CHIEF COMPLAINT: This is a 56 year old man with metastatic
pancreatic carcinoma transferred to [**Hospital1 18**] for neurosurgery
for C-4 compression fracture.  On [**2112-10-24**] had respiratory
arrest.  Patient extubated on [**2112-10-24**], transferred to medical
team on [**2112-10-25**].

PRESENT ILLNESS: This is a 56 year old man with
metastatic pancreatic adenocarcinoma (with known liver
metastases) who was at [**State 1558**] [**2112-10-13**]
receiving radiation therapy session nine of 14 to an anterior
neck mass.  There he was noted to have neck drooping.  MRI
showed a large mass at C-4 (mass was initially seen on
[**2112-9-29**], but was not causing symptoms at that time).
Therefore, patient was transferred to [**Hospital1 18**] for surgery.  He
had right shoulder weakness one week prior to transfer to
[**Hospital1 18**].  He went to the operating room on [**2112-10-14**] and received
C-4 and partial C-3 vertebrectomy, C2-C5 anterior fusion with
anterior cages and screw plate fixation.  Pathology on the
spinal mass from the operation was metastatic poorly
differentiated adenocarcinoma.  Postoperatively patient
complained of difficulty swallowing.  On [**2112-10-19**] he had an
acute episode of shortness of breath.  Chest x-ray showed
patchiness at bases consistent with aspiration.  Patient did
have an episode of choking on water shortly prior.  CT of
chest was obtained which showed fatty infiltration of the
liver with multiple lesions, largest 2.7 cm, no pulmonary
embolus, bilateral consolidation in the lower lobes, severe
calcification of the coronary arteries consistent with
coronary artery disease.  Patient was sent to the surgical
intensive care unit where he was started on levofloxacin and
Flagyl on [**2112-10-20**].  On [**10-20**] a swallow study showed high
aspiration risk.  Tube feeds were recommended.  A Dobbhoff
tube was placed on [**2112-10-21**].  The tube was placed by
interventional radiology because it could not be successfully
placed on the floor.  On [**2112-10-22**] patient was transferred to
the surgical floor.  On [**2112-10-23**] he was found tachycardiac and
unresponsive with respiratory rate of 5, systolic blood
pressure in the 80s.  He was intubated.  Arterial blood gas
was 6.99/138/197.  Patient was given intravenous fluids and
transferred to the medical intensive care unit.  Antibiotics
were changed from levofloxacin to ceftazidime (for greater
gram negative coverage) and vancomycin.  He was hypernatremic
with sodium of 155.  He was started on half normal saline.
Sodium was 145 on [**2112-10-25**].  He was extubated on the morning
of [**2112-10-24**].  He recalled difficulty clearing a thick mucus
plug prior to his episode of unresponsiveness that required
intubation.  Patient pulled out his NG tube on [**2112-10-25**].
Overnight [**2112-10-24**] he was noted to be agitated and confused
and this was felt to be due to delirium and sundowning.  On
[**2112-10-25**] antibiotics were switched back to levofloxacin and
Flagyl and he was transferred to the medical floor on this
day.

MEDICAL HISTORY: Bladder cancer, transitional cell
diagnosed in [**2110**], status post BCG, status post transurethral
resection of bladder in [**2110**].  Pancreatic adenocarcinoma with
liver metastases.  He has received four cycles of 5FU and
leucovorin.  Previously he had been receiving gemcitabine,
but it was stopped because of severe edema.  Hypertension.
Type 2 diabetes.  Hypercholesterolemia.  Depression.
Anxiety.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Father died of myocardial infarction at age
39.  Mother alive at age 83.

SOCIAL HISTORY: Lives with mother in [**Name (NI) 34422**].  Has a grown
son in the area, another grown son on the west coast.
Brother and sister live in the area.  Divorced.  Quit tobacco
and alcohol 25 years ago.  Was working in the glass bottle
industry until six months ago.
Secondary malignant neoplasm of bone and bone marrow,Pathologic fracture of vertebrae,Malignant neoplasm of other specified sites of pancreas,Pneumonitis due to inhalation of food or vomitus,Respiratory arrest,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension
Secondary malig neo bone,Path fx vertebrae,Malig neo pancreas NEC,Food/vomit pneumonitis,Respiratory arrest,Hyperosmolality,Hypertension NOS
Admission Date:  [**2112-10-13**]       Discharge Date:  [**2112-10-27**]

Date of Birth:   [**2055-10-26**]       Sex:  M

Service:  NEUROSUR

CHIEF COMPLAINT:  This is a 56 year old man with metastatic
pancreatic carcinoma transferred to [**Hospital1 18**] for neurosurgery
for C-4 compression fracture.  On [**2112-10-24**] had respiratory
arrest.  Patient extubated on [**2112-10-24**], transferred to medical
team on [**2112-10-25**].

HISTORY OF PRESENT ILLNESS:  This is a 56 year old man with
metastatic pancreatic adenocarcinoma (with known liver
metastases) who was at [**State 1558**] [**2112-10-13**]
receiving radiation therapy session nine of 14 to an anterior
neck mass.  There he was noted to have neck drooping.  MRI
showed a large mass at C-4 (mass was initially seen on
[**2112-9-29**], but was not causing symptoms at that time).
Therefore, patient was transferred to [**Hospital1 18**] for surgery.  He
had right shoulder weakness one week prior to transfer to
[**Hospital1 18**].  He went to the operating room on [**2112-10-14**] and received
C-4 and partial C-3 vertebrectomy, C2-C5 anterior fusion with
anterior cages and screw plate fixation.  Pathology on the
spinal mass from the operation was metastatic poorly
differentiated adenocarcinoma.  Postoperatively patient
complained of difficulty swallowing.  On [**2112-10-19**] he had an
acute episode of shortness of breath.  Chest x-ray showed
patchiness at bases consistent with aspiration.  Patient did
have an episode of choking on water shortly prior.  CT of
chest was obtained which showed fatty infiltration of the
liver with multiple lesions, largest 2.7 cm, no pulmonary
embolus, bilateral consolidation in the lower lobes, severe
calcification of the coronary arteries consistent with
coronary artery disease.  Patient was sent to the surgical
intensive care unit where he was started on levofloxacin and
Flagyl on [**2112-10-20**].  On [**10-20**] a swallow study showed high
aspiration risk.  Tube feeds were recommended.  A Dobbhoff
tube was placed on [**2112-10-21**].  The tube was placed by
interventional radiology because it could not be successfully
placed on the floor.  On [**2112-10-22**] patient was transferred to
the surgical floor.  On [**2112-10-23**] he was found tachycardiac and
unresponsive with respiratory rate of 5, systolic blood
pressure in the 80s.  He was intubated.  Arterial blood gas
was 6.99/138/197.  Patient was given intravenous fluids and
transferred to the medical intensive care unit.  Antibiotics
were changed from levofloxacin to ceftazidime (for greater
gram negative coverage) and vancomycin.  He was hypernatremic
with sodium of 155.  He was started on half normal saline.
Sodium was 145 on [**2112-10-25**].  He was extubated on the morning
of [**2112-10-24**].  He recalled difficulty clearing a thick mucus
plug prior to his episode of unresponsiveness that required
intubation.  Patient pulled out his NG tube on [**2112-10-25**].
Overnight [**2112-10-24**] he was noted to be agitated and confused
and this was felt to be due to delirium and sundowning.  On
[**2112-10-25**] antibiotics were switched back to levofloxacin and
Flagyl and he was transferred to the medical floor on this
day.

PAST MEDICAL HISTORY:  Bladder cancer, transitional cell
diagnosed in [**2110**], status post BCG, status post transurethral
resection of bladder in [**2110**].  Pancreatic adenocarcinoma with
liver metastases.  He has received four cycles of 5FU and
leucovorin.  Previously he had been receiving gemcitabine,
but it was stopped because of severe edema.  Hypertension.
Type 2 diabetes.  Hypercholesterolemia.  Depression.
Anxiety.

OUTPATIENT MEDICATIONS:  Accupril, atenolol, Neurontin 600 mg
b.i.d., buspirone 15 mg b.i.d., Xanax, fentanyl patch 50 mcg
per hour, Percocet, Vioxx, insulin NPH 32 units q.a.m. and 66
units q.p.m.

TRANSFER MEDICATIONS:  Medications on transfer to the medical
floor on [**2112-10-25**] included levofloxacin 500 mg IV q.24 hours,
fentanyl patch 50 mcg per hour q.72 hours, olanzapine 5 mg
q.h.s., Ambien 5 to 10 mg q.h.s. p.r.n., droperidol 0.625 mg
IV q.six hours p.r.n. nausea, Percocet one to two tablets
p.o. q.four hours p.r.n. pain, morphine 2 mg IV q.four hours
p.r.n., Flagyl 500 mg IV q.eight hours, Protonix 40 mg p.o.
q.24 hours, acetaminophen p.r.n., insulin sliding scale
(standing doses of insulin held because patient not eating),
buspirone 15 mg p.o. b.i.d., gabapentin 600 mg p.o. b.i.d.

ALLERGIES:  No known drug allergies.

FAMILY HISTORY:  Father died of myocardial infarction at age
39.  Mother alive at age 83.

SOCIAL HISTORY:  Lives with mother in [**Name (NI) 34422**].  Has a grown
son in the area, another grown son on the west coast.
Brother and sister live in the area.  Divorced.  Quit tobacco
and alcohol 25 years ago.  Was working in the glass bottle
industry until six months ago.

PHYSICAL EXAMINATION:  On [**2112-10-25**] temperature max equals
temperature current equals 101.6; pulse 102 to 122, currently
102; blood pressure 130 to 174 over 72 to 90; respiratory
rate 22 to 31; O2 saturation 92% to 98% on 4 liters O2 nasal
cannula.  In general, pleasant, middle aged man in a cervical
collar in no apparent distress.  HEENT: pupils equal, round
and reactive to light 6 to 4 mm.  Oropharynx slightly dry.
Neck difficult to assess given presence of neck brace.  Chest
clear to auscultation bilaterally anteriorly.  Crackles at
right base posteriorly.  Decreased breath sounds at left
base.  Cardiovascular regular rate and rhythm, normal S1, S2,
no murmur.  Abdomen soft, nondistended, nontender with
hypoactive bowel sounds.  He is moving all four extremities
spontaneously.

LABORATORY DATA:  On [**2112-10-27**] WBC 14.6, hematocrit 24.2.  On
[**2112-10-25**] WBC 23.2, hematocrit 27.2.  On [**2112-10-22**] WBC 22.5,
hematocrit 31.3.  On [**2112-10-20**] WBC 22.9, hematocrit 29.2.  On
[**2112-10-15**] WBC 10.0, hematocrit 28.5.  On [**10-12**] WBC 9.4,
hematocrit 34.7.  Platelets 221 on [**2112-10-27**].  On [**2112-10-23**] PT
14.0, PTT 23.4, INR 1.4.  On [**2112-10-13**] PT 13.6, PTT 23.7, INR
1.3; platelets 367.  On [**2112-10-27**] sodium 139, K 3.7, Cl 105,
CO2 24, BUN 7, creatinine 0.4, glucose 259.  On [**2112-10-12**]
sodium 139, K 5.0, Cl 101, CO2 27, BUN 23, creatinine 1.0.
Cardiac enzymes, CPK drawn on [**2112-10-23**] and [**2112-10-24**] was 57, 46,
49.  Troponin was less than 0.3.  On [**2112-10-26**] calcium 7.3,
phosphate 3.0, magnesium 1.6.  Microbiology data included
blood culture [**2112-10-25**] anaerobic bottle with gram positive
cocci, aerobic bottle with coagulase negative Staphylococcus.
On [**2112-10-24**] blood culture no growth to date as of [**2112-10-27**].
Sputum culture [**2112-10-23**] positive for yeast, but appears to be
contaminant.  On [**2112-10-20**] blood culture no growth as of
[**2112-10-27**].  Significant imaging studies included on [**2112-10-13**]
cervical spine x-rays showed complete destruction of the C-4
vertebral body, marked prevertebral soft tissue swelling.
There was slight anterior kyphosis.  CT of chest [**2112-10-19**]
showed fatty infiltration of liver with some round,
relatively hyperdense lesions within it.  Lesions are seen on
both sides of the lobes of the liver.  The largest lesion had
a diameter of 2.7 cm.  There was no pulmonary embolus
present.  There was an air fluid level within the trachea
which may be consistent with secretions or aspiration.  Chest
x-ray [**2112-10-19**] at lung bases bilaterally there are patchy
opacities which are new in comparison with the prior study,
question aspiration.  Chest x-ray [**2112-10-20**] in the interval
there has been resolution of the previously visible right
middle lobe and left lower lobe opacities, however,
plate-like atelectasis persists at the bases.  Chest x-ray
[**2112-10-25**] there is again evidence of patchy atelectasis at the
left lung base and minimal atelectatic changes may also be
present in the right lower lobe.  No evidence of failure.

HOSPITAL COURSE:  This is a 56 year old man with metastatic
pancreatic cancer who presented to [**Hospital1 18**] for cervical spine
surgery.  His postoperative course was complicated by
aspiration pneumonia and respiratory arrest on [**2112-10-22**].  Much
of the hospital course has already been dictated in the
history of present illness.

1.  Respiratory arrest.  Per history it appears that the
arrest occurred because he had a large mucus plug that he was
unable to clear.  Hypercarbia then led to depressed mental
status.  When we saw patient on [**2112-10-27**] he was breathing
comfortably and reported only minimal sputum production.  He
was continued on suctioning as well as chest P.T.

2.  Pneumonia.  Patient likely had aspiration pneumonia by
history with x-rays showing bibasilar opacities and by
increase in WBC from 10 to 20 on the day of the witnessed
aspiration event.  Patient was continued on levofloxacin and
Flagyl.  As of [**2112-10-27**] WBC count had fallen from 23.2 on
[**2112-10-25**] to 14.6 on [**2112-10-27**].  Patient was hemodynamically
stable and afebrile on [**2112-10-27**].

3.  Spinal surgery.  Neurosurgery recommended leaving the
collar in place for a full 12 weeks.  Patient is allowed to
sit up in bed and get out to a chair.

4.  Nutrition.  Patient failed a repeat swallow study on
[**2112-10-26**] and had severe aspiration of both thin and thick
liquids.  Prior to his admission to the hospital his ability
to swallow food had deteriorated greatly secondary to the
mass in his neck.  At time of admission he was taking four
containers of yogurt a day, but had been unable to take other
foods.  Given this poor baseline swallowing as well as his
difficulty with swallowing postoperatively, the decision was
made to have a G-tube placed for nutrition.  G-tube placement
tentatively scheduled for [**2112-10-28**].

5.  Diabetes.  Patient had blood sugars covered with insulin
sliding scale while not taking oral intake.  We plan to
transition back to standing doses of insulin after he is able
to have oral or tube feed intake.

6.  Cancer.  In terms of his cancer, he would not be
undergoing radiation therapy nor chemotherapy while he has an
active infection.  This issue can be resolved after the
infection has resolved.

DISPOSITION:  The patient may go to a rehabilitation facility
when he is medically cleared.  Patient is up to date as of
[**2112-10-27**] at 12:00 p.m.






                            [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D.  [**MD Number(1) 1341**]

Dictated By:[**Name8 (MD) 4123**]
MEDQUIST36

D:  [**2112-10-27**]  12:18
T:  [**2112-10-27**]  12:37
JOB#:  [**Job Number 35754**]


Admission Date:  [**2112-10-13**]       Discharge Date:  [**2112-11-2**]

Date of Birth:   [**2055-10-26**]       Sex:  M

Service:  [**Doctor Last Name 1181**]

ADDENDUM TO HOSPITAL COURSE THROUGH [**2112-10-27**]:  1.  Pulmonary:
Per the previous discharge summary the patient had an
aspiration pneumonia.  He was treated on Levofloxacin and
Metronidazole to complete a fourteen day course, which will
end on [**2112-11-5**].  The patient continues to show evidence of
bilateral lower lobe processes on chest x-ray and had
physical findings in those areas as well suggestive of
aspiration pneumonia.  On [**10-31**] the patient had a low grade
fever.  Chest x-ray was rechecked, which showed the
possibility of another aspiration event mostly seen in the
right lower lobe.  The patient's temperature went as high as
101.  He was continued on the Levo and Flagyl to cover what
was thought to be a recurrent aspiration event.  At the time
of discharge the patient continues to run low grade
temperatures from 99 to 100.5.  It is unclear if these
temperatures are due to his pneumonia or if they are a tumor
fever.  Blood cultures and urine cultures are negative to
date from that previous spike to 101.  The likelihood that
this is a tumor fever is very real.  He continued to have
chest physical therapy and suctioning as needed, which he did
by himself with a yank hour suction.  He had no complaints of
any difficulty breathing at the time of discharge.

2.  Nutrition:  As stated in previous discharge summary a PEG
was planned for [**10-28**].  A PEG was placed by
interventional radiology and after 24 hours tube feeds were
begun.  Tube feeds consisted of ProMod with fiber and at the
time of discharge the patient is at his goal rate of 85 cc
per hour, which he is tolerating without a problem.

3.  Type 2 diabetes:  The patient continues to have high
finger sticks in the 200s and 300s.  He has been covered with
an insulin sliding scale as well as NPH insulin fixed doses.
The doses of NPH were recently increased to 20 units in the
morning and 30 units in the evening.  His outpatient doses,
however, were 32 units in the morning and 66 units in the
evening with slowly increase in the dosages of his NPH,
because he had been not eating for so long or titrating to
proper doses.  In addition to the NPH he was covered with a
regular insulin sliding scale.

4.  Hematology:  The patient's hematocrit fell slowly over
the course of days to a low point of 24.2 and on the [**10-27**] he was transfused 1 unit of packed red blood cells,
which he tolerated without a problem.  Since then his
hematocrit has remained stable at around 30.  It is
recommended that while at rehab his hematocrit is followed
and that he is transfused if he drops below 25 as he has no
history of coronary artery disease.

5.  Status post C4 vertebrectomy and C2-C5 anterior fusion:
The patient continues to have his neck collar in place, which
will have to be worn for twelve weeks.  The patient is
instructed to follow up with Dr. [**Last Name (STitle) 1327**] three weeks after
discharge with AP and lateral C spine films prior to that
appointment.  Throughout his stay on the [**Doctor Last Name **] Service the
patient had no symptoms of right upper extremity weakness as
he had prior to the surgery.  He still does complain of pain
in his neck, which is well treated with morphine elixir 10 to
20 mg q 4 hours prn.

6.  Anxiety:  The patient's anxiety continued.  Once the PEG
tube was placed we were able to restart his Buspirone and
Xanax with good effect.

DISCHARGE MEDICATIONS:  Levofloxacin 500 mg per PEG tube q.d.
to end on [**2112-11-5**].  Flagyl 500 mg per PEG t.i.d. to end on
[**2112-11-5**].  Morphine elixir 10 to 20 mg q 4 hours prn,
Fentanyl patch 75 micrograms per hour q 72 hours to be
changed next on [**2112-11-3**].  Xanax 0.5 mg t.i.d. prn, Buspirone
15 mg b.i.d., Lansoprazole 30 mg q day, Zyprexa 5 mg q.h.s.,
Zyprexa 5 mg prn delirium or agitation.  Compazine 10 mg per
PEG q 6 hours prn for nausea.  NPH insulin 20 units q.a.m.,
30 units q.p.m., Tylenol 325 to 650 mg q 4 to 6 hours prn,
Gabapentin 600 mg b.i.d., regular insulin sliding scale,
Colace 100 mg b.i.d., Dulcolax suppository 10 mg pr h.s. prn.

DISCHARGE DIAGNOSES:
1.  Stage four pancreatic cancer status post C4 vertebrectomy
and C2-5 anterior fusion.
2.  Transitional cell carcinoma.
3.  Hypertension.
4.  Type 2 diabetes.
5.  High cholesterol.
6.  Anxiety.
7.  Status post PEG tube placement on [**2112-10-28**].

DISCHARGE STATUS:  The patient is discharged to [**Hospital3 45430**] Rehab Facility with instructions to follow up with
Dr. [**Last Name (STitle) 1327**] from neurosurgery in three weeks at [**Telephone/Fax (1) 1669**].






                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 34939**]

Dictated By:[**First Name3 (LF) 18523**]
MEDQUIST36

D:  [**2112-11-2**]  10:11
T:  [**2112-11-2**]  10:30
JOB#:  [**Job Number 45431**]


Name:  [**Known lastname **], [**Known firstname 63**]                      Unit No:  [**Numeric Identifier 8338**]

Admission Date:  [**2112-10-13**]     Discharge Date:  [**2112-11-4**]

Date of Birth:   [**2055-10-26**]     Sex:  M

Service:  [**Doctor Last Name **]

AGE:  57-YEAR-OLD MALE.

ADDENDUM:  The patient was not discharged as planned.  On the
day of the proposed discharge, the patient continued to spike
fevers, as high as 101.7, axillary temperature.  Chest x-ray
was obtained again, which showed possibly slightly worsening
of the infiltrate in the right lower lobe.  In addition, the
patient had had increased sputum production with a change in
character, changing from yellow to green.  The patient did
not require any increase in supplemental oxygen saturation
nor did he feel febrile in the setting of his fevers.  At
this point, he was day #11 on Levofloxacin and Metronidazole.
Antibiotics were changed to Ceftazidime and Clindamycin to
broaden coverage to include Pseudomonal and Staphylococcus
coverage empirically.  He defervesced and remained afebrile,
thereafter.  The plan would be to continue the Ceftazidime
and to Clindamycin to complete another ten-day course.

DISCHARGE MEDICATIONS:
1.  Ceftazidime 1 gram IV q.8h. to end on [**2112-11-13**].
2.  Clindamycin 600 mg IV q.8h. to end on [**2112-11-13**].
3.  Fentanyl patch 75 mcg per hour q.72 hours.
4.  MSIR 10 mg to 20 mg per PEG q.4h.  The patient may refuse
dose.
5.  Dilaudid 2 mg per PEG q.4h.to 6h.p.r.n. pain.
6.  Lansoprazole 30 mg per PEG q.d.
7.  Zoloft 50 mg per PEG q.d.
8.  Klonopin 0.5 mg per PEG t.i.d.
9.  NPH insulin 30 units b.i.d.
10. Regular insulin sliding scale.
11. Colace 100 mg per PEG b.i.d.
12. Dulcolax 10 mg pr, q.d. p.r.n. constipation.
13. Compazine 10 mg per PEG q.6h.p.r.n. nausea.
14. Buspirone 15 mg per PEG b.i.d.











15. Gabapentin 600 mg per PEG b.i.d.
16. Heparin 5000 units subcutaneously q.12h.
17. Tylenol 325 mg to 650 mg q.4h. to 6h.p.r.n.
18. Zyprexa 5 mg per PEG q.h.s. p.r.n. agitation.


                          [**Name6 (MD) 511**] [**Name8 (MD) 512**], M.D.  [**MD Number(1) 513**]

Dictated By:  [**Name6 (MD) **] [**Name8 (MD) **], M.D.
MEDQUIST36
D:  [**2112-11-4**]  13:27
T:  [**2112-11-4**]  15:56
JOB#:  [**Job Number 8339**]
{'Secondary malignant neoplasm of bone and bone marrow,Pathologic fracture of vertebrae,Malignant neoplasm of other specified sites of pancreas,Pneumonitis due to inhalation of food or vomitus,Respiratory arrest,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension'}


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: This is a 56 year old man with metastatic
pancreatic carcinoma transferred to [**Hospital1 18**] for neurosurgery
for C-4 compression fracture.  On [**2112-10-24**] had respiratory
arrest.  Patient extubated on [**2112-10-24**], transferred to medical
team on [**2112-10-25**].

PRESENT ILLNESS: This is a 56 year old man with
metastatic pancreatic adenocarcinoma (with known liver
metastases) who was at [**State 1558**] [**2112-10-13**]
receiving radiation therapy session nine of 14 to an anterior
neck mass.  There he was noted to have neck drooping.  MRI
showed a large mass at C-4 (mass was initially seen on
[**2112-9-29**], but was not causing symptoms at that time).
Therefore, patient was transferred to [**Hospital1 18**] for surgery.  He
had right shoulder weakness one week prior to transfer to
[**Hospital1 18**].  He went to the operating room on [**2112-10-14**] and received
C-4 and partial C-3 vertebrectomy, C2-C5 anterior fusion with
anterior cages and screw plate fixation.  Pathology on the
spinal mass from the operation was metastatic poorly
differentiated adenocarcinoma.  Postoperatively patient
complained of difficulty swallowing.  On [**2112-10-19**] he had an
acute episode of shortness of breath.  Chest x-ray showed
patchiness at bases consistent with aspiration.  Patient did
have an episode of choking on water shortly prior.  CT of
chest was obtained which showed fatty infiltration of the
liver with multiple lesions, largest 2.7 cm, no pulmonary
embolus, bilateral consolidation in the lower lobes, severe
calcification of the coronary arteries consistent with
coronary artery disease.  Patient was sent to the surgical
intensive care unit where he was started on levofloxacin and
Flagyl on [**2112-10-20**].  On [**10-20**] a swallow study showed high
aspiration risk.  Tube feeds were recommended.  A Dobbhoff
tube was placed on [**2112-10-21**].  The tube was placed by
interventional radiology because it could not be successfully
placed on the floor.  On [**2112-10-22**] patient was transferred to
the surgical floor.  On [**2112-10-23**] he was found tachycardiac and
unresponsive with respiratory rate of 5, systolic blood
pressure in the 80s.  He was intubated.  Arterial blood gas
was 6.99/138/197.  Patient was given intravenous fluids and
transferred to the medical intensive care unit.  Antibiotics
were changed from levofloxacin to ceftazidime (for greater
gram negative coverage) and vancomycin.  He was hypernatremic
with sodium of 155.  He was started on half normal saline.
Sodium was 145 on [**2112-10-25**].  He was extubated on the morning
of [**2112-10-24**].  He recalled difficulty clearing a thick mucus
plug prior to his episode of unresponsiveness that required
intubation.  Patient pulled out his NG tube on [**2112-10-25**].
Overnight [**2112-10-24**] he was noted to be agitated and confused
and this was felt to be due to delirium and sundowning.  On
[**2112-10-25**] antibiotics were switched back to levofloxacin and
Flagyl and he was transferred to the medical floor on this
day.

MEDICAL HISTORY: Bladder cancer, transitional cell
diagnosed in [**2110**], status post BCG, status post transurethral
resection of bladder in [**2110**].  Pancreatic adenocarcinoma with
liver metastases.  He has received four cycles of 5FU and
leucovorin.  Previously he had been receiving gemcitabine,
but it was stopped because of severe edema.  Hypertension.
Type 2 diabetes.  Hypercholesterolemia.  Depression.
Anxiety.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Father died of myocardial infarction at age
39.  Mother alive at age 83.

SOCIAL HISTORY: Lives with mother in [**Name (NI) 34422**].  Has a grown
son in the area, another grown son on the west coast.
Brother and sister live in the area.  Divorced.  Quit tobacco
and alcohol 25 years ago.  Was working in the glass bottle
industry until six months ago. 

### Response:
{'Secondary malignant neoplasm of bone and bone marrow,Pathologic fracture of vertebrae,Malignant neoplasm of other specified sites of pancreas,Pneumonitis due to inhalation of food or vomitus,Respiratory arrest,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension'}
