CHIEF COMPLAINT: Abnormal labs

PRESENT ILLNESS: Mr. [**Known lastname 73639**] is a 44 year old man with metastatic renal cell
carcinoma, s/p R nephrectomy, who was sent to the ED by his
oncologist after a routine, in clinic lab draw revealed ARF with
Cr >7.  He denies any urinary symptoms, shortness of breath or
edema, but does endorse decreased appetite.  Confirms he may
have been mildly dehydrated upon arrival at his clinic visit.
Denies any other localizing signs or symptoms of infection.  He
does endorse sleeping more in the last 2-3 weeks and that he's
been taking more pain medication to keep his pain at his
baseline level.

MEDICAL HISTORY: Renal Cell Carcinoma (please see below)
- h/o RLE DVT [**8-/2107**]
- Colonic perforation
- Hyponatremia
- Anemia
- Cervical surgery with rod-placement due to C2 met

MEDICATION ON ADMISSION: Fentanyl Patch 125mcg/hr q72H
Colace 100mg [**Hospital1 **]
Dulcolax 10mg QDaily PRN constipation
Senna [**Hospital1 **]
Tylenol Q6H PRN
Lorazepam 1mg Q8H PRN
Dilaudid 2-4mg Q3H PRN breakthrough

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Exam:
VITALS: 97.8 126/76 95 16 97/RA Pain [**7-14**] Ht 5'7" Wght 12.5lb
GENERAL: Thin, pale gentleman in NAD
HEENT: NCAT, eyes disconjegate (baseline), PERRLA, MMM
NECK: Very limited ROM [**1-5**] cervical fusion, without LAD
CARD: RRR without m/g/r
RESP: CTAB without wheeze/rale/rhonchi
ABD: (+) BS, thin, flat with palpable mass R flank, warm to the
touch with post-resection scar, very TTP with only slight touch

FAMILY HISTORY: Mother died of a brain tumor.  Father diagnosed with prostate
cancer in his 70s and is still living.  He has 3 siblings and 2
children without medical concerns.  Maternal aunt with lymphoma.
 Father and sister have had h/o "blood clots."

SOCIAL HISTORY: Married. Quit drinking alcohol.  [**Doctor First Name **] tobacco and illicit drug
use.  Not currently emplyed, but worked as an electrician.
Acute kidney failure, unspecified,Secondary malignant neoplasm of retroperitoneum and peritoneum,Perforation of intestine,Peritoneal abscess,Secondary malignant neoplasm of bone and bone marrow,Hyperosmolality and/or hypernatremia,Anemia in neoplastic disease,Other drugs and medicinal substances causing adverse effects in therapeutic use,Personal history of malignant neoplasm of kidney,Arthrodesis status
Acute kidney failure NOS,Sec mal neo peritoneum,Perforation of intestine,Peritoneal abscess,Secondary malig neo bone,Hyperosmolality,Anemia in neoplastic dis,Adv eff medicinal NEC,Hx of kidney malignancy,Arthrodesis status
Admission Date:  [**2109-1-10**]              Discharge Date:   [**2109-1-31**]

Date of Birth:  [**2064-2-2**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Abnormal labs


Major Surgical or Invasive Procedure:
PEG placement, diverting ileostomy, intubation, catheter
placement into abdominal abscess


History of Present Illness:
Mr. [**Known lastname 73639**] is a 44 year old man with metastatic renal cell
carcinoma, s/p R nephrectomy, who was sent to the ED by his
oncologist after a routine, in clinic lab draw revealed ARF with
Cr >7.  He denies any urinary symptoms, shortness of breath or
edema, but does endorse decreased appetite.  Confirms he may
have been mildly dehydrated upon arrival at his clinic visit.
Denies any other localizing signs or symptoms of infection.  He
does endorse sleeping more in the last 2-3 weeks and that he's
been taking more pain medication to keep his pain at his
baseline level.

At baseline he has pain in his right upper qaudrant and flank
from his tumor progression.  There is also rib involement
adjoining the tumor site.  His describes his pain as constant,
pulsing in quality, worsening for last several weeks.  Now feels
skin over his R flank is warm to touch.

His initial vitals in the ED were T98.6, HR 99, BP 142/91, RR
16, and Sat 98%RA. He rated his abdominal pain as [**4-13**]. His
initial labs were remarkable for hyperkalemia (6.4), for which
he received insulin/D50, kayexalate x 1 (did not tolerate second
dose of kayexalate). EKG did not demonstrate peaked T waves.  A
renal ultrasound demonstrated no obstruction or hydronephrosis.
He was seen by the renal consult service who were concerned for
contrast nephropathy.  He was given a total of 5L NS while in
the ED with minimal Cr drop.  Now being admitted to OMED for
continued management of acute renal failure.

Upon arrival to the floor, confirms history as above.
Additionally c/o baseline dysphagia since emergency trach last
[**Month (only) 116**].  Confirms poor pain management at baseline.  He currently
wakes himself up during the night to take more breakthrough
medication.

Past Medical History:
Renal Cell Carcinoma (please see below)
- h/o RLE DVT [**8-/2107**]
- Colonic perforation
- Hyponatremia
- Anemia
- Cervical surgery with rod-placement due to C2 met

ONCOLOGIC HISTORY
Mr. [**Known lastname 73639**] presented with hematuria and flank pain in [**1-/2107**]
and was found to have a 5.1 x 5.8 cm R renal mass by CT scan and
underwent partial R nephrectormy in 2/[**2106**].  In [**10/2107**], his
renal cell carcinoma developed in the R subcostal region and was
resected.  In [**2108-4-3**], he was found to have a soft tissue mass
(2.5 x 3.2 cm replacing the C2 vertebral body) and underwent
posterior cervical fusion form the occiput to C5 as well as left
sided C2 laminectomy and decompression. He had postop radiaion
to the c-spine.  In [**7-/2108**], he was treated with 1 cycle of
high-dose IL-2, but a follow up CT showed progression, and this
was stopped.  In [**2108-11-3**], he was enrolled in a phase II
trial evaluating sorafenib and concurrent bevacizumab.
Monitored qMonth with CT scan.  Last CT [**2109-1-3**] revealed
decreased tumor size, but also colonic perforation which is
currently encapsulated - not a surgical candidate until
sorafenib & bevacizumab have cleared system given concern for
poor wound healing.

Social History:
Married. Quit drinking alcohol.  [**Doctor First Name **] tobacco and illicit drug
use.  Not currently emplyed, but worked as an electrician.


Family History:
Mother died of a brain tumor.  Father diagnosed with prostate
cancer in his 70s and is still living.  He has 3 siblings and 2
children without medical concerns.  Maternal aunt with lymphoma.
 Father and sister have had h/o "blood clots."

Physical Exam:
Admission Exam:
VITALS: 97.8 126/76 95 16 97/RA Pain [**7-14**] Ht 5'7" Wght 12.5lb
GENERAL: Thin, pale gentleman in NAD
HEENT: NCAT, eyes disconjegate (baseline), PERRLA, MMM
NECK: Very limited ROM [**1-5**] cervical fusion, without LAD
CARD: RRR without m/g/r
RESP: CTAB without wheeze/rale/rhonchi
ABD: (+) BS, thin, flat with palpable mass R flank, warm to the
touch with post-resection scar, very TTP with only slight touch

BACK: R CVA tenderness, no left CVA tenderness, cervical midline
scar
EXT: WWP without c/c/e
NEURO: A&O, appropriate


Pertinent Results:
[**2109-1-9**] 03:18PM   WBC-12.6* RBC-4.29* HGB-11.6* HCT-36.3*
MCV-85 MCH-27.1 MCHC-32.0 RDW-17.6*

[**2109-1-9**] 03:18PM   PLT COUNT-716*#

[**2109-1-9**] 03:18PM   ALT(SGPT)-38 AST(SGOT)-41* ALK PHOS-435*

[**2109-1-9**] 03:18PM   ALBUMIN-3.2* CALCIUM-9.5

[**2109-1-9**] 03:18PM   GLUCOSE-106* UREA N-46* CREAT-6.7*#
SODIUM-134 POTASSIUM-5.8* CHLORIDE-94* TOTAL CO2-27 ANION GAP-19

[**2109-1-14**] 4:40 PM  CT ABDOMEN W/O CONTRAST; CT PELVIS W/O
CONTRAST
1. Interval increase in left nephrectomy bed fluid collection,
including extravasated oral contrast, which has tumor seen at
least along surrounding the inferior portions of this
collection.
2. Right abdominal wall mass described above.
3. Diffusely fatty liver and distended gallbladder, as before.
4. Bibasilar atelectasis. Small foci of ill-defined opacity
within both lungs are likely inflammatory or infectious in
nature.


Brief Hospital Course:
44 yo F metastatic renal cell cancer and known colonic
perforation presenting five days after last admission with ARF
and hyperkalemia.

#) Acute renal failure. Noted to have Cr > 7 while in clinic.
Baseline Cr approximately 1. Confirmed poor po intake but denied
any other new nephrotoxic drugs, dysuria or difficulty urinating
when has urge. Imaging revealed no evidence of hydronephrosis so
unlikely to be post-renal etiology. AIN an additional
consideration, but urine eosinophils netative. Other
consideration would be progression of cancer but this seems
unlikely to have occurred so quickly given no prior involvement
of contralateral kidney.  Ultimately attributed to contrast
nephropathy from CT obtained during the prior admission when he
may have also been dehydrated.  Renal consult was obtained on
admission and followed him throughout his his stay until clearly
resolving.  Treated with IVF hydration.  Additionally avoided
nephrotoxic medications and renally dose medications. Creatinine
normalized to 1.1 by discharge.

#) Hyperkalemia. Secondary to ARF and poor renal clearing. Given
insulin/D50, kayexalate x 1 (did not tolerate second dose of
kayexalate) while in ED. No peaked Ts observed on EKG. Stable K
at 6. Continued monitoring on telemetry with daily EKGs and
kayexelate PR for potasssium > 6.  Resolved [**2109-1-14**] so telemetry
and EKGs were discontinued.  Continued to monitor electrolytes
throughout stay.

#) Renal cell carcinoma/Colonic Perforation: S/p R kidney
resection with diffuse metastases. Most recently with colonic
perforation on R flank. Last treatment was phase II trial
evaluating sorafenib and concurrent bevacizumab. Both of these
medications had been stopped with perforation. From the day
following admission had worsening abdominal pain despite
dramatic increases in both fentanyl patch and dilaudid pca. CT
Abd/pelvis [**1-14**] with increased extravasation, as well as
increased perinephric fluid at L kidney. Surgery consulted and
discussed various options with patient. Plan was ultimately to
have IR place a CT-guided drain [**1-16**] into the fluid collection.
Mr. [**Known lastname 73639**], however, could not tolerate the pain of this
procedure and was subsequently taken to the OR for surgery.  Now
s/p ileostomy & pigtail placement with decreased pain. Also
started on TPN while in ICU. goals of care and hospice discussed
with palliatve care consult. goal to dc home. CT Scan [**1-24**] to
assess abscess with increased size of right middle lobe nodule
from [**1-2**] and an increase in size of the right
anterolateral abdominal wall metastasis since [**1-14**].
Pigtail in abscess putting aout 50-100 cc on discharge. He will
f/u with his oncologist and Dr. [**Last Name (STitle) 519**] for this.

#) Leukocytosis - Newly noted [**1-11**] AM. Denies any localizing
symptoms/signs of infection beyond worsening R flank pain. Does
have known colonic perforation which is concerning for occult
bacteremia. Work-up for colonic perforation as above.
Additionally obtained blood cultures which were pending and no
growth to date.  Started empirically on Cipro/Flagyl for GI
pathogens.
Newly increased [**1-23**], resolved [**1-29**]. No localizing symptoms of
infection, but does have known colonic perforation with abscess.
Afebrile. pancultured and restarted empiric flagyl/cipro for
perforation. With lactobacillius in abscess so transitioned off
cipro and have started Unasyn [**1-25**]. Unasyn continued for 7 days.
Flagyl for total of 7 days.

#) Pain - Only fairly well controlled on admission, stable on
discharge. As an outpatient had recently increased Fentanyl
patch from 75mcg to 125mcg. Still needed significant
breakthrough dilaudid IV.  Increased fentanyl patch [**1-14**] from
125 to 150mcg/72 hours.  Started dilaudid pca for breakthrough.
eventually was weaned off dilauded and was stable on 250mg
fentanyl patch q72 hours.

DNR/DNI
Decided [**1-15**] with wife and patient after extensive discussion
about current illness. Would still like to pursue palliative
surgery and reversed code-status for OR.


Medications on Admission:
Fentanyl Patch 125mcg/hr q72H
Colace 100mg [**Hospital1 **]
Dulcolax 10mg QDaily PRN constipation
Senna [**Hospital1 **]
Tylenol Q6H PRN
Lorazepam 1mg Q8H PRN
Dilaudid 2-4mg Q3H PRN breakthrough

Discharge Medications:
1. White Petrolatum-Mineral Oil     Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed.
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO TID (3 times a day) as needed.
3. Normal Saline Flush 0.9 % Syringe Sig: One (1)  Injection
three times a day: Please flush pigtail catheter three times a
day. Thanks. .
Disp:*90 flushes* Refills:*2*
4. Fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2)  Transdermal
every seventy-two (72) hours: Please use two of the 100 mcg
patches and one 50 mcg patch every three days, to make a total
of 250 mcg every 3 days. .
Disp:*20 patches* Refills:*2*
5. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1)  Transdermal
every seventy-two (72) hours: Please apply two 100 mcg patches
and 1 50 mcg patch every 72 hours. .
Disp:*10 patches* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 511**] Home Therapies

Discharge Diagnosis:
Primary: Metastatic renal cell carcinoma, colonic perforation,
acute kidnedy failure


Discharge Condition:
Hemodynamically stable and afebrile.


Discharge Instructions:
You were admitted to the hospital with acute renal failure,
infection surrounding your intestinal wall, and poor nutrition.
Regarding your acute renal failure, your kidney function
improved significantly and has now returned to its baseline.
Upon admission, you were known to have a collection of fluid in
your abdomen from your cancer communicating with your colon.  To
treat this, a drain was placed in the fluid collection and a
diverting ileostomy was performed.  You are being discharged
with continued visiting nurse services to help you with your
ileostomy, monitor your nutritional status, answer any questions
you may have and monitor your weight.

Your medications have changed while you were in the hospital.
Take all medications as prescribed.  You will be provided a list
of the medications you should be taking and when to take them.

Keep all outpatient appointments.

Return to the hospital or consult a medical specialist if you
notice fever, chills, worsening abdominal pain, vomiting, bloody
vomit, inability to take in enough nutrition or fluid to keep
yourself healthy, or for any other symptom which is concerning
to you.

Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2109-2-6**] 2:00

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2109-2-6**] 3:30

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2109-2-6**] 3:30

Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/CUT. ONC. DERM Date/Time:[**2109-2-6**]
11:00

To follow-up with your ostomy care, please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10132**]
[**Telephone/Fax (1) 73642**] for a follow-up appointment for your ostomy care
and for any further questions regarding your ostomy.

Regarding your pigtail drain, your visiting nurse will continue
to monitor its output. Once your drainage decreases to [**9-23**] mL
per day, please call [**First Name8 (NamePattern2) 14735**] [**Last Name (NamePattern1) 5545**], the nurse [**First Name (Titles) 151**] [**Last Name (Titles) 73643**]l radiology for further follow-up. You will need an
additional CT scan at this time before the drain can be pulled.



Completed by:[**2109-2-13**]
{'Acute kidney failure, unspecified,Secondary malignant neoplasm of retroperitoneum and peritoneum,Perforation of intestine,Peritoneal abscess,Secondary malignant neoplasm of bone and bone marrow,Hyperosmolality and/or hypernatremia,Anemia in neoplastic disease,Other drugs and medicinal substances causing adverse effects in therapeutic use,Personal history of malignant neoplasm of kidney,Arthrodesis status'}


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: Abnormal labs

PRESENT ILLNESS: Mr. [**Known lastname 73639**] is a 44 year old man with metastatic renal cell
carcinoma, s/p R nephrectomy, who was sent to the ED by his
oncologist after a routine, in clinic lab draw revealed ARF with
Cr >7.  He denies any urinary symptoms, shortness of breath or
edema, but does endorse decreased appetite.  Confirms he may
have been mildly dehydrated upon arrival at his clinic visit.
Denies any other localizing signs or symptoms of infection.  He
does endorse sleeping more in the last 2-3 weeks and that he's
been taking more pain medication to keep his pain at his
baseline level.

MEDICAL HISTORY: Renal Cell Carcinoma (please see below)
- h/o RLE DVT [**8-/2107**]
- Colonic perforation
- Hyponatremia
- Anemia
- Cervical surgery with rod-placement due to C2 met

MEDICATION ON ADMISSION: Fentanyl Patch 125mcg/hr q72H
Colace 100mg [**Hospital1 **]
Dulcolax 10mg QDaily PRN constipation
Senna [**Hospital1 **]
Tylenol Q6H PRN
Lorazepam 1mg Q8H PRN
Dilaudid 2-4mg Q3H PRN breakthrough

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Exam:
VITALS: 97.8 126/76 95 16 97/RA Pain [**7-14**] Ht 5'7" Wght 12.5lb
GENERAL: Thin, pale gentleman in NAD
HEENT: NCAT, eyes disconjegate (baseline), PERRLA, MMM
NECK: Very limited ROM [**1-5**] cervical fusion, without LAD
CARD: RRR without m/g/r
RESP: CTAB without wheeze/rale/rhonchi
ABD: (+) BS, thin, flat with palpable mass R flank, warm to the
touch with post-resection scar, very TTP with only slight touch

FAMILY HISTORY: Mother died of a brain tumor.  Father diagnosed with prostate
cancer in his 70s and is still living.  He has 3 siblings and 2
children without medical concerns.  Maternal aunt with lymphoma.
 Father and sister have had h/o "blood clots."

SOCIAL HISTORY: Married. Quit drinking alcohol.  [**Doctor First Name **] tobacco and illicit drug
use.  Not currently emplyed, but worked as an electrician. 

### Response:
{'Acute kidney failure, unspecified,Secondary malignant neoplasm of retroperitoneum and peritoneum,Perforation of intestine,Peritoneal abscess,Secondary malignant neoplasm of bone and bone marrow,Hyperosmolality and/or hypernatremia,Anemia in neoplastic disease,Other drugs and medicinal substances causing adverse effects in therapeutic use,Personal history of malignant neoplasm of kidney,Arthrodesis status'}
