CHIEF COMPLAINT: Displaced Nephrostomy Tube, Hyponatremia

PRESENT ILLNESS: Ms. [**Known lastname **] is a 52 y/o F with a h/o stage IV appendiceal
adenocarcinoma recently complicated by pseudomonal urosepsis
from bilateral hydronephrosis requiring the placement of
bilateral nephrostomy tubes who presents from home after one of
the tubes has been displaced.  She was recently discharged from
[**Hospital1 18**] on [**2104-9-3**], at which time she was found to have
pseudomonal urosepsis and was discharged on ciprofloxacin 400mg
IV BID to complete a 14 day course, during that hospital stay
she was also found to be hyponatremic with a sodium in the high
120's, thought to be due to SIADH.  Today when her family was
helping move her from the couch her right nephrostomy tube got
caught on something and was accidentally pulled out so her
family brought her to the ER to have the tube replaced.  She
currently feels weaker than her baseline but has trouble
describing how she feels, denies any fever/chills, CP, SOB,
n/v/d, HA or changes in her vision, denies any changes in her
ostomy output.
.
In the ED, initial vs were: 98.7, 76, 92/72, 16, 98% RA.  The
initial plan had been to have IR replace the nephrostomy tube
tonight, however when her labs returned this was put off.  Her
labs were notable for a white count of 33.7, Na of 114, K of
6.4, lactate of 3.8, and a BUN of 35.  Her EKG was NSR at 97bpm,
no peaked T-waves or PR prolongation, poor R wave progression.
She was given 10 units of IV insulin, 1 amp of D50, calcium
gluconate, her scheduled dose of ciprofloxacin, along with
cefepime and vancomycin for her leukocytosis.  A repeat K after
treatment was 5.4 and her sodium was 116.  While in the ER it
was noted that her left sided nephrostomy tube was not draining
anymore either.  By report, after multiple discussions in the ER
she refused kayexelate and placement of a peripheral IV,
although she would like the nephrostomy tubes replaced for
comfort, as she is no longer seeking treatment for her
underlying cancer and is DNR/DNI on home hospice.  VS on
transfer were: 106, 104/74, 10, 100% on RA.
.
On arrival to the ICU her initial VS were: 95.8, 99, 101/75, 9,
99% on RA.  She says that her pain is improved after the pain
medication, she has no other complaints.  Also on arrival to the
ICU it was noted that her left sided nephrostomy tube was not
draining or flushing.
.
Review of systems:
(+) Per HPI and for anorexia
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation or changes in bowel habits.

MEDICAL HISTORY: Stage IV appendiceal adenocarcinoma (pT3 Nx pM1b);
K-Ras mutation confirmed
- [**2102-11-3**]: Presented to [**Hospital1 18**] ED for progressive
abdominal/pelvic discomfort. CT demonstrated "marked abnormal
distention of the endometrial cavity measuring up to 6.5 cm"
which was filled with high-density fluid. There was a possible
mass within the cervix as well as a 2.2 x 3.2 cm cystic lesion
within the right adnexa. Of note, the appendix was described as

MEDICATION ON ADMISSION: oxycodone 5 mg: 1-2 Tablets PO Q4H as needed for pain
acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever: Max of 3 grams daily.
Ativan 0.5 mg: One Tablet PO at bedtime as needed for insomnia
ciprofloxacin 400 mg IV every 12 hours to end on [**2104-9-13**]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam on Admission:
Vitals T 95.8 BP 101/75 HR 99 O2 99% on 2L NC
General Appearance: Anxious, cachetic
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : throughout )
Abdominal: Soft, Bowel sounds present, Distended, Tender:
throughout
Extremities: Right lower extremity edema: 4+, Left lower
extremity edema: 4+
Musculoskeletal: Muscle wasting
Skin:  Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time , Movement:
Purposeful, Tone: Not assessed

FAMILY HISTORY: She denies any family history of breast cancer, ovarian cancer,
uterine cancer, or colon cancer.

SOCIAL HISTORY: She is married.  She denies tobacco, drug, or alcohol use.  She
lives with her husband and son.  She reports feeling safe at
home.
Other mechanical complication of genitourinary device, implant, and graft,Hyposmolality and/or hyponatremia,Cachexia,Secondary malignant neoplasm of retroperitoneum and peritoneum,Acute kidney failure, unspecified,Personal history of malignant neoplasm of large intestine,Encounter for palliative care
Malfunc gu dev/graft NEC,Hyposmolality,Cachexia,Sec mal neo peritoneum,Acute kidney failure NOS,Hx of colonic malignancy,Encountr palliative care
Admission Date:  [**2104-9-12**]              Discharge Date:   [**2104-9-13**]

Date of Birth:  [**2052-1-25**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Displaced Nephrostomy Tube, Hyponatremia


Major Surgical or Invasive Procedure:
Nephrostomy tube placement


History of Present Illness:
Ms. [**Known lastname **] is a 52 y/o F with a h/o stage IV appendiceal
adenocarcinoma recently complicated by pseudomonal urosepsis
from bilateral hydronephrosis requiring the placement of
bilateral nephrostomy tubes who presents from home after one of
the tubes has been displaced.  She was recently discharged from
[**Hospital1 18**] on [**2104-9-3**], at which time she was found to have
pseudomonal urosepsis and was discharged on ciprofloxacin 400mg
IV BID to complete a 14 day course, during that hospital stay
she was also found to be hyponatremic with a sodium in the high
120's, thought to be due to SIADH.  Today when her family was
helping move her from the couch her right nephrostomy tube got
caught on something and was accidentally pulled out so her
family brought her to the ER to have the tube replaced.  She
currently feels weaker than her baseline but has trouble
describing how she feels, denies any fever/chills, CP, SOB,
n/v/d, HA or changes in her vision, denies any changes in her
ostomy output.
.
In the ED, initial vs were: 98.7, 76, 92/72, 16, 98% RA.  The
initial plan had been to have IR replace the nephrostomy tube
tonight, however when her labs returned this was put off.  Her
labs were notable for a white count of 33.7, Na of 114, K of
6.4, lactate of 3.8, and a BUN of 35.  Her EKG was NSR at 97bpm,
no peaked T-waves or PR prolongation, poor R wave progression.
She was given 10 units of IV insulin, 1 amp of D50, calcium
gluconate, her scheduled dose of ciprofloxacin, along with
cefepime and vancomycin for her leukocytosis.  A repeat K after
treatment was 5.4 and her sodium was 116.  While in the ER it
was noted that her left sided nephrostomy tube was not draining
anymore either.  By report, after multiple discussions in the ER
she refused kayexelate and placement of a peripheral IV,
although she would like the nephrostomy tubes replaced for
comfort, as she is no longer seeking treatment for her
underlying cancer and is DNR/DNI on home hospice.  VS on
transfer were: 106, 104/74, 10, 100% on RA.
.
On arrival to the ICU her initial VS were: 95.8, 99, 101/75, 9,
99% on RA.  She says that her pain is improved after the pain
medication, she has no other complaints.  Also on arrival to the
ICU it was noted that her left sided nephrostomy tube was not
draining or flushing.
.
Review of systems:
(+) Per HPI and for anorexia
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation or changes in bowel habits.


Past Medical History:
Stage IV appendiceal adenocarcinoma (pT3 Nx pM1b);
K-Ras mutation confirmed
- [**2102-11-3**]: Presented to [**Hospital1 18**] ED for progressive
abdominal/pelvic discomfort. CT demonstrated "marked abnormal
distention of the endometrial cavity measuring up to 6.5 cm"
which was filled with high-density fluid. There was a possible
mass within the cervix as well as a 2.2 x 3.2 cm cystic lesion
within the right adnexa. Of note, the appendix was described as

normal. TVUS revealed an enlarged right ovary with a complex
cyst
thought to be hemorrhagic, as well as an abnormal endometrial
cavity containing a heterogeneous lesion with mixed solid and
cystic elements, thought to be concerning for neoplasm. She was

recommended to follow up with GYN.
- [**2102-12-11**]: Endometrial biopsy demonstrated adenocarcinoma,
endometroid type, grade I.
- [**2102-12-12**]: Re-presented to [**Hospital1 18**] ED with continued lower
abdominal pain as well as about a month's worth of vaginal
bleeding.
- [**2103-1-17**]: CA-125 elevated at 113
- [**2103-1-23**]: Went to the operating room with Dr. [**Last Name (STitle) 2028**] for a
planned hysterectomy, bilateral salpingo-oophorectomy, and
staging procedure for presumed endometrial adenocarcinoma.
Intraoperatively, her appendix was noted to be "pulled down in
towards the right adnexa." The right adnexa itself was
completely adherent to the pelvic side wall and right fallopian

tube. There was evidence of gross tumor on the anterior surface

of the uterus. The left fallopian tube and ovary were also
replaced by hemorrhagic mass. There was also a 2 cm nodularity
on the omentum, worrisome for metastasis. Intraoperatively, she

underwent rigid proctoscopy which showed no evidence of
intralumenal tumor. Peritoneal washings were negative for
malignant cells. Surprisingly, the pathology from this operation

revealed the primary source of her cancer to actually be the
appendix with a 1.5 cm histologic grade II primary lesion
invading through the muscularis propria and into the
subserosa/mesoappendix (pT3). This stained positive for
cytokeratin 7, cytokeratin 20, ER, and CDX2, confirming this as

an appendiceal primary. The same adenocarcinoma was found to be

involving the right fallopian tube and ovary, uterus, cervix,
omentum, and the serosal surface of the bowel wall (pM1b). There

was no perineural invasion. K-Ras mutation confirmed.
- [**2103-3-21**]: Began cycle 1 of FOLFOX; required 20% dose reduction
of
all medications after cycle 1 due to neutropenia; oxaliplatin
stopped after 4 cycles due to neuropathy; completed sixth cycle

on [**2103-8-22**]
- [**2104-1-5**]: Presented to [**Hospital1 18**] ED with small bowel obstruction,

thought to be due to intraperitoneal relapse. PET CT confirmed
FDG-avidity of multiple peritoneal/pelvic implants and several
liver masses.
- [**2-/2104**]: Underwent evaluation by Dr. [**Last Name (STitle) 12982**] at [**Hospital1 336**] for
hyperthermic intraperitoneal chemotherapy (HIPEC). Underwent
debulking of intraperitoneal carcinomatosis by HIPEC was
deferred
given obvious hepatic metastases.
- [**2104-5-15**]: Began cycle 1 of palliative FOLFIRI and bevacizumab;

on day 27, was admitted to the hospital with a colovaginal
fistula after complaining of stool per vagina
- [**2104-7-15**]: Underwent a complicated surgical takedown of the
enterovaginal fistula, diverting ileostomy, and repair of a
bladder perforation with Dr. [**Last Name (STitle) **].
- [**2104-8-2**]: Presented to the ED with abdominal pain and
leukocytosis. Found to have diffuse enteritis with new bilateral

obstructive hydronephrosis and progression of peritoneal and
hepatic metastases. Eventually discharged on home hospice on
[**2104-8-10**].


Social History:
She is married.  She denies tobacco, drug, or alcohol use.  She
lives with her husband and son.  She reports feeling safe at
home.


Family History:
She denies any family history of breast cancer, ovarian cancer,
uterine cancer, or colon cancer.

Physical Exam:
Physical Exam on Admission:
Vitals T 95.8 BP 101/75 HR 99 O2 99% on 2L NC
General Appearance: Anxious, cachetic
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : throughout )
Abdominal: Soft, Bowel sounds present, Distended, Tender:
throughout
Extremities: Right lower extremity edema: 4+, Left lower
extremity edema: 4+
Musculoskeletal: Muscle wasting
Skin:  Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time , Movement:
Purposeful, Tone: Not assessed

.
Physical Exam on Disharge:
Vitals T 96.1 BP 94/67 HR 96 O2 100% on 2L NC
General Appearance: Anxious, cachetic
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : throughout )
Abdominal: Soft, Bowel sounds present, Distended, Tender:
throughout
Extremities: Right lower extremity edema: 4+, Left lower
extremity edema: 4+
Musculoskeletal: Muscle wasting
Skin:  Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time , Movement:
Purposeful, Tone: Not assessed


Pertinent Results:
Labs on Admission:
.

[**2104-9-12**] 10:42PM URINE  HOURS-RANDOM UREA N-640 CREAT-93
SODIUM-35 POTASSIUM-40 CHLORIDE-37
[**2104-9-12**] 10:42PM URINE  OSMOLAL-486
[**2104-9-12**] 10:00PM URINE  COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.016
[**2104-9-12**] 10:00PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
[**2104-9-12**] 10:00PM URINE  RBC-21-50* WBC-[**12-7**]* BACTERIA-FEW
YEAST-NONE EPI-[**3-22**]
[**2104-9-12**] 10:51PM   LACTATE-3.8* NA+-116* K+-5.4*
[**2104-9-12**] 08:05PM   GLUCOSE-95 UREA N-35* CREAT-0.8 SODIUM-114*
POTASSIUM-6.4* CHLORIDE-87* TOTAL CO2-18* ANION GAP-15
[**2104-9-12**] 08:05PM   OSMOLAL-258*
[**2104-9-12**] 08:05PM   WBC-33.7* RBC-3.82* HGB-10.5* HCT-32.6*
MCV-86 MCH-27.5 MCHC-32.2 RDW-17.5*
[**2104-9-12**] 08:05PM   NEUTS-90.7* LYMPHS-5.5* MONOS-2.0 EOS-1.9
BASOS-0
[**2104-9-12**] 08:05PM   PT-19.8* PTT-35.5* INR(PT)-1.8*
.
Micro:
[**9-12**] blood cx: pnd
[**9-12**] urine cx: pnd
.
Imaging:
.
CXR: IMPRESSION: Increased right moderate right effusion and
right basilar
pneumonia. (unchanged from [**8-30**])

.
EKG: NSR at 97bpm, no peaked T-waves or PR prolongation, poor R
wave progression


Brief Hospital Course:
Ms. [**Known lastname **] is a 52 y/o F with a h/o stage IV appendiceal carcinoma
who presented after her right nephrostomy tube had dislodged,
found to be hyponatremic and hyperkalemic, with a Cr above her
baseline on labs.
.
#) Dislodged Nephrostomy tubes: right tube was completely
dislodged and the left tube no longer flushes or drains.  Went
to IR and had tube replaced successfully without any
complications.
.
#) Hyponatremia: Etiology not completely clear based on her
urine lytes or serum osms, likely has a component of hypovolemic
hyponatremic, while on exam she appeared total body volume up,
her JVD was flat and her MM dry.  Her urine lytes show a low
urine sodium and high osms, consistent with hypovolemic
hyponatremia, however she does not appear as sodium avid on labs
as one would expect, this could be due to a degree of [**Last Name (un) **] as her
Cr is up to 0.8 from her baseline of 0.2-0.3.  Also likely a
component of SIADH in the setting of malignancy. With
administration of normal saline, Na improved from 114 to 117,
where it remained stable. Further correction with IVF in the
hospital setting was discussed with the patient and family, but
it was decided to opt in favor of discharge home w/ hospice
given current goals of care. She was discharged with some
additional bags of NS for use PRN until hospice arrives on
Monday.
.
#) Hyperkalemia: potassium was 6.4 on admission with no EKG
changes, improved to 5.4 after calcium gluconate, insulin and
D50, possibly related to worsening renal function.  Patient was
monitored on telemetry and did not develop any arrhythmias.
.
#) Leukocytosis: At the time of her recent discharge she had a
leukocytosis in the mid-twenties, now elevated to the mid 30's,
no evidence of infection on exam.  Does have right basilar
opacity, but chest x-ray appears largely unchanged from [**8-30**].
U/A from the ER with WBC's, RBC's and bacteria, however since
the nephrostomy tubes were not draining well it is not clear
where the urine was collected from. Continued ciprofloxacin
400mg IV bid to complete prior course for pseudomonas urosepsis,
did not continue vanc/cefepime started in the ER. Urine and
blood cultures had no growth to date.
.
#) [**Last Name (un) **]: Cr up to 0.8 from 0.2 to 0.3 as a recent baseline, given
her hypovolemia on exam was likely pre-renal, however may also
be partially due to an obstructive picture given dislodged
urostomy tube on the right and the left is not draining. She was
given IVF and nephrostomy tubes were replaced as above.
.
#) Stage IV Appendiceal Carcinoma: Currently not seeking further
therapy and on home hospice.  Continued oxycodone 5mg Q4h prn
pain, acetaminophen prn, and ativan prn.

Medications on Admission:
oxycodone 5 mg: 1-2 Tablets PO Q4H as needed for pain
acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever: Max of 3 grams daily.
Ativan 0.5 mg: One Tablet PO at bedtime as needed for insomnia
ciprofloxacin 400 mg IV every 12 hours to end on [**2104-9-13**]


Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain: maximum of 3g daily.
3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for insomnia.


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **]

Discharge Diagnosis:
Primary:
Displaced nephrostomy tube
Hyponatremia
Hyperkalemia
Metastatic appendiceal adenocarcinoma


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


Discharge Instructions:
Dear Mrs. [**Known lastname **],

It was a pleasure taking care of you during your admission to
[**Hospital3 **] Medical Center.  You came into the hospital because
one of your nephrostomy tubes was displaced.  The interventional
radiologists replaced the tube successfully without any
complications.  You also had some abnormalities in your blood
work with low sodium and high potassium.  After a discussion
with you and your family, we decided that it would be more
beneficial for you to go home than for us to keep you in the
hospital to correct these abnormalities.
.
We did not start you on any new medications.  You completed your
course of Ciprofloxacin here, so you can STOP the Ciprofloxacin
when you go home.

Followup Instructions:
none



Completed by:[**2104-9-13**]
{'Other mechanical complication of genitourinary device, implant, and graft,Hyposmolality and/or hyponatremia,Cachexia,Secondary malignant neoplasm of retroperitoneum and peritoneum,Acute kidney failure, unspecified,Personal history of malignant neoplasm of large intestine,Encounter for palliative care'}


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: Displaced Nephrostomy Tube, Hyponatremia

PRESENT ILLNESS: Ms. [**Known lastname **] is a 52 y/o F with a h/o stage IV appendiceal
adenocarcinoma recently complicated by pseudomonal urosepsis
from bilateral hydronephrosis requiring the placement of
bilateral nephrostomy tubes who presents from home after one of
the tubes has been displaced.  She was recently discharged from
[**Hospital1 18**] on [**2104-9-3**], at which time she was found to have
pseudomonal urosepsis and was discharged on ciprofloxacin 400mg
IV BID to complete a 14 day course, during that hospital stay
she was also found to be hyponatremic with a sodium in the high
120's, thought to be due to SIADH.  Today when her family was
helping move her from the couch her right nephrostomy tube got
caught on something and was accidentally pulled out so her
family brought her to the ER to have the tube replaced.  She
currently feels weaker than her baseline but has trouble
describing how she feels, denies any fever/chills, CP, SOB,
n/v/d, HA or changes in her vision, denies any changes in her
ostomy output.
.
In the ED, initial vs were: 98.7, 76, 92/72, 16, 98% RA.  The
initial plan had been to have IR replace the nephrostomy tube
tonight, however when her labs returned this was put off.  Her
labs were notable for a white count of 33.7, Na of 114, K of
6.4, lactate of 3.8, and a BUN of 35.  Her EKG was NSR at 97bpm,
no peaked T-waves or PR prolongation, poor R wave progression.
She was given 10 units of IV insulin, 1 amp of D50, calcium
gluconate, her scheduled dose of ciprofloxacin, along with
cefepime and vancomycin for her leukocytosis.  A repeat K after
treatment was 5.4 and her sodium was 116.  While in the ER it
was noted that her left sided nephrostomy tube was not draining
anymore either.  By report, after multiple discussions in the ER
she refused kayexelate and placement of a peripheral IV,
although she would like the nephrostomy tubes replaced for
comfort, as she is no longer seeking treatment for her
underlying cancer and is DNR/DNI on home hospice.  VS on
transfer were: 106, 104/74, 10, 100% on RA.
.
On arrival to the ICU her initial VS were: 95.8, 99, 101/75, 9,
99% on RA.  She says that her pain is improved after the pain
medication, she has no other complaints.  Also on arrival to the
ICU it was noted that her left sided nephrostomy tube was not
draining or flushing.
.
Review of systems:
(+) Per HPI and for anorexia
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation or changes in bowel habits.

MEDICAL HISTORY: Stage IV appendiceal adenocarcinoma (pT3 Nx pM1b);
K-Ras mutation confirmed
- [**2102-11-3**]: Presented to [**Hospital1 18**] ED for progressive
abdominal/pelvic discomfort. CT demonstrated "marked abnormal
distention of the endometrial cavity measuring up to 6.5 cm"
which was filled with high-density fluid. There was a possible
mass within the cervix as well as a 2.2 x 3.2 cm cystic lesion
within the right adnexa. Of note, the appendix was described as

MEDICATION ON ADMISSION: oxycodone 5 mg: 1-2 Tablets PO Q4H as needed for pain
acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever: Max of 3 grams daily.
Ativan 0.5 mg: One Tablet PO at bedtime as needed for insomnia
ciprofloxacin 400 mg IV every 12 hours to end on [**2104-9-13**]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam on Admission:
Vitals T 95.8 BP 101/75 HR 99 O2 99% on 2L NC
General Appearance: Anxious, cachetic
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : throughout )
Abdominal: Soft, Bowel sounds present, Distended, Tender:
throughout
Extremities: Right lower extremity edema: 4+, Left lower
extremity edema: 4+
Musculoskeletal: Muscle wasting
Skin:  Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): person, place, time , Movement:
Purposeful, Tone: Not assessed

FAMILY HISTORY: She denies any family history of breast cancer, ovarian cancer,
uterine cancer, or colon cancer.

SOCIAL HISTORY: She is married.  She denies tobacco, drug, or alcohol use.  She
lives with her husband and son.  She reports feeling safe at
home. 

### Response:
{'Other mechanical complication of genitourinary device, implant, and graft,Hyposmolality and/or hyponatremia,Cachexia,Secondary malignant neoplasm of retroperitoneum and peritoneum,Acute kidney failure, unspecified,Personal history of malignant neoplasm of large intestine,Encounter for palliative care'}
