CHIEF COMPLAINT: melanoma resection

PRESENT ILLNESS: Pt is a 68 yo F with h/o DMII, HTN, paroxysmal Afib and now s/p
left temporal melanoma resection, parotidectomy, left neck
dissection and flap reconstruction on [**2165-9-13**]. Since then, pt
was intermittently in Afib RVR (HR iun 130-140s) and had
received IV boluses of metoprolol. She was also restarted her
Sotalol 120 [**Hospital1 **]. She has also had brief episodes of asymptomatic
sinus bradycardia (slowest rate in 30s, no hemodynamic
instability). Pt is being transferred to our service today for
management of Afib RVR and possible cardioversion tomorrow.
.
Upon arrival the floor, pt appears well, denies any pain.
Denies any palpitations. No nausea/vomiting or abdominal pain.
Admits to constipation (no BM since admission). Denies any CP,
DOE.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools.
Admits to joint pains (from arthritis) and occasional bloody
stools (hemorrhoids). She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope. Admits to occasional bilat
leg swelling.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Hypertension
2. CARDIAC HISTORY: Atrial fibrillation  (dx in [**2161**] on Sotalol
and Coumadin at home)
-CABG:  none
-PERCUTANEOUS CORONARY INTERVENTIONS:  none
-PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
arthritis  (s/p R total hip replacement in [**2161**])
DMII (on no meds, recent HbA1C 7.1)
HTN
infectious hepatitis ([**2115**])

MEDICATION ON ADMISSION: CELEBREX
HYDROCHLOROTHIAZIDE
LORAZEPAM [ATIVAN]
SOTALOL -   120mg [**Hospital1 **]
WARFARIN -   2.5mg daily
CALCIUM -  Dosage uncertain
MULTIVITAMIN -

ALLERGIES: Adhesive Tape / Hayfever

PHYSICAL EXAM: VS: T= 96.9 BP= 127/78 HR= 99 RR= 18 O2 sat=  96% on 3L
GENERAL: AOriented x3. Mood, affect appropriate.
HEENT: L temporal flap in place, appears well, JP drain in place
draining serosangious fluid
NECK: Supple with no JVD
CARDIAC: irregularly irregular rhythm, normal rate, normal S1,
S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. pneumoboots in place.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother died of PE at 52yrs of age.

SOCIAL HISTORY: -Tobacco history:  quit in [**2127**], 1PPD x 20yrs previously
-ETOH:  occ
-Illicit drugs:  denies
Malignant neoplasm of connective and other soft tissue of head, face, and neck,Cardiac complications, not elsewhere classified,Secondary malignant neoplasm of bone and bone marrow,Melanoma of skin, site unspecified,Atrial fibrillation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of anticoagulants,Obesity, unspecified,Anemia, unspecified,Hip joint replacement
Mal neo soft tissue head,Surg compl-heart,Secondary malig neo bone,Malig melanoma skin NOS,Atrial fibrillation,Hypertension NOS,DMII wo cmp nt st uncntr,Long-term use anticoagul,Obesity NOS,Anemia NOS,Joint replaced hip
Admission Date:  [**2165-9-13**]              Discharge Date:   [**2165-9-21**]

Date of Birth:  [**2097-9-1**]             Sex:   F

Service: MEDICINE

Allergies:
Adhesive Tape / Hayfever

Attending:[**Doctor First Name 1402**]
Chief Complaint:
melanoma resection

Major Surgical or Invasive Procedure:
PROCEDURE #1:
1. Radical resection of malignant melanoma involving the
    left temporalis muscle and adjacent soft tissue.
2. Left parotidectomy with facial nerve monitoring and
    dissection.
3. Left modified radical neck dissection.
4. Zygomatic osteotomy.

PROCEDURE #2:
1. Left radial forearm free flap to left temporal defect.
2. Open reduction internal fixation of zygomatic arch
    defect.
3. Autologous fat grafting to the pedicle.
4. Split-thickness skin graft of the left upper arm and a 7
    x 7 cm 14/1000 of an inch skin graft on the left thigh.


History of Present Illness:
Pt is a 68 yo F with h/o DMII, HTN, paroxysmal Afib and now s/p
left temporal melanoma resection, parotidectomy, left neck
dissection and flap reconstruction on [**2165-9-13**]. Since then, pt
was intermittently in Afib RVR (HR iun 130-140s) and had
received IV boluses of metoprolol. She was also restarted her
Sotalol 120 [**Hospital1 **]. She has also had brief episodes of asymptomatic
sinus bradycardia (slowest rate in 30s, no hemodynamic
instability). Pt is being transferred to our service today for
management of Afib RVR and possible cardioversion tomorrow.
.
Upon arrival the floor, pt appears well, denies any pain.
Denies any palpitations. No nausea/vomiting or abdominal pain.
Admits to constipation (no BM since admission). Denies any CP,
DOE.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools.
Admits to joint pains (from arthritis) and occasional bloody
stools (hemorrhoids). She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope. Admits to occasional bilat
leg swelling.

Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Hypertension
2. CARDIAC HISTORY: Atrial fibrillation  (dx in [**2161**] on Sotalol
and Coumadin at home)
-CABG:  none
-PERCUTANEOUS CORONARY INTERVENTIONS:  none
-PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
arthritis  (s/p R total hip replacement in [**2161**])
DMII (on no meds, recent HbA1C 7.1)
HTN
infectious hepatitis ([**2115**])

Social History:
-Tobacco history:  quit in [**2127**], 1PPD x 20yrs previously
-ETOH:  occ
-Illicit drugs:  denies

Family History:
Mother died of PE at 52yrs of age.

Physical Exam:
VS: T= 96.9 BP= 127/78 HR= 99 RR= 18 O2 sat=  96% on 3L
GENERAL: AOriented x3. Mood, affect appropriate.
HEENT: L temporal flap in place, appears well, JP drain in place
draining serosangious fluid
NECK: Supple with no JVD
CARDIAC: irregularly irregular rhythm, normal rate, normal S1,
S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. pneumoboots in place.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

Pertinent Results:
                       WBC  Hb  Hct  Plts
[**2165-9-20**] 07:10AM    15.2 9.9 29.5 372
[**2165-9-18**] 01:42AM    9.8  9.2 27.7 290
[**2165-9-17**] 01:48AM    12.0 8.6 25.7 240
[**2165-9-16**] 01:14AM    13.1 9.4 26.9 222
[**2165-9-15**] 01:04AM    9.7  9.2 27.0 190
[**2165-9-14**] 04:20AM    7.7  8.5 25.4 179
[**2165-9-13**] 11:23PM    6.4  8.8 26.3 202
                       PT    PTT    INR
[**2165-9-20**] 07:10AM    15.5  85.9   1.4
[**2165-9-19**] 07:00AM    14.0         1.2
[**2165-9-18**] 01:42AM    14.0  25.4   1.2
[**2165-9-17**] 01:48AM    14.0         1.2
[**2165-9-13**] 11:23PM    15.1  34.0   1.3
                       Gluc BUN Cr  Na  K   Cl  HCO3
[**2165-9-20**] 07:10AM    139  19  0.9 139 4.0 106 26
[**2165-9-18**] 01:42AM    116  13  0.7 142 3.8 112 23
[**2165-9-17**] 07:42PM    [**Telephone/Fax (2) 84744**] 3.6 109 25
[**2165-9-17**] 01:48AM    132  13  0.8 142 3.7 108 27
[**2165-9-16**] 12:11PM    162  9   0.8 141 3.8 108 27
[**2165-9-16**] 01:14AM    155  7   0.8 140 3.8 110 25
[**2165-9-15**] 01:04AM    167  8   0.8 142 3.4 111 26
[**2165-9-14**] 04:20AM    163  14  0.8 142 3.7 112 25
[**2165-9-13**] 11:23PM    133  16  0.8 141 4.2 113 22
[**2165-9-20**] 07:10AM          Ca 8.3 Ph 3.4 Mg 1.9

CXR [**2165-9-17**]:
IMPRESSION: Improved aeration of bilateral lower lungs with
improved
atelectasis and vascular congestion.


Brief Hospital Course:
68 yo F with h/o DMII, HTN, paroxysmal Afib on Sotalol and
Coumadin at home here for left temporal melanoma resection,
parotidectomy, left neck dissection and flap reconstruction on
[**2165-9-13**] and then in Afib RVR peri-op.
.
# Afib RVR: Pt was in Afib RVR, HR in 130-140s, subsequently
rate controlled with IV Metoprolol doses PRN then, switched to
50mg PO BID. Also, anticoagulation with heparin gtt was started,
but given the recent surgery was very cautious (no bolus, PTT
goal of 50-70 and q3h checks).  Pt was started back on Coumadin
which was held for the surgery.  Daily INRs were checked and
Coumadin dose was adjusted accordingly. Although
TEE/cardioversion was initially considered, this pt's current
Afib is likely [**12-31**] to stress from recent surgery and period off
her home Sotalol. Given recent surgery of neck and temporal
area, head cannot be extended and a TEE may be putting the pt at
risk in regards to the surgery. Thus, rate-control with Sotalol
(120mg [**Hospital1 **]) and Metoprolol (50mg [**Hospital1 **]) and bridging to Coumadin
for anticoagulation was pursued.  Once pt is therapeutic on INR
for 3-4 weeks, can consider cardioversion (with no need for TEE)
at that time if pt is still in Afib.  Meanwhile, pt
spontaneously converted to NSR, thus Heparin gtt was
discontinued.  Coumadin was continud however and pt was
discharged on home dose, to be followed up with INR check soon.
.
#  S/P melanoma excision: Left temporal melanoma resection,
parotidectomy, left neck dissection and flap reconstruction were
performed by Plastics on [**2165-9-13**]. pt tolerated surgery well.
Flap checks were performed every 4 hours.  Pt is to be in soft
diet for 2 weeks. Left forearm had xeroform/kerlex dressing
changed daily. Left thig area has Xeroform that is left to open
air, does not need changing. No head extension or full turning
to the left.  JP drain remained for a few days, was taken out
eventually. Ancef was given as long as JP drain was in.
.
# DMII: Pt is diet controlled at home, no meds. Pt was
maintained on insulin sliding scale.  Fingersticks were checked
4x/day.
.
#  HTN: Was well-controlled, not on home HCTZ currently. Can be
restarted as outpatient.
.
#  Arthritis:  Was stable, with pain well-controlled on
Percocet. Pt did well with physical therpy, needs more
conditioning at a rehab facility.
.
# Anemia: Hct was 39 pre-op on [**9-6**], has been in 25-28 range
since [**9-13**]. Pt is asymptomatic, hemodynamically stable.
Required no tranfusions.
.
# Pt was on a diabetic diet. For DVT ppx, pt was initially on
Heparin gtt, bridging to Coumadin, however once Heparin gtt
stopped and Coumadin was still not therapeutic, started SC
Heparin.  Pain management was with Percocet and bowel regimen
was with Docusate, Senna, Bisacodyl. Pt was full code.

Medications on Admission:
CELEBREX
HYDROCHLOROTHIAZIDE
LORAZEPAM [ATIVAN]
SOTALOL -   120mg [**Hospital1 **]
WARFARIN -   2.5mg daily
CALCIUM -  Dosage uncertain
MULTIVITAMIN -

Discharge Medications:
1. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day)
as needed for afib.
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain for 2 weeks: hold for
sedation.
Disp:*30 Tablet(s)* Refills:*0*
3. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Health Care Center - [**Hospital1 1559**]

Discharge Diagnosis:
1) Left skull base defect and temple defect, status post
resection of melanotic lesion.
2) Atrial Fibrillation with rapid rate


Discharge Condition:
stable


Discharge Instructions:
You were admitted to the hospital for melanoma removal and
reconstruction. After your surgery you had a rapid irregular
heart rhythm called atrial fibrillation. You were given
medication to improve you heart and it returned to a normal
rhythm.

Please make the following changes to your medications:
1. Continue Sotalol 120 mg twice a day
2. Start Famotidine 20 mg twice a day
3. Start Oxycodone-Acetaminophen  5-325 mg 1-2 Tablets every 6
hours as needed for pain for 2 weeks
4. Start Docusate Sodium 100 mg twice a day
5. Start Toprol XL  100 mg once a day
6. Continue Coumadin 2.5 mg once a day
7. Stop HCTZ until you follow-up with your PCP
8. Stop Celebrex until you follow-up with your PCP

Please seek immediate medical attention if you have chest pain,
increased shortness of breath, dizziness, fainting spells,
increased leg swelling, confusion or any other concerning
symptoms.

Followup Instructions:
Follow-up with ENT: Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 41**] Date/Time:[**2165-9-24**] 2:20 PM

Follow-up with Cardiology: Provider: [**Name10 (NameIs) **] BROWNING, MD
Phone: ([**Telephone/Fax (1) 84745**]
Date/Time: [**2165-9-26**] 11:00 AM

Follow-up with Plastics: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] Phone: [**Telephone/Fax (1) 6742**]
Date/Time: [**2165-9-27**] 10:00 AM

Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 50416**] within 1-2 weeks of
discharge. Please call [**Telephone/Fax (1) 84746**] for appointment time.



Completed by:[**2165-9-21**]
{'Malignant neoplasm of connective and other soft tissue of head, face, and neck,Cardiac complications, not elsewhere classified,Secondary malignant neoplasm of bone and bone marrow,Melanoma of skin, site unspecified,Atrial fibrillation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of anticoagulants,Obesity, unspecified,Anemia, unspecified,Hip joint replacement'}


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: melanoma resection

PRESENT ILLNESS: Pt is a 68 yo F with h/o DMII, HTN, paroxysmal Afib and now s/p
left temporal melanoma resection, parotidectomy, left neck
dissection and flap reconstruction on [**2165-9-13**]. Since then, pt
was intermittently in Afib RVR (HR iun 130-140s) and had
received IV boluses of metoprolol. She was also restarted her
Sotalol 120 [**Hospital1 **]. She has also had brief episodes of asymptomatic
sinus bradycardia (slowest rate in 30s, no hemodynamic
instability). Pt is being transferred to our service today for
management of Afib RVR and possible cardioversion tomorrow.
.
Upon arrival the floor, pt appears well, denies any pain.
Denies any palpitations. No nausea/vomiting or abdominal pain.
Admits to constipation (no BM since admission). Denies any CP,
DOE.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools.
Admits to joint pains (from arthritis) and occasional bloody
stools (hemorrhoids). She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope. Admits to occasional bilat
leg swelling.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Hypertension
2. CARDIAC HISTORY: Atrial fibrillation  (dx in [**2161**] on Sotalol
and Coumadin at home)
-CABG:  none
-PERCUTANEOUS CORONARY INTERVENTIONS:  none
-PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
arthritis  (s/p R total hip replacement in [**2161**])
DMII (on no meds, recent HbA1C 7.1)
HTN
infectious hepatitis ([**2115**])

MEDICATION ON ADMISSION: CELEBREX
HYDROCHLOROTHIAZIDE
LORAZEPAM [ATIVAN]
SOTALOL -   120mg [**Hospital1 **]
WARFARIN -   2.5mg daily
CALCIUM -  Dosage uncertain
MULTIVITAMIN -

ALLERGIES: Adhesive Tape / Hayfever

PHYSICAL EXAM: VS: T= 96.9 BP= 127/78 HR= 99 RR= 18 O2 sat=  96% on 3L
GENERAL: AOriented x3. Mood, affect appropriate.
HEENT: L temporal flap in place, appears well, JP drain in place
draining serosangious fluid
NECK: Supple with no JVD
CARDIAC: irregularly irregular rhythm, normal rate, normal S1,
S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. pneumoboots in place.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother died of PE at 52yrs of age.

SOCIAL HISTORY: -Tobacco history:  quit in [**2127**], 1PPD x 20yrs previously
-ETOH:  occ
-Illicit drugs:  denies 

### Response:
{'Malignant neoplasm of connective and other soft tissue of head, face, and neck,Cardiac complications, not elsewhere classified,Secondary malignant neoplasm of bone and bone marrow,Melanoma of skin, site unspecified,Atrial fibrillation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of anticoagulants,Obesity, unspecified,Anemia, unspecified,Hip joint replacement'}
