CHIEF COMPLAINT: Elective nephrectomy for metastatic renal cell carcinoma

PRESENT ILLNESS: This is a 71 year-old woman with  metastatic renal cell
carcinoma diagnosed in [**3-22**] and COPD being transferred to the
[**Hospital Unit Name 153**] s/p left radical nephrectomy for respiratory monitoring.
Patient was hypoxic to the 80's prior to intubation and
therefore aneasthesia and surgery preferred monitoring in ICU
with likely extubation tomorrow AM.  History obtained largely
from providers and their notes, patient intubated, sedated.

MEDICAL HISTORY: Metastatic renal cell carcinoma
COPD, FEV1 2.17-67%predicted
Cholecystectomy.
Status post surgical repair of uterine prolapse, TAH/BSO
Obesity
Heavy Smoker
H/o DVT s/p IVC filter implantation

MEDICATION ON ADMISSION: see H&P

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:  Temp: 98.1     BP:124 /66    HR:75   RR:12   99% O2sat

FAMILY HISTORY: Her mother died in her 50s from a postoperative pulmonary
embolus.  Father died in his 70s from congestive heart failure.
She reports having 5 siblings.  Her brother with esophageal
cancer and there is a prominent family history of type
2 diabetes.  She is of Irish descent.  She has 6 children all of
whom are in good health.  There is no family history of breast,
GYN, colonic, or renal cell cancer in the family.

SOCIAL HISTORY: The patient lives with her daughter in [**Name (NI) 8391**].  She
formally worked in a factory, however, denies any chemical or
radiation or asbestos exposure to her knowledge.  She also
worked at stop-and-shop briefly.  She reports a 80-pack-year
history of tobacco.  She quit approximately 9 years ago.  She
reports occasional alcohol use, however, none currently
Malignant neoplasm of kidney, except pelvis,Chronic airway obstruction, not elsewhere classified,Pulmonary collapse,Secondary malignant neoplasm of lung,Chronic kidney disease, unspecified,Paralytic ileus,Hypoxemia,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Long-term (current) use of anticoagulants
Malig neopl kidney,Chr airway obstruct NEC,Pulmonary collapse,Secondary malig neo lung,Chronic kidney dis NOS,Paralytic ileus,Hypoxemia,Abn reac-organ rem NEC,Long-term use anticoagul
Admission Date:  [**2153-12-18**]              Discharge Date:   [**2154-1-1**]

Date of Birth:  [**2082-7-24**]             Sex:   F

Service: UROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
Elective nephrectomy for metastatic renal cell carcinoma

Major Surgical or Invasive Procedure:
Left radical nephrectomy


History of Present Illness:
This is a 71 year-old woman with  metastatic renal cell
carcinoma diagnosed in [**3-22**] and COPD being transferred to the
[**Hospital Unit Name 153**] s/p left radical nephrectomy for respiratory monitoring.
Patient was hypoxic to the 80's prior to intubation and
therefore aneasthesia and surgery preferred monitoring in ICU
with likely extubation tomorrow AM.  History obtained largely
from providers and their notes, patient intubated, sedated.

As per anaesthesia and surgery, surgery was uneventful, no
complications.

On arrival, patient easily arousable, denies pain.


Past Medical History:
Metastatic renal cell carcinoma
COPD, FEV1 2.17-67%predicted
Cholecystectomy.
Status post surgical repair of uterine prolapse, TAH/BSO
Obesity
Heavy Smoker
H/o DVT s/p IVC filter implantation


Social History:
The patient lives with her daughter in [**Name (NI) 8391**].  She
formally worked in a factory, however, denies any chemical or
radiation or asbestos exposure to her knowledge.  She also
worked at stop-and-shop briefly.  She reports a 80-pack-year
history of tobacco.  She quit approximately 9 years ago.  She
reports occasional alcohol use, however, none currently

Family History:
Her mother died in her 50s from a postoperative pulmonary
embolus.  Father died in his 70s from congestive heart failure.
She reports having 5 siblings.  Her brother with esophageal
cancer and there is a prominent family history of type
2 diabetes.  She is of Irish descent.  She has 6 children all of
whom are in good health.  There is no family history of breast,
GYN, colonic, or renal cell cancer in the family.

Physical Exam:
VS:  Temp: 98.1     BP:124 /66    HR:75   RR:12   99% O2sat

I/O: 2750/540--last 24 hours/Weight 106.7

Vent setting: AC 12x700 (no spont breaths) FiO2 of 60% PEEP:5

ABG:7.34/51/233

general: intubated, sedated, easily arousable
HEENT: PERLLA, EOMI, anicteric, no sinus tenderness, MMM, op
without lesions, no supraclavicular or cervical lymphadenopathy,
no jvd
lungs: CTA b/l with good air movement throughout
heart: RR, S1 and S2 wnl, distant heart sounds, no murmurs, rubs
or gallops appreciated
abdomen: obese, large ventral hernia, +b/s, soft, nt,
left flank: large dressing in place, NT, without signficant
bleeding
extremities: no edema, pneumoboots
skin/nails: no rashes/no jaundice
neuro: sedated, easily arousable, responsive to commands, moves
all four extremities, wiggles toes and squeezes fingers to
command

Brief Hospital Course:
ICU and hospital course:

Mrs. [**Known lastname **] is a 71 yo F with a PMH of metastatic renal cell
carcinoma, COPD, chronic kidney disease, h/o DVT who presented
to the ICU after a nephrectomy. Prior to the nephrectomy, she
was mildly hypoxic, and it was felt that she would not be easy
to extubate.

## Respiratory failure: The pt arrived to the ICU intubated and
sedated. Her sedation was slowly weaned and she was extubated
successfully on the day after admission. She continued to
require oxygen by nasal canula to maintain O2 sats in the 90s.
Her hypoxia was likley secondary to chronic insufficiecny in the
context of atelectasis and volume overload. She was continued on
her fluticasone/salmeterol 500/50 and albuterol and ipatropium
nebulizer treatments prn. She will need supplemental O2 on
discharge. On discharge she was sating at 95% on 2L (pre-op
88-92% on RA).

## s/p nephrectomy: pt tolerated the procedure well. She
initially had pain at the surgical site which slowly resolved.
Her wound was C/D/I at discharge after staples were removed. Her
final pathology revealed conventional (clear cell) renal cell
carcinoma pT3a: tumor directly invades adrenal gland or
perirenal and/or renal sinus fat but not beyond Gerota's fascia;
spoke with Dr. [**Last Name (STitle) **] regarding her follow-up and the results of
the lung biopsy, which after review are consistent with
metastatic disease obviating the need for a lung biopsy. She
will follow-up with Dr. [**Last Name (STitle) **] in the next week in clinic and is
instructed to call to confirm this appt; in addition she is
scheduled for CT Chest [**1-2**].



## ileus/SBO:  patient stopped passing flatus and had worsening
abdominal distention. She then had bilious emesis x 2 for a
total of 600 cc.  An NG tube was placed which returned 200 cc of
bilious, nonbloody fluid.  Abdominal imaging showed evidence of
small bowel dilation consistent with ileus vs. obstruction.  As
patient's operation was not within the peritoneal cavity but
retroperitoneal, it was believed to be more likely ileus in the
setting of increased pain med requirements. Indeed her prolonged
hospital course was secondary to a prostracted ileaus that was
initially managed with NGT/decompression however by POD [**11-28**]
the NG was remvoed, her diet was advanced and she tolerated it
well. Of note, she consistently passed flatus and had BMs
throughout the ileus. Also, C Diff was sent which was negative.
Interval KUBs would show dilated small loops with AFLs, no free
air that would resolve thorughout her course. She was placed on
RTC Reglan toward the end of her course to expedite resolution;
GI was curbsided and beleived she has a protracted ileus that
was responded to conservative measures. In addition surgery was
consulted and recommended similar conservative measures. By the
end of her hospital course she was tolerating a regular diet and
having regular bowel movements.

## CKD: Baseline Cr 1.2-1.4. Normal increase in Cr after
nephrectomy is approximately 30-40%. Her creatinine was 1.6 on
discharge from the ICU. This had settled at 1.3 at time of
discharge. Her lytes were otherwise stable throughout; her
potassim was optimized.

## Hyperglycemia: Likely in setting of stress from surgery and
mild underlying insulin resistance. Was no longer requiring
insulin at time of discharge from the ICU.

## h/o DVT: Should likely be on life-long anticoagulation given
she had a malignancy-associated DVT. Was maintained on heparin
SC TID while in house. Will need to restart warfarin 1-2 weeks
post-op.

## Dispo: PT worked throughout her course and she successfully
ambulated with assistance. She will need to continue aggressive
PT at rehab.

Medications on Admission:
see H&P

Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
[**12-18**] Disk with Devices Inhalation [**Hospital1 **] ().
3. Acetaminophen 650 mg Suppository Sig: [**12-18**] Suppositorys Rectal
Q6H (every 6 hours) as needed for fever, pain.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for wheeze.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for wheeze.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Metastatic Renal Cell Carcinoma


Discharge Condition:
Good


Discharge Instructions:
Please see the nephrectomy discharge instructions
* Increasing pain or persistent pain that is not relieved by
pain medications
*Inability to urinate
* Fever (>101.5 F)
*Nausea or Vomiting that last longer than 24 hours
* Inability to pass gas or stool
* Other symptoms concerning to you

Followup Instructions:
Please follow up with Dr [**Last Name (STitle) 3748**] in [**1-20**] weeks. Call ([**Telephone/Fax (1) 39050**] to make an appointment.
Please follow up with Hematology Oncology, Dr. [**Last Name (STitle) **] at
[**0-0-**]. You have an appt. for next week. This was
confirmed with Dr. [**Last Name (STitle) **].  She is scheduled for CT Chest [**1-2**]
coordinated with Heme-Oncology.



Completed by:[**2154-1-1**]
{'Malignant neoplasm of kidney, except pelvis,Chronic airway obstruction, not elsewhere classified,Pulmonary collapse,Secondary malignant neoplasm of lung,Chronic kidney disease, unspecified,Paralytic ileus,Hypoxemia,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Long-term (current) use of anticoagulants'}


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: Elective nephrectomy for metastatic renal cell carcinoma

PRESENT ILLNESS: This is a 71 year-old woman with  metastatic renal cell
carcinoma diagnosed in [**3-22**] and COPD being transferred to the
[**Hospital Unit Name 153**] s/p left radical nephrectomy for respiratory monitoring.
Patient was hypoxic to the 80's prior to intubation and
therefore aneasthesia and surgery preferred monitoring in ICU
with likely extubation tomorrow AM.  History obtained largely
from providers and their notes, patient intubated, sedated.

MEDICAL HISTORY: Metastatic renal cell carcinoma
COPD, FEV1 2.17-67%predicted
Cholecystectomy.
Status post surgical repair of uterine prolapse, TAH/BSO
Obesity
Heavy Smoker
H/o DVT s/p IVC filter implantation

MEDICATION ON ADMISSION: see H&P

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:  Temp: 98.1     BP:124 /66    HR:75   RR:12   99% O2sat

FAMILY HISTORY: Her mother died in her 50s from a postoperative pulmonary
embolus.  Father died in his 70s from congestive heart failure.
She reports having 5 siblings.  Her brother with esophageal
cancer and there is a prominent family history of type
2 diabetes.  She is of Irish descent.  She has 6 children all of
whom are in good health.  There is no family history of breast,
GYN, colonic, or renal cell cancer in the family.

SOCIAL HISTORY: The patient lives with her daughter in [**Name (NI) 8391**].  She
formally worked in a factory, however, denies any chemical or
radiation or asbestos exposure to her knowledge.  She also
worked at stop-and-shop briefly.  She reports a 80-pack-year
history of tobacco.  She quit approximately 9 years ago.  She
reports occasional alcohol use, however, none currently 

### Response:
{'Malignant neoplasm of kidney, except pelvis,Chronic airway obstruction, not elsewhere classified,Pulmonary collapse,Secondary malignant neoplasm of lung,Chronic kidney disease, unspecified,Paralytic ileus,Hypoxemia,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Long-term (current) use of anticoagulants'}
