CHIEF COMPLAINT: Bloody stool, hypotension

PRESENT ILLNESS: This is a 67 year old lady with stage [**Doctor First Name **] oropharyngeal SCC
cancer c/b dysphagia requiring PEG tube, h/o jejunal perforation
c/b peritonitis s/p primary repair c/b sepsis and anastamotic
leak s/p SB resection, who presents for management of a GI bleed
after a recent admission in [**Location (un) 5354**] where she receives her
medical care.

MEDICAL HISTORY: - stage [**Doctor First Name **] (T4a N2b) SCC of the right oropharynx and
hypopharyns, s/p chemo-XRT (last tx [**2159-4-12**])
- paroxysmal atrial fibrillation, not on anticoagulation
- h/o jejunal perforation in [**4-/2158**] c/b peritonitis, s/p primary
repair c/b sepsis and anastamotic leak, s/p SB resection
- h/o UTI and E.coli septicemia

MEDICATION ON ADMISSION: Medications: (home)
- amiodarone 200mg daily
- digoxin 0.125mg daily
- K-dur 20 meq daily
- reglan 10mg qid
- Omeprazole 40mg daily
- Solu-Cortef 50mg IV q8hrs taper

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: GENERAL - NAD.
HEENT - NC/AT, PERRLA, right eye close, MM dry, OP dry.
NECK - supple, no JVD
HEART - RRR, nl S1-S2, no m/r/g
LUNGS - Mild upper airway sounds. Mild crackles at bases. No inc
work of breathing.
ABDOMEN - NABS, soft/NT/ND, PEG in place without bleeding, no
rebound/guarding.
EXTREMITIES - R arm with some swelling up to the elbow, WWP, no
c/c/e, 1+ peripheral pulses (radials, DPs).
NEURO - awake, A&Ox3, decreased sensation to light touch on
right side of face in V1,2 and 3 distributions. Right eye closed
and fixed. Left eye with some movement superior, medial and
inferior. Pupils are equal and round. Strenth 4+ in all
extremities. Sensation intact to light touch in all extremities
distally.

FAMILY HISTORY: Mother - complications of pneumonia age 35.
Father unknown.
A sister died from EtOH abuse.
A half-sister had throat or esophageal cancer.
No other known GI or liver disease.

SOCIAL HISTORY: - Tobacco: quit in [**4-21**], 1ppd x 35 years
- Alcohol:  etoh
- Illicits: non
- Housing: lives alone in [**Location (un) **]
- Employment: Retired from police dept and small business
accounting. Divorced, with 2 grown children.
Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Glucocorticoid deficiency,Acute posthemorrhagic anemia,Do not resuscitate status,Duodenitis, without mention of hemorrhage,Atrial fibrillation,Gastrostomy status,Personal history of tobacco use,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx,Personal history, urinary (tract) infection,Family history of malignant neoplasm of trachea, bronchus, and lung,Family history of malignant neoplasm of gastrointestinal tract
Chr duoden ulcer w hem,Food/vomit pneumonitis,Acute respiratry failure,Glucocorticoid deficient,Ac posthemorrhag anemia,Do not resusctate status,Duodenitis w/o hmrhg,Atrial fibrillation,Gastrostomy status,History of tobacco use,Hx antineoplastic chemo,Hx of irradiation,Hx-oral/pharynx malg NEC,Personal history UTI,Fm hx-trach/bronchog mal,Family hx-gi malignancy
Admission Date:  [**2159-7-22**]              Discharge Date:   [**2159-8-2**]

Date of Birth:  [**2092-5-31**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Bloody stool, hypotension

Major Surgical or Invasive Procedure:
Endoscopy via PEG, PEG replaced

History of Present Illness:
This is a 67 year old lady with stage [**Doctor First Name **] oropharyngeal SCC
cancer c/b dysphagia requiring PEG tube, h/o jejunal perforation
c/b peritonitis s/p primary repair c/b sepsis and anastamotic
leak s/p SB resection, who presents for management of a GI bleed
after a recent admission in [**Location (un) 5354**] where she receives her
medical care.

In brief, the patient has a recent history of stage [**Doctor First Name **] SCC
cancer of the throat.  She completed primary chemoradiation in
[**Month (only) 958**] of this year. Her management has been complicated by CN
impairment of her right eye, severe dysphagia necessitating PEG
tube placement, ecoli bacteremoa and sepsis and neutropenic
fever and more recently significant failure to thrive with
multiple recent admissions in [**Location (un) 5354**].

Most recently, she was admitted on [**7-9**] to an OSH after a fall
in the setting of generalized weakness. She was treated for
hyponatremia (Na 119) felt to be SIADH. In the setting of
hypotension, hypokalemia and hyponatremia, there as concern for
adrenal insufficiency and she was given stress dose steroids. An
cortisol level was 18. She was subsequently transitioned to a
rehab facility where she initially did well. On [**7-20**] her RN noted
she had large amount of BRBPR and transferred her back to the
hospital. She was hypotensive, with a hct drop 31->19.  Per her
son, an upper endoscopy was not possible given her throat
anatomy. She was given IVF and 3 units of pRBC. An attempt at an
IR embolization was made yesterday which was negative. In the
setting of persistent bloody (black) stool, her son who is from
[**Name (NI) 86**], made contact with a GI physician at [**Hospital1 18**] and signed out
his mother AMA and brought her to the emergency department via
the airport to establish care.  Her labs on [**7-21**] were WBC 11.6,
Hgb 11.1, Hct 32.5, Plt 278; BUN 35, Cr 0.75. She denies prior
colonscopy, recent NSAID use, hemorrhoids, recent diarrhea or
constipation, etoh history or liver disease. She is not
currently on chemotherapy. No recent fevers per her knowledge.

In the ED, initial VS were:  98.0 75/43 17 95%  Exam revealed
brown guaic positive stool.  Labs were significant for WBC 9.9
(90% PMNs), Hgb 11.0, Hct 32.2, Na 141, creatinine 0.7.  An EKG
demonstrated sinus rhythm w/ TWI across the precordium. A CXR
was unremarkable. Blood cultures were sent. She was t/s and
crossed for 2 units. GI was consulted who did a PEG-tube lavage
with clear return, no bilious fluid, no blood or coffee grounds.
 Blood pressures improved to the 90-100s with 500 NS bolus.  She
was started on IV ppi gtt with bolus and admitted to the MICU
for management of a GIB and hypotension. Her access was a port
and 18guage PIV. Vitals on transfer: 104/52, 71, 21, 93% RA
(500cc of fluid total)

On arrival to the MICU,  initial vitals were: 97.8 67 100/48 12
96% RA.

Past Medical History:
- stage [**Doctor First Name **] (T4a N2b) SCC of the right oropharynx and
hypopharyns, s/p chemo-XRT (last tx [**2159-4-12**])
- paroxysmal atrial fibrillation, not on anticoagulation
- h/o jejunal perforation in [**4-/2158**] c/b peritonitis, s/p primary
repair c/b sepsis and anastamotic leak, s/p SB resection
- h/o UTI and E.coli septicemia

Past Surgical History:
- right sphenoidectomy with biopsy [**2159-7-4**]
- right neck FNA [**1-/2159**]
- right breast biopsy
- tonsillectomy
- s/p perforated jejunal repair [**4-/2158**], s/p anastamotic leak
repair [**4-/2158**]
- s/p PEG tube placement

Social History:
- Tobacco: quit in [**4-21**], 1ppd x 35 years
- Alcohol:  etoh
- Illicits: non
- Housing: lives alone in [**Location (un) **]
- Employment: Retired from police dept and small business
accounting. Divorced, with 2 grown children.

Family History:
Mother - complications of pneumonia age 35.
Father unknown.
A sister died from EtOH abuse.
A half-sister had throat or esophageal cancer.
No other known GI or liver disease.

Physical Exam:
GENERAL - NAD.
HEENT - NC/AT, PERRLA, right eye close, MM dry, OP dry.
NECK - supple, no JVD
HEART - RRR, nl S1-S2, no m/r/g
LUNGS - Mild upper airway sounds. Mild crackles at bases. No inc
work of breathing.
ABDOMEN - NABS, soft/NT/ND, PEG in place without bleeding, no
rebound/guarding.
EXTREMITIES - R arm with some swelling up to the elbow, WWP, no
c/c/e, 1+ peripheral pulses (radials, DPs).
NEURO - awake, A&Ox3, decreased sensation to light touch on
right side of face in V1,2 and 3 distributions. Right eye closed
and fixed. Left eye with some movement superior, medial and
inferior. Pupils are equal and round. Strenth 4+ in all
extremities. Sensation intact to light touch in all extremities
distally.


Pertinent Results:
ADMISSION LABS:
[**2159-7-22**] 09:45PM BLOOD WBC-9.9 RBC-3.61* Hgb-11.0* Hct-32.2*
MCV-89 MCH-30.4 MCHC-34.0 RDW-16.9* Plt Ct-238
[**2159-7-22**] 09:45PM BLOOD Neuts-90* Bands-0 Lymphs-4* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-4* Myelos-0
[**2159-7-22**] 09:45PM BLOOD PT-12.3 PTT-30.5 INR(PT)-1.1
[**2159-7-22**] 09:45PM BLOOD Glucose-78 UreaN-28* Creat-0.7 Na-141
K-4.1 Cl-104 HCO3-25 AnGap-16
[**2159-7-22**] 09:45PM BLOOD Calcium-8.7 Phos-3.8 Mg-1.7
[**2159-7-22**] 09:57PM BLOOD Lactate-0.8
[**2159-7-23**] 02:19AM BLOOD Digoxin-1.1

CHEST X-RAY ([**2159-7-22**]):  Findings suggestive of chronic
obstructive airways disease.  No evidence of pneumonia.

[**7-23**] EGD:
The pediatric gastroscope was entered through the gastrostomy
site. We were able to enter the esophagus up to the upper
esophageal sphincter as well as the duodenum. Mild esophagitis.
Linear gastric body mucosa abnormality consistent with possible
tear [**3-15**] trauma from PEG removal v. linear gastric ulcer, not
bleeding. Severe diffuse duodenal edema, erythema, friability,
which is the likely source of the melena. Otherwise normal EGD
to third part of the duodenum, upper esophageal sphincter.

[**7-25**] Left Upper Extremity Doppler:
IMPRESSION:  Occlusive thrombus seen in the right cephalic vein,
which is a superficial vein.  No deep vein thrombosis is seen.
Dampened phasicity of waveforms noted throughout the right upper
extremity could represent a more central stenosis or thrombosis.
 A CT or MRI could provide further assessment if clinically
indicated.

[**7-26**] CXR:
IMPRESSION:  New left lower lobe airspace consolidation,
consistent with
aspiration pneumonitis or pneumonia, given clinical context.

[**7-26**] CT Chest:
IMPRESSION:
1.  Equivocal filling defect in the right subclavian vein may be
artifactual though small thrombus would be difficult to exclude.
Changes from the initial interpretation regarding this finding
were discussed with Dr. [**Last Name (STitle) 18835**] by Dr. [**First Name (STitle) **] at 1015 on [**2159-7-27**]
by phone 10 minutes after discovery.
2.  Diffuse mid and distal esophageal thickening with small
hiatal hernia, correlate for symptoms of esophagitis
3.  Oropharyngeal mass better assessed on a dedicated neck CT
concurrently obtained.
4.  Prominent but not pathologically enlarged mediastinal nodes
as above.
5.  Hepatic hypodensities which are too small to be
characterized and left adrenal nodularity are both incompletely
evaluated. Comparisons to prior outside imaging would be prudent
in the setting of known malignancy.
6.  Trace bibasilar pleural effusions and atelectasis.
7.  Thyroid hypodensity as above can be assessed with
non-emergent ultrasound if clinically relevant.

[**7-26**] CT head/neck (w + w/o contrast):
IMPRESSION:
1.  Large 4 x 5 cm extradural enhancing mass obliterates the
sphenoid sinuses and erodes into the adjacent skullbase, right
ethmoid and maxillary sinuses. Differential includes metastasis,
nasopharyngeal carcinoma, sphenoid sinus malignancy , chordoma
or chondrosarcoma.Recommend MRI skull base for further
evaluation.
2.  No evidence of obstructive hydrocephalus.
3.  The mass surrounds the bilateral internal carotid arteries,
patency of which is better demonstrated on CT neck.

[**7-27**]-AM CXR:
IMPRESSION:  Resolving left basal atelectasis, without acute
chest
abnormality.

[**7-27**]-PM CXR:
Since the previous study, there has been development of new
consolidation at the right base.  This is concerning for
pneumonia or partial right lower lobe collapse.  There is also
some volume loss.  There is a right-sided Port-A-Cath with the
distal lead tip in the proximal SVC.  There is some atelectasis
at the left base.  Heart size is enlarged but stable.

[**7-28**] CXR:
There has been mild improved aeration at the right base;
however, a right
basilar opacity remains.  There is atelectasis at the left base.
 There are bilateral pleural effusions, right side worse than
left.  A right-sided Port-A-Cath with the distal lead tip in the
proximal SVC is again seen and stable. There are no
pneumothoraces.  Heart size is within normal limits. There is
calcification in the thoracic aorta.

[**7-29**] CXR:
Bibasilar opacities have improved on the right and worsened on
the left
consistent with aspiration, pleural effusions and increasing
atelectasis in the left lower lobe, also contribute to the
radiologic findings.
Cardiomediastinal contours are normal.  Right Port-A-Cath tip is
in the upper SVC.  There is no pneumothorax.

[**8-1**] CXR:
Cardiac size is top normal.  Increasing opacities in the left
lower lobe could be due to worsening atelectasis, but
superimposed infection cannot be excluded in the appropriate
clinical setting.  Small left pleural effusion has increased.
If any, there is a small right pleural effusion.  Right
Port-A-Cath tip is in the upper SVC.  There is no pneumothorax.


Brief Hospital Course:
Hospital Summary:
67 year old woman with stage [**Doctor First Name **] oropharyngeal SCC cancer s/p
chemoradiation c/b sepsis w small bowel perfs, atrial
fibrillation not on coumadin, who originally presented for
management of a GIB with a hospital course complicated by
multiple episodes of respiratory distress requiring transfer to
the ICU. The patient ultimately developed hypercarbic
respiratory failure in the setting of advanced metastatic
cancer. She was ultimately made comfortable and passed on
[**2159-8-2**] at 6:48pm. The family refused autopsy.

*****1ST MICU COURSE******* ([**7-23**] - [**7-27**])
# Gastro-Intestinal Bleeding: The patient presented to OSH in
[**State 5864**] with BRBPR - reportedly, Hct was 19, down from baseline
of 30.7. At OSH, GI was unable to perform endoscopy due to
anatomy and IR was unable to detect the bleeding vessel. She was
transfused 3U PRBC and then signed out AMA by her son and
brought to the [**Hospital1 **]. At the [**Hospital1 **], initial Hct was 32.2. She was
initially hypotensive to 75/43 but pressures normalized after
500 cc bolus in ER. GI was consulted and performed upper
endoscopy through her PEG tube site on [**7-23**]. Endoscopy showed
mild esophagitis and severe, diffuse duodenal edema, erythema,
and friability. She was started on a protonix gtt (later changed
to protonix [**Hospital1 **]). She was transfused 1U PRBC for a Hct of 26.7
but Hcts remained stable thereafter and she was HDS at time of
transfer to the floor. Access was with PIVs and R port.
.
# Adrenal Insufficiency: According to OSH records, patient had
recently been diagnosed with adrenal insufficiency and arrived
on a steroid taper (was only on 10 mg hydrocortisone at hs on
transfer). Repeat [**Last Name (un) 104**] stim was performed and was nl with
response from 8.4 -> 30.7. Hydrocort 10 mg qhs was continued
initially, DC'd on [**7-24**] as was minimum dose and thus no need to
continue tapering.
.
# Atrial Fibrillation: Not on coumadin. Patient remained in
sinus rhythm while in the ICU. Her digoxin 0.125 mg qday and
amiodaraone 200 mg qday was continued.
.
# SCC oropharyngeal cancer: s/p radiation/chemotherapy last in
3/[**2159**].  Has now transitioned care from [**Location (un) 5354**] to [**Location (un) 86**].
Spoke to son about overall plan who expressed that he was aware
his mother's disease was metastatic to her nasopharynx
accounting for her cranial nerve palsies. He intends to have her
care transferred to [**Location (un) 86**].
.
# Failure to Thrive: Pt/ot c/s when able.
.
Prophylaxis was with protonix and heparin SC BID. Communication
was with her son [**Name (NI) **] [**Telephone/Fax (1) 112212**] (HCP). Patient is DNR/DNI,
confirmed.
.
*****MEDICINE FLOOR********
#Hypotension: On HD4 had sBP in 80s but continued to mentate ok.
Responded to 1L IVF fluids and thought to be likely volume
depletion. She was started on iv vanc/cefepime/flagyl for
because of concern for aspiration PNA. Her sBPs were confirmed
with dopplers in her arms. Her heart rate was from 60-90s and
she continued to be afebrile. She was transfered back to the ICU
because of concern for systemic infection.
.
# Aspiration PNA/Mucus plugging - CXR showed opacity in LLL.
Given her hypotension she was started on empiric HCAP/aspiration
therapy w/ vanc/cefepime/flagyl. She continued to be afebrile.
Overnight HD 4->5 had desat to 82% on RA thought to be due to
mucus plugging. CXR overnight w/o evidance of volume overload
and improvement in LLL opasity. CT chest with trace bibasilar
effusions and atelectasis. Otherwise clear lungs. She was on 94%
on 5L shovel mask on transfer the the ICU.
.
#Gastro-Intestinal Bleeding: Hct remained stable since she came
to the floor without signs of melena, hematochemia or brbpr. She
was continued on PPI therapy and hct were monitored dialy.
.
# SCC oropharyngeal cancer: Stage [**Doctor First Name **] (T4a N2b) SCC s/p
radiation/chemotherapy last in 3/[**2159**]. Is now trying to
transition care from [**Location (un) 5354**] to [**Location (un) 86**]. Before her recent
hospitalization, she was schedule to receive further
chemotherapy and XRT. She desires continued treatment for her
cancer. Outpatient oncology follup was arranged. PT and social
work evaluted. CT of head, neck and chest was ordered to better
characterize her cancer and to rule out acute cranial process.
.
# Hyponateremia - Sodium trending down (136->132) but improved
with fluids
.
# R. Arm swelling: RUE US - no dvt. +superficial clot. Abnormal
doppler waveform with concern for SVC obstruction. CT chest
showed right port-a-cath, with the tip in the upper SVC which is
though to explain the doppler abnormalities.
.
# Failure to Thrive/Nutrition - Restarted tube nutrition
regiment per nutrition consult recs.
.
#Atrial Fibrillation: She continued on digoxin 0.125mg daily and
amiodarone 200mg daily.
.
*****2nd MICU COURSE******* ([**Date range (1) 112054**])
Patient was transferred for hypoxia and hypotension and the
morning of [**7-27**]. On arrival to the MICU, patient was mildly
hypotensive which responded to IV fluids (received 2L on the
floor and 1.5L in ICU). It was discovered that her leg BP were
far more accurate and precise than non-invasive pressures on her
arm. Her BPs on [**7-29**] were 130s-140s/60s. Her amiodarone and
digoxin were initially held in setting of hypotension;
amiodarone was restarted on [**7-29**] without incident with plans to
restart digoxin on [**7-30**]. She was hypoxic likely secondary to
chronic aspiration of tube feeds (frequently suctioned tube
feeds from airway, RLL infiltrate seen on CXR) so her tube feeds
were changed to continuous, she was started on Mucinex [**Hospital1 **] and
she was educated re: self-suctioning. Oxygen sats prior to
call-out were 97% on 4L cn. Her antibiotics that had been
started for possible aspiration (vanc/cefepime/[**Last Name (un) 2830**]) were
stopped as her picture was thought to be more consistent with
pneumonitis. She will need q4 hrs suctioning on the floor. The
patient and her son emphasize that they would like her oncology
care transferred to [**Hospital1 18**] and are interested in establishing
care with a new oncologist here.
.
*****2ND MEDICINE FLOOR COURSE******* ([**Date range (1) 85670**])
# Hypoxia: Improving today. Likely due to recent aspiration
events and mucous plugging from oropharyngeal secretions. CXR
showed RLL opacity that is probably a pneumonitis from recent
aspiration events. She has been afebrile since discontinuing
antibiotics, but it is possible that she is continuing to
aspirate despite being NPO. O2 sat is 93-100% on 3L NC. EKG w/o
evidance of r. heart strain.
.
# Hyponateremia - Sodium trending down (134->131). Also bicarb
increasing 28->34. Look euvolemic to hypovolemic on exam.
Hyponatremia (Na 119 at OSH) felt to be SIADH at OSH before
admission. Cortisol stim test here negative. It is possible that
with her recovery and fluids she is having a recrudescence of
her SIADH vs hypovolemic hyponatremia. gentle fluid bolus -
500cc NS given.
.
.
# Afib: not on coumadin, in sinus rhythm and normal rate.
Digoxin and amiodarone were initially held in the setting of
hypotension. She has been hemodynamically stable over the last 2
days. Continued amiodarone 200 mg PO daily, digoxin 0.125 mg.
.
# Hypotension: Felt to be inaccurate measurements. BP from thigh
have yielded normal BPs. She is afebrile and feeling improved so
low suspicion for sepsis. Considered adrenal insuffiancy as a
cause of her symptoms given diagnosis on previous
hospitalization but her cortisol stimulation test in the ICU was
negative.
.
# Oropharyngeal SCC: s/p radiation/chemotherapy last in 3/[**2159**].
Has now transitioned care from [**Location (un) 5354**] to [**Location (un) 86**].  Back in
[**Month (only) 958**] she she was supposed to continue her therapy of
chemotherapy and radiation therapy but this was put on hold due
to her episode of neutropenia and e.coli septicemia and then
subsequent GI bleed.
.
# Failure to thrive: PEG tube in place. On continuous tube feeds
due to trouble with aspiration.
------------
.
# Gastro-Intestinal Bleeding: The patient presented to OSH in
[**State 5864**] with BRBPR - reportedly, Hct was 19, down from baseline
of 30.7. At OSH, GI was unable to perform endoscopy due to
anatomy and IR was unable to detect the bleeding vessel. She was
transfused 3U PRBC and then signed out AMA by her son and
brought to the [**Hospital1 **]. At the [**Hospital1 **], initial Hct was 32.2. She was
initially hypotensive to 75/43 but pressures normalized after
500 cc bolus in ER. GI was consulted and performed upper
endoscopy through her PEG tube site on [**7-23**]. Endoscopy showed
mild esophagitis and severe, diffuse duodenal edema, erythema,
and friability. She was started on a protonix gtt (later changed
to protonix [**Hospital1 **]). She was transfused 1U PRBC for a Hct of 26.7
but Hcts remained stable thereafter and she was HDS at time of
transfer to the floor. Access was with PIVs and R port.
.
# Adrenal Insufficiency: According to OSH records, patient had
recently been diagnosed with adrenal insufficiency and arrived
on a steroid taper (was only on 10 mg hydrocortisone at hs on
transfer). Repeat [**Last Name (un) 104**] stim was performed and was nl with
response from 8.4 -> 30.7. Hydrocort 10 mg qhs was continued
initially, DC'd on [**7-24**] as was minimum dose and thus no need to
continue tapering.
.
*****3rd MICU Course ([**Date range (3) 112213**])
# Hypercarbia: The patient was most likely in hypercarbic
respiratory distress [**3-15**]. Initially felt likely due to
oversedation given the time course with oxycodone administration
and worsening Co2/MS, however response to Narcan not supportive
of this as underlying etiology. Ultimately felt secondary to
combination of progressive respiratory muscle weakness,
underlying COPD, and probably central neurologic impairement
leading to reduced respiratory drive in the setting of
metastatic cancer. She failed BIPAP trial. The patient's
respiratory acidosis continued to worsen, and the patient was
made CMO.
.
# Hypoxia: The patient's oxygen requirement was stable on the
floor until her hypercarbia worsened to a PCO2 of 80. This was
most likely due to recent aspiration events and mucous plugging
from oropharyngeal secretions. The patient was managed with HOB
elevation, continuation of chest PT, frequent suctioning of
secretions, standing nebs, and standing orders of guaifenesin.
.
# Hyponatremia: The patient's sodium was trending down on floor
(134->131-> 130->129). [**Last Name (un) **] stim test was negative.  The patient
apparently became more hyponatremic after receiving NS on the
floor. The patient was recently treated at [**Hospital 5354**] Hospital
for hyponatremia thought to be [**3-15**] SiADH.  Urine electrolytes in
the MICU were found to be U Na 111, FENa 1.13% (intrinsic
renal), FEUrea% 40.75 (>35% intrinsic renal); Uosm high with
significant Na wasting consistent with SIADH.
.
# GIB: Hct overall stable since 1U PRBC transfusion. Thought to
be [**3-15**] duodenitis seen on EGD here on admission. Was treated
with PPI and remained stable.
.
# Afib: The patient was not anticoagulated on coumadin, and
while in the MICU, was in sinus rhythm at a normal rate. The
patient was monitored on telemetry.  Her home amiodarone and
digoxin were continued.  The patient was made CMO.
.
# Hypotension: Felt to be inaccurate measurements. BP from her
thigh yielded normal BPs.
.
# Oropharyngeal SCC: The patient is s/p radiation/chemotherapy
last in 3/[**2159**]. she has now transitioned care from [**Location (un) 5354**] to
[**Location (un) 86**]. Back in [**Month (only) 958**] she was supposed to continue her therapy
of chemotherapy and radiation therapy but this was put on hold
due to her episode of neutropenia and e.coli septicemia and then
subsequent GI bleed. Patient was found on imaging during this
hospitalization to have very advanced metatastatic disease with
note of large 4 x 5 cm extradural enhancing mass obliterating
the sphenoid sinuses, eroding into the adjacent skullbase, right
ethmoid and maxillary sinuses. Internal carotid arteries were
also surrounded by tumor. Patient's cancer was felt to be
terminal and ultimately was made CMO.
.
# Failure to thrive: the patient has a PEG tube in place. She
was on continuous tube feeds due to trouble with aspiration, but
her diet was advanced and she was made CMO.

Medications on Admission:
Medications: (home)
- amiodarone 200mg daily
- digoxin 0.125mg daily
- K-dur 20 meq daily
- reglan 10mg qid
- Omeprazole 40mg daily
- Solu-Cortef 50mg IV q8hrs taper

Medications:  (prior to transfer)
- aspirin 81mg daily
- amiodarone 200mg daily
- KCl 20mEq daily
- digoxin 0.125 mg daily
- Lovenox 40mg daily
- Miralax 17 grams daily
- Prilosec 40mg daily
- Salt tabs daily
- Xopenex Q6hrs PRN
- 10mg QHS
- Ambien 10mg QHS
- Lactulose 20gm daily PR
- Vicodin
- Reglan 10mg QID PRN
- Zofran 4mg Q4hrs PRN


Discharge Medications:
n/a

Discharge Disposition:
Expired

Discharge Diagnosis:
Upper GI bleed - duodenal tear vs ulcer
Metastatic squamous cell carcinoma
Respiratory failure


Discharge Condition:
Expired

Discharge Instructions:
n/a

Followup Instructions:
n/a

                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Glucocorticoid deficiency,Acute posthemorrhagic anemia,Do not resuscitate status,Duodenitis, without mention of hemorrhage,Atrial fibrillation,Gastrostomy status,Personal history of tobacco use,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx,Personal history, urinary (tract) infection,Family history of malignant neoplasm of trachea, bronchus, and lung,Family history of malignant neoplasm of gastrointestinal tract'}


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: Bloody stool, hypotension

PRESENT ILLNESS: This is a 67 year old lady with stage [**Doctor First Name **] oropharyngeal SCC
cancer c/b dysphagia requiring PEG tube, h/o jejunal perforation
c/b peritonitis s/p primary repair c/b sepsis and anastamotic
leak s/p SB resection, who presents for management of a GI bleed
after a recent admission in [**Location (un) 5354**] where she receives her
medical care.

MEDICAL HISTORY: - stage [**Doctor First Name **] (T4a N2b) SCC of the right oropharynx and
hypopharyns, s/p chemo-XRT (last tx [**2159-4-12**])
- paroxysmal atrial fibrillation, not on anticoagulation
- h/o jejunal perforation in [**4-/2158**] c/b peritonitis, s/p primary
repair c/b sepsis and anastamotic leak, s/p SB resection
- h/o UTI and E.coli septicemia

MEDICATION ON ADMISSION: Medications: (home)
- amiodarone 200mg daily
- digoxin 0.125mg daily
- K-dur 20 meq daily
- reglan 10mg qid
- Omeprazole 40mg daily
- Solu-Cortef 50mg IV q8hrs taper

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: GENERAL - NAD.
HEENT - NC/AT, PERRLA, right eye close, MM dry, OP dry.
NECK - supple, no JVD
HEART - RRR, nl S1-S2, no m/r/g
LUNGS - Mild upper airway sounds. Mild crackles at bases. No inc
work of breathing.
ABDOMEN - NABS, soft/NT/ND, PEG in place without bleeding, no
rebound/guarding.
EXTREMITIES - R arm with some swelling up to the elbow, WWP, no
c/c/e, 1+ peripheral pulses (radials, DPs).
NEURO - awake, A&Ox3, decreased sensation to light touch on
right side of face in V1,2 and 3 distributions. Right eye closed
and fixed. Left eye with some movement superior, medial and
inferior. Pupils are equal and round. Strenth 4+ in all
extremities. Sensation intact to light touch in all extremities
distally.

FAMILY HISTORY: Mother - complications of pneumonia age 35.
Father unknown.
A sister died from EtOH abuse.
A half-sister had throat or esophageal cancer.
No other known GI or liver disease.

SOCIAL HISTORY: - Tobacco: quit in [**4-21**], 1ppd x 35 years
- Alcohol:  etoh
- Illicits: non
- Housing: lives alone in [**Location (un) **]
- Employment: Retired from police dept and small business
accounting. Divorced, with 2 grown children. 

### Response:
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Glucocorticoid deficiency,Acute posthemorrhagic anemia,Do not resuscitate status,Duodenitis, without mention of hemorrhage,Atrial fibrillation,Gastrostomy status,Personal history of tobacco use,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Personal history of malignant neoplasm of other and unspecified oral cavity and pharynx,Personal history, urinary (tract) infection,Family history of malignant neoplasm of trachea, bronchus, and lung,Family history of malignant neoplasm of gastrointestinal tract'}
