CHIEF COMPLAINT: hypotension

PRESENT ILLNESS: 74yo F w/ hx Addison's, HTN, and metastatic spindle cell sarcoma
with recent initiation of chemotherapy (gemcitabine, adriamycin,
prednisone) 1 weeks PTA.  Over the past week, she has been
generally feeling "sick" and tired.  The night prior to
admission, she had one episode of vomiting and had non-bloody
watery/mucousy diarrhea and a mild cough.  The morning of
admission, she had a fever to 101 and came to the ED.  She
otherwise denied any sore throat, dyspnea, chest pain, abdominal
pain, dysuria, new rashes or sick contacts.

MEDICAL HISTORY: 1. Addison disease diagnosed at 37 years of age.
2. Hypercholesterolemia, on Lipitor in the past. The patient
recently stopped the Lipitor, which resulted in improved kidney

MEDICATION ON ADMISSION: atenolol
diovan
isosorbide
lisinopril
prednisone 2.5mg [**Hospital1 **]
aspirin 325
magnesium 60 qd
calcium 600 [**Hospital1 **]
plavix

ALLERGIES: Penicillins / Caffeine / Quinine / Ampicillin

PHYSICAL EXAM: general: alert, pleasant, interactive and in NAD
HEENT: PERRL, EOMI, anicteric, MMM, oropharynx clear,
neck: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
lungs: crackles bilaterally
chest: kyphosis, tenderness at former port-a-cath site;
erythematous, warm and indurated
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or HSM
extremities: no cyanosis, clubbing or edema
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch

FAMILY HISTORY: One brother died at a young age probably secondary to Addison
disease. One brother has prostate cancer. One daughter has
melanoma. Her father had [**Name2 (NI) 499**] cancer. Two brothers have
coronary artery disease. There is no history of
osteoporosis in her family.

SOCIAL HISTORY: The patient used to smoke a pack and a half since [**17**] years of
age until 65 years of age. She does not drink alcohol. She is a
widow. She has 6 children and 18 grandchildren. She currently
lives with her son and his family. She used to work as a
waitress and then she had an office job.
Hypovolemia,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of kidney, except pelvis,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Chronic airway obstruction, not elsewhere classified,Other iatrogenic hypotension,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Disorders of phosphorus metabolism,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Long-term (current) use of steroids,Peripheral vascular disease, unspecified,Personal history of other diseases of circulatory system,Tubal ligation status,Unspecified hearing loss
Hypovolemia,Secondary malig neo lung,Secondary malig neo bone,Malig neopl kidney,Acute kidney failure NOS,Chronic kidney dis NOS,Chr airway obstruct NEC,Iatrogenc hypotnsion NEC,Adv eff antineoplastic,Dis phosphorus metabol,Hypertension NOS,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Long-term use steroids,Periph vascular dis NOS,Hx-circulatory dis NEC,Tubal ligation status,Hearing loss NOS
Admission Date:  [**2108-4-10**]              Discharge Date:   [**2108-4-18**]

Date of Birth:  [**2033-9-26**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Caffeine / Quinine / Ampicillin

Attending:[**First Name3 (LF) 18369**]
Chief Complaint:
hypotension

Major Surgical or Invasive Procedure:
None


History of Present Illness:
74yo F w/ hx Addison's, HTN, and metastatic spindle cell sarcoma
with recent initiation of chemotherapy (gemcitabine, adriamycin,
prednisone) 1 weeks PTA.  Over the past week, she has been
generally feeling "sick" and tired.  The night prior to
admission, she had one episode of vomiting and had non-bloody
watery/mucousy diarrhea and a mild cough.  The morning of
admission, she had a fever to 101 and came to the ED.  She
otherwise denied any sore throat, dyspnea, chest pain, abdominal
pain, dysuria, new rashes or sick contacts.

In the ED, her temp was 101, WBC 0.8, and her SBP was 80.  She
was given 2L IVF NS and her SBP increased to 110.  She was also
given a dose of cefepime and hydrocortisone 100mg.  She was then
transferred to the [**Hospital Unit Name 153**].

Past Medical History:
1. Addison disease diagnosed at 37 years of age.
2. Hypercholesterolemia, on Lipitor in the past. The patient
recently stopped the Lipitor, which resulted in improved kidney

function, which allowed her to enter the chemotherapy trial.
3. Hypotension.
4. Chronic renal insufficiency.
5. COPD.
6. Peripheral vascular disease with bilateral carotid stenoses
status post TIA. In [**8-/2103**], the patient had left upper
extremity weakness and slurred speech with complete resolution
in less than 24 hours.
7. Coronary artery disease (1 vessel). The first cardiac cath
in [**8-/2103**] showed total occlusion of right coronary artery. PCI

failed at that time. However, there were significant
left-to-right collaterals. Second cardiac cath in [**12/2107**] showed
 no progression of her coronary artery disease. 60% diag, 40%lad

8. Preserved EF in past--echo [**2103**]-50%, cath showed normal index
in [**2107**] and RVG [**2108-3-28**] recently with ef of 72%
9. Osteoporosis, on Fosamax for 2 years and then on Forteo for 2
 months, which she stopped at the end of [**Month (only) 359**]. Status post
undisplaced pathological fracture of her right pelvis, both
inferior and superior rami in 09/[**2107**].
10. Metastatic sarcomatoid kidney cancer.
11. Right ear deafness.
12. RAD


Social History:
The patient used to smoke a pack and a half since [**17**] years of
age until 65 years of age. She does not drink alcohol. She is a
widow. She has 6 children and 18 grandchildren. She currently
lives with her son and his family. She used to work as a
waitress and then she had an office job.


Family History:
One brother died at a young age probably secondary to Addison
disease. One brother has prostate cancer. One daughter has
melanoma. Her father had [**Name2 (NI) 499**] cancer. Two brothers have
coronary artery disease. There is no history of
osteoporosis in her family.


Physical Exam:
general: alert, pleasant, interactive and in NAD
HEENT: PERRL, EOMI, anicteric, MMM, oropharynx clear,
neck: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
lungs: crackles bilaterally
chest: kyphosis, tenderness at former port-a-cath site;
erythematous, warm and indurated
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or HSM
extremities: no cyanosis, clubbing or edema
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch


Pertinent Results:
CXR AP [**4-10**]:
1. Pleural and pulmonary metastatic spread of known renal
carcinoma.
2. Bilateral interstitial opacities which may represent
congestive heart failure or infectious process. Clinical
correlation is suggested.

CXR AP [**4-12**]:
1. Prominent interstitial markings. This could be either due to
interstitial pulmonary edema or drug reaction.
2. Multiple pulmonary nodules consistent with known metastases
from renal cell carcinoma.

CXR PA/Lat [**4-16**]:
Emphysema and pulmonary metastases as previously demonstrated.
No evidence of new pneumonia or pulmonary edema.

[**2108-4-10**] 01:00PM BLOOD WBC-0.8*# RBC-3.10* Hgb-9.3* Hct-25.3*#
MCV-82 MCH-29.8 MCHC-36.5* RDW-13.3 Plt Ct-100*#
[**2108-4-16**] 06:36AM BLOOD WBC-31.3*# RBC-3.20* Hgb-9.1* Hct-27.4*
MCV-86 MCH-28.5 MCHC-33.3 RDW-14.0 Plt Ct-73*#
[**2108-4-18**] 06:10AM BLOOD WBC-22.5* RBC-3.15* Hgb-9.2* Hct-27.0*
MCV-86 MCH-29.2 MCHC-34.1 RDW-14.8 Plt Ct-98*
[**2108-4-10**] 01:00PM BLOOD Neuts-4* Bands-0 Lymphs-88* Monos-0
Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2108-4-15**] 06:46AM BLOOD Neuts-62 Bands-12* Lymphs-5* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-9* Myelos-2*
[**2108-4-10**] 01:00PM BLOOD Plt Smr-LOW Plt Ct-100*#
[**2108-4-14**] 07:00AM BLOOD Plt Ct-34*
[**2108-4-11**] 05:52AM BLOOD Gran Ct-40*
[**2108-4-13**] 06:35AM BLOOD Gran Ct-1160*
[**2108-4-10**] 01:00PM BLOOD Glucose-99 UreaN-32* Creat-1.7* Na-133
K-3.7 Cl-99 HCO3-22 AnGap-16
[**2108-4-18**] 06:10AM BLOOD Glucose-101 UreaN-22* Creat-1.5* Na-140
K-3.7 Cl-102 HCO3-30 AnGap-12
[**2108-4-10**] 01:00PM BLOOD ALT-14 AST-18 AlkPhos-78 Amylase-53
TotBili-0.5
[**2108-4-11**] 05:52AM BLOOD ALT-14 AST-14 LD(LDH)-149 AlkPhos-70
TotBili-0.3
[**2108-4-10**] 01:00PM BLOOD Calcium-10.4* Phos-1.0* Mg-0.9*
[**2108-4-18**] 06:10AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.7
[**2108-4-17**] 01:00PM BLOOD PTH-141*
[**2108-4-10**] 01:08PM BLOOD Lactate-3.4*
[**2108-4-10**] 04:49PM BLOOD Lactate-1.4

Brief Hospital Course:
74yo F w/ recent diagnosis of spindle cell sarcoma s/p 1st cycle
of chemotx who presents w/ neutropenic fever, hypotension,
vomiting and fatigue.

Neutropenic fever: She had no obvious infectious etiology, CXR
notable only for intersitial markings c/w pulmonary edema or
drug reaction.  Changed cefepime to ciprofloxacin when she was
afebrile and no longer neutropenic.  Neupogen increased from 300
[**Hospital1 **] to 480 [**Hospital1 **].

Hypotension: This was likely due to poor po, relative adrenal
insufficiency, sepsis, or cardiomyopathy from adriamycin.  Pt
responded to IVF boluses and stress dose steroids which support
sepsis, adrenal insufficiency and hypovolemia.  Hydrocortisone
100 tid was started in ICU given h/o Addison's, and this was
tapered as described below.  After transfer to the floor, she
became more hypertensive, and her home medications were
restarted without further episodes of hypotension.

Pancytopenia: Likely from bone marrow suppression, and she was
continued on neupogen.

Metastatic sarcomatoid kidney cancer: s/p 1st cycle chemotx and
will continue chemotherapy as an outpatient.

Addison's: She had erratic and uncontrolled BP while receiving
chemotherapy. Endocrine service was consulted to help manage her
steroid dosing.  They recommended tapering down hydrocortisone
100 tid to 50 tid for 24hrs, then 25 tid for 24hrs followed by
prednisone 10mg daily.  Arranged for transfer of her endocrine
care to [**Hospital1 18**] physician, [**Name10 (NameIs) **] she will follow up with
endocrinologist after discharge.

CAD: She continued ASA and plavix; held briefly for port
placement.

HTN: Could attribute some fluctuation of BP to endocrine issues.
Restarted lisinopril, atenolol, isosorbide when BP stabilized.

COPD: She was given nebs prn; she had 2L NC O2 requirement w/
ambulation at time of discharge.

CRI: Baseline creatinine is 1.5, and she did not have worsening
renal function during this admission.

PPX: Pt was provided with bowel regimen and heparin SC for
prophylaxis.

Code: full

Medications on Admission:
atenolol
diovan
isosorbide
lisinopril
prednisone 2.5mg [**Hospital1 **]
aspirin 325
magnesium 60 qd
calcium 600 [**Hospital1 **]
plavix


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **]

Discharge Diagnosis:
Primary:
1. Neutropenic Fevers
2. Spindle Cell Sarcoma
3. Addison's disease


Discharge Condition:
Afebrile and no longer neutropenic; still requiring 2L NC for
ambulation.


Discharge Instructions:
Please take all your medications as prescribed. Please restart
your aspirin; plavix should be restarted w/ guidance from Dr.
[**Last Name (STitle) 7047**].

Please follow up in the hematology/oncology clinic as listed
below. Also, an appointment was made for you to see an
endocrinologist here at [**Hospital1 18**]. The information is provided
below.

Please call your doctor or return to the hospital if you develop
fevers, chills, nausea, vomiting, unable to tolerate food or
have any other concerns.

Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3972**] [**Last Name (NamePattern1) **] - endocrinologist.
Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2108-4-20**] 4:00 [**Hospital Ward Name 23**] [**Location (un) 436**].

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2108-4-23**] 1:30

Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2108-4-23**] 1:30



Completed by:[**2108-7-28**]
{'Hypovolemia,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of kidney, except pelvis,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Chronic airway obstruction, not elsewhere classified,Other iatrogenic hypotension,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Disorders of phosphorus metabolism,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Long-term (current) use of steroids,Peripheral vascular disease, unspecified,Personal history of other diseases of circulatory system,Tubal ligation status,Unspecified hearing loss'}


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: hypotension

PRESENT ILLNESS: 74yo F w/ hx Addison's, HTN, and metastatic spindle cell sarcoma
with recent initiation of chemotherapy (gemcitabine, adriamycin,
prednisone) 1 weeks PTA.  Over the past week, she has been
generally feeling "sick" and tired.  The night prior to
admission, she had one episode of vomiting and had non-bloody
watery/mucousy diarrhea and a mild cough.  The morning of
admission, she had a fever to 101 and came to the ED.  She
otherwise denied any sore throat, dyspnea, chest pain, abdominal
pain, dysuria, new rashes or sick contacts.

MEDICAL HISTORY: 1. Addison disease diagnosed at 37 years of age.
2. Hypercholesterolemia, on Lipitor in the past. The patient
recently stopped the Lipitor, which resulted in improved kidney

MEDICATION ON ADMISSION: atenolol
diovan
isosorbide
lisinopril
prednisone 2.5mg [**Hospital1 **]
aspirin 325
magnesium 60 qd
calcium 600 [**Hospital1 **]
plavix

ALLERGIES: Penicillins / Caffeine / Quinine / Ampicillin

PHYSICAL EXAM: general: alert, pleasant, interactive and in NAD
HEENT: PERRL, EOMI, anicteric, MMM, oropharynx clear,
neck: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
lungs: crackles bilaterally
chest: kyphosis, tenderness at former port-a-cath site;
erythematous, warm and indurated
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or HSM
extremities: no cyanosis, clubbing or edema
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch

FAMILY HISTORY: One brother died at a young age probably secondary to Addison
disease. One brother has prostate cancer. One daughter has
melanoma. Her father had [**Name2 (NI) 499**] cancer. Two brothers have
coronary artery disease. There is no history of
osteoporosis in her family.

SOCIAL HISTORY: The patient used to smoke a pack and a half since [**17**] years of
age until 65 years of age. She does not drink alcohol. She is a
widow. She has 6 children and 18 grandchildren. She currently
lives with her son and his family. She used to work as a
waitress and then she had an office job. 

### Response:
{'Hypovolemia,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of kidney, except pelvis,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Chronic airway obstruction, not elsewhere classified,Other iatrogenic hypotension,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Disorders of phosphorus metabolism,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Long-term (current) use of steroids,Peripheral vascular disease, unspecified,Personal history of other diseases of circulatory system,Tubal ligation status,Unspecified hearing loss'}
