CHIEF COMPLAINT: Right upper extremity DVT

PRESENT ILLNESS: Mr. [**Known lastname **] is a 43yo man with h/o lung adenoca, recurrent SVC
syndrome with DVTs in R and L subclavian vein s/p several stents
and throbmolysis most recently in [**1-3**] when he was treated with
3 stents to the R and L subclavian. He returns to the hospital
today after he noticed slowed venous drainage of his R arm as
well as mild R shoulder/back pain which is typical for his
recurrences. He did not notice swelling in the arm per se. He
was otherwise feeling quite well and had no complaints. He has
been taking his lovenox 60mg sq [**Hospital1 **] faithfully with the last
dose last night. He came in today for IR venogram to evaluate
his SC vein stents. His venogram showed total occlusion of R
sided Subclavian stents. The radiologist commented that there
was a "clear cut focal stenosis at the junction of clavicle and
first rib suggesting thoracic inlet syndrome - suspicious as
cause of recurrence." They performed balloon dilation of inside
of R SVC stents and recanalized with slow flow. They began TPA
infusion to thrombolize clots, starting at noon with rate
1mg/hr, decreased to 0.5mg/hr at 4pm to be run overnight. He was
admitted to the ICU for monitoring while receiving TPA infusion.
Current plan is to take her back for a repeat venogram tomorrow
morning to re-evaluate.
.
Notably, during his last hospitalization in [**1-3**] for similar
complaints, he was seen by thoracic surgery as well as vascular
surgery to determine whether any type of venous bypass (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 97935**]) or resection of 1st rib (Dr. [**Last Name (STitle) **] would
be indicated however it was decided to continue on his lovenox
until any other recurrence before revisiting these
conversations.
.
ROS: negative except as above. denies HA, F/C, cough, SOB, CP,
N/V/C/D.

MEDICAL HISTORY: Onc Hx: Patient presented in [**2185**] with increasing respiratory
infections and with large mediastinal mass leading to SVC
syndrome.  Found to have bulky adenocarcinoma.  Tx with XRT,
carboplatin, Taxol. Followed by Gemcitibine with an almost
complete response. He then took gefitinib for 4 years with no
recurrence of disease. Stopped gefitinib this spring after
discussions with Dr. [**Last Name (STitle) 3274**].Patient has had mult episodes of
SVC syndrome requiring lysis and stenting on 3 occasions from
[**2186**]-[**2187**].  He had been anticoagulated on lovenox.
.
PMH:
- congenital absence of kidney

MEDICATION ON ADMISSION: proscar 5mg po qday (for hematuria)
lovenox 60 sQ [**Hospital1 **]

ALLERGIES: Iodine Containing Agents Classifier

PHYSICAL EXAM: 96.6, HR 86, 107/54, RR 21, O2 99% RA
gen: NAD, pleasant, conversant, [**Location (un) 1131**] in bed
HEENT: PERRLA (small), OP not injected, MMM, NCAT
Neck: no LAD, supple
Cor: s1s2, RRR, no r/g/m
Pulm: CTAB
Abd: soft, NT,ND, +bs, no HSM
Ext: no c/c/e, w/w/p, R arm not grossly larger diameter than
left
Skin: L side of forehead with three small pink papules

FAMILY HISTORY: mGF - lung ca

SOCIAL HISTORY: lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] with wife and 3 sons
works in construction/landscaping
no tob, occ etoh, no drugs
former tob > 40 pack years quit [**2185**]
Compression of vein,Personal history of malignant neoplasm of bronchus and lung
Compression of vein,Hx-bronchogenic malignan
Admission Date:  [**2191-12-14**]              Discharge Date:   [**2191-12-16**]

Date of Birth:  [**2148-10-8**]             Sex:   M

Service: MEDICINE

Allergies:
Iodine Containing Agents Classifier

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Right upper extremity DVT

Major Surgical or Invasive Procedure:
TPA infusion
IR guided stent placement to the R SVC

History of Present Illness:
Mr. [**Known lastname **] is a 43yo man with h/o lung adenoca, recurrent SVC
syndrome with DVTs in R and L subclavian vein s/p several stents
and throbmolysis most recently in [**1-3**] when he was treated with
3 stents to the R and L subclavian. He returns to the hospital
today after he noticed slowed venous drainage of his R arm as
well as mild R shoulder/back pain which is typical for his
recurrences. He did not notice swelling in the arm per se. He
was otherwise feeling quite well and had no complaints. He has
been taking his lovenox 60mg sq [**Hospital1 **] faithfully with the last
dose last night. He came in today for IR venogram to evaluate
his SC vein stents. His venogram showed total occlusion of R
sided Subclavian stents. The radiologist commented that there
was a "clear cut focal stenosis at the junction of clavicle and
first rib suggesting thoracic inlet syndrome - suspicious as
cause of recurrence." They performed balloon dilation of inside
of R SVC stents and recanalized with slow flow. They began TPA
infusion to thrombolize clots, starting at noon with rate
1mg/hr, decreased to 0.5mg/hr at 4pm to be run overnight. He was
admitted to the ICU for monitoring while receiving TPA infusion.
Current plan is to take her back for a repeat venogram tomorrow
morning to re-evaluate.
.
Notably, during his last hospitalization in [**1-3**] for similar
complaints, he was seen by thoracic surgery as well as vascular
surgery to determine whether any type of venous bypass (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 97935**]) or resection of 1st rib (Dr. [**Last Name (STitle) **] would
be indicated however it was decided to continue on his lovenox
until any other recurrence before revisiting these
conversations.
.
ROS: negative except as above. denies HA, F/C, cough, SOB, CP,
N/V/C/D.


Past Medical History:
Onc Hx: Patient presented in [**2185**] with increasing respiratory
infections and with large mediastinal mass leading to SVC
syndrome.  Found to have bulky adenocarcinoma.  Tx with XRT,
carboplatin, Taxol. Followed by Gemcitibine with an almost
complete response. He then took gefitinib for 4 years with no
recurrence of disease. Stopped gefitinib this spring after
discussions with Dr. [**Last Name (STitle) 3274**].Patient has had mult episodes of
SVC syndrome requiring lysis and stenting on 3 occasions from
[**2186**]-[**2187**].  He had been anticoagulated on lovenox.
.
PMH:
- congenital absence of kidney

Social History:
lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] with wife and 3 sons
works in construction/landscaping
no tob, occ etoh, no drugs
former tob > 40 pack years quit [**2185**]


Family History:
mGF - lung ca

Physical Exam:
96.6, HR 86, 107/54, RR 21, O2 99% RA
gen: NAD, pleasant, conversant, [**Location (un) 1131**] in bed
HEENT: PERRLA (small), OP not injected, MMM, NCAT
Neck: no LAD, supple
Cor: s1s2, RRR, no r/g/m
Pulm: CTAB
Abd: soft, NT,ND, +bs, no HSM
Ext: no c/c/e, w/w/p, R arm not grossly larger diameter than
left
Skin: L side of forehead with three small pink papules


Pertinent Results:
[**2191-12-14**] 10:27PM   PT-12.4 PTT-33.2 INR(PT)-1.1
[**2191-12-14**] 08:05PM   FIBRINOGE-252
[**2191-12-14**] 08:20AM   WBC-3.4* RBC-4.44* HGB-13.7* HCT-38.3* MCV-86
MCH-30.8 MCHC-35.7* RDW-13.4
[**2191-12-14**] 08:20AM   CREAT-1.1
[**2191-12-14**] 08:20AM   PLT COUNT-167
.
TPA CATH CHECK
IMPRESSION:
1. Patent right subclavian stent with new stent placed.
2. Status post TPA infusion overnight, with good angiographic
results.
3. In order to maintain stent patency, it is suggested to begin
with anticoagulation.
.
CT Chest with contrast: IMPRESSION:
1. Stable 3 mm left lower lobe pulmonary nodule.
2. Interval development of moderate right pleural effusion.
3. Stable post-radiation changes.
4. Narrowing and possible fragmentation of the right subclavian
stent as it passes between the clavicle and first rib.
.
Unilateral Venogram of the right subclavian: IMPRESSION:
1. Right arm venogram via brachial vein shows thrombosis in the
subclavian/SVC stent.
2. Wire advanced through the clot into the SVC up to the
inferior vena cava.
3. 6-mm to 8-mm balloons were used to recanalize and macerate
clot.
4. Infusion catheter placed to infuse TPA and patient was
admitted for overnight infusion of TPA in the ICU unit.
[**Unit Number **]. Patient would come back tomorrow for a check of venogram.


Brief Hospital Course:
43yo man with h/o lung adenoca s/p XRT/[**Doctor Last Name **]/taxol/gemcitabine/
gefitinib with recurrent thoracic inlet syndrome due to
thrombosis of hte R (and L) SC vein s/p several stenting
procedures presents with recurrent R subclavian thrombosis
ballooned and now on TPA infusion.
.
# r subclavian vein thrombosis/ thoracic inlet syndrome: pt has
had this recurrent problem since his cancer diagnosis. This time
has clotted through lovenox [**Hospital1 **] dosing, indicating his first
real failure of therapy. Suggests that patient should have more
definitive treatment at this time and discuss with surgery
possible options.
- continued TPA at 0.5mg/kg/hr from 4pm until 7am, at which time
IR reevaluated the patient and placed a stent in the right SVC.
- monitored PT/PTT/fibrinogen q3h, which remained in normal
range.
- the patient was restarted on his lovanox dose at 60mg
subcutaneous, twice daily.
- vascular surgery evaluated patient and felt that patient could
follow up with them as an outpatient upon discharge for question
of definitive management.
.
# lung adenoca: last CT has shown no recurrence at this time. no
treatment at this time, as s/p XRT and chemo.


Medications on Admission:
proscar 5mg po qday (for hematuria)
lovenox 60 sQ [**Hospital1 **]


Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1)  Subcutaneous
Q12H (every 12 hours).


Discharge Disposition:
Home

Discharge Diagnosis:
Right Subclavian Thrombosis

Discharge Condition:
Stable

Discharge Instructions:
Please return to the hospital if you have recurrence of your
initial symptoms (back pain, arm swelling, discoloration), or if
you have chest pain, shortness of breath, fevers or chills.
.
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1617**], upon 1-2 weeks of
being discharged.
.
Please follow up in the Vascular Surgery clinic ([**Telephone/Fax (1) 8343**]
within 3 weeks of discharge to discuss possible surgical
management for repeated upper extremity venous thrombi.

Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1617**], upon 1-2 weeks of
being discharged.
.
Please follow up in the Vascular Surgery clinic ([**Telephone/Fax (1) 8343**]
within 3 weeks of discharge to discuss possible surgical
management for repeated upper extremity venous thrombi.
{'Compression of vein,Personal history of malignant neoplasm of bronchus and lung'}


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: Right upper extremity DVT

PRESENT ILLNESS: Mr. [**Known lastname **] is a 43yo man with h/o lung adenoca, recurrent SVC
syndrome with DVTs in R and L subclavian vein s/p several stents
and throbmolysis most recently in [**1-3**] when he was treated with
3 stents to the R and L subclavian. He returns to the hospital
today after he noticed slowed venous drainage of his R arm as
well as mild R shoulder/back pain which is typical for his
recurrences. He did not notice swelling in the arm per se. He
was otherwise feeling quite well and had no complaints. He has
been taking his lovenox 60mg sq [**Hospital1 **] faithfully with the last
dose last night. He came in today for IR venogram to evaluate
his SC vein stents. His venogram showed total occlusion of R
sided Subclavian stents. The radiologist commented that there
was a "clear cut focal stenosis at the junction of clavicle and
first rib suggesting thoracic inlet syndrome - suspicious as
cause of recurrence." They performed balloon dilation of inside
of R SVC stents and recanalized with slow flow. They began TPA
infusion to thrombolize clots, starting at noon with rate
1mg/hr, decreased to 0.5mg/hr at 4pm to be run overnight. He was
admitted to the ICU for monitoring while receiving TPA infusion.
Current plan is to take her back for a repeat venogram tomorrow
morning to re-evaluate.
.
Notably, during his last hospitalization in [**1-3**] for similar
complaints, he was seen by thoracic surgery as well as vascular
surgery to determine whether any type of venous bypass (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 97935**]) or resection of 1st rib (Dr. [**Last Name (STitle) **] would
be indicated however it was decided to continue on his lovenox
until any other recurrence before revisiting these
conversations.
.
ROS: negative except as above. denies HA, F/C, cough, SOB, CP,
N/V/C/D.

MEDICAL HISTORY: Onc Hx: Patient presented in [**2185**] with increasing respiratory
infections and with large mediastinal mass leading to SVC
syndrome.  Found to have bulky adenocarcinoma.  Tx with XRT,
carboplatin, Taxol. Followed by Gemcitibine with an almost
complete response. He then took gefitinib for 4 years with no
recurrence of disease. Stopped gefitinib this spring after
discussions with Dr. [**Last Name (STitle) 3274**].Patient has had mult episodes of
SVC syndrome requiring lysis and stenting on 3 occasions from
[**2186**]-[**2187**].  He had been anticoagulated on lovenox.
.
PMH:
- congenital absence of kidney

MEDICATION ON ADMISSION: proscar 5mg po qday (for hematuria)
lovenox 60 sQ [**Hospital1 **]

ALLERGIES: Iodine Containing Agents Classifier

PHYSICAL EXAM: 96.6, HR 86, 107/54, RR 21, O2 99% RA
gen: NAD, pleasant, conversant, [**Location (un) 1131**] in bed
HEENT: PERRLA (small), OP not injected, MMM, NCAT
Neck: no LAD, supple
Cor: s1s2, RRR, no r/g/m
Pulm: CTAB
Abd: soft, NT,ND, +bs, no HSM
Ext: no c/c/e, w/w/p, R arm not grossly larger diameter than
left
Skin: L side of forehead with three small pink papules

FAMILY HISTORY: mGF - lung ca

SOCIAL HISTORY: lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] with wife and 3 sons
works in construction/landscaping
no tob, occ etoh, no drugs
former tob > 40 pack years quit [**2185**] 

### Response:
{'Compression of vein,Personal history of malignant neoplasm of bronchus and lung'}
