CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: This is a 53 y/o F with a PMHx of metastatic breast CA
unresponsive to previous chemo regimens recently 1 dose of doxil
([**2168-5-25**]), chronic PE on Lovenox, asthma, allergic rhinitis,
now presenting with 5 days of L lower chest/left upper abdominal
pain, accompanied with occasional nausea.  She denies any
pleuritic component to this L lower chest pain, without
radiation to her back or neck/arm.  She denies any [**Month/Day/Year 9140**]
SOB, or dyspnea on exertion from her prior baseline.   She has
been taking her Lovenox injections regularly since her discharge
1 month ago.  She does state that she has had [**Month/Day/Year 9140**]
abdominal distension and describes her LUQ abd pain as
"gurgling" in nature.  Does admit to constipation, with normal
BM over 6 days ago.  Has taken Miralax since Monday without much
improvement.  No hematemesis, diarrhea.
.
On arrival to the ED, VS T97.1, HR145, BP94/49, RR32, satting
90%on NRB.  She received 2L NS, 6mg MS IV, Levaquin 500mg x1,
Ceftriaxone 2g IV x1.  She had an US-guided paracentesis
performed that removed 3L of yellow-green fluid.

MEDICAL HISTORY: 1) Metastatic breast cancer: T2-NO, ER/PR + HER-2/neu (-),
diagnosed [**2158**]
-[**2158**]: She was treated with CMF plus tamoxifen and local
radiation.
-[**2162**]: Treated with epirubicin/taxotere after found to have
adrenal met
-[**2162**]-[**2164**]: On Arimidex, then found to have liver mets
-[**2164**]: Started on Xeloda
-[**2165**]: Treated with taxol
-[**2165**]: Phase II study of [**Doctor First Name **] [**Numeric Identifier 99361**] (tyrosine kinase inhibitor)
-[**2165**]: Cancer metastasized to liver and adrenals
-[**2166**]: Has received 2 treatments with gemcitabine
[**2167-8-28**]: thoracentesis with fluid positive for malignant cells
[**2167-10-16**]: Right VATS, talc pleurodesis by Dr. [**Last Name (STitle) 952**] with
placement of pleur-X cath
[**2167-10-30**]: 3rd dose of Gemcitabine
Currently treated w/ Navelbine, last dose 2 wks ago.
2) Malignant pleural effusion s/p pleurex catheter placed [**9-29**]
removed [**3-31**]
3) Asthma
4) Allergic rhinitis
5) GERD

MEDICATION ON ADMISSION: Lovenox 70mg q12
Zofran 8 mg PO BID
Megestrol 40 [**Hospital1 **]
Protonix 40
Percocet prn
Ativan prn

ALLERGIES: Compazine

PHYSICAL EXAM: VS: T95.5  HR135  BP 104/78  RR 28 o2sat: 96% on 4L NC
GEN: Appears stated age, mild discomfort due to pain, able to
speak in full sentences
HEENT: Anicteric sclera bilat.  PERRL.  EOMi.
NECK: No elevated JVP
CV: Tachycardic.  Nml s1,s2.  No murmurs
RESP: Decreased BS at bases R>L, crackles @ both bases.
Decreased percussion bilat.
CHEST/ABD: Mild TTP over distal ribs on L chest.  No TTP over
abdomen.  No rebound/guarding. No fluid wave.
EXT:  No edema bilat.
NEURO: AAOx3.

FAMILY HISTORY: 1. Breast cancer:  uncle
2. Lung CA:  father, sister

SOCIAL HISTORY: lives with husband, 23 year-old daughter, and 6 month-old
grandson.  [**Name (NI) 4084**] smoked.  No alcohol, cocaine, or IVDU.
Secondary malignant neoplasm of retroperitoneum and peritoneum,Secondary malignant neoplasm of bone and bone marrow,Personal history of malignant neoplasm of breast,Asthma, unspecified type, unspecified,Esophageal reflux
Sec mal neo peritoneum,Secondary malig neo bone,Hx of breast malignancy,Asthma NOS,Esophageal reflux
Admission Date:  [**2168-6-3**]              Discharge Date:   [**2168-6-8**]

Date of Birth:  [**2115-2-18**]             Sex:   F

Service: MEDICINE

Allergies:
Compazine

Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
none


History of Present Illness:
This is a 53 y/o F with a PMHx of metastatic breast CA
unresponsive to previous chemo regimens recently 1 dose of doxil
([**2168-5-25**]), chronic PE on Lovenox, asthma, allergic rhinitis,
now presenting with 5 days of L lower chest/left upper abdominal
pain, accompanied with occasional nausea.  She denies any
pleuritic component to this L lower chest pain, without
radiation to her back or neck/arm.  She denies any [**Month/Day/Year 9140**]
SOB, or dyspnea on exertion from her prior baseline.   She has
been taking her Lovenox injections regularly since her discharge
1 month ago.  She does state that she has had [**Month/Day/Year 9140**]
abdominal distension and describes her LUQ abd pain as
"gurgling" in nature.  Does admit to constipation, with normal
BM over 6 days ago.  Has taken Miralax since Monday without much
improvement.  No hematemesis, diarrhea.
.
On arrival to the ED, VS T97.1, HR145, BP94/49, RR32, satting
90%on NRB.  She received 2L NS, 6mg MS IV, Levaquin 500mg x1,
Ceftriaxone 2g IV x1.  She had an US-guided paracentesis
performed that removed 3L of yellow-green fluid.


Past Medical History:
1) Metastatic breast cancer: T2-NO, ER/PR + HER-2/neu (-),
diagnosed [**2158**]
-[**2158**]: She was treated with CMF plus tamoxifen and local
radiation.
-[**2162**]: Treated with epirubicin/taxotere after found to have
adrenal met
-[**2162**]-[**2164**]: On Arimidex, then found to have liver mets
-[**2164**]: Started on Xeloda
-[**2165**]: Treated with taxol
-[**2165**]: Phase II study of [**Doctor First Name **] [**Numeric Identifier 99361**] (tyrosine kinase inhibitor)
-[**2165**]: Cancer metastasized to liver and adrenals
-[**2166**]: Has received 2 treatments with gemcitabine
[**2167-8-28**]: thoracentesis with fluid positive for malignant cells
[**2167-10-16**]: Right VATS, talc pleurodesis by Dr. [**Last Name (STitle) 952**] with
placement of pleur-X cath
[**2167-10-30**]: 3rd dose of Gemcitabine
Currently treated w/ Navelbine, last dose 2 wks ago.
2) Malignant pleural effusion s/p pleurex catheter placed [**9-29**]
removed [**3-31**]
3) Asthma
4) Allergic rhinitis
5) GERD


Social History:
lives with husband, 23 year-old daughter, and 6 month-old
grandson.  [**Name (NI) 4084**] smoked.  No alcohol, cocaine, or IVDU.


Family History:
1. Breast cancer:  uncle
2. Lung CA:  father, sister


Physical Exam:
VS: T95.5  HR135  BP 104/78  RR 28 o2sat: 96% on 4L NC
GEN: Appears stated age, mild discomfort due to pain, able to
speak in full sentences
HEENT: Anicteric sclera bilat.  PERRL.  EOMi.
NECK: No elevated JVP
CV: Tachycardic.  Nml s1,s2.  No murmurs
RESP: Decreased BS at bases R>L, crackles @ both bases.
Decreased percussion bilat.
CHEST/ABD: Mild TTP over distal ribs on L chest.  No TTP over
abdomen.  No rebound/guarding. No fluid wave.
EXT:  No edema bilat.
NEURO: AAOx3.


Pertinent Results:
EKG: Sinus tach, 150.  Nml axis, nml intervals. No ST or TW
changes.
.
Imaging:
ECHO [**6-3**]:
EF >60%.  PASP 41.
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The mitral valve appears structurally normal with
trivial mitral regurgitation. Tricuspid regurgitation is present
but cannot be quantified. There is moderate pulmonary artery
systolic hypertension. There is an anteriorspace which most
likely represents a fat pad, though a loculated anterior
pericardial effusion cannot be excluded.
.
CT Torso c contrast [**6-3**]:
1.  Chronic pulmonary embolism of the left main pulmonary artery
and right lower lobe pulmonary artery with interval retraction
of left main PA clot.  No acute pulmonary embolism identified.
2.  New moderate left pleural effusion with left basilar
consolidation, probably atelectasis, but pneumonia cannot be
excluded.
3.  No significant change in appearance of the right hemithorax
including moderate right pleural effusion, concentric pleural
thickening, and right lower lobe consolidation with interstitial
thickening possibly indicating lymphangitic spread of tumor.
4.  No significant change in mediastinal and hilar
lymphadenopathy.
5.  Interval [**Month/Day (4) 9140**] in now moderate-to-severe ascites and
increased omental
soft tissue consistent with [**Month/Day (4) 9140**] omental carcinomatosis.
6.  No significant change in innumerable hepatic metastases.
7.  No significant change in diffuse osseous metastases.
8.  Enlarged subcutaneous soft tissue densities of the abdominal
wall may represent injection sites or less likely metastatic
foci.


Brief Hospital Course:
This was a 53 year-old female with a history of metastatic
breast CA unresponsive to previous chemo regimens, chronic PE on
Lovenox, and asthma who presented with hypoxia and abdominal
pain.
.
#HYPOXIA
The patient had a known chronic R pleural effusion, with stable
chronic PEs who presented with SOB and new L pleural effusion.
Her SOB appears to be at her baseline.  Her new L pleural
effusion likely represents a malignant effusion given lack of
infectious symptoms and h/o R malignant effusion.  She required
only nasal cannula supplementation during her admission.
.
#HYPOTENSION/TACHYCARDIA
Likely etiology of hypotension is hypovolemia secondary to
decreased PO intake.  She received 2L NS in the ED with mild
improvement in hemodynamics.  No PE was seen on CT.  3L of
ascites fluid was drained in ED without evidence of SBP or other
systemic infection.  There may have been an element of adrenal
insufficiency given metastatic involvement of R adrenal gland
and prior removal.  She was continued with IV hydration as
needed on the floor.
.
#L CHEST/ABD PAIN
This likely represented an element of musculoskeletal pain from
osteolytic lesions as seen on CT torso, with a component of
hypercalcemia.  She had no evidence of new/[**Month/Day (4) 9140**] PE burden
on CT torso.  She underwent paracentesis in the ED with removal
of 3L to make the patient more comfortable.  She was given an
aggressive bowel regimen with IV hydration.  She was started on
a fentanyl patch with prn dilaudid.
.
#Hypercalcemia
This was thought to be due to malignancy.  She was given
pamidronate 90 mg IV, with some response in her calcium levels.

.
# Hx of PE
She was continued on her treatment regimen of Lovenox 70mg SC
bid.  There was no evidence of new/[**Month/Day (4) 9140**] clot burden at this
time.
.
#Breast CA
Pt with metastatic breast CA that has not responded to tx as
above.  Recently started on doxorubicin 1 month ago for
refractory metastatic breast CA.  CT torso today revealed
[**Month/Day (4) 9140**] metastatic disease with [**Month/Day (4) 9140**] omental
carcinomatosis.  After speaking with her primary oncologist, it
was clear that there were no further treatments for the patient.
 The patient and her family requested a palliative care
consultation.  Plans were made for home hospice.  She was
discharged home with pain medications and home hopsice services.

Medications on Admission:
Lovenox 70mg q12
Zofran 8 mg PO BID
Megestrol 40 [**Hospital1 **]
Protonix 40
Percocet prn
Ativan prn

Discharge Medications:
1. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
2. Dilaudid-5 1 mg/mL Liquid Sig: 4-10 MG PO q 1-2 hr: Please
administer 20 mg/mL.
Disp:*1 vial* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Hospice of the Good [**Doctor Last Name 9995**]

Discharge Diagnosis:
metastatic breast cancer


Discharge Condition:
stable, pain-controlled


Discharge Instructions:
Please take all of your medications as prescribed.
Please return to the emergency room should you experience severe
nausea, vomiting, chest discomfort, diarrhea or other symptoms
that concern you.

Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 15108**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2168-6-22**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2168-6-22**]
1:30


                             [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
{'Secondary malignant neoplasm of retroperitoneum and peritoneum,Secondary malignant neoplasm of bone and bone marrow,Personal history of malignant neoplasm of breast,Asthma, unspecified type, unspecified,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: abdominal pain

PRESENT ILLNESS: This is a 53 y/o F with a PMHx of metastatic breast CA
unresponsive to previous chemo regimens recently 1 dose of doxil
([**2168-5-25**]), chronic PE on Lovenox, asthma, allergic rhinitis,
now presenting with 5 days of L lower chest/left upper abdominal
pain, accompanied with occasional nausea.  She denies any
pleuritic component to this L lower chest pain, without
radiation to her back or neck/arm.  She denies any [**Month/Day/Year 9140**]
SOB, or dyspnea on exertion from her prior baseline.   She has
been taking her Lovenox injections regularly since her discharge
1 month ago.  She does state that she has had [**Month/Day/Year 9140**]
abdominal distension and describes her LUQ abd pain as
"gurgling" in nature.  Does admit to constipation, with normal
BM over 6 days ago.  Has taken Miralax since Monday without much
improvement.  No hematemesis, diarrhea.
.
On arrival to the ED, VS T97.1, HR145, BP94/49, RR32, satting
90%on NRB.  She received 2L NS, 6mg MS IV, Levaquin 500mg x1,
Ceftriaxone 2g IV x1.  She had an US-guided paracentesis
performed that removed 3L of yellow-green fluid.

MEDICAL HISTORY: 1) Metastatic breast cancer: T2-NO, ER/PR + HER-2/neu (-),
diagnosed [**2158**]
-[**2158**]: She was treated with CMF plus tamoxifen and local
radiation.
-[**2162**]: Treated with epirubicin/taxotere after found to have
adrenal met
-[**2162**]-[**2164**]: On Arimidex, then found to have liver mets
-[**2164**]: Started on Xeloda
-[**2165**]: Treated with taxol
-[**2165**]: Phase II study of [**Doctor First Name **] [**Numeric Identifier 99361**] (tyrosine kinase inhibitor)
-[**2165**]: Cancer metastasized to liver and adrenals
-[**2166**]: Has received 2 treatments with gemcitabine
[**2167-8-28**]: thoracentesis with fluid positive for malignant cells
[**2167-10-16**]: Right VATS, talc pleurodesis by Dr. [**Last Name (STitle) 952**] with
placement of pleur-X cath
[**2167-10-30**]: 3rd dose of Gemcitabine
Currently treated w/ Navelbine, last dose 2 wks ago.
2) Malignant pleural effusion s/p pleurex catheter placed [**9-29**]
removed [**3-31**]
3) Asthma
4) Allergic rhinitis
5) GERD

MEDICATION ON ADMISSION: Lovenox 70mg q12
Zofran 8 mg PO BID
Megestrol 40 [**Hospital1 **]
Protonix 40
Percocet prn
Ativan prn

ALLERGIES: Compazine

PHYSICAL EXAM: VS: T95.5  HR135  BP 104/78  RR 28 o2sat: 96% on 4L NC
GEN: Appears stated age, mild discomfort due to pain, able to
speak in full sentences
HEENT: Anicteric sclera bilat.  PERRL.  EOMi.
NECK: No elevated JVP
CV: Tachycardic.  Nml s1,s2.  No murmurs
RESP: Decreased BS at bases R>L, crackles @ both bases.
Decreased percussion bilat.
CHEST/ABD: Mild TTP over distal ribs on L chest.  No TTP over
abdomen.  No rebound/guarding. No fluid wave.
EXT:  No edema bilat.
NEURO: AAOx3.

FAMILY HISTORY: 1. Breast cancer:  uncle
2. Lung CA:  father, sister

SOCIAL HISTORY: lives with husband, 23 year-old daughter, and 6 month-old
grandson.  [**Name (NI) 4084**] smoked.  No alcohol, cocaine, or IVDU. 

### Response:
{'Secondary malignant neoplasm of retroperitoneum and peritoneum,Secondary malignant neoplasm of bone and bone marrow,Personal history of malignant neoplasm of breast,Asthma, unspecified type, unspecified,Esophageal reflux'}
