CHIEF COMPLAINT: abdominal pain, constipation

PRESENT ILLNESS: Mr. [**Known lastname **] is a 58 year old man with a history of metastatic
melanoma with brain mets who presents to the ER with abdominal
pain and constipation.  History is obtained with the assistance
of his wife who states that they recently traveled on a cruise
and during this trip he was developing worsening headache which
were treated with Oxycontin (10-20 mg [**Hospital1 **]) and Oxycodone 5 mg
taken 2-4 tablets per day.  He has been taking Dexamethasone 4
mg every 6 hours for the past few weeks.  He has been
constipated and last moved his bowels 5 days ago.  He has had
increasing abdominal discomfort over the past few days and his
narcotics have been held for the past 3 days.  For the
constipation he was taking an over the counter senna but this
has not been helping.  He was taking this once a day.

MEDICAL HISTORY: PAST ONCOLOGIC HISTORY:
- [**2194**]: noticed a mole on the right temple
- [**2195-4-17**] mole was resected, pathology revealed melanoma
involving the dermis and subcutis extending to the deep margin,
measuring 9 mm in thickness.
- [**2195-5-8**] CT Torso revealed a 2.5 x 1.2 cm dominant left upper
lobe
ill-defined lung nodule, additional small satellite nodules, a
1.8 x 1.7 cm RUL nodule anteriorly, and multiple liver lesions;
largest measuring 1.6 cm. Head MRI revealed right cerebellar
lesion. He underwent gamma knife radiosurgery on [**2195-5-19**]. He
commenced in temozolomide 200 mg/m2 x 5 days course with largely
stable disease but some areas of disease progression.
- [**2195-8-12**]: CTLA4-ab compassionate access protocol
- [**2195-10-14**] admitted with Hypotension, Acute renal failure,
Pan-hypopituitary syndrome, amd grade 4 rash. He was discharged
on [**2195-10-16**] in good condition. His Rash responded to 2mg/kg/day
dose of prednisone with grade [**1-30**].
- His CT scan and head MRI for week 24 revelaed a new R deep
insular, L parietal CNS lesions, parotid gland involvement as
well as a new
subcutaneous mass in the R temple. He was taken off of protocol
at that time.
- [**12/2195**]: underwent CK to the two new lesion found on the MRI,
R insular and L parietal lesions
- [**2196-4-7**] underwent resection of a melanoma from the right
parotid region by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**].
- [**2195-5-4**]: Cyberknife radiosurgery on [**2196-5-3**] to a left frontal
metastasis to 2200 cGy at 74% isodose line, and status external
beam
irradiation to the parotid gland at [**Hospital 1474**] Hospital by [**Last Name (NamePattern1) 85702**].
- [**9-/2196**]: began WBXRT due to progression in the CNS, completed
[**10/2196**]

MEDICATION ON ADMISSION: Dexamethasone 4 mg every 6 hours
Levothyroxine 50 mcg PO daily
Oxycodone 5 mg Tablet 1-2 tabs PO q4H PRN
Oxycontin 10-20 mg PO q12H
Compazine 10mg PO TID PRN
Ranitidine 150 mg PO BID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
VS: T96.1 BP 126/84 HR 104 RR 16 97% RA
GENERAL: Lethargic but arousable and answers questions
appropriately, NAD
HEENT: No scleral icterus. Inability to abdjuct eyes
bilaterally.  MMM, OP clear
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: Soft, non-distended.  Discomfort with palpation of the
lower quadrants bilaterally.  No rebound. + guarding.
EXTREMITIES: No c/c/e. Left first finger with work-related
injury in which the fingertip has been cut off.  Does not appear
infected.
NEURO: Inability to abdjuct the eyes.  Other cranial nerves
appear intact.  4/5 strength of left upper and lower extremities
bilaterally.  Right side is intact.  Sensation intact. Gait
assessment deferred.

FAMILY HISTORY: No malignancy in family.

SOCIAL HISTORY: Married, four children.  The patient owns business in sheet
metal parts.  He is still working.
Secondary malignant neoplasm of small intestine including duodenum,Perforation of intestine,Other suppurative peritonitis,Acute kidney failure, unspecified,Candidiasis of mouth,Secondary malignant neoplasm of brain and spinal cord,Pulmonary collapse,Panhypopituitarism,Delirium due to conditions classified elsewhere,Dehydration,Other constipation,Adult failure to thrive,Esophageal reflux,Disorders of phosphorus metabolism,Peritoneal adhesions (postoperative) (postinfection),Unspecified acquired hypothyroidism,Diplopia,Leukocytosis, unspecified,Headache,Do not resuscitate status,Personal history of irradiation, presenting hazards to health,Personal history of malignant melanoma of skin,Personal history of antineoplastic chemotherapy,Other opiates and related narcotics causing adverse effects in therapeutic use
Sec malig neo sm bowel,Perforation of intestine,Suppurat peritonitis NEC,Acute kidney failure NOS,Thrush,Sec mal neo brain/spine,Pulmonary collapse,Panhypopituitarism,Delirium d/t other cond,Dehydration,Constipation NEC,Failure to thrive-adult,Esophageal reflux,Dis phosphorus metabol,Peritoneal adhesions,Hypothyroidism NOS,Diplopia,Leukocytosis NOS,Headache,Do not resusctate status,Hx of irradiation,Hx-malig skin melanoma,Hx antineoplastic chemo,Adv eff opiates
Admission Date:  [**2197-2-2**]              Discharge Date:   [**2197-2-10**]

Date of Birth:  [**2138-10-15**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abdominal pain, constipation

Major Surgical or Invasive Procedure:
Small-bowel resection plus primary anastomosis.


History of Present Illness:
Mr. [**Known lastname **] is a 58 year old man with a history of metastatic
melanoma with brain mets who presents to the ER with abdominal
pain and constipation.  History is obtained with the assistance
of his wife who states that they recently traveled on a cruise
and during this trip he was developing worsening headache which
were treated with Oxycontin (10-20 mg [**Hospital1 **]) and Oxycodone 5 mg
taken 2-4 tablets per day.  He has been taking Dexamethasone 4
mg every 6 hours for the past few weeks.  He has been
constipated and last moved his bowels 5 days ago.  He has had
increasing abdominal discomfort over the past few days and his
narcotics have been held for the past 3 days.  For the
constipation he was taking an over the counter senna but this
has not been helping.  He was taking this once a day.

In the emergency department, initial vitals: 97.1 120 109/84 16
100%.  A KUB was performed which showed moderate fecal loading
in the colon and no free air.  CXR was unremarkable.  He was
given Miralax in the ER.  Rectal exam showed no stool in the
rectal vault and guaiac was negative.  His wife states he
received 2L of IVF in the ER (unable to confirm this on
documentation).

On arrival to the floor, he is somnolent which his wife states
occurs when he stops the dexamethasone.  He has no headache and
denies abdominal pain.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies current 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.  Denied arthralgias or myalgias.

Past Medical History:
PAST ONCOLOGIC HISTORY:
- [**2194**]: noticed a mole on the right temple
- [**2195-4-17**] mole was resected, pathology revealed melanoma
involving the dermis and subcutis extending to the deep margin,
measuring 9 mm in thickness.
- [**2195-5-8**] CT Torso revealed a 2.5 x 1.2 cm dominant left upper
lobe
ill-defined lung nodule, additional small satellite nodules, a
1.8 x 1.7 cm RUL nodule anteriorly, and multiple liver lesions;
largest measuring 1.6 cm. Head MRI revealed right cerebellar
lesion. He underwent gamma knife radiosurgery on [**2195-5-19**]. He
commenced in temozolomide 200 mg/m2 x 5 days course with largely
stable disease but some areas of disease progression.
- [**2195-8-12**]: CTLA4-ab compassionate access protocol
- [**2195-10-14**] admitted with Hypotension, Acute renal failure,
Pan-hypopituitary syndrome, amd grade 4 rash. He was discharged
on [**2195-10-16**] in good condition. His Rash responded to 2mg/kg/day
dose of prednisone with grade [**1-30**].
- His CT scan and head MRI for week 24 revelaed a new R deep
insular, L parietal CNS lesions, parotid gland involvement as
well as a new
subcutaneous mass in the R temple. He was taken off of protocol
at that time.
- [**12/2195**]: underwent CK to the two new lesion found on the MRI,
R insular and L parietal lesions
- [**2196-4-7**] underwent resection of a melanoma from the right
parotid region by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**].
- [**2195-5-4**]: Cyberknife radiosurgery on [**2196-5-3**] to a left frontal
metastasis to 2200 cGy at 74% isodose line, and status external
beam
irradiation to the parotid gland at [**Hospital 1474**] Hospital by [**Last Name (NamePattern1) 85702**].
- [**9-/2196**]: began WBXRT due to progression in the CNS, completed
[**10/2196**]

OTHER PAST MEDICAL HISTORY:
GERD
Panhypopit [**3-2**] Ipilimumab
Hypothyroidism

Social History:
Married, four children.  The patient owns business in sheet
metal parts.  He is still working.


Family History:
No malignancy in family.

Physical Exam:
On admission:
VS: T96.1 BP 126/84 HR 104 RR 16 97% RA
GENERAL: Lethargic but arousable and answers questions
appropriately, NAD
HEENT: No scleral icterus. Inability to abdjuct eyes
bilaterally.  MMM, OP clear
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: Soft, non-distended.  Discomfort with palpation of the
lower quadrants bilaterally.  No rebound. + guarding.
EXTREMITIES: No c/c/e. Left first finger with work-related
injury in which the fingertip has been cut off.  Does not appear
infected.
NEURO: Inability to abdjuct the eyes.  Other cranial nerves
appear intact.  4/5 strength of left upper and lower extremities
bilaterally.  Right side is intact.  Sensation intact. Gait
assessment deferred.

On discharge:
VS:  96.2 94 126/80 20 90%RA
GEN: alert, NAD
CARD: RRR. No m/r/g
LUNGS: CTA bilaterally, slightly diminished LLL
ABD: Soft, nontender, nondistended. +flatus, incision OTA with
staples, minimal errythema or drainage
EXTR: Pink, warm, well-perfused. No edema.

Pertinent Results:
[**2197-2-2**] 11:45AM BLOOD WBC-15.5*# RBC-4.64 Hgb-13.5* Hct-41.1
MCV-89 MCH-29.2 MCHC-33.0 RDW-13.9 Plt Ct-392#
[**2197-2-2**] 11:45AM BLOOD Neuts-85* Bands-13* Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2197-2-2**] 11:45AM BLOOD Glucose-142* UreaN-82* Creat-3.1*# Na-140
K-5.4* Cl-99 HCO3-23 AnGap-23*
[**2197-2-2**] 02:11PM BLOOD Lactate-1.9
[**2197-2-2**] 03:30PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2197-2-2**] 03:30PM URINE Blood-SM  Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2197-2-2**] 03:30PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0

KUB:
FINDINGS: Bowel gas is seen within non-dilated small bowel and
large bowel including down to the rectum. There is no evidence
of free air. Moderate fecal loading is seen in the colon. Imaged
osseous structures appear unremarkable.
IMPRESSION: Nonobstructive bowel gas pattern. No free air.

CXR: No evidence of acute cardiopulmonary disease. Likely stable

nodule at the right lung apex.

[**2197-2-3**] CT of abd:
1. Jejunal dilatation and wall thickening. Aneurysmally dilated
loop of
jejunum with nodular wall thickening and adjacent contrast and
free air
consistent with perforation. Additional areas of nodular wall
thickening and enlarged mesenteric lymph nodes. Findings most
likely secondary to known melanoma.
2. Sigmoid colon diverticulosis without associated inflammatory
changes.
3. Focal hepatic hypodensities, which likely represent cysts or
hamartomas, stable.

[**2197-2-9**] c-xray
Cardiomediastinal contours are normal. Aside from minimal
atelectasis in the left lower lobe, the lungs are grossly clear.
There is no pneumothorax or pleural effusion.

Brief Hospital Course:
Mr. [**Known lastname **] is a 58 year old man with a history of metastatic
melanoma with brain metastases who presents with constipation
and abdominal pain. His initial KUB and c-xray on admission did
not show evidence of free air in the abdomen, and revealed only
fecal loading in the colon. He was initially admitted to the
medical service for further evaluation of his abdominal pain and
treatment of his presumed constipation. He was given stool
softeners and a bowel regimen and hydrated with IV fluids. His
dexamethasone was continued. Blood and urine cultures were
obtained on admission which have no growth.

On [**2197-2-3**] his abdominal pain did not improve and a CT of
abd/pelvis was contained which demonstrated SB perforation with
contrast extravasation. The Acute Care Surgery Service was
consulted and took Mr. [**Known lastname **] to the operating room on [**2197-2-4**] for
a small bowel resection with primary anastomosis. Findings
intra-operatively included diffuse intra-abdominal metastatic
melanoma including two areas of proximal small bowel perforation
with related purulent peritonitis.  Please see note by Dr. [**Last Name (STitle) 853**]
for further details. Pt tolerated the procedure well and was
brought to the SICU intubated for further care under the ACS
service.

Shortly after arrival to the SICU patient was deemed stable for
extubation.  Pain was initially controlled with dilaudid PCA
though switched to intermittent dilaudid [**3-2**] poor patient
comprehension of PCA usage.  Patient remained A&Ox3 though
confused and perseverative as was apparent preoperative
baseline.  Remained hemodynamically stable without pressor
requirement and did require intermittent IV hydralazine for
hypertension.  Pulmonary toilet was encourage and patient
complied with this appropriately.  Pt kept NPO and hydrated w
IVF.  NGT placed intra-operatively was self-d/c'd by pt [**2-3**]
following extubation.  Foley catheter was kept in place
throughout ICU stay and patient made adequate urine without need
for IVF bolus.  From an endocrine standpoint pt was restarted on
preoperative dose of steroids on POD1.  Stress dose steroids
were not given or required.  Consideration given to
fludrocortisone though electrolytes remained within appropriate
balance and this was deferred.  Insulin sliding scale was
utilized to maintain euglycemia.  Cipro and flagyl were
continued postop while in SICU to prophylax against tertiary
peritonitis and pt remained afebrile while in SICU.  On [**2-5**] pt
deemed appropriate for floor xfer given stable hemodynamics and
appropriate recovery.

His vitals signs were routinely monitored on the floor and he
remained hemodynamically stable and afebrile. Of note, he
continued to have an oxygen requirement of only 1-2L NC, and
mild crackles were noted on lung exam on [**2-9**]. A cxray was
obtained which showed only mild LLL atelectasis. Incentive
spirometry was encouraged and his oxygen saturations remained
stable in the low 90's on room air at discharge.
On [**2-6**] he reported passing flatus. He was started on sips of
clear liquids and his diet was advanced slowly over the next 48
hours. Prior to discharge he had a bowel movement and was
tolerating a regular diet without nausea or abdominal pain.
However, it was noted that he had a decrease in appetite and
poor PO intake. He was started on an appetite stimulant
(marinol) as well as ensure supplements.  His poor intake was
thought to be related to his depressed/flat affect, and he was
also started on a low dose of lexapro for this. Palliative care
was consulted who recommneded changing the marinol to ritalin.
He continued to pass flatus and deny symptoms of nausea or
abdominal pain.
A foley catheter was placed intraoperatively and removed on [**2-6**],
at which time he voided without difficulty. His intake and
output were closely monitored throughout the remainder of his
hospitalization.

Physical therapy was consulted to evaluate the patient's
mobility status who recommended rehab when medically cleared. He
was encouraged to mobilize out of bed as tolerated throughout
his hospitalization. He was also started on SC heparin for DVT
prophylaxis.

Palliative care was also consulted given the patient's prognosis
and diagnosis of metastatic melanoma. The discussion of post
hospital care included options of rehab, home with hospice, or
home with VNA bridging to hospice care. The discussion occurred
with both the patient and his wife, who expressed the desire for
rehab upon leaving the hospital.

Today, he feels well from his abdominal surgery and is preparing
for discharge. His vital signs are stable and he is without
complaints of abdominal pain. He has evidence of bowel function.
He is scheduled for ACS follow as well as follow up with Dr.
[**Last Name (STitle) 724**].

Medications on Admission:
Dexamethasone 4 mg every 6 hours
Levothyroxine 50 mcg PO daily
Oxycodone 5 mg Tablet 1-2 tabs PO q4H PRN
Oxycontin 10-20 mg PO q12H
Compazine 10mg PO TID PRN
Ranitidine 150 mg PO BID


Discharge Medications:
1. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for breakthrough pain.
3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 2 days: 2 days starting [**2-8**]. last dose in PM of
[**2-9**].
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days: 2 days starting [**2-8**]. Last dose in
PM of [**2-9**].
5. dexamethasone 4 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily):
titrating steroid dose to patient's headches and diplopia. .
6. levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for pain: not to exceed 4 gm in 24 hours.
9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
10. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ritalin 5 mg Tablet Sig: One (1) Tablet PO twice a day:
Please give at 0800 and 1400.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 5503**] healthcare center

Discharge Diagnosis:
Primary:
perforated small bowel

Secondary:
metastatic melanoma


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 to the hospital with a small bowel
perforation. You were taken to the operating room and had part
of your small bowel removed. You are recovering well from the
procedure and have resumed bowel function. You are being
discharged to continue your recovery. You may resume a regular
diet.

ACTIVITY:

Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Hospital 5059**] at your next visit.
Don't lift more than 15-20 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.

HOW YOU [**Month (only) **] FEEL:

You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time.  If they do not, tell your [**Month (only) 5059**].

YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.

YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your [**Month (only) 5059**].


PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain

MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].

DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound

Followup Instructions:
Department: NEUROLOGY
When: TUESDAY [**2197-2-21**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2197-2-28**] at 2:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2197-2-14**]
{'Secondary malignant neoplasm of small intestine including duodenum,Perforation of intestine,Other suppurative peritonitis,Acute kidney failure, unspecified,Candidiasis of mouth,Secondary malignant neoplasm of brain and spinal cord,Pulmonary collapse,Panhypopituitarism,Delirium due to conditions classified elsewhere,Dehydration,Other constipation,Adult failure to thrive,Esophageal reflux,Disorders of phosphorus metabolism,Peritoneal adhesions (postoperative) (postinfection),Unspecified acquired hypothyroidism,Diplopia,Leukocytosis, unspecified,Headache,Do not resuscitate status,Personal history of irradiation, presenting hazards to health,Personal history of malignant melanoma of skin,Personal history of antineoplastic chemotherapy,Other opiates and related narcotics causing adverse effects in therapeutic use'}


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: abdominal pain, constipation

PRESENT ILLNESS: Mr. [**Known lastname **] is a 58 year old man with a history of metastatic
melanoma with brain mets who presents to the ER with abdominal
pain and constipation.  History is obtained with the assistance
of his wife who states that they recently traveled on a cruise
and during this trip he was developing worsening headache which
were treated with Oxycontin (10-20 mg [**Hospital1 **]) and Oxycodone 5 mg
taken 2-4 tablets per day.  He has been taking Dexamethasone 4
mg every 6 hours for the past few weeks.  He has been
constipated and last moved his bowels 5 days ago.  He has had
increasing abdominal discomfort over the past few days and his
narcotics have been held for the past 3 days.  For the
constipation he was taking an over the counter senna but this
has not been helping.  He was taking this once a day.

MEDICAL HISTORY: PAST ONCOLOGIC HISTORY:
- [**2194**]: noticed a mole on the right temple
- [**2195-4-17**] mole was resected, pathology revealed melanoma
involving the dermis and subcutis extending to the deep margin,
measuring 9 mm in thickness.
- [**2195-5-8**] CT Torso revealed a 2.5 x 1.2 cm dominant left upper
lobe
ill-defined lung nodule, additional small satellite nodules, a
1.8 x 1.7 cm RUL nodule anteriorly, and multiple liver lesions;
largest measuring 1.6 cm. Head MRI revealed right cerebellar
lesion. He underwent gamma knife radiosurgery on [**2195-5-19**]. He
commenced in temozolomide 200 mg/m2 x 5 days course with largely
stable disease but some areas of disease progression.
- [**2195-8-12**]: CTLA4-ab compassionate access protocol
- [**2195-10-14**] admitted with Hypotension, Acute renal failure,
Pan-hypopituitary syndrome, amd grade 4 rash. He was discharged
on [**2195-10-16**] in good condition. His Rash responded to 2mg/kg/day
dose of prednisone with grade [**1-30**].
- His CT scan and head MRI for week 24 revelaed a new R deep
insular, L parietal CNS lesions, parotid gland involvement as
well as a new
subcutaneous mass in the R temple. He was taken off of protocol
at that time.
- [**12/2195**]: underwent CK to the two new lesion found on the MRI,
R insular and L parietal lesions
- [**2196-4-7**] underwent resection of a melanoma from the right
parotid region by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**].
- [**2195-5-4**]: Cyberknife radiosurgery on [**2196-5-3**] to a left frontal
metastasis to 2200 cGy at 74% isodose line, and status external
beam
irradiation to the parotid gland at [**Hospital 1474**] Hospital by [**Last Name (NamePattern1) 85702**].
- [**9-/2196**]: began WBXRT due to progression in the CNS, completed
[**10/2196**]

MEDICATION ON ADMISSION: Dexamethasone 4 mg every 6 hours
Levothyroxine 50 mcg PO daily
Oxycodone 5 mg Tablet 1-2 tabs PO q4H PRN
Oxycontin 10-20 mg PO q12H
Compazine 10mg PO TID PRN
Ranitidine 150 mg PO BID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
VS: T96.1 BP 126/84 HR 104 RR 16 97% RA
GENERAL: Lethargic but arousable and answers questions
appropriately, NAD
HEENT: No scleral icterus. Inability to abdjuct eyes
bilaterally.  MMM, OP clear
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: Soft, non-distended.  Discomfort with palpation of the
lower quadrants bilaterally.  No rebound. + guarding.
EXTREMITIES: No c/c/e. Left first finger with work-related
injury in which the fingertip has been cut off.  Does not appear
infected.
NEURO: Inability to abdjuct the eyes.  Other cranial nerves
appear intact.  4/5 strength of left upper and lower extremities
bilaterally.  Right side is intact.  Sensation intact. Gait
assessment deferred.

FAMILY HISTORY: No malignancy in family.

SOCIAL HISTORY: Married, four children.  The patient owns business in sheet
metal parts.  He is still working. 

### Response:
{'Secondary malignant neoplasm of small intestine including duodenum,Perforation of intestine,Other suppurative peritonitis,Acute kidney failure, unspecified,Candidiasis of mouth,Secondary malignant neoplasm of brain and spinal cord,Pulmonary collapse,Panhypopituitarism,Delirium due to conditions classified elsewhere,Dehydration,Other constipation,Adult failure to thrive,Esophageal reflux,Disorders of phosphorus metabolism,Peritoneal adhesions (postoperative) (postinfection),Unspecified acquired hypothyroidism,Diplopia,Leukocytosis, unspecified,Headache,Do not resuscitate status,Personal history of irradiation, presenting hazards to health,Personal history of malignant melanoma of skin,Personal history of antineoplastic chemotherapy,Other opiates and related narcotics causing adverse effects in therapeutic use'}
