CHIEF COMPLAINT: hypotension

PRESENT ILLNESS: Mr. [**Known lastname **] is a 39M with ESRD on HD and renal cell CA with brain,
pulmonary, and hepatic mets.  He underwent MRI this morning on
[**Hospital Ward Name 516**].  Shortly after receiving gadolinium contrast he
developed worsening RLQ abdominal pain, then developed shaking
of all 4 extremities. He reports that he was awake and alert
throughout the episode. He was noted to be alert and oriented x3
directly afterward.  BP noted to be 70s/40s on machine and
manual recheck. He has had worsening RLQ pain for the last five
days.

MEDICAL HISTORY: Metastatic renal cell carcinoma:
-- [**2106-3-10**]: cough x 2 weeks
-- [**2106-4-15**]: Chest/Abd/Pelvis CT with pulm nodules, RUL mass,
mediastinal/hilar lymphadenopathy, retroperitoneal adenopathy
-- [**2106-5-3**]: Brain MRI with lesions in R choroid plexus, L
parieto-occipital junction, L frontal lobe
-- [**2106-5-5**]: VATS wedge resection of RUL mass; path confirmed
renal cell carcinoma with clear cell features as well as the
presence of a TFE3 gene fusion
-- [**2106-6-10**]: CyberKnife radiosurgery to brain met
-- [**2106-7-23**]: CyberKnife radiosurgery to brain met
ESRD - secondary to focal glomerulonephritis, on HD since [**2089**]
HTN
Anxiety

MEDICATION ON ADMISSION: NIFEDIPINE 60 mg QSunday/Tues/Thurs
OXYCODONE-ACETAMINOPHEN PRN
TRAMADOL 50 mg TID

ALLERGIES: lisinopril

PHYSICAL EXAM: At [**Hospital Unit Name 153**] admission:
General: Alert, oriented, appears uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.  JVP flat.
Lungs: Shallow breathing with accessory muscle use.  Distant
breath sounds, crackles at bilateral bases, no wheezes, rales,
ronchi.  Posterior lung fields not examined due to patient's
pain attempting to sit up.
Abdomen: Distended, tense, diminished bowel sounds.  Nontender
to palpation.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.  AV fistula in RUE; scars of prior AV fistula in LUE.  R
hand exquisitely tender to palpation.
Neuro: CNII-XII intact, 2+ reflexes bilaterally, gait deferred.

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. He
has been living with friends in [**Name (NI) 1110**].
Unspecified septicemia,Spontaneous bacterial peritonitis,End stage renal disease,Septic shock,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Malignant neoplasm of kidney, except pelvis,Malignant ascites,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Severe sepsis,Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney,Neoplasm related pain (acute) (chronic),Tobacco use disorder,Anemia in chronic kidney disease,Disorders of magnesium metabolism,Hypovolemia,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Renal dialysis status,Personal history of alcoholism,Family history of malignant neoplasm of trachea, bronchus, and lung,Family history of malignant neoplasm of gastrointestinal tract,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Examination of participant in clinical trial
Septicemia NOS,Spontan bact peritonitis,End stage renal disease,Septic shock,Sec mal neo brain/spine,Secondary malig neo lung,Malig neopl kidney,Malignant ascites,Hyp kid NOS w cr kid V,Severe sepsis,Nephritis NOS,Neoplasm related pain,Tobacco use disorder,Anemia in chr kidney dis,Dis magnesium metabolism,Hypovolemia,Hx antineoplastic chemo,Hx of irradiation,Renal dialysis status,Hx of alcoholism,Fm hx-trach/bronchog mal,Family hx-gi malignancy,Adv eff antineoplastic,Exam-clincal trial
Admission Date:  [**2106-8-19**]              Discharge Date:   [**2106-8-25**]

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

Service: MEDICINE

Allergies:
lisinopril

Attending:[**First Name3 (LF) 16851**]
Chief Complaint:
hypotension

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Mr. [**Known lastname **] is a 39M with ESRD on HD and renal cell CA with brain,
pulmonary, and hepatic mets.  He underwent MRI this morning on
[**Hospital Ward Name 516**].  Shortly after receiving gadolinium contrast he
developed worsening RLQ abdominal pain, then developed shaking
of all 4 extremities. He reports that he was awake and alert
throughout the episode. He was noted to be alert and oriented x3
directly afterward.  BP noted to be 70s/40s on machine and
manual recheck. He has had worsening RLQ pain for the last five
days.

Today he noticed his abdomen to be more distended than usual.
Approximately one week ago his oxycodone was increased.  Last HD
session yesterday.  Last round of chemotherapy was [**8-11**].

In ED, he received 2L NS but SBP still in 80s. Started
peripheral levophed at 0.09 with response to 100s-110s.

Initial VS in ED:
T 98.1 HR 105 BP: 104/68 RR 22 O2Sat 97 on 4L NC

In the ED, he started empiric vancomycin and cefepime for
broad-spectrum coverage. CT revealed significant progression of
his metastases (pulmonary, hepatic) but could not rule out
pneumonia. New ascites but no evidence of appendicitis or acute
abscess.

Initial VS in MICU:
T 98.5 HR 101 BP 105/72 RR 19 O2Sat 96% on 4L NC


Past Medical History:
Metastatic renal cell carcinoma:
-- [**2106-3-10**]: cough x 2 weeks
-- [**2106-4-15**]: Chest/Abd/Pelvis CT with pulm nodules, RUL mass,
mediastinal/hilar lymphadenopathy, retroperitoneal adenopathy
-- [**2106-5-3**]: Brain MRI with lesions in R choroid plexus, L
parieto-occipital junction, L frontal lobe
-- [**2106-5-5**]: VATS wedge resection of RUL mass; path confirmed
renal cell carcinoma with clear cell features as well as the
presence of a TFE3 gene fusion
-- [**2106-6-10**]: CyberKnife radiosurgery to brain met
-- [**2106-7-23**]: CyberKnife radiosurgery to brain met
ESRD - secondary to focal glomerulonephritis, on HD since [**2089**]
HTN
Anxiety

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. He
has been living with friends in [**Name (NI) 1110**].


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:
At [**Hospital Unit Name 153**] admission:
General: Alert, oriented, appears uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.  JVP flat.
Lungs: Shallow breathing with accessory muscle use.  Distant
breath sounds, crackles at bilateral bases, no wheezes, rales,
ronchi.  Posterior lung fields not examined due to patient's
pain attempting to sit up.
Abdomen: Distended, tense, diminished bowel sounds.  Nontender
to palpation.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.  AV fistula in RUE; scars of prior AV fistula in LUE.  R
hand exquisitely tender to palpation.
Neuro: CNII-XII intact, 2+ reflexes bilaterally, gait deferred.


At discharge:
VS: 97.4  92/60  97% on 2L pain 3
GEN: nad, laying in bed
NECK: supple
HEENT: op clear, poor dentition
CHEST: faint wheezing anteriorly
CV: rrr no m/r/g
ABD: distended
EXT: feet tender (chronic) no edema
NEURO: AAOx3
PSYCH: appropriate, pleasant


Pertinent Results:
CT C/A/P on admission:
1.  New enhancing hepatic mass and increased number and size of
pulmonary
nodules at the lung bases compatible with worsening metastatic
disease.
Several osseous metastatic lesions with soft tissue components
are not
significantly changed in the interval.
2.  Worsening diffuse septal thickening, likely reflective of
worsening
pulmonary edema, though lymphangitic carcinomatosis is not
excluded. Small
bilateral pleural effusions, right larger than left.
3.  New moderate volume ascites.
4.  Atrophic kidneys with multiple cysts, likely related to
dialysis.
Dominant, peripherally calcified complex cystic lesion in the
right upper pole
of the kidney could reflect the patient's primary renal
carcinoma.

[**2106-8-24**] 09:36AM BLOOD WBC-4.3# RBC-3.18* Hgb-9.2* Hct-29.6*
MCV-93 MCH-29.0 MCHC-31.1 RDW-18.6* Plt Ct-204
[**2106-8-24**] 09:36AM BLOOD Glucose-95 UreaN-22* Creat-6.5*# Na-140
K-4.2 Cl-102 HCO3-26 AnGap-16
[**2106-8-24**] 09:36AM BLOOD Calcium-9.2 Phos-4.0 Mg-1.8
[**2106-8-20**] 10:53AM ASCITES WBC-2050* RBC-1475* Polys-80* Lymphs-3*
Monos-14* Atyps-0 Mesothe-3*

Brief Hospital Course:
Mr. [**Known lastname **] is a 39M with ESRD on HD and renal cell CA with brain,
pulmonary, and hepatic mets admitted to the MICU with
hypotension after receiving gadolinium during MRI on day of
admission.


Active Issues:
---------------
# Septic shock: [**3-11**] SBP:  He met SIRS criteria (HR, RR, WBC)on
admission and required levophed after 2L NS with most likely
etiology SBP. He was treated with ceftriaxone (see SBP for
further details).  Hypersensitivity reaction to gadolinium has
been described but is rare, and he has previously received
gadolinium.  He received HD to remove gadolinum once he was
hemodynamically stabilized.  Adrenal insufficiency was ruled
out. His shock resolved and he was transferred to the general
medical floor without any further infectious issues.

# SBP: He completed a course of ceftriaxone and given albumin on
day 1 and day 3. He will continue on norfloxacin for
prophylaxis.

#New Onset Ascites: likely due to new hepatic mets and or
carcinomatosis. No portal or splenic vein thrombosis seen.

# ESRD: The patient received HD to remove gadolinum for MRI .
He then continued on a MWF HD schedule. He had difficulty
removing fluid during HD due to hypotension, which had been a
problem at his out patient facility as well and so he was
started on midorine.

# Pain: pt with groin, leg, feet, back and abdominal pain. Pain
regimen adjusted to increased home oxycontin dose, continued
home oxycodone, tramadol, started naproxen and tylenol around
the clock.


# HTN: pt remained normo-tensive with his baseline SBP in the
100s. He was not discharged on his previous anti-hypertensive,
nifedipine.

# Anemia: likely [**3-11**] chronic disease and chemo.  No evidence of
bleeding.
- cont epo

# Metastatic renal cell CA: Pt had been followed by Dr. [**Last Name (STitle) 22658**] in
[**Location (un) 1110**]. Will establish care in [**Location (un) 86**] with Dr. [**Last Name (STitle) **]. His
records from Dr. [**Last Name (STitle) 22658**] were faxed to the new office on the day
of discharge. He was found to have progression of known brain
and pulmonary mets and new hepatic mets during admission.
Patient and mother are aware of this. Pt expressed wishes to be
resuscitated but not intubated. Explained that this was not
possible. Discussed his poor prognosis of weeks to months and
the likelyhood of suscessful resuscitation would be at most 5%.
Patient stated that he would remain full code for now and would
discuss it with his friends and mother.


Medications on Admission:
NIFEDIPINE 60 mg QSunday/Tues/Thurs
OXYCODONE-ACETAMINOPHEN PRN
TRAMADOL 50 mg TID


Discharge Medications:
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


Discharge Disposition:
Expired

Facility:
[**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **] Center

Discharge Diagnosis:
spontaneous bacertial peritonitis
new hepatic metastasis of renal cell carcinoma


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted due to an infection in your abdomen which has
been treated.You will require prophylactic antibiotics from now
on to prevent this infection from returning.

Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2106-8-31**] at 4:00 PM
With: DRS. [**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
{'Unspecified septicemia,Spontaneous bacterial peritonitis,End stage renal disease,Septic shock,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Malignant neoplasm of kidney, except pelvis,Malignant ascites,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Severe sepsis,Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney,Neoplasm related pain (acute) (chronic),Tobacco use disorder,Anemia in chronic kidney disease,Disorders of magnesium metabolism,Hypovolemia,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Renal dialysis status,Personal history of alcoholism,Family history of malignant neoplasm of trachea, bronchus, and lung,Family history of malignant neoplasm of gastrointestinal tract,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Examination of participant in clinical trial'}


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: hypotension

PRESENT ILLNESS: Mr. [**Known lastname **] is a 39M with ESRD on HD and renal cell CA with brain,
pulmonary, and hepatic mets.  He underwent MRI this morning on
[**Hospital Ward Name 516**].  Shortly after receiving gadolinium contrast he
developed worsening RLQ abdominal pain, then developed shaking
of all 4 extremities. He reports that he was awake and alert
throughout the episode. He was noted to be alert and oriented x3
directly afterward.  BP noted to be 70s/40s on machine and
manual recheck. He has had worsening RLQ pain for the last five
days.

MEDICAL HISTORY: Metastatic renal cell carcinoma:
-- [**2106-3-10**]: cough x 2 weeks
-- [**2106-4-15**]: Chest/Abd/Pelvis CT with pulm nodules, RUL mass,
mediastinal/hilar lymphadenopathy, retroperitoneal adenopathy
-- [**2106-5-3**]: Brain MRI with lesions in R choroid plexus, L
parieto-occipital junction, L frontal lobe
-- [**2106-5-5**]: VATS wedge resection of RUL mass; path confirmed
renal cell carcinoma with clear cell features as well as the
presence of a TFE3 gene fusion
-- [**2106-6-10**]: CyberKnife radiosurgery to brain met
-- [**2106-7-23**]: CyberKnife radiosurgery to brain met
ESRD - secondary to focal glomerulonephritis, on HD since [**2089**]
HTN
Anxiety

MEDICATION ON ADMISSION: NIFEDIPINE 60 mg QSunday/Tues/Thurs
OXYCODONE-ACETAMINOPHEN PRN
TRAMADOL 50 mg TID

ALLERGIES: lisinopril

PHYSICAL EXAM: At [**Hospital Unit Name 153**] admission:
General: Alert, oriented, appears uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.  JVP flat.
Lungs: Shallow breathing with accessory muscle use.  Distant
breath sounds, crackles at bilateral bases, no wheezes, rales,
ronchi.  Posterior lung fields not examined due to patient's
pain attempting to sit up.
Abdomen: Distended, tense, diminished bowel sounds.  Nontender
to palpation.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.  AV fistula in RUE; scars of prior AV fistula in LUE.  R
hand exquisitely tender to palpation.
Neuro: CNII-XII intact, 2+ reflexes bilaterally, gait deferred.

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. He
has been living with friends in [**Name (NI) 1110**]. 

### Response:
{'Unspecified septicemia,Spontaneous bacterial peritonitis,End stage renal disease,Septic shock,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Malignant neoplasm of kidney, except pelvis,Malignant ascites,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Severe sepsis,Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney,Neoplasm related pain (acute) (chronic),Tobacco use disorder,Anemia in chronic kidney disease,Disorders of magnesium metabolism,Hypovolemia,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Renal dialysis status,Personal history of alcoholism,Family history of malignant neoplasm of trachea, bronchus, and lung,Family history of malignant neoplasm of gastrointestinal tract,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Examination of participant in clinical trial'}
