CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is an 984-year-old
male who presented to [**Hospital1 69**] on
[**2108-2-12**], status post a fall.  He reported a decreased
stability over the past 10 months.  A magnetic resonance
imaging showed a large mass behind his odontoid compressing
C1 and C2.  He received surgery for an anterior cervical
decompression on [**2108-3-12**].  The mass was found to be
from pseudogout.

MEDICAL HISTORY: 1.  Gout.
2.  Hypertension.
3.  Coronary artery disease (100% left anterior descending
artery lesion).
4.  Congestive heart failure with an ejection fraction
of 20%.
5.  Status post myocardial infarction in [**2085**].
6.  Chronic renal insufficiency with a baseline creatinine
of 1.9 to 2.3.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Other disorders of calcium metabolism,Chondrocalcinosis, unspecified, other specified sites,Myelopathy in other diseases classified elsewhere,Pneumonitis due to inhalation of food or vomitus,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Cardiac arrest,Coronary atherosclerosis of native coronary artery,Old myocardial infarction
Dis calcium metablsm NEC,Chondrocalc NOS-oth site,Myelopathy in oth dis,Food/vomit pneumonitis,Chr airway obstruct NEC,CHF NOS,Cardiac arrest,Crnry athrscl natve vssl,Old myocardial infarct
Admission Date:  [**2108-3-12**]       Discharge Date: [**2108-3-21**]


Service:

Surgeon:  [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.

First assistant:  None

NOTE:  This is a re-dictation for a lost operative note.

PREOPERATIVE DIAGNOSIS:  Cervical vertebral oropharyngeal
tumor process with spinal cord compression and associated
neurological deficits

POSTOPERATIVE DIAGNOSIS:  Cervical vertebral oropharyngeal
tumor process with spinal cord compression and associated
neurological deficits

PROCEDURE:
1.  Transoral transpalatal approach for excision of C1-C2
vertebral column tumor/destructive process with resection of
oropharyngeal tumor

ANESTHESIA:  General endotracheal tube

INDICATIONS:  The patient is an older gentleman who has been
identified within a C1-2 cervical vertebral body tumor.
There is suspicion for malignancy versus an arthropathy.  I
have been consulted by Dr. [**Last Name (STitle) 1338**] and Dr. [**Last Name (STitle) 1007**] to assist in
the transoral approach of this tumor since it is an
anteriorly based lesion.  The approach is being used for
diagnostic and therapeutic purposes.  I have been asked to
provide the approach for this tumor and resection.  I met
with the patient's family and the patient preoperatively and
discussed the various approaches including extension of the
approach transpalatally and laterally.  They are aware of all
the risks, benefits and recovery from my portion of the
approach to the surgery and wished to proceed.

PROCEDURE IN DETAIL:  The patient was identified, brought to
the Operating Room and positioned supine on the Operating
Room table.  General endotracheal tube anesthesia was induced
with a standard oral tube without difficulty.  Care was taken
to protect the cervical spine during intubation.  I
supervised the intubation entirely.  Once the armored
endotracheal tube had been placed, the patient was relaxed.

The patient was edentulous, facilitating the exposure.
Initially, a wet gauze was introduced to break the upper
gingiva.  Initially, I attempted to place the [**Last Name (un) 102453**] mouth
gag, but we did not have any slotted tongue blades so I
elected to proceed with the [**Last Name (un) **]-[**Location (un) **] mouth gag.  The
[**Last Name (un) **]-[**Location (un) **] mouth gag with the largest blade was placed
atraumatically and the mouth was opened.  The patient was
placed into tonsil suspension.  Sequentially, the oral cavity
was dilated with the [**Last Name (un) **]-[**Location (un) **] mouth gag until it could be
maximally opened.  No dislocation of the temporomandibular
joint occurred.  Palpation of the oropharyngeal wall
confirmed that the posterior pharyngeal wall had no ectatic
vasculature.  It was evident, however, that since the neck
could only be extended to some degree, that there would be
additional exposure required to get to the superior aspect of
C1-C2.  Therefore, a red rubber catheter was introduced
through the nose and out through the mouth for palatal
retraction.  This did not provide enough retraction, because
the patient was status post tonsillectomy with tethering of
the posterior pharyngeal pillars to the aspect of the
oropharynx.

Therefore, a palatal splitting approach was considered.
Working in the midline, lateral retraction was placed along
the uvula.  Using [**Last Name (un) 4161**] and cutting current, I suctioned the
oropharyngeal mucosa.  I dissected along the median raphe in
an avascular plane with a cutting current and the palatal
split was carried to within about 2 cm of the posterior
palatine spine.  Retraction sutures were placed on the
palate.  These were sutured to red rubber catheters which
were placed in the nose and then sutured together.  These
were drawn out through the nose and tethered laterally with
snaps to provide soft palatal retraction.

Next, a needle was placed in the posterior pharyngeal wall
and the C-arm was brought in and a lateral cervical spine
film was taken.  Confirmation of that exposure to the C1-C2
area was achieved.  This was marked with a small dot of
methylene blue.

At this point, I turned the case over to Dr. [**Last Name (STitle) 1338**] and Dr.
[**Last Name (STitle) 1007**] for their approach to the cervical spine, through the
posterior oropharyngeal wall.  We reviewed the approach, the
angulation and the closure that would be required for the
oropharyngeal mucosal incision and then the subsequent
prevertebral fascial incisions.  We also discussed various
trap door flaps, etc. but we elected to proceed with a
standard midline posterior pharyngotomy.

The patient was then turned over to the neurosurgery and
orthopedic teams.  He underwent his surgical procedure.  I
checked in during the case and everything was proceeding
quite nicely.  Closure was conducted after the
neurosurgical/orthopedic approach.

There was no bleeding.

COMPLICATIONS:  None

ESTIMATED BLOOD LOSS:  Nil

MEDICATIONS:  Decadron and antibiotics consisting of
anaerobic coverage.

DISPOSITION:  Stable to the orthopedic and neurosurgical
teams for subsequent tumor approach and resection.




                            [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) **]

Dictated By:[**Last Name (NamePattern1) 102454**]
MEDQUIST36

D:  [**2108-3-21**]  11:32
T:  [**2108-3-21**]  12:55
JOB#:  [**Job Number 102455**]


Admission Date:  [**2108-3-12**]     Discharge Date:  [**2108-3-25**]


Service:  MICU

HISTORY OF PRESENT ILLNESS:  The patient is an 984-year-old
male who presented to [**Hospital1 69**] on
[**2108-2-12**], status post a fall.  He reported a decreased
stability over the past 10 months.  A magnetic resonance
imaging showed a large mass behind his odontoid compressing
C1 and C2.  He received surgery for an anterior cervical
decompression on [**2108-3-12**].  The mass was found to be
from pseudogout.

He was transferred to the Medicine Service on [**2108-3-20**]
for management of respiratory difficulties.  He was suspected
to have pneumonia (possibly from aspiration).  He was started
on ceftazidime, vancomycin, and Flagyl.  He was also started
on ciprofloxacin to double cover for pseudomonas.

On the afternoon of [**2108-3-23**], he was found to be in his
room unresponsive and pulseless.  Cardiopulmonary
resuscitation was started, during which he received 3 amps of
atropine, 3 of epinephrine, and 2 of bicarbonate.  He was
intubated.  He had pulseless electrical activity for 15
minutes during the code before regaining his pulse.  He was
intubated.  He was started on dopamine for hypotension.

He was transferred to the Medical Intensive Care Unit for
further management.

PAST MEDICAL HISTORY:
1.  Gout.
2.  Hypertension.
3.  Coronary artery disease (100% left anterior descending
artery lesion).
4.  Congestive heart failure with an ejection fraction
of 20%.
5.  Status post myocardial infarction in [**2085**].
6.  Chronic renal insufficiency with a baseline creatinine
of 1.9 to 2.3.

HOSPITAL COURSE:  After the patient was transferred to the
Medical Intensive Care Unit he continued to require
ventilator support and also to require blood pressure support
with dopamine.

The etiology of his pulseless electrical activity was
unclear; although, this could have been from a combination of
his poor baseline cardiac status, possible hypoxia from
pneumonia, as well as possible hypovolemia/sepsis from his
pneumonia.  In addition, he had chronic pain and was on high
doses of pain medications which could also have contributed
to the pulseless electrical activity.

After arriving in the Medical Intensive Care Unit he failed
to regain consciousness.  He was not responsive to verbal or
to painful stimuli.  He was evaluated by his neurosurgeon,
Dr. [**Last Name (STitle) 1338**], who concurred that the patient's prognosis for
recovery would be extremely poor.

Given these circumstances, the family opted to withdraw care.
The pressor dopamine was stopped on [**2108-3-25**], and the
patient subsequently expired at 8:43 p.m.

CAUSE OF DEATH:  Immediate cause of death was coronary artery
disease and congestive heart failure.



                         DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-207

Dictated By:[**Name8 (MD) 4123**]

MEDQUIST36

D:  [**2108-3-25**]  20:49
T:  [**2108-3-27**]  07:22
JOB#:  [**Job Number **]
{'Other disorders of calcium metabolism,Chondrocalcinosis, unspecified, other specified sites,Myelopathy in other diseases classified elsewhere,Pneumonitis due to inhalation of food or vomitus,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Cardiac arrest,Coronary atherosclerosis of native coronary artery,Old myocardial infarction'}


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: 

PRESENT ILLNESS: The patient is an 984-year-old
male who presented to [**Hospital1 69**] on
[**2108-2-12**], status post a fall.  He reported a decreased
stability over the past 10 months.  A magnetic resonance
imaging showed a large mass behind his odontoid compressing
C1 and C2.  He received surgery for an anterior cervical
decompression on [**2108-3-12**].  The mass was found to be
from pseudogout.

MEDICAL HISTORY: 1.  Gout.
2.  Hypertension.
3.  Coronary artery disease (100% left anterior descending
artery lesion).
4.  Congestive heart failure with an ejection fraction
of 20%.
5.  Status post myocardial infarction in [**2085**].
6.  Chronic renal insufficiency with a baseline creatinine
of 1.9 to 2.3.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Other disorders of calcium metabolism,Chondrocalcinosis, unspecified, other specified sites,Myelopathy in other diseases classified elsewhere,Pneumonitis due to inhalation of food or vomitus,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Cardiac arrest,Coronary atherosclerosis of native coronary artery,Old myocardial infarction'}
