CHIEF COMPLAINT: UGIB, ?infection

PRESENT ILLNESS: This is a 67 y.o male with h.o metastatic RCC to the pancreas,
recent ICU course for UGIB (12units pRBCs) who reports sudden
intermittent chills since wednesday for which he took tylenol.
Pt also reports R.side gnawing rib pain, while lying in bed
before the onset of chills. In addition, pt reports dark stools
for the last few days which started after taking "iron pills".
Pt states he went to [**Hospital1 2436**] ED because of a fever of 101.3,
however he felt better and did not want to wait to be seen. He
returned to [**Hospital1 2436**] today and was transferred to [**Hospital1 18**] after
a dose of zosyn, HCT 25. Pt denies headache/dizziness/blurred
vision, URI/cough, sick contacts, CP, +palp when anxious, -abd
pain/n/v/d/brbpr, dysuria/hematuria, joint pain, rash,
paresthesias.
.
At [**Hospital1 18**], pt found to be hypotensive to 75/40, asymptomatic. He
was given 3L IVF, lactate 6.8. HCT 22.8 from a baseline of 35 a
few weeks ago. He was found to have black, guaiac +stool. GI saw
pt, pt s/p stent to pancreatic ampulla, ?blocked  from blood.
Plan is to transfuse, ERCP tomorrow. ED also treated for
possible cholangitis/sepsis and pt was given dose of vanco.
Vitals 99.2, BP 99/66 HR 88 sat 98% on RA. Access 3PIV's 2,
20's, 18. Pt also found to be in ARF.
.
Currently, pt reports that he is anxious.
.

MEDICAL HISTORY: # GIB [**2184**], EGD revealed duodenal ulcer c/w malignancy
# Hypertension.
.
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,

MEDICATION ON ADMISSION: allopurinol 100mg,2 tabs daily
atenolol 50mg daily
diltiazem 180mg, 2 capsules daily
nexium 40mg daily
lisinopril 40mg daily
lorazepam 0.5mg 1-2tabs q6h prn anxiety
compazine 5mg 1-2tab [**Hospital1 **] nausea
acetaminophen 500mg [**11-22**] Q6h prn
ferrous sulfate 325mg 1 daily.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Per admission note:
vitals:T. 96.9, BP 102/65, HR 92, RR 27, sat 96% on RA
gen-nad, lying in bed, appears stated age, cooperative, anxious
HEENT-perrla, eomi, anicteric, mmm, poor dentition
neck-no lad, no JVD, supple
chest-b/l ae no w/c/r
heart-s1s2 +2/6 systolic flow murmur, no r/g
abd-+bs,soft, NT, ND, +irregular hepatomegaly, ~2cm below costal
margin, +abdominal masses
ext-no c/c/e 2+pulses
neuro-aaox3, CN2-12 intact, non-focal.
.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: He is married and has two children. He is retired from GM.
Reports quit smoking [**2186-11-21**], former 1/2ppd, quit ETOH as well in
[**Month (only) **], no drug use
Secondary malignant neoplasm of other digestive organs and spleen,Acute kidney failure, unspecified,Blood in stool,Acidosis,Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Acute posthemorrhagic anemia,Personal history of malignant neoplasm of kidney,Thrombocytopenia, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Procedure not carried out for other reasons,Benign essential hypertension
Sec mal neo GI NEC,Acute kidney failure NOS,Blood in stool,Acidosis,Cholelith w ac cholecyst,Ac posthemorrhag anemia,Hx of kidney malignancy,Thrombocytopenia NOS,Chr blood loss anemia,No proc for reasons NEC,Benign hypertension
Admission Date:  [**2187-9-30**]              Discharge Date:   [**2187-10-8**]

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

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
UGIB, ?infection

Major Surgical or Invasive Procedure:
ERCP
Messenteric catheterization +/- embolization

History of Present Illness:
This is a 67 y.o male with h.o metastatic RCC to the pancreas,
recent ICU course for UGIB (12units pRBCs) who reports sudden
intermittent chills since wednesday for which he took tylenol.
Pt also reports R.side gnawing rib pain, while lying in bed
before the onset of chills. In addition, pt reports dark stools
for the last few days which started after taking "iron pills".
Pt states he went to [**Hospital1 2436**] ED because of a fever of 101.3,
however he felt better and did not want to wait to be seen. He
returned to [**Hospital1 2436**] today and was transferred to [**Hospital1 18**] after
a dose of zosyn, HCT 25. Pt denies headache/dizziness/blurred
vision, URI/cough, sick contacts, CP, +palp when anxious, -abd
pain/n/v/d/brbpr, dysuria/hematuria, joint pain, rash,
paresthesias.
.
At [**Hospital1 18**], pt found to be hypotensive to 75/40, asymptomatic. He
was given 3L IVF, lactate 6.8. HCT 22.8 from a baseline of 35 a
few weeks ago. He was found to have black, guaiac +stool. GI saw
pt, pt s/p stent to pancreatic ampulla, ?blocked  from blood.
Plan is to transfuse, ERCP tomorrow. ED also treated for
possible cholangitis/sepsis and pt was given dose of vanco.
Vitals 99.2, BP 99/66 HR 88 sat 98% on RA. Access 3PIV's 2,
20's, 18. Pt also found to be in ARF.
.
Currently, pt reports that he is anxious.
.

Past Medical History:
# GIB [**2184**], EGD revealed duodenal ulcer c/w malignancy
# Hypertension.
.
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
toSBO 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.
Reports quit smoking [**2186-11-21**], former 1/2ppd, quit ETOH as well in
[**Month (only) **], no drug use

Family History:
Non-contributory


Physical Exam:
Per admission note:
vitals:T. 96.9, BP 102/65, HR 92, RR 27, sat 96% on RA
gen-nad, lying in bed, appears stated age, cooperative, anxious
HEENT-perrla, eomi, anicteric, mmm, poor dentition
neck-no lad, no JVD, supple
chest-b/l ae no w/c/r
heart-s1s2 +2/6 systolic flow murmur, no r/g
abd-+bs,soft, NT, ND, +irregular hepatomegaly, ~2cm below costal
margin, +abdominal masses
ext-no c/c/e 2+pulses
neuro-aaox3, CN2-12 intact, non-focal.
.


Pertinent Results:
[**2187-9-30**] 07:36PM   WBC-5.1 RBC-2.82*# HGB-7.5*# HCT-22.8*#
MCV-81* MCH-26.6* MCHC-32.8 RDW-18.1*
[**2187-9-30**] 07:36PM   NEUTS-73* BANDS-14* LYMPHS-9* MONOS-2 EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2187-9-30**] 07:36PM   PLT SMR-NORMAL PLT COUNT-142*
.
[**2187-9-30**] 07:36PM   HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-OCCASIONAL POLYCHROM-1+ BURR-1+
.
[**2187-9-30**] 07:36PM   PT-15.6* PTT-35.0 INR(PT)-1.4*
.
[**2187-9-30**] 07:36PM   GLUCOSE-78 UREA N-28* CREAT-1.6* SODIUM-141
POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-13* ANION GAP-22*
[**2187-9-30**] 07:36PM   ALT(SGPT)-59* AST(SGOT)-59* LD(LDH)-181
CK(CPK)-14* ALK PHOS-513* TOT BILI-2.5*
[**2187-9-30**] 07:36PM   LIPASE-12
.
[**2187-9-30**] 07:36PM   cTropnT-<0.01
[**2187-9-30**] 07:36PM   CK-MB-NotDone
.
TRENDS:
HCT: Admit -> 23, 27, 22, 25, 27, 34, 28, 27, 26, 22, 28
.
Bands on Diff: Admit -> 14, 10, 7, 0
.
[**2187-9-30**] 07:42PM BLOOD Lactate-6.8*
[**2187-10-1**] 02:52AM BLOOD Lactate-4.8*
[**2187-10-1**] 05:30AM BLOOD Lactate-3.3*
[**2187-10-1**] 02:22PM BLOOD Lactate-1.8
.
ECG:sinus, poor baseline, similar morphology to [**2187-8-21**] EKG.
.
Imaging:
CXR: [**2187-9-30**]:
Added density behind the left heart border in the left lower
lobe may
represent a focus of pneumonic consolidation; alternatively
metastases from the known metastatic renal cell cancer cannot be
entirely excluded. CT would be of benefit for further
evaluation.
A CBD stent is seen in the upper abdomen.
.
Liver U/S [**2187-9-30**]:
Increase in size and number of hepatic mets. CBD or stent not
seen. Small perihepatic ascites. Portal vein remains occluded
with numerous collaterals. Gallladder wall thickening and edema
but no focal tenderness during scanning. Large hypoechoic mass
in the region of the pancreatic head not well assessed due to
overlying bowel gas.
"findings equivocal for cholecystitis, stones"
.
[**2187-10-1**] ERCP/Biliary:
IMPRESSION:
1. No filling defects within previously placed metallic common
bile duct
stent.
2. Smooth impression on the common bile duct, proximal to stent,
suggests
extrinsic compression. Correlate with real-time findings.
Please refer to GI procedural note for further details.
.
[**2187-10-3**] MESSENTERIC CATHETERIZAION +/- EMBOLIZATION:
***Prelim Report***
Gastrointestinal arteriograms demonstrated massive tumor
staining from
multiple feeding arteries originating from celiac artery,
superior mesenteric artery, and isolated pancreatic artery
without active ______.


Brief Hospital Course:
67 y.o male with metastatic RCC who presents with HCT drop,
melena, recent fever, hypotension.
.
#melena/HCT drop - Pt has h.o GIB in past that were secondary to
bleeding metastasis. Pt had recent admit to MICU course [**7-30**]
where angiography was performed to stop bleeding. Hct on admit
was 22.8, down from 35 on discharge. Patient underwent ERCP in
which showed ulcerated mass at duodenum, able to temporarily
stem blood flow. On day 3 of ICU stay he had more melena and was
taken by IR for messenteric catheterization +/- embolization,
but were unable to isolate source of bleeding. Melena continued
and ERCP, IR and surgery say pt is not eligible for further
interventions to stop the bleeding.
.
Pt continued to be transfused units of PRBC while H/H was being
followed.  This was consistent with patient's stated goals of
living long enough to make it to hospice care, where he can be
closer to family.
.
# Infection - Pt with fever, normal white count but with
bandemia, recent RUQ/rib pain. Slightly elevated LFT's, elevated
bili -> RUQ u/s finding gallbladder wall thickening and edema,
"possible cholecystitis". Potentially transient cholangitis. Pt
completed a total of 7 days of Vancomycin and Pip/Tazo.
.
# Metastatic RCC - Pain controlled. Heme met with family offered
chemo for one final round but with the caution that this could
make the duodenal met bleed faster. The patient and family did
not want to pursue this.
.
# Lactic acidosis - likely from poor perfusion secondary to
recent hypotension and infection. Could also be secondary to
metastatic disease. Resolved within 2 days.
.
#ARF - baseline 0.9-1.0, admitted at 1.6. Likely prerenal in the
setting of hypotension, hypovolemia. Resolved with hydration.
.
#HTN-currently normotensive, hold home anti-HTN medications.
.
# Anxiety
- receiving scheduled ativan per pt request.
.
# Thrombocytopenia:
- PLT count now improving
- no heparin d/t bleed
- HIT Ab negative
- Transfused prn for bleeding
.
CODE: DNR/DNI
DISPO: discharged to hospice care:
[**Last Name (un) 1502**] Family Hospice House - [**Location (un) **]. [**Telephone/Fax (1) 21227**]

Medications on Admission:
allopurinol 100mg,2 tabs daily
atenolol 50mg daily
diltiazem 180mg, 2 capsules daily
nexium 40mg daily
lisinopril 40mg daily
lorazepam 0.5mg 1-2tabs q6h prn anxiety
compazine 5mg 1-2tab [**Hospital1 **] nausea
acetaminophen 500mg [**11-22**] Q6h prn
ferrous sulfate 325mg 1 daily.


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
4. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
8. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Last Name (un) 1502**] Family Hospice House [**Location (un) **]

Discharge Diagnosis:
# Gastrointestinal bleed; ongoing
# Cholecystitis/Cholangitis
# Metastatic renal cell carcinoma
# Acute renal failure; resolved
# Thrombocytopenia


Discharge Condition:
poor; dying.


Discharge Instructions:
Patient is being discharged to hospice.
Please take medications as necessary for patient comfort.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-10-17**] 3:30
Provider: [**Name10 (NameIs) 11021**] [**Name11 (NameIs) 11022**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-10-17**] 3:30
{'Secondary malignant neoplasm of other digestive organs and spleen,Acute kidney failure, unspecified,Blood in stool,Acidosis,Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Acute posthemorrhagic anemia,Personal history of malignant neoplasm of kidney,Thrombocytopenia, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Procedure not carried out for other reasons,Benign essential hypertension'}


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: UGIB, ?infection

PRESENT ILLNESS: This is a 67 y.o male with h.o metastatic RCC to the pancreas,
recent ICU course for UGIB (12units pRBCs) who reports sudden
intermittent chills since wednesday for which he took tylenol.
Pt also reports R.side gnawing rib pain, while lying in bed
before the onset of chills. In addition, pt reports dark stools
for the last few days which started after taking "iron pills".
Pt states he went to [**Hospital1 2436**] ED because of a fever of 101.3,
however he felt better and did not want to wait to be seen. He
returned to [**Hospital1 2436**] today and was transferred to [**Hospital1 18**] after
a dose of zosyn, HCT 25. Pt denies headache/dizziness/blurred
vision, URI/cough, sick contacts, CP, +palp when anxious, -abd
pain/n/v/d/brbpr, dysuria/hematuria, joint pain, rash,
paresthesias.
.
At [**Hospital1 18**], pt found to be hypotensive to 75/40, asymptomatic. He
was given 3L IVF, lactate 6.8. HCT 22.8 from a baseline of 35 a
few weeks ago. He was found to have black, guaiac +stool. GI saw
pt, pt s/p stent to pancreatic ampulla, ?blocked  from blood.
Plan is to transfuse, ERCP tomorrow. ED also treated for
possible cholangitis/sepsis and pt was given dose of vanco.
Vitals 99.2, BP 99/66 HR 88 sat 98% on RA. Access 3PIV's 2,
20's, 18. Pt also found to be in ARF.
.
Currently, pt reports that he is anxious.
.

MEDICAL HISTORY: # GIB [**2184**], EGD revealed duodenal ulcer c/w malignancy
# Hypertension.
.
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,

MEDICATION ON ADMISSION: allopurinol 100mg,2 tabs daily
atenolol 50mg daily
diltiazem 180mg, 2 capsules daily
nexium 40mg daily
lisinopril 40mg daily
lorazepam 0.5mg 1-2tabs q6h prn anxiety
compazine 5mg 1-2tab [**Hospital1 **] nausea
acetaminophen 500mg [**11-22**] Q6h prn
ferrous sulfate 325mg 1 daily.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Per admission note:
vitals:T. 96.9, BP 102/65, HR 92, RR 27, sat 96% on RA
gen-nad, lying in bed, appears stated age, cooperative, anxious
HEENT-perrla, eomi, anicteric, mmm, poor dentition
neck-no lad, no JVD, supple
chest-b/l ae no w/c/r
heart-s1s2 +2/6 systolic flow murmur, no r/g
abd-+bs,soft, NT, ND, +irregular hepatomegaly, ~2cm below costal
margin, +abdominal masses
ext-no c/c/e 2+pulses
neuro-aaox3, CN2-12 intact, non-focal.
.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: He is married and has two children. He is retired from GM.
Reports quit smoking [**2186-11-21**], former 1/2ppd, quit ETOH as well in
[**Month (only) **], no drug use 

### Response:
{'Secondary malignant neoplasm of other digestive organs and spleen,Acute kidney failure, unspecified,Blood in stool,Acidosis,Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Acute posthemorrhagic anemia,Personal history of malignant neoplasm of kidney,Thrombocytopenia, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Procedure not carried out for other reasons,Benign essential hypertension'}
