CHIEF COMPLAINT: Right middle lobe syndrome

PRESENT ILLNESS: Mr. [**Known lastname 12130**] is a 79 year old male s/p RULobectomy by Dr.
[**Last Name (STitle) **] on [**2130-6-12**] for Stage 1A squamous cell carcinoma with
clean margins (0.2cm distance from bronchial margin) with
recurrent RML PNA s/p RULobectomy. The pt notes that he has had
recurrent RML PNA, averaging an episode every other month, since
his initial RULobectomy. Pt also has a stable O2 requirement of
2L NC s/p RULobectomy. He underwent a rigid/flex bronch and
balloon dilation w/stent placement on [**2133-2-9**] by Dr. [**Last Name (STitle) **].
However, the stent was not visualized on CT or bronchoscopy
after
the procedure and was likely coughed out. Pt's last episode of
PNA required hospitalization ending on [**2-12**] at [**Hospital 1562**]
Hospital. Pt is being referred for evaluation of RMLobectomy for
RML syndrome by Dr. [**Last Name (STitle) **].

MEDICAL HISTORY: -COPD
-Anemia of Chronic Disease(hct 27-30)
-Hypogammaglobulinemia
-Benign prostatic hypertrophy
-Coronary Artery Disease (remote hx per report but patient
denies)
-Transient ischemic attack >5 yrs ago status post carotid
endarterectomy without further events
-Hypertension
-Rheumatoid arthritis (on chronic low dose of prednisone)
-Stage IIA non-small cell lung cancer status post right upper
lobe lobectomy
-colovesicular fistula
-Rheumatic Fever
-LE edema for which he was started on Lasix
-s/p Partial colectomy
-S/p cholecystectomy
-s/p RULobectomy
-s/p discectomy

MEDICATION ON ADMISSION: lansoprazol 30mg daily, cardura 4mg daily, plavix 75mg daily,
lipitor 10mg daily, asa 325mg daily, cartia XT 120mg daily, MVI
+ Vit C, lasix 40mg daily, vicodin prn, prednisone 10mg daily,
symbicort inh 160/4.5 2x [**Hospital1 **]

ALLERGIES: Flagyl

PHYSICAL EXAM: VS: T: 97.5  HR: 88-90 SR  BP: 130's/60 Sats: 97% 4L  WT: 73 kg
(75 kg)
General: 79 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple
Card: RRR
Resp: crackles right 1/4 up left clear
GI: benign
Extr: warm no edema.  Left mid-line in place no erythema
Incision: Right thoracotomy site clean, dry, intact.  no
erythema
Neuro: awake, alert oriented

FAMILY HISTORY: Son w cardiac arrhythmia.  Mother died in an accident.  Father
had peptic ulcer disease and lived to over 100.  He had a sister

SOCIAL HISTORY: Cigarettes: [ ] never  [x] ex-smoker   [ ] current Pack-yrs:____
                       quit: [**2122**], 110 pack years
ETOH:       [x] No   [ ] Yes     drinks/day: _____
Drugs:
Exposure:   [x] No   [ ] Yes  [ ] Radiation
                     [ ] Asbestos [ ] Other:
Occupation:
Marital Status: [ ] Married  [x] Single
Lives:          [x] Alone    [ ] w/ family  [ ] Other:
Other pertinent social history: VNA 1-2 times weekly
Pulmonary collapse,Pneumonia, organism unspecified,Hypogammaglobulinemia, unspecified,Hemorrhage complicating a procedure,Bronchiectasis without acute exacerbation,Rheumatoid arthritis,Hemophilus influenzae [H. influenzae] infection in conditions classified elsewhere and of unspecified site,Thoracoscopic surgical procedure converted to open procedure,Personal history of malignant neoplasm of bronchus and lung,Long-term (current) use of steroids,Coronary atherosclerosis of native coronary artery,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Atrial fibrillation
Pulmonary collapse,Pneumonia, organism NOS,Hypogammaglobulinem NOS,Hemorrhage complic proc,Bronchiectas w/o ac exac,Rheumatoid arthritis,H. influenzae infect NOS,Thoracoscop conv to open,Hx-bronchogenic malignan,Long-term use steroids,Crnry athrscl natve vssl,Abn reac-organ rem NEC,Atrial fibrillation
Admission Date:  [**2133-3-27**]              Discharge Date:   [**2133-4-14**]

Date of Birth:  [**2053-11-16**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Flagyl

Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right middle lobe syndrome

Major Surgical or Invasive Procedure:
[**2133-3-27**]: VATS converted to open thoracotomy RML lobectomy

History of Present Illness:
Mr. [**Known lastname 12130**] is a 79 year old male s/p RULobectomy by Dr.
[**Last Name (STitle) **] on [**2130-6-12**] for Stage 1A squamous cell carcinoma with
clean margins (0.2cm distance from bronchial margin) with
recurrent RML PNA s/p RULobectomy. The pt notes that he has had
recurrent RML PNA, averaging an episode every other month, since
his initial RULobectomy. Pt also has a stable O2 requirement of
2L NC s/p RULobectomy. He underwent a rigid/flex bronch and
balloon dilation w/stent placement on [**2133-2-9**] by Dr. [**Last Name (STitle) **].
However, the stent was not visualized on CT or bronchoscopy
after
the procedure and was likely coughed out. Pt's last episode of
PNA required hospitalization ending on [**2-12**] at [**Hospital 1562**]
Hospital. Pt is being referred for evaluation of RMLobectomy for
RML syndrome by Dr. [**Last Name (STitle) **].

The pt notes on ROS that he has DOE that is increased from his
baseline since his last episode of PNA. Continues to have a
minimally productive cough of non-bloody sputum. Pt reports
improving black diarrhea without sig abd pain, N/V since his
recent course of PO antibiotics for PNA. Pt has a hx of a GI
bleed 1-2 years ago, but is unable to provide further details.
Notes reproducible RUQ pain with bending over that has lasted
for
several months. Denies fevers, chills, nightsweats, recent
changes in weight, headache. Pt denies chest pain, palpitations.

Past Medical History:
-COPD
-Anemia of Chronic Disease(hct 27-30)
-Hypogammaglobulinemia
-Benign prostatic hypertrophy
-Coronary Artery Disease (remote hx per report but patient
denies)
-Transient ischemic attack >5 yrs ago status post carotid
endarterectomy without further events
-Hypertension
-Rheumatoid arthritis (on chronic low dose of prednisone)
-Stage IIA non-small cell lung cancer status post right upper
lobe lobectomy
-colovesicular fistula
-Rheumatic Fever
-LE edema for which he was started on Lasix
-s/p Partial colectomy
-S/p cholecystectomy
-s/p RULobectomy
-s/p discectomy

Social History:
Cigarettes: [ ] never  [x] ex-smoker   [ ] current Pack-yrs:____
                       quit: [**2122**], 110 pack years
ETOH:       [x] No   [ ] Yes     drinks/day: _____
Drugs:
Exposure:   [x] No   [ ] Yes  [ ] Radiation
                     [ ] Asbestos [ ] Other:
Occupation:
Marital Status: [ ] Married  [x] Single
Lives:          [x] Alone    [ ] w/ family  [ ] Other:
Other pertinent social history: VNA 1-2 times weekly

Family History:
Son w cardiac arrhythmia.  Mother died in an accident.  Father
had peptic ulcer disease and lived to over 100.  He had a sister

with pancreatic cancer and a son with rheumatic fever, MS, and
back problems.

Physical Exam:
VS: T: 97.5  HR: 88-90 SR  BP: 130's/60 Sats: 97% 4L  WT: 73 kg
(75 kg)
General: 79 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple
Card: RRR
Resp: crackles right 1/4 up left clear
GI: benign
Extr: warm no edema.  Left mid-line in place no erythema
Incision: Right thoracotomy site clean, dry, intact.  no
erythema
Neuro: awake, alert oriented


Pertinent Results:
[**2133-4-13**] WBC-11.4* RBC-3.14* Hgb-9.0* Hct-27.5 Plt Ct-454*
[**2133-4-12**] WBC-13.4* RBC-3.25* Hgb-9.7* Hct-28.3 Plt Ct-476*
[**2133-4-9**] WBC-13.3* RBC-3.28* Hgb-9.6* Hct-28.5 Plt Ct-427
[**2133-4-7**] WBC-18.8*# RBC-3.26*# Hgb-9.7*# Hct-28.5 Plt Ct-425
[**2133-3-27**] WBC-17.4* RBC-3.17* Hgb-9.5* Hct-27.2  Plt Ct-239

[**2133-4-14**] Glucose-97 UreaN-16 Creat-0.7 Na-143 K-3.9 Cl-103
HCO3-34
[**2133-4-12**] Glucose-94 UreaN-20 Creat-0.6 Na-139 K-4.0 Cl-101
HCO3-31
[**2133-3-27**] Glucose-137* UreaN-13 Creat-0.8 Na-137 K-3.9 Cl-102
HCO3-27
[**2133-4-7**] CK(CPK)-17, [**2133-4-7**] CK(CPK)-11, [**2133-4-7**] CK(CPK)-24*
[**2133-4-7**] CK-MB-2 cTropnT-<0.01, [**2133-4-7**] CK-MB-2 cTropnT-<0.01
[**2133-4-14**] Mg-2.3
[**2133-4-13**] Calcium-9.1 Phos-3.3 Mg-2.0

[**2133-4-3**] IgG-389* IgA-270 IgM-55
[**2133-4-1**] IgG-358

Micro:
[**2133-4-7**]: UCx Yeast
[**2133-4-6**]: MRSA SCREEN (Final [**2133-4-8**]): No MRSA isolated.
[**2133-3-31**] sputum cx >25 PMNs, <10 epith, 2+ budding yeast; yeast,
moderate growth
[**2133-3-27**] BAL 4+ PMLs, 4+ GNRs, 1+ GPCs; haemophilus
BETA-LACTAMASE POSITIVE.

CXR:
[**2133-4-9**]: As compared to the previous radiograph, there is no
relevant
change. Minimal increase in severity of the pre-existing left
parenchymal
opacities. The diffuse right parenchymal opacities are stable.
No newly
appeared focal parenchymal opacities. Moderate retrocardiac
atelectasis.
Unchanged size of the cardiac silhouette. No pneumothorax.
Unchanged course of the left-sided PICC line.

[**2133-4-2**]:
1. No evidence of pulmonary embolism.
2. Left lower and upper lobe pneumonia.
3. Interval increase in size of mediastinal lymph nodes, most
likely
reactive.
4. Small residual right hilar hematoma after right middle
lobectomy.

[**2133-4-3**]: Echocardiogram
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The number of aortic valve leaflets cannot be determined.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are structurally normal.
Physiologic mitral regurgitation is seen (within normal limits).
The pulmonary artery systolic pressure could not be determined.

IMPRESSION: Normal left ventricular cavity size with mild
symmetric left ventricular hypertrophy and preserved global
biventricular systolic function. Due to sub-optimal image
quality a regional wall motion cannot be fully excluded. Mildly
dilated aortic root. No clinically signficant valvular disease.
Indeterminate pulmonary artery systolic pressure.


Brief Hospital Course:
Mr. [**Known lastname 12130**] was admitted [**2133-3-27**] following Video-assisted
thoracoscopic surgery converted to open thoracotomy, right
middle lobectomy, pericardial fat pad buttress, and bronchoscopy
with bronchoalveolar lavage.  He was extubated in the operating
room and transfer to the TSICU for respiratory and hemodynamic
close monitoring.  He transfer to the floor [**2133-3-31**]. On [**4-2**]
he developed respiratory failure requiring transfer to the ICU.
A CT done [**2133-4-2**] showed Left lobe pneumonia, no pulmonary
embolism. Antibiotics were continued and he improved.  He
transfer back to the floor.  He did well for a few days then
again developed respiratory distress requiring transfer back to
the unit for volume overload.  He was aggressively diuresed,
pneumonia improved and transfer back to the floor on [**2133-4-9**] in
stable condition.

Pulmonary: aggressive pulmonary toilet, nebs, good pain control
his oxygen requirements improved to 97% 3L NC

Chest-tubes: posterior and anterior apical were to suction
initially with persistent air-leak then to water-seal.  On
[**2133-3-30**] the posterior apical tube was removed.

Chest films: Diffuse bilateral interstitial pulmonary
infiltrates consistent with
edema. confluent density at the left lung base which improved.
The diffuse right parenchymal opacities are stable

Cardiac: Episode of RAF 140's converted to SR with IV Lopressor,
he was restarted on his home dose of Diltiazem 120 mg daily.
Over the course of his hospital stay he intermittent SVT 140's.
His Diltiazem was changed to immediate release and increased to
60 mg qid with good rate control 80-90's  His cardiac enzymes
were negative.  Echocardiogram [**2133-4-2**] revealed Normal left
ventricular cavity size with mild symmetric left ventricular
hypertrophy and preserved global biventricular systolic
function. History of TI As on Plavix and Aspirin was held until
the Epidural was removed [**2133-3-31**].

GI: PPI and bowel regime.  He required additional laxatives and
enemas to stimulate a bowel.

Nutrition: He was seen by Speech and swallow on [**2133-4-2**] for
concern of aspiration.  On bedside exam they found him to be
silently aspirating.  A video-swallow on [**2133-4-3**] confirmed
aspiration.  His diet was changed to PO diet of nectar thick
liquids and soft consistency solids.

Renal: He was restarted on his home dose lasix 40 mg daily. His
renal function stayed within normal limits with good urine
output. His BPH medications were restarted. Electrolytes were
replete as needed.

ID: infectious disease was consulted on [**2133-3-30**] for the
intra-operative cultures growing H. influenzae. They recommended
continuing with vancomycin and cefepime until [**2133-4-1**] then
changed to ceftriaxone to complete an 9 day course. His PNA
improved. His IVIG level was found to be low.  He was given 1
dose of IVIG 0.5 k/kg for hypogammaglobulinemia to help clear
his infection and to prevent future infections.

Heme: [**2133-3-30**] transfuse 1 unit of PRBC for HCT 21->26 and
[**2133-3-29**] transfused 1 unit PRBC for HCT 24->28.

Endocrine: Blood sugars were < 200.  he was given stress dose
steroids intraoperative and his home dose prednisone 10 mg was
restarted for his rheumatoid arthritis.

Epitaxis: [**2133-4-7**] left nasal nare resolved with nasal packing.

Pain: [**2133-3-27**] the acute pain service placed a Bupivacaine
Epidural at the bedside.  The Epidural was removed [**2133-3-31**]. He
was started on Dilaudid PCA transition to PO Dilaudid,
acetaminophen and Lidoderm patch with good control.

IV access: Left PICC with tip in proximal left brachiocephalic
vein was placed on [**2133-4-1**]. Removed [**2133-4-14**].

Disposition: seen by physical therapy who recommended rehab.  He
was discharged to [**Hospital3 **] Hospital [**Telephone/Fax (1) 77266**] on
[**2133-4-14**].  He will follow-up with Dr. [**Last Name (STitle) **] as an
outpatient.


Medications on Admission:
lansoprazol 30mg daily, cardura 4mg daily, plavix 75mg daily,
lipitor 10mg daily, asa 325mg daily, cartia XT 120mg daily, MVI
+ Vit C, lasix 40mg daily, vicodin prn, prednisone 10mg daily,
symbicort inh 160/4.5 2x [**Hospital1 **]

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)

Discharge Diagnosis:
Right middle lobe nodule
COPD
Bronchiectasis
Rheumatoid arthritis, Rheumatic fever
h/x of recurrent PNAs
Barrett's esophagus


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


Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage
-Shower daily. Wash incisions with mild soap and water, rinse,
pat dry
-No tub bathing, swimming or hot tubs until incision healed

Pulmonary
-Aggressive pulmonary toilet, nebs, incentive spirometer and
ambulation

Daily weight: please adjust diuretics as needed.  Replete
electrolytes as needed to keep K > 4.0 and Mg 2.0

Pain
-Acetaminophen 650 every 6-8 hours
-Dilaudid 2-4 mg prn
-Lidoderm patch split in [**1-11**] and placed on either side of right
thoracotomy incision

Acivity
-No lifting greater than 10 pounds until seen


Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2133-5-12**]
3:30
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]

Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment



Completed by:[**2133-4-21**]
{'Pulmonary collapse,Pneumonia, organism unspecified,Hypogammaglobulinemia, unspecified,Hemorrhage complicating a procedure,Bronchiectasis without acute exacerbation,Rheumatoid arthritis,Hemophilus influenzae [H. influenzae] infection in conditions classified elsewhere and of unspecified site,Thoracoscopic surgical procedure converted to open procedure,Personal history of malignant neoplasm of bronchus and lung,Long-term (current) use of steroids,Coronary atherosclerosis of native coronary artery,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Atrial fibrillation'}


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 middle lobe syndrome

PRESENT ILLNESS: Mr. [**Known lastname 12130**] is a 79 year old male s/p RULobectomy by Dr.
[**Last Name (STitle) **] on [**2130-6-12**] for Stage 1A squamous cell carcinoma with
clean margins (0.2cm distance from bronchial margin) with
recurrent RML PNA s/p RULobectomy. The pt notes that he has had
recurrent RML PNA, averaging an episode every other month, since
his initial RULobectomy. Pt also has a stable O2 requirement of
2L NC s/p RULobectomy. He underwent a rigid/flex bronch and
balloon dilation w/stent placement on [**2133-2-9**] by Dr. [**Last Name (STitle) **].
However, the stent was not visualized on CT or bronchoscopy
after
the procedure and was likely coughed out. Pt's last episode of
PNA required hospitalization ending on [**2-12**] at [**Hospital 1562**]
Hospital. Pt is being referred for evaluation of RMLobectomy for
RML syndrome by Dr. [**Last Name (STitle) **].

MEDICAL HISTORY: -COPD
-Anemia of Chronic Disease(hct 27-30)
-Hypogammaglobulinemia
-Benign prostatic hypertrophy
-Coronary Artery Disease (remote hx per report but patient
denies)
-Transient ischemic attack >5 yrs ago status post carotid
endarterectomy without further events
-Hypertension
-Rheumatoid arthritis (on chronic low dose of prednisone)
-Stage IIA non-small cell lung cancer status post right upper
lobe lobectomy
-colovesicular fistula
-Rheumatic Fever
-LE edema for which he was started on Lasix
-s/p Partial colectomy
-S/p cholecystectomy
-s/p RULobectomy
-s/p discectomy

MEDICATION ON ADMISSION: lansoprazol 30mg daily, cardura 4mg daily, plavix 75mg daily,
lipitor 10mg daily, asa 325mg daily, cartia XT 120mg daily, MVI
+ Vit C, lasix 40mg daily, vicodin prn, prednisone 10mg daily,
symbicort inh 160/4.5 2x [**Hospital1 **]

ALLERGIES: Flagyl

PHYSICAL EXAM: VS: T: 97.5  HR: 88-90 SR  BP: 130's/60 Sats: 97% 4L  WT: 73 kg
(75 kg)
General: 79 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple
Card: RRR
Resp: crackles right 1/4 up left clear
GI: benign
Extr: warm no edema.  Left mid-line in place no erythema
Incision: Right thoracotomy site clean, dry, intact.  no
erythema
Neuro: awake, alert oriented

FAMILY HISTORY: Son w cardiac arrhythmia.  Mother died in an accident.  Father
had peptic ulcer disease and lived to over 100.  He had a sister

SOCIAL HISTORY: Cigarettes: [ ] never  [x] ex-smoker   [ ] current Pack-yrs:____
                       quit: [**2122**], 110 pack years
ETOH:       [x] No   [ ] Yes     drinks/day: _____
Drugs:
Exposure:   [x] No   [ ] Yes  [ ] Radiation
                     [ ] Asbestos [ ] Other:
Occupation:
Marital Status: [ ] Married  [x] Single
Lives:          [x] Alone    [ ] w/ family  [ ] Other:
Other pertinent social history: VNA 1-2 times weekly 

### Response:
{'Pulmonary collapse,Pneumonia, organism unspecified,Hypogammaglobulinemia, unspecified,Hemorrhage complicating a procedure,Bronchiectasis without acute exacerbation,Rheumatoid arthritis,Hemophilus influenzae [H. influenzae] infection in conditions classified elsewhere and of unspecified site,Thoracoscopic surgical procedure converted to open procedure,Personal history of malignant neoplasm of bronchus and lung,Long-term (current) use of steroids,Coronary atherosclerosis of native coronary artery,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Atrial fibrillation'}
