CHIEF COMPLAINT: S/p arrest in the OR during IP stent procedure.

PRESENT ILLNESS: 69 y/o F with PMHX of COPD and Small Cell Lung Cancer (diagnosed
[**2159**]) s/p XRT/chemo/tumor debridement/R mainstem bronchus stent
placement ([**2164**]) and recent LUE DVT on Coumadin who initially
presented to [**Hospital 1474**] hospital on [**3-27**] with 3-4 episodes of
hemoptysis, increased cough, wheezing and shortness of breath.
She was started on IV SoluMedrol 125mg IV q6hrs, Nebs and
tessalon pearles. She was supratherapeutic with an INR of 4.1
and Coumadin was held. CTA was negative for PE and revealed
right mainstem stent with distal intraluminal narrowing or tumor
effusion, mediastinal and subcarinal confluent metastatic
lymphadenopathy. Decision was made for transfer to [**Hospital1 18**] for
bronch and IP evaluation.
.
Pt was admitted to [**Hospital1 18**] and was continued on steroids, nebs and
cough suppressants.  She went for flexible bronchoscopy on [**3-30**]
which revealed normal trachea, extensive tumor at carina
obstructing both mainstem bronchi, extrinsic mediastinal
compression of L mainstem and unable to visualize stent in right
mainstem due to intraluminal tumor.
Pt was taken to the OR on [**4-1**] and had stent placed in the left
mainstem with good result.  There was attempted argon plasma
coagulation inside of the right stent to remove intraluminal
obstruction.  During this procedure, pt became progressively
hypoxic, bradycardic and loss of pulse at approx 3:38pm. CPR was
started immediately and pt received a total of 2mg of epi.
After approximately 2-3minutes of CPR, rhythm was checked and
there was a palpable pulse with HR >100 and sbp >180.  TEE was
performed and showed bubbles in the right atrium suggestive of
APC related air embolism but no RV dilation suggestive of acute
PE.  Oxygen sats recovered into the 90s, right femoral a-line
and left femoral CVL was placed.  Pt was given an additional
bolus of Midazolam and some neosynephrine for BP support prior
to transfer to the ICU.
.
On arrival to the ICU, pt was intubated and sedated with HR >100
and BP 140/90s.  Sedation was rapidly weaned and pt was clearly
responding to commands and moving all extremities.

MEDICAL HISTORY: 1. Small Cell lung cancer - diagnosed in [**2159**] and recurred in
[**2161**]. Initially started 6 weeks of XRT, followed by multiple
regimens of chemo. Has been off chemo for the last 4 months
"because CT scans have been stable." Last bronchoscopy was in
[**2165-12-23**] - small amounts of granulation tissue seen in
stent.
2. Recent LUE DVT (mid-[**2166-2-20**]) - L arm port was changed,
after which she developed dramatic swelling from shoulder to
wrist; UENIs confirmed LUE DVT. Coumadin 5mg was started.
3. COPD - longstanding, unknown date of diagnosis
4. Lupus - diagnosed 8 years ago after work-up for painful knee
and finger joints (L finger joints > R finger joints) - treated
with "pills" but not prednisone
5. Shingles infection in T10 dermatome in [**10/2165**] - treated with
acyclovir and recovered within 1 week
5. Anxiety/Insomnia

MEDICATION ON ADMISSION: Aspirin 81 mg PO daily
Warfarin 5 mg PO daily
Diltiazem 240 mg PO daily
Magnesium oxide 400 mg PO daily
Lorazepam 0.5 mg PO bid
Benzonoatate 100 mg PO 1 tab tid
Spiriva inhaler (tiotropium)

ALLERGIES: Levofloxacin / Lisinopril / Diphenhydramine

PHYSICAL EXAM: Vitals: T: 98.1 BP: 130/84 P: 117 R: 22 O2: 98% on 3 L
General: Alert, oriented, not in acute respiratory distress,
sitting upright in bed watching TV with audible upper airway
inspiratory and expiratory stridor.
HEENT: Sclera anicteric, pupils equal round & reactive to light,
mucous membranes moist, no jugular venous distention, mucous
membranes moist, oropharynx clear without thrush, no
oropharyngeal source of bleeding seen
Neck: supple, JVP not elevated, no lymphadenopathy, no carotid
bruits, loud and harsh inspiratory upper airway stridor heard,
trachea not deviated
Lungs: Nasal cannula intact, patient sitting upright with
audible upper airway inspiratory and expiratory stridor. Patient
appears comfortable and is not using any accessory muscles of
inspiration. Respiratory rate is mildly elevated. Scattered
anterior inspiratory and expiratory wheezes. Left-sided
bronchial breath sounds bases>apices. Right-sided bronchial
breath sounds with fine crackles at bases. Scattered inspiratory
and expiratory wheezes but not consistently.
CV: Tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Skin: No skin rash or ecchymoses noted, dressing over left
anterior pectoral region covering old PortaCath.
Neuro: Alert & oriented x 3, extraocular movements intact, CNs
II-XII grossly intact and patient moving all four extremities
spontaneously

FAMILY HISTORY: She reports no family history of lung cancer, SLE, or CAD. Her
mom died of "stomach cancer" at 51yo and her niece has breast
cancer. Her son has [**Name2 (NI) **].

SOCIAL HISTORY: She lives in [**Hospital1 1474**] with her husband. She has 4 children and 7
grandchildren who live within a mile of her house. She worked as
a homemaker. She smoked tobacco for approximately 20 pack years
(1 pack per day for 20+ years) and quit in the [**2145**]. She does
not know of any asbestos exposure. She drinks alcohol only on
social occasions and uses no other drugs.
Malignant neoplasm of other parts of bronchus or lung,Cardiac arrest,Acute respiratory failure,Methicillin resistant pneumonia due to Staphylococcus aureus,Obstructive chronic bronchitis with (acute) exacerbation,Urinary tract infection, site not specified,Cardiac complications, not elsewhere classified,Unspecified pleural effusion,Bacteremia,Unspecified disease of pericardium,Candidiasis of mouth,Infection and inflammatory reaction due to other vascular device, implant, and graft,Air embolism as a complication of medical care, not elsewhere classified,Unspecified essential hypertension,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Hypoxemia,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Long-term (current) use of anticoagulants,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of tobacco use,Systemic lupus erythematosus,Edema of larynx,Oliguria and anuria,Personal history of venous thrombosis and embolism
Mal neo bronch/lung NEC,Cardiac arrest,Acute respiratry failure,Meth res pneu d/t Staph,Obs chr bronc w(ac) exac,Urin tract infection NOS,Surg compl-heart,Pleural effusion NOS,Bacteremia,Pericardial disease NOS,Thrush,React-oth vasc dev/graft,Air embol comp med care,Hypertension NOS,Oth gram negatv bacteria,Hypoxemia,Abn react-surg proc NEC,Accid in resident instit,Long-term use anticoagul,Abn react-procedure NEC,History of tobacco use,Syst lupus erythematosus,Edema of larynx,Oliguria & anuria,Hx-ven thrombosis/embols
Admission Date:  [**2166-3-29**]              Discharge Date:   [**2166-4-11**]

Date of Birth:  [**2097-3-17**]             Sex:   F

Service: MEDICINE

Allergies:
Levofloxacin / Lisinopril / Diphenhydramine

Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
S/p arrest in the OR during IP stent procedure.

Major Surgical or Invasive Procedure:
Left main stem stent placement.
Endotracheal intubation.
Left femoral tripple lumen catheter placement.

History of Present Illness:
69 y/o F with PMHX of COPD and Small Cell Lung Cancer (diagnosed
[**2159**]) s/p XRT/chemo/tumor debridement/R mainstem bronchus stent
placement ([**2164**]) and recent LUE DVT on Coumadin who initially
presented to [**Hospital 1474**] hospital on [**3-27**] with 3-4 episodes of
hemoptysis, increased cough, wheezing and shortness of breath.
She was started on IV SoluMedrol 125mg IV q6hrs, Nebs and
tessalon pearles. She was supratherapeutic with an INR of 4.1
and Coumadin was held. CTA was negative for PE and revealed
right mainstem stent with distal intraluminal narrowing or tumor
effusion, mediastinal and subcarinal confluent metastatic
lymphadenopathy. Decision was made for transfer to [**Hospital1 18**] for
bronch and IP evaluation.
.
Pt was admitted to [**Hospital1 18**] and was continued on steroids, nebs and
cough suppressants.  She went for flexible bronchoscopy on [**3-30**]
which revealed normal trachea, extensive tumor at carina
obstructing both mainstem bronchi, extrinsic mediastinal
compression of L mainstem and unable to visualize stent in right
mainstem due to intraluminal tumor.
Pt was taken to the OR on [**4-1**] and had stent placed in the left
mainstem with good result.  There was attempted argon plasma
coagulation inside of the right stent to remove intraluminal
obstruction.  During this procedure, pt became progressively
hypoxic, bradycardic and loss of pulse at approx 3:38pm. CPR was
started immediately and pt received a total of 2mg of epi.
After approximately 2-3minutes of CPR, rhythm was checked and
there was a palpable pulse with HR >100 and sbp >180.  TEE was
performed and showed bubbles in the right atrium suggestive of
APC related air embolism but no RV dilation suggestive of acute
PE.  Oxygen sats recovered into the 90s, right femoral a-line
and left femoral CVL was placed.  Pt was given an additional
bolus of Midazolam and some neosynephrine for BP support prior
to transfer to the ICU.
.
On arrival to the ICU, pt was intubated and sedated with HR >100
and BP 140/90s.  Sedation was rapidly weaned and pt was clearly
responding to commands and moving all extremities.

Past Medical History:
1. Small Cell lung cancer - diagnosed in [**2159**] and recurred in
[**2161**]. Initially started 6 weeks of XRT, followed by multiple
regimens of chemo. Has been off chemo for the last 4 months
"because CT scans have been stable." Last bronchoscopy was in
[**2165-12-23**] - small amounts of granulation tissue seen in
stent.
2. Recent LUE DVT (mid-[**2166-2-20**]) - L arm port was changed,
after which she developed dramatic swelling from shoulder to
wrist; UENIs confirmed LUE DVT. Coumadin 5mg was started.
3. COPD - longstanding, unknown date of diagnosis
4. Lupus - diagnosed 8 years ago after work-up for painful knee
and finger joints (L finger joints > R finger joints) - treated
with "pills" but not prednisone
5. Shingles infection in T10 dermatome in [**10/2165**] - treated with
acyclovir and recovered within 1 week
5. Anxiety/Insomnia

PAST SURGICAL HISTORY:
1. Right eye cataract surgery
2. Bronchial stent placement in [**2165-2-20**] by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
3. Lung cancer tumor debridement and ablation in [**2165-2-20**] by
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]

Social History:
She lives in [**Hospital1 1474**] with her husband. She has 4 children and 7
grandchildren who live within a mile of her house. She worked as
a homemaker. She smoked tobacco for approximately 20 pack years
(1 pack per day for 20+ years) and quit in the [**2145**]. She does
not know of any asbestos exposure. She drinks alcohol only on
social occasions and uses no other drugs.

Family History:
She reports no family history of lung cancer, SLE, or CAD. Her
mom died of "stomach cancer" at 51yo and her niece has breast
cancer. Her son has [**Name2 (NI) **].

Physical Exam:
Vitals: T: 98.1 BP: 130/84 P: 117 R: 22 O2: 98% on 3 L
General: Alert, oriented, not in acute respiratory distress,
sitting upright in bed watching TV with audible upper airway
inspiratory and expiratory stridor.
HEENT: Sclera anicteric, pupils equal round & reactive to light,
mucous membranes moist, no jugular venous distention, mucous
membranes moist, oropharynx clear without thrush, no
oropharyngeal source of bleeding seen
Neck: supple, JVP not elevated, no lymphadenopathy, no carotid
bruits, loud and harsh inspiratory upper airway stridor heard,
trachea not deviated
Lungs: Nasal cannula intact, patient sitting upright with
audible upper airway inspiratory and expiratory stridor. Patient
appears comfortable and is not using any accessory muscles of
inspiration. Respiratory rate is mildly elevated. Scattered
anterior inspiratory and expiratory wheezes. Left-sided
bronchial breath sounds bases>apices. Right-sided bronchial
breath sounds with fine crackles at bases. Scattered inspiratory
and expiratory wheezes but not consistently.
CV: Tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Skin: No skin rash or ecchymoses noted, dressing over left
anterior pectoral region covering old PortaCath.
Neuro: Alert & oriented x 3, extraocular movements intact, CNs
II-XII grossly intact and patient moving all four extremities
spontaneously

On Discharge:
vs: 98.8  126/70  108   18   95% 2L
Gen: ill appearing female, appearing older than stated age.
CV: tachycardic, no rubs, gallops, murmurs.
Lungs: diffuse rhonchi, few wheezes, scant basilar rales on the
left.  moderate [**Location (un) **] movement
Abd: soft, ND, NT ABS
Ext: wwp with palpable DP pulses
Neuro: alert and oriented, EOMI, patient moving all extremities
spontaneously


Pertinent Results:
[**2166-3-29**] 09:50PM   WBC-9.8# RBC-3.21* HGB-10.0* HCT-28.9* MCV-90
MCH-31.1 MCHC-34.5 RDW-18.7*
[**2166-3-29**] 09:50PM   NEUTS-94.3* LYMPHS-3.6* MONOS-1.9* EOS-0.1
BASOS-0.1
[**2166-3-29**] 09:50PM   PLT COUNT-256
[**2166-3-29**] 09:50PM   PT-24.0* PTT-34.8 INR(PT)-2.3*
[**2166-3-29**] 09:50PM   GLUCOSE-224* UREA N-30* CREAT-1.0 SODIUM-138
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
[**2166-3-29**] 09:50PM   CALCIUM-8.6 PHOSPHATE-2.1* MAGNESIUM-1.8
.

[**2166-4-9**] Radiology CHEST (PORTABLE AP)
Known treated right upper lobe mass with expected post-treatment

change and soft tissue density seen in a right paramediastinal
location is
stable. New mild bilateral pleural effusions. Otherwise no
significant
interval change with no focal consolidation, and pulmonary
vascularity within normal limits. No new abnormality involving
cardiomediastinal contours.  Stable appearance of bilateral
bronchial stents and port with tip terminating within the upper
SVC. No evidence of pneumothorax.

[**2166-4-7**] Radiology MR HEAD W & W/O CONTRAS
There is a linear region of decreased diffusion within the right

frontal lobe, predominantly involving the cortex and subcortical
white matter, as well as multiple additional punctate foci of
decreased diffusion within the biparieto-occipital lobes,
including extending into the splenium of the corpus callosum on
the right. There is an additional focus of abnormal slow
diffusion within the inferior aspect of the right cerebellar
hemisphere, measuring 1.5 cm, with associated brisk enhancement.
There is [**Doctor Last Name **] enhancement over the right frontal lobe signal
abnormalities described above. All of the regions of decreased
diffusion have associated T2 signal abnormality. There are no
regions of abnormal marrow replacement, despite limitations by
motion artifact. Focus of susceptibility artifact along the
posterior focus likely represents a small calcified dural
plaque. There are multifocal regions of punctate post-embolic
encephalomalacia within the left cerebellar hemisphere
suggesting chronic embolic disease.

IMPRESSION:
1. Multifocal regions of abnormally decreased diffusion, most
prominent
within the right frontal lobe, which has an appearance
suggestive of watershed infarction. The more punctate foci of
decreased diffusion posteriorly suggest multiple small emboli.

2. Well-defined 15 mm focus of enhancement and decreased
diffusion within the right cerebellar hemisphere may represent a
subacute enhancing infarct, but is more concerning for a
metastatic lesion in this patient with lung cancer.
Consideration could be given to neck MRA or CTA to evaluate the
cervical
circulation, though the pattern suggests a proximal source.

[**2166-4-2**] Radiology BILAT LOWER EXT VEINS P
Grayscale and color Doppler images of bilateral common femoral,
superficial femoral, and popliteal veins were performed. There
is normal
compressibility, flow and augmentation.

[**2166-4-2**] Cardiology ECHO   [**2166-4-2**]
The estimated right atrial pressure is 10-15mmHg. Left
ventricular systolic function is hyperdynamic (EF>75%). Right
ventricular chamber size is normal with mild global free wall
hypokinesis. There is a small to moderate sized pericardial
effusion. There are no echocardiographic signs of tamponade.


[**2166-4-1**] Cardiology ECHO
No atrial septal defect is seen by 2D or color Doppler. Right
ventricular chamber size is normal. with borderline normal free
wall function. The aortic valve leaflets (3) are mildly
thickened. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. Mild (1+) TR. Upon initial
placement small air bubbles visualized in ascending aorta. No
air visualized in LA/LV. No LV wall motion abnormalities. No
thrombus visualized in RA, RV, PA. Right PA appears compressed
by large mass but still patent.

Arrest possibly secondary to left sided intracardiac
air/coronary air embolism but unable to determine given time
between event and images. PE also on the differential but no
signs of significant RV failure, however inotropes (epinephrine)
were administered.

[**2166-4-1**] Pathology Tissue: Bronchus Intermedius.
Small cell carcinoma

[**2166-3-31**] Radiology VENOUS DUP EXT UNI (MAP
Grayscale, color and Doppler images were obtained of the left
subclavian IJ axillary, brachial, basilic, and cephalic veins.
There is
normal flow, compression and augmentation seen in all of the
vessels.

.


Brief Hospital Course:
69 y/o F with PMHx of large mediastinal SCC s/p right mainstem
stenting who presented with recurrent compressive symptoms who
underwent OR placement of left mainstem stent and right mainstem
APC complicated by hypoxia and PEA arrest.
.
Pt thought to have had PEA arrest after rigid bronchoscopy was
removed, subsequent to L main stent placement for SCLC and use
of argon anticoagulation.  She underwent CPR immediately for <1
minute. The etilogy was thought to be air emboli secondarely to
argon coagulation vs. hypoxia. TEE was not done during procedure
due to technical difficulties secondarely to the mediastinal
mass. However, TEE done after arrest showing air bubbles in L
atrium. On admission the A-a gradient with pO2 was of >450 on
100% Fi02 and lactate was 1.7. She was moving all extremities
and following commands. CE were negative x2. Repeat TTE was
normal. Anticoagulation was initially held (For DVT) and patient
was extubated succesfuly 3 days after initial intubation.

Her ventilatory support was minimal, RISBI was <105 with air
leak and she was extuabted 24 hours after procedure.
Unfortunately, she developped stridor and increase number of
secretions in the upper airways with respiratory rate in the 40s
and SpO2 in 70s. She required emergent re-intubation. High-dose
steroids (methylprednisolone 125 mg q 6hrs) were started and
continued for 48 hours and patient was succesfully extubated on
day 3. Steroids were slowly down-tapered.
Due to long standing disease with e/o hyperinflation on CXR and
report of bronchospasm on presentation, she was also treated for
COPD exacerbation with standing and prn nebulizers.

After several days on the medical floor, patient's respiratory
status was not improving.  Interventional pulmonology was
reconsulted.  Pt was taken for flexible bronchoscopy which
showed significant mucus, some of which was removed, and [**Female First Name (un) **]
on the vocal cords.  Thoracentesis was also performed.  800cc
were removed and sent for culture. Culture was still pending at
time of discharge.

LUE DVT: Per PSH report, pt had portacath associated upper
extremity DVT and has been on Coumadin, p/w supratherapeutic
INR.  However, ultrasound on [**3-31**] did not show any DVT. LENIs
were negative. Anticoagulation was held prior to procedure and
re-started 24 hours afterwards (with lovenox) given her
malignancy and higher bleeding risk.  During her hospitalization
there was concern of a cerebellar metastasis of SCLC.  Per
radiology, pt should undergo a repeat MRI in 6 weeks for further
characterization.  Due to h/o DVT and atrial fibrillation as
well as evidence of embolic stroke, anticoagulation was
continued upon discharge.  Primary oncologist, Dr. [**Last Name (STitle) 65126**] was
informed of this and he agreed with the plan.

Tachycardia / SVT : Pt has remained tachycardic since admission,
suspect some component of dehydration and underlying malignancy.
 CTA neg for PE at OSH prior to transfer. LENIs were negative.
Patient was hydrated and tachycardia did not improve. Then, she
had episodes of atrial fibrillation up to 140-150 BPM with
stable BP. She was started on metoprolol and it was titrated up
to 50 mg TID which maintained a HR of 100 as monitored on
telemetry.  Metoprolol was not further uptitrated as sinus
tachycardia was thought to be secondary to her illness.  She was
discharged on this regimen. Would consider uptitration of
metoprolol if rate requies better control.  She was diltiazem
prior to this admission, but it did not control her heart rate
adequately.

SCLC: Pt with SCLC s/p chemo/radiation and now with L and R main
bronchus metal stents. Given that she has already received max
radiation doses plan is to do brachitherapy and chemo as
outpatient.  She will need follow up MRI in 6 weeks for further
charactization of a potential brain metastasis.  Outpatient
providers will also have to reassess whether or not to continue
anticoagulation.  Plan for patient to follow up with Dr. [**Last Name (STitle) **]
[**Name (STitle) 109613**] ([**Hospital **] [**Hospital 3278**] Medical Center) for HDR ?????? brachytherapy
in the Bronchus intermedius in the next week.  Follow up with
primary oncologist within 2-3wks with a repeat MRI head and CT
chest.  And follow up with Dr. [**Last Name (STitle) **] in IP in 4 wks for return
visit and flex bronch.

Bacteremia: Pt grew STAPHYLOCOCCUS, COAGULASE NEGATIVE from
a-line, which was removed <24 after positive blood culture and
started on Vancomycin (Day 1 [**4-2**]). Then, patient grew MRSA from
sputum and plan was to treat with Vanc for 2 weeks given
endovascular infection.
.
UTI: Pts urine was growing GNRs so ciprofloxacin was started.
Speciation showed ENTEROBACTER CLOACAE pan-sensitive. She was
switched to bactrim to continue treatment for 7 days (D1 [**4-5**]).


Medications on Admission:
Aspirin 81 mg PO daily
Warfarin 5 mg PO daily
Diltiazem 240 mg PO daily
Magnesium oxide 400 mg PO daily
Lorazepam 0.5 mg PO bid
Benzonoatate 100 mg PO 1 tab tid
Spiriva inhaler (tiotropium)

Discharge Medications:
1. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
3. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): for two days then reduce to 20 mg daily for two days,
then reduce to 10mg daily for 2 days.
4. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) [**Last Name (un) 74210**]
syringe Subcutaneous Q12H (every 12 hours).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): pt should also gargle with this medication for
treatment of her sore throat ([**Female First Name (un) **]).
8. Guaifenesin 1,200 mg Tab, Multiphasic Release 12 hr Sig: One
(1) Tab, Multiphasic Release 12 hr PO BID (2 times a day).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb
neb
neb Inhalation Q6H (every 6 hours).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb
neb Inhalation Q2H (every 2 hours) as needed for SOB.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for SOB.
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
13. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
14. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day): last dose is evening of  [**2166-4-12**].

15. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
twice a day: please resume on [**4-13**] after checking vanco trough
to ensure level is not supratherapeutic.  Goal 15-20.  Last day
of treatment is [**4-16**].
16. Outpatient Lab Work
Please check vanco trough every third dose.  Please check on
trough on [**4-12**] prior to resuming vancomycin administration.
17. Port a cath
Please deaccess permanent catheter after antibiotic regimen is
complete.
18. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
19. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
20. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1 and half tablet daily Tablet Sustained Release 24 hr PO
once a day: 150mg daily.
21. Outpatient Lab Work
Please check weekly CBC and chem 10 to ensure no major
abnormalities


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 **]

Discharge Diagnosis:
primary:
small cell lung cancer
PEA arrest
COPD exacerbation
pulmonary effusion
atrial fibrillation
MSSA bacteremia
Enterobacter UTI

secondary:
hypertension
h/o DVT
anxiety


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Ms. [**Known lastname **] - It was pleasure to care for you during your
hospitalization.  You were admitted for hematemesis.  You were
to have one of your stents reopened and have another stent
placed in your lungs.  However, shortly after the procedure you
developed very low blood pressure and required ICU
hospitalization.  You were intubated twice.  Upon extubation you
had swelling in your neck impairing your breathing, as well as
severe wheezing.  You were treated with steroids and nebulizers.
 Unfortunately your breathing did not improve so you underwent
another bronchoscopy which showed alot of mucus, some of which
was removed.  You had fluid removed from your lungs also.  Your
vocal cords show a candidal infection (thrush) so you should
continue to gargle with nystatin swish and swallow. You will
require oxygen for some time until your lung function improved.

Also during your hospitalization you were found to have Staph
aureus infection of your blood stream and possibly a Staph
aureus pneumonia.  You will complete a 14 day course of
Vancomycin (antibiotic). You were also found to have a urinary
tract infection for which you are on a second antibiotic called
Bactrim.

You were also treated for atrial fibrillation (irregular heart
rhythm) which requires medication to control the heart rate and
continuation of blood thinners to prevent strokes.  You were
previously on coumadin and this is being switched to lovenox.
Unfortunately, to complicate this matter, a small abnormality
was found in your brain that may be a metastasis of the lung
cancer.  This is not entirely clear.  If it is, you could
potentially have a bleed in the brain.  On the other hand, if
you do not continue with the lovenox treatment, you could have a
stroke from a blood clot formed in the heart, which you may have
already had in the past.  The present plan is to continue you on
blood thinners until we can obtain a repeat MRI to confirm a
metastatic brain tumor.  At that time, the matter of continuing
blood thinners can be readdressed.

Regarding treatment - you should discuss further treatment of
your lung cancer with your pulmonologists and your primary
oncologist.

Many medications were changed during this hospitalization:
- you will start prednisone taper, ipratropium and albuterol for
treatment of COPD
- guifenessin has been added to break up mucus
- bactrim and vancomycin have been added for treatment of
urinary tract infection and blood stream infection
- nystatin swish and swallow for treatment of oral and vocal
throat [**Female First Name (un) **] infection (yeast).  Please gargle with this
medication for most effective treatment.
- metoprolol has been started for better heart rate control.
stop taking diltiazem
- lovenox has been started to thin the blood.  stop taking
coumadin.
- aspirin has been discontinued due to increased risk of
bleeding.
- lorazepam may be used as frequently as every 6 hrs as needed.

Followup Instructions:
Please make the following appointments.

Name: [**Last Name (LF) **],[**First Name3 (LF) 5445**]
Address: [**Hospital1 **], [**Hospital1 **],[**Numeric Identifier 93461**]
Phone: [**Telephone/Fax (1) 37687**]
Appointment: Thursday [**2166-4-24**] 11:15am

Department: INTERVENTIONAL PULMONARY
When: TUESDAY [**2166-5-13**] at 11:30 AM [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: CHEST DISEASE CENTER
When: TUESDAY [**2166-5-13**] at 12:00 PM [**Telephone/Fax (1) 5072**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

We are working on a follow up appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) 109613**]
in the Pulmonary Department at [**Hospital 3278**] Medical Center within 2
weeks. The office will be contacting you at home with an
appointment. If you have not heard or have any questions please
call [**Telephone/Fax (1) 32678**].



Completed by:[**2166-4-11**]
{'Malignant neoplasm of other parts of bronchus or lung,Cardiac arrest,Acute respiratory failure,Methicillin resistant pneumonia due to Staphylococcus aureus,Obstructive chronic bronchitis with (acute) exacerbation,Urinary tract infection, site not specified,Cardiac complications, not elsewhere classified,Unspecified pleural effusion,Bacteremia,Unspecified disease of pericardium,Candidiasis of mouth,Infection and inflammatory reaction due to other vascular device, implant, and graft,Air embolism as a complication of medical care, not elsewhere classified,Unspecified essential hypertension,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Hypoxemia,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Long-term (current) use of anticoagulants,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of tobacco use,Systemic lupus erythematosus,Edema of larynx,Oliguria and anuria,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: S/p arrest in the OR during IP stent procedure.

PRESENT ILLNESS: 69 y/o F with PMHX of COPD and Small Cell Lung Cancer (diagnosed
[**2159**]) s/p XRT/chemo/tumor debridement/R mainstem bronchus stent
placement ([**2164**]) and recent LUE DVT on Coumadin who initially
presented to [**Hospital 1474**] hospital on [**3-27**] with 3-4 episodes of
hemoptysis, increased cough, wheezing and shortness of breath.
She was started on IV SoluMedrol 125mg IV q6hrs, Nebs and
tessalon pearles. She was supratherapeutic with an INR of 4.1
and Coumadin was held. CTA was negative for PE and revealed
right mainstem stent with distal intraluminal narrowing or tumor
effusion, mediastinal and subcarinal confluent metastatic
lymphadenopathy. Decision was made for transfer to [**Hospital1 18**] for
bronch and IP evaluation.
.
Pt was admitted to [**Hospital1 18**] and was continued on steroids, nebs and
cough suppressants.  She went for flexible bronchoscopy on [**3-30**]
which revealed normal trachea, extensive tumor at carina
obstructing both mainstem bronchi, extrinsic mediastinal
compression of L mainstem and unable to visualize stent in right
mainstem due to intraluminal tumor.
Pt was taken to the OR on [**4-1**] and had stent placed in the left
mainstem with good result.  There was attempted argon plasma
coagulation inside of the right stent to remove intraluminal
obstruction.  During this procedure, pt became progressively
hypoxic, bradycardic and loss of pulse at approx 3:38pm. CPR was
started immediately and pt received a total of 2mg of epi.
After approximately 2-3minutes of CPR, rhythm was checked and
there was a palpable pulse with HR >100 and sbp >180.  TEE was
performed and showed bubbles in the right atrium suggestive of
APC related air embolism but no RV dilation suggestive of acute
PE.  Oxygen sats recovered into the 90s, right femoral a-line
and left femoral CVL was placed.  Pt was given an additional
bolus of Midazolam and some neosynephrine for BP support prior
to transfer to the ICU.
.
On arrival to the ICU, pt was intubated and sedated with HR >100
and BP 140/90s.  Sedation was rapidly weaned and pt was clearly
responding to commands and moving all extremities.

MEDICAL HISTORY: 1. Small Cell lung cancer - diagnosed in [**2159**] and recurred in
[**2161**]. Initially started 6 weeks of XRT, followed by multiple
regimens of chemo. Has been off chemo for the last 4 months
"because CT scans have been stable." Last bronchoscopy was in
[**2165-12-23**] - small amounts of granulation tissue seen in
stent.
2. Recent LUE DVT (mid-[**2166-2-20**]) - L arm port was changed,
after which she developed dramatic swelling from shoulder to
wrist; UENIs confirmed LUE DVT. Coumadin 5mg was started.
3. COPD - longstanding, unknown date of diagnosis
4. Lupus - diagnosed 8 years ago after work-up for painful knee
and finger joints (L finger joints > R finger joints) - treated
with "pills" but not prednisone
5. Shingles infection in T10 dermatome in [**10/2165**] - treated with
acyclovir and recovered within 1 week
5. Anxiety/Insomnia

MEDICATION ON ADMISSION: Aspirin 81 mg PO daily
Warfarin 5 mg PO daily
Diltiazem 240 mg PO daily
Magnesium oxide 400 mg PO daily
Lorazepam 0.5 mg PO bid
Benzonoatate 100 mg PO 1 tab tid
Spiriva inhaler (tiotropium)

ALLERGIES: Levofloxacin / Lisinopril / Diphenhydramine

PHYSICAL EXAM: Vitals: T: 98.1 BP: 130/84 P: 117 R: 22 O2: 98% on 3 L
General: Alert, oriented, not in acute respiratory distress,
sitting upright in bed watching TV with audible upper airway
inspiratory and expiratory stridor.
HEENT: Sclera anicteric, pupils equal round & reactive to light,
mucous membranes moist, no jugular venous distention, mucous
membranes moist, oropharynx clear without thrush, no
oropharyngeal source of bleeding seen
Neck: supple, JVP not elevated, no lymphadenopathy, no carotid
bruits, loud and harsh inspiratory upper airway stridor heard,
trachea not deviated
Lungs: Nasal cannula intact, patient sitting upright with
audible upper airway inspiratory and expiratory stridor. Patient
appears comfortable and is not using any accessory muscles of
inspiration. Respiratory rate is mildly elevated. Scattered
anterior inspiratory and expiratory wheezes. Left-sided
bronchial breath sounds bases>apices. Right-sided bronchial
breath sounds with fine crackles at bases. Scattered inspiratory
and expiratory wheezes but not consistently.
CV: Tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Skin: No skin rash or ecchymoses noted, dressing over left
anterior pectoral region covering old PortaCath.
Neuro: Alert & oriented x 3, extraocular movements intact, CNs
II-XII grossly intact and patient moving all four extremities
spontaneously

FAMILY HISTORY: She reports no family history of lung cancer, SLE, or CAD. Her
mom died of "stomach cancer" at 51yo and her niece has breast
cancer. Her son has [**Name2 (NI) **].

SOCIAL HISTORY: She lives in [**Hospital1 1474**] with her husband. She has 4 children and 7
grandchildren who live within a mile of her house. She worked as
a homemaker. She smoked tobacco for approximately 20 pack years
(1 pack per day for 20+ years) and quit in the [**2145**]. She does
not know of any asbestos exposure. She drinks alcohol only on
social occasions and uses no other drugs. 

### Response:
{'Malignant neoplasm of other parts of bronchus or lung,Cardiac arrest,Acute respiratory failure,Methicillin resistant pneumonia due to Staphylococcus aureus,Obstructive chronic bronchitis with (acute) exacerbation,Urinary tract infection, site not specified,Cardiac complications, not elsewhere classified,Unspecified pleural effusion,Bacteremia,Unspecified disease of pericardium,Candidiasis of mouth,Infection and inflammatory reaction due to other vascular device, implant, and graft,Air embolism as a complication of medical care, not elsewhere classified,Unspecified essential hypertension,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Hypoxemia,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Long-term (current) use of anticoagulants,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of tobacco use,Systemic lupus erythematosus,Edema of larynx,Oliguria and anuria,Personal history of venous thrombosis and embolism'}
