CHIEF COMPLAINT: Shortness of breath and lactic acidosis

PRESENT ILLNESS: 55M with hep B/C, HCC who presents to [**Hospital1 18**] ED with SOB.
.
He was recently admitted from [**Date range (1) **] for a large right-sided
pleural effusion, which was drained by interventional
pulmonology on [**2117-8-24**]. The fluid was bloody with negative
gram stain and cytology. He initially felt less dyspnea
following the thoracentesis, but his breathing has worsened over
the past day.
.
He presented to [**Hospital3 **] Hospital, where CXR showed elevation of
the right hemidiaphragm. He was given cefepime 1 gm IV and was
transferred to [**Hospital1 18**] for futher management.
.
In the ED at [**Hospital1 18**], initial vital signs were T 96.7, BP 125/87,
HR 110, RR 24, Sat 100%/4L NC. He was noted to be in respiratory
distrss. Labs were notable for pH 7.14, lactate 19.9, Na 126, K
5.7, WBC 26.3, INR 3.1, glucose 32. CTA torso showed Mod right
pleural effusion. Medial RML and medial basal RLL atelectasis.
No PE. Large 4.5cm pre-carinal node is unchanged. Diffuse HCC
with peritoneal implants. Ascites. He was given 3L NS,
vancomycin 1 gm IV, thiamine 100 mg IV, and morphine 4 mg IV x
2.
.
In the MICU, the patient complained of shortness of breath. He
had no other complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills. Denies headache. Denies cough. Denies
chest pain. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria.
Denies arthralgias or myalgias.
.
HPI UPON PATIENT ARRIVAL TO OMED SERVICE FROM MICU
.
In brief patient was recently admitted from [**Date range (1) **] for a
large right-sided pleural effusion, which was drained by
interventional pulmonology on [**2117-8-24**]. The fluid was bloody
with negative gram stain and cytology. Prior to his transfer to
[**Hospital1 18**] he presented to [**Hospital3 **] Hospital, where CXR showed
elevation of the right hemidiaphragm. He was given cefepime 1 gm
IV and was transferred to [**Hospital1 18**] for futher management, where he
was admitted to the medical ICU.
.
Hospital course significant for ED initial vital signs: T 96.7,
BP 125/87, HR 110, RR 24, Sat 100%/4L NC. He was noted to be in
respiratory distrss. Labs were notable for pH 7.14, lactate
19.9, Na 126, K 5.7, WBC 26.3, INR 3.1, glucose 32. CTA torso
showed Mod right pleural effusion. Medial RML and medial basal
RLL atelectasis. No PE. Large 4.5cm pre-carinal node is
unchanged. Diffuse HCC with peritoneal implants. Ascites. He was
given 3L NS, vancomycin 1 gm IV, thiamine 100 mg IV, and
morphine 4 mg IV x 2.
.
In the MICU, the patient complained of shortness of breath. He
had no other complaints. Thoracentesis was contemplated however
ultimately decided to hold. Per house staff sing out, patient
was given IVF with bicarb, which ultimately improved acidemia,
and lactic acidosis. Infection is not thought to be present,
therefore antibiotics were not continued. Paracentesis to rule
out SBP was not performed to avoid further metastasis. Lovenox
for caval vein thrombus was not continued due to elevated INR.
Patient being now transferred to oncology floor given fall in
lactic acidosis and stable condition.
.
currently patient reports significant improvement in respiratory
symptoms, with oxygen supplementation being per patient the main
reason for this
.
Review of Systems:
(+) Per HPI
(-) Review of Systems: GEN: No fever, chills, night sweats,
recent weight loss or gain. HEENT: No headache, sinus
tenderness, rhinorrhea or congestion. CV: No chest pain or
tightness, palpitations. PULM: No cough,GI: No nausea, vomiting,
diarrhea, constipation or abdominal pain, but some occasional
dyscomfort. No recent change in bowel habits, no hematochezia or
melena. GUI: No dysuria or change in bladder habits. MSK: No
arthritis, arthralgias, or myalgias. DERM: No rashes or skin
breakdown. NEURO: No numbness/tingling in extremities. All other
review of systems negative.

MEDICAL HISTORY: Past Oncologic History:
locally-advanced HCC who started using
sorafenib on [**2117-8-9**]
.
Other Past Medical History:
- Hepatitis B cab +, sag and sab (-)
- Hepatitis C cirrhosis, genotype 1
- GERD
- Hyperglycemia
- PE
.
Past Surgical History:
- Tonsillectomy
- Right inguinal hernia

MEDICATION ON ADMISSION: 1. metoprolol tartrate 12.5 mg PO BID
2. oxycodone 5 mg PO Q4H prn pain
3. pantoprazole 40 mg PO BID
4. prochlorperazine maleate 10 mg PO Q6H prn nausea
5. enoxaparin 70 mg Subcutaneous Q12H
6. sodium chloride 1 gram Tablet PO TID
7. sorafenib 400 mg PO twice a day.
8. ferrous sulfate 300  mg PO Daily
9. docusate sodium 100 mg Capsule PO BID
10. acetaminophen 650mg  PO Q6H prn pain/fever

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION
Vitals: T:99 BP:138/87 P:99 R:20 O2 Sat:96%/3L NC
General: Alert, mildly tachypneic, taking deep breaths; jaundice
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: Supple.
Lungs: Decreased breath sounds at bilateral bases R>L.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: Distended. Tender in central abdomen. No rebound or
guarding.
GU: Foley in place.
Ext: Warm, well perfused, 1+ RLE edema
Neuro: A+Ox3. CN II-XII intact. Strength 5/5 throughout.
.
ON DISCHARGE FROM ICU:
Vitals: 95.5 121-124/84-86 103-106 20-21 90-93 6L NC
I/O: 2600/1240
General: Alert, mildly tachypneic, no SOB; jaundice,
malnourished appearing
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: Supple.
Lungs: Decreased breath sounds at bilateral bases R>L, no inc
work of breath.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: Distended. Tender in central abdomen. No rebound or
guarding.
GU: Foley in place.
Ext: Warm, well perfused, 2+ LE edema
Neuro: A+Ox3. CN II-XII intact. Strength 5/5 throughout.
.
ON DISCHARGE FROM OMED:
VS: 95.4-96.4 114-129/82-94 101-102 20-22 94-95% 4L NC
GEN: A&O x 3, NAD, fatigued appearing, odd affect, does not make
good eye contact, sunken eyes, icteric, wasted appearing
HEENT: PERRL. MMM. no JVD. neck supple.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: breath sounds diminished at right, dullness to percussion
[**1-3**] way up R posterior lung fields, scattered crackles on left
Abd: BS+, significantly distended, non-tender, no
hepatosplenomegaly appreciated
Extremities: 3+ pitting to knees bilaterally
Skin: no rashes or bruising

FAMILY HISTORY: Brother - alive in his 50s, lupus arthritis and is s/p renal
transplant x 2
Brother - alive in his 60s, HCV
Sister - alive in her 50s, Mother - alive in her 70s
Father - alive in his 80s
No known family history for liver cancer, colon cancer, CAD or
DM

SOCIAL HISTORY: Works full-time as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3456**] contractor.  Married and his wife is
in remission from breast cancer s/p lumpectomy and
chemoradiation in [**2115**].  She works full-time at [**Company 25795**]. Has a
son and a daughter in their 20s who are healthy.  50 pack year
smoking history, now quit.  Last alcoholic drink around [**2117-5-2**]
and drank 2-3 beers daily x 25 years at his most. Born in the
U.S. and his ancestors are from [**Location (un) 22627**]/Poland.  No IVDU,
cocaine use, tattoos, incarceration, significant overseas
travel.
Acidosis,Acute and subacute necrosis of liver,Secondary malignant neoplasm of retroperitoneum and peritoneum,Acute kidney failure, unspecified,Malignant neoplasm of liver, primary,Other ascites,Unspecified essential hypertension,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol,Esophageal reflux
Acidosis,Acute necrosis of liver,Sec mal neo peritoneum,Acute kidney failure NOS,Mal neo liver, primary,Ascites NEC,Hypertension NOS,Chrnc hpt C wo hpat coma,Cirrhosis of liver NOS,Esophageal reflux
Admission Date:  [**2117-8-26**]              Discharge Date:   [**2117-8-31**]

Date of Birth:  [**2061-10-27**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
Shortness of breath and lactic acidosis


Major Surgical or Invasive Procedure:
Thoracentesis ([**8-24**])


History of Present Illness:
55M with hep B/C, HCC who presents to [**Hospital1 18**] ED with SOB.
.
He was recently admitted from [**Date range (1) **] for a large right-sided
pleural effusion, which was drained by interventional
pulmonology on [**2117-8-24**]. The fluid was bloody with negative
gram stain and cytology. He initially felt less dyspnea
following the thoracentesis, but his breathing has worsened over
the past day.
.
He presented to [**Hospital3 **] Hospital, where CXR showed elevation of
the right hemidiaphragm. He was given cefepime 1 gm IV and was
transferred to [**Hospital1 18**] for futher management.
.
In the ED at [**Hospital1 18**], initial vital signs were T 96.7, BP 125/87,
HR 110, RR 24, Sat 100%/4L NC. He was noted to be in respiratory
distrss. Labs were notable for pH 7.14, lactate 19.9, Na 126, K
5.7, WBC 26.3, INR 3.1, glucose 32. CTA torso showed Mod right
pleural effusion. Medial RML and medial basal RLL atelectasis.
No PE. Large 4.5cm pre-carinal node is unchanged. Diffuse HCC
with peritoneal implants. Ascites. He was given 3L NS,
vancomycin 1 gm IV, thiamine 100 mg IV, and morphine 4 mg IV x
2.
.
In the MICU, the patient complained of shortness of breath. He
had no other complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills. Denies headache. Denies cough. Denies
chest pain. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria.
Denies arthralgias or myalgias.
.
HPI UPON PATIENT ARRIVAL TO OMED SERVICE FROM MICU
.
In brief patient was recently admitted from [**Date range (1) **] for a
large right-sided pleural effusion, which was drained by
interventional pulmonology on [**2117-8-24**]. The fluid was bloody
with negative gram stain and cytology. Prior to his transfer to
[**Hospital1 18**] he presented to [**Hospital3 **] Hospital, where CXR showed
elevation of the right hemidiaphragm. He was given cefepime 1 gm
IV and was transferred to [**Hospital1 18**] for futher management, where he
was admitted to the medical ICU.
.
Hospital course significant for ED initial vital signs: T 96.7,
BP 125/87, HR 110, RR 24, Sat 100%/4L NC. He was noted to be in
respiratory distrss. Labs were notable for pH 7.14, lactate
19.9, Na 126, K 5.7, WBC 26.3, INR 3.1, glucose 32. CTA torso
showed Mod right pleural effusion. Medial RML and medial basal
RLL atelectasis. No PE. Large 4.5cm pre-carinal node is
unchanged. Diffuse HCC with peritoneal implants. Ascites. He was
given 3L NS, vancomycin 1 gm IV, thiamine 100 mg IV, and
morphine 4 mg IV x 2.
.
In the MICU, the patient complained of shortness of breath. He
had no other complaints. Thoracentesis was contemplated however
ultimately decided to hold. Per house staff sing out, patient
was given IVF with bicarb, which ultimately improved acidemia,
and lactic acidosis. Infection is not thought to be present,
therefore antibiotics were not continued. Paracentesis to rule
out SBP was not performed to avoid further metastasis. Lovenox
for caval vein thrombus was not continued due to elevated INR.
Patient being now transferred to oncology floor given fall in
lactic acidosis and stable condition.
.
currently patient reports significant improvement in respiratory
symptoms, with oxygen supplementation being per patient the main
reason for this
.
Review of Systems:
(+) Per HPI
(-) Review of Systems: GEN: No fever, chills, night sweats,
recent weight loss or gain. HEENT: No headache, sinus
tenderness, rhinorrhea or congestion. CV: No chest pain or
tightness, palpitations. PULM: No cough,GI: No nausea, vomiting,
diarrhea, constipation or abdominal pain, but some occasional
dyscomfort. No recent change in bowel habits, no hematochezia or
melena. GUI: No dysuria or change in bladder habits. MSK: No
arthritis, arthralgias, or myalgias. DERM: No rashes or skin
breakdown. NEURO: No numbness/tingling in extremities. All other
review of systems negative.

Past Medical History:
Past Oncologic History:
locally-advanced HCC who started using
sorafenib on [**2117-8-9**]
.
Other Past Medical History:
- Hepatitis B cab +, sag and sab (-)
- Hepatitis C cirrhosis, genotype 1
- GERD
- Hyperglycemia
- PE
.
Past Surgical History:
- Tonsillectomy
- Right inguinal hernia

Social History:
Works full-time as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3456**] contractor.  Married and his wife is
in remission from breast cancer s/p lumpectomy and
chemoradiation in [**2115**].  She works full-time at [**Company 25795**]. Has a
son and a daughter in their 20s who are healthy.  50 pack year
smoking history, now quit.  Last alcoholic drink around [**2117-5-2**]
and drank 2-3 beers daily x 25 years at his most. Born in the
U.S. and his ancestors are from [**Location (un) 22627**]/Poland.  No IVDU,
cocaine use, tattoos, incarceration, significant overseas
travel.


Family History:
Brother - alive in his 50s, lupus arthritis and is s/p renal
transplant x 2
Brother - alive in his 60s, HCV
Sister - alive in her 50s, Mother - alive in her 70s
Father - alive in his 80s
No known family history for liver cancer, colon cancer, CAD or
DM

Physical Exam:
ADMISSION
Vitals: T:99 BP:138/87 P:99 R:20 O2 Sat:96%/3L NC
General: Alert, mildly tachypneic, taking deep breaths; jaundice
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: Supple.
Lungs: Decreased breath sounds at bilateral bases R>L.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: Distended. Tender in central abdomen. No rebound or
guarding.
GU: Foley in place.
Ext: Warm, well perfused, 1+ RLE edema
Neuro: A+Ox3. CN II-XII intact. Strength 5/5 throughout.
.
ON DISCHARGE FROM ICU:
Vitals: 95.5 121-124/84-86 103-106 20-21 90-93 6L NC
I/O: 2600/1240
General: Alert, mildly tachypneic, no SOB; jaundice,
malnourished appearing
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: Supple.
Lungs: Decreased breath sounds at bilateral bases R>L, no inc
work of breath.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: Distended. Tender in central abdomen. No rebound or
guarding.
GU: Foley in place.
Ext: Warm, well perfused, 2+ LE edema
Neuro: A+Ox3. CN II-XII intact. Strength 5/5 throughout.
.
ON DISCHARGE FROM OMED:
VS: 95.4-96.4 114-129/82-94 101-102 20-22 94-95% 4L NC
GEN: A&O x 3, NAD, fatigued appearing, odd affect, does not make
good eye contact, sunken eyes, icteric, wasted appearing
HEENT: PERRL. MMM. no JVD. neck supple.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: breath sounds diminished at right, dullness to percussion
[**1-3**] way up R posterior lung fields, scattered crackles on left
Abd: BS+, significantly distended, non-tender, no
hepatosplenomegaly appreciated
Extremities: 3+ pitting to knees bilaterally
Skin: no rashes or bruising

Pertinent Results:
ICU LABS & STUDIES & IMAGING
CBC TREND:

[**2117-8-25**] 11:20PM BLOOD WBC-26.3*# RBC-4.38* Hgb-10.6* Hct-36.8*
MCV-84 MCH-24.2* MCHC-28.8* RDW-19.7* Plt Ct-191
[**2117-8-25**] 11:20PM BLOOD Neuts-88.1* Lymphs-9.0* Monos-2.3 Eos-0.3
Baso-0.3
[**2117-8-26**] 09:21AM BLOOD WBC-25.5* RBC-3.68* Hgb-8.8* Hct-30.4*
MCV-82 MCH-24.0* MCHC-29.1* RDW-19.9* Plt Ct-129*
[**2117-8-26**] 09:21AM BLOOD Neuts-84.1* Lymphs-13.5* Monos-2.1
Eos-0.1 Baso-0.2
[**2117-8-27**] 01:59AM BLOOD WBC-14.6* RBC-3.96* Hgb-9.5* Hct-31.0*
MCV-78* MCH-24.1* MCHC-30.7* RDW-19.3* Plt Ct-110*

COAGS TREND:

[**2117-8-25**] 11:20PM BLOOD PT-31.7* PTT-50.3* INR(PT)-3.1*
[**2117-8-26**] 09:21AM BLOOD PT-31.3* PTT-55.3* INR(PT)-3.1*
[**2117-8-27**] 01:59AM BLOOD PT-28.0* PTT-45.5* INR(PT)-2.7*

CHEM TREND:

[**2117-8-25**] 11:20PM BLOOD Glucose-32* UreaN-35* Creat-1.5* Na-126*
K-5.7* Cl-86* HCO3-6* AnGap-40*
[**2117-8-26**] 09:21AM BLOOD Glucose-278* UreaN-35* Creat-1.3* Na-126*
K-5.3* Cl-91* HCO3-11* AnGap-29*
[**2117-8-27**] 01:59AM BLOOD Glucose-96 UreaN-40* Creat-1.2 Na-128*
K-4.8 Cl-89* HCO3-23 AnGap-21*

LFT TREND:

[**2117-8-25**] 11:20PM BLOOD ALT-175* AST-568* LD(LDH)-520*
AlkPhos-459* TotBili-3.8*
[**2117-8-25**] 11:20PM BLOOD Lipase-96*
[**2117-8-25**] 11:20PM BLOOD Albumin-3.5
[**2117-8-26**] 09:21AM BLOOD ALT-160* AST-530* LD(LDH)-510*
AlkPhos-371* TotBili-3.5*
[**2117-8-26**] 09:21AM BLOOD Lipase-181*
[**2117-8-27**] 01:59AM BLOOD ALT-172* AST-549* LD(LDH)-526*
AlkPhos-345* TotBili-3.1*
[**2117-8-27**] 01:59AM BLOOD Lipase-229*
[**2117-8-27**] 01:59AM BLOOD Albumin-4.5 Calcium-9.4 Phos-2.5*# Mg-2.4

TOX SCREEN:
[**2117-8-25**] 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

VENOUS LACTATE:
[**2117-8-26**] 01:40AM BLOOD Lactate-19.9*
[**2117-8-26**] 04:44AM BLOOD Lactate-15.2* K-5.2
[**2117-8-26**] 09:58AM BLOOD Lactate-13.1*
[**2117-8-26**] 02:52PM BLOOD Lactate-10.8*
[**2117-8-26**] 09:20PM BLOOD Lactate-7.7*
[**2117-8-27**] 03:07AM BLOOD Lactate-6.1*

CXR: CHEST (PORTABLE AP) Study Date of [**2117-8-25**] 10:49 PM
FINDINGS: The right hemidiaphragm is persistently elevated.
Right basilar
atelectasis has increased from the prior study. Right and middle
lobes remain collapsed. No pneumothorax or effusion is
identified. There is no definite consolidation. Mediastinum is
persistently widened due to known mediastinal mass.

CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2117-8-26**]
12:31 AM
FINDINGS: Centrilobular emphysema is seen. A moderate right
pleural effusion is present. Middle lobe and medial basilar
right lower lobe atelectasis is present. No pneumothorax is
seen. Pulmonary arteries are patent to the segmental level. No
embolism or filling defect is noted. A 2.4 x 4.6 cm precarinal
mass impinges on the right middle lobe pulmonary artery
(5:42,5:48). No additional mediastinal, axillary or hilar
adenopathy is present. A multilobulated dense liver lesion is
seen in the right lobe expanding out from segment VIII.
Perihepatic ascites is present. Several rim-enhancing peritoneal
implants are present in the right upper quadrant and
midepigastrium (5:108, 5:99). The dense ascites measures complex
density of 30 Hounsfield units. The adrenal glands are normal.

IMPRESSION:
1. Large precarinal and mediastinal mass consistent with
metastatic disease.
Stable middle and right lower lobe atelectasis and moderate
right pleural
effusion. No pulmonary embolism.
2. Large mass consistent with known hepatocellular carcinoma
with peritoneal carcinomatosis and complex ascites.

CT ABD & PELVIS W/O CONTRAST Study Date of [**2117-8-26**] 2:46 AM
FINDINGS: Right middle and medial basilar lobe atelectasis is
unchanged since [**2117-8-3**]. A small right pleural effusion
is also similar in size. The left lung base is clear.

A multilobulated hypodense lesion infiltrates the right lobe of
the liver,
predominantly involving segment VIII but extending medially and
inferiorly.
The overall size of the lesion appears similar to [**2117-8-3**]. A large 5.2 x 6.1 cm necrotic portacaval node has
increased in size from [**2117-6-23**] when it measured 4 x 4 cm.
A second enlarged necrotic lymph node measures 3.1 x 2.7 cm.
Dense perihepatic ascites is present with peritoneal implants
which are better visualized on the CT of the chest with
contrast. The ascites has attenuation consistent with complex
fluid. Mild ascites is seen throughout the mesentery and both
paracolic gutters with the largest pocket in the right lower
quadrant. The small and large bowel have normal caliber without
obvious wall thickening. The abdominal aorta is atherosclerotic
without any focal aneurysms. The pancreas, spleen, and adrenal
glands are normal. The kidneys excrete contrast symmetrically.
The hypodensity in the upper pole of the left kidney is too
small to characterize and most likely a cyst.

BONE WINDOWS: No concerning lytic or sclerotic lesions are seen.


IMPRESSION: Large infiltrative liver lesion consistent with
known
hepatocellular carcinoma. Increased size of mesenteric
metastasis. Dense
ascites consistent with metastatic peritoneal disease. No
dilated or
abnormally thickened bowel, though evaluation is limited without
intravenous or oral contrast.

DUPLEX DOPP ABD/PEL Study Date of [**2117-8-26**] 10:54 AM
CLINICAL INDICATION: Patient with known and previously ruptured
hepatoma with invasion of the hepatic veins in inferior vena
cava. Now with markedly elevated lactate levels and rising INR.

The liver demonstrates a coarsened and hyperechoic echotexture.
There is a
moderate volume of perihepatic ascites most of which is
relatively clear but some of which has a complex appearance
consistent with the prior
hemoperitoneum. A 5 x 8 cm hypoechoic mass is seen in segment I
and a much
larger mass is seen in segment VII and VIII which is difficult
to measure with precision but is at least 10-11 cm in diameter.
This extends to the liver capsule. Fluid adjacent to this shows
some complexity compatible with hematoma.

The right hepatic vein and inferior vena cava were also assessed
and appear again to be filled with thrombus which extends well
into the inferior vena cava towards the right atrium. The upper
extent cannot be demonstrated by this study. Color flow on pulse
Doppler demonstrates full patency of the right, left and main
portal vein although the main portal vein is somewhat narrowed
as it courses over the segment I liver mass. The left hepatic
vein is patent but the middle hepatic vein could not be
identified and is presumably obliterated by the tumor. As
previously stated the right hepatic vein has tumor thrombus
which extends into the IVC.

CONCLUSION: Multiple hepatic masses as described, with segment
VII-VIII mass invading the right hepatic vein and inferior vena
cava as noted on prior CTA study from [**2117-7-30**]. Portal venous
system remains patent. Perihepatic ascites is somewhat complex
but much more clear than on the prior studies at the time of the
ruptured hemoperitoneum.
OMED LABS & STUDIES & IMAGING:
[**2117-8-31**] 06:10AM BLOOD WBC-19.5* RBC-3.99* Hgb-9.6* Hct-31.4*
MCV-79* MCH-24.0* MCHC-30.5* RDW-19.1* Plt Ct-77*
[**2117-8-31**] 06:10AM BLOOD Neuts-82.7* Lymphs-10.5* Monos-6.3
Eos-0.3 Baso-0.1
[**2117-8-31**] 06:10AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-NORMAL Microcy-3+ Polychr-OCCASIONAL Ovalocy-1+
Target-1+ Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2117-8-31**] 06:10AM BLOOD PT-19.4* PTT-61.5* INR(PT)-1.8*
[**2117-8-31**] 06:10AM BLOOD Glucose-140* UreaN-47* Creat-1.3* Na-125*
K-4.2 Cl-90* HCO3-23 AnGap-16
[**2117-8-30**] 06:50AM BLOOD ALT-163* AST-369* LD(LDH)-407*
AlkPhos-278* TotBili-4.1*
[**2117-8-31**] 06:10AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.9*
.
CXR [**2117-8-29**]: Large right pleural effusion has increased.
Cardiac size cannot be evaluated.
Small left pleural effusion has probably increased. Left lower
lobe atelectasis has increased. The upper lobes are clear. There
is no evident pneumothorax.
.
CXR [**2117-8-30**]: Unchanged appearance of right pleural effusion.

Brief Hospital Course:
HOSPITAL COURSE
55yo M PMHx HBV/HCV HCC, recent hospital stay w R-sided
exudative pleural effusion s/p thoracentesis, now re-presenting
with worsening shortness of breath, found to have marked lactic
acidosis, thought to be secondary aggressive tumor metastasis,
stable and transferred to floor. Patient was given IV fluids to
neutralize acid levels which caused swelling in his lower
extremities.
.
ACTIVE
#Metabolic Acidosis: Patient w recent pleural effusion s/p
thoracentesis re-presenting with dyspnea; no signs of infectious
pulmonary process on CT, UA; no PE on CTA; culture from recent
thoracentesis remained without growth arguing against infected
pleural effusion; imaging notable for marked progression of
tumor burden; respiratory findings were thought to be
compensatory for severe metabolic acidosis [**2-3**] type B
(non-ischemic) lactic acidosis.  Lactic acid was markedly
elevated out of proportion to patient's overall hemodynamic
stability, and was thought to be related to lactate secretion by
the patient's known hepatocellular carcinoma. Patient was
treated with IV bicarbonate with improvement in respiratory
status.  Lactate (initially 19.9) trended to 10.8 w hydration;
as no clear sources of infection were identified, leukocytosis
was attributed to tumor burden.
.
#Worsening Hepatic Function: Rapid increase in INR, and tbili,
lactate concerning for worsening hepatic function, thought to be
secondary to worsening tumor burden.  RUQ u/s did not
demonstrate new thrombosis of portal vein. Lovenox was held
given elevated INR
.
#Acute renal failure: Admitted with Cr 1.5 from 0.7, thought to
be hypovolemic, trended to 1.3 with rehydration.
.
#HCC: Patient on Sorafenib as an outpatient, but with w marked
increase in tumor burden on imaging.  Patient expressed interest
in being able to go home and maximize comfort; paliative care
was consulted.
.
# SIADH: Patient with SIADH on prior admissions, w Na 126 on
this admisison (up from 122 on prior admission).  Na will need
to be monitored.
.
#HYPOTHERMIA: Patient has remained hypothermic throughout stay
(94.2 - 95.6).  Patient presented with SIRS with no obvious
source of infection, but with broad coverage antibiotics.
Patient was temporarily put on bearhugger with little response.
At time of discharge, temperature trending upward at 95.6.
.
ELEVATED LIPASE: Patient's lipase has been trending upward.  On
admission 96; on discharge 229.  Patient complains of minor
epigastrium tenderness to deep palpation but not of pain.  CT
scan does not show any evidence of

INACTIVE
# CAD: Continued metoprolol
.
#GERD: Continued pantoprazole
.
# DM: Conservative sliding scale insulin given episode of
hypoglycemia
.
TRANSITIONAL FROM ICU -> OMED -> DISCHARGE
-IP thought effusion too small to tap so did not
-Followed lactate and temperatures closely for signs of rapid
clinical decline
-Followed lipase as trending upward toward end of ICU stay
-Followed sodium closely as history of SIADH

Medications on Admission:
1. metoprolol tartrate 12.5 mg PO BID
2. oxycodone 5 mg PO Q4H prn pain
3. pantoprazole 40 mg PO BID
4. prochlorperazine maleate 10 mg PO Q6H prn nausea
5. enoxaparin 70 mg Subcutaneous Q12H
6. sodium chloride 1 gram Tablet PO TID
7. sorafenib 400 mg PO twice a day.
8. ferrous sulfate 300  mg PO Daily
9. docusate sodium 100 mg Capsule PO BID
10. acetaminophen 650mg  PO Q6H prn pain/fever

Discharge Medications:
1. Equipment
Please provide home O2 apparatus.
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
6. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-3**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
7. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1)  Subcutaneous
Q12H (every 12 hours).
8. trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as
needed for insomnia.
Disp:*60 Tablet(s)* Refills:*2*
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
10. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
11. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
One (1) 0.25mL spoonful PO every four (4) hours as needed for
pain for 1 weeks.
Disp:*1 container* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Country 28334**] oxygen

Discharge Diagnosis:
Metastatic Hepatocellular Carcinoma


Discharge Condition:
Ambulatory: requires assistance or aid (walker or cane).
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.

Discharge Instructions:
You were transferred to [**Hospital1 18**] because you were having shortness
of breath and had a lot of acid in your blood. We think this
happened because of your tumor in your liver. We gave you a lot
of fluid to help clear this acid which resulted in swelling of
your belly and legs.

You continued to have low oxygen levels. The interventional
pulmonary team looked at the fluid around your right lung and
they did not feel that there was enough fluid to remove.

After a long discussion, you decided that you wanted to go home
and not pursue further interventions for your cancer. We
arranged for you to have home oxygen and hospice services.

There were no changes to your home medications from before. We
did add a prescription for Trazadone 75mg every night to help
you sleep. Additionally, since the hospice services take a
little time to completely set-up, you were discharged with some
liquid Morphine which you can take to help with pain or
shortness of breath. The hospice will provide all other
medications and services to make your time at home as
comfortable and easy as possible.

Please keep your appointments as scheduled below or call and let
the office know if you cannot make it.

We wish you a smooth and peaceful return home.

Followup Instructions:
Department: TRANSPLANT
When: FRIDAY [**2117-9-17**] at 9:00 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2117-9-10**] at 2:30 PM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2117-9-10**] at 2:30 PM
With: [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) 4913**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


Completed by:[**2117-9-28**]
{'Acidosis,Acute and subacute necrosis of liver,Secondary malignant neoplasm of retroperitoneum and peritoneum,Acute kidney failure, unspecified,Malignant neoplasm of liver, primary,Other ascites,Unspecified essential hypertension,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol,Esophageal reflux'}


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: Shortness of breath and lactic acidosis

PRESENT ILLNESS: 55M with hep B/C, HCC who presents to [**Hospital1 18**] ED with SOB.
.
He was recently admitted from [**Date range (1) **] for a large right-sided
pleural effusion, which was drained by interventional
pulmonology on [**2117-8-24**]. The fluid was bloody with negative
gram stain and cytology. He initially felt less dyspnea
following the thoracentesis, but his breathing has worsened over
the past day.
.
He presented to [**Hospital3 **] Hospital, where CXR showed elevation of
the right hemidiaphragm. He was given cefepime 1 gm IV and was
transferred to [**Hospital1 18**] for futher management.
.
In the ED at [**Hospital1 18**], initial vital signs were T 96.7, BP 125/87,
HR 110, RR 24, Sat 100%/4L NC. He was noted to be in respiratory
distrss. Labs were notable for pH 7.14, lactate 19.9, Na 126, K
5.7, WBC 26.3, INR 3.1, glucose 32. CTA torso showed Mod right
pleural effusion. Medial RML and medial basal RLL atelectasis.
No PE. Large 4.5cm pre-carinal node is unchanged. Diffuse HCC
with peritoneal implants. Ascites. He was given 3L NS,
vancomycin 1 gm IV, thiamine 100 mg IV, and morphine 4 mg IV x
2.
.
In the MICU, the patient complained of shortness of breath. He
had no other complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills. Denies headache. Denies cough. Denies
chest pain. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria.
Denies arthralgias or myalgias.
.
HPI UPON PATIENT ARRIVAL TO OMED SERVICE FROM MICU
.
In brief patient was recently admitted from [**Date range (1) **] for a
large right-sided pleural effusion, which was drained by
interventional pulmonology on [**2117-8-24**]. The fluid was bloody
with negative gram stain and cytology. Prior to his transfer to
[**Hospital1 18**] he presented to [**Hospital3 **] Hospital, where CXR showed
elevation of the right hemidiaphragm. He was given cefepime 1 gm
IV and was transferred to [**Hospital1 18**] for futher management, where he
was admitted to the medical ICU.
.
Hospital course significant for ED initial vital signs: T 96.7,
BP 125/87, HR 110, RR 24, Sat 100%/4L NC. He was noted to be in
respiratory distrss. Labs were notable for pH 7.14, lactate
19.9, Na 126, K 5.7, WBC 26.3, INR 3.1, glucose 32. CTA torso
showed Mod right pleural effusion. Medial RML and medial basal
RLL atelectasis. No PE. Large 4.5cm pre-carinal node is
unchanged. Diffuse HCC with peritoneal implants. Ascites. He was
given 3L NS, vancomycin 1 gm IV, thiamine 100 mg IV, and
morphine 4 mg IV x 2.
.
In the MICU, the patient complained of shortness of breath. He
had no other complaints. Thoracentesis was contemplated however
ultimately decided to hold. Per house staff sing out, patient
was given IVF with bicarb, which ultimately improved acidemia,
and lactic acidosis. Infection is not thought to be present,
therefore antibiotics were not continued. Paracentesis to rule
out SBP was not performed to avoid further metastasis. Lovenox
for caval vein thrombus was not continued due to elevated INR.
Patient being now transferred to oncology floor given fall in
lactic acidosis and stable condition.
.
currently patient reports significant improvement in respiratory
symptoms, with oxygen supplementation being per patient the main
reason for this
.
Review of Systems:
(+) Per HPI
(-) Review of Systems: GEN: No fever, chills, night sweats,
recent weight loss or gain. HEENT: No headache, sinus
tenderness, rhinorrhea or congestion. CV: No chest pain or
tightness, palpitations. PULM: No cough,GI: No nausea, vomiting,
diarrhea, constipation or abdominal pain, but some occasional
dyscomfort. No recent change in bowel habits, no hematochezia or
melena. GUI: No dysuria or change in bladder habits. MSK: No
arthritis, arthralgias, or myalgias. DERM: No rashes or skin
breakdown. NEURO: No numbness/tingling in extremities. All other
review of systems negative.

MEDICAL HISTORY: Past Oncologic History:
locally-advanced HCC who started using
sorafenib on [**2117-8-9**]
.
Other Past Medical History:
- Hepatitis B cab +, sag and sab (-)
- Hepatitis C cirrhosis, genotype 1
- GERD
- Hyperglycemia
- PE
.
Past Surgical History:
- Tonsillectomy
- Right inguinal hernia

MEDICATION ON ADMISSION: 1. metoprolol tartrate 12.5 mg PO BID
2. oxycodone 5 mg PO Q4H prn pain
3. pantoprazole 40 mg PO BID
4. prochlorperazine maleate 10 mg PO Q6H prn nausea
5. enoxaparin 70 mg Subcutaneous Q12H
6. sodium chloride 1 gram Tablet PO TID
7. sorafenib 400 mg PO twice a day.
8. ferrous sulfate 300  mg PO Daily
9. docusate sodium 100 mg Capsule PO BID
10. acetaminophen 650mg  PO Q6H prn pain/fever

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION
Vitals: T:99 BP:138/87 P:99 R:20 O2 Sat:96%/3L NC
General: Alert, mildly tachypneic, taking deep breaths; jaundice
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: Supple.
Lungs: Decreased breath sounds at bilateral bases R>L.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: Distended. Tender in central abdomen. No rebound or
guarding.
GU: Foley in place.
Ext: Warm, well perfused, 1+ RLE edema
Neuro: A+Ox3. CN II-XII intact. Strength 5/5 throughout.
.
ON DISCHARGE FROM ICU:
Vitals: 95.5 121-124/84-86 103-106 20-21 90-93 6L NC
I/O: 2600/1240
General: Alert, mildly tachypneic, no SOB; jaundice,
malnourished appearing
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: Supple.
Lungs: Decreased breath sounds at bilateral bases R>L, no inc
work of breath.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Abdomen: Distended. Tender in central abdomen. No rebound or
guarding.
GU: Foley in place.
Ext: Warm, well perfused, 2+ LE edema
Neuro: A+Ox3. CN II-XII intact. Strength 5/5 throughout.
.
ON DISCHARGE FROM OMED:
VS: 95.4-96.4 114-129/82-94 101-102 20-22 94-95% 4L NC
GEN: A&O x 3, NAD, fatigued appearing, odd affect, does not make
good eye contact, sunken eyes, icteric, wasted appearing
HEENT: PERRL. MMM. no JVD. neck supple.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: breath sounds diminished at right, dullness to percussion
[**1-3**] way up R posterior lung fields, scattered crackles on left
Abd: BS+, significantly distended, non-tender, no
hepatosplenomegaly appreciated
Extremities: 3+ pitting to knees bilaterally
Skin: no rashes or bruising

FAMILY HISTORY: Brother - alive in his 50s, lupus arthritis and is s/p renal
transplant x 2
Brother - alive in his 60s, HCV
Sister - alive in her 50s, Mother - alive in her 70s
Father - alive in his 80s
No known family history for liver cancer, colon cancer, CAD or
DM

SOCIAL HISTORY: Works full-time as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3456**] contractor.  Married and his wife is
in remission from breast cancer s/p lumpectomy and
chemoradiation in [**2115**].  She works full-time at [**Company 25795**]. Has a
son and a daughter in their 20s who are healthy.  50 pack year
smoking history, now quit.  Last alcoholic drink around [**2117-5-2**]
and drank 2-3 beers daily x 25 years at his most. Born in the
U.S. and his ancestors are from [**Location (un) 22627**]/Poland.  No IVDU,
cocaine use, tattoos, incarceration, significant overseas
travel. 

### Response:
{'Acidosis,Acute and subacute necrosis of liver,Secondary malignant neoplasm of retroperitoneum and peritoneum,Acute kidney failure, unspecified,Malignant neoplasm of liver, primary,Other ascites,Unspecified essential hypertension,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol,Esophageal reflux'}
