CHIEF COMPLAINT: chest pain, dyspnea on exertion

PRESENT ILLNESS: 79 yo w/GIST, diastolic CHF, Afib presents with dyspnea on
exertion and chest pain. Pt reports sx began 7-10 days ago.
Exertional only, resolved with rest. Also with LH upon standing.
No rectal bleeding, no hematemesis or hematuria. Last BM
yesterday.
In ED found to have drop in Hct from 32 to 22. ECG without ST
changes.
Vitals: 97.5  130/67 79  18 90%
On arrival to floor pt reports feeling better after blood
transfusion. Denies CP, SOB, abd pain.
10 point 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. Sunitinib 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 [**2153-12-25**].

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. ammonium lactate *NF* 12 % Topical daily
2. clotrimazole-betamethasone *NF* 1-0.05 % Topical [**Hospital1 **]
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Furosemide 60 mg PO DAILY
5. Levothyroxine Sodium 200 mcg PO DAILY
6. Lorazepam 0.5-1 mg PO HS:PRN insomnia/muscle aches
7. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain
8. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
9. Sorafenib 400 mg PO BID
10. Timolol Maleate 0.5% 1 DROP BOTH EYES [**Hospital1 **]
11. Zolpidem Tartrate 10 mg PO HS:PRN insmonia
12. Acetaminophen 325-650 mg PO Q8H:PRN pain
13. Aspirin 81 mg PO DAILY
14. camphor-menthol *NF* 230-70 mg Topical QID prn itching
15. diphenhydramine-zinc acetate *NF* 2-0.1 % Topical QID prn
itching
16. Docusate Sodium 100 mg PO BID
17. Senna 1 TAB PO BID:PRN constipation
18. urea *NF* 10 % Topical QID
hands and feet

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
VS: 97.4  154/91  70  28  98% on 2.5L
Gen: nad
Heent: op clear
Chest: wheezing in RUE, distant breath sounds
CV: irreg, irreg, normal rate, no m/r/g
Abd: distended, soft, nabs, nt/nd
Ext: no e/c/c
Neuro: alert, follows commands
.
Discharge exam
-patient passed away, Dr. [**First Name (STitle) **] pronounced patient

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
Malignant neoplasm of connective and other soft tissue of abdomen,Acute on chronic diastolic heart failure,Hemoperitoneum (nontraumatic),Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Unspecified pleural effusion,Delirium due to conditions classified elsewhere,Hyposmolality and/or hyponatremia,Secondary malignant neoplasm of retroperitoneum and peritoneum,Atrial fibrillation,Unspecified acquired hypothyroidism,Benign essential hypertension,Unspecified pruritic disorder,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Encounter for palliative care,Do not resuscitate status
Mal neo soft tis abdomen,Ac on chr diast hrt fail,Hemoperitoneum,Ac posthemorrhag anemia,Acute kidney failure NOS,Pleural effusion NOS,Delirium d/t other cond,Hyposmolality,Sec mal neo peritoneum,Atrial fibrillation,Hypothyroidism NOS,Benign hypertension,Pruritic disorder NOS,Hx TIA/stroke w/o resid,Encountr palliative care,Do not resusctate status
Admission Date:  [**2154-10-7**]              Discharge Date:   [**2154-10-25**]

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

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
chest pain, dyspnea on exertion

Major Surgical or Invasive Procedure:
chest tube placement

History of Present Illness:
79 yo w/GIST, diastolic CHF, Afib presents with dyspnea on
exertion and chest pain. Pt reports sx began 7-10 days ago.
Exertional only, resolved with rest. Also with LH upon standing.
No rectal bleeding, no hematemesis or hematuria. Last BM
yesterday.
In ED found to have drop in Hct from 32 to 22. ECG without ST
changes.
Vitals: 97.5  130/67 79  18 90%
On arrival to floor pt reports feeling better after blood
transfusion. Denies CP, SOB, abd pain.
10 point 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. Sunitinib 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 [**2153-12-25**].

- 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:
ADMISSION EXAM:
VS: 97.4  154/91  70  28  98% on 2.5L
Gen: nad
Heent: op clear
Chest: wheezing in RUE, distant breath sounds
CV: irreg, irreg, normal rate, no m/r/g
Abd: distended, soft, nabs, nt/nd
Ext: no e/c/c
Neuro: alert, follows commands
.
Discharge exam
-patient passed away, Dr. [**First Name (STitle) **] pronounced patient

Pertinent Results:
[**2154-10-7**] 11:00AM   WBC-7.1 RBC-2.33*# HGB-6.2*# HCT-22.0*#
MCV-95# MCH-26.6* MCHC-28.1* RDW-22.6*
[**2154-10-7**] 11:00AM   PLT SMR-NORMAL PLT COUNT-391#
[**2154-10-7**] 12:57PM   PT-12.2 PTT-29.1 INR(PT)-1.1

[**2154-10-7**] 11:00AM   cTropnT-<0.01
[**2154-10-7**] 11:00AM   GLUCOSE-109* UREA N-32* CREAT-1.5* SODIUM-141
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-16
[**2154-10-7**] 11:00AM   CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-2.5

[**2154-10-7**] CXR (PA/lat)
IMPRESSION: Increased opacity at the right lung base, likely a
combination of effusion and atelectasis, though underlying
pneumonia difficult to exclude.
.
[**2154-10-8**] CXR (portable)
IMPRESSION:  AP chest compared to [**10-7**]:
There is greater consolidation at the right lung base today,
which could be atelectasis worsening in the setting of
persistent moderate right pleural effusion or worsening
pneumonia.  Improvement in perihilar opacification in the left
mid lung may be a function of difference in radiographic
technique.
The area is not clear, whether it is edema or a second focus of
pneumonia, is radiographically indeterminate.  Moderate
enlargement of the cardiac silhouette is longstanding.
.
[**2154-10-10**] CT Abd/Pelvis (with contrast)
IMPRESSION:
1.  Large-volume hemoperitoneum concerning for bleeding from
diffuse
peritoneal metastases, though there is no active extravasation.

.
2.  Increased right pleural effusion with possibly hemorrhagic
contents,
raising the question of thoracoabdominal communication through a
diaphragmatic rent.
.
3.  Volume overload.
.
[**2154-10-15**] CT Abd/Pelvis (non-contrast)
IMPRESSION:
1.  Mild interval increase in the complex abdominal fluid,
likely
hemoperitoneum, compared to [**2154-10-10**].  Multiple stable
peritoneal and
mesenteric metastasis.
.
2.  Mild interval increase in the hemorrhagic moderate-to-large
right pleural effusion.
.
[**2154-10-15**] CT Abd/Pelvis (non-contrast)
IMPRESSION:
1.  Stable intra-abdominal and pelvic hemoperitoneum, overall
unchanged since CT from 9 hours prior.
2.  Foci of hyperdensity within the anterior aspect of the left
side of the hemoperitoneum may represent residual contrast
within bowel.  Overall, no significant change in attenuation of
the hemoperitoneum to suggest accumulating acute blood product.
3.  Stable moderate right basilar high density pleural effusion
and basilar atelectasis.
4.  Completely decompressed urinary bladder with Foley catheter
in place and no residual urine noted within the bladder.  Large
amount of pelvic
hemoperitoneum overlies the urinary bladder superiorly.  No
evidence of
hydronephrosis. On review of the prior CT, no distended bladder
is identified
- it is possible that the post void residual seen was due to
above loculated hemoperitoneum given the extent of fluid as
described.
.
[**2154-10-17**] CT Chest (non-contrast)
IMPRESSION:
1.  Complete drainage of right pleural fluid collection after
placement of right basal pleural catheter. Bibasilar opacities
are more likely atelectasis than aspiration. Status of the
effusion can be monitored with serial radiographs if clinically
relevant.
.
2.  Intervally enlarged epicardial lymph node with possibly
enlarging right hilar lymph nodes are not fully assessed on this
non-contrast study. These findings should be reassessed in [**3-19**]
weeks (or per continuing surveillance plans for intraabdominal
malignancy) with a contrast CT study.
.
3. Complex ascites and other findings of known intra-abdominal
malignancy are incompletely assessed on this study.
.
.
[**2154-10-20**] CT AP

IMPRESSION:
1.  Mild interval increase in high density ascites along the
left paracolic
gutter, representing mild progression of hemoperitoneum compared
to [**2154-10-15**].
2.  Interval drainage of right pleural effusion with pleural
catheter in place
and hydropneumothorax.
3.  Redemonstration of the diffuse omental and peritoneal
metastases.
4.  No evidence of renal vein compression in particular (as
queried) given the
limitations of this non-contrast study.
.




Brief Hospital Course:
79 yo w/GIST, diastolic CHF, Afib presents with dyspnea on
exertion and chest pain, found to have dropping Hgb likely
source was hemoperitoneum and hemothorax
.
# Symptomatic Acute Blood Loss Anemia: [**2-14**] GIST tumor bleeding
pt received a total of 3 units pRBC with improvement in her
symptoms. CT abd/pelvis to look for recurrent RP bleed, was
delayed due to [**Last Name (un) **] as the study required contrast. On hosptial
day 3 pt had CT scan which showed hemoperitoneum without any
active bleeding.  She initially remained stable, however, her
Hct after a period of stability, began to downtrend again,
suggesting recurrent bleed.  She received 2 additional units of
PRBC's, with appropriate response.  Repeat non-contrast CT's
showed relatively stable hemoperitoneum, but did suggest
expanding pleural effusion, suggesting potential blood loss into
the thorax.  She underwent chest tube placement by IP at the
bedside (see below).  She was also seen by Surgery Consult for
possible surgical intervention, however, given the metastatic
disease, she is a poor surgical candidate.  Furthermore, pt and
her family did not want to pursue surgery as an option.  Her
case was discussed with IR and they could not see a localized
source of bleeding on the CT scans and suggested a tagged RBC
scan to further eval for bleeding.  However, b/c of [**Last Name (un) **], even if
a tagged RBC scan could localize bleeding, angiography and
intervention would come at high risk for worsening [**Last Name (un) **] given
contrast load and risk of contrast-induced nephropathy.  As
such, given that pt was clinically stable after the 2nd
transfusion, held off a tagged RBC scan.
.
# GIST Tumor: Was potentially a risk factor for her bleeding, as
such, Sorafenib was held.  This was d/w her primary oncologist,
Dr. [**Last Name (STitle) **].  Of note, pt was found to have her brought to
the hospital her own pill bottles from home of sorafenib, and
had to be instructed multiple times not to take her own pills.
Her care was further d/w Dr. [**Last Name (STitle) **], and there are no chemo
options at this time that will provided acute resolution of her
bleed.  In terms of long term management of her GIST, there were
still some potential options for chemotherapy, but after a goals
of care discussion was had, the patient was made CMO.
.
# Distolic Heart Failure: Home lasix was held on admission due
to [**Last Name (un) **]. Pt then developed volume overload with hydration. IV
lasix was started and a Foley was placed.  She initially
responded well with good UOP and improvement in her Cr and
respiratory status, suggesting successful diuresis.  However,
her Hct then dropped and she developed [**Last Name (LF) **], [**First Name3 (LF) **] her diuresis had
to be stopped.  Her medications were then discontinued when the
family decided to shift the concentration of the patients care
towards comfort.
.
# Worsening Pleural Effusion
Initially felt to be possibly due to [**Last Name (LF) 9215**], [**First Name3 (LF) **] she was diuresed,
with improvement in her respiratory status.  CT scan however,
showed significantly larger right-sided pleural effusion.  IP
was consulted for a thoracentesis and a chest tube was placed,
which drained significantly bloody effusion.  The effusion was
consistent with exudative effusion and hemothorax, as it had a
Hct of 39.  The pt continued to have bloody drainage, suggesting
possible connection between the abdominal cavity and
hemoperitoneum with the thoracic cavity and pleural space.
.
# Acute Kidney Injury / Acute Renal Failure
Presented with [**Last Name (un) **] with elevated Creatinine to 1.6 (baseline 1)
in the setting of anemia.  Improved after transfusion of PRBC's
as well as IV diuresis for presumed volume overload with acute
on chronic [**Last Name (un) 9215**].  [**Last Name (un) **] then recurred, in the setting of
intravascular volume depletion with acute blood loss anemia and
aggressive IV diuresis.  Urine lytes c/w pre-renal etiology,
Foley catheter placement and abdominal imaging ruled out
post-renal obstruction.  Was seen by Renal Consult service due
to oliguria, sediment showed non-specific granular casts, but no
overt evidence of ATN.  Urine with only rare urine eos.
Creatinine and UOP improved with additional PRBC transfusion.

.
# ICU course:
Patient transferred to ICU on [**10-19**] due to concern for
hemoperitoneum, oliguric renal failure, and compartment
syndrome. Per daughter/HCP, do not want to proceed with surgery
and paracentesis not an option given increased risk of bleeding.
CT abdomen was obtained which showed mild interval increase of
bleeding in the peritoneum cavity and diffuse omental and
peritoneal metastases. There was no evidence of renal vein
compression, but image was limited as it was non-contrast. Her
hematocrit came down to 23 and she was transfused 1 unit of pRBC
on [**10-20**] with appropriate bump in hematocrit to 26.1
post-transfusion. Her urine output decreased and was bolused
with 500cc but without much response. Her urine output continues
to be 10-20 cc/hr. Patient had a period of resp distress with
spo2 in low 80s and appeared cyanotic, but improved with sitting
up on chair and morphine. A family meeting with [**Name (NI) 13762**]
(HCP/daughter), ICU team, palliative care, and social work
occurred on [**10-21**] with decision to move to comfort care. Patient
was also placed DNR/DNI. Her insulin sliding scale and
ceftriaxone were discontinued. She was started on dilaudid IV
0.3-0.6mg q1h:PRN for shortness of breath and pain.  The
Palliative Care team followed the patient when transfered to the
floor.  Her symptoms were agressviely managed and support was
offered to the family.  The patient passed away comfortably on
[**2154-10-25**].


Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. ammonium lactate *NF* 12 % Topical daily
2. clotrimazole-betamethasone *NF* 1-0.05 % Topical [**Hospital1 **]
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Furosemide 60 mg PO DAILY
5. Levothyroxine Sodium 200 mcg PO DAILY
6. Lorazepam 0.5-1 mg PO HS:PRN insomnia/muscle aches
7. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain
8. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
9. Sorafenib 400 mg PO BID
10. Timolol Maleate 0.5% 1 DROP BOTH EYES [**Hospital1 **]
11. Zolpidem Tartrate 10 mg PO HS:PRN insmonia
12. Acetaminophen 325-650 mg PO Q8H:PRN pain
13. Aspirin 81 mg PO DAILY
14. camphor-menthol *NF* 230-70 mg Topical QID prn itching
15. diphenhydramine-zinc acetate *NF* 2-0.1 % Topical QID prn
itching
16. Docusate Sodium 100 mg PO BID
17. Senna 1 TAB PO BID:PRN constipation
18. urea *NF* 10 % Topical QID
hands and feet


Discharge Medications:
None-patient passed away

Discharge Disposition:
Expired

Discharge Diagnosis:
Acute Blood Loss Anemia
Bleeding GIST Tumor
Acute on chronic diastolic heart failure
pleural effusion
.
Patient passed away

Discharge Condition:
patient passed away

Discharge Instructions:
patient passed away

Followup Instructions:
patient passed away
{'Malignant neoplasm of connective and other soft tissue of abdomen,Acute on chronic diastolic heart failure,Hemoperitoneum (nontraumatic),Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Unspecified pleural effusion,Delirium due to conditions classified elsewhere,Hyposmolality and/or hyponatremia,Secondary malignant neoplasm of retroperitoneum and peritoneum,Atrial fibrillation,Unspecified acquired hypothyroidism,Benign essential hypertension,Unspecified pruritic disorder,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Encounter for palliative care,Do not resuscitate status'}


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: chest pain, dyspnea on exertion

PRESENT ILLNESS: 79 yo w/GIST, diastolic CHF, Afib presents with dyspnea on
exertion and chest pain. Pt reports sx began 7-10 days ago.
Exertional only, resolved with rest. Also with LH upon standing.
No rectal bleeding, no hematemesis or hematuria. Last BM
yesterday.
In ED found to have drop in Hct from 32 to 22. ECG without ST
changes.
Vitals: 97.5  130/67 79  18 90%
On arrival to floor pt reports feeling better after blood
transfusion. Denies CP, SOB, abd pain.
10 point 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. Sunitinib 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 [**2153-12-25**].

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. ammonium lactate *NF* 12 % Topical daily
2. clotrimazole-betamethasone *NF* 1-0.05 % Topical [**Hospital1 **]
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Furosemide 60 mg PO DAILY
5. Levothyroxine Sodium 200 mcg PO DAILY
6. Lorazepam 0.5-1 mg PO HS:PRN insomnia/muscle aches
7. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain
8. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
9. Sorafenib 400 mg PO BID
10. Timolol Maleate 0.5% 1 DROP BOTH EYES [**Hospital1 **]
11. Zolpidem Tartrate 10 mg PO HS:PRN insmonia
12. Acetaminophen 325-650 mg PO Q8H:PRN pain
13. Aspirin 81 mg PO DAILY
14. camphor-menthol *NF* 230-70 mg Topical QID prn itching
15. diphenhydramine-zinc acetate *NF* 2-0.1 % Topical QID prn
itching
16. Docusate Sodium 100 mg PO BID
17. Senna 1 TAB PO BID:PRN constipation
18. urea *NF* 10 % Topical QID
hands and feet

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
VS: 97.4  154/91  70  28  98% on 2.5L
Gen: nad
Heent: op clear
Chest: wheezing in RUE, distant breath sounds
CV: irreg, irreg, normal rate, no m/r/g
Abd: distended, soft, nabs, nt/nd
Ext: no e/c/c
Neuro: alert, follows commands
.
Discharge exam
-patient passed away, Dr. [**First Name (STitle) **] pronounced patient

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:
{'Malignant neoplasm of connective and other soft tissue of abdomen,Acute on chronic diastolic heart failure,Hemoperitoneum (nontraumatic),Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Unspecified pleural effusion,Delirium due to conditions classified elsewhere,Hyposmolality and/or hyponatremia,Secondary malignant neoplasm of retroperitoneum and peritoneum,Atrial fibrillation,Unspecified acquired hypothyroidism,Benign essential hypertension,Unspecified pruritic disorder,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Encounter for palliative care,Do not resuscitate status'}
