CHIEF COMPLAINT: Bright red blood per rectum

PRESENT ILLNESS: 67 y.o.m. with metastatic renal cell carcinoma with metastasis
to the pancreas and liver as well as known duodenal/ampullary
mass presents with BRBPR x 2 days. Of note, the patient was
recently started on sutent. Pt states that he first noticed
bloody bowel movement yesterday am. He called his oncologist who
recommended bowel prep in anticipation of colonoscopy today
given known side effect of bleeding with sutent. Pt has
colonoscopy this am that showed blood in colon but no
identifiable source. Pt was referred to the ED for tagged RBC
scan and labs.
Here, a tagged RBC scan was positive at 60 min, and pt was taken
to angiography. There, they couldn't find any obvious source of
bleed, but was consistent with a small bowel source.
HCT noted to drop further to 21 and patient was then referred
for MICU admission.
On admission, he denies fast heart rate, lightheadedness,
dizziness, chest or abdominal pain, tenesmus.  He feels
generally well, though a little anxious.

MEDICAL HISTORY: # GIB [**2184**], EGD revealed duodenal ulcer c/w malignancy
# Hypertension.
# No cardiac problems, diabetes, or cholesterol.
# Traumatic fracture of the right fibula which require open
reduction.
# RCC in [**2167**], treated with IL 2/LAK and was disease free until

MEDICATION ON ADMISSION: Allopurinol 200 mg daily
Atenolol 50 mg daily
Diltiazem 360 mg daily
Nexium 40 mg daily
Lisinopril 40 mg daily
Iron 325 daily
Acetaminophen prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VITALS:  HR 89  BP 145/92  RR 15  Sat 99 (intubated)
GENERAL:  Well-appearing in NAD
HEENT: NC/AT
CARD:  RRR, nl s1 s2, no m/r/g
RESP:  CTAB
ABD:  Soft, Non-tender, Non-distended, with scattered nodules.
RECTAL: Deferred
BACK:  Mild winging of right scapula.  No CVA tenderness.
EXT:  WWP, 2+ PT, DP pulses, No C/C/E

FAMILY HISTORY: .
FAMILY HISTORY:  Non-contributory

SOCIAL HISTORY: He is married and has two children. He is retired from GM. He is
a part-time smoker and drinks alcohol socially.
Secondary malignant neoplasm of other digestive organs and spleen,Portal vein thrombosis,Hemorrhage of gastrointestinal tract, unspecified,Unspecified disease of pericardium,Personal history of malignant neoplasm of kidney,Diverticulosis of colon (without mention of hemorrhage),Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Benign neoplasm of colon,Benign essential hypertension,Anemia in neoplastic disease
Sec mal neo GI NEC,Portal vein thrombosis,Gastrointest hemorr NOS,Pericardial disease NOS,Hx of kidney malignancy,Dvrtclo colon w/o hmrhg,Cholelithiasis NOS,Gstr/ddnts NOS w/o hmrhg,Benign neoplasm lg bowel,Benign hypertension,Anemia in neoplastic dis
Admission Date:  [**2187-8-17**]              Discharge Date:   [**2187-8-28**]

Date of Birth:  [**2119-12-3**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Bright red blood per rectum

Major Surgical or Invasive Procedure:
[**8-19**]: Gastrointestinal arteriogram and embolization of
metastatic pancreatic tumor feeding arteries with no immediate
complications.
[**8-17**] IMPRESSION:  Positive GI bleeding study at 60 minutes with
findings highly suggestive of small bowel bleeding, likely
related to known midline duodenal/pancreatic metastasis. The
transverse colon is noted to positioned more superior (on prior
CT's) then site of bleeding on current study.


History of Present Illness:
67 y.o.m. with metastatic renal cell carcinoma with metastasis
to the pancreas and liver as well as known duodenal/ampullary
mass presents with BRBPR x 2 days. Of note, the patient was
recently started on sutent. Pt states that he first noticed
bloody bowel movement yesterday am. He called his oncologist who
recommended bowel prep in anticipation of colonoscopy today
given known side effect of bleeding with sutent. Pt has
colonoscopy this am that showed blood in colon but no
identifiable source. Pt was referred to the ED for tagged RBC
scan and labs.
Here, a tagged RBC scan was positive at 60 min, and pt was taken
to angiography. There, they couldn't find any obvious source of
bleed, but was consistent with a small bowel source.
HCT noted to drop further to 21 and patient was then referred
for MICU admission.
On admission, he denies fast heart rate, lightheadedness,
dizziness, chest or abdominal pain, tenesmus.  He feels
generally well, though a little anxious.


Past Medical History:
# GIB [**2184**], EGD revealed duodenal ulcer c/w malignancy
# Hypertension.
# No cardiac problems, diabetes, or cholesterol.
# Traumatic fracture of the right fibula which require open
reduction.
# RCC in [**2167**], treated with IL 2/LAK and was disease free until

[**2181**], now with metastatic disease to pancreas and likely liver.

.
ONCOLOGIC HISTORY :
1.  Status post left nephrectomy followed by high-dose IL-2
[**2166**].
2.  LAK therapy in [**2167**].
3. st. post resection of residual renal bed mass in [**2168**]
4.  Recurrence in the left renal fossa and pancreas in [**4-/2182**]
5. Low-dose interleukin-2 in 12/[**2181**].
6.  Atrasentan medication trial 11/[**2181**].
7.  initiated on Nexavar 400 mg twice daily, dose reduced on
10/1005 in the setting of hypertension.  His course has been
complicated by a GI bleed with possible small bowel obstruction,
and an admission to [**Hospital3 **] in [**8-/2185**] for anemia
and acute renal failure while on full dose Nexavar 400 mg given
twice daily.
8.  Nexavar dose reduced to 400 mg q.a.m., 200 mg q.p.m.
9.  Nexavar dose increased to 400 mg b.i.d. following CT in
[**9-/2186**], which showed progression of pancreatic metastases.
10.  Enrolled in perifosine trial 06-408 on [**2187-2-28**].
11.  Perifosine held since [**2187-6-13**] due to GI bleed.
12. ERCP on [**2187-6-20**] showed a malignant appearing mass in
duodenum, pathology consistent with metastatic renal cell Ca.
13. Perifosine restarted [**2187-6-27**] for one week, held on [**7-4**] due
to
SBO requiring hospital admission in [**Hospital3 2783**], and
restarted again on [**7-11**].
14. Perifosine held due to elevated LFTs on [**2187-7-25**].
15. ERCP on [**2187-8-3**] - biliary stent placed to proximal CBD.
.


Social History:
He is married and has two children. He is retired from GM. He is
a part-time smoker and drinks alcohol socially.


Family History:
.
FAMILY HISTORY:  Non-contributory


Physical Exam:
PHYSICAL EXAMINATION:
VITALS:  HR 89  BP 145/92  RR 15  Sat 99 (intubated)
GENERAL:  Well-appearing in NAD
HEENT: NC/AT
CARD:  RRR, nl s1 s2, no m/r/g
RESP:  CTAB
ABD:  Soft, Non-tender, Non-distended, with scattered nodules.
RECTAL: Deferred
BACK:  Mild winging of right scapula.  No CVA tenderness.
EXT:  WWP, 2+ PT, DP pulses, No C/C/E


Pertinent Results:
[**2187-8-17**] 12:00PM BLOOD WBC-5.9 RBC-3.88* Hgb-9.0* Hct-29.0*
MCV-75* MCH-23.3* MCHC-31.2 RDW-20.6* Plt Ct-149*
[**2187-8-17**] 05:50PM BLOOD WBC-4.1 RBC-2.73*# Hgb-6.5*# Hct-20.6*#
MCV-75* MCH-23.7* MCHC-31.6 RDW-19.5* Plt Ct-103*
[**2187-8-18**] 12:04PM BLOOD WBC-7.2 RBC-3.88* Hgb-10.0* Hct-29.3*
MCV-76* MCH-25.7* MCHC-34.0 RDW-19.3* Plt Ct-116*
[**2187-8-19**] 05:45PM BLOOD WBC-7.5# RBC-3.77* Hgb-10.5* Hct-30.2*
MCV-80* MCH-27.8 MCHC-34.8 RDW-18.1* Plt Ct-103*
[**2187-8-20**] 12:18PM BLOOD Hct-31.0*
[**2187-8-20**] 02:07AM BLOOD Glucose-120* UreaN-10 Creat-0.9 Na-137
K-4.5 Cl-110* HCO3-18* AnGap-14
[**2187-8-21**] 12:49PM BLOOD Hct-30.1*
[**2187-8-21**] 09:28PM BLOOD Hct-30.4*
[**2187-8-22**] 10:09AM BLOOD WBC-9.2 RBC-4.25* Hgb-12.1* Hct-34.4*
MCV-81* MCH-28.5 MCHC-35.1* RDW-19.0* Plt Ct-112*
Blood cx [**8-22**] NGTD x 2
.
[**8-17**] Bleeding study: Positive GI bleeding study at 60 minutes
with findings highly suggestive of small bowel bleeding, likely
related to known midline duodenal/pancreatic metastasis. The
transverse colon is noted to positioned more superior (on prior
CT's) then site of bleeding on current study.
.
[**8-17**] Arteriogram: Arteriogram of celiac trunk and superior
mesenteric artery with no extravasation.
.
[**8-19**] Bleeding Study: Intermittent brisk bleeding. Origin of the
bleeding appears to be just to the left of midline in the
epigastrium.
.
[**8-19**] IR study: Gastrointestinal arteriogram and embolization of
metastatic pancreatic tumor feeding arteries with no immediate
complications.
.
[**8-20**] Femoral ultrasound: No evidence of pseudoaneurysm.
.
[**8-22**] CXR: Low lung volumes. Left lower lobe retrocardiac opacity
is most likely atelectasis.
.
[**8-24**] Knee X-ray: Mild patellofemoral compartment osteoarthritis.
.
[**8-24**] Ultrasound: Examination limited by extensive bowel gas,
which may represent the source of the patient's distention. Mild
ascites. Mild interval increase in size of a right hepatic mass,
allowing for differences in technique.
.
[**8-25**] CT Abd/Pelvis: 1. Bilateral pleural effusions, left greater
than right. Interval increase in intra-abdominal and intrapelvic
ascites. Small pericardial effusion. 2. Cholelithiasis. 3.
Diverticulosis. Mild edema of the colonic wall could reflect a
mild portal colopathy. 4. No significant change in multiple
areas of metastatic disease, including multiple large masses of
the pancreas. Status post left nephrectomy. 5. Patent biliary
stent. 6. Portal vein thrombosis with innumerable coallaterals.
7. Left inguinal hematoma. 8. No evidence of bowel obstruction.
9. Suboptimal evaluation of the spleen; while the appearance may
reflect heterogeneous enhancement due to the phase of contrast,
the possibility of infarcts should be considered. Attention to
this area on follow-up imaging is
advised.
.
[**8-27**] Abd Ultrasound for diagnostic paracentesis: Very small
amount of ascites adjacent to the liver dome. Given the small
amount of fluid and resolution of patient's symptoms, no
paracentesis was performed at this time.


Brief Hospital Course:
Mr. [**Known lastname 21223**] is a 67yM with metastatic RCC, h/o GIB c malignant
ulcer, p/w BRBPR for 2 days and admitted to MICU for careful
hemodynamic monitoring.

1. GI Bleed: Likely related to a metastatic lesion, complicated
by starting Sutent. Patient has a history of bleeding GI masses,
and had been temporarily stopped in Atrasentan trial for anemia.
 EGD showed no bleeding from duodenal/ampullary mass or
hematobilia.  He thus likely has a lower GI source, which is
consistent with colonoscopy with blood throughout.  Pt had RBC
scan w/ bleeding at 60min and nothing on angio, then had more
BRBPR in the MICU, was re-RBC scanned w/ bleeding at 7 min, and
was re-angioed this am, where they embolized feeding arteries
around tumor, but did not see any large bleeds. The following
day ([**8-21**]) the patient was hemodynamically stable and had a Hct
of 31 in the AM, yet her afternoon HCT was found to be 24 and
confirmed on repeat. The patient was transfused 2 units and
responded appropriately. The patient was continued on a PPI [**Hospital1 **],
and had two IVs kept in place. His hematocrit remained stable 24
hours after. However, he was transferred to [**Hospital Unit Name 153**] given continued
repeated drops in HCT. GI and surgery consulted but did not
recommend further interventions at time of transfer. Once
transferred to the floor, his hematocrit remained stable. He
received a total of 12 units of pRBC's during this admission.

#. Gout. He developed a gout flare during admission (despite
being on allopurinol), confirmed by arthrocentesis. He was
started on a steroid taper, which he will complete as an
outpatient.

#. Abdominal distention. His abdomen was noted to be distended,
although nontender. An ultrasound identified mild ascites and
increased bowel gas, and a CT abd/pelvis was performed,
demonstrating pleural effusions and mild ascites. A diagnostic
paracentesis was attempted but could not be safely performed
given the small amount of fluid.

#. Hypertension. His outpatient regimen was initially held in
the setting of lower GI bleed. His nodal blocking agents were
slowly added back (diltiazem first), and he was discharged to
continue all of his home blood pressure medications.

#. Fever. He had low grade temperatures for several days during
the admission but no sources were identified. Cultures were
negative at the time of discharge and should be followed up as
an outpatient.

#. Renal Cell cancer: He will complete his course of XRT at
discharge and will follow up with Dr. [**Last Name (STitle) **] afterward.

Medications on Admission:
Allopurinol 200 mg daily
Atenolol 50 mg daily
Diltiazem 360 mg daily
Nexium 40 mg daily
Lisinopril 40 mg daily
Iron 325 daily
Acetaminophen prn


Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Gas-X 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
every eight (8) hours as needed for gas.
7. Diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
10. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day
for 6 days: [**Date range (1) 21224**] take 3 tablets; [**Date range (1) 21225**] take 2
tablets; [**Date range (1) 21226**] take 1 tablet, then stop.
Disp:*12 Tablet(s)* Refills:*0*
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Metastatic Renal Cell Carcinoma
Gastrointestinal Bleed


Discharge Condition:
The patient was hemodynamicall stable, afebrile and without
pain.


Discharge Instructions:
You were admitted for gastrointestinal bleeding which required
ICU care.  Your bleeding was determined to be caused by a mass
in your intestine.  You underwent endoscopy and blood vessels in
your tumor were treated.  You received several blood
transfusions but have had not evidence of bleeding for several
days.
.
In addition, you developed a gout flare of your right knee. You
should continue taking the prednisone as prescribed.
.
Take all of your medications as prescribed. You should resume
taking all of the pills you were taking prior to this admission
(EXCEPT for Sutent; this will be discussed with Dr. [**Last Name (STitle) **] at
your next visit).
.
If you develop any concerning symptoms, such as more bleeding
from your rectum, vomiting any blood, increasing abdominal
fullness or abdominal pain, dizziness, numbness, chest pain,
shortness of breath, or other concerning symptoms, please seek
medical attention immediately.

Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] after your radiation is finished;
his office will contact you for an appointment.
.
Continue going to radiation until you complete the course; they
will give you a time for daily visits.
{'Secondary malignant neoplasm of other digestive organs and spleen,Portal vein thrombosis,Hemorrhage of gastrointestinal tract, unspecified,Unspecified disease of pericardium,Personal history of malignant neoplasm of kidney,Diverticulosis of colon (without mention of hemorrhage),Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Benign neoplasm of colon,Benign essential hypertension,Anemia in neoplastic 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: Bright red blood per rectum

PRESENT ILLNESS: 67 y.o.m. with metastatic renal cell carcinoma with metastasis
to the pancreas and liver as well as known duodenal/ampullary
mass presents with BRBPR x 2 days. Of note, the patient was
recently started on sutent. Pt states that he first noticed
bloody bowel movement yesterday am. He called his oncologist who
recommended bowel prep in anticipation of colonoscopy today
given known side effect of bleeding with sutent. Pt has
colonoscopy this am that showed blood in colon but no
identifiable source. Pt was referred to the ED for tagged RBC
scan and labs.
Here, a tagged RBC scan was positive at 60 min, and pt was taken
to angiography. There, they couldn't find any obvious source of
bleed, but was consistent with a small bowel source.
HCT noted to drop further to 21 and patient was then referred
for MICU admission.
On admission, he denies fast heart rate, lightheadedness,
dizziness, chest or abdominal pain, tenesmus.  He feels
generally well, though a little anxious.

MEDICAL HISTORY: # GIB [**2184**], EGD revealed duodenal ulcer c/w malignancy
# Hypertension.
# No cardiac problems, diabetes, or cholesterol.
# Traumatic fracture of the right fibula which require open
reduction.
# RCC in [**2167**], treated with IL 2/LAK and was disease free until

MEDICATION ON ADMISSION: Allopurinol 200 mg daily
Atenolol 50 mg daily
Diltiazem 360 mg daily
Nexium 40 mg daily
Lisinopril 40 mg daily
Iron 325 daily
Acetaminophen prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VITALS:  HR 89  BP 145/92  RR 15  Sat 99 (intubated)
GENERAL:  Well-appearing in NAD
HEENT: NC/AT
CARD:  RRR, nl s1 s2, no m/r/g
RESP:  CTAB
ABD:  Soft, Non-tender, Non-distended, with scattered nodules.
RECTAL: Deferred
BACK:  Mild winging of right scapula.  No CVA tenderness.
EXT:  WWP, 2+ PT, DP pulses, No C/C/E

FAMILY HISTORY: .
FAMILY HISTORY:  Non-contributory

SOCIAL HISTORY: He is married and has two children. He is retired from GM. He is
a part-time smoker and drinks alcohol socially. 

### Response:
{'Secondary malignant neoplasm of other digestive organs and spleen,Portal vein thrombosis,Hemorrhage of gastrointestinal tract, unspecified,Unspecified disease of pericardium,Personal history of malignant neoplasm of kidney,Diverticulosis of colon (without mention of hemorrhage),Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Benign neoplasm of colon,Benign essential hypertension,Anemia in neoplastic disease'}
