CHIEF COMPLAINT: left sided hip pain

PRESENT ILLNESS: 81 yo M w/ L hip pain, wt. loss, anemia, and acute renal failure
presenting from visit at [**Hospital **] clinic due to acute rise in Cr.
Pt used to live in US but has been living back in his native
island of Dominica for last 3 years since the death of his wife.
Lived along and was very active and independent, doing his own
cooking and cleaning. He was visited by his two children [**First Name8 (NamePattern2) **]
[**Known lastname 88565**] and [**First Name8 (NamePattern2) **] [**Known lastname 88565**] four times a year.
.
One month prior to admission daughter reports he started
reported L hip pain. His PCP in [**Name9 (PRE) **] gave him one week of
predisone and tramadol which helped his symptoms. However, after
this course finished his symptoms returned. Last week his
daughter went from the US to visit him and found him to have
poor appetite. He was easily fatigued and rarely willing to
leave the house. He reports feeling slightly SOB over the last
few weeks and his daughter reports his sugars were abnormally
low (55-75 range when normally 90-110s). Found to have lost
roughly 30lbs in last 2-3 months. His daughter [**Name (NI) 4662**] him back
to the US this past week but his PCP was out of town. He saw the
[**Hospital **] clinic regarding his diabetes today and they found his
BUN/Cr to be extremely elevated from prior labs in Dominica (had
been Cr of 1.9 in [**2152-11-6**] but > 6 today). [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) 88566**]y to [**Hospital1 18**] for evaluation.
.
In ED VS were initially 98.2 72 124/50 18 100% RA. Pt was found
to be anemic but guiac negative. LDH was elevated and BUN 96
with Cr of 6.5. Hip xrays showed lytic lesion in proximal femur
and CT Abd/Pelvis confirmed this and also noted lytic lesions in
L hip and lumbar spine. In ED recieved 1L IVF. VS on transfer HR
74, BP 152/66, RR 18, 98% RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: - HTN
- DMII
- HLD

MEDICATION ON ADMISSION: -simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime
-glipizide 10 mg Tab Oral 1 Tablet(s) Once Daily
-lisinopril-hydrochlorothiazide 20 mg-12.5 mg 1 Tablet(s) Once
Daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: 97.0 / 158/64 / 80 / 17 / 100% on RA
GA: AOx3, NAD, frail appearing
HEENT: PERRLA. dry MM. no LAD. no JVD. neck supple. large lipoma
on back of neck left of midline
Cards: RRR S1/S2 heard. mild systolic ejectin murmur, no
gallops/rubs.
Pulm: CTAB no crackles or wheezes on posterior exam
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, radial 2+, spotty skin
discoloration on lower extremities
Skin: patchy light discoloration on scalp as well as those
mentioned on lower extremities
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (patellar). sensation intact to LT. cerebellar fxn
intact (FTN, HTS). gait not tested. no asterixis.

FAMILY HISTORY: - DMII (3 sisters)

SOCIAL HISTORY: Lived in Dominica last 3 years. Was living alone and
independently. Two children ([**Location (un) **] is daughter and [**Name (NI) **] is
son) live in [**Name (NI) 86**] area and are involved and concerned. Smoked
may years ago but quite in [**2112**]. No alcohol use.
Multiple myeloma, without mention of having achieved remission,Acute respiratory failure,Acute kidney failure, unspecified,Shock, unspecified,Paroxysmal ventricular tachycardia,Alkalosis,Thrombocytopenia, unspecified,Chronic kidney disease, Stage III (moderate),Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypercalcemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Mult mye w/o achv rmson,Acute respiratry failure,Acute kidney failure NOS,Shock NOS,Parox ventric tachycard,Alkalosis,Thrombocytopenia NOS,Chr kidney dis stage III,Anemia NOS,DMII wo cmp nt st uncntr,Hypercalcemia,Hy kid NOS w cr kid I-IV
Admission Date:  [**2153-6-8**]              Discharge Date:   [**2153-6-26**]

Date of Birth:  [**2072-4-27**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 8810**]
Chief Complaint:
left sided hip pain

Major Surgical or Invasive Procedure:
Bone marrow biopsy
Temporary central venous catheter for dialysis - right internal
jugular
Right subclavian central venous catheter
Tunneled dialysis line placement


History of Present Illness:
81 yo M w/ L hip pain, wt. loss, anemia, and acute renal failure
presenting from visit at [**Hospital **] clinic due to acute rise in Cr.
Pt used to live in US but has been living back in his native
island of Dominica for last 3 years since the death of his wife.
Lived along and was very active and independent, doing his own
cooking and cleaning. He was visited by his two children [**First Name8 (NamePattern2) **]
[**Known lastname 88565**] and [**First Name8 (NamePattern2) **] [**Known lastname 88565**] four times a year.
.
One month prior to admission daughter reports he started
reported L hip pain. His PCP in [**Name9 (PRE) **] gave him one week of
predisone and tramadol which helped his symptoms. However, after
this course finished his symptoms returned. Last week his
daughter went from the US to visit him and found him to have
poor appetite. He was easily fatigued and rarely willing to
leave the house. He reports feeling slightly SOB over the last
few weeks and his daughter reports his sugars were abnormally
low (55-75 range when normally 90-110s). Found to have lost
roughly 30lbs in last 2-3 months. His daughter [**Name (NI) 4662**] him back
to the US this past week but his PCP was out of town. He saw the
[**Hospital **] clinic regarding his diabetes today and they found his
BUN/Cr to be extremely elevated from prior labs in Dominica (had
been Cr of 1.9 in [**2152-11-6**] but > 6 today). [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) 88566**]y to [**Hospital1 18**] for evaluation.
.
In ED VS were initially 98.2 72 124/50 18 100% RA. Pt was found
to be anemic but guiac negative. LDH was elevated and BUN 96
with Cr of 6.5. Hip xrays showed lytic lesion in proximal femur
and CT Abd/Pelvis confirmed this and also noted lytic lesions in
L hip and lumbar spine. In ED recieved 1L IVF. VS on transfer HR
74, BP 152/66, RR 18, 98% RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.


Past Medical History:
- HTN
- DMII
- HLD


Social History:
Lived in Dominica last 3 years. Was living alone and
independently. Two children ([**Location (un) **] is daughter and [**Name (NI) **] is
son) live in [**Name (NI) 86**] area and are involved and concerned. Smoked
may years ago but quite in [**2112**]. No alcohol use.

Family History:
- DMII (3 sisters)

Physical Exam:
VS: 97.0 / 158/64 / 80 / 17 / 100% on RA
GA: AOx3, NAD, frail appearing
HEENT: PERRLA. dry MM. no LAD. no JVD. neck supple. large lipoma
on back of neck left of midline
Cards: RRR S1/S2 heard. mild systolic ejectin murmur, no
gallops/rubs.
Pulm: CTAB no crackles or wheezes on posterior exam
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, radial 2+, spotty skin
discoloration on lower extremities
Skin: patchy light discoloration on scalp as well as those
mentioned on lower extremities
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (patellar). sensation intact to LT. cerebellar fxn
intact (FTN, HTS). gait not tested. no asterixis.


Pertinent Results:
Labs upon admission:
[**2153-6-8**] 01:23PM BLOOD WBC-6.4 RBC-2.64* Hgb-7.8* Hct-22.4*
MCV-85 MCH-29.4 MCHC-34.6 RDW-16.6* Plt Ct-101*
[**2153-6-8**] 01:23PM BLOOD Neuts-64.7 Lymphs-24.3 Monos-8.4 Eos-2.0
Baso-0.6
[**2153-6-9**] 08:00AM BLOOD PT-13.4 PTT-30.2 INR(PT)-1.1
[**2153-6-11**] 05:43AM BLOOD Fibrino-499*
[**2153-6-9**] 08:00AM BLOOD ESR-25*
[**2153-6-9**] 08:00AM BLOOD Ret Aut-0.8*
[**2153-6-18**] 06:00AM BLOOD SerVisc-1.5
[**2153-6-8**] 01:23PM BLOOD Glucose-123* UreaN-96* Creat-6.5* Na-144
K-4.2 Cl-101 HCO3-29 AnGap-18
[**2153-6-8**] 01:23PM BLOOD ALT-14 AST-26 LD(LDH)-444* AlkPhos-72
TotBili-0.2
[**2153-6-11**] 05:43AM BLOOD Lipase-24
[**2153-6-10**] 07:25AM BLOOD CK-MB-29* MB Indx-8.5* cTropnT-0.29*
[**2153-6-8**] 01:23PM BLOOD TotProt-7.2 Calcium-15.2* Phos-6.7*
Mg-2.7* UricAcd-13.0* Iron-102
[**2153-6-8**] 01:23PM BLOOD calTIBC-295 Ferritn-991* TRF-227
[**2153-6-9**] 03:35PM BLOOD VitB12-1095* Folate-13.4
[**2153-6-11**] 04:25PM BLOOD Hapto-259*
[**2153-6-10**] 08:55AM BLOOD PTH-42
[**2153-6-18**] 06:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2153-6-9**] 08:00AM BLOOD CRP-1.6 PSA-6.5*
[**2153-6-8**] 01:23PM BLOOD PEP-TRACE ABNO IgG-683* IgA-19* IgM-16*
IFE-MONOCLONAL
[**2153-6-9**] 08:00AM BLOOD b2micro-16.3* IgG-534* IgA-15* IgM-13*
[**2153-6-9**]:
FREE KAPPA, SERUM             [**Numeric Identifier **].0  H          3.3-19.4 mg/L
FREE LAMBDA, SERUM            10.4                5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO       1111.54  H          0.26-1.65
[**2153-6-14**]:
FREE KAPPA, SERUM             4260.0  H           3.3-19.4 mg/L
FREE LAMBDA, SERUM            6.5                 5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO       655.38  H           0.26-1.65

Labs upon discharge:
[**2153-6-25**] 04:59AM BLOOD WBC-9.7 RBC-3.03* Hgb-8.9* Hct-25.3*
MCV-83 MCH-29.2 MCHC-35.0 RDW-14.3 Plt Ct-137*
[**2153-6-25**] 04:59AM BLOOD Glucose-180* UreaN-82* Creat-6.8*# Na-135
K-5.0 Cl-96 HCO3-26 AnGap-18
[**2153-6-19**] 05:33AM BLOOD ALT-121* AST-50* LD(LDH)-468* CK(CPK)-189
AlkPhos-78 TotBili-0.4
[**2153-6-25**] 04:59AM BLOOD LD(LDH)-383* AlkPhos-69
[**2153-6-19**] 05:33AM BLOOD CK-MB-3 cTropnT-2.74*
[**2153-6-25**] 04:59AM BLOOD Albumin-3.4* Calcium-7.8* Phos-7.1*#
Mg-2.3

CXR [**2153-6-21**]: FINDINGS: As compared to the previous radiograph,
the lung volumes have slightly decreased, and the size of the
cardiac silhouette has minimally increased. No pneumothorax.
Bilateral central venous access lines. No pleural effusions. No
pulmonary edema.

Hip films/AP pelvix [**2153-6-20**]:
There is again seen a very large expansile lesion within the
left proximal
femora: There is a cortical breakthrough along the more medial
aspect in the region of the lesser trochanter. The more lateral
and posterior aspects of the femoral cortex appears intact.
There are also diffuse lucent lesions throughout the pelvis and
findings and proximal femurs consistent with no myelomatous
deposits. Degenerative changes of bilateral hips are present.
There are vascular calcifications.

[**2153-6-18**]: CT head: IMPRESSION:
1. No acute intracranial hemorrhage.
2. Low-attenuating region within the left frontal cortex is
concerning for
chronic versus less likely subacute process. Findings were
discussed with Dr. [**Last Name (STitle) **], who reported no evidence of focal
neurological deficits in the patient's recent history.
3. Asymmetry of the ventricles with the left ventricle larger
than the right ventricle, likely representing ex vacuo
phenomenon.
4. Sequelae consistent with small vessel ischemic disease.
5. Mucosal thickening within the left maxillary sinus as well as
possible
mucus retention cyst within the left portion of the sphenoid
sinus.

CT chest [**2153-6-12**]: IMPRESSION:
1. Extensive ground-glass and consolidative parenchymal
opacities, involving all lobes, with a nondependent-dependent
gradient increased in severity, most compatible with ARDS.
2. Trace pericardial effusion.
3. Numerous mediastinal nodes, likely reactive.
4. Numerous destructive lytic osseous lesions, compatible with
history of
known multiple myeloma.

[**2153-6-11**]: IMPRESSION: Suboptimal image quality. Mild symmetric
left ventricular hypertrophy with preserved regional and global
systolic function. Mild right ventricular cavity enlargement
with low normal systolic function. Pulmonary artery systolic
hypertension. Moderate mitral regurgitation. Moderate tricuspid
regurgitation.

[**2153-6-9**]: Skeletal series: IMPRESSION: Diffuse lytic lesions
throughout the appendicular and peripheral skeleton, consistent
with myeloma or metastases.


Brief Hospital Course:
81 year old male who was admited for hip pain found to have
multiple myeloma.
.
Hypoxic respiratory failure: He was initially given aggressive
intravenous fluids (5L) to correct severe hypercalcemia and
developed pulmonary edema and acute respiratory failure
prompting intubation and ICU admission.  He was placed on a
furosemide drip but urine output was minimal due to acutre renal
failure secondary to light chain nephrotoxicity.  He required
CVVH (started [**2153-6-12**]) which successfully removed fluid and
allowed for extubation.

Multiple myeloma: He initially presented with calcium of 15 and
acute renal failure.  He received aggressive intravenous fluids
and pamidronate infusion.  SPEP/UPEP showed bence-[**Doctor Last Name 49**] protein
in his urine and free kappa chains were elevated.  Skeletal
survey showed diffuse lytic lesions.  He received a bone marrow
biopsy on [**2153-6-19**] that showed plasma cell myeloma with plasma
cells comprising 33% of aspirate.  He was started on velcade and
dexamethasone on [**2153-6-18**], and needs his last dose of velcade on
[**2153-6-29**] and dexamethasone on [**2153-6-29**] and [**2153-6-30**].  He was
started on PCP prophylaxis with bactrim and continued on
acyclovir for HSV prophylaxis.  He was seen by ortho/oncology
for his large lytic lesion in his left femur, but was deemed not
a surgical candidate for hip fixation due to his poor functional
status and multiple comorbidities.  Alternatively he received
radiation to the femur lesion (total 5 treatments, last
treatment [**2153-6-27**]).  He is touch down weight bearing on left
lower extremity with full assist with left leg lift due to his
high risk of femur fracture.

Acute Renal failure: Baseline creatinine from [**12/2152**] was <1.5.
Presented to ICU with creatinine of 5 to 6, with evidence of
fluid overload and worsening hyperkalemia.  Initially as still
making urine and able to diuresis with Lasix, however the
patient became progressively anuric, with his creatinine peaking
at 9.9. CVVH was initiated as above.  He commenced dialysis and
will continue with HD M/W/F as an outpatient.  He may recover
kidney function once light chain burden decreases.  He did not
receive plasmapheresis per recommendations from the transfusion
medicine team (data shows lack of benefit from plasmapheresis
with elevated light chains due to extensive tissue/fat
distribution and short half life of proteins).

NSTEMI:  Presented with ST depressions in lateral leads while
extremely tachycardic during flash pulmonary edema.  Repeat ECG
showed resolultion of ST changes.  Follow up cardiac enzymes
showed up trending troponins with elevated but steady CK-MB.
Echo showed EF 55%, mild symmetric LVF, 2+ mitral regurg, 2+
tricuspid regurg, but no focal wall abnormalities. The study was
done in the setting of gross fluid overload.  CKMB trended down,
although troponin T remained elevated likely secondary to renal
insufficiency.  He developed non-sustained ventricular
tachcardia (one episode of ~50 beats, asymptomatic) on the
wards.  He was seen by cardiology and started on metoprolol with
adequate rate control.

Anemia: Hct down to 17.  Likely related to bone marrow
suppression from multiple myeloma and renal failure. Received a
total of 8 units of PRBCs during admission.

Thrombocytopenia:  Likely secondary to multiple myeloma causing
bone marrow suppression.  He was started on heparin SQ DVT
prophylaxis once platelets improved and should continue this
upon discharge due to ongoing immobility.

Mental status: Per baseline per family upon discharge.  He
answers questions appropriately and is oriented to name and
place but not time.

He was FULL CODE for this admission.

Medications on Admission:
-simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime
-glipizide 10 mg Tab Oral 1 Tablet(s) Once Daily
-lisinopril-hydrochlorothiazide 20 mg-12.5 mg 1 Tablet(s) Once
Daily


Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
2. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day) as needed for constipation.
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)  PO
DAILY (Daily) as needed for constipation.
4. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea.
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. insulin lispro 100 unit/mL Solution Sig: asdir  Subcutaneous
ASDIR (AS DIRECTED): please see sliding scale.
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): please crush.
11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): on hemodialysis days, please give AFTER
dialysis.
12. dexamethasone 4 mg Tablet Sig: Five (5) Tablet PO asdir for
2 doses: please give 20mg on [**2153-6-29**] and [**2153-6-30**].
13. VELCADE 3.5 mg Recon Soln Sig: 2.1 mg Intravenous once for 1
doses: to be given on [**2153-6-29**] at clinic appointment with Dr.
[**Last Name (STitle) 3759**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Hospital - [**Hospital1 8**]

Discharge Diagnosis:
Multiple myeloma
Acute respiratory failure: pulmonary edema and ARDS
Diffuse Lytic bony lesions
Acute renal failure - secondary to light chains
Hypercalcemia
Non-sustained ventricular tachycardia
Anemia
Thrombocytopenia
Diabetes Mellitus type 2


Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You came to the hospital because of hip pain.  You were found to
have multiple myeloma.  You received intravenous fluids due to
high calcium and temporarily required intubation because of
fluid overload in your lungs.  Your kidneys were injured
secondary to multiple myeloma.  You were started on
hemodialysis.  You improved significantly overtime and were able
to begin chemotherapy.  You were seen by orthopedics who
determined you have a high risk of left femur fracture, but
unfortunately surgery is not safe at this point.  You are
receiving radiation to your femur to help prevent fracture.

We made the following changes to your medications:
- STOP simvastatin
- STOP glipizide
- STOP lisinopril-hydrochlorothiazide
- START senna 8.6mg twice daily as needed for constipation
- START colace 100mg twice daily as needed for constipation
- START miralax 17g daily as needed for constipation
- START compazine 10mg every 8 hours as needed for nausea
- START acyclovir 400mg daily
- START insulin sliding scale as directed
- START metoprolol 25mg three times daily
- START nephrocaps 1 cap daily
- START heparin SQ 5000 units three times daily
- START calcium acetate 2668mg three times daily with meals,
please crush
- START bactrim SS 1 tab daily
- START dexamethasone 20mg on [**6-29**] (with velcade) and [**6-30**] only
- Velcade 2.1mg IV to be given on [**2153-6-29**] at oncology clinic
appointment

It was a pleasure caring for you.  We wish you a speedy
recovery.

Followup Instructions:
Radiation therapy
[**Hospital1 69**], [**Hospital Ward Name **]
Basement level, [**Hospital Unit Name **]
Wednesday [**2153-6-27**] at 4:00PM

Department: HEMATOLOGY/BMT
When: FRIDAY [**2153-6-29**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2153-6-29**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/BMT
When: FRIDAY [**2153-6-29**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2153-6-26**]
{'Multiple myeloma, without mention of having achieved remission,Acute respiratory failure,Acute kidney failure, unspecified,Shock, unspecified,Paroxysmal ventricular tachycardia,Alkalosis,Thrombocytopenia, unspecified,Chronic kidney disease, Stage III (moderate),Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypercalcemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}


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: left sided hip pain

PRESENT ILLNESS: 81 yo M w/ L hip pain, wt. loss, anemia, and acute renal failure
presenting from visit at [**Hospital **] clinic due to acute rise in Cr.
Pt used to live in US but has been living back in his native
island of Dominica for last 3 years since the death of his wife.
Lived along and was very active and independent, doing his own
cooking and cleaning. He was visited by his two children [**First Name8 (NamePattern2) **]
[**Known lastname 88565**] and [**First Name8 (NamePattern2) **] [**Known lastname 88565**] four times a year.
.
One month prior to admission daughter reports he started
reported L hip pain. His PCP in [**Name9 (PRE) **] gave him one week of
predisone and tramadol which helped his symptoms. However, after
this course finished his symptoms returned. Last week his
daughter went from the US to visit him and found him to have
poor appetite. He was easily fatigued and rarely willing to
leave the house. He reports feeling slightly SOB over the last
few weeks and his daughter reports his sugars were abnormally
low (55-75 range when normally 90-110s). Found to have lost
roughly 30lbs in last 2-3 months. His daughter [**Name (NI) 4662**] him back
to the US this past week but his PCP was out of town. He saw the
[**Hospital **] clinic regarding his diabetes today and they found his
BUN/Cr to be extremely elevated from prior labs in Dominica (had
been Cr of 1.9 in [**2152-11-6**] but > 6 today). [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) 88566**]y to [**Hospital1 18**] for evaluation.
.
In ED VS were initially 98.2 72 124/50 18 100% RA. Pt was found
to be anemic but guiac negative. LDH was elevated and BUN 96
with Cr of 6.5. Hip xrays showed lytic lesion in proximal femur
and CT Abd/Pelvis confirmed this and also noted lytic lesions in
L hip and lumbar spine. In ED recieved 1L IVF. VS on transfer HR
74, BP 152/66, RR 18, 98% RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: - HTN
- DMII
- HLD

MEDICATION ON ADMISSION: -simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime
-glipizide 10 mg Tab Oral 1 Tablet(s) Once Daily
-lisinopril-hydrochlorothiazide 20 mg-12.5 mg 1 Tablet(s) Once
Daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: 97.0 / 158/64 / 80 / 17 / 100% on RA
GA: AOx3, NAD, frail appearing
HEENT: PERRLA. dry MM. no LAD. no JVD. neck supple. large lipoma
on back of neck left of midline
Cards: RRR S1/S2 heard. mild systolic ejectin murmur, no
gallops/rubs.
Pulm: CTAB no crackles or wheezes on posterior exam
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, radial 2+, spotty skin
discoloration on lower extremities
Skin: patchy light discoloration on scalp as well as those
mentioned on lower extremities
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (patellar). sensation intact to LT. cerebellar fxn
intact (FTN, HTS). gait not tested. no asterixis.

FAMILY HISTORY: - DMII (3 sisters)

SOCIAL HISTORY: Lived in Dominica last 3 years. Was living alone and
independently. Two children ([**Location (un) **] is daughter and [**Name (NI) **] is
son) live in [**Name (NI) 86**] area and are involved and concerned. Smoked
may years ago but quite in [**2112**]. No alcohol use. 

### Response:
{'Multiple myeloma, without mention of having achieved remission,Acute respiratory failure,Acute kidney failure, unspecified,Shock, unspecified,Paroxysmal ventricular tachycardia,Alkalosis,Thrombocytopenia, unspecified,Chronic kidney disease, Stage III (moderate),Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypercalcemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}
