CHIEF COMPLAINT: Breast Cancer

PRESENT ILLNESS: Ms. [**Last Name (un) 86590**] is a 63 year-old F w/ CAD w/ DES--> LAD c/b
in-stent restenosis on [**Last Name (un) **], BRCA s/p R-lumpectomy '[**63**] w/
chemo-XRT, ovarian CA s/p partial hysterectomy '[**43**], hep C from
blood x-fusion, admitted to [**Hospital Unit Name 153**] for post-operative management
after having L-breast modified radical mastectomy c/b large
hematoma for which pt was taken back to OR for surgical
evacuation of 200cc blood and drainage w/ wound-vac placement
(that is draining frank blood currently).  Patient has been
hemodynamically stable throughout her surgical and PACU course,
and was sent to [**Hospital Unit Name 153**] for further monitoring of her
pain/hemodynamics.  Pain has been controlled on Dilaudid PCA.

MEDICAL HISTORY: 1. CAD s/p MI [**2177-6-15**] w /DES--> LAD c/b in-stent restenosis on
[**Year (2 digits) **]
2. Hepatitis C (from blood transfusion)
3. hiatal hernia
4. GERD
5. anxiety
6. depression
7. R-breast lumpectomy [**2163**] s/p chemo XRT
8. uterine cancer s/p partial hysterectomy [**2143**]
9. Hypertension
10. Hyperlipidemia

MEDICATION ON ADMISSION: Carisoprodol 350mg [**Hospital1 **]
Carvedilol 12.5mg [**Hospital1 **]
[**Hospital1 **] 75 mg daily
Methadone 10mg QID
Oxycodone 60mg TID
Simvastatin 80 mg daily
[**Hospital1 **] 81mg daily
MVI

ALLERGIES: Amitriptyline / Protonix

PHYSICAL EXAM: VS: afebrile, HR 77 BP 127/84 SaO2 95% on NC
GEN: chronically ill-appearing thin F appearing much older than
stated age (looks 80 i/o 60) in mod distress [**1-6**] pain
HEENT: PERRLA, no scleral icterus
CV: regular rate and rhythm
LUNGS: anterior clear, wound vac in place over left breast w/
large area of ecchymoses and soft tissue swelling
ABD: +BS soft ND NT
EXT: distal pulses palpable
NEURO: alert, awake, in pain, answering questions

FAMILY HISTORY: Diabetes and breast CA.

SOCIAL HISTORY: She is currently living with her daughter in [**Name (NI) 4288**].  She
moved here from [**State 108**], where she was in an abusive
relationship w/ her husband for the past 14 years, which
affected her access to health care.  With regards to her history
of abuse, she is currently seeing a social worker at [**Name (NI) 61**]; however, she does not have any psychologist involved in
her care to help her
deal with her anxiety and depressive symptoms.  She denies any
alcohol use.  She has smoked one pack per day for 40 years;
however, there has been no smoking since [**74**]/[**2176**].
Malignant neoplasm of upper-outer quadrant of female breast,Hematoma complicating a procedure,Opioid type dependence, continuous,Other complications due to other cardiac device, implant, and graft,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Atrial fibrillation,Other chronic pain,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Debility, unspecified,Personal history of malignant neoplasm of ovary,Dysthymic disorder,Unspecified viral hepatitis C without hepatic coma,History of emotional abuse,Long-term (current) use of antiplatelet/antithrombotic,Anemia, unspecified
Mal neo breast up-outer,Hematoma complic proc,Opioid dependence-contin,Comp-oth cardiac device,Abn react-artif implant,Atrial fibrillation,Chronic pain NEC,Crnry athrscl natve vssl,Status-post ptca,Old myocardial infarct,Hypertension NOS,Hyperlipidemia NEC/NOS,Debility NOS,Hx of ovarian malignancy,Dysthymic disorder,Hpt C w/o hepat coma NOS,Hx of emotional abuse,Lng use antiplte/thrmbtc,Anemia NOS
Admission Date:  [**2178-4-24**]              Discharge Date:   [**2178-5-8**]

Date of Birth:  [**2114-5-23**]             Sex:   F

Service: SURGERY

Allergies:
Amitriptyline / Protonix

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Breast Cancer

Major Surgical or Invasive Procedure:
Left modified radical mastectomy

History of Present Illness:
Ms. [**Last Name (un) 86590**] is a 63 year-old F w/ CAD w/ DES--> LAD c/b
in-stent restenosis on [**Last Name (un) **], BRCA s/p R-lumpectomy '[**63**] w/
chemo-XRT, ovarian CA s/p partial hysterectomy '[**43**], hep C from
blood x-fusion, admitted to [**Hospital Unit Name 153**] for post-operative management
after having L-breast modified radical mastectomy c/b large
hematoma for which pt was taken back to OR for surgical
evacuation of 200cc blood and drainage w/ wound-vac placement
(that is draining frank blood currently).  Patient has been
hemodynamically stable throughout her surgical and PACU course,
and was sent to [**Hospital Unit Name 153**] for further monitoring of her
pain/hemodynamics.  Pain has been controlled on Dilaudid PCA.

Past Medical History:
1. CAD s/p MI [**2177-6-15**] w /DES--> LAD c/b in-stent restenosis on
[**Year (2 digits) **]
2. Hepatitis C (from blood transfusion)
3. hiatal hernia
4. GERD
5. anxiety
6. depression
7. R-breast lumpectomy [**2163**] s/p chemo XRT
8. uterine cancer s/p partial hysterectomy [**2143**]
9. Hypertension
10. Hyperlipidemia

Social History:
She is currently living with her daughter in [**Name (NI) 4288**].  She
moved here from [**State 108**], where she was in an abusive
relationship w/ her husband for the past 14 years, which
affected her access to health care.  With regards to her history
of abuse, she is currently seeing a social worker at [**Name (NI) 61**]; however, she does not have any psychologist involved in
her care to help her
deal with her anxiety and depressive symptoms.  She denies any
alcohol use.  She has smoked one pack per day for 40 years;
however, there has been no smoking since [**74**]/[**2176**].

Family History:
Diabetes and breast CA.

Physical Exam:
VS: afebrile, HR 77 BP 127/84 SaO2 95% on NC
GEN: chronically ill-appearing thin F appearing much older than
stated age (looks 80 i/o 60) in mod distress [**1-6**] pain
HEENT: PERRLA, no scleral icterus
CV: regular rate and rhythm
LUNGS: anterior clear, wound vac in place over left breast w/
large area of ecchymoses and soft tissue swelling
ABD: +BS soft ND NT
EXT: distal pulses palpable
NEURO: alert, awake, in pain, answering questions

Pertinent Results:
[**2178-4-24**] 06:54PM BLOOD WBC-14.1*# RBC-3.54* Hgb-10.6* Hct-31.8*
MCV-90 MCH-30.0 MCHC-33.4 RDW-12.7 Plt Ct-218
[**2178-4-25**] 02:41AM BLOOD PT-13.7* PTT-31.1 INR(PT)-1.2*
[**2178-4-25**] 02:41AM BLOOD Glucose-107* UreaN-12 Creat-0.5 Na-132*
K-4.7 Cl-98 HCO3-27 AnGap-12
[**2178-4-25**] 02:41AM BLOOD Calcium-7.9* Phos-4.2 Mg-1.3*

STUDIES:
[**4-25**] CXR: There are no old films available for comparison. A
drain is seen
overlying the left anterior chest. Coronary stent is visualized.
There is
some minimal biapical scarring. Right axillary clips are
visualized. The
heart is upper limits normal in size. There is no infiltrate or
effusion.

Pathology:
[**4-24**] Breast tissue: ****

Brief Hospital Course:
63 y/o F w/ CAD on [**Month/Year (2) **]/[**Month/Year (2) **], hx ovarian CA, hep C, BRCA s/p
modified radical mastectomy c/b hematoma, on wound vac.

#  S/P MRM:  Patient tolerated procedure w/o complication. Has
wound VAC in place after removing out ~200cc blood from
hematoma.  Her HCT was monitored carefully in setting of recent
[**Month/Year (2) **] administration.  Pain was controlled with PCA.  She was
given post-op cefazolin 2g IV for 3 doses. While in the [**Hospital Ward Name 332**]
ICU, she was transfused a total of 2 units of packed RBCs, with
a subsequent hematocrit of 29.7. She was subsequently
transferred to the surgical floor. Her HCT continued to be
stable for the remainder of her admission and her wound VAC
output and her wound were monitored for evidence of further
hematoma or bleeding, of which none was demonstrated. The
patient continued to do well and on POD 6 was taken back to the
OR where a split thickness skin graft from her left thigh was
placed on the surgical wound. This was held in place using an
additional wound VAC on low continuous suction (50mmHg), and was
removed on POD6. During the dressing change, the skin graft was
well granulated and continued to appear viable.

#  CAD:  DES to LAD c/b instent re-stenosis, crucial to continue
[**Hospital Ward Name **] even during surgery as cardiac risks are significant.
Patient was continued on [**Last Name (LF) **], [**First Name3 (LF) **], carvedilol, and high-dose
statin. She was followed throughout the admission.

# ATRIAL FIBRILLATION: On [**4-25**], the patient was nearing transfer
out of the ICU, but subsequently developed atrial fibrillation
with rapid ventricular response, with a heart rate in the high
130s. She was given normal saline boluses, occasional doses of
intravenous metoprolol, and the dose of her standing carvedilol
was increased. She was not symptomatic from these episodes, and
her heart rate was subsequently under good control, for the rest
of her stay in the [**Hospital Unit Name 153**]. She did continued to require increased
doses of carvedilol compared to admission for rate control of
her atrial fibrillation.

#  CHRONIC PAIN:  Patient was continued on methadone 10mg QID,
oxycodone 60mg IR TID, and standing Tylenol q6 hours. A
hydromorphone PCA was added on [**4-25**]. She was seen by the chronic
pain service for further assistance with her regimen, and was
eventually stabilized on a regimen of methadone QID
(15mg,10mg,10mg,15mg respectively) and Dilaudid 2-8mg PO q3hrs
prn with good results. The patient did require IV pain control
(Dilaudid) along with Ativan for dressing changes, but did not
require additional pain medications at other times. Upon
discharge an EKG was preformed at the recommendation of the
chronic pain service to evaluate the patient's QT interval after
increasing her methadone dose. The QTc interval was prolonged
however this appeared to be the patient's baseline. Chronic pain
was consulted again over the phone related to this finding and
advised that the patient return to her home dose of methadone
10mg four times daily and be seen in follow up by her  primary
care provider. [**Name10 (NameIs) 6**] appointment with the patient's primary care
provider was made and the provider was called and made aware of
the need for a follow-up EKG. She was discharge home with this
dose of Methadone as well as Dilaudid as needed by mouth.

# DECONDITIONING: ON HD5 the patient was seen by physical
therapy who recommended several inpatient visits and training,
and this was performed while the patient was admitted.

#Social Work and Discharge Plan: The patient is followed by
[**Hospital1 18**] social work on an outpatient basis and the inpatient
social worker connected with this provider during the [**Hospital 228**]
hospital stay related to coping and home safety. Due to some
social situations at home the surgical team requested that
social work to assess the safety of the patient home environment
and social work evaluated the patient's situation and reported
it appropriate for her return. Visiting nursing services were
coordinated and will be following the patient's progress and
preforming daily dressing changes to the left breast.

Medications on Admission:
Carisoprodol 350mg [**Hospital1 **]
Carvedilol 12.5mg [**Hospital1 **]
[**Hospital1 **] 75 mg daily
Methadone 10mg QID
Oxycodone 60mg TID
Simvastatin 80 mg daily
[**Hospital1 **] 81mg daily
MVI

Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Methadone 10 mg Tablet Sig: One (1) Tablet PO four times a
day for 14 days: please hold for sedation.
Disp:*56 Tablet(s)* Refills:*0*
5. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours for 5 days: please do not take if you are sleepy, or
confused.
Disp:*84 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Left breast infiltrating ductal carcinoma.


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital for surgical treatment of
cancer in your left breast. You had a mastectomy of the left
breast on [**2178-4-24**]. After this procedure because of the blood
thinning medication you take for the stent in your heart, you
had some bleeding under the skin at the surgical site. This
bleeding was stopped and the blood was washed out from the skin.
The wound was left open after this procedure and a VAC dressing
was placed, this allowed for the tissue at the base of the wound
to be kept clean and begin to grow. After some time with the VAC
dressing a split thickness skin graft. You know will be able to
go home with a xeroform dressing with a dry gauze sterile
dressing over the skin graft on the left breast which will be
monitored and changed daily by a visiting nurse who will come to
your home. The donor site on your left tigh can be left  with a
xeroform dressing and dry sterile dressing. The xeroform will
eventually dry and lift off but this will happen on its own, it
is important that you let this dressing fall off on its own, the
skin is healing underneath. If you notice any signs and symptoms
of infection near or around the wound such as: green or white
discharge, swelling, increasing redness around the wound,
increased pain, foul odor, or you develop a fever, please call
the office or if severe go to the emergency room. If the wound
opens or bleeds please call the office or seek medical attention
if severe. If you notice the area that has been skin grafted is
turning dark in color please call the office.

Please eat small frequent meals high in protien to encorage your
wound to heal. Keep yourself well hydrated. You should not
shower, just sponge baths for now until your follow-up
appointment with Dr. [**Last Name (STitle) 519**] and he will give you new instructions.
Please use your left are as little as possible, preventing
pressure on the left arm pit area. You may lift your arm up and
down, just avoid heavy lifting.

You will continue your current chronic pain regimen at home.
Your primary care doctor as well as the chronic pain team has
been working with you to atempt to decrease these doses and you
should follow-up with them in 2 weeks to monitor your progress.
Please follow the directions on the prescription bottles, the
regimen has been changed. We have made an appointment with you
with your primary care doctor as written below. You have not
been taking your Carisoprodol, please do not take this until you
have folowed up with your primary care provider.

Followup Instructions:
Please seek Dr. [**Last Name (STitle) 519**] in his office in 1 week, Provider: [**First Name11 (Name Pattern1) **]
[**Last Name (NamePattern4) 520**], M.D. Phone:[**Telephone/Fax (1) 6554**] Date/Time:[**2178-5-18**] 2:30

Please make an appointment with your Primary Care Provider
[**Name Initial (PRE) 176**] 2 weeks. An appointment has been made for you as listed
below. If this is not convient for you you may have it changed
however you will need refills on your methadone in 2 weeks.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-5-19**] 10:40

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 83742**], MD Phone:[**Telephone/Fax (1) 1652**]
Date/Time:[**2178-6-26**] 1:10


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

Completed by:[**2178-5-11**]
{'Malignant neoplasm of upper-outer quadrant of female breast,Hematoma complicating a procedure,Opioid type dependence, continuous,Other complications due to other cardiac device, implant, and graft,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Atrial fibrillation,Other chronic pain,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Debility, unspecified,Personal history of malignant neoplasm of ovary,Dysthymic disorder,Unspecified viral hepatitis C without hepatic coma,History of emotional abuse,Long-term (current) use of antiplatelet/antithrombotic,Anemia, unspecified'}


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: Breast Cancer

PRESENT ILLNESS: Ms. [**Last Name (un) 86590**] is a 63 year-old F w/ CAD w/ DES--> LAD c/b
in-stent restenosis on [**Last Name (un) **], BRCA s/p R-lumpectomy '[**63**] w/
chemo-XRT, ovarian CA s/p partial hysterectomy '[**43**], hep C from
blood x-fusion, admitted to [**Hospital Unit Name 153**] for post-operative management
after having L-breast modified radical mastectomy c/b large
hematoma for which pt was taken back to OR for surgical
evacuation of 200cc blood and drainage w/ wound-vac placement
(that is draining frank blood currently).  Patient has been
hemodynamically stable throughout her surgical and PACU course,
and was sent to [**Hospital Unit Name 153**] for further monitoring of her
pain/hemodynamics.  Pain has been controlled on Dilaudid PCA.

MEDICAL HISTORY: 1. CAD s/p MI [**2177-6-15**] w /DES--> LAD c/b in-stent restenosis on
[**Year (2 digits) **]
2. Hepatitis C (from blood transfusion)
3. hiatal hernia
4. GERD
5. anxiety
6. depression
7. R-breast lumpectomy [**2163**] s/p chemo XRT
8. uterine cancer s/p partial hysterectomy [**2143**]
9. Hypertension
10. Hyperlipidemia

MEDICATION ON ADMISSION: Carisoprodol 350mg [**Hospital1 **]
Carvedilol 12.5mg [**Hospital1 **]
[**Hospital1 **] 75 mg daily
Methadone 10mg QID
Oxycodone 60mg TID
Simvastatin 80 mg daily
[**Hospital1 **] 81mg daily
MVI

ALLERGIES: Amitriptyline / Protonix

PHYSICAL EXAM: VS: afebrile, HR 77 BP 127/84 SaO2 95% on NC
GEN: chronically ill-appearing thin F appearing much older than
stated age (looks 80 i/o 60) in mod distress [**1-6**] pain
HEENT: PERRLA, no scleral icterus
CV: regular rate and rhythm
LUNGS: anterior clear, wound vac in place over left breast w/
large area of ecchymoses and soft tissue swelling
ABD: +BS soft ND NT
EXT: distal pulses palpable
NEURO: alert, awake, in pain, answering questions

FAMILY HISTORY: Diabetes and breast CA.

SOCIAL HISTORY: She is currently living with her daughter in [**Name (NI) 4288**].  She
moved here from [**State 108**], where she was in an abusive
relationship w/ her husband for the past 14 years, which
affected her access to health care.  With regards to her history
of abuse, she is currently seeing a social worker at [**Name (NI) 61**]; however, she does not have any psychologist involved in
her care to help her
deal with her anxiety and depressive symptoms.  She denies any
alcohol use.  She has smoked one pack per day for 40 years;
however, there has been no smoking since [**74**]/[**2176**]. 

### Response:
{'Malignant neoplasm of upper-outer quadrant of female breast,Hematoma complicating a procedure,Opioid type dependence, continuous,Other complications due to other cardiac device, implant, and graft,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Atrial fibrillation,Other chronic pain,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Debility, unspecified,Personal history of malignant neoplasm of ovary,Dysthymic disorder,Unspecified viral hepatitis C without hepatic coma,History of emotional abuse,Long-term (current) use of antiplatelet/antithrombotic,Anemia, unspecified'}
