CHIEF COMPLAINT: Palpitations

PRESENT ILLNESS: This is a 79 year-old female with h/o hypothyroidism, CVA in
[**2186**], HTN, hyperlipidemia who presents with weakness,
palpitations, and feeling presyncopal when upright. She reports
weight loss over last few months, dropping two dress sizes since
[**Month (only) 116**], with minimal PO intake over the past few days. She denies
diarrhea, BRBPR, fevers, chills, SOB, chest pain. She has no
history of colonoscopy.
.
In the ED, VS T 97.2 BP 108/44 HR 74 RR 16 POx 100% on RA.
Orthostatics positive by HR and BP dropping to 84/36 on
standing. Guaiac positive stool in ED. NG leavage negative.
Patient received 2 units FFP, 2 units PRBCs, 10mg po and 1mg IV
vitamin K, IV Protonix, and 1500cc NS. GI contact[**Name (NI) **] in the [**Name (NI) **]
with plan for colonscopy/EGD when INR reversed. 2 large bore IVs
placed.
.
ROS: The patient denies any fevers, chills, nausea, vomiting,
abdominal pain, diarrhea, constipation, melena, hematochezia,
chest pain, shortness of breath, orthopnea, PND, lower extremity
edema, cough, urinary frequency, urgency, dysuria, gait
unsteadiness, focal weakness, vision changes, headache, rash or
skin changes.

MEDICAL HISTORY: B12 Deficiency
Hypertension
Hyperlipidemia
S/P CVA [**2186**] without residual deficits
Hypothyroidism
Cataract surgery [**2188**]

MEDICATION ON ADMISSION: Coumadin  5 mg qd  except 2.5 mg on Sunday
atenolol 50mg PO qd
HCTZ 25mg po qd
atorvastatin 40mg PO qd
levothyroxine 100mcg PO 1tab qd 6d/week
ASA 81mg PO qd
folic acid .4mg PO qd
cyanocobalamin 1,000mcg/ml sln, 1cc every other mo.
Ca-citrate+ vitamin D+ Mag (OTC)
Omega 3 fatty acid (OTC)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.5 BP: 108/54 HR:77 RR:18 O2Sat: 100% on RA
GEN: Pale, in no acute distress
HEENT: NCAT, EOMI, PERRL, sclera anicteric, conj pallor, no
epistaxis or rhinorrhea, MMM, OP Clear
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses, no rebound or
guarding
EXT: No C/C/E
NEURO: A&Ox3. Interactive and appropriate.
SKIN: No jaundice, cyanosis. No ecchymoses. Dry, cracked skin
throughout.

FAMILY HISTORY: CAD in parents, sibling. [**Name (NI) 10060**] mom, sister.

SOCIAL HISTORY: lives w/husband in [**Name (NI) 10059**]. Denies etoh, tobacco, drugs. Retired
flight attendant.
Malignant neoplasm of other specified sites of stomach,Hemorrhage of gastrointestinal tract, unspecified,Secondary malignant neoplasm of retroperitoneum and peritoneum,Acute posthemorrhagic anemia,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Other B-complex deficiencies,Other and unspecified hyperlipidemia,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Orthostatic hypotension,Long-term (current) use of anticoagulants,Hypovolemia
Malig neopl stomach NEC,Gastrointest hemorr NOS,Sec mal neo peritoneum,Ac posthemorrhag anemia,Hypothyroidism NOS,Hypertension NOS,B-complex defic NEC,Hyperlipidemia NEC/NOS,Cholelithiasis NOS,Orthostatic hypotension,Long-term use anticoagul,Hypovolemia
Admission Date:  [**2190-8-16**]              Discharge Date:   [**2190-8-20**]

Date of Birth:  [**2111-5-18**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Palpitations

Major Surgical or Invasive Procedure:
EGD

History of Present Illness:
This is a 79 year-old female with h/o hypothyroidism, CVA in
[**2186**], HTN, hyperlipidemia who presents with weakness,
palpitations, and feeling presyncopal when upright. She reports
weight loss over last few months, dropping two dress sizes since
[**Month (only) 116**], with minimal PO intake over the past few days. She denies
diarrhea, BRBPR, fevers, chills, SOB, chest pain. She has no
history of colonoscopy.
.
In the ED, VS T 97.2 BP 108/44 HR 74 RR 16 POx 100% on RA.
Orthostatics positive by HR and BP dropping to 84/36 on
standing. Guaiac positive stool in ED. NG leavage negative.
Patient received 2 units FFP, 2 units PRBCs, 10mg po and 1mg IV
vitamin K, IV Protonix, and 1500cc NS. GI contact[**Name (NI) **] in the [**Name (NI) **]
with plan for colonscopy/EGD when INR reversed. 2 large bore IVs
placed.
.
ROS: The patient denies any fevers, chills, nausea, vomiting,
abdominal pain, diarrhea, constipation, melena, hematochezia,
chest pain, shortness of breath, orthopnea, PND, lower extremity
edema, cough, urinary frequency, urgency, dysuria, gait
unsteadiness, focal weakness, vision changes, headache, rash or
skin changes.

Past Medical History:
B12 Deficiency
Hypertension
Hyperlipidemia
S/P CVA [**2186**] without residual deficits
Hypothyroidism
Cataract surgery [**2188**]


Social History:
lives w/husband in [**Name (NI) 10059**]. Denies etoh, tobacco, drugs. Retired
flight attendant.

Family History:
CAD in parents, sibling. [**Name (NI) 10060**] mom, sister.

Physical Exam:
Vitals: T: 98.5 BP: 108/54 HR:77 RR:18 O2Sat: 100% on RA
GEN: Pale, in no acute distress
HEENT: NCAT, EOMI, PERRL, sclera anicteric, conj pallor, no
epistaxis or rhinorrhea, MMM, OP Clear
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses, no rebound or
guarding
EXT: No C/C/E
NEURO: A&Ox3. Interactive and appropriate.
SKIN: No jaundice, cyanosis. No ecchymoses. Dry, cracked skin
throughout.


Pertinent Results:
[**2190-8-16**] 11:50AM   PT-25.2* PTT-26.1 INR(PT)-2.5*
[**2190-8-16**] 11:50AM   PLT COUNT-342
[**2190-8-16**] 11:50AM   NEUTS-77.5* LYMPHS-17.7* MONOS-3.9 EOS-0.6
BASOS-0.3
[**2190-8-16**] 11:50AM   WBC-11.4* RBC-1.92*# HGB-6.0*# HCT-17.7*#
MCV-92 MCH-31.4 MCHC-34.0 RDW-17.1*
[**2190-8-16**] 11:50AM   CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-1.8
[**2190-8-16**] 11:50AM   CK-MB-NotDone
[**2190-8-16**] 11:50AM   cTropnT-<0.01
[**2190-8-16**] 11:50AM   LIPASE-66*
[**2190-8-16**] 11:50AM   ALT(SGPT)-22 AST(SGOT)-30 CK(CPK)-50 ALK
PHOS-53 TOT BILI-0.3
[**2190-8-16**] 11:50AM   estGFR-Using this
[**2190-8-16**] 11:50AM   GLUCOSE-104 UREA N-43* CREAT-1.2* SODIUM-140
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-29 ANION GAP-12
[**2190-8-16**] 01:45PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2190-8-16**] 01:45PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017

[**2190-8-17**] CT abd/pelvis)
IMPRESSION:

1. Large infiltrative mass arising from the lesser curvature of
the stomach,
with possible invasion of the left hepatic lobe and pancreas -
findings are
consistent with extensive gastric malignancy. There is also
omental caking
and intra- abdominal fluid consistent with intraperitoneal
metastases.

2. Multiple large gallstones within a non-distended gallbladder.


3. Prominence of the CBD with mild intrahepatic biliary ductal
dilatation,
without definite distal CBD obstruction. Clinical correlation is
recommended.

4. Small bilateral pleural effusions.

[**8-17**] Pathology:
Stomach mass biopsy:
1.  Adenocarcinoma, diffuse cell type.
2.  Immunostains of the tumor are positive for cytokeratin
cocktail and focally positive for CD68 with satisfactory
controls.
3.  Special stains (PAS-D and mucicarmine) of the tumor cells
are faintly positive for mucin.
4.  Chronic mildly active inflammation of the adjacent mucosa.
[**Doctor Last Name 6311**] stain is negative for H. pylori, with satisfactory
control.




Brief Hospital Course:
This is a 79 year-old female with a history of HTN, embolic CVA
on coumadin, hypothyroidism who presented with weakness,
palpitations, orthostasis and unintentional weight loss found to
have +guaiac stools  and HCT of 17 in ED. Patient with very low
hematocrit, elevated INR of 2.5 on admission and blood in her
stool raised initial concern of active GI bleeding, possibly due
to undiagnosed malignancy. The patient was transfused 4 units
PRBC in ICU and underwent upper endoscopy revealing large
gastric adenocarcinoma with CT revealing evidence of likely
metastatic spread to left hepatic lobe, pancreas and omental
caking.

# Metastatic gastric adenocarcinoma)
The patient was seen by the GI, oncology, radiation oncology and
palliative care services. The patient repetedly stated that she
did not any aggressive interventions.  She did not want IR
embolization if she had a rapid GI bleed.  She is not currently
a candidate for palliative radiation XRT per radiation oncology.
 She will f/u with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4149**] of palliative care.  She did not
want hospice at this time.

# Anemia of acute blood loss)  Stable after PRBC transfusions.

# Palpitations: Patient currently without palpitations, issue
appears to have resolved. Likely initially secondary to
hypotension and orthostasis given poor PO intake. Unlikely to be
hyperthyroid given elevated TSH. Troponins negative x2.
# Hypotension: Patient currently normotensive (resolved)

# CVA: Embolic CVA in [**2186**], on coumadin. INR 2.5 on admission
which is within goal range, however in setting of significant GI
bleed from her gastric cancer permanently discontinued her
coumadin and aspirin.

# Hypertension: patient on atenolol and hctz as outpatient.
Restarted on discharge.
.
# Hyperlipidemia:

- continue home statin

.
# Hypothyroidism: Patient has been on levothyroxine for some
time. TSH 7 which is slightly elevated. appears that patient on
100 of levothroxyine at home 6 times a week, will change to
daily in the setting of elevated TSH, would also consider
uptitration of medication
-cont  levothyroxine as above


Medications on Admission:
Coumadin  5 mg qd  except 2.5 mg on Sunday
atenolol 50mg PO qd
HCTZ 25mg po qd
atorvastatin 40mg PO qd
levothyroxine 100mcg PO 1tab qd 6d/week
ASA 81mg PO qd
folic acid .4mg PO qd
cyanocobalamin 1,000mcg/ml sln, 1cc every other mo.
Ca-citrate+ vitamin D+ Mag (OTC)
Omega 3 fatty acid (OTC)


Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO every
other month: OF NOTE, PATIENT WAS receiving cyanocobalamin 1000
mcg/ml sln every other month.
7. omega three  Sig: One (1) tab  once a day: take per home
dose.
8. Calcium Citrate + D with Mag 250-40-5-125 mg-mg-mg-unit
Tablet Sig: One (1) Tablet PO once a day: take per prior home
dosing.


Discharge Disposition:
Home

Discharge Diagnosis:
Metastatic Gastric Adenocarcinoma
GI Bleed
Anemia, Acute Blood Loss

Discharge Condition:
Vital Signs Stable

Discharge Instructions:
Return to Emergency Department if having active bright red blood
from the rectum, dizziness, abdominal pain, protracted nausea
and vomitting.

Followup Instructions:
Patient to arrange f/u appointment with PCP [**Last Name (NamePattern4) **] 2 week Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 4775**].

Patient to f/u with palliative care [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4149**].  [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10061**]
office to call patient with appointment.
{'Malignant neoplasm of other specified sites of stomach,Hemorrhage of gastrointestinal tract, unspecified,Secondary malignant neoplasm of retroperitoneum and peritoneum,Acute posthemorrhagic anemia,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Other B-complex deficiencies,Other and unspecified hyperlipidemia,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Orthostatic hypotension,Long-term (current) use of anticoagulants,Hypovolemia'}


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: Palpitations

PRESENT ILLNESS: This is a 79 year-old female with h/o hypothyroidism, CVA in
[**2186**], HTN, hyperlipidemia who presents with weakness,
palpitations, and feeling presyncopal when upright. She reports
weight loss over last few months, dropping two dress sizes since
[**Month (only) 116**], with minimal PO intake over the past few days. She denies
diarrhea, BRBPR, fevers, chills, SOB, chest pain. She has no
history of colonoscopy.
.
In the ED, VS T 97.2 BP 108/44 HR 74 RR 16 POx 100% on RA.
Orthostatics positive by HR and BP dropping to 84/36 on
standing. Guaiac positive stool in ED. NG leavage negative.
Patient received 2 units FFP, 2 units PRBCs, 10mg po and 1mg IV
vitamin K, IV Protonix, and 1500cc NS. GI contact[**Name (NI) **] in the [**Name (NI) **]
with plan for colonscopy/EGD when INR reversed. 2 large bore IVs
placed.
.
ROS: The patient denies any fevers, chills, nausea, vomiting,
abdominal pain, diarrhea, constipation, melena, hematochezia,
chest pain, shortness of breath, orthopnea, PND, lower extremity
edema, cough, urinary frequency, urgency, dysuria, gait
unsteadiness, focal weakness, vision changes, headache, rash or
skin changes.

MEDICAL HISTORY: B12 Deficiency
Hypertension
Hyperlipidemia
S/P CVA [**2186**] without residual deficits
Hypothyroidism
Cataract surgery [**2188**]

MEDICATION ON ADMISSION: Coumadin  5 mg qd  except 2.5 mg on Sunday
atenolol 50mg PO qd
HCTZ 25mg po qd
atorvastatin 40mg PO qd
levothyroxine 100mcg PO 1tab qd 6d/week
ASA 81mg PO qd
folic acid .4mg PO qd
cyanocobalamin 1,000mcg/ml sln, 1cc every other mo.
Ca-citrate+ vitamin D+ Mag (OTC)
Omega 3 fatty acid (OTC)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.5 BP: 108/54 HR:77 RR:18 O2Sat: 100% on RA
GEN: Pale, in no acute distress
HEENT: NCAT, EOMI, PERRL, sclera anicteric, conj pallor, no
epistaxis or rhinorrhea, MMM, OP Clear
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses, no rebound or
guarding
EXT: No C/C/E
NEURO: A&Ox3. Interactive and appropriate.
SKIN: No jaundice, cyanosis. No ecchymoses. Dry, cracked skin
throughout.

FAMILY HISTORY: CAD in parents, sibling. [**Name (NI) 10060**] mom, sister.

SOCIAL HISTORY: lives w/husband in [**Name (NI) 10059**]. Denies etoh, tobacco, drugs. Retired
flight attendant. 

### Response:
{'Malignant neoplasm of other specified sites of stomach,Hemorrhage of gastrointestinal tract, unspecified,Secondary malignant neoplasm of retroperitoneum and peritoneum,Acute posthemorrhagic anemia,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Other B-complex deficiencies,Other and unspecified hyperlipidemia,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Orthostatic hypotension,Long-term (current) use of anticoagulants,Hypovolemia'}
