CHIEF COMPLAINT: low abdominal pain, bloating, CT with abdominal ascites

PRESENT ILLNESS: This is a 55 yo G0 s/p [**4-7**] exlap/BSO for a large left adnexal
mass found to be stage 1C mucinous borderline tumor of the ovary
who presented to gyn oncology clinic yesterday with concern for
low abdominal pain and bloating.  This has been getting
progressively worse for several months.  She had been
attributing her abdominal pain to diet and NSAID use, but found
that altering these had minimal effect.  She reports that laying
supine leads to nausea and vomitting.  This has led her to sleep
in a reclining chair, which she believes has caused some back
pain.  She endorses significant constipation.  Of note, she
reports being seen at [**Hospital **] Hospital ED recently where she
was told she had a subclinical UTI infection.  For this she was
prescribed macrobid, which has caused further emesis.

MEDICAL HISTORY: Ob/Gyn Hx: G0.  Stage IC borderline mucinous tumor of the left
ovary, treated with BSO and biopsy as above.

MEDICATION ON ADMISSION: macrobid, ativan prn

ALLERGIES: Latex / Cefazolin / Red Dye / Cephalosporins / Nickel

PHYSICAL EXAM: At the time of admission:

FAMILY HISTORY: No history of breast or gyn malignancy.

SOCIAL HISTORY: Lives with husband in [**Name (NI) 47**].  Denies T/E/D.
Secondary malignant neoplasm of retroperitoneum and peritoneum,Acute kidney failure with lesion of tubular necrosis,Malignant ascites,Urinary tract infection, site not specified,Other specified intestinal obstruction,Hyposmolality and/or hyponatremia,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Secondary malignant neoplasm of genital organs,Urinary complications, not elsewhere classified,Other (abnormal) findings on radiological examination of breast,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Personal history of malignant neoplasm of ovary
Sec mal neo peritoneum,Ac kidny fail, tubr necr,Malignant ascites,Urin tract infection NOS,Intestinal obstruct NEC,Hyposmolality,Mal neo lymph-intrathor,Second malig neo genital,Surg compl-urinary tract,Abn finding-breast NEC,Abn react-surg proc NEC,Hx of ovarian malignancy
Admission Date:  [**2146-11-10**]              Discharge Date:   [**2146-11-21**]

Date of Birth:  [**2091-9-24**]             Sex:   F

Service: OBSTETRICS/GYNECOLOGY

Allergies:
Latex / Cefazolin / Red Dye / Cephalosporins / Nickel

Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
low abdominal pain, bloating, CT with abdominal ascites

Major Surgical or Invasive Procedure:
paracentesis

History of Present Illness:
This is a 55 yo G0 s/p [**4-7**] exlap/BSO for a large left adnexal
mass found to be stage 1C mucinous borderline tumor of the ovary
who presented to gyn oncology clinic yesterday with concern for
low abdominal pain and bloating.  This has been getting
progressively worse for several months.  She had been
attributing her abdominal pain to diet and NSAID use, but found
that altering these had minimal effect.  She reports that laying
supine leads to nausea and vomitting.  This has led her to sleep
in a reclining chair, which she believes has caused some back
pain.  She endorses significant constipation.  Of note, she
reports being seen at [**Hospital **] Hospital ED recently where she
was told she had a subclinical UTI infection.  For this she was
prescribed macrobid, which has caused further emesis.

Following her gyn oncology appointment yesterday, she was sent
for CT of the abdomen and pelvis.  Prelim read revealed:

"Moderate ascites with multiple enlarged mesenteric and
retroperitoneal nodes and peritoneal implants, worrisome for
metastatic disease. There is a loop of jejunum demonstrating
marked wall thickening, raising concern for metastatic
involvement. There is no evidence of obstruction with passage of
contrast beyond this point and lack of upstream dilation. Other
loops of small bowel also demonstrate mild mucosal thickening.
Periumbilical subcutaneous nodule, measuring 2.1 cm, may also
represent metastatic disease. There is a 8 mm right breast
nodule. Correlation with mammogram is recommended.  Simple cyst
in the 6th hepatic segment is noted. LLL 5 mm subpleural nodule,
given underlying malignancy close interval follow-up is
recommended. Moderate sized axial hiatal hernia. R kidney lower
pole 1 cm low attenuation lesion, incompletely characterized
given lack of IV contrast.  Evaluation of uterus and adnexa is
limited given technique, correlation with MR or US is
recommended."

The decision was made to directly admit the patient for further
workup including paracentesis.

Past Medical History:
Ob/Gyn Hx: G0.  Stage IC borderline mucinous tumor of the left
ovary, treated with BSO and biopsy as above.

PMH: migraines, seasonal allergies.  She reports that her last
mammogram was "several years ago."  Colonoscopy was performed
last year.

PSH: [**2141**] exlap, BSO, omental bx, cervical polypectomy


Social History:
Lives with husband in [**Name (NI) 47**].  Denies T/E/D.

Family History:
No history of breast or gyn malignancy.

Physical Exam:
At the time of admission:

98.4, 110, 142/82, 20, 96% RA
no I/O recorded yet
Gen: awake and alert, sitting up at side of bed, well appearing
CV: regular rhythm, tachy
lungs: CTAB ant and post, good inspiratory effort
back: no CVAT
abd: soft, NT, +distended, tympanic to percussion superiorly
bilaterally, well healed vertical midline scar, +bs
GU: no VB
Extr: nontender, nonedematous

Pertinent Results:
[**2146-11-9**] 03:50PM   CEA-3.3 CA125-275*
[**2146-11-9**] 03:50PM   WBC-17.3* RBC-4.31# HGB-13.0# HCT-38.9#
MCV-90 MCH-30.2 MCHC-33.4 RDW-14.1
[**2146-11-9**] 03:50PM   PLT COUNT-536*
[**2146-11-9**] 03:50PM   PT-12.3 PTT-22.1 INR(PT)-1.0
[**2146-11-9**] 03:50PM   UREA N-9 CREAT-0.6 SODIUM-136 POTASSIUM-4.1
CHLORIDE-95* TOTAL CO2-26 ANION GAP-19
[**2146-11-9**] 03:50PM   GLUCOSE-108*
.
[**2146-11-17**] CT scan Final Report
INDICATION: 55-year-old woman with symptoms consistent with
recurrent ovarian cancer. Please evaluate for obstruction.

COMPARISON: CT abdomen and pelvis without contrast [**2146-11-9**].

TECHNIQUE: MDCT axial images from the lung bases to the pubic
symphysis were obtained with and without IV contrast.
Multiplanar reformatted images (axial,coronal, sagittal) were
generated.

FINDINGS:

CT ABDOMEN: The visualized lung bases show evidence of small
bilateral
pleural effusions. The visualized heart and pericardium are
unremarkable. A 2-mm nodule reported along the pleura of the
left lower lobe is not visualized in this study. A hiatal hernia
is once again noted. A hyperdense lesion measuring 9.2 x 9.2 mm
is once again noted in the right breast.

At the junction of segments V and VI of the right lobe of the
liver, there is a 25 x 25 mm well-demarcated, low-density lesion
which has not changed in size, previously measuring 25 x 25 mm.

The gallbladder appears contracted. The spleen appears normal in
size and
appearance. The pancreas is normal appearing without evidence of
masses.

The adrenals appear unremarkable. The kidneys enhance and
excrete contrast
symmetrically without evidence of hydronephrosis. In the lower
pole of the right kidney, there is a 12 x 9.8 mm
well-circumscribed hypodensity (2, 34) with attenuation
coefficient of 36.5. This is unchanged in size from that noted
on prior CT scan.

Ascitic fluid is noted throughout the abdominal cavity,
unchanged in
appearance from that noted on prior CT. Mesenteric stranding and
thickening consistent with omental caking is noted. There is
thickened peritoneum suggesting peritoneal implants. Findings
are consistent with peritoneal carcinomatosis, concerning for
metastatic disease. Numerous mesenteric and retroperitoneal
lymph nodes are noted. Small supradiaphragmatic/left paracardial
lymph nodes are noted (2, 15). Within the region of the
umbilicus, in the soft tissues, there is a 20 x 10 mm density
that likely represents a small umbilical hernia, but could
represent a metastatic lesion (2, 38).

The proximal and mid small bowel loops appear dilated. The
distal terminal ileum is not dilated, likely representing a
transition point at the terminal ileum. The large bowel does not
appear dilated. Findings are suggestive of partial small-bowel
obstruction.

The aorta and abdominal vasculature appear patent. There is no
free air
noted.

CT OF THE PELVIS: Ascitic fluid is noted within the pelvis,
obscuring
contours of the pelvic organs. The bladder appears normal. The
uterus and
adnexa are not clearly visualized secondary to ascitic fluid,
however a
nodular mass about the fundus of the uterus is noted, which
could be exophytic fibroid or metastases. There is no pelvic
lymphadenopathy.

OSSEOUS STRUCTURES: An area of sclerosis is seen in the
posterior aspect of the right iliac bone.

IMPRESSION:

1. Proximal and mid small bowel loops are dilated with a
possible transition point in the distal terminal ileum, with no
dilation of large bowel. Findings are consistent with partial
small-bowel obstruction.

2. Ascites with omental caking and peritoneal implants are noted
unchanged from prior CT, concerning for recurrence of ovarian
metastatic disease. Small bilateral pleural effusion.

3. A nodular mass is noted above the fundus of the uterus. The
differential diagnosis includes metastases versus exophytic
fibroid.

4. A right-sided breast nodule is noted. Correlation with
mammogram
recommended.

5. A simple cyst is noted in segment VI of the liver, stable in
size and
appearance from that noted on prior CT.

6. A hypodense lesion is noted in the lower pole of the right
kidney, too
small to characterize; attention on follow up.

Dr. [**Last Name (STitle) 61028**] was notified of results on the same day.
The study and the report were reviewed by the staff radiologist.

.
[**2146-11-17**]
Final Report
INDICATION: 55-year-old woman with likely recurrence of ovarian
cancer,
scheduled for OR, pre-op.

COMPARISON: CT abdomen and pelvis of [**2146-11-16**].

CHEST, TWO VIEWS: Heart size, mediastinal and hilar contours are
normal. No focal consolidation or pneumothorax. Small right
pleural effusion persists. Pulmonary vasculature is normal. No
gross osseous abnormality.

IMPRESSION: No acute intrathoracic abnormality. Small right
pleural
effusion.
.
[**2146-11-19**]
SINGLE AP PORTABLE VIEW OF THE CHEST

REASON FOR EXAM: Followup lung abnormalities.

Comparison is made with prior study performed a day earlier.

Extensive alveolar diffuse opacities and consolidations have
worsened
consistent with worsening severe pulmonary edema. Cardiac
silhouette is
obscured by the parenchymal abnormalities. The lines and tubes
remain in
standard position.
.
[**2146-11-20**]
SINGLE AP PORTABLE VIEW OF THE CHEST

REASON FOR EXAM: Severe ARDS.

Comparison is made with prior study performed a day earlier.

There has been markedly improvement in still moderate diffuse
alveolar
opacities most likely due to markedly improved moderate
pulmonary edema.
Cardiac size is normal. There is no pneumothorax. ET tube is in
standard
position. Right IJ catheter tip is in the mid SVC. NG tube tip
is in the
stomach. If any there are small bilateral pleural effusions.


Brief Hospital Course:
The patient was admitted to the gyn oncology service for further
work up of her ascites, abd pain, and nausea and vomiting.
.
*) Recurrence of ovarian mucinous cancer
The pt was given IV fluids for rehydration and symptomatic
relief with zofran and famotidine.  Her CA-125 was noted to be
elevated at 275.  She underwent paracentesis on HD#2 which led
to drainage of 3000cc of ascitic fluid.  Cytology revealed
malignant cells consistent with involvement by the patients
known mucinous ovarian neoplasm and likely represented a
recurrence.  At attempt was made to obtain an MRI of the abdomen
and pelvis but the pt was unable to tolerate the procedure.  A
pelvic US [**11-12**] revealed a heterogeneous endometrium consistent
with appearance in [**2142**] and a large amount of complex ascites.
HD#5 the pt was to undergo a biopsy of an abdominal nodule but
this area was felt to be a hernia at time of biopsy and no
biopsy was performed.  HD#6 a mammogram was done to evaluate the
right breast nodule and it was felt to be benign.  HD#7 the pt
underwent another CT abd/pelvis due to worsening abd sx which
revealed a partial SBO.  The patient declined an NGT.  She was
added on for the OR for a likely bowel resection, possible
resection of recurrent mucinous borderline tumor on HD#9.  She
was kept NPO after midnight and received an enema prior to
surgery.  She had an EKG which was unremarkable except for sinus
tachycardia and a normal CXR.
...

Post-operative course:
The patient was taken to the Operating room on HD#9 for a
possible bowel resection and tumor debulking.  Pre-operatively a
right IJ line was placed and a right A-line.  She was also noted
to have aspirated despite a rapid sequence intubation.

Upon entering the abdomen 5 liters of ascites was drained and
diffuse invasive tumor was noted throughout her dilated small
bowel as well as within the mesentery and coating the large
bowel and stomach.  There were multiple areas of small bowel
with also complete obstruction.  The small bowel was edematous
and there were no areas noted to be free of tumor.  The
ileocecal junction and appendix noted to be the area with the
highest grade obstruction.  There was no distinct tumor seen on
the appendix.  The tumor also covered the surface of the uterus
and bladder and pelvic sidewall.  Please see operative report
for full details.  Given the extensive tumor [**Last Name (LF) 8373**], [**First Name3 (LF) **]
intraoperative consult was made to Dr. [**Last Name (STitle) **] of general
surgery to help create a palliative loop ileostomy and
gastrostomy tube which was done.  While closing the abdomen, a
needle perforation of the small bowel was oversewn with silk
sutures.

The patient became unstable with hypotension requiring a pressor
and becoming hypoxic and tachycardic.  Anesthesia had noted a
small amount of aspiration at the time of intubation and a
bronchoscopy was done which revealed a small amount of aspirate
and this was suctioned.  The patient became slightly less
hypoxic but later again desaturated and anesthesia again did
bronchoscopy and pushed in 100% oxygen to open the aeriolae.
She was given deep, high pressure breaths and 2units of PRBCs
were pushed to improve the hypotension and likely hypovolemia
given the 5 liters of ascites removed.  Once the patient's
stabilization improved to O2 sats in the low 90s and BPs steady
in the 90s/40s on one pressor, she was transferred to the ICU.

In the ICU the paient remained hypoxic, hypotensive, and
tachycardic.  She was noted to be in shock and a CXR revealed
signficant bilateral infiltrates consistent with ARDS.  The
patient continued to be mechanically ventilated on ARDS
protocol.  CXR showed radiographic improvement of lung opacities
bilaterally the following day, however the patient remained
hypoxic with multiple pressor requirement.  A family meeting was
held to discuss goals of care.  Given substantial tumor [**Last Name (STitle) 8373**]
and poor prognosis, the patient's husband made the decision to
make the patient comfort-measures only.  All non-comfort
interventions, including pressors were dicontinued at this time.
 Pain was controlled with morphine.  The patient was
subsequently extubated.  She became progressively more hypoxic
and hypotensive.  She went into asystole and expired 12 hours
post-extubation.


Medications on Admission:
macrobid, ativan prn


Discharge Medications:
n/a

Discharge Disposition:
Expired

Discharge Diagnosis:
Deceased
Ovarian cancer

Discharge Condition:
Deceased

Discharge Instructions:
n/a

Followup Instructions:
n/a

                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
{'Secondary malignant neoplasm of retroperitoneum and peritoneum,Acute kidney failure with lesion of tubular necrosis,Malignant ascites,Urinary tract infection, site not specified,Other specified intestinal obstruction,Hyposmolality and/or hyponatremia,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Secondary malignant neoplasm of genital organs,Urinary complications, not elsewhere classified,Other (abnormal) findings on radiological examination of breast,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Personal history of malignant neoplasm of ovary'}


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: low abdominal pain, bloating, CT with abdominal ascites

PRESENT ILLNESS: This is a 55 yo G0 s/p [**4-7**] exlap/BSO for a large left adnexal
mass found to be stage 1C mucinous borderline tumor of the ovary
who presented to gyn oncology clinic yesterday with concern for
low abdominal pain and bloating.  This has been getting
progressively worse for several months.  She had been
attributing her abdominal pain to diet and NSAID use, but found
that altering these had minimal effect.  She reports that laying
supine leads to nausea and vomitting.  This has led her to sleep
in a reclining chair, which she believes has caused some back
pain.  She endorses significant constipation.  Of note, she
reports being seen at [**Hospital **] Hospital ED recently where she
was told she had a subclinical UTI infection.  For this she was
prescribed macrobid, which has caused further emesis.

MEDICAL HISTORY: Ob/Gyn Hx: G0.  Stage IC borderline mucinous tumor of the left
ovary, treated with BSO and biopsy as above.

MEDICATION ON ADMISSION: macrobid, ativan prn

ALLERGIES: Latex / Cefazolin / Red Dye / Cephalosporins / Nickel

PHYSICAL EXAM: At the time of admission:

FAMILY HISTORY: No history of breast or gyn malignancy.

SOCIAL HISTORY: Lives with husband in [**Name (NI) 47**].  Denies T/E/D. 

### Response:
{'Secondary malignant neoplasm of retroperitoneum and peritoneum,Acute kidney failure with lesion of tubular necrosis,Malignant ascites,Urinary tract infection, site not specified,Other specified intestinal obstruction,Hyposmolality and/or hyponatremia,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Secondary malignant neoplasm of genital organs,Urinary complications, not elsewhere classified,Other (abnormal) findings on radiological examination of breast,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Personal history of malignant neoplasm of ovary'}
