CHIEF COMPLAINT: weakness, anemia

PRESENT ILLNESS: 79 yo F with GI stromal tumor most recently on Sutent with
recent CT scan showing progression of disease now on sorafenib,
past admissions for intraperitoneal bleed [**2-14**] omental metastasis
while on coumadin (now off), DM, hypothyroidism, atrial
fibrillation, dCHF who presented to the ED yesterday ([**2154-4-14**])
with fatigue, weakness and sob for three days. Patient was found
to have a hematocrit of 16 (baseline 28-30). She was
hemodynamically stable and transfused 2 units of pRBCs. Patient
was guaiac negative. She had a CT of the abdomen with contrast
which showed hemoperitoneum with the origin of hemorrhage likely
near known soft tissue mass. Surgery was contact[**Name (NI) **] and said that
she was not an operative candidate. IR was consulted, reviewed
the CT, did not see any evidence of active extravasation and
felt that there was no indication for intervention at this time.
Patient was admitted to the [**Hospital Unit Name 153**] for further monitoring. Patient
was transfused a third unit of packed cells early this am and
kept NPO. During transfusion of third unit of packed cells
patient developed a red pruritic rash thought to be a
transfusion reaction, given iv benadryl. She had a new 2L oxygen
requirement which was thought to be due to increased cardiac
demand due to severe acute anemia. She was found to have new TWI
on ECG for which cardiac biomarkers were checked and negative x
3. Patient's sorafenib was held and per discussion with oncology
fellow, patient to restart at home after discharge. Patient had
mild [**Last Name (un) **] thought to be prerenal that improved with transfusions.
Patient started on clears today, hematocrit continued to
increase to 26.9 then 30.7 this evening.
.
Of note, patient had a recent admission [**12-24**] for acute on
chronic diastolic heart failure which improved with diuresis.
Also with multiple admissions in [**2153**] for intraperitoneal bleed
due to omental metastasis in the setting of coumadin use for
atrial fibrillation. Patient also has a right medial thigh wound
that has been persistently open after cellulitis in [**2153**].
.
Currently patient denies any abdominal pain. SOB and fatigue
have improved. Her oxygen has been weaned to off. Patient does
have constipation with last BM 2 days ago. Also continues to
have pruritis and red rash, managed with sarna lotion and one
dose of po benadryl today.
.
ROS as per HPI, 10 pt ROS otherwise negative

MEDICAL HISTORY: - RIGHT MEDIAL THIGH WOUND: Developed after developing severe
cellulitis in late [**2153**] and underwent a biopsy of the area
[**2153-11-22**]. Did not heal due to DM and chemo, as was on sudent.
Was on sunitinib and this was put on hold to allow further
healing, but has since restarted low dose. Measurement of wound
was 8 x 0.5cm. The first 4 cm on the right was still open with
hypergranulation tissue present on [**12-26**].
- GIST: Diagnosed in [**2143**], treated with surgery and multiple
intermittant courses of gleevac, complicated by side effects.
She had partial gastrectomy and GIST resection in [**2143**], and a
GIST omental metastasis resection in 03/[**2153**]. Noted to have GIB
in [**Month (only) 205**] and [**2153-8-13**] due to enlarging GIST lesions. Started
on Sutent since [**2153-10-1**]. Currently on low dose Sutent
following poor wound healing as above.
- ANEMIA, iron deficiency
- Paroxysmal ATRIAL FIBRILLATION, not on AC due to multiple RP
bleeds
- CONGESTIVE HEART FAILURE, Diastolic, ef >70%.
- DIABETES MELLITUS
- Chronic DYSPNEA, exertional
- HYPERTENSION
- HYPOTHYROIDISM
- CVA in [**2136**], Residual R hemiparesis and intermittent aphasia,
- TIA in [**2148**]
- Status post knee surgery in [**2137**].

MEDICATION ON ADMISSION: diltiazem 180mg ER daily Am
furosemide 60mg daily
levothyroxine 200mcg daily
oxycodone - unclear if currently taking
- rx is for 5mg q4-6hrs for pain prn
sitagliptin 100mg tab daily
sunitinib 25mg daily
timolol 0.5% drops right eye [**Hospital1 **]
zolpidem 10mg qhs prn insomnia
asa 81mg daily
docusate
senna

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: 98.5 130/78 97P 18 100%RA
Appearance: alert, NAD, obese
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2 -m/r/g, tr peripheral edema, 1+ dp/pt bilaterally
Pulm: clear bilaterally, diminished at bases
Abd: soft, nt, nd, +bs
Msk: 5/5 strength throughout
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: diffuse blanching confluent erythematous rash involving
back, upper arms and upper chest
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]

FAMILY HISTORY: No family history of cancer, lung disease or heart disease. +
for DM.

SOCIAL HISTORY: Lives alone. Has 2 daughters. Moved from [**Country **] in [**2137**]. Has
grandchildren who visit her.
-Tobacco history:  negative
-ETOH:  negative
-Illicit drugs: negative
Neoplasm of uncertain behavior of connective and other soft tissue,Hemoperitoneum (nontraumatic),Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Chronic diastolic heart failure,Iron deficiency anemia secondary to blood loss (chronic),Atrial fibrillation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Constipation, unspecified,Rash and other nonspecific skin eruption,Long-term (current) use of aspirin
Unc behav neo soft tissu,Hemoperitoneum,Ac posthemorrhag anemia,Acute kidney failure NOS,Late ef-hemplga side NOS,Chr diastolic hrt fail,Chr blood loss anemia,Atrial fibrillation,Hypertension NOS,DMII wo cmp nt st uncntr,Hypothyroidism NOS,Constipation NOS,Nonspecif skin erupt NEC,Long-term use of aspirin
Admission Date:  [**2154-4-14**]              Discharge Date:   [**2154-4-18**]

Date of Birth:  [**2074-11-10**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
weakness, anemia

Major Surgical or Invasive Procedure:
none


History of Present Illness:
79 yo F with GI stromal tumor most recently on Sutent with
recent CT scan showing progression of disease now on sorafenib,
past admissions for intraperitoneal bleed [**2-14**] omental metastasis
while on coumadin (now off), DM, hypothyroidism, atrial
fibrillation, dCHF who presented to the ED yesterday ([**2154-4-14**])
with fatigue, weakness and sob for three days. Patient was found
to have a hematocrit of 16 (baseline 28-30). She was
hemodynamically stable and transfused 2 units of pRBCs. Patient
was guaiac negative. She had a CT of the abdomen with contrast
which showed hemoperitoneum with the origin of hemorrhage likely
near known soft tissue mass. Surgery was contact[**Name (NI) **] and said that
she was not an operative candidate. IR was consulted, reviewed
the CT, did not see any evidence of active extravasation and
felt that there was no indication for intervention at this time.
Patient was admitted to the [**Hospital Unit Name 153**] for further monitoring. Patient
was transfused a third unit of packed cells early this am and
kept NPO. During transfusion of third unit of packed cells
patient developed a red pruritic rash thought to be a
transfusion reaction, given iv benadryl. She had a new 2L oxygen
requirement which was thought to be due to increased cardiac
demand due to severe acute anemia. She was found to have new TWI
on ECG for which cardiac biomarkers were checked and negative x
3. Patient's sorafenib was held and per discussion with oncology
fellow, patient to restart at home after discharge. Patient had
mild [**Last Name (un) **] thought to be prerenal that improved with transfusions.
Patient started on clears today, hematocrit continued to
increase to 26.9 then 30.7 this evening.
.
Of note, patient had a recent admission [**12-24**] for acute on
chronic diastolic heart failure which improved with diuresis.
Also with multiple admissions in [**2153**] for intraperitoneal bleed
due to omental metastasis in the setting of coumadin use for
atrial fibrillation. Patient also has a right medial thigh wound
that has been persistently open after cellulitis in [**2153**].
.
Currently patient denies any abdominal pain. SOB and fatigue
have improved. Her oxygen has been weaned to off. Patient does
have constipation with last BM 2 days ago. Also continues to
have pruritis and red rash, managed with sarna lotion and one
dose of po benadryl today.
.
ROS as per HPI, 10 pt ROS otherwise negative


Past Medical History:
- RIGHT MEDIAL THIGH WOUND: Developed after developing severe
cellulitis in late [**2153**] and underwent a biopsy of the area
[**2153-11-22**]. Did not heal due to DM and chemo, as was on sudent.
Was on sunitinib and this was put on hold to allow further
healing, but has since restarted low dose. Measurement of wound
was 8 x 0.5cm. The first 4 cm on the right was still open with
hypergranulation tissue present on [**12-26**].
- GIST: Diagnosed in [**2143**], treated with surgery and multiple
intermittant courses of gleevac, complicated by side effects.
She had partial gastrectomy and GIST resection in [**2143**], and a
GIST omental metastasis resection in 03/[**2153**]. Noted to have GIB
in [**Month (only) 205**] and [**2153-8-13**] due to enlarging GIST lesions. Started
on Sutent since [**2153-10-1**]. Currently on low dose Sutent
following poor wound healing as above.
- ANEMIA, iron deficiency
- Paroxysmal ATRIAL FIBRILLATION, not on AC due to multiple RP
bleeds
- CONGESTIVE HEART FAILURE, Diastolic, ef >70%.
- DIABETES MELLITUS
- Chronic DYSPNEA, exertional
- HYPERTENSION
- HYPOTHYROIDISM
- CVA in [**2136**], Residual R hemiparesis and intermittent aphasia,
- TIA in [**2148**]
- Status post knee surgery in [**2137**].

Social History:
Lives alone. Has 2 daughters. Moved from [**Country **] in [**2137**]. Has
grandchildren who visit her.
-Tobacco history:  negative
-ETOH:  negative
-Illicit drugs: negative


Family History:
No family history of cancer, lung disease or heart disease. +
for DM.

Physical Exam:
VS: 98.5 130/78 97P 18 100%RA
Appearance: alert, NAD, obese
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2 -m/r/g, tr peripheral edema, 1+ dp/pt bilaterally
Pulm: clear bilaterally, diminished at bases
Abd: soft, nt, nd, +bs
Msk: 5/5 strength throughout
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: diffuse blanching confluent erythematous rash involving
back, upper arms and upper chest
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]


Pertinent Results:
[**2154-4-17**] 06:10PM BLOOD Hct-26.8*
[**2154-4-17**] 07:05AM BLOOD WBC-2.9* RBC-2.62* Hgb-8.2* Hct-26.6*
MCV-102* MCH-31.4 MCHC-30.9* RDW-20.0* Plt Ct-230
[**2154-4-16**] 10:15PM BLOOD Hct-25.8*
[**2154-4-16**] 02:35PM BLOOD Hct-27.9*
[**2154-4-16**] 07:08AM BLOOD WBC-3.3* RBC-2.96* Hgb-9.4* Hct-29.6*
MCV-100* MCH-31.9 MCHC-31.9 RDW-20.2* Plt Ct-211
[**2154-4-15**] 04:28PM BLOOD Hct-30.7*
[**2154-4-15**] 11:57AM BLOOD Hct-28.2*
[**2154-4-15**] 05:30AM BLOOD WBC-2.5* RBC-2.73* Hgb-8.9*# Hct-26.9*
MCV-99* MCH-32.7* MCHC-33.2 RDW-20.1* Plt Ct-185
[**2154-4-14**] 10:00PM BLOOD WBC-3.1* RBC-2.24*# Hgb-7.1*# Hct-22.4*#
MCV-100*# MCH-31.8 MCHC-31.8# RDW-20.8* Plt Ct-198
[**2154-4-14**] 02:00PM BLOOD WBC-3.7* RBC-1.54*# Hgb-4.7*# Hct-16.7*#
MCV-108* MCH-30.2 MCHC-27.9* RDW-20.9* Plt Ct-230
[**2154-4-14**] 10:00PM BLOOD WBC-3.1* RBC-2.24*# Hgb-7.1*# Hct-22.4*#
MCV-100*# MCH-31.8 MCHC-31.8# RDW-20.8* Plt Ct-198
[**2154-4-14**] 02:00PM BLOOD WBC-3.7* RBC-1.54*# Hgb-4.7*# Hct-16.7*#
MCV-108* MCH-30.2 MCHC-27.9* RDW-20.9* Plt Ct-230
[**2154-4-17**] 07:05AM BLOOD Neuts-70.4* Lymphs-13.6* Monos-4.2
Eos-11.7* Baso-0.1
[**2154-4-14**] 02:00PM BLOOD Neuts-79.8* Lymphs-14.8* Monos-4.8
Eos-0.2 Baso-0.3
[**2154-4-17**] 07:05AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Target-2+ Schisto-1+
Burr-OCCASIONAL Stipple-1+ Acantho-1+
[**2154-4-14**] 10:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-1+
Burr-OCCASIONAL Stipple-1+
[**2154-4-14**] 02:00PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Target-OCCASIONAL Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2154-4-16**] 07:08AM BLOOD PT-11.4 PTT-25.9 INR(PT)-1.1
[**2154-4-14**] 05:56PM BLOOD PT-12.4 PTT-29.8 INR(PT)-1.1
[**2154-4-17**] 07:05AM BLOOD Glucose-104* UreaN-26* Creat-1.3* Na-139
K-4.2 Cl-104 HCO3-26 AnGap-13
[**2154-4-16**] 07:08AM BLOOD Glucose-116* UreaN-25* Creat-1.3* Na-140
K-4.1 Cl-103 HCO3-27 AnGap-14
[**2154-4-15**] 05:30AM BLOOD Glucose-112* UreaN-30* Creat-1.3* Na-140
K-4.0 Cl-104 HCO3-24 AnGap-16
[**2154-4-14**] 10:00PM BLOOD Glucose-102*
[**2154-4-14**] 02:00PM BLOOD Glucose-131* UreaN-37* Creat-1.5* Na-136
K-4.3 Cl-102 HCO3-25 AnGap-13
[**2154-4-16**] 07:08AM BLOOD ALT-9 AST-15 AlkPhos-57 TotBili-1.4
[**2154-4-14**] 02:00PM BLOOD LD(LDH)-319* CK(CPK)-79 TotBili-0.8
[**2154-4-15**] 05:30AM BLOOD CK-MB-2 cTropnT-<0.01
[**2154-4-14**] 10:00PM BLOOD CK-MB-2 cTropnT-<0.01
[**2154-4-14**] 02:00PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-2632*
[**2154-4-17**] 07:05AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.3
[**2154-4-16**] 07:08AM BLOOD Phos-2.7 Mg-2.3
[**2154-4-15**] 05:30AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3
[**2154-4-14**] 02:00PM BLOOD Hapto-111
.
EKG:Atrial fibrillation. Poor R wave progression. Non-specific T
wave inverions in leads V4-V6. Compared to the previous tracing
of [**2154-1-4**] atrial fibrillation remains present but now is
slightly slower. Otherwise, no interval change.
.
CXR:
IMPRESSION: Mild pulmonary vascular congestion. Cardiomegaly.
Pulmonary
nodules documented on CT from [**2154-3-29**] are better appreciated
on that study
.
CT abdomen/pelvis:
IMPRESSION:
1. Interval increase in heterogeneous intra-abdominal fluid,
consistent with hemoperitoneum. The higher density material is
present along the lesser sac and along the gallbladder fossa,
likely indicating the region of origin of hemorrhage near known
soft tissue mass.
2. Multilobulated soft tissue masses consistent with known GIST
recurrence
with increased omental nodularity. Stable liver lesions.


Brief Hospital Course:
79 y/o F PMH significant for metastatic intra-abdominal GIST
tumor, anemia, dCHF (last EF 55% 12/11) presents with lethargy,
SOB and weakness x3 days found with HCT of 16.7.
.
#ACUTE ON CHRONIC ANEMIA/acute blood loss - presented with H/H
4.7/16.7. More recent baseline values were HCT of 28-30 as
recently as [**2154-4-5**] suggesting acute change. MCV was chronically
>100. Anemia w/u including b12/folate/fe studies checked in [**Month (only) **]
[**2153**] wnl. Hemoperitoneum noted on abd CT presumably from
metastatic GIST. Stool was guiaic negative so unlikely
intra-intestinal bleeding. Pt with Afib but not on coumadin, INR
wnl on presentation. Her hemolysis labs were negative. IR and
surgery evaluated the pt and noted no acute intervention needed
to be taken. She was transfused a total of 3U PRBCs with good
effect. She was restarted on aspirin therapy. Oncology team's
plan is to stop sutent and start pt on sorefenib as an
outpatient.
.
#SHORTNESS OF BREATH - pt reported 3 days of increasing DOE on
admission with oxygen saturation in the high 90s on 2L NC. This
was felt to be due to acute severe anemia. Her SOB improved
after blood transfusions. Her EKG was significant for new TWI on
ECG and slightly deeper 1mm ST dep in lateral leads which was
felt to be due to demand ischemia in the setting of her acute
anemia. Her cardiac enzymes were negative times three.
.
# GIST: Patient with hx of GIST s/p incomplete resection in [**2143**]
and omental resections in 3/[**2153**]. Intermittently treated with
gleevac now on low dose sutent. The sutent was initially held on
admission. Heme/onc was consulted for further recommendations an
decided to stop sutent and start pt on sorafenib after
discharge.

# ARF: Cr at 1.5 on admission above b/l 1.1-1.2. Improved after
PRBC transfusions back to her baseline.
.
#Pruritic rash: initially thought to be due to transfusion
reaction from [**4-15**], unusual that it was initially persistent. No
hives seen, rash was generalized erythema. No new medications. ?
Malignancy related. ?chemo related. Bilirubin was normal. Pt was
given benedryl and sarna lotion prn with good effect. This
resolved.
.
CHRONIC/INACTIVE ISSUES:
# Paroxysmal AFib: Given h/o bleeding, pt is no longer on
warfarin, on ASA only. We continued ASA but held Diltiazem in
the setting of acute bleed. Diltiazem was restarted on the
medical floor. Need to address whether the benefits of ASA
outweight the risks in this patient.
.
#HTN: Stable. Takes 180mg diltiazem ER at home. Thus far
normotensive. Diltiazem was held in setting of actue bleed but
restarted on the floor.
.
#Hypothyroidism: Continued home synthyroid.
.
#DM: placed on insulin sliding scale. Pt can resume Januvia upon
discharge.

Medications on Admission:
diltiazem 180mg ER daily Am
furosemide 60mg daily
levothyroxine 200mcg daily
oxycodone - unclear if currently taking
- rx is for 5mg q4-6hrs for pain prn
sitagliptin 100mg tab daily
sunitinib 25mg daily
timolol 0.5% drops right eye [**Hospital1 **]
zolpidem 10mg qhs prn insomnia
asa 81mg daily
docusate
senna


Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. bimatoprost 0.03 % Drops Sig: One (1)  Ophthalmic Left eye
qhs ().
7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
8. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
9. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO once a day.

10. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.


Discharge Disposition:
Home With Service

Facility:
Family Care Extended

Discharge Diagnosis:
acute blood loss anemia due to intraperitoneal bleeding
GI stromal tumor with metastasis
atrial fibrillation
DM type II
hypothyroidism
chronic diastolic heart failure
hypertension


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted with weakness and found to have anemia. You
had a CT scan of your abdomen that showed recurrence of bleeding
from your cancer. For this, you were initially evaluated in the
ICU and given blood transfusions. Your anemia improved and your
aspirin was restarted.
.
Medication changes: lasix and Januvia were stopped but you can
restart them at home tomorrow.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Department: [**Hospital3 249**]
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
When: MONDAY [**2154-4-22**] at 3:40 PM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
*This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider.  [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.

We are working on a follow up appointment with Dr. [**Last Name (STitle) **] in
the next week. You will be called at home with the appointment.
If you have not heard within 2 business days or have questions,
please call [**Telephone/Fax (1) 11133**]

Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2154-5-1**] at 3:00 PM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: WEDNESDAY [**2154-5-8**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: WEDNESDAY [**2154-5-29**] at 2:35 PM
With: [**Name6 (MD) 13757**] [**Name8 (MD) 13758**], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Completed by:[**2154-4-18**]
{'Neoplasm of uncertain behavior of connective and other soft tissue,Hemoperitoneum (nontraumatic),Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Chronic diastolic heart failure,Iron deficiency anemia secondary to blood loss (chronic),Atrial fibrillation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Constipation, unspecified,Rash and other nonspecific skin eruption,Long-term (current) use of aspirin'}


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: weakness, anemia

PRESENT ILLNESS: 79 yo F with GI stromal tumor most recently on Sutent with
recent CT scan showing progression of disease now on sorafenib,
past admissions for intraperitoneal bleed [**2-14**] omental metastasis
while on coumadin (now off), DM, hypothyroidism, atrial
fibrillation, dCHF who presented to the ED yesterday ([**2154-4-14**])
with fatigue, weakness and sob for three days. Patient was found
to have a hematocrit of 16 (baseline 28-30). She was
hemodynamically stable and transfused 2 units of pRBCs. Patient
was guaiac negative. She had a CT of the abdomen with contrast
which showed hemoperitoneum with the origin of hemorrhage likely
near known soft tissue mass. Surgery was contact[**Name (NI) **] and said that
she was not an operative candidate. IR was consulted, reviewed
the CT, did not see any evidence of active extravasation and
felt that there was no indication for intervention at this time.
Patient was admitted to the [**Hospital Unit Name 153**] for further monitoring. Patient
was transfused a third unit of packed cells early this am and
kept NPO. During transfusion of third unit of packed cells
patient developed a red pruritic rash thought to be a
transfusion reaction, given iv benadryl. She had a new 2L oxygen
requirement which was thought to be due to increased cardiac
demand due to severe acute anemia. She was found to have new TWI
on ECG for which cardiac biomarkers were checked and negative x
3. Patient's sorafenib was held and per discussion with oncology
fellow, patient to restart at home after discharge. Patient had
mild [**Last Name (un) **] thought to be prerenal that improved with transfusions.
Patient started on clears today, hematocrit continued to
increase to 26.9 then 30.7 this evening.
.
Of note, patient had a recent admission [**12-24**] for acute on
chronic diastolic heart failure which improved with diuresis.
Also with multiple admissions in [**2153**] for intraperitoneal bleed
due to omental metastasis in the setting of coumadin use for
atrial fibrillation. Patient also has a right medial thigh wound
that has been persistently open after cellulitis in [**2153**].
.
Currently patient denies any abdominal pain. SOB and fatigue
have improved. Her oxygen has been weaned to off. Patient does
have constipation with last BM 2 days ago. Also continues to
have pruritis and red rash, managed with sarna lotion and one
dose of po benadryl today.
.
ROS as per HPI, 10 pt ROS otherwise negative

MEDICAL HISTORY: - RIGHT MEDIAL THIGH WOUND: Developed after developing severe
cellulitis in late [**2153**] and underwent a biopsy of the area
[**2153-11-22**]. Did not heal due to DM and chemo, as was on sudent.
Was on sunitinib and this was put on hold to allow further
healing, but has since restarted low dose. Measurement of wound
was 8 x 0.5cm. The first 4 cm on the right was still open with
hypergranulation tissue present on [**12-26**].
- GIST: Diagnosed in [**2143**], treated with surgery and multiple
intermittant courses of gleevac, complicated by side effects.
She had partial gastrectomy and GIST resection in [**2143**], and a
GIST omental metastasis resection in 03/[**2153**]. Noted to have GIB
in [**Month (only) 205**] and [**2153-8-13**] due to enlarging GIST lesions. Started
on Sutent since [**2153-10-1**]. Currently on low dose Sutent
following poor wound healing as above.
- ANEMIA, iron deficiency
- Paroxysmal ATRIAL FIBRILLATION, not on AC due to multiple RP
bleeds
- CONGESTIVE HEART FAILURE, Diastolic, ef >70%.
- DIABETES MELLITUS
- Chronic DYSPNEA, exertional
- HYPERTENSION
- HYPOTHYROIDISM
- CVA in [**2136**], Residual R hemiparesis and intermittent aphasia,
- TIA in [**2148**]
- Status post knee surgery in [**2137**].

MEDICATION ON ADMISSION: diltiazem 180mg ER daily Am
furosemide 60mg daily
levothyroxine 200mcg daily
oxycodone - unclear if currently taking
- rx is for 5mg q4-6hrs for pain prn
sitagliptin 100mg tab daily
sunitinib 25mg daily
timolol 0.5% drops right eye [**Hospital1 **]
zolpidem 10mg qhs prn insomnia
asa 81mg daily
docusate
senna

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: 98.5 130/78 97P 18 100%RA
Appearance: alert, NAD, obese
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2 -m/r/g, tr peripheral edema, 1+ dp/pt bilaterally
Pulm: clear bilaterally, diminished at bases
Abd: soft, nt, nd, +bs
Msk: 5/5 strength throughout
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: diffuse blanching confluent erythematous rash involving
back, upper arms and upper chest
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]

FAMILY HISTORY: No family history of cancer, lung disease or heart disease. +
for DM.

SOCIAL HISTORY: Lives alone. Has 2 daughters. Moved from [**Country **] in [**2137**]. Has
grandchildren who visit her.
-Tobacco history:  negative
-ETOH:  negative
-Illicit drugs: negative 

### Response:
{'Neoplasm of uncertain behavior of connective and other soft tissue,Hemoperitoneum (nontraumatic),Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Chronic diastolic heart failure,Iron deficiency anemia secondary to blood loss (chronic),Atrial fibrillation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Constipation, unspecified,Rash and other nonspecific skin eruption,Long-term (current) use of aspirin'}
