CHIEF COMPLAINT: fatigue, chills, ?subphrenic/pleural fluid collection,
metastatic ocular melanoma

PRESENT ILLNESS: [**Known firstname **] [**Known lastname 1391**] is a pleasant 46F from [**State 1727**] with metastatic
ocular melanoma most recently treated with ipilimumab (held on
C1D64). The patient reports considerable difficulties with
ipilimumab including intermittent abdominal pain and diarrhea
which began on [**2171-7-4**] and arthalgias which started on [**2171-8-11**].
The arthralgias involve her wrists, elbows, small joints of the
hands, knees and ankles, and sometimes she notices associated
swelling. The patient experiences frequent loose bowel
movements, up to 2-3 per day, that are somewhat manageable with
loperamide. On [**2171-8-26**] she called the clinic at [**Hospital1 18**] to report a
fever to 102.5 and associatd chills. On [**2171-9-1**] she developed
bright red blood per rectum and was hospitalized in [**State 1727**]
([**Hospital 63985**] Medical Center). She received a blood transfusions,
was placed on levofloxacin and vancomycin and her ASA and Plavix
were discontinued. She is currently on ASA and Plavix for a
portal vein stent. Her fevers and gastrointestinal bleed
subsided and she was discharged on [**2171-9-6**].

MEDICAL HISTORY: Hypertension
Left fibula fracture [**12/2170**]
Metastatic ocular melanoma

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 10 mg PO DAILY
2. Loperamide 4 mg PO QID:PRN diarrhea
3. Nystatin Oral Suspension 5 mL PO QID
4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE DAILY

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Gentamicin / Cefepime /
Betadine / chlorhexidine

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS 98.6 155/87 108 20 99%Ra
General: Appears fatigued. No acute distress.
Head and Neck:  No conjunctival pallor or scleral icterus. No
cervical or supraclavicular LAD. Left eye ptosis.
Chest:  Decreased breath sounds bilaterally at bases R>L,
bilateral course crackles. No wheezing.
Cardiovascular:  S1/S2 normal. No audible murmurs. Rate is
regular. No JVD.
Abdomen: Obese, soft, nontender. Tympanic. Normal BS. No
splenomegaly or hepatomegaly. Well healed surgical incision
scar.
Extremities:  2+ extremity edema (non-pitting). There are no
inflammatory changes of the joints (no wartmth, erythema or
edema). No rashes.
Neurological: No gross neurological deficits.  Slow gait.
Skin: hypopigmented lesions on skin

FAMILY HISTORY: Mother died at the age of 77, she had HTN, father passed away at
79 from HTN, stroke. There is no family history of cancer.

SOCIAL HISTORY: Married, lives in [**State 1727**] with husband and son. Worked as an
accounting officer in [**Company **]. Social EtOH, denies tobacco, no
illicits.
Empyema with fistula,Candidiasis of lung,Acute kidney failure, unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Other specified forms of effusion, except tuberculous,Fistula of bile duct,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of bone and bone marrow,Urinary tract infection, site not specified,Left-sided ulcerative (chronic) colitis,Profound impairment, one eye, impairment level not further specified,Unspecified essential hypertension,Personal history of irradiation, presenting hazards to health,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other disorders of plasma protein metabolism,Personal history of malignant melanoma of skin,Bilious emesis,Surgical or other procedure not carried out because of contraindication,Other fluid overload
Empyema with fistula,Candidiasis of lung,Acute kidney failure NOS,Pseudomonas infect NOS,Effusion NEC exc tb,Fistula of bile duct,Second malig neo liver,Secondary malig neo bone,Urin tract infection NOS,Lftsded ulcertve colitis,Blindness, one eye,Hypertension NOS,Hx of irradiation,Adv eff antineoplastic,Dis plas protein met NEC,Hx-malig skin melanoma,Bilious emesis,No proc/contraindication,Fluid overload NEC
Admission Date:  [**2171-9-9**]              Discharge Date:   [**2171-10-3**]

Date of Birth:  [**2125-7-23**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics) / Gentamicin / Cefepime /
Betadine / chlorhexidine

Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
fatigue, chills, ?subphrenic/pleural fluid collection,
metastatic ocular melanoma

Major Surgical or Invasive Procedure:
- VATS [**2171-9-13**]
- PICC line placement [**2171-9-14**]
- PTC [**2171-9-24**]

History of Present Illness:
[**Known firstname **] [**Known lastname 1391**] is a pleasant 46F from [**State 1727**] with metastatic
ocular melanoma most recently treated with ipilimumab (held on
C1D64). The patient reports considerable difficulties with
ipilimumab including intermittent abdominal pain and diarrhea
which began on [**2171-7-4**] and arthalgias which started on [**2171-8-11**].
The arthralgias involve her wrists, elbows, small joints of the
hands, knees and ankles, and sometimes she notices associated
swelling. The patient experiences frequent loose bowel
movements, up to 2-3 per day, that are somewhat manageable with
loperamide. On [**2171-8-26**] she called the clinic at [**Hospital1 18**] to report a
fever to 102.5 and associatd chills. On [**2171-9-1**] she developed
bright red blood per rectum and was hospitalized in [**State 1727**]
([**Hospital 63985**] Medical Center). She received a blood transfusions,
was placed on levofloxacin and vancomycin and her ASA and Plavix
were discontinued. She is currently on ASA and Plavix for a
portal vein stent. Her fevers and gastrointestinal bleed
subsided and she was discharged on [**2171-9-6**].

Ms [**Known lastname 1391**] is currently being admitted for continued chills,
fatigue and subphrenic/subpleural collection
(?abscess,?metastatic lesion). Over the past few days she has
noticed a significant decrease in her energy level; she spends
most of her day in the recliner and has alternating periods of
time that she feels hot or cold. Recently her PO fluid and food
intake has been poor. She received 1 unit of IVFs in the clinic
before she was transferred to the floor. She is hemodynamically
stable and her surgeon has been contact[**Name (NI) **] regarding the fluid
collection.

ROS:
Gen: +chills, +fatigue, +weakness, denies fevers
E&E: denies recent changes in vision/hearing
HNT: denies headache, nasal congestion, sore throat
Neck: denies neck pain/neck masses
Resp: denies SOB/cough/hemoptysis
Card: denies chest pain/palpitations/syncope
GI: +diarrhea, denies abdominal pain/n/v/melena/hematochezia
GU: denies dysuria/hematuria
Ext: mild edema
Skin: denies rashes/bruising
Neuro: denies weakness/numbness/tingling

Past Medical History:
Hypertension
Left fibula fracture [**12/2170**]
Metastatic ocular melanoma

ONCOLOGIC HISTORY:
- [**2158**]: Diagnosed with choroidal melanoma in her left eye
treated
with proton beam radiation.
- [**2163**]: Had a local recurrence and received repeat proton beam
radiation.
- [**2167-11-17**]: Surveillance labs revealed a rising alkaline
phosphatase to 189.
- [**2167-12-31**]: CT abdomen reportedly showed a 4 cm and a 5 cm
metastases within the right lobe of the liver (both new from
[**2166-10-13**]).
- [**2168-3-4**]: [**Month/Day/Year **] extended right hepatic lobectomy,
cholecystectomy, and Roux-en-Y hepaticojejunostomy with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] which, postoperatively, was complicated by a bile
leak and perihepatic abscess requiring a PTC drain and another
perihepatic drain.
- [**11/2168**]: Noted to have a growing right neck mass.
- [**2169-1-12**]: FNA of right neck mass confirmed metastatic melanoma.
- [**2169-2-14**]: PET CT confirmed FDG-avidity of right neck mass
without any other areas on concern.
- [**2169-3-2**]: [**Month/Day/Year **] a right upper anterior neck dissection with
removal of a 4.3 cm lymph node confirmed to have extensive
metastatic melanoma; there was evidence of extracapsular
extension. [**2169-4-22**] completed XRT to the right neck.
- [**2169-11-13**]: CT neck and torso: no evidence of disease
recurrence.
- [**2-/2170**]: CT neck and torso negative for disease recurrence
- [**2170-10-8**]: CT torso negative for disease recurrence
- [**2171-2-18**]: CT torso - increased size of the left lower quadrant
nodule
- [**2171-2-28**]: Biopsy consistent with melanoma
- [**2171-3-1**]: Portal venous stenting
- [**2171-4-5**]: Resection of the left lower quadrant nodule -
Pathology consistent with melanoma
- [**2171-6-10**]: New liver and spleen lesions. Enlarging L4 lesion;
concerning for progression of disease
- [**2171-6-24**]: Started on ipilimumab
- [**2171-7-15**]: C1D22 Ipilimumab
- [**2171-8-5**]: C1D43 Ipilimumab
- [**2171-8-27**]: C1D64 Ipilimumab held

PSH:
-C-section ([**2149**])
-photoablation left eye for ocular melanoma ([**2158**],[**2163**])
-portal vein embolization ([**1-/2168**])
-right hepatic lobectomy, cholecystectomy, anastomosis of the
left portal vein to the main portal vein, portal vein
thrombectomy, Roux-en-Y hepaticojejunostomy to the left hepatic
duct, and intraoperative ultrasound for metastatic melanoma
([**2168-3-4**])
-multiple biliary drainage procedures
-VATS decortication ([**2168-3-24**])
-excision neck mass ([**2-/2169**])
-excision retroperitoneal melenaoma metastasis ([**2171-4-5**])

Social History:
Married, lives in [**State 1727**] with husband and son. Worked as an
accounting officer in [**Company **]. Social EtOH, denies tobacco, no
illicits.

Family History:
Mother died at the age of 77, she had HTN, father passed away at
79 from HTN, stroke. There is no family history of cancer.

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.6 155/87 108 20 99%Ra
General: Appears fatigued. No acute distress.
Head and Neck:  No conjunctival pallor or scleral icterus. No
cervical or supraclavicular LAD. Left eye ptosis.
Chest:  Decreased breath sounds bilaterally at bases R>L,
bilateral course crackles. No wheezing.
Cardiovascular:  S1/S2 normal. No audible murmurs. Rate is
regular. No JVD.
Abdomen: Obese, soft, nontender. Tympanic. Normal BS. No
splenomegaly or hepatomegaly. Well healed surgical incision
scar.
Extremities:  2+ extremity edema (non-pitting). There are no
inflammatory changes of the joints (no wartmth, erythema or
edema). No rashes.
Neurological: No gross neurological deficits.  Slow gait.
Skin: hypopigmented lesions on skin

Pertinent Results:
ADMISSION LABS:
[**2171-9-9**] 03:20PM BLOOD WBC-5.7 RBC-2.71* Hgb-8.0* Hct-24.3*
MCV-90 MCH-29.4 MCHC-32.8 RDW-15.2 Plt Ct-323
[**2171-9-9**] 03:20PM BLOOD Neuts-82.8* Lymphs-11.6* Monos-4.5
Eos-0.7 Baso-0.3
[**2171-9-9**] 03:20PM BLOOD UreaN-20 Creat-1.5* Na-132* K-3.9 Cl-100
HCO3-24 AG-12
[**2171-9-9**] 03:20PM BLOOD ALT-66* AST-112* LD(LDH)-191 AlkPhos-151*
TotBili-0.7
[**2171-9-9**] 03:20PM BLOOD Albumin-2.3* Calcium-7.5* Mg-2.0
[**2171-9-9**] 03:20PM BLOOD TSH-4.0
[**2171-9-9**] 03:20PM BLOOD Free T4-1.1

CT CHEST/ABD [**2171-9-9**]
IMPRESSION: 1. New soft tissue mass at the right base which
appears to involve the diaphragm and extends superiorly to the
lung parenchyma and inferiorly to the region of the
postoperative bed from prior right hepatectomy. Additionally,
there is a loculated pleural effusion with air consistent with
hydropneumothorax. Air is seen outside of the thoracic cage
which may be related to a prior intervention. If not already
performed, this lesion is amenable to biopsy. 2. Findings
consistent with colitis involving the transverse and descending
colon.

LUE US [**2171-9-17**]:
IMPRESSION:  No evidence of DVT in the left arm.

CHOLANGIOGRAPHY VIA EXISTING PTC [**2171-9-27**]:
IMPRESSION: 1. Small biliary leak seen from a peripheral branch
duct, on selective cholangiography. 2. No intervention was
performed - continued biliary diversion using the existing 8Fr
PTBD.

CT CHEST [**2171-10-1**]:
CONCLUSION: 1. Patient had prior hemihepatectomy in [**2167**] for
metastatic ocular melanoma. Presumed biliary pleural fistula is
smaller and air inside the tract has resolved. Small loculated
right pleural effusion has also decreased in size, with
improvement of adjacent atelectasis. 2. Soft tissue loculated
fluid collection is in the surgical bed in the inferior lateral
chest wall. The superior component is stable and inferior
component has less air, but is slightly bigger in size. 3.
Multiple lung nodules are seen. Some are stable since [**2168**],
consistent with benign etiolgy.  One is slowly progressive since
[**2170-9-22**] in the left upper lobe, worrisome for metastasis.
In the left lung, two have increased in size and one is new
since [**2171-9-9**] : this is probably not related to the
malignancy considering the fact that they appeared over a short
period of time. They will have to be followed up. 3.  Unchanged
12 mm lesion in the spleen. 4.  Unchanged lytic lesion in L4
vertebral body.

Brief Hospital Course:
46F with metastatic ocular melanoma recently treated with
ipilimumab presenting for evaluation of a soft tissue mass in
the right lung base associated with fatigue and chills. Recent
hospitalization at [**Hospital 63985**] Medical Center in [**State 1727**] for fevers
and GIB [**Date range (1) 81838**], treated with IV antibiotics and red cell
transfusions.

#RIGHT LUNG BASE SOFT TISSUE MASS: In the setting of recent
fevers/chills/fatigue there was a concern for an abscess
formation and potentially a bronchopleural fistula. She was
treated with vancomycin and levofloxacin at an outside hospital
from [**Date range (3) 81838**] with resolution of fevers. One blood culture
yielded staph epidermidis which was thought to be a contaminate.
On [**2171-9-9**] she spiked a fever to 101.3. Vancomycin and
levofloxacin were restarted and blood/urine/sputum/stool
cultures were ordered. The lesion was amendable to percutaneous
biopsy/drainage. She had IR quided drainage on [**9-11**] w 30 cc pus
removed. This grew [**Female First Name (un) **] and pseudomonas and rare growth of
Lactobacilli. She then had a chest tube placement with washout
by thoracic surgery (Dr. [**Last Name (STitle) **] on [**2171-9-13**]. She produced
significant bilious output from this chest tube over the
proceeding days. She was also coughing up bilious fluid (bile
level in sputum measured at 28). It was theorized this was
secondary to biliary-pleural fistula. Hepatobiliary surgery (Dr.
[**Last Name (STitle) **] was consulted for further evaluation and management.
Ultimately, she [**Last Name (STitle) 1834**] placement of a percutaneous
transhepatic catheter (PTC) into her biliary tree. This
intervention significantly reduced the volume of output via the
chest tube and improved her cough as well. Definitive
demonstration of biliary-pleural fistula was performed via
angiography on [**2171-9-27**], which found a small fistula at the
medial aspect of right hemidiaphragm. Plan for management of
this fistula is to continue diverting flow through her PTC until
sufficient time has passed for the fistula to close. At that
time the PTC will be able to be removed. Her chest tube will be
slowly withdrawn over a series of visits with the thoracic
surgery department. A CT prior to departure demonstrated partial
resolution of her biliary-pleural fluid collection. Antibiotic
recommendations for this infected fluid collection were tailored
according to ID recommendations. She was initially treated with
vancomycin, ceftazidime, metronidazole, and micafungin.
Vancomycin was later discontinued and she was discharged on
vancomycing, ceftazidime, and metronidazole. The duration of
treatment with these agents remains unclear and will likely
continue while her sub-pleural collection continues to drain via
the existing chest tube. During management of this complicated
condition, she unfortunately suffered an acute kidney injury.
This was most likely secondary to her peri-septic state, and
completely improved following fluid resuscitation and
antibiotics.

#DIARRHEA: Well known adverse effect of ipilimumab. C.diff
colitis was ruled out with PCR assay. The outside records from
admission [**Date range (3) 81838**] were obtained and C.diff assay was
negative.

#GIB/COLITIS: Thought to be ipilumimab colitis but seemed to be
improving. She continued to have some diarrhea with bloody bowel
movements. ASA and Plavix were discontinued. GIB likely
secondary to inflammatory bowel disease initiated by ipilumimab.
Her anti-diarrheal agents were optimized as below, with some
improvement.

#HYPOALBUMINEMIA: Secondary to poor nutrition and potentially
protein loss through colitis. The patient's edema is likely
secondary to her low albumin and recent IVFs. Her albumin
improved throughout her hospitalization as her nutrition
improved and fluid overload was corrected.

#METASTATIC OCULAR MELANOMA: Patient with long history of ocular
melanoma, treated by Dr. [**Last Name (STitle) **] with ipilumumab. Patient's
prior hospitalization in [**State 1727**] due to upper GI bleed is
suspicious for autoimmune colitis secondary to ipilumumab
toxicity. Her biliary-pleural fistula is potentially related to
metastatic melanoma, but insufficient tissue was able to
biopsied during her IR procedures. She received ocular
prednisolone throughout her stay. Ipilumumab was withheld during
her stay. Final decisions on whether to resume this regimen will
be made after this acute process resolves.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 10 mg PO DAILY
2. Loperamide 4 mg PO QID:PRN diarrhea
3. Nystatin Oral Suspension 5 mL PO QID
4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE DAILY


Discharge Medications:
1. Loperamide 4 mg PO QID:PRN diarrhea
2. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE DAILY
3. Acetaminophen 325-650 mg PO Q6H:PRN fever
4. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing
5. Artificial Tear Ointment 1 Appl BOTH EYES [**Hospital1 **]:PRN dryness
6. Benzonatate 100 mg PO TID
7. Bismuth Subsalicylate 30 mL PO Q3HR:PRN diarrhea
8. CefTAZidime 2 g IV Q8H
9. Dextromethorphan Poly Complex 30 mg PO Q12H
10. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea
11. Guaifenesin-CODEINE Phosphate 15 mL PO Q6H:PRN severe cough
12. Heparin 5000 UNIT SC TID
13. HYDROmorphone (Dilaudid) 0.5 mg IV Q2H:PRN pain
14. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN shortness of breath

15. Lorazepam 0.5-1 mg IV Q4H:PRN anxiety/insomnia/nausea
16. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
17. Micafungin 100 mg IV Q24H
18. Ondansetron 8 mg IV Q8H:PRN nausea
19. Opium Tincture 10 DROP PO Q6H:PRN diarrhea
20. Pantoprazole 40 mg IV Q24H
21. Phosphorus 250 mg PO TID


Discharge Disposition:
Extended Care

Facility:
The [**Hospital 63985**] Medical Center

Discharge Diagnosis:
PRIMARY:
- metastatic ocular melanoma
- biliary-pleural fistula
- biliary abscess
SECONDARY:
- autoimmune colitis
- anemia


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


Discharge Instructions:
Dear Mrs. [**Known lastname 1391**],

Thank you for choosing [**Hospital1 18**] for your medical care. You were
admitted to the hospital on [**2171-9-9**] for management of a fluid
collection in your right lung. During your work-up, you were
found to have a connection between a portion of your bile system
in your liver and your right lung. You had a chest tube placed
to drain this collection from your lung, and then had a drain
placed into your liver to drain the bile. You also received
intravenous antibiotics for this collection, as it proved to be
infected. You will continue these antibiotics via your PICC
line. You will need to follow-up with the thoracic surgery team
(Dr. [**Last Name (STitle) **] for management of your chest tube. You will
need to follow-up with the hepatobiliary surgery team for
management of your biliary drain (Dr. [**Last Name (STitle) **]. You will need to
follow-up with the infectious disease clinic for management of
your antibiotics (Dr. [**Last Name (STitle) 7443**]. Finally, you will need to
follow-up with Dr. [**Last Name (STitle) **] for management of your
chemotherapy.

Upon discharge, please call Dr.[**Doctor Last Name 20641**] office at
[**Telephone/Fax (1) 13016**] or present to your local ER if you experience any
of the following: fever, chills, chest pain, worsening cough
productive of bile, abdominal pain, nausea, vomiting, worsening
diarrhea, bloody or dark colored bowel movements, increasing
extremity swelling, or any other symptoms that concern you.

Once discharged, you should have the chest tube flushed once per
day with 20ml of normal saline. Record the output daily. Record
the output of your biliary drain (PTC) daily. Please let Dr. [**Name (NI) 5794**] office ([**0-0-**]) know if Dr.[**Name (NI) 1369**] team
decides to cap the PTC tube.

Please take all medications only as prescribed. Please keep your
scheduled follow-up appointments as indicated below.

Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY - THORACIC SURGERY
When: TUESDAY [**2171-10-15**] at 2:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min
prior to your appointment for a chest xray.

Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2171-10-15**] at 2:15 PM
With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2171-10-15**] at 3:00 PM
With: [**Year (4 digits) 1220**]. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: TRANSPLANT CENTER
When: WEDNESDAY [**2171-10-16**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: INFECTIOUS DISEASE
When: THURSDAY [**2171-10-17**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Name: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Specialty: Primary Care
Location: FAMILY PRACTICE & INTERNAL MEDICINE
Address: [**Street Address(2) 81839**] [**Apartment Address(1) **], [**Location (un) 81840**],[**Numeric Identifier 81841**]
Phone: [**Telephone/Fax (1) 81842**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
{'Empyema with fistula,Candidiasis of lung,Acute kidney failure, unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Other specified forms of effusion, except tuberculous,Fistula of bile duct,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of bone and bone marrow,Urinary tract infection, site not specified,Left-sided ulcerative (chronic) colitis,Profound impairment, one eye, impairment level not further specified,Unspecified essential hypertension,Personal history of irradiation, presenting hazards to health,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other disorders of plasma protein metabolism,Personal history of malignant melanoma of skin,Bilious emesis,Surgical or other procedure not carried out because of contraindication,Other fluid overload'}


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: fatigue, chills, ?subphrenic/pleural fluid collection,
metastatic ocular melanoma

PRESENT ILLNESS: [**Known firstname **] [**Known lastname 1391**] is a pleasant 46F from [**State 1727**] with metastatic
ocular melanoma most recently treated with ipilimumab (held on
C1D64). The patient reports considerable difficulties with
ipilimumab including intermittent abdominal pain and diarrhea
which began on [**2171-7-4**] and arthalgias which started on [**2171-8-11**].
The arthralgias involve her wrists, elbows, small joints of the
hands, knees and ankles, and sometimes she notices associated
swelling. The patient experiences frequent loose bowel
movements, up to 2-3 per day, that are somewhat manageable with
loperamide. On [**2171-8-26**] she called the clinic at [**Hospital1 18**] to report a
fever to 102.5 and associatd chills. On [**2171-9-1**] she developed
bright red blood per rectum and was hospitalized in [**State 1727**]
([**Hospital 63985**] Medical Center). She received a blood transfusions,
was placed on levofloxacin and vancomycin and her ASA and Plavix
were discontinued. She is currently on ASA and Plavix for a
portal vein stent. Her fevers and gastrointestinal bleed
subsided and she was discharged on [**2171-9-6**].

MEDICAL HISTORY: Hypertension
Left fibula fracture [**12/2170**]
Metastatic ocular melanoma

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 10 mg PO DAILY
2. Loperamide 4 mg PO QID:PRN diarrhea
3. Nystatin Oral Suspension 5 mL PO QID
4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE DAILY

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Gentamicin / Cefepime /
Betadine / chlorhexidine

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS 98.6 155/87 108 20 99%Ra
General: Appears fatigued. No acute distress.
Head and Neck:  No conjunctival pallor or scleral icterus. No
cervical or supraclavicular LAD. Left eye ptosis.
Chest:  Decreased breath sounds bilaterally at bases R>L,
bilateral course crackles. No wheezing.
Cardiovascular:  S1/S2 normal. No audible murmurs. Rate is
regular. No JVD.
Abdomen: Obese, soft, nontender. Tympanic. Normal BS. No
splenomegaly or hepatomegaly. Well healed surgical incision
scar.
Extremities:  2+ extremity edema (non-pitting). There are no
inflammatory changes of the joints (no wartmth, erythema or
edema). No rashes.
Neurological: No gross neurological deficits.  Slow gait.
Skin: hypopigmented lesions on skin

FAMILY HISTORY: Mother died at the age of 77, she had HTN, father passed away at
79 from HTN, stroke. There is no family history of cancer.

SOCIAL HISTORY: Married, lives in [**State 1727**] with husband and son. Worked as an
accounting officer in [**Company **]. Social EtOH, denies tobacco, no
illicits. 

### Response:
{'Empyema with fistula,Candidiasis of lung,Acute kidney failure, unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Other specified forms of effusion, except tuberculous,Fistula of bile duct,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of bone and bone marrow,Urinary tract infection, site not specified,Left-sided ulcerative (chronic) colitis,Profound impairment, one eye, impairment level not further specified,Unspecified essential hypertension,Personal history of irradiation, presenting hazards to health,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other disorders of plasma protein metabolism,Personal history of malignant melanoma of skin,Bilious emesis,Surgical or other procedure not carried out because of contraindication,Other fluid overload'}
