CHIEF COMPLAINT: liver cancer

PRESENT ILLNESS: 63-year-old female originally from the
[**Country 13622**] Republic who was recently evaluated at [**Hospital6 14430**] for elevated liver function tests and multifocal liver
lesions.

MEDICAL HISTORY: PMH: DM2, HEP B exposure, LGIB, NASH
PSH: c-section x 3, clavicle lipoma excision
Meds: Lantus insulin 20 units q.h.s. and sitagliptin 50 mg p.o.
daily.

MEDICATION ON ADMISSION: Lantus insulin 20 units q.h.s. and sitagliptin 50 mg p.o. daily.

ALLERGIES: Acetaminophen / IV Dye, Iodine Containing Contrast Media

PHYSICAL EXAM: VS at clinic visit: BP 158/86, pulse 90, respirations 16,
temperature 98.6, weight 51.9 kilos, and height 5 feet 5 inches.

FAMILY HISTORY: mother who died at age 87 of unknown causes.  Her father died at
107 of natural
causes.  Her maternal grandmother died at 38 from a fall while
pregnant.  Her maternal grandfather died at age [**Age over 90 **] from natural
causes.  Her paternal grandmother died in her 100s of natural
causes and her paternal grandfather died in his 100s from
natural
causes.

SOCIAL HISTORY: she is married and has four children.  She is a retired
teacher's aide.
She has an associate's degree.
She has no history of alcohol use.
She is a nonsmoker.  She has no history of IV drug use,
marijuana
use, blood transfusions, or tattoos.  She does have pierced
ears.
Malignant neoplasm of liver, primary,Hepatic encephalopathy,Acidosis,Acute kidney failure, unspecified,Chronic cholecystitis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Cardiac arrest
Mal neo liver, primary,Hepatic encephalopathy,Acidosis,Acute kidney failure NOS,Chronic cholecystitis,DMII wo cmp nt st uncntr,Cardiac arrest
Admission Date:  [**2189-9-28**]              Discharge Date:   [**2189-10-1**]

Date of Birth:  [**2125-11-2**]             Sex:   F

Service: SURGERY

Allergies:
Acetaminophen / IV Dye, Iodine Containing Contrast Media

Attending:[**First Name3 (LF) 695**]
Chief Complaint:
liver cancer

Major Surgical or Invasive Procedure:
[**2189-9-28**]: Cholecystectomy, right hepatic
trisegmentectomy, intraoperative ultrasound.

[**2189-9-30**]: Exploratory laparotomy, 8-mm [**Doctor Last Name 4726**]-Tex
ribbed portacaval shunt, repair of portal vein, pexy of
liver.


History of Present Illness:
63-year-old female originally from the
[**Country 13622**] Republic who was recently evaluated at [**Hospital6 14430**] for elevated liver function tests and multifocal liver
lesions.

She presented to the [**Hospital1 2177**] Emergency Department in [**2189-6-3**] for
complaints of right shoulder pain and underwent an ultrasound on
[**2189-6-9**].  This demonstrated multiple well-demarcated
hyperechoic focal lesions seen throughout the liver, with the
largest measuring 2.0 x 1.5 x 1.7 cm within the right lobe of
the
liver.  The liver was noted to have a heterogeneous nodular
echotexture.
On [**2189-8-24**] she underwent a followup MRI that
demonstrated enlargement of the left lobe of the liver with a
micronodular contour compatible with cirrhosis.  She had
multiple
heterogeneous masses in the right lobe of the liver; the largest
component of this mass was centered in Segment V measuring 7.6 x
6.3 x 3.4 cm.  There were four 2-cm lesions superiorly and
additional six subcentimeter lesions in Segment VIII.  By
report,
there is a 1.4-cm lesion within Segment II.  There was also a
question of involvement of the right portal vein.

This scan was reviewed at our Liver Tumor Multidisciplinary
Conference on
[**2189-9-17**] and demonstrated the multifocal tumor in the
right lobe of the liver and also involving Segment [**Doctor First Name 690**] of the
medial segment.  However, Segments II and III (left lateral
segment) were free of disease.  The right portal vein was
thrombosed.

A triphasic CT scan was done at [**Hospital1 18**] on [**2189-9-21**].
She
also underwent a chest CT that demonstrated a 4-mm pulmonary
nodule in the right upper lobe, and within the posterior segment
of the left upper lobe there was an ill-defined 3-mm nodule.
These will warrant followup, but were nonspecific at this point.
Most importantly, there was a heterogeneous mass within the
liver
in the right lobe including Segments V, VI, VII, and VIII.  The
mass also extended into the superior medial segment (Segment
[**Doctor First Name 690**]).  There was thrombus in the right anterior and right
posterior portal vein extending down just proximal to the
confluence with the portal vein.  The left portal vein is
patent.
 Within Segment III there is an 8 x 9-mm arterial enhancing
lesion, which by CT criteria may represent a hemangioma, but the
lack of T2 hyperintensity on the MRI raises the concern of a
metastatic lesion.  There is a 9 x 9-mm hypodense area in the
portal venous phase imaging within Segment [**Doctor First Name 690**] that is
indeterminate.  The hepatic veins are patent.  The hepatic
arterial variant anatomy was noted with a replaced right hepatic
artery arising from the superior mesenteric artery.  There is
also a replaced left hepatic artery arising from the left
gastric.  There is an 11-mm periportal lymph node.  Liver
volumes
were performed and these included total liver volume of 1001 mL,
the right lobe has 394 mL, left lobe 606 mL, left lateral
segment
401 mL, and the caudate lobe 17 mL.

CA19-9 on [**9-18**] was 18.2 and her AFP was 98.3.


Past Medical History:
PMH: DM2, HEP B exposure, LGIB, NASH
PSH: c-section x 3, clavicle lipoma excision
Meds: Lantus insulin 20 units q.h.s. and sitagliptin 50 mg p.o.
daily.


Social History:
she is married and has four children.  She is a retired
teacher's aide.
She has an associate's degree.
She has no history of alcohol use.
She is a nonsmoker.  She has no history of IV drug use,
marijuana
use, blood transfusions, or tattoos.  She does have pierced
ears.


Family History:
mother who died at age 87 of unknown causes.  Her father died at
107 of natural
causes.  Her maternal grandmother died at 38 from a fall while
pregnant.  Her maternal grandfather died at age [**Age over 90 **] from natural
causes.  Her paternal grandmother died in her 100s of natural
causes and her paternal grandfather died in his 100s from
natural
causes.


Physical Exam:
VS at clinic visit: BP 158/86, pulse 90, respirations 16,
temperature 98.6, weight 51.9 kilos, and height 5 feet 5 inches.


On physical examination she
is a thin, alert, well-developed female who appears younger than
her stated age.  Skin:  Normal.  HEENT:  No scleral icterus.
Oropharynx clear.  Neck:  No lymphadenopathy or thyromegaly.
Carotids 2+/4+ without bruits.  Her lungs are clear to
auscultation.  Cardiac exam:  Normal S1-S2.  She has a 2/6
systolic ejection murmur along the left sternal border.  She has
regular rate and rhythm.  Her abdominal exam is benign.  She has
no hepatosplenomegaly, masses, or tenderness.  Her liver is 10
cm
in span by percussion.  Extremities:  No peripheral edema.
Neurologically grossly intact.


Pertinent Results:
Laboratory studies drawn on [**9-21**] include hemoglobin
14.2,
hematocrit 44.8, WBC 5.2, platelets 170, INR 1.2, sodium 128,
potassium 4.9, chloride 92, creatinine 0.7, BUN 15, AST 96, ALT
93, alkaline phosphatase 327, total bilirubin 1.0, direct
bilirubin 0.5, albumin 4.0, magnesium 1.7, AMA negative, [**Doctor First Name **]
smooth positive, CEA 6.4, AFP 98.3, HCV antibody negative, and
CA19-9 1639, hemoglobin A1c 9.3, hepatitis B surface antigen
negative, hepatitis B surface antibody positive, and hepatitis B
core antibody positive,.


Brief Hospital Course:
Patient underwent CCY, Right trisegmentectomy, and IOUS on
[**2189-9-28**] with Dr. [**Last Name (STitle) **].

In the PACU, she was noted to be mildly tachcardiac and then
became mildly hypotensive with low UOP.  IVFs were given with
improvement in UOP and MAP, Hct was checked which was stable.
She was still mildly hypotensive, and given the degree of
surgery she had, we elected to place her in the ICU overnight.

That night she required more fluid resuscitation as her CVP was
only 2, and she was still somewhat hypotensive and oliguric.
Her labs that night demonstrated a severe metabolic acidosis
7.10/28/213/9/-19  lactate 14.6.  This corrected with HCO3 but
the elevated lactate did not improve.

Over the next 24 hours she remained in the ICU.  She required
Neosynephrine for BP augmentation.  She was adequately fluid
resuscitated with greater than 10 liters of fluid.  Despite
this, her UOP decreased, she went into renal failure with a
rising Cr that peaked at 2.8, and her LFTs continued to rise,
with an unclear [**Name2 (NI) **] into the 6000 range.  A liver
Duplex was performed on three separate occassions, since her
clinical status was not improving.  All three U/S exams
demonstrated normal portal venous, arterial, and hepatic venous
flow without reversal.

She became moderately encephalopathic from her liver failure,
and volume overloaded from fluid resuscitation.  This lead to a
semi-elective intubation in the SICU.
On the evening of POD 2 she suddenly had an increase in her
pressor requirement along with a drop in her Hct from 32->26->20


Given her overall clinical picture, it was felt that only
operative exploration could diagnose the etiology of her liver
dysfunction.  In the operating room we did find some bleeding
from the porta and liver edge with 2 liters of blood in the
abdomen.  This was felt to be secondary to her coagulapathy, as
she had no evidence of bleeding the prior 48 hours.  The liver
was very hard and congested, and appeared to be somewhat twisted
into the RUQ.  This was untwisted, and we noticed improvements
in her hemodynamics very quickly.  It was decided to perform a
portocaval shunt at this point with PTFE.  Upon completion of
the case her hemodynamics were much improved.  She was nearly
off of pressors, not requiring fluid or product resuscitation
any longer, and improving labs.

She was taken to the SICU and a HD line was placed and CVVHD was
started to help her clear her acidosis and begin taking fluid
off.

However, about 4 hours postop she suddenly went into cardiac
arrest.  It appeared to be PEA.  There was no antecedent cause
that we could identify.  Despite CPR and ACLS for 15 minutes, we
were unable to revive her and she expired.  Autopsy was deferred
by the family.

Medications on Admission:
Lantus insulin 20 units q.h.s. and sitagliptin 50 mg p.o. daily.


Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
1.) hepatocellular carcinoma
2.) Hepatic failure
3.) Multiorgan system failure

Discharge Condition:
Deceased

Discharge Instructions:
none

Followup Instructions:
none

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
{'Malignant neoplasm of liver, primary,Hepatic encephalopathy,Acidosis,Acute kidney failure, unspecified,Chronic cholecystitis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Cardiac arrest'}


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: liver cancer

PRESENT ILLNESS: 63-year-old female originally from the
[**Country 13622**] Republic who was recently evaluated at [**Hospital6 14430**] for elevated liver function tests and multifocal liver
lesions.

MEDICAL HISTORY: PMH: DM2, HEP B exposure, LGIB, NASH
PSH: c-section x 3, clavicle lipoma excision
Meds: Lantus insulin 20 units q.h.s. and sitagliptin 50 mg p.o.
daily.

MEDICATION ON ADMISSION: Lantus insulin 20 units q.h.s. and sitagliptin 50 mg p.o. daily.

ALLERGIES: Acetaminophen / IV Dye, Iodine Containing Contrast Media

PHYSICAL EXAM: VS at clinic visit: BP 158/86, pulse 90, respirations 16,
temperature 98.6, weight 51.9 kilos, and height 5 feet 5 inches.

FAMILY HISTORY: mother who died at age 87 of unknown causes.  Her father died at
107 of natural
causes.  Her maternal grandmother died at 38 from a fall while
pregnant.  Her maternal grandfather died at age [**Age over 90 **] from natural
causes.  Her paternal grandmother died in her 100s of natural
causes and her paternal grandfather died in his 100s from
natural
causes.

SOCIAL HISTORY: she is married and has four children.  She is a retired
teacher's aide.
She has an associate's degree.
She has no history of alcohol use.
She is a nonsmoker.  She has no history of IV drug use,
marijuana
use, blood transfusions, or tattoos.  She does have pierced
ears. 

### Response:
{'Malignant neoplasm of liver, primary,Hepatic encephalopathy,Acidosis,Acute kidney failure, unspecified,Chronic cholecystitis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Cardiac arrest'}
