
[**2143-11-24**] 04:58PM BLOOD Cortsol-35.5*
[**2143-11-24**] 06:19PM BLOOD Cortsol-35.8*
[**2143-11-24**] 06:32PM BLOOD Cortsol-36.3*
[**2143-11-28**] 03:05PM BLOOD Vanco-17.4
[**2143-12-6**] 10:27AM BLOOD Type-ART Temp-37.4 Rates-15/ Tidal V-500
PEEP-5 FiO2-50 pO2-81* pCO2-37 pH-7.26* calTCO2-17* Base XS--9
-ASSIST/CON Intubat-INTUBATED
[**2143-12-6**] 05:19AM BLOOD Lactate-2.7*
.
ABG on admission: 7.13/46/113/16
.
MICROBIOLOGY:
Blood cultures grew Klebsiella and then later Enterococcus
faecium
.
IMAGING/REPORTS:
.
[**2143-10-8**] CBD brushings/cytology: no evidence of malignant cells.
.
Echo [**2143-10-10**]: Preserved global left ventricular systolic
function. Right ventricle appears dilated with probable RV
systolic dysfunction. Mildly dilated thoracic aorta. Limited
study.
EKG: Sinus tachycardia at 107bpm. Q in III. Normal axis, normal
intervals. Wavy baseline. TWF in V1-V3.
.
CT Abd/Pelvis [**2143-10-8**]: 1.  3.5 x 3.5 cm mass in the head of the
pancreas concerning for malignancy. There is approximately 50%
involvement of the SMV circumference. 2.  Fatty liver without
evidence of focal lesion.
.
CXR [**2143-11-22**]: 1.  Tip of the endotracheal tube is 2 cm from the
carina and may be withdrawn approximately 2 cm for standard
positioning. 2.  Apparent widening of the cardiomediastinum
likely secondary to rotation, and can be reassessed once repeat
radiographs are obtained following ET tube repositioning. 3.  No
acute process identified.
.
CXR [**2143-11-22**] (line placement): 1.  Right IJ in cavoatrial
junction.
2.  Otherwise, no change since one hour ago.

Liver US [**11-24**]:
The liver displays no focal masses and unremarkable parenchyma.
Again identified is mild prominence to the extra- hepatic
biliary system measuring approximately 6 mm and large amount of
sludge within the gallbladder. Portal vein is patent with normal
hepatopetal flow. Of note, the recently placed CBD stents were
unable to be visualized by ultrasound.

Non-contrast CT Head [**12-3**]:
Limited study. No acute intracranial hemorrhage or mass effect.
Old lacunar infarct. Please note that MRI is more sensitive for
acute stroke and metastasis.

Renal US [**12-3**]:
Normal renal ultrasound without evidence of hydronephrosis.

Liver US [**12-5**]:
1. Dilated extrahepatic common bile duct, with stent and sludge
seen within. No evidence of intrahepatic biliary ductal
dilatation.
2. Sludge again seen within the gallbladder, without evidence of
acute cholecystitis.

CXR [**12-6**]:
Improved bibasilar atelectasis and bilateral pleural effusions,
now very small.

Brief Hospital Course:
Mr. [**Known lastname **] is a 59yM with pancreatic mass (likely malignant) s/p
CBD stenting in [**2143-4-9**] who presents with abdominal pain,
jaundice, and hypotension, found to have blocked CBD stent with
frank pus.  He developed respiratory failure and was treated in
the ICU for septic shock.  On [**12-6**], after discussing the matter
with his family, he was made comfort measures only and he passed
away that evening.

# Hypotension/Septic Shock:
Most likely secondary to biliary source. ERCP performed and
re-stented in ICU on arrival, with frank pus behind occluded
stent. Re-ERCP on [**11-24**] after deterioration and re-intubation.
This ERCP showing occluded stent and frank pus.  Another stent
placed in parallel. Blood grew klebsiella pneumoniae (2 species,
pan-sensitive), VRE (sensitive only to linezolid).  Patient was
put on linezolid and zosyn according to ID recommendations.  His
blood pressure was supported with levophed and IV fluids.
Nevertheless, he continued to develop episodes of hypotension
with recurrent fevers on [**12-5**] and [**12-6**].  While awaiting
another repeat ERCP, he continued to deteriorate.  After meeting
with the patient's family, the team agreed to withdraw pressors
and provide comfort measures only.  He passed away in the
evening of [**12-6**].

#) Respiratory failure:
Intubated in ED secondary to altered mental status, extubated
[**11-23**] and re-intubated [**11-24**] with low bp and rigors.  He had
underlying CHF and COPD, and he continued to be difficult to
wean from the vent.

#) Acute on chronic renal failure:
Likely secondary to hypotension (SBP in 50s prior to intubation.
 His ACE inhibitor was held and his medications were renally
dosed.  He was supported with IV fluids and pressors.
Nevertheless, his Cr continued to increase to 2.9 on the day of
his death.

#) Pancreatic mass:
Patient was deemed a poor surgical candidate.  He had no tissue
diagnosis, but given that his CA [**54**]-9 was elevated, there was
high suspicion that the mass represented a malignant process.

#) Mental status.
Unclear if he may have underlying encephalopathy vs delerium
related to critical illness. Poor synthetic function indicates
likely underlying liver abnormality. With upgoing Babinski (?
new [**12-2**]) and slight tremor in upper extremities b/l with
repositioning. No clonus on exam. Head CT negative for acute
process.  He was given lactulose empirically.

#) Coagulopathy:
Nutritional vs. liver disease.  He received FFP prior to
procedures, and his coagulopathy somewhat increased during his
course.

#) Type 2 Diabetes:
He was alternately treated with insulin gtt and with fixed and
sliding scale insulin for sugar control.

#) CAD:
He was given ASA, and beta blocker was started once his
hypotension resolved.  ACE inhibitor was held because of his
renal failure.

Medications on Admission:
- Omeprazole 20mg PO daily
- ASA 81mg PO daily
- Furosemide 40mg daily
- Metoprolol 12.5mg PO BID
- Captopril 25mg PO TID
- Fluoxetine 40mg PO daily
- Colchicine 0.6mg daily
- Lantus 50mg SQ Qam
- Regular Insulin Sliding Scale
- Dilaudid 2-4mg IV Q3H PRN severe pain
- Dilaudid 4mg PO Q3H PRN pain
- Heparin SubQ DVT prophylaxis
- Colace 100mg PO BID

Discharge Medications:
none/deceased

Discharge Disposition:
Expired

Discharge Diagnosis:
Possible pancreatic malignancy.
Sepsis
Biliary duct obstruction

Discharge Condition:
Deceased.

Discharge Instructions:
Deceased.

Followup Instructions:
Deceased.


Completed by:[**2143-12-16**]
{'Other septicemia due to gram-negative organisms,Acute kidney failure, unspecified,Cholangitis,Malignant neoplasm of head of pancreas,Acute respiratory failure,Septic shock,Other and unspecified coagulation defects,Encounter for palliative care,Unspecified disorder of kidney and ureter,Old myocardial infarction,Lack of housing,Lumbago,Other chronic pain,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Chronic kidney disease, unspecified,Severe sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, 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: Septic shock

PRESENT ILLNESS: Mr. [**Known lastname **] is a 59 year old man with history of likely pancreatic
malignancy who was transferred from [**Hospital **] Hospital with
abdominal pain and rising bilirubin for ERCP evaluation. At
[**Hospital1 **], he had worsening abdominal pain, and he was noted to
have a rising bilirubin. ERCP/stenting cannot be performed at
[**Last Name (LF) **], [**First Name3 (LF) **] he was transferred here for urgent evaluation and
stenting.

MEDICAL HISTORY: Pancreatic mass s/p stent placement ([**4-/2143**])
Type 2 Diabetes, on insulin
CVA
Chronic renal insufficiency - baseline 1.5
s/p pacemaker placement for bradycardia
Hypertension
CAD s/p MI
Gout
COPD/OSA
Chronic LBP
Arthritis
History of venous stasis ulcers, recent cellulitis

MEDICATION ON ADMISSION: - Omeprazole 20mg PO daily
- ASA 81mg PO daily
- Furosemide 40mg daily
- Metoprolol 12.5mg PO BID
- Captopril 25mg PO TID
- Fluoxetine 40mg PO daily
- Colchicine 0.6mg daily
- Lantus 50mg SQ Qam
- Regular Insulin Sliding Scale
- Dilaudid 2-4mg IV Q3H PRN severe pain
- Dilaudid 4mg PO Q3H PRN pain
- Heparin SubQ DVT prophylaxis
- Colace 100mg PO BID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: T99.9F, BP 167/90, HR 130, RR 21, Sat 100%
VENT: A/C, FiO2 100%, TV 550, Rate 14, PEEP 5
GEN: Sedated, intubated, jaundiced
HEENT: Scleral icterus, PERRL
NECK: Unable to appreciate JVP
RESP: CTA bilaterally anteriorly
CV: Tachycardic, no murmurs
ABD: Obese, distended, decreased bowel sounds; opens eyes and
becomes agitated with palpation and shaking the bed
EXT: Trace edema bilaterally, lower extremities with 2+ DP
pulses, dry skin
SKIN: Jaundiced
RECTAL: Guaiac + in ED

FAMILY HISTORY: Unable to obtain

SOCIAL HISTORY: Unemployed, previously worked as a mechanic. Lives at [**First Name8 (NamePattern2) 2048**]
[**Last Name (NamePattern1) **] house. H/o tobacco x 4-5 years, alcohol and
polysubstance abuse, but currently sober. Per previous notes,
wheelchair bound and very little ambulation. 

### Response:
{'Other septicemia due to gram-negative organisms,Acute kidney failure, unspecified,Cholangitis,Malignant neoplasm of head of pancreas,Acute respiratory failure,Septic shock,Other and unspecified coagulation defects,Encounter for palliative care,Unspecified disorder of kidney and ureter,Old myocardial infarction,Lack of housing,Lumbago,Other chronic pain,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Chronic kidney disease, unspecified,Severe sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled'}
