CHIEF COMPLAINT: Transferred from [**Hospital3 3583**] for ST elevations on EKG

PRESENT ILLNESS: 75yo woman w/ PMH of HTN, hypothyroidism, Hep C, transferred
from [**Hospital3 3583**] for cardiac catheterization for ST
elevations. She was admitted to [**Hospital3 3583**] on [**8-20**] for
cervical LAD, fatigue, weight loss, worked up for lymphoma.
While there, she was found to have bilateral pleural effusions,
LAD. Went today ([**8-25**]) for LN biopsy. Sometime on [**8-25**], she
developed dyspnea, tachycardia to 130s-140s, and ST elevations
in the anteroseptal and inferior leads. She was transferred here
for cardiac catheterization. Upon arrival (on heparin and nitro
gtt), she was confused, diaphoretic, and lethargic. Cardiac cath
showed clean coronary arteries. She was noted to have RAP 19,
RVP 45/19, PAP 45/30, PCWP 27, CO 3.94, CI 2.43, and anterior
wall motion hypokinesis suggestive of myocardial stunning. She
did not have pericardial effusions. ABG was 7.17/23/79/11 with
lactate 12.9 and repeat 7.13/30/89/11 with lactate 14.6. Glucose
was 20 and she was given D50. She was admitted to the CCU.

MEDICAL HISTORY: HTN
GERD
HCV
osteoporosis
glaucoma
hypothyroidism
s/p hysterectomy
?s/p thyroidectomy
?s/p back [**Last Name (un) **]

MEDICATION ON ADMISSION: at home:
synthroid 100mcg qd
protonix 40mg qd
diltiazem 180mg qd
actonel 35mg qd

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: PE: VS: T96.8, HR 104, BP 108/69, MAP 68, RR 17, SaO2 100%
AC FiO2 1.00, TV 450, RR 14, PEEP 5.0
Genl: sedated, intubated
HEENT: NCAT, ETT in place
Neck: dressing C/D/I from LN biopsy today
Pulm: on vent, decreased flow
CV: RRR, nl S1, S2, no m/r/g appreciated
Abd: BS+, soft, nontender, nondistended
GU: femoral sheath in place in R, dressing C/D/I
Ext: cool, mottled, PP present, [**12-24**]+ edema
Neuro: intubated, sedated, unresponsive

FAMILY HISTORY: unknown

SOCIAL HISTORY: remote h/o tobacco use, no alcohol, married w/ 2 children
Unspecified septicemia,Septic shock,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Other primary cardiomyopathies,Chronic hepatitis C without mention of hepatic coma,Pneumonia, organism unspecified,Defibrination syndrome,Severe sepsis,Encounter for palliative care,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Esophageal reflux,Unspecified glaucoma,Other respiratory abnormalities
Septicemia NOS,Septic shock,Oth lymp unsp xtrndl org,Subendo infarct, initial,Acute kidney failure NOS,Prim cardiomyopathy NEC,Chrnc hpt C wo hpat coma,Pneumonia, organism NOS,Defibrination syndrome,Severe sepsis,Encountr palliative care,Hypertension NOS,Hypothyroidism NOS,Esophageal reflux,Glaucoma NOS,Respiratory abnorm NEC
Admission Date:  [**2140-8-26**]              Discharge Date:   [**2140-9-3**]

Date of Birth:  [**2067-4-12**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides)

Attending:[**Known lastname 134**]
Chief Complaint:
Transferred from [**Hospital3 3583**] for ST elevations on EKG

Major Surgical or Invasive Procedure:
Cardiac catheterization
Intubation and ventilation
Placement of arterial and central venous lines
Placement of Swan-Ganz catheter

History of Present Illness:
75yo woman w/ PMH of HTN, hypothyroidism, Hep C, transferred
from [**Hospital3 3583**] for cardiac catheterization for ST
elevations. She was admitted to [**Hospital3 3583**] on [**8-20**] for
cervical LAD, fatigue, weight loss, worked up for lymphoma.
While there, she was found to have bilateral pleural effusions,
LAD. Went today ([**8-25**]) for LN biopsy. Sometime on [**8-25**], she
developed dyspnea, tachycardia to 130s-140s, and ST elevations
in the anteroseptal and inferior leads. She was transferred here
for cardiac catheterization. Upon arrival (on heparin and nitro
gtt), she was confused, diaphoretic, and lethargic. Cardiac cath
showed clean coronary arteries. She was noted to have RAP 19,
RVP 45/19, PAP 45/30, PCWP 27, CO 3.94, CI 2.43, and anterior
wall motion hypokinesis suggestive of myocardial stunning. She
did not have pericardial effusions. ABG was 7.17/23/79/11 with
lactate 12.9 and repeat 7.13/30/89/11 with lactate 14.6. Glucose
was 20 and she was given D50. She was admitted to the CCU.

Past Medical History:
HTN
GERD
HCV
osteoporosis
glaucoma
hypothyroidism
s/p hysterectomy
?s/p thyroidectomy
?s/p back [**Last Name (un) **]


Social History:
remote h/o tobacco use, no alcohol, married w/ 2 children

Family History:
unknown

Physical Exam:
PE: VS: T96.8, HR 104, BP 108/69, MAP 68, RR 17, SaO2 100%
AC FiO2 1.00, TV 450, RR 14, PEEP 5.0
Genl: sedated, intubated
HEENT: NCAT, ETT in place
Neck: dressing C/D/I from LN biopsy today
Pulm: on vent, decreased flow
CV: RRR, nl S1, S2, no m/r/g appreciated
Abd: BS+, soft, nontender, nondistended
GU: femoral sheath in place in R, dressing C/D/I
Ext: cool, mottled, PP present, [**12-24**]+ edema
Neuro: intubated, sedated, unresponsive


Pertinent Results:
Labs:

OSH:
Chem 7: Na128, K3.7, Cl95, HCO3 18, BUN12, Cr0.7, Gluc98
ABG 11pm 7.32/23/124/12
CPK 76 at 2p
U/A negative
Micro: blood cx [**Date range (1) 8258**] NGTD

Admission at [**Hospital1 18**]:
WBC-26.0* RBC-3.59* Hgb-10.8* Hct-33.8* MCV-94 MCH-30.1
MCHC-31.9 RDW-14.4 Plt Ct-116*
PT-18.0* PTT->150* INR(PT)-2.3
Glucose-153* UreaN-22* Creat-1.0 Na-130* K-4.0 Cl-92* HCO3-9*
AnGap-33*
ALT-33 AST-191* LD(LDH)-1693* CK(CPK)-335* AlkPhos-76
Amylase-154* TotBili-1.2 Lipase-260*
Albumin-2.8* Calcium-7.8* Phos-5.0* Mg-2.6
Fibrino-176
D-Dimer-7059*
FDP-40-80
Ret Man-2.3*
CK-MB-46* MB Indx-13.7* cTropnT-1.18*
Hapto-28*
Type-ART Rates-/30 O2 Flow-2 pO2-79* pCO2-28* pH-7.17*
calHCO3-11* Base XS--16 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
Lactate-12.9* freeCa-1.10*

Other
Triglyc-761* HDL-20 CHOL/HD-8.2
TSH-2.2
Free T4-1.5
Cortsol-30.5*
HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-NEGATIVE HAV Ab-POSITIVE
(NEGATIVE on another sample) HCV Ab-POSITIVE
C3-48* C4-23
GGT-299*

Labs on [**2140-9-3**]
WBC-29.5* RBC-3.80* Hgb-12.1 Hct-36.5 MCV-96 MCH-31.9 MCHC-33.2
RDW-18.3* Plt Ct-61*
PT-18.3* PTT-46.8* INR(PT)-2.4
Glucose-59* UreaN-69* Creat-3.2* Na-131* K-5.0 Cl-80* HCO3-11*
AnGap-45*
ALT-116* AST-201* LD(LDH)-1284* AlkPhos-560* TotBili-16.3*
DirBili-14.4* IndBili-1.9
Calcium-10.7* Phos-7.5* Mg-2.7*
Fibrino-159
Hapto-<20* ([**9-1**])
Type-ART pO2-151* pCO2-26* pH-7.24* calHCO3-12* Base XS--14
Lactate-14.3* freeCa-1.22
--------
Path from OSH, read at [**Hospital1 18**]:

Lymph node, right neck, excisional Biopsy (Consult slides
received from [**Hospital3 3583**], [**Location (un) 3320**], MA; dated [**2140-8-25**];
labelled: 05:S7476):

Non-Hodgkin B-cell lymphoma with high-grade features, diffuse
large B-cell vs. atypical Burkitt lymphoma, see note.

Note:  Nodal architecture is diffusely effaced by a
proliferation of large atypical cells with round-to-convoluted
nuclear outlines, dispersed chromatin, and one-to-several small
nucleoli.  There is prominent apoptotic debris and brisk mitotic
activity.  The infiltrate extends into adipose tissue and around
blood vessels and nerves.  Focal areas of geographic necrosis
are seen.
By report, flow cytometry performed at [**Company 2475**] (NY-05-[**Numeric Identifier 62875**]),
showed a kappa-restricted B-cell lymphoproliferative disorder.
CD10 staining was reportedly equivocal.  No immunohistochemical
work-up and/or blocks were submitted.
Overall, the features are of a high-grade non-Hodgkin B-cell
lymphoma.  Given the brisk mitoses and reported questionable
CD10 positivity by flow cytometry, the differential diagnosis
includes a high grade diffuse large B-cell lymphoma versus an
atypical Burkitt lymphoma. The block will be requested for
additional immunohistochemical and possible FISH studies, and
the findings reported in an addendum.
ADDENDUM:
Immunoperoxidase studies performed on the requested block shows
that the lymphoma is immunoreactive for CD20, BCL-2, dimming for
BCL-2, and negative for CD10.  CD3 stain reveals scattered
mature T-lymphocytes.  This consternation of immunophenotypic
findings supports the diagnosis of a high-grade diffuse large
B-cell lymphoma.  And would be atypical for Burkitt's lymphoma
(whether morphologically typical or atypical).
--------
Cardiac info:

EKG:
1426 sinus tachycardia at 115bpm, nl axis, nl intervals, low
voltage in limb leads, no ST changes, q waves, TWI

ECHO:
([**8-25**]) Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
focal akinesis of the distal half of the septum, distal third of
the anterior and inferior walls, and apex. The remaining
segments contract well. No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD (mid-LAD lesion; if no significant CAD, c/w Takasubo's
cardiomyopathy).

ECHO ([**9-2**]): Conclusions:
1. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Resting regional wall motion
abnormalities include akinesis of the lower half to [**12-24**]'s of the
left ventricle . The left ventricular function is severely
depressed.
2.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
3.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
4.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
5.There is no pericardial effusion.
6. There is both ascites and a large left sided pleural effusion
present.
Compared with the findings of the prior study (tape reviewed) of
10/605, no change. The previous assessment of the LV function
was possibly overestimated.

Cath:
COMMENTS: 1.  Selective coronary angiography in this right
dominant
patient revealed no angiographically significant coronary artery

disease.  The LMCA, LCX, LAD, RCA and branch vessels were all
normal.
The LAD had a myocardial bridge with minor systolic compression.

2.  Resting hemodynamics revealed severe elevation of right and
left
sided filling pressures with mean RA 19 and mean PCWP of 28
which
increased to almost 40 when repeated at the end of the case.
The
cardiac index was preserved at 2.3.  A bedside echo showed
anterior and
apical akinesis with severely depressed EF of 25%.  There was no

significant effusion.

FINAL DIAGNOSIS:
1. No coronary artery disease.
2. Severely elevated filling pressures and LV dysfunction
possibly due
to sepsis with acidosis or Takotsubo stress cardiomyopathy as
echo in
cath lab showed apical ballooning.

--------
Imaging:
OSH:
[**8-19**]: No DVT in bilateral femoral popliteal vv
CT [**8-19**]: No PE, +axillary, mediastinal, hilar, external iliac, L
inguinal LAD. Small bilateral pleural effusions. Splenomegaly,
hepatomegaly, small-mod ascites.
CXR [**8-25**]: atelectasis vs consolidation of lower lobes with
bilateral pleural effusions

[**Hospital1 18**]:
Abd u/s: IMPRESSION: Patent portal veins, hepatic veins, and
hepatic arteries. Small amount of ascites. Multiple hepatic
cysts and right renal cyst. Gallbladder wall edema and
pericholecystic fluid, likely related to the patient's
underlying hepatic failure, but correlate clinically. No
cholelithiasis.

CT Chest, Abd & Pelvis: IMPRESSION:
1. Patchy opacities in the upper lobes of both lungs. These
could represent pulmonary edema. Other differentials include
aspiration or infection.
2. Bilateral moderate-sized pleural effusions.
3. Bulky axillary lymphadenopathy.
5. Anasarca.
6. No evidence of bowel pathology.
7. Multiple liver cysts.

Renal u/s: 1. No evidence of hydronephrosis. Possibly mildly
echogenic renal cortices, suggestive of medical renal disease.
2. Ascites.
3. Heterogeneous, enlarged spleen.

CT head: IMPRESSION: No intracranial hemorrhage or mass effect.

CXR ([**9-3**]): FINDINGS: Single radiograph of the chest
demonstrates ETT in satisfactory position; right subclavian
venous catheter is noted with the tip at the level of the SVC.
NGT is noted with the tip at the pylorus. Left basilar
atelectasis and small left pleural effusion were noted. No
significant change is noted compared to the prior study done on
[**2140-9-2**].

KUB ([**9-2**]): History of renal failure with abdominal distention.
Tip of NG tube is in region of pyloric duodenal junction. There
is retained contrast in the colon and few gas filled loops of
bowel probably curled in the mid abdomen. A vascular access
catheter overlies the region of the left common iliac vessel.
There is persistent bilateral nephrogram and splenomegaly.

Brief Hospital Course:
Assessment: 75yo woman with HTN, hypothyroidism, recently
admitted to [**Hospital3 3583**] for work-up of lymphadenopathy,
found to have aggressive diffuse B-cell lymphoma, transferred
here for cardiac catheterization for ST elevations on EKG, and
found to have clean coronaries but elevated SVR, low cardiac
output, anterolateral hypokinesis, and lactic acidosis,
concerning for septic and cardiogenic shock.
.
Hospital course is reviewed below by problem:
.
1. Shock - The patient was initially thought to be in
cardiogenic shock given her non-ischemic cardiomyopathy. This
seemed consistent with [**Last Name (un) **]-Tsubo syndrome, as she had STE on
EKG with clean coronaries, apical ballooning with anterolateral
hypokinesis, and a recent stressor. However, she spiked
temperatures, her Swan-Ganz catheter showed lower SVR (500s)
with increased cardiac output to 8, less concerning for cardiac
etiology and more concerning for sepsis. Her blood pressure was
stabilized on dobutamine initially, which was weaned off except
when propofol was used for sedation, when levophed was started.
She was initially started on antibiotics (zosyn, levo, and
vanco), but these were stopped per ID recommendations, as there
was no source for infection. She was eventually made CMO and
pressors were stopped.
.
2. Lactic acidosis - The patient was noted to have significant
lactic acidosis that was uncontrolled. Etiology was likely
multifactorial including initially sepsis, tumor lysis and, by
the end of the hospitalization, renal failure. The team became
unable to stabilize the pt's acid-base status - attempts to keep
pt from acidemia were counteracted by low pCO2. A bicarb drip
helped but could not prevent the acidemia. Even dialysis was
unable to correct the problem. The underlying etiology was
unclear, thought to be secondary to either sepsis (no source
identified) or more likely tumor load/lysis. Her family decided
to make her comfort measures only and all care was withdrawn
except for morphine and tylenol.
.
3. Renal failure - The patient had steadily increasing
creatinine without any clear cause. Per renal service, this may
have been pre-renal or ATN, likely a combination. Could be
secondary to lymphoma. It was unlikely hepatorenal as hepatic
dysfunction was clearing, and unlikely cardiogenic as the pt had
good CO. It was initially though that it might just lagging
behind improved CO, but it never began to improve. Renal
ultrasound ruled out a post-renal obstruction. Her kidneys were
holding Na appropriately. It was possible that it was secondary
to third spacing and therefore prerenal, though would not expect
persistent worsening with this etiology. She was started on
dialysis for uncontrollable acidemia, fluid status, and uremia
without improvement. Her care was thus withdrawn except for
comfort measures.
.
4. Pulmonary function - The patient had to be intubated for
acid-base control. This was limited by low pCO2 as mentioned
above. She was overbreathing with low sedation, so sedation had
to be increased. As a result, levophed was needed as her MAPs
dropped. She was then made CMO and was extubated.
.
5. B cell lymphoma - The patient was diagnosed with aggressive B
cell lymphoma by slides and flow cytometry, possibly
infiltrating her liver. This was thought to possibly be the
primary reason for her uncontrollable acidosis. She also
demonstrated a DIC picture, which may also be associated with
lymphoma and/or sepsis, however she did not have signs of
significant bleeding. The hematology-oncology service followed
her during her hospitalization. They recommended treatment with
decadron daily, and allopurinol and bicarb to alkanalize her
urine. They considered chemotherapy, but they could not start
therapy as the patient remained too sick. Eventually, the
decision was made that she would be unlikely to get well enough
to have chemo, and the family decided to change treatment goals
to comfort measures only.
.
6. Liver dysfunction - She had transaminitis on admission, which
may have been secondary to sepsis vs. lymphoma infiltration.
Budd Chiari was ruled out by Doppler. Her LFTs peaked, making an
acute process more likely. However, later in the hospitalization
her cholestasis labs were elevated - TBili doubled (direct)
within one day, and alk phos continued to rise. HIDA scan was
considered per GI service to rule out cholestasis, but it would
have only been definitive if it was normal. At that point, it
would have been difficult for her to have this scan. As such, it
was not done prior to being made CMO.
.
7. Hypoglycemia - She was noted to be hypoglycemic in the cath
lab, most likely due to liver failure. She was initially started
on a D5 drip, but then became hyperglycemic. As a result, she
was changed to an insulin drip. Her liver function, which had
improved, began to worsen and her sugars began to trend downward
again, so she was treated with all IV medications in D5. This
kept her glucose closer to the normal range.
.
8. Sedation/Mental status - The patient was anesthetized with
propofol in an effort to control her breathing. She was taken
off sedation occasionally to check her neurologic status, and
was responding to stimulus but not following commands. She had a
HCT, which was negative for acute issues. It was unclear what
her neurologic status would have been if she was able to get
better otherwise, but there was concern that she had a
significant time when she was hypoglycemic and perhaps ischemic,
and that she would not have recovery of her mental status.
.
9. Hypothyroidism - She was maintained on her levothyroxine. TSH
and FT4 were normal.
.

Medications on Admission:
at home:
synthroid 100mcg qd
protonix 40mg qd
diltiazem 180mg qd
actonel 35mg qd


Discharge Medications:
None, expired

Discharge Disposition:
Expired

Discharge Diagnosis:
Diffuse B-cell lymphoma
Septic shock
[**Last Name (un) **]-Tsubo syndrome
Cardiogenic shock
End organ failure

Discharge Condition:
Expired

Discharge Instructions:
Not applicable

Followup Instructions:
Not applicable
{'Unspecified septicemia,Septic shock,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Other primary cardiomyopathies,Chronic hepatitis C without mention of hepatic coma,Pneumonia, organism unspecified,Defibrination syndrome,Severe sepsis,Encounter for palliative care,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Esophageal reflux,Unspecified glaucoma,Other respiratory abnormalities'}


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: Transferred from [**Hospital3 3583**] for ST elevations on EKG

PRESENT ILLNESS: 75yo woman w/ PMH of HTN, hypothyroidism, Hep C, transferred
from [**Hospital3 3583**] for cardiac catheterization for ST
elevations. She was admitted to [**Hospital3 3583**] on [**8-20**] for
cervical LAD, fatigue, weight loss, worked up for lymphoma.
While there, she was found to have bilateral pleural effusions,
LAD. Went today ([**8-25**]) for LN biopsy. Sometime on [**8-25**], she
developed dyspnea, tachycardia to 130s-140s, and ST elevations
in the anteroseptal and inferior leads. She was transferred here
for cardiac catheterization. Upon arrival (on heparin and nitro
gtt), she was confused, diaphoretic, and lethargic. Cardiac cath
showed clean coronary arteries. She was noted to have RAP 19,
RVP 45/19, PAP 45/30, PCWP 27, CO 3.94, CI 2.43, and anterior
wall motion hypokinesis suggestive of myocardial stunning. She
did not have pericardial effusions. ABG was 7.17/23/79/11 with
lactate 12.9 and repeat 7.13/30/89/11 with lactate 14.6. Glucose
was 20 and she was given D50. She was admitted to the CCU.

MEDICAL HISTORY: HTN
GERD
HCV
osteoporosis
glaucoma
hypothyroidism
s/p hysterectomy
?s/p thyroidectomy
?s/p back [**Last Name (un) **]

MEDICATION ON ADMISSION: at home:
synthroid 100mcg qd
protonix 40mg qd
diltiazem 180mg qd
actonel 35mg qd

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: PE: VS: T96.8, HR 104, BP 108/69, MAP 68, RR 17, SaO2 100%
AC FiO2 1.00, TV 450, RR 14, PEEP 5.0
Genl: sedated, intubated
HEENT: NCAT, ETT in place
Neck: dressing C/D/I from LN biopsy today
Pulm: on vent, decreased flow
CV: RRR, nl S1, S2, no m/r/g appreciated
Abd: BS+, soft, nontender, nondistended
GU: femoral sheath in place in R, dressing C/D/I
Ext: cool, mottled, PP present, [**12-24**]+ edema
Neuro: intubated, sedated, unresponsive

FAMILY HISTORY: unknown

SOCIAL HISTORY: remote h/o tobacco use, no alcohol, married w/ 2 children 

### Response:
{'Unspecified septicemia,Septic shock,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Other primary cardiomyopathies,Chronic hepatitis C without mention of hepatic coma,Pneumonia, organism unspecified,Defibrination syndrome,Severe sepsis,Encounter for palliative care,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Esophageal reflux,Unspecified glaucoma,Other respiratory abnormalities'}
