CHIEF COMPLAINT: Fatigue and hematocrit drop

PRESENT ILLNESS: This is a 52-year-old gentleman with a pmhx. of newly diagnosed
metastatic esophageal CA s/p stenting  (started treatment last
week with EOX, epirubicin, oxaliplatin and xeloda) who presents
to the ED with weakness, fatigue, and a 10 point hematocrit drop
over the last 6 days (20 point drop since late [**Month (only) 547**]).  Patient
states that he was doing well at home, though noticed increasing
fatigue and shortness of breath with minimal exertion for the
past few days.  He was seen by VNA who checked blood and told
him to go to the ED because of marked anemia.

MEDICAL HISTORY: GERD
Torn R ACL - not repaired

MEDICATION ON ADMISSION: Omeprazole 20 mg QD
Oxycodone SR (OxyconTIN) 20 mg Q12
OxycoDONE (Immediate Release)  5-10 mg Q4 prn
Compazine
Zolpidem 10mg QHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: afebrile, HR: 110, RR: 16, SP02: 99% on RA, BP: 107/61
General: Eyes closed but responds to voice, lying in bed, no
acute distress
SKIN:  Slightly icteric, excoriations (crusted lesions) over
upper extremities
HEENT: Sclera anicteric, PEARLA, mucous membranes dry
NECK:  Supple, no LAD
LUNGS: Clear to auscultation bilaterally; no wheezes, rales, or
rhonchi
ABDOMEN: +BS, distended, tender to light palpation in epigastric
region, mildly tender to deep palpations throughout
EXTREMITIES:  2+ edema bilaterally up to knees

FAMILY HISTORY: Grandfather with melanoma.

SOCIAL HISTORY: Patient lives with his wife and 2 children (aged 14 and 11).
They have a pet lizard.  He works as a CFO at a software
company.  Has never smoked and drinks only occassionally.  No
other drug use.
Iron deficiency anemia secondary to blood loss (chronic),Acute kidney failure, unspecified,Malignant neoplasm of liver, secondary,Hyposmolality and/or hyponatremia,Hemorrhage of gastrointestinal tract, unspecified,Malignant neoplasm of cardia,Acute venous embolism and thrombosis of deep veins of upper extremity,Unspecified pruritic disorder
Chr blood loss anemia,Acute kidney failure NOS,Second malig neo liver,Hyposmolality,Gastrointest hemorr NOS,Mal neo stomach cardia,Ac DVT/embl up ext,Pruritic disorder NOS
Admission Date:  [**2123-6-23**]              Discharge Date:   [**2123-6-28**]

Date of Birth:  [**2071-5-15**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Fatigue and hematocrit drop

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
This is a 52-year-old gentleman with a pmhx. of newly diagnosed
metastatic esophageal CA s/p stenting  (started treatment last
week with EOX, epirubicin, oxaliplatin and xeloda) who presents
to the ED with weakness, fatigue, and a 10 point hematocrit drop
over the last 6 days (20 point drop since late [**Month (only) 547**]).  Patient
states that he was doing well at home, though noticed increasing
fatigue and shortness of breath with minimal exertion for the
past few days.  He was seen by VNA who checked blood and told
him to go to the ED because of marked anemia.

Initial vitals in the ED were: T: 97.4, BP: 101/58,  HR: 140,
RR: 16,  SP02: 100% on RA.  Hct noted to be 16.8, K 5.6, and
sodium 125 (Na has been slowly trending down since [**Month (only) 547**]).
Stools were trace guiac positive.  Patient was typed and crossed
4 units and sent to the ICU.  Vitals on transfer were: HR: 118,
BP: 110/50, RR: 16, SP02: 100% RA, afebrile.

ROS:
(+) Per HPI.  Reports weight loss of 30lbs in the last few
months.  Cannot tolerate solid food and drinks milkshakes and
ensure.  Significant lower extremity edema, worked up previously
and negative for DVT.  Reports [**9-14**] pain in his epigastric
region, which comes in spasms, especially when he burps.

(-) Patient denies fevers, chills, night sweats, chest pain or
tightness, palpitations.

Past Medical History:
GERD
Torn R ACL - not repaired

Social History:
Patient lives with his wife and 2 children (aged 14 and 11).
They have a pet lizard.  He works as a CFO at a software
company.  Has never smoked and drinks only occassionally.  No
other drug use.

Family History:
Grandfather with melanoma.

Physical Exam:
Vitals: afebrile, HR: 110, RR: 16, SP02: 99% on RA, BP: 107/61
General: Eyes closed but responds to voice, lying in bed, no
acute distress
SKIN:  Slightly icteric, excoriations (crusted lesions) over
upper extremities
HEENT: Sclera anicteric, PEARLA, mucous membranes dry
NECK:  Supple, no LAD
LUNGS: Clear to auscultation bilaterally; no wheezes, rales, or
rhonchi
ABDOMEN: +BS, distended, tender to light palpation in epigastric
region, mildly tender to deep palpations throughout
EXTREMITIES:  2+ edema bilaterally up to knees

Pertinent Results:
Admission labs:
[**2123-6-23**] 03:51PM BLOOD WBC-8.9 RBC-2.02*# Hgb-5.4*# Hct-16.8*#
MCV-83 MCH-27.0 MCHC-32.4 RDW-15.0 Plt Ct-771*
[**2123-6-23**] 03:51PM BLOOD Neuts-88.1* Lymphs-10.8* Monos-0.7*
Eos-0.2 Baso-0.3
[**2123-6-23**] 04:25PM BLOOD PT-14.9* PTT-26.3 INR(PT)-1.3*
[**2123-6-23**] 10:58PM BLOOD Ret Aut-0.8*
[**2123-6-23**] 03:51PM BLOOD Glucose-107* UreaN-21* Creat-0.9 Na-125*
K-5.6* Cl-87* HCO3-24 AnGap-20
[**2123-6-23**] 03:51PM BLOOD ALT-30 AST-122* AlkPhos-312* TotBili-0.3
[**2123-6-23**] 03:51PM BLOOD Lipase-69*
[**2123-6-23**] 03:51PM BLOOD Albumin-2.8*
[**2123-6-23**] 03:51PM BLOOD TSH-5.3*
[**2123-6-25**] 09:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.030
[**2123-6-25**] 09:20AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.5 Leuks-NEG
[**2123-6-25**] 09:20AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
TransE-<1
[**2123-6-25**] 09:20AM URINE CastGr-8*
[**2123-6-24**] 10:30AM URINE Osmolal-651

Reports:
[**6-23**] ECG: Resting sinus tachycardia. Borderline low precordial
voltage. S1-Q3 pattern which is non-diagnostic and was present
on the previous tracing of [**2123-6-3**]. Compared to the previous
tracing resting heart rate is faster

[**6-24**] CTA Abd/Pelvis:
  1. Large mass centered within the lesser sac, larger in size
compared to
[**2123-5-25**]. The distal tip of the esophageal stent has the
suggestion of extending directly into this mass rather than
entering the lumen of the
stomach. Newly developed within the mass are multiple areas of
air and high density contents, concerning for representing
ingested contents or interval development of necrosis within the
mass. For confirmation of stent positioning, a repeat limited CT
of the upper abdomen immediately following the administration of
water soluble oral contrast could be considered.
  2. Hepatic metastases, larger in size from prior study.
  3. Retroperitoneal lymphadenopathy, also larger in size.

[**6-25**] EGD: Esophagus contains large amount of debris and fluid,
noted immediately upon intubation. Unable to clear. Scope
withdrawn, discussed with anesthesia, for intubation. prior to
proceeding further. Therapeutic large channel endoscope
introduced, esophagus cleared of debris, rapid influx of debris
and blood stained fluid into esophagus. Esophageal stent appears
to have migrated proximally. Esophagus cleared again and note
was made of debris partially occluding distal end of stent.
Scope advanced to distal end of stent. Immediately entered
cavity lined with large amount of debris. This may be gastric
cavity but given the findings of recent CT may also be erosion
of stent into mass in lesser sac. Scope immediately withdrawn.
  Impression: Proximal migration of stent Large volume of fluid
and debris noted in stent Distal end may have eroded into
observed mass

[**6-26**] CT non-contrast Abdomen:
  1. Large mass centered in the lesser sac is redemonstrated,
with low-density areas consistent with necrosis. Swallow study
confirms that the previously described fluid- and gas-containing
collection in the center of this mass communicates with the
esophagus and stomach.
  2. Circumferential wall thickening of the distal esophagus
redemonstrated, with unchanged position of esophageal stent.
  3. Fluid layering in dilated distal esophagus, increasing risk
for
aspiration.
  4. Retroperitoneal lymphadenopathy and large liver masses
redemonstrated.
  5. Small bilateral pleural effusions, slightly larger than two
days prior.

Brief Hospital Course:
This is a 52-year-old gentleman with newly diagnosed metastatic
esophageal CA who presented from home with a hematocrit drop of
10 points over the last 6 days.
.
ANEMIA:  Unclear source, but looking back in OMR, appears as
though hct has been slowly trending down since [**Month (only) 547**].  On
admission, hct was at its nadir of 16.8 likely in the setting of
a slow bleed from his GI tract.  Stool was weakly guiac positive
which made a brisk bleed unlikely.  He remained hemodynamically
stable aside from tachycardia.  Decreased marrow production may
also be contributing with a low reticulocyte count.  He received
a total of 9 units of pRBCs until his hematocrit stabilized in
the low to mid 30s.  He was started on a PPI IV BID and
continued on telemetry.
.
ESOPHAGEAL CA:  Chemotherapy was started 1 week prior to
presentation with Xeloda; however, it was unclear whether the
medication was passing beyond the large necrotic esophageal
tumor to be absorbed so it was stopped.  Long discussions were
held with patient and his wife regarding his poor prognosis and
palliative nature of his current regimen.  EGD and CT abdomen
were both consistent with a large, necrotic mass that was
metastatic to the liver.  He was made NPO for fear of esophageal
rupture with continued PO intake.  The patient wanted to leave
the hospital AMA to maximize time spent with his family before
meeting with IV access team to get a Portacath for future chemo
or to meet with surgery to have a J-tube placed.  Follow-up
appointments were made with Dr. [**First Name (STitle) **] for J tube placement and
with Dr. [**Last Name (STitle) 3274**] for oncology follow-up.
.
TACHYCARDIA:  Resolved after treatent of hypovolemia and pain.
.
RIGHT UPPER EXTREMITY DVT:  Patient with swollen, cold right
upper extremity in the setting of PICC line placement.  An
ultrasound showed evidence of thrombus and the PICC was removed.
No anticoagulation was pursued.
.
LOWER EXTREMITY EDEMA:  Patient with marked lower extremity
swelling, worked up previously and negative for DVT.  Likely
marked third spacing from decreased PO intake, poor synthetic
function, and low intravascular oncotic pressure, given albumin
levels ranging from 2.1-2.8.
.
PAIN CONTROL:  Patient had been taking home oxycontin and
oxycodone. He has had mild mental status changes; was slow to
respond and tangential, thought to possibly be adverse effect
from narcotics.  Palliative care was consulted for
recommendations on the patient's analgesic regimen and the
patient did well on oxycontin 10 mg Q12 and oxycodone 5 mg PO Q4
hrs PRN.
.
PRURITIS: Patient was seen by dermatology for long-standing
pruritus of upper and lower extremities with evidence of
excoriated lesions.  He was started on clobetasol .05% ointment
applied to his arms and legs [**Hospital1 **] (covered with ACE bandage wrap
after application) and Mupirocin 2% ointment to apply to the
open areas TID.
.
Code:  Confirmed full code

Medications on Admission:
Omeprazole 20 mg QD
Oxycodone SR (OxyconTIN) 20 mg Q12
OxycoDONE (Immediate Release)  5-10 mg Q4 prn
Compazine
Zolpidem 10mg QHS

Discharge Medications:
1. Clobetasol 0.05 % Ointment Sig: Apply sparingly  Topical
twice a day: Apply to arms and legs and then cover the areas
with an ACE bandage.
Disp:*120 grams* Refills:*10*
2. Mupirocin 2 % Ointment Sig: Appy to open areas  Topical three
times a day.
Disp:*QS grams* Refills:*10*
3. Dulcolax 10 mg Suppository Sig: One (1)  Rectal once a day as
needed for constipation.
Disp:*30 * Refills:*2*
4. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO every [**4-8**]
hours as needed for pain: Please place 5mLs under your tongue.
Disp:*240 mLs* Refills:*0*
5. Compazine 25 mg Suppository Sig: One (1) suppository Rectal
twice a day as needed for nausea.
Disp:*60 * Refills:*2*
6. Outpatient Lab Work
Please check CBC on [**6-30**] and fax results to Dr. [**Last Name (STitle) 3274**] at fax
number [**Telephone/Fax (1) 22294**].


Discharge Disposition:
Home With Service

Facility:
[**Hospital **] Home Health Care

Discharge Diagnosis:
Primary diagnosis: Metastatic espohageal cancer, upper GI bleed


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital for
evaluation of fatigue.  You were found to have significant blood
loss and were admitted to the intensive care unit.  You received
9 units of blood and your blood level remained stable
thereafter.  Please continue to monitor your stools for blood.
You will need to follow-up with Dr. [**Last Name (STitle) 3274**] and Dr. [**First Name (STitle) **] as an
outpatient to discuss possible J-tube placement and further
chemotherapy.

Followup Instructions:
Please follow-up with all of your outpatient medical
appointments listed below:
.
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2123-6-29**] 9:00 on [**Hospital Ward Name 23**] [**Location (un) **]
.
2. Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2123-7-6**] 9:30
.
3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2123-7-6**] 12:00


                             [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
{'Iron deficiency anemia secondary to blood loss (chronic),Acute kidney failure, unspecified,Malignant neoplasm of liver, secondary,Hyposmolality and/or hyponatremia,Hemorrhage of gastrointestinal tract, unspecified,Malignant neoplasm of cardia,Acute venous embolism and thrombosis of deep veins of upper extremity,Unspecified pruritic disorder'}


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 and hematocrit drop

PRESENT ILLNESS: This is a 52-year-old gentleman with a pmhx. of newly diagnosed
metastatic esophageal CA s/p stenting  (started treatment last
week with EOX, epirubicin, oxaliplatin and xeloda) who presents
to the ED with weakness, fatigue, and a 10 point hematocrit drop
over the last 6 days (20 point drop since late [**Month (only) 547**]).  Patient
states that he was doing well at home, though noticed increasing
fatigue and shortness of breath with minimal exertion for the
past few days.  He was seen by VNA who checked blood and told
him to go to the ED because of marked anemia.

MEDICAL HISTORY: GERD
Torn R ACL - not repaired

MEDICATION ON ADMISSION: Omeprazole 20 mg QD
Oxycodone SR (OxyconTIN) 20 mg Q12
OxycoDONE (Immediate Release)  5-10 mg Q4 prn
Compazine
Zolpidem 10mg QHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: afebrile, HR: 110, RR: 16, SP02: 99% on RA, BP: 107/61
General: Eyes closed but responds to voice, lying in bed, no
acute distress
SKIN:  Slightly icteric, excoriations (crusted lesions) over
upper extremities
HEENT: Sclera anicteric, PEARLA, mucous membranes dry
NECK:  Supple, no LAD
LUNGS: Clear to auscultation bilaterally; no wheezes, rales, or
rhonchi
ABDOMEN: +BS, distended, tender to light palpation in epigastric
region, mildly tender to deep palpations throughout
EXTREMITIES:  2+ edema bilaterally up to knees

FAMILY HISTORY: Grandfather with melanoma.

SOCIAL HISTORY: Patient lives with his wife and 2 children (aged 14 and 11).
They have a pet lizard.  He works as a CFO at a software
company.  Has never smoked and drinks only occassionally.  No
other drug use. 

### Response:
{'Iron deficiency anemia secondary to blood loss (chronic),Acute kidney failure, unspecified,Malignant neoplasm of liver, secondary,Hyposmolality and/or hyponatremia,Hemorrhage of gastrointestinal tract, unspecified,Malignant neoplasm of cardia,Acute venous embolism and thrombosis of deep veins of upper extremity,Unspecified pruritic disorder'}
