CHIEF COMPLAINT: Chief Complaint: Hypotension
Reason for MICU transfer: Hypotension

PRESENT ILLNESS: Mr. [**Known lastname **] is a 39 y.o. man with history of ESRD on HD due to
FSGS, RCC with known brain, pulmonary, and hepatic metastases
s/p chemo and XRT, who presented to the MICU for hypotension.

MEDICAL HISTORY: Past Medical History:
# ESRD DUE TO:  FSGS
# ON RENAL REPLACEMENT SINCE:  [**2090**]
# ACCESS HISTORY AND COMPLICATIONS:  R forearm AVF
# Renal cell carcinoma, diagnosed on lymph node dissection and
wedge resection of RUL, [**2106-4-8**]; brain mets seen on MRI same
month; s/p cyberknife radiosurgery, [**2106-6-8**]
Hypotension/Hypertension

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Midodrine 5 mg PO TID
4. Naproxen 500 mg PO Q12H
5. Nephrocaps 1 CAP PO DAILY
6. OxycoDONE (Immediate Release)  5-10 mg PO Q4H:PRN pain
hold for sedation
7. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
hold for sedation or RR<10,
8. Polyethylene Glycol 17 g PO DAILY
Hold if patient having daily BMs.
9. Senna 1 TAB PO BID constipation
10. TraMADOL (Ultram) 50 mg PO TID
11. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
12. norfloxacin *NF* 400 mg Oral daily SBP prophylaxis
***Clarify whether pt taking sunitinib***

ALLERGIES: lisinopril

PHYSICAL EXAM: Vitals: T 97.7, HR 91, BP 120/84, RR 18, 100% on 4LNC
General: Alert and oriented x 3, NAD
HEENT: oropharnyx clear, MMM
Neck: no LAD
CV: RRR, nl S1/S2, no murmurs, rubs, gallops
Lungs: diffuse crackles b/l
Abdomen: soft, NT, markedly distended, BS absent, no
organomegaly
Ext: WWP
Neuro: alert and oriented x 3, asterixis present

FAMILY HISTORY: His mother is healthy at age 60. His father died at age 48 from
throat cancer (he consumed cigarettes and alcohol) and colon
cancer. His sister and brother are healthy but another brother
has the "gene" for colon cancer and gets
yearly check ups

SOCIAL HISTORY: Mr. [**Known lastname **] is single. He is currently on disability. Smoked 1PPD x
20yrs and quit approximately one month ago. Prior history of
alcohol dependence, but quit approximately four years ago.
Malignant neoplasm of liver, secondary,Pneumonia, organism unspecified,End stage renal disease,Secondary malignant neoplasm of brain and spinal cord,Malignant neoplasm of kidney, except pelvis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Malignant ascites,Personal history of tobacco use,Personal history of antineoplastic chemotherapy,Hypovolemia,Encounter for palliative care,Other shock without mention of trauma,Do not resuscitate status,Anemia in chronic kidney disease,Constipation, unspecified,Unspecified acquired hypothyroidism
Second malig neo liver,Pneumonia, organism NOS,End stage renal disease,Sec mal neo brain/spine,Malig neopl kidney,Hyp kid NOS w cr kid V,Malignant ascites,History of tobacco use,Hx antineoplastic chemo,Hypovolemia,Encountr palliative care,Shock w/o trauma NEC,Do not resusctate status,Anemia in chr kidney dis,Constipation NOS,Hypothyroidism NOS
Admission Date:  [**2106-8-26**]              Discharge Date:   [**2106-8-31**]

Date of Birth:  [**2066-11-7**]             Sex:   M

Service: MEDICINE

Allergies:
lisinopril

Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Chief Complaint: Hypotension
Reason for MICU transfer: Hypotension


Major Surgical or Invasive Procedure:
Central Line Placement

History of Present Illness:
Mr. [**Known lastname **] is a 39 y.o. man with history of ESRD on HD due to
FSGS, RCC with known brain, pulmonary, and hepatic metastases
s/p chemo and XRT, who presented to the MICU for hypotension.

Notably, he was discharged from [**Hospital1 18**] yesterday to [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **].
 On his last admission, he was sent to the [**Hospital Unit Name 153**] for hypotension
which he developed during an MRI. There was concern that it was
a contrast reaction, although this was considered unlikely. He
also was found to have new ascites and progression of his
metastatic disease. His ascites was tapped, and given the 1600
neutrophils he was treated for SBP w/ ceftriaxone.

This morning, he was brought for dialysis. When he sat up for
dialysis, he became dizzy and hypotensive to the 80s. He was
unable to receive dialysis in this setting. He mother notes that
he may not have received all of his medications yesterday given
the gap between discharge from [**Hospital1 18**] and admission to [**First Name4 (NamePattern1) 5279**]
[**Last Name (NamePattern1) **].

He noted a new raspy voice since this morning, diaphoresis, and
a non-productive cough. He also reports that he hasn't had a
bowel movement in a week and a half and has had intermittent
abdominal pain. He also has had intermittent groin, leg, feet,
back, and collarbone pain. He denied fevers/chills, chest pain,
SOB, nausea/vomiting, and abdominal pain.

Due to his hypotension, he was brought to [**Hospital 47**] Hospital,
where they performed a CXR showing an infiltrate. He was started
on levaquin and vancomycin, given 1L NS, and he had a R IJ
placed. He became hypotensive to the 80s and hypoxic. However,
he was 100% on a non-rebreather mask. He was started on a
phenylephrine drip (2.5 mcg). He was then transferred to the
[**Hospital1 18**] ED.

In the [**Hospital1 18**] ED, VS: T 97.1, HR 96, BP 96/54, RR 26, O2sat 97%
2L NC.
Labs in the ED were remarkable for K 4.6, BUN 25, Cre 5.4, WBC
7.1, and Hct 28.7. CXR was concerning for a pneumonia.  He was
continued on phenylephrine and received 2g cefepime. Renal was
made aware and will see in the morning.

On arrival to the MICU, VS: T 97.7, HR 91, BP 120/84, RR 18,
100% on 4LNC. He had b/l crackles on pulmonary exam, and he had
a markedly distended abdomen and absent bowel sounds.


Past Medical History:
Past Medical History:
# ESRD DUE TO:  FSGS
# ON RENAL REPLACEMENT SINCE:  [**2090**]
# ACCESS HISTORY AND COMPLICATIONS:  R forearm AVF
# Renal cell carcinoma, diagnosed on lymph node dissection and
wedge resection of RUL, [**2106-4-8**]; brain mets seen on MRI same
month; s/p cyberknife radiosurgery, [**2106-6-8**]
Hypotension/Hypertension

Past Surgical History:
-multiple AV fistula placements/repairs
-2 breast reduction procedures
-2 operations for undescented testes
-right orchiectomy
-kidney biopsy
-repair of a ruptured quadriceps tendon

Social History:
Mr. [**Known lastname **] is single. He is currently on disability. Smoked 1PPD x
20yrs and quit approximately one month ago. Prior history of
alcohol dependence, but quit approximately four years ago.


Family History:
His mother is healthy at age 60. His father died at age 48 from
throat cancer (he consumed cigarettes and alcohol) and colon
cancer. His sister and brother are healthy but another brother
has the "gene" for colon cancer and gets
yearly check ups

Physical Exam:
Vitals: T 97.7, HR 91, BP 120/84, RR 18, 100% on 4LNC
General: Alert and oriented x 3, NAD
HEENT: oropharnyx clear, MMM
Neck: no LAD
CV: RRR, nl S1/S2, no murmurs, rubs, gallops
Lungs: diffuse crackles b/l
Abdomen: soft, NT, markedly distended, BS absent, no
organomegaly
Ext: WWP
Neuro: alert and oriented x 3, asterixis present


Pertinent Results:
[**2106-8-26**] 10:42PM   LACTATE-1.6
[**2106-8-26**] 10:18PM   GLUCOSE-91 UREA N-27* CREAT-5.6* SODIUM-141
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-27 ANION GAP-19
[**2106-8-26**] 10:18PM   ALT(SGPT)-7 AST(SGOT)-11 LD(LDH)-195 ALK
PHOS-128 TOT BILI-0.2
[**2106-8-26**] 10:18PM   cTropnT-0.06* proBNP-4374*
[**2106-8-26**] 10:18PM   ALBUMIN-3.3* CALCIUM-9.8 PHOSPHATE-4.9*
MAGNESIUM-2.0
[**2106-8-26**] 10:18PM   TSH-15*
[**2106-8-26**] 10:18PM   CORTISOL-19.8
[**2106-8-26**] 10:18PM   WBC-10.8# RBC-3.29* HGB-9.5* HCT-31.5* MCV-96
MCH-28.9 MCHC-30.1* RDW-19.2*
[**2106-8-26**] 10:18PM   PLT COUNT-401
[**2106-8-26**] 05:38PM   COMMENTS-GREEN
[**2106-8-26**] 05:38PM   LACTATE-1.2
[**2106-8-26**] 05:35PM   GLUCOSE-83 UREA N-25* CREAT-5.4*# SODIUM-141
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-28 ANION GAP-19
[**2106-8-26**] 05:35PM   estGFR-Using this
[**2106-8-26**] 05:35PM   WBC-7.1# RBC-2.98* HGB-8.7* HCT-28.7* MCV-96
MCH-29.1 MCHC-30.3* RDW-18.9*
[**2106-8-26**] 05:35PM   NEUTS-88.5* LYMPHS-7.2* MONOS-3.3 EOS-0.5
BASOS-0.4
[**2106-8-26**] 05:35PM   HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-1+
STIPPLED-1+
[**2106-8-26**] 05:35PM   PLT SMR-NORMAL PLT COUNT-299
[**2106-8-25**] 11:20AM   CREAT-4.1*#
[**2106-8-25**] 11:20AM   HCT-29.6*
.
CXR [**8-26**]
The multifocal airspace opacities have overall slightly improved
in
the background of metastatic disease and mild pulmonary edema;
however, the right upper lobe opacity remains.  There is also
unchanged mild pulmonary edema.  The right IJ line ends in the
right cavoatrial junction.  No pneumothorax.
.
KUB [**8-27**]
NGS:  Three supine images of the abdomen show some stacking of
the small bowel.  This could represent ileus, but would also be
consistent with patient's history of ascites.  The loops of
bowel do not appear to be distended and there is no obvious
evidence of obstruction.  Given the supine nature of these
films, we are unable to assess for fluid levels or free air in
the abdomen.  Visualized osseous structures are unremarkable,
though these images are limited somewhat because of
underpenetration.
IMPRESSION:  Slight stacking of the small bowel which likely
represents ileus but may also be secondary to ascites.

Brief Hospital Course:
39 y.o. man w/ a history of ESRD on HD due to FSGS, RCC with
known brain, pulmonary, and hepatic metastases s/p chemo and
XRT, admitted to the MICU for hypotension which was likely a
manifestation of his chronic hypotension from loss of tone from
his metastatic disease burden, hypothyroidism, and hypovolemia.
The patient's condition deteriorated in the MICU, and after
discussion with the patient's family, we transitioned care to
comfort measures only.

Hypotension:
He had several potential etiologies for his hypotension. He does
have known baseline hypotension which may have worsened in the
setting of not receiving all of his doses of midodrine the day
prior to admission. He may also have been volume depleted in the
setting of not having air conditioning and becoming diaphoretic,
increasing his insensible losses. Hypothyroidism is a
possibility given TSH of 15.  Obstructive shock due to
metastatic disease/ascites is another possibility. Much less
likely was the development of septic shock from his possible
pneumonia found on CXR. Given his known pulmonary metastases, he
is at high risk for a post-obstructive pneumonia. Arguing
against sepsis was his lack of elevated WBC, lack of fever, and
lack of elevated RR. Also, CXR is generally improved since last
performed 1 week prior.  A cardiac cause was considered unlikely
given the lack of history and unremarkable EKG, but still
possible, especially given long history of dialysis and BNP of
4374. His ECHO revealed pulmonary HTN and biatrial enlargement.
Adrenal insufficiency was essentially ruled out w/ a cortisol of
22.6 [**2106-8-22**]. Overall, his presentation seemed to be most
consistent with rapid progression of his underlying metastatic
renal cell cancer with progressive distributive pathophysiology
and refractory shock due to the burden and extent of his
disease.

The patient's condition and mental status continued to
deteriorate despite the above treatments.  On [**8-28**], in concert
with the patient's pre-specified wishes, the patient's family
decided that they would like the medical team to perform
comfort-focused care. The patient was transferred to the
medicine floor on [**8-30**] where he shortly thereafter died. He was
comfortable throughout his hospital course. His family declined
autopsy.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Midodrine 5 mg PO TID
4. Naproxen 500 mg PO Q12H
5. Nephrocaps 1 CAP PO DAILY
6. OxycoDONE (Immediate Release)  5-10 mg PO Q4H:PRN pain
hold for sedation
7. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
hold for sedation or RR<10,
8. Polyethylene Glycol 17 g PO DAILY
Hold if patient having daily BMs.
9. Senna 1 TAB PO BID constipation
10. TraMADOL (Ultram) 50 mg PO TID
11. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
12. norfloxacin *NF* 400 mg Oral daily SBP prophylaxis
***Clarify whether pt taking sunitinib***


Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired


Completed by:[**2106-9-7**]
{'Malignant neoplasm of liver, secondary,Pneumonia, organism unspecified,End stage renal disease,Secondary malignant neoplasm of brain and spinal cord,Malignant neoplasm of kidney, except pelvis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Malignant ascites,Personal history of tobacco use,Personal history of antineoplastic chemotherapy,Hypovolemia,Encounter for palliative care,Other shock without mention of trauma,Do not resuscitate status,Anemia in chronic kidney disease,Constipation, unspecified,Unspecified acquired hypothyroidism'}


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: Chief Complaint: Hypotension
Reason for MICU transfer: Hypotension

PRESENT ILLNESS: Mr. [**Known lastname **] is a 39 y.o. man with history of ESRD on HD due to
FSGS, RCC with known brain, pulmonary, and hepatic metastases
s/p chemo and XRT, who presented to the MICU for hypotension.

MEDICAL HISTORY: Past Medical History:
# ESRD DUE TO:  FSGS
# ON RENAL REPLACEMENT SINCE:  [**2090**]
# ACCESS HISTORY AND COMPLICATIONS:  R forearm AVF
# Renal cell carcinoma, diagnosed on lymph node dissection and
wedge resection of RUL, [**2106-4-8**]; brain mets seen on MRI same
month; s/p cyberknife radiosurgery, [**2106-6-8**]
Hypotension/Hypertension

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Midodrine 5 mg PO TID
4. Naproxen 500 mg PO Q12H
5. Nephrocaps 1 CAP PO DAILY
6. OxycoDONE (Immediate Release)  5-10 mg PO Q4H:PRN pain
hold for sedation
7. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
hold for sedation or RR<10,
8. Polyethylene Glycol 17 g PO DAILY
Hold if patient having daily BMs.
9. Senna 1 TAB PO BID constipation
10. TraMADOL (Ultram) 50 mg PO TID
11. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
12. norfloxacin *NF* 400 mg Oral daily SBP prophylaxis
***Clarify whether pt taking sunitinib***

ALLERGIES: lisinopril

PHYSICAL EXAM: Vitals: T 97.7, HR 91, BP 120/84, RR 18, 100% on 4LNC
General: Alert and oriented x 3, NAD
HEENT: oropharnyx clear, MMM
Neck: no LAD
CV: RRR, nl S1/S2, no murmurs, rubs, gallops
Lungs: diffuse crackles b/l
Abdomen: soft, NT, markedly distended, BS absent, no
organomegaly
Ext: WWP
Neuro: alert and oriented x 3, asterixis present

FAMILY HISTORY: His mother is healthy at age 60. His father died at age 48 from
throat cancer (he consumed cigarettes and alcohol) and colon
cancer. His sister and brother are healthy but another brother
has the "gene" for colon cancer and gets
yearly check ups

SOCIAL HISTORY: Mr. [**Known lastname **] is single. He is currently on disability. Smoked 1PPD x
20yrs and quit approximately one month ago. Prior history of
alcohol dependence, but quit approximately four years ago. 

### Response:
{'Malignant neoplasm of liver, secondary,Pneumonia, organism unspecified,End stage renal disease,Secondary malignant neoplasm of brain and spinal cord,Malignant neoplasm of kidney, except pelvis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Malignant ascites,Personal history of tobacco use,Personal history of antineoplastic chemotherapy,Hypovolemia,Encounter for palliative care,Other shock without mention of trauma,Do not resuscitate status,Anemia in chronic kidney disease,Constipation, unspecified,Unspecified acquired hypothyroidism'}
