CHIEF COMPLAINT: CC:[**CC Contact Info 89949**]
Major Surgical or Invasive Procedure:
None

PRESENT ILLNESS: [**Age over 90 **] yo F PMH dementia presented to OSH following evaluation at
nursing home for cough, decreased appetite that demonstrated
creatinine increase to 3.6. Patient describes recent cough (per
HCP 1 week duration) but denies fever or chills. Denies
abdominal pain, nausea, vomiting. Denies chest pain or shortness
of breath. Per HCP patient has not been eating well last several
months.
.
Patient presented to OSH found to have T 94.5, creatinine 3.6,
WBC 8.6 (N80%), bilirubin of 8 and an ALP of almost 1400. Her
ultrasound showed some thickening of the GB wall, and did not
comment on her CBD. There were stones and sludge reported. CXR
demonstrated increased opacity right lung base medially and left
retrocardiac region. She was transferred to [**Hospital1 18**] for further
management.
.
On arrival to our ED VS T 97.7, BP 96/54, HR 90, O2Sat 95% 2L.
SBP dropped to 60 which improved to SBP 90s with 3 L of NS. Labs
notable for lactate 2.1, creatinine 3.5 (from baseline of 1.1),
ALT 58, AST 120, AP 1061, Tbili 6.1, Alb 2.9, lipase 13, WBC 7.1
(N 79, L 14), INR 1.3. Gallbladder ultrasound demonstrated
markedly distended GB with sludge/stones but no thickening or
definite [**Doctor Last Name 515**] sign. CBD irregular in appearance measuring up
to 1 cm in diameter. Moderate to large amount of ascites. Patent
main portal vein. Blood and urine cultures sent. Patient given
Levofloxacin (received Unasyn at OSH). Surgery was consulted -
patient's HCP declined surgery but will consider ERCP.
Consequently patient is being admitted to the MICU.
.
On arrival to the ICU, patient overall looks well and is
conversant.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath. Patient
has chronic edema. Describes increase in urinary frequency but
no dysur

MEDICAL HISTORY: Dementia
Glaucoma
HTN
Cholelithiasis
GERD
Osteopenia
Spinal stenosis
Lymphedema
Right hip replacement

MEDICATION ON ADMISSION: ASA 81
Colace 100 mg [**Hospital1 **]
Lisinopril 10 mg qd
Prilosec 20 mg daily
Lasix 40 mg daily
Lumigan 0.03% one drop each at bedtime
Robitussin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: GEN: elderly female, no acute distress
HEENT: Dry mucosa, EOMI, PERRL, sclera icteric, no epistaxis or
rhinorrhea, OP Clear.
NECK: No JVD
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Decreased breath sounds throughout
ABD: Soft, moderately distended, non-tender to light and deep
palpation. No fluid wave. No rebound or gaurding. + BS.
EXT: 3+ pitting edema b/l, no palpable cords
NEURO: alert, oriented to place and season. CN II ?????? XII grossly
intact. Moves all 4 extremities.
SKIN: + jaundice.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient lives in long-term care facility Blueberry [**Doctor Last Name **]. Son is
HCP. [**Name (NI) **] history of tobacco abuse
Other malignant neoplasm without specification of site,Acute kidney failure with lesion of tubular necrosis,Obstruction of bile duct,Other ascites,Shock, unspecified,Esophageal reflux,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Encounter for palliative care
Malignant neoplasm NOS,Ac kidny fail, tubr necr,Obstruction of bile duct,Ascites NEC,Shock NOS,Esophageal reflux,Mental disor NEC oth dis,Hypertension NOS,Crnry athrscl natve vssl,Encountr palliative care
Admission Date:  [**2163-2-22**]              Discharge Date:   [**2163-2-24**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
CC:[**CC Contact Info 89949**]
Major Surgical or Invasive Procedure:
None

History of Present Illness:
[**Age over 90 **] yo F PMH dementia presented to OSH following evaluation at
nursing home for cough, decreased appetite that demonstrated
creatinine increase to 3.6. Patient describes recent cough (per
HCP 1 week duration) but denies fever or chills. Denies
abdominal pain, nausea, vomiting. Denies chest pain or shortness
of breath. Per HCP patient has not been eating well last several
months.
.
Patient presented to OSH found to have T 94.5, creatinine 3.6,
WBC 8.6 (N80%), bilirubin of 8 and an ALP of almost 1400. Her
ultrasound showed some thickening of the GB wall, and did not
comment on her CBD. There were stones and sludge reported. CXR
demonstrated increased opacity right lung base medially and left
retrocardiac region. She was transferred to [**Hospital1 18**] for further
management.
.
On arrival to our ED VS T 97.7, BP 96/54, HR 90, O2Sat 95% 2L.
SBP dropped to 60 which improved to SBP 90s with 3 L of NS. Labs
notable for lactate 2.1, creatinine 3.5 (from baseline of 1.1),
ALT 58, AST 120, AP 1061, Tbili 6.1, Alb 2.9, lipase 13, WBC 7.1
(N 79, L 14), INR 1.3. Gallbladder ultrasound demonstrated
markedly distended GB with sludge/stones but no thickening or
definite [**Doctor Last Name 515**] sign. CBD irregular in appearance measuring up
to 1 cm in diameter. Moderate to large amount of ascites. Patent
main portal vein. Blood and urine cultures sent. Patient given
Levofloxacin (received Unasyn at OSH). Surgery was consulted -
patient's HCP declined surgery but will consider ERCP.
Consequently patient is being admitted to the MICU.
.
On arrival to the ICU, patient overall looks well and is
conversant.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath. Patient
has chronic edema. Describes increase in urinary frequency but
no dysur

Past Medical History:
Dementia
Glaucoma
HTN
Cholelithiasis
GERD
Osteopenia
Spinal stenosis
Lymphedema
Right hip replacement

Social History:
Patient lives in long-term care facility Blueberry [**Doctor Last Name **]. Son is
HCP. [**Name (NI) **] history of tobacco abuse

Family History:
Non-contributory

Physical Exam:
GEN: elderly female, no acute distress
HEENT: Dry mucosa, EOMI, PERRL, sclera icteric, no epistaxis or
rhinorrhea, OP Clear.
NECK: No JVD
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Decreased breath sounds throughout
ABD: Soft, moderately distended, non-tender to light and deep
palpation. No fluid wave. No rebound or gaurding. + BS.
EXT: 3+ pitting edema b/l, no palpable cords
NEURO: alert, oriented to place and season. CN II ?????? XII grossly
intact. Moves all 4 extremities.
SKIN: + jaundice.


Pertinent Results:
[**2163-2-22**] 06:30PM   WBC-7.1 RBC-3.82* HGB-11.5* HCT-35.5* MCV-93
MCH-30.0 MCHC-32.3 RDW-16.0*
[**2163-2-22**] 06:30PM   PLT COUNT-202
[**2163-2-22**] 06:30PM   NEUTS-79.6* LYMPHS-14.1* MONOS-5.4 EOS-0.6
BASOS-0.3
[**2163-2-22**] 06:30PM   PT-14.8* PTT-24.6 INR(PT)-1.3*
[**2163-2-22**] 06:30PM   GLUCOSE-110* UREA N-110* CREAT-3.5*
SODIUM-141 POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-26 ANION GAP-21*
[**2163-2-22**] 06:30PM   ALT(SGPT)-58* AST(SGOT)-120* CK(CPK)-51 ALK
PHOS-1061* TOT BILI-6.1* DIR BILI-5.2* INDIR BIL-0.9
[**2163-2-22**] 06:30PM   LIPASE-13
[**2163-2-22**] 06:30PM   cTropnT-0.09*
[**2163-2-22**] 06:30PM   CK-MB-5
[**2163-2-22**] 06:31PM   LACTATE-2.1*
[**2163-2-22**] 07:00PM URINE  RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2163-2-22**] 07:00PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
[**2163-2-22**] 07:00PM URINE  COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2163-2-22**] 09:54PM URINE  HOURS-RANDOM CREAT-71 SODIUM-61
POTASSIUM-33 CHLORIDE-54
.
Renal US:
The right kidney measures 9.2 cm and shows cortical thinning but
no
hydronephrosis. The left kidney is only partially seen but it
too shows no
evidence of hydronephrosis.

The spleen is not enlarged. The bowel is predominantly pulled
posteriorly
suggesting that the cause of the ascites is intra-abdominal
spread of
malignancy.Neither pancreas or aorta could be seen.

IMPRESSION: Pancreas and aorta not seen. Extensive ascites that
is probably
malignant.
.
EXAM: Right upper quadrant ultrasound.

COMPARISONS: None available.

FINDINGS:

There is a large amount of intra-abdominal ascites. The liver
demonstrates no
focal or textural abnormalities. There is irregularity of the
common bile
duct which measures up to 10 mm. The gallbladder is distended
containing
layering stones and sludge. There is no appreciable gallbladder
wall
thickening. There was a negative son[**Name (NI) 493**] [**Name (NI) **] sign. The
main portal
vein is patent with appropriate hepatopetal flow. The pancreas
is not well
visualized.

IMPRESSION:

1. Markedly distended gallbladder containing stones and sludge.
No
gallbladder wall thickening or pericholecystic fluid. However,
in the
appropriate clinical setting, acute cholecystitis would be of
concern and
further evaluation with HIDA scan could be obtained.

2. Large amount of intra-abdominal ascites.

3. Irregularity of the common bile duct, which measures up to
10mm.

The study and the report were reviewed by the staff radiologist
.
CXR:
HISTORY: [**Age over 90 **]-year-old woman with cough and hypotension.

IMPRESSION: AP chest reviewed in the absence of any prior chest
imaging:

Pulmonary edema is at least mild in severity. Large region of
opacification in the left lower lobe, seen through the cardiac
silhouette, obscures the left diaphragmatic pleural surface and
could be pneumonia or left lower lobe collapse, but could also
be mediastinal abnormality such as a thoracic aortic aneurysm or
large hiatus hernia. Lateral view would be very helpful. Small
bilateral pleural effusions are presumed. Heart is at least
moderately enlarged if not severely. Elevation of the left main
bronchus suggests substantial left atrial dilatation, and a
ring-like calcification could be in the mitral annulus. Once
again, lateral view would be very helpful. Dr. [**First Name (STitle) 89950**] and I
discussed these findings by telephone.


Brief Hospital Course:
[**Age over 90 **] year-old female with a history of dementia trasnferred from
OSH for obstructive jaundice.
.
# Jaundice: Initial concern for choledocholithiasis and patient
covered with antibiotics. After review, growing concern for
malignant etiology: cholangiocarcinoma vs pancreatic malignancy.
 Discussion held with family regarding goals of care. Central
venous line, ERCP and surgery declined. Palliative care
consulted. Decision made to return to [**Hospital3 **] facility
with hospice. Interventions were miniminalized prior to
discharge. Antibiotics were discontinued, pressors were weaned
off.

# Goals of care. Palliative care consulted shortly after
admission. Referral made to Hospice [**Location (un) 1121**] for palliative
care at Blueberry [**Doctor Last Name **]. Family counseled and prepared regarding
likely upcoming events such as continued anorexia secondary to
the natural consequence of aging, cancer, dying process as well
as further inability to ambulate. Palliative care recommended:
trial of pain medication of low dose  morphine 2.5 mg prn.
Tylenol avoiding in setting of abnormal liver function tests.
Patient was without complaints of pain at time of discharge.
.
# Hypotension. On admission patient with asymptomatic
hypotension in the 70s. Started on low dose pressor support.
After discussion regarding goals of care decision made to wean
pressors unless symptomatic. All anti-hypertensives medications
held. Patient hemodynamically stable at time of transfer.
.
# Renal failure: Most likely pre-renal versus ATN from shock.
Renal US without hydronephrosis. Creatinine improved with trial
of fluids. Renal function was not trended after goals of care
discussion took place.
.
# Glaucoma: Continue Lumigan.
.
# GERD: Continue prilosec.
.
#. CAD. Continued Aspirin. Held ACE in setting of hypotension
and renal failure.

Medications on Admission:
ASA 81
Colace 100 mg [**Hospital1 **]
Lisinopril 10 mg qd
Prilosec 20 mg daily
Lasix 40 mg daily
Lumigan 0.03% one drop each at bedtime
Robitussin


Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for SOB.
5. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for SOB.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
9. morphine 10 mg/5 mL Solution Sig: 2.5 mg PO Q4H (every 4
hours) as needed for pain: Please use if tylenol ineffective.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
Blueberry [**Doctor Last Name **] Healthcare - [**Hospital1 **]

Discharge Diagnosis:
Primary
Obstructive Jaundice
.
Secondary
Dementia
Congestive Heart Failure
Lymphedema


Discharge Condition:
Mental status: confused at times
Unable to ambulate


Discharge Instructions:
Dear Ms [**Known lastname 89951**], you were admitted to [**Hospital3 **] Hospital for
further evaluation of your distended belly.
.
Shortly after arrival to the ICU decisions were made to avoid
invasive intervention and refocus goals of care on continued
comfort.
The palliative care team was consulted. The plan is for you to
return to Blue [**Doctor Last Name 3646**] [**Doctor Last Name **] with additional supports in place.
.
CHANGES TO YOUR MEDICATIONS:
Stop take Lisinopril
Hold Lasix given low blood pressure.
Start taking low dose Morphine as needed for pain
Start taking cough suppressants for comfort

Followup Instructions:
Plan to return to Blue [**Doctor Last Name 3646**] [**Doctor Last Name **] with hospice


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Completed by:[**2163-2-24**]
{'Other malignant neoplasm without specification of site,Acute kidney failure with lesion of tubular necrosis,Obstruction of bile duct,Other ascites,Shock, unspecified,Esophageal reflux,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Encounter for palliative care'}


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: CC:[**CC Contact Info 89949**]
Major Surgical or Invasive Procedure:
None

PRESENT ILLNESS: [**Age over 90 **] yo F PMH dementia presented to OSH following evaluation at
nursing home for cough, decreased appetite that demonstrated
creatinine increase to 3.6. Patient describes recent cough (per
HCP 1 week duration) but denies fever or chills. Denies
abdominal pain, nausea, vomiting. Denies chest pain or shortness
of breath. Per HCP patient has not been eating well last several
months.
.
Patient presented to OSH found to have T 94.5, creatinine 3.6,
WBC 8.6 (N80%), bilirubin of 8 and an ALP of almost 1400. Her
ultrasound showed some thickening of the GB wall, and did not
comment on her CBD. There were stones and sludge reported. CXR
demonstrated increased opacity right lung base medially and left
retrocardiac region. She was transferred to [**Hospital1 18**] for further
management.
.
On arrival to our ED VS T 97.7, BP 96/54, HR 90, O2Sat 95% 2L.
SBP dropped to 60 which improved to SBP 90s with 3 L of NS. Labs
notable for lactate 2.1, creatinine 3.5 (from baseline of 1.1),
ALT 58, AST 120, AP 1061, Tbili 6.1, Alb 2.9, lipase 13, WBC 7.1
(N 79, L 14), INR 1.3. Gallbladder ultrasound demonstrated
markedly distended GB with sludge/stones but no thickening or
definite [**Doctor Last Name 515**] sign. CBD irregular in appearance measuring up
to 1 cm in diameter. Moderate to large amount of ascites. Patent
main portal vein. Blood and urine cultures sent. Patient given
Levofloxacin (received Unasyn at OSH). Surgery was consulted -
patient's HCP declined surgery but will consider ERCP.
Consequently patient is being admitted to the MICU.
.
On arrival to the ICU, patient overall looks well and is
conversant.
.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, shortness of breath. Patient
has chronic edema. Describes increase in urinary frequency but
no dysur

MEDICAL HISTORY: Dementia
Glaucoma
HTN
Cholelithiasis
GERD
Osteopenia
Spinal stenosis
Lymphedema
Right hip replacement

MEDICATION ON ADMISSION: ASA 81
Colace 100 mg [**Hospital1 **]
Lisinopril 10 mg qd
Prilosec 20 mg daily
Lasix 40 mg daily
Lumigan 0.03% one drop each at bedtime
Robitussin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: GEN: elderly female, no acute distress
HEENT: Dry mucosa, EOMI, PERRL, sclera icteric, no epistaxis or
rhinorrhea, OP Clear.
NECK: No JVD
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Decreased breath sounds throughout
ABD: Soft, moderately distended, non-tender to light and deep
palpation. No fluid wave. No rebound or gaurding. + BS.
EXT: 3+ pitting edema b/l, no palpable cords
NEURO: alert, oriented to place and season. CN II ?????? XII grossly
intact. Moves all 4 extremities.
SKIN: + jaundice.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient lives in long-term care facility Blueberry [**Doctor Last Name **]. Son is
HCP. [**Name (NI) **] history of tobacco abuse 

### Response:
{'Other malignant neoplasm without specification of site,Acute kidney failure with lesion of tubular necrosis,Obstruction of bile duct,Other ascites,Shock, unspecified,Esophageal reflux,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Encounter for palliative care'}
