CHIEF COMPLAINT: nausea and vomiting

PRESENT ILLNESS: Ms. [**Known lastname 55865**] is a 60 yo F w/PMHx sx for metastatic RCC (liver,
brain, lungs) on Avastin, on 3L home oxygen who presents to the
ED with two days of nausea and vomiting of brownish, feculent
material, with no BMs. She had also noted increasing abdominal
distension, but without significant pain. Per patient's
daughter, she has been otherwise doing well. She denies BRBPR,
melena, dysuria, hematuria, chest pain, SOB, fevers, chills. She
has been tolerating the Avastin without any significant side
effects and last received a dose on Wednesday.
.
In the ED, her vitals were T97.3 P 99 BP 147/110 O2sat 92% on
3L.
She underwent a CT abdomen that showed SBO with transition point
in distal jejunum/proximal ileum. NGT placed -- 2800cc feculant
material drained. She was treated with levofloxacin 750mg IV and
cultures were sent. She was seen by the surgical service but
they declined surgical intervention. She was subsequently noted
to have lower pO2 on repeat ABG and was intubated for hypoxemia.

MEDICAL HISTORY: * Metastatic renal cell carcinoma, dx [**2106**]
-s/p right nephrectomy [**12/2106**] with path showing grade 2 clear
cell carcinoma; post-op course c/b colovesical fistula s/p LAR,
drainage of peritoneal abscess, ventral hernia repair
-known mets to lungs, adrenals, brain
-is on home O2 3L/min thought [**2-13**] to pulm mets
-s/p cyberknife tx to brain mets [**3-/2110**] and [**12/2110**]
-s/p 2 weeks IL2 [**12/2109**] c/b neurotoxicity
-s/p tx with sorafenib, sunitinib, and most recently avastin
* h/o DVT [**11/2110**] on coumadin
* PUD
* s/p ccy
* Anxiety

MEDICATION ON ADMISSION: Tylenol prn
Albuterol 1-2 puffs q4-6h prn
Atenolol 50 mg qd
Ativan 0.5 mg q6h prn
VBenzonatate 100 mg tid
Compazine 10 mg q6h prn
Coumadin
Effexor 187.5 mg qd
Gabapentin 100 -300 mg qhs
Lisinopril 10 mg qd
Ondansetron 8 mg q6h prn
Oxycodone prn
Oxycontin 80 mg tid
Zolpidem 5 mg qhs

ALLERGIES: Penicillins

PHYSICAL EXAM: General: Intubated and sedated.
HEENT: MMM. No scleral icterus.
Neck: Supple. JVD flat.
Pulm: Fine crackles at bases anteriorly.
CV: RRR. No MRG.
Abd: Obese, distended. Minimal bowel sounds. NGT in place
draining feculent material.
Extrem: Cool. 1+pulses.
Neuro: Intubated and sedated.
Derm: No skin lesions seen.

FAMILY HISTORY: n/c

SOCIAL HISTORY: Lives with husband. Denies [**Name2 (NI) **]/EtOH/drug use.
Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Ventral, unspecified, hernia with obstruction,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of adrenal gland,Acute kidney failure, unspecified,Unspecified pleural effusion,Encounter for palliative care,Hypovolemia,Lumbago,Other acute pain,Anxiety state, unspecified,Edema,Personal history of malignant neoplasm of kidney,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Other postprocedural status,Personal history of peptic ulcer disease
Food/vomit pneumonitis,Acute respiratry failure,Obstr ventral hernia NOS,Secondary malig neo lung,Second malig neo adrenal,Acute kidney failure NOS,Pleural effusion NOS,Encountr palliative care,Hypovolemia,Lumbago,Acute pain NEC,Anxiety state NOS,Edema,Hx of kidney malignancy,Hx-ven thrombosis/embols,Long-term use anticoagul,Post-proc states NEC,Prsnl hst peptic ulcr ds
Admission Date:  [**2112-2-22**]              Discharge Date:   [**2112-2-28**]

Date of Birth:  [**2051-4-12**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
nausea and vomiting

Major Surgical or Invasive Procedure:
NG tube placement
endotracheal intubation

History of Present Illness:
Ms. [**Known lastname 55865**] is a 60 yo F w/PMHx sx for metastatic RCC (liver,
brain, lungs) on Avastin, on 3L home oxygen who presents to the
ED with two days of nausea and vomiting of brownish, feculent
material, with no BMs. She had also noted increasing abdominal
distension, but without significant pain. Per patient's
daughter, she has been otherwise doing well. She denies BRBPR,
melena, dysuria, hematuria, chest pain, SOB, fevers, chills. She
has been tolerating the Avastin without any significant side
effects and last received a dose on Wednesday.
.
In the ED, her vitals were T97.3 P 99 BP 147/110 O2sat 92% on
3L.
She underwent a CT abdomen that showed SBO with transition point
in distal jejunum/proximal ileum. NGT placed -- 2800cc feculant
material drained. She was treated with levofloxacin 750mg IV and
cultures were sent. She was seen by the surgical service but
they declined surgical intervention. She was subsequently noted
to have lower pO2 on repeat ABG and was intubated for hypoxemia.

.
She is admitted to the MICU for medical management of her SBO.

Past Medical History:
* Metastatic renal cell carcinoma, dx [**2106**]
-s/p right nephrectomy [**12/2106**] with path showing grade 2 clear
cell carcinoma; post-op course c/b colovesical fistula s/p LAR,
drainage of peritoneal abscess, ventral hernia repair
-known mets to lungs, adrenals, brain
-is on home O2 3L/min thought [**2-13**] to pulm mets
-s/p cyberknife tx to brain mets [**3-/2110**] and [**12/2110**]
-s/p 2 weeks IL2 [**12/2109**] c/b neurotoxicity
-s/p tx with sorafenib, sunitinib, and most recently avastin
* h/o DVT [**11/2110**] on coumadin
* PUD
* s/p ccy
* Anxiety

Social History:
Lives with husband. Denies [**Name2 (NI) **]/EtOH/drug use.


Family History:
n/c

Physical Exam:
General: Intubated and sedated.
HEENT: MMM. No scleral icterus.
Neck: Supple. JVD flat.
Pulm: Fine crackles at bases anteriorly.
CV: RRR. No MRG.
Abd: Obese, distended. Minimal bowel sounds. NGT in place
draining feculent material.
Extrem: Cool. 1+pulses.
Neuro: Intubated and sedated.
Derm: No skin lesions seen.

Pertinent Results:
[**2112-2-21**] 06:00PM   WBC-5.2 RBC-4.20 HGB-11.7* HCT-37.8 MCV-90
MCH-27.8 MCHC-30.9* RDW-18.5*
[**2112-2-21**] 06:00PM   PLT SMR-NORMAL PLT COUNT-275
[**2112-2-21**] 06:00PM   NEUTS-83* BANDS-2 LYMPHS-10* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2112-2-21**] 06:00PM   HYPOCHROM-1+ ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL
[**2112-2-21**] 06:00PM   PT-34.8* PTT-35.4* INR(PT)-3.7*
[**2112-2-21**] 06:00PM   ALBUMIN-3.8
[**2112-2-21**] 06:00PM   LIPASE-24
[**2112-2-21**] 06:00PM   ALT(SGPT)-10 AST(SGOT)-22 ALK PHOS-200*
AMYLASE-28 TOT BILI-0.8
[**2112-2-21**] 06:00PM   GLUCOSE-137* UREA N-19 CREAT-0.9 SODIUM-141
POTASSIUM-4.6 CHLORIDE-96 TOTAL CO2-31 ANION GAP-19
[**2112-2-21**] 08:55PM URINE  COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.037*
[**2112-2-21**] 08:55PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG
[**2112-2-21**] 08:55PM URINE  RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2112-2-21**] 10:44PM   LACTATE-2.7*
.
Micro
[**2-21**] urine cx negative
[**2-21**] blood cx negative
[**2-22**] sputum gram 1+ GNRs, 1+ GPC in pairs, 1+ budding yeast;
culture with >3 colony types including MSSA, GNRs, beta strep,
oral flora, yeast
.
Imaging
[**2-21**] CT abd/pelvis
IMPRESSION:
1. Findings consistent with a small-bowel obstruction with
transition point in the distal jejunum/proximal ileum.
2. New centrilobular and patchy opacities in the lower lobes
bilaterally. This raises the question of aspiration. Stable soft
tissue density in the left hilum, incompletely evaluated and may
represent lymphadenopathy.
3. Stable pneumobilia and mild intrahepatic biliary ductal
dilation.
4. Central hernia containing small bowel as well as transverse
colon.
5. Stable bilateral adrenal masses consistent with metastatic
disease.
.
[**2-27**] CXR
Moderate cardiomegaly and marked pulmonary, hilar, and
mediastinal vascular engorgement are all unchanged. There is
suggestion of mild interstitial edema on today's study. Left
lower lobe consolidation is longstanding, probably atelectasis.
ET tube, left subclavian line, and nasogastric tube are in
standard placements respectively. Pleural effusion is presumed,
small on the left. No pneumothorax.
.
[**2-24**] Renal U/S
FINDINGS: The left kidney measures 11.6 cm. There is
preservation of corticomedullary differentiation. There are no
perinephric fluid collections. There is no hydronephrosis. No
renal masses or stones are present. A Foley balloon is present
within a collapsed bladder which is grossly unremarkable.
Evaluation of the right renal fossa is unremarkable.
IMPRESSION: No evidence of left renal hydronephrosis.
.


Brief Hospital Course:
1. Small bowel obstruction: The patient's abdominal imaging
showed a SBO. She was evaluated in the emergency room by the
surgery team, who felt that she did not initially require urgent
intervention in the operating room. Her family preferred that
surgery be avoided if possibile. She was initially medically
managed with placement of a nasogastric tube. She was started on
levofloxacin and flagyl empirically to cover possible
intrabdominal infection. Her NG tube continued to put out large
volumes of feculent material during her admission. After
discussion with her family, she was made CMO.
Ms. [**Known lastname 55865**] [**Last Name (Titles) **] on [**2112-2-28**] at 2:35 am.

2. Respiratory distress: Ms. [**Known lastname 55865**] developed increasing dyspnea
and hypoxemia in the emergency department, and was therefore
intubated. Her respiratory distress was thought to be secondary
to increased abdominal distension in addition to possible
aspiration pneumonia. Of note, she required O2 at home thought
secondary to pulmonary metastases. She was extubated following
decision to change code status to CMO.

3. Oliguria
The patient's urine output remained poor during her
hospitalization, and responded only marginally to volume
resuscitation. Renal ultrasound showed no evidence of
obstruction, and measurement of bladder pressures showed no
evidence of abdominal compartment syndrome.

Medications on Admission:
Tylenol prn
Albuterol 1-2 puffs q4-6h prn
Atenolol 50 mg qd
Ativan 0.5 mg q6h prn
VBenzonatate 100 mg tid
Compazine 10 mg q6h prn
Coumadin
Effexor 187.5 mg qd
Gabapentin 100 -300 mg qhs
Lisinopril 10 mg qd
Ondansetron 8 mg q6h prn
Oxycodone prn
Oxycontin 80 mg tid
Zolpidem 5 mg qhs

Discharge Medications:
n/a

Discharge Disposition:
[**Known lastname **]

Discharge Diagnosis:
Primary:
1. Small bowel obstruction
2. Aspiration pneumonia, suspected
3. Renal cell carcinoma


Discharge Condition:
[**Known lastname **]


Discharge Instructions:
n/a

Followup Instructions:
n/a


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Ventral, unspecified, hernia with obstruction,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of adrenal gland,Acute kidney failure, unspecified,Unspecified pleural effusion,Encounter for palliative care,Hypovolemia,Lumbago,Other acute pain,Anxiety state, unspecified,Edema,Personal history of malignant neoplasm of kidney,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Other postprocedural status,Personal history of peptic ulcer disease'}


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: nausea and vomiting

PRESENT ILLNESS: Ms. [**Known lastname 55865**] is a 60 yo F w/PMHx sx for metastatic RCC (liver,
brain, lungs) on Avastin, on 3L home oxygen who presents to the
ED with two days of nausea and vomiting of brownish, feculent
material, with no BMs. She had also noted increasing abdominal
distension, but without significant pain. Per patient's
daughter, she has been otherwise doing well. She denies BRBPR,
melena, dysuria, hematuria, chest pain, SOB, fevers, chills. She
has been tolerating the Avastin without any significant side
effects and last received a dose on Wednesday.
.
In the ED, her vitals were T97.3 P 99 BP 147/110 O2sat 92% on
3L.
She underwent a CT abdomen that showed SBO with transition point
in distal jejunum/proximal ileum. NGT placed -- 2800cc feculant
material drained. She was treated with levofloxacin 750mg IV and
cultures were sent. She was seen by the surgical service but
they declined surgical intervention. She was subsequently noted
to have lower pO2 on repeat ABG and was intubated for hypoxemia.

MEDICAL HISTORY: * Metastatic renal cell carcinoma, dx [**2106**]
-s/p right nephrectomy [**12/2106**] with path showing grade 2 clear
cell carcinoma; post-op course c/b colovesical fistula s/p LAR,
drainage of peritoneal abscess, ventral hernia repair
-known mets to lungs, adrenals, brain
-is on home O2 3L/min thought [**2-13**] to pulm mets
-s/p cyberknife tx to brain mets [**3-/2110**] and [**12/2110**]
-s/p 2 weeks IL2 [**12/2109**] c/b neurotoxicity
-s/p tx with sorafenib, sunitinib, and most recently avastin
* h/o DVT [**11/2110**] on coumadin
* PUD
* s/p ccy
* Anxiety

MEDICATION ON ADMISSION: Tylenol prn
Albuterol 1-2 puffs q4-6h prn
Atenolol 50 mg qd
Ativan 0.5 mg q6h prn
VBenzonatate 100 mg tid
Compazine 10 mg q6h prn
Coumadin
Effexor 187.5 mg qd
Gabapentin 100 -300 mg qhs
Lisinopril 10 mg qd
Ondansetron 8 mg q6h prn
Oxycodone prn
Oxycontin 80 mg tid
Zolpidem 5 mg qhs

ALLERGIES: Penicillins

PHYSICAL EXAM: General: Intubated and sedated.
HEENT: MMM. No scleral icterus.
Neck: Supple. JVD flat.
Pulm: Fine crackles at bases anteriorly.
CV: RRR. No MRG.
Abd: Obese, distended. Minimal bowel sounds. NGT in place
draining feculent material.
Extrem: Cool. 1+pulses.
Neuro: Intubated and sedated.
Derm: No skin lesions seen.

FAMILY HISTORY: n/c

SOCIAL HISTORY: Lives with husband. Denies [**Name2 (NI) **]/EtOH/drug use. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Ventral, unspecified, hernia with obstruction,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of adrenal gland,Acute kidney failure, unspecified,Unspecified pleural effusion,Encounter for palliative care,Hypovolemia,Lumbago,Other acute pain,Anxiety state, unspecified,Edema,Personal history of malignant neoplasm of kidney,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Other postprocedural status,Personal history of peptic ulcer disease'}
