CHIEF COMPLAINT: Lethargy, fever

PRESENT ILLNESS: Patient is a 50yo woman with adenoid cystic carcinoma s/p left
pneumonectomy, known mets to liver/kidney, PE, presenting with
fevers, lethargy, and pleuritic CP.
.
In ED, T 102.5, SBPs initially 110/62, HR 150, on 2Lnc, received
2L of NS with drop of HR to 110, SBPs 80/40, given CTX for
putative PNA. CT (-) for PE but flashed at CT scan, relieved
nitro gtt and NIPPV. Received CTX IVx1, combivent nebs, 60poKCl,
Mg 5g, 3L NS.
.
Most recent chemotherapy was cisplatin on [**9-9**] with 4 clinic
visits over next 12 days with Dr. [**Last Name (STitle) **]/[**Last Name (un) 31899**]. Found to be
tachycardic at all visits for unknown reason with resolution
post fluids. As per primary oncologist, no plans for further
chemotherapy with plan for hospice care discussion soon as
outpatient.

MEDICAL HISTORY: PMH:
1. Adenoid cystic carcinoma, diagnosed [**3-/2103**], details below
2. Left vocal cord paralysis
3. GERD
4. History of PE, [**2099**], [**2107**]
5. Cerebral vein thrombosis
6. Depression? (found in ED note)
7. CVA? (found in ED note)
.
Onc Hx:
[**2102**]: diag after work-up 8 months of cough, L pneumonectomy and
carinal resection and postop radiation.
[**2105**]: Recurrent dz in pleural space.
[**2106**]: palliative radiation with concurrent low-dose Taxotere.
[**2107**]: Hepatic involvement --> 4 cycles of cisplatin and
Adriamycin.
[**2107**]: CT showed progression in lungs/liver. 2 cycles of
carboplatin and Taxol given, still with pulm progression. Tx
complicated by thrombocytopenia and PE on CT, started on
Lovenox.
[**2108**]: Brachial plexus MRI showed tumor L paraspinal region from
T2-T5
[**2108**]: 4 cycles of dose-reduced cisplatin, Navelbine
[**2108**]: CT showed renal hepatic progression.
[**2108**]: started on gemcitabine, held sev times for
myelosuppression.
[**2108**]: MRI showed leptomeningeal enhancement L frontal lobe.
[**2109**]: seizure, vein of Trolard thrombosis.
[**2109**]: weekly epirubicin, received 3 cycles, but multiple doses
were held because of poor performance status.
[**2109**]: onc team and pt decided upon symptom managment as CT scan
showed progression, she received single [**Doctor Last Name 360**] cisplatin.

MEDICATION ON ADMISSION: COMPAZINE 10mg prn
COUMADIN 2mg
DEXAMETHASONE 4mg during chemo
EMEND 125mg 80mg 80mg during chemo.
FENTANYL 225 mcg/hr q72
GABAPENTIN 250 tid
LANSOPRAZOLE 30mg
Megace 400mg
OXYCODONE 5mg q6hrs prn
ZOFRAN 8mg prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: T 99.7, BP 111/78, HR 136, RR 18, 96% 2L
Gen: thin, chronically ill-appearing F in NAD, mostly Spanish
speaking.
HEENT: EOMi dry mucous membranes, clear oropharynx without
thrush.
Neck: flat JVP, no LAD.
Lungs: good air movement on R, decreased to no movement on left.

FAMILY HISTORY: Her mother is alive and healthy. Her father died at age 80 from
a stroke and heart attack. She has 5 sisters and 2 brothers, and
some of them have hypertension, hypercholesterolemia, and
diabetes. She has 6 daughters and a
son; they are all healthy.

SOCIAL HISTORY: She does not smoke cigarettes or drink alcohol.
She moved from [**Country 3594**] to [**State 350**] in [**2091**]. She has a
daughter who lives in [**Name (NI) 17065**]. She also has a brother and
sister who live in the Greater [**Name (NI) 86**] area. She denies  tobacco
or alcohol use and is currently not working. In the  past, she
has worked in a bakery.
Pneumonitis due to inhalation of food or vomitus,Nutritional marasmus,Secondary malignant neoplasm of pleura,Secondary malignant neoplasm of kidney,Acquired coagulation factor deficiency,Stricture and stenosis of esophagus,Personal history of malignant neoplasm of bronchus and lung,Personal history of venous thrombosis and embolism
Food/vomit pneumonitis,Nutritional marasmus,Second malig neo pleura,Second malig neo kidney,Acq coagul factor defic,Esophageal stricture,Hx-bronchogenic malignan,Hx-ven thrombosis/embols
Admission Date:  [**2110-9-25**]              Discharge Date:   [**2110-10-6**]

Date of Birth:  [**2060-5-13**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 2499**]
Chief Complaint:
Lethargy, fever

Major Surgical or Invasive Procedure:
Esophageal stent placement


History of Present Illness:
Patient is a 50yo woman with adenoid cystic carcinoma s/p left
pneumonectomy, known mets to liver/kidney, PE, presenting with
fevers, lethargy, and pleuritic CP.
.
In ED, T 102.5, SBPs initially 110/62, HR 150, on 2Lnc, received
2L of NS with drop of HR to 110, SBPs 80/40, given CTX for
putative PNA. CT (-) for PE but flashed at CT scan, relieved
nitro gtt and NIPPV. Received CTX IVx1, combivent nebs, 60poKCl,
Mg 5g, 3L NS.
.
Most recent chemotherapy was cisplatin on [**9-9**] with 4 clinic
visits over next 12 days with Dr. [**Last Name (STitle) **]/[**Last Name (un) 31899**]. Found to be
tachycardic at all visits for unknown reason with resolution
post fluids. As per primary oncologist, no plans for further
chemotherapy with plan for hospice care discussion soon as
outpatient.


Past Medical History:
PMH:
1. Adenoid cystic carcinoma, diagnosed [**3-/2103**], details below
2. Left vocal cord paralysis
3. GERD
4. History of PE, [**2099**], [**2107**]
5. Cerebral vein thrombosis
6. Depression? (found in ED note)
7. CVA? (found in ED note)
.
Onc Hx:
[**2102**]: diag after work-up 8 months of cough, L pneumonectomy and
carinal resection and postop radiation.
[**2105**]: Recurrent dz in pleural space.
[**2106**]: palliative radiation with concurrent low-dose Taxotere.
[**2107**]: Hepatic involvement --> 4 cycles of cisplatin and
Adriamycin.
[**2107**]: CT showed progression in lungs/liver. 2 cycles of
carboplatin and Taxol given, still with pulm progression. Tx
complicated by thrombocytopenia and PE on CT, started on
Lovenox.
[**2108**]: Brachial plexus MRI showed tumor L paraspinal region from
T2-T5
[**2108**]: 4 cycles of dose-reduced cisplatin, Navelbine
[**2108**]: CT showed renal hepatic progression.
[**2108**]: started on gemcitabine, held sev times for
myelosuppression.
[**2108**]: MRI showed leptomeningeal enhancement L frontal lobe.
[**2109**]: seizure, vein of Trolard thrombosis.
[**2109**]: weekly epirubicin, received 3 cycles, but multiple doses
were held because of poor performance status.
[**2109**]: onc team and pt decided upon symptom managment as CT scan
showed progression, she received single [**Doctor Last Name 360**] cisplatin.

Social History:
She does not smoke cigarettes or drink alcohol.
She moved from [**Country 3594**] to [**State 350**] in [**2091**]. She has a
daughter who lives in [**Name (NI) 17065**]. She also has a brother and
sister who live in the Greater [**Name (NI) 86**] area. She denies  tobacco
or alcohol use and is currently not working. In the  past, she
has worked in a bakery.


Family History:
Her mother is alive and healthy. Her father died at age 80 from
a stroke and heart attack. She has 5 sisters and 2 brothers, and
some of them have hypertension, hypercholesterolemia, and
diabetes. She has 6 daughters and a
son; they are all healthy.

Physical Exam:
PE: T 99.7, BP 111/78, HR 136, RR 18, 96% 2L
Gen: thin, chronically ill-appearing F in NAD, mostly Spanish
speaking.
HEENT: EOMi dry mucous membranes, clear oropharynx without
thrush.
Neck: flat JVP, no LAD.
Lungs: good air movement on R, decreased to no movement on left.

Cardiac: tachycardic, RRR, S1, S2, no murmurs
Abd: SNTND, +bs
Extr: thin, warm, well perfused. no clubbing/cyanosis/edema.
Skin: no rashes or other lesions. port on right chest c/d/i, no
erythema, tenderness to palpation.
Neuro: A&O, CNs grossly intact, no focal deficits
Psych: pleasant, appropriate

Pertinent Results:
Admission labs:
[**2110-9-24**] 11:00AM   WBC-4.0 RBC-4.00* HGB-11.0* HCT-34.6* MCV-87
MCH-27.5 MCHC-31.8 RDW-16.6*
[**2110-9-24**] 11:00AM   GRAN CT-2890
[**2110-9-24**] 11:00AM   PLT COUNT-313
[**2110-9-24**] 11:00AM   GLUCOSE-88 UREA N-5* CREAT-0.7 SODIUM-143
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-16
[**2110-9-24**] 11:00AM   ALBUMIN-3.6 CALCIUM-8.3* PHOSPHATE-3.3
MAGNESIUM-1.2*
.
CHEST (PORTABLE AP)  [**2110-9-25**]
IMPRESSION: Extensive opacification in the right lung, with both
alveolar and interstitial characteristics, most likely due to
aspiration. Stomach is mildly distended with gas. Left
pneumonectomy space is free of gas or other evidence of stump
leak. Cardiac silhouette is obscured in the left hemithorax.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY  [**2110-9-25**]
IMPRESSION:
1. Nodular and patchy opacities in the right lower lobe
consistent with aspiration or infection.
2. Enlarging right lower lobe pleural-based mass.
3. Increased paravertebral soft tissue mildly narrowing the
right bronchus intermedius.
4. No pulmonary embolism.
.
EGD [**2110-9-30**]
Impression: 1. Stricture of the middle third of the esophagus
probably related to extrinsic compression.
2. A 7cm covered ultraflex metal stent (Lot no. [**Serial Number 31900**]) was
placed successfully across the stricture. This was done under
fluoroscopic guidance after placement of a jagwire. The stent
placement was confirmed endoscopically.
Otherwise normal EGD to third part of the duodenum

Brief Hospital Course:
Patient is a 50 yo woman with metastatic adenoid cystic lung
cancer progressing on cisplatin who presents with fevers to 102,
productive cough, lethargy.  Given the respiratory distress
after 2 L of IVFs, episode of hypotension in the ED, and
tachycardia, she was admitted to MICU.
.
Her hypotension resolved with the IVFs prior to arrival to the
MICU.  Per outpatient notes, her blood pressure does run low
with SBPs in the 90s.  Her tachycardia was also at baseline.
.
Her acute respiratory distress resolved after nebulizer
treatments and NIPPV.  The cause may be due to bronchospasm.
She was also found to have a RLL pneumonia.  She was started on
cefepime and vancomycin.  As her respiratory distress resolved,
she was transferred to the oncology floor the day after
admission.
.
On the oncology floor, patient's antibiotics were changed to
cefepime and metronidazole to cover for aspiration.  Recent
speech and swallow evaluation did show evidence of mild-moderate
oropharyngeal dysphagia with aspiration if not using proper
swallowing technique.  Her fever did defervesce and her cough is
resolving.  Blood cultures were negative.  She was discharged on
levofloxacin and metronidazole to complete 2 weeks of
antibiotics.
.
After discussion with her outpatient oncology team and family,
her care was shifted to center on comfort.  Her pain was
controlled with her outpatient regimen of fentanyl patch and po
morphine for breakthrough.  She also responded well to Compazine
for any nausea.  Patient was also discontinued on Coumadin for
her h/o PE and cerebral vein thrombosis.
.
Patient also had an esophageal stent placed to help with her
dysphagia.  Hopefully this will decrease risk of aspiration.
She had some mild neck discomfort from the stent, which resolved
with morphine and time.
.
Patient was comfortable upon discharge and was discharged to
home with hospice.

Medications on Admission:
COMPAZINE 10mg prn
COUMADIN 2mg
DEXAMETHASONE 4mg during chemo
EMEND 125mg 80mg 80mg during chemo.
FENTANYL 225 mcg/hr q72
GABAPENTIN 250 tid
LANSOPRAZOLE 30mg
Megace 400mg
OXYCODONE 5mg q6hrs prn
ZOFRAN 8mg prn

Discharge Medications:
1. oxyfast  [**Serial Number **]: 1-20 mg  q1 hr prn as needed for pain.
Disp:*30 ml* Refills:*0*
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
3. Fentanyl 100 mcg/hr Patch 72 hr [**Last Name (STitle) **]: Two (2)  Transdermal
Q72H (every 72 hours).
Disp:*60 * Refills:*2*
4. Fentanyl 25 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1)  Transdermal
every seventy-two (72) hours.
Disp:*30 * Refills:*2*
5. Gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: One (1)  PO Q8H (every 8
hours).
Disp:*qs x 1 mo * Refills:*2*
6. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Five (5) ML PO BID (2 times a day).

9. Codeine-Guaifenesin 10-100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H
(every 6 hours) as needed.
Disp:*qs x 1 mo * Refills:*0*
10. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a
day for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
11. Levofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
12. Compazine 5 mg/5 mL Syrup [**Last Name (STitle) **]: [**4-3**] mL PO every 6-8 hours as
needed for nausea.
Disp:*qs x 1 mo * Refills:*0*


Discharge Disposition:
Home With Service

Facility:
Hospice of the Good [**Doctor Last Name 9995**]

Discharge Diagnosis:
Metastatic adenoid cystic lung cancer
Aspiration pneumonia
Esophageal stricture


Discharge Condition:
Stable


Discharge Instructions:
You were admitted for difficulty breathing.  You were found to
have a pneumonia and were treated with antibiotics.
.
You also had an esophageal stent placed to ease your swallowing.
.
Please take your medications as prescribed.
.
If you develop a fever, nausea or vomiting, pain, or any other
worrisome symptoms, please call your oncologist.

Followup Instructions:
Hospice nurse will be taking care of you while you stay at your
sister's place.
.
If you have any concerns or questions, please call your
oncologist Dr. [**Last Name (STitle) **] at ([**2110**] or Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 31901**].





Name:  [**Known lastname 5545**],[**Known firstname 5546**]                    Unit No:   [**Numeric Identifier 5547**]

Admission Date:  [**2110-9-25**]              Discharge Date:   [**2110-10-6**]

Date of Birth:  [**2060-5-13**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 2808**]
Addendum:
Severe malnutrition:  Nutrition was consulted and followed the
patient while in the hospital.

Discharge Disposition:
Home With Service

Facility:
Hospice of the Good [**Doctor Last Name 5548**]

                             [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 2809**]

Completed by:[**2110-10-27**]
{'Pneumonitis due to inhalation of food or vomitus,Nutritional marasmus,Secondary malignant neoplasm of pleura,Secondary malignant neoplasm of kidney,Acquired coagulation factor deficiency,Stricture and stenosis of esophagus,Personal history of malignant neoplasm of bronchus and lung,Personal history of venous thrombosis and embolism'}


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: Lethargy, fever

PRESENT ILLNESS: Patient is a 50yo woman with adenoid cystic carcinoma s/p left
pneumonectomy, known mets to liver/kidney, PE, presenting with
fevers, lethargy, and pleuritic CP.
.
In ED, T 102.5, SBPs initially 110/62, HR 150, on 2Lnc, received
2L of NS with drop of HR to 110, SBPs 80/40, given CTX for
putative PNA. CT (-) for PE but flashed at CT scan, relieved
nitro gtt and NIPPV. Received CTX IVx1, combivent nebs, 60poKCl,
Mg 5g, 3L NS.
.
Most recent chemotherapy was cisplatin on [**9-9**] with 4 clinic
visits over next 12 days with Dr. [**Last Name (STitle) **]/[**Last Name (un) 31899**]. Found to be
tachycardic at all visits for unknown reason with resolution
post fluids. As per primary oncologist, no plans for further
chemotherapy with plan for hospice care discussion soon as
outpatient.

MEDICAL HISTORY: PMH:
1. Adenoid cystic carcinoma, diagnosed [**3-/2103**], details below
2. Left vocal cord paralysis
3. GERD
4. History of PE, [**2099**], [**2107**]
5. Cerebral vein thrombosis
6. Depression? (found in ED note)
7. CVA? (found in ED note)
.
Onc Hx:
[**2102**]: diag after work-up 8 months of cough, L pneumonectomy and
carinal resection and postop radiation.
[**2105**]: Recurrent dz in pleural space.
[**2106**]: palliative radiation with concurrent low-dose Taxotere.
[**2107**]: Hepatic involvement --> 4 cycles of cisplatin and
Adriamycin.
[**2107**]: CT showed progression in lungs/liver. 2 cycles of
carboplatin and Taxol given, still with pulm progression. Tx
complicated by thrombocytopenia and PE on CT, started on
Lovenox.
[**2108**]: Brachial plexus MRI showed tumor L paraspinal region from
T2-T5
[**2108**]: 4 cycles of dose-reduced cisplatin, Navelbine
[**2108**]: CT showed renal hepatic progression.
[**2108**]: started on gemcitabine, held sev times for
myelosuppression.
[**2108**]: MRI showed leptomeningeal enhancement L frontal lobe.
[**2109**]: seizure, vein of Trolard thrombosis.
[**2109**]: weekly epirubicin, received 3 cycles, but multiple doses
were held because of poor performance status.
[**2109**]: onc team and pt decided upon symptom managment as CT scan
showed progression, she received single [**Doctor Last Name 360**] cisplatin.

MEDICATION ON ADMISSION: COMPAZINE 10mg prn
COUMADIN 2mg
DEXAMETHASONE 4mg during chemo
EMEND 125mg 80mg 80mg during chemo.
FENTANYL 225 mcg/hr q72
GABAPENTIN 250 tid
LANSOPRAZOLE 30mg
Megace 400mg
OXYCODONE 5mg q6hrs prn
ZOFRAN 8mg prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: T 99.7, BP 111/78, HR 136, RR 18, 96% 2L
Gen: thin, chronically ill-appearing F in NAD, mostly Spanish
speaking.
HEENT: EOMi dry mucous membranes, clear oropharynx without
thrush.
Neck: flat JVP, no LAD.
Lungs: good air movement on R, decreased to no movement on left.

FAMILY HISTORY: Her mother is alive and healthy. Her father died at age 80 from
a stroke and heart attack. She has 5 sisters and 2 brothers, and
some of them have hypertension, hypercholesterolemia, and
diabetes. She has 6 daughters and a
son; they are all healthy.

SOCIAL HISTORY: She does not smoke cigarettes or drink alcohol.
She moved from [**Country 3594**] to [**State 350**] in [**2091**]. She has a
daughter who lives in [**Name (NI) 17065**]. She also has a brother and
sister who live in the Greater [**Name (NI) 86**] area. She denies  tobacco
or alcohol use and is currently not working. In the  past, she
has worked in a bakery. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Nutritional marasmus,Secondary malignant neoplasm of pleura,Secondary malignant neoplasm of kidney,Acquired coagulation factor deficiency,Stricture and stenosis of esophagus,Personal history of malignant neoplasm of bronchus and lung,Personal history of venous thrombosis and embolism'}
