CHIEF COMPLAINT: Fatigue

PRESENT ILLNESS: 65 yo M with h/o duodenal ulcer and GERD p/w BRBPR who was
recently diagnosed with a splenic flexure mass, most likely
originating from the kidney who presents with fatigue, chills,
shortness of breath and decreased appetite. The pt reports that
for about one week now he has had decreased appetite and has
only been able to soft foods and liquids. Last Friday he started
to notice worsening SOB but only with ambulation associated with
a mild, dry cough. Today in the afternoon he started to note
chills and rigors and decided to come into the hospital.
.
In the ED, VS were 101.9, HR 124, BP 139/61, RR30, O2Sat 93RA. A
CXR showed b/l LL infiltrates R>L. The patient was given
Levofloxacin and Ceftriaxone for PNA. Lactate was found to be
elevated at 7.8. He was given 4L of NS. Lactate decreased to
2.7. A CT abdomen was done whihc confirmed the large LUQ mass
but did not show signs of other pathology, specifically an
ischemic bowel. The patient continued to be tachycardic but was
never hypotensive in the ED (lowest BP 92/66). His O2
requirements remained at 3L with O2 sats 96-99.
.
ROS: positive for about 15lb weight loss in last 2 weeks. The
patient also reports intermittent abdominal pain, present for
weeks, but worsening since discharge from the hospital. He
reports that the pain is worse when lying on the R side and
about 15-20min after eating especially cold foods. Pt denies HA,
vision changes, CP, N, V, D, changes in the color of his stool
or urine and specifically melena or BRBPR. He also denies
myalgias or arthralgias.
.

MEDICAL HISTORY: GERD
Duodenal ulcer, [**10-7**] yrs ago
Borderline diabetes
.

MEDICATION ON ADMISSION: Ranitidine 150mg PO BID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp:97.9 BP: 103/53 HR: 98 RR: 20 O2sat 93 2LNC
GEN: pleasant, comfortable, NAD, speaking in full sentences
HEENT: PERRL, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
RESP: moderate air movement throughout, decreased breath sounds
at the bases, mild crackles in R base
CV: RR, S1 and S2 wnl, no m/r/g, PMI non-displaced
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly,
positive for blood in ED, brown stool
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. moving all extremities

FAMILY HISTORY: No family history of heart disease, cancers (including colon
cancer) or bleeding disorders.

SOCIAL HISTORY: Drinks 1-7 beers/week (last drink was 6 days ago during
superbowl), 45 pky smoking hx, no illicit drugs. At one point
was a heavy drinker, quit liquor 27 years ago but denies abuse
now. Retired, lives in senior citizen apartment complex because
of permanent disability.
Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Secondary malignant neoplasm of lung,Septic shock,Acute kidney failure, unspecified,Acidosis,Acute respiratory failure,Severe sepsis,Other malignant neoplasm without specification of site,Other diseases of spleen,Esophageal reflux,Chronic obstructive asthma, unspecified
Septicemia NOS,Food/vomit pneumonitis,Secondary malig neo lung,Septic shock,Acute kidney failure NOS,Acidosis,Acute respiratry failure,Severe sepsis,Malignant neoplasm NOS,Spleen disease NEC,Esophageal reflux,Chronic obst asthma NOS
Admission Date:  [**2105-2-22**]              Discharge Date:   [**2105-3-7**]

Date of Birth:  [**2039-8-21**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Fatigue

Major Surgical or Invasive Procedure:
ICU stay, Intubation, Mechanical Ventilation
CT guided biopsy of liver.

History of Present Illness:
65 yo M with h/o duodenal ulcer and GERD p/w BRBPR who was
recently diagnosed with a splenic flexure mass, most likely
originating from the kidney who presents with fatigue, chills,
shortness of breath and decreased appetite. The pt reports that
for about one week now he has had decreased appetite and has
only been able to soft foods and liquids. Last Friday he started
to notice worsening SOB but only with ambulation associated with
a mild, dry cough. Today in the afternoon he started to note
chills and rigors and decided to come into the hospital.
.
In the ED, VS were 101.9, HR 124, BP 139/61, RR30, O2Sat 93RA. A
CXR showed b/l LL infiltrates R>L. The patient was given
Levofloxacin and Ceftriaxone for PNA. Lactate was found to be
elevated at 7.8. He was given 4L of NS. Lactate decreased to
2.7. A CT abdomen was done whihc confirmed the large LUQ mass
but did not show signs of other pathology, specifically an
ischemic bowel. The patient continued to be tachycardic but was
never hypotensive in the ED (lowest BP 92/66). His O2
requirements remained at 3L with O2 sats 96-99.
.
ROS: positive for about 15lb weight loss in last 2 weeks. The
patient also reports intermittent abdominal pain, present for
weeks, but worsening since discharge from the hospital. He
reports that the pain is worse when lying on the R side and
about 15-20min after eating especially cold foods. Pt denies HA,
vision changes, CP, N, V, D, changes in the color of his stool
or urine and specifically melena or BRBPR. He also denies
myalgias or arthralgias.
.


Past Medical History:
GERD
Duodenal ulcer, [**10-7**] yrs ago
Borderline diabetes
.


Social History:
Drinks 1-7 beers/week (last drink was 6 days ago during
superbowl), 45 pky smoking hx, no illicit drugs. At one point
was a heavy drinker, quit liquor 27 years ago but denies abuse
now. Retired, lives in senior citizen apartment complex because
of permanent disability.


Family History:
No family history of heart disease, cancers (including colon
cancer) or bleeding disorders.

Physical Exam:
VS: Temp:97.9 BP: 103/53 HR: 98 RR: 20 O2sat 93 2LNC
GEN: pleasant, comfortable, NAD, speaking in full sentences
HEENT: PERRL, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
RESP: moderate air movement throughout, decreased breath sounds
at the bases, mild crackles in R base
CV: RR, S1 and S2 wnl, no m/r/g, PMI non-displaced
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly,
positive for blood in ED, brown stool
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. moving all extremities


Pertinent Results:
[**2105-2-22**] 04:30PM BLOOD WBC-16.3*# RBC-3.21* Hgb-9.7* Hct-29.1*
MCV-91 MCH-30.2 MCHC-33.3 RDW-13.8 Plt Ct-266
[**2105-2-22**] 09:30PM BLOOD WBC-15.2* RBC-2.58* Hgb-7.6* Hct-23.4*
MCV-91 MCH-29.5 MCHC-32.5 RDW-13.7 Plt Ct-206
[**2105-3-5**] 03:24AM BLOOD WBC-48.9* RBC-2.47* Hgb-7.3* Hct-23.1*
MCV-93 MCH-29.4 MCHC-31.5 RDW-15.4 Plt Ct-106*
[**2105-3-6**] 03:06AM BLOOD WBC-62.3* RBC-2.54* Hgb-7.6* Hct-23.7*
MCV-93 MCH-29.8 MCHC-32.0 RDW-15.7* Plt Ct-107*
[**2105-3-6**] 03:06AM BLOOD Neuts-72* Bands-9* Lymphs-10* Monos-2
Eos-4 Baso-0 Atyps-0 Metas-2* Myelos-1* NRBC-5*
[**2105-2-22**] 04:30PM BLOOD Glucose-177* UreaN-27* Creat-1.2 Na-138
K-4.2 Cl-101 HCO3-18* AnGap-23*
[**2105-3-6**] 02:44PM BLOOD Glucose-158* UreaN-82* Creat-2.1* Na-148*
K-5.1 Cl-111* HCO3-26 AnGap-16
[**2105-2-22**] 04:30PM BLOOD ALT-39 AST-29 LD(LDH)-323* AlkPhos-169*
Amylase-26 TotBili-0.6
[**2105-2-23**] 05:32AM BLOOD ALT-35 AST-42* LD(LDH)-445* AlkPhos-128*
TotBili-0.3
[**2105-3-2**] 02:56AM BLOOD ALT-57* AST-35 LD(LDH)-441* AlkPhos-189*
TotBili-0.9
[**2105-3-3**] 03:16AM BLOOD ALT-112* AST-194* LD(LDH)-[**2093**]*
AlkPhos-201* TotBili-0.8
[**2105-2-22**] 04:30PM BLOOD Calcium-8.9 Phos-3.2 Mg-2.3
[**2105-2-24**] 07:20AM BLOOD calTIBC-169* Ferritn-616* TRF-130*
[**2105-2-24**] 11:54AM BLOOD Hapto-338*

BLOOD CULTURES:
[**2105-2-22**] 4:30 pm BLOOD CULTURE
   Blood Culture, Routine (Final [**2105-3-1**]):
      ANAEROBIC GRAM POSITIVE ROD(S).
         NOT CLOSTRIDIUM PERFRINGENS OR CLOSTRIDIUM SEPTICUM.

SPUTUM CULTURE:
   GRAM STAIN (Final [**2105-3-2**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   BUDDING YEAST WITH
PSEUDOHYPHAE.

CT ABDOMEN
1. Marked short-interval progression of extremely large and
aggressive left upper quadrant mass that appears to arise from
the tail of the pancreas with new compression of the stomach and
near-complete encasement of the splenic flexure of the colon.
Frank infiltration of the stomach and colon cannot be excluded.

2. Previously reported splenic vein thrombus now extends to the
portal venous confluence and there are now new enlarged
collateral vessels present within the anterior abdomen. The
presence of splenic thrombosis at time of presentation also
favors a pancreatic origin of this mass.

3. Innumerable new liver metastasis with interval growth of two
dominant metastases compared to CT of only two weeks ago.
Multiple lung metastases and left hilar nodal masses, as
described.

4. No CT evidence of mesenteric ischemia.

CTA CHEST
1. No pulmonary embolus.

2. Multiple nodules/masses scattered throughout the lungs
consistent with metastases. Mediastinal and hilar
lymphadenopathy.

3. Small bilateral pleural effusions and adjacent atelectasis.
Scattered ground-glass opacities seen throughout both lungs with
more focal consolidative process within the right lower lobe
which may represent infection.

4. Diffuse hepatic metastatic lesions and splenic flexure mass,
better evaluated on CT abdomen and pelvis of [**2105-2-22**].

5. Asymmetric enlargement of the left lobe of the thyroid.

BIOPSY: CYTOLOGY
POSITIVE FOR MALIGNANT CELLS
  consistent with poorly-differentiated malignant neoplasm,
  see note.


Brief Hospital Course:
PNEUMONIA / GRAM POSITIVE ROD BACTEREMIA:
The patient was admitted to the MICU from the ED for an elevated
lactate and concern for early/evolving sepsis, with new RLL
pneumonia. He was fluid resussitated and empirically started on
vanco, cipro, and cefepime for antimicrobial coverage. His
lactate level dropped over the course of several hours. Imaging
showed interval progression of his flank mass, including more
hepatic lesions and extension of his splenic vein thrombosis,
previously seen but not anticoagulated given his admission for
GIB. Blood cultures grew out gram positive rods, and he was
continued on his empiric antibiotics. Overall, he was
hemodynamically stable, lactate cleared, and he was transferred
to the floor.

He was later readmitted to the medical intensive care unit with
respiratory distress. He was intubated for respiratory distress.
He had low negative inspiratory pressures. He was extubated but
required high oxygen amounts, including non-rebreather. His CXR
was consistent with aspiration or hemorrhage, along with several
metastatic desposits.

METASTATIC CARCINOMA, UNKNOWN PRIMARY
The patient was found to have a malignant lesion, large in size
and diffusely metastatic to liver, peritoneum, and lung, on
prior admission last month. On admission, he had interval
progression and increase in number of his liver lesions. He
underwent CT guided biopsy of one liver lesion. Final pathology
was pending at time of discharge, but consistent with a very
poorly differentiated carcinoma.

Given the patient's extensive tumor burden, and in conjunction
with palliative care consultation and help from the patient's
primary care physician, [**Name10 (NameIs) **] decision was ultimately reached by
his health care proxy and family to make the patient comfort
measures/comfort care only. He was transferred to the floor of
the hospital where he expired.

METABOLIC ACIDOSIS
The patient had an increase in lactate, likely reflective of
anaerobic metabolism from his extensive tumor burden.

ACUTE RENAL FAILURE
Pre-renal etiology by low FENa, possibly contrast induced
nephropathy.
Continued to have elevated creatinine toward end of course.

SPLENIC VEIN THROMBOSIS
No active management given recent large GI bleed.


Medications on Admission:
Ranitidine 150mg PO BID

Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
Primary:
Metastatic Carcinoma, Unknown Primary
Acute Renal Failure
Sepsis/ Gram Positive Rod Bacteremia
Pneumonia, Aspiration, Bacterial
Splenic Vein Thrombosis.

Secondary:
Gastroesophageal Reflux Disorder

Discharge Condition:
Expired
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Secondary malignant neoplasm of lung,Septic shock,Acute kidney failure, unspecified,Acidosis,Acute respiratory failure,Severe sepsis,Other malignant neoplasm without specification of site,Other diseases of spleen,Esophageal reflux,Chronic obstructive asthma, unspecified'}


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: Fatigue

PRESENT ILLNESS: 65 yo M with h/o duodenal ulcer and GERD p/w BRBPR who was
recently diagnosed with a splenic flexure mass, most likely
originating from the kidney who presents with fatigue, chills,
shortness of breath and decreased appetite. The pt reports that
for about one week now he has had decreased appetite and has
only been able to soft foods and liquids. Last Friday he started
to notice worsening SOB but only with ambulation associated with
a mild, dry cough. Today in the afternoon he started to note
chills and rigors and decided to come into the hospital.
.
In the ED, VS were 101.9, HR 124, BP 139/61, RR30, O2Sat 93RA. A
CXR showed b/l LL infiltrates R>L. The patient was given
Levofloxacin and Ceftriaxone for PNA. Lactate was found to be
elevated at 7.8. He was given 4L of NS. Lactate decreased to
2.7. A CT abdomen was done whihc confirmed the large LUQ mass
but did not show signs of other pathology, specifically an
ischemic bowel. The patient continued to be tachycardic but was
never hypotensive in the ED (lowest BP 92/66). His O2
requirements remained at 3L with O2 sats 96-99.
.
ROS: positive for about 15lb weight loss in last 2 weeks. The
patient also reports intermittent abdominal pain, present for
weeks, but worsening since discharge from the hospital. He
reports that the pain is worse when lying on the R side and
about 15-20min after eating especially cold foods. Pt denies HA,
vision changes, CP, N, V, D, changes in the color of his stool
or urine and specifically melena or BRBPR. He also denies
myalgias or arthralgias.
.

MEDICAL HISTORY: GERD
Duodenal ulcer, [**10-7**] yrs ago
Borderline diabetes
.

MEDICATION ON ADMISSION: Ranitidine 150mg PO BID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp:97.9 BP: 103/53 HR: 98 RR: 20 O2sat 93 2LNC
GEN: pleasant, comfortable, NAD, speaking in full sentences
HEENT: PERRL, anicteric, MMM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
RESP: moderate air movement throughout, decreased breath sounds
at the bases, mild crackles in R base
CV: RR, S1 and S2 wnl, no m/r/g, PMI non-displaced
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly,
positive for blood in ED, brown stool
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. moving all extremities

FAMILY HISTORY: No family history of heart disease, cancers (including colon
cancer) or bleeding disorders.

SOCIAL HISTORY: Drinks 1-7 beers/week (last drink was 6 days ago during
superbowl), 45 pky smoking hx, no illicit drugs. At one point
was a heavy drinker, quit liquor 27 years ago but denies abuse
now. Retired, lives in senior citizen apartment complex because
of permanent disability. 

### Response:
{'Unspecified septicemia,Pneumonitis due to inhalation of food or vomitus,Secondary malignant neoplasm of lung,Septic shock,Acute kidney failure, unspecified,Acidosis,Acute respiratory failure,Severe sepsis,Other malignant neoplasm without specification of site,Other diseases of spleen,Esophageal reflux,Chronic obstructive asthma, unspecified'}
