CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 74 year old
female with past medical history of thymic cancer, status
post resection at [**Hospital6 1129**] in [**2125**];
status post chemotherapy times 18 sessions, who presented to
Dr.[**Name (NI) 1482**] office after having undergone a work-up of
her dysphagia for one month's duration. The patient found
that she was having difficulty swallowing which was
progressively worsening over the course of one month.  The
difficulty swallowing was primarily solid foods, resulting in
frequent regurgitation. The patient denies having any
hematemesis.  Over a course of six months prior to admission,
the patient reported having a 12 pound weight loss.  The
patient denied having any other symptoms such as fever,
chills, diaphoresis, chest pain; denied having other
significant pulmonary symptoms.  Despite reporting history of
chronic right sided pleural effusion, status post radiation
therapy for thymic cancer.

MEDICAL HISTORY: As noted above, significant for thymic
cancer, diagnosed in [**2125**].  Status post resection at
[**Hospital6 1129**].  Status post chemotherapy
times 18 rounds.  The patient's last follow-up at
[**Hospital6 1129**] was three years prior to
current admission.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Patient reports her mother having died of
complications of pneumonia and chronic obstructive pulmonary
disease.  Father also had emphysema and had hypertension and
died at the age of 86.  There is a questionable history of
valve replacement in her mother.

SOCIAL HISTORY: The patient reports a 10 pack year history
of cigarette smoking which she stopped in [**2124**].  The patient
denies having used any alcohol.  The patient is currently
living alone.
Malignant neoplasm of middle third of esophagus,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Unspecified pleural effusion,Bacteremia,Cardiac arrest,Urinary tract infection, site not specified,Other complications due to other vascular device, implant, and graft,Other noninfectious disorders of lymphatic channels
Mal neo middle 3rd esoph,Mal neo lymph-intrathor,Pleural effusion NOS,Bacteremia,Cardiac arrest,Urin tract infection NOS,Comp-oth vasc dev/graft,Noninfect lymph dis NEC
Admission Date:  [**2137-12-20**]       Discharge Date:  [**2138-1-18**]

Date of Birth:   [**2063-10-13**]       Sex:  F

Service:

HISTORY OF PRESENT ILLNESS:  The patient is a 74 year old
female with past medical history of thymic cancer, status
post resection at [**Hospital6 1129**] in [**2125**];
status post chemotherapy times 18 sessions, who presented to
Dr.[**Name (NI) 1482**] office after having undergone a work-up of
her dysphagia for one month's duration. The patient found
that she was having difficulty swallowing which was
progressively worsening over the course of one month.  The
difficulty swallowing was primarily solid foods, resulting in
frequent regurgitation. The patient denies having any
hematemesis.  Over a course of six months prior to admission,
the patient reported having a 12 pound weight loss.  The
patient denied having any other symptoms such as fever,
chills, diaphoresis, chest pain; denied having other
significant pulmonary symptoms.  Despite reporting history of
chronic right sided pleural effusion, status post radiation
therapy for thymic cancer.

On [**2137-11-22**], the patient presented to [**Hospital6 2121**], the place of her usual health care, and
underwent an esophagogastroduodenoscopy which showed a
"concerning lesion at the proximal esophagus."  The patient
was discharged from the [**Hospital6 **] for
referral to Dr.[**Name (NI) 1482**] office.

PAST MEDICAL HISTORY:  As noted above, significant for thymic
cancer, diagnosed in [**2125**].  Status post resection at
[**Hospital6 1129**].  Status post chemotherapy
times 18 rounds.  The patient's last follow-up at
[**Hospital6 1129**] was three years prior to
current admission.

The patient also reports a significant history of Crohn's
disease for eight years, relatively well controlled on
Asacol.  The patient has a history of hypertension and aortic
stenosis.  Last echocardiogram done at [**Hospital6 1130**] showed "moderate aortic stenosis."  The patient's
past medical history is also significant for osteoporosis,
tinnitus and history of colonic polyps seen on colonoscopy in
[**2129**].  The patient also has a history of vitiligo and a
history of seizures versus syncope, a total of two episodes,
the last episode in [**2136-5-2**], for which she was evaluated
at [**University/College 4700**].  The patient's work-up was not clear;
however, she was discharged with Dilantin as part of her
medication list.

PAST SURGICAL HISTORY:  As mentioned above, status post
thymus resection in [**2125**] for thymic cancer.  The patient also
reports lumbar fusion and surgery in [**2113**]. The patient denies
any known allergies to medications.

MEDICATIONS AT HOME:
Verapamil 120 mg p.o. q. day.
Dilantin 300 mg p.o. q. day.
Asacol 400 mg three times a day.
Fosamax 70 mg q. weekly.
Calcium.
Vitamin B-12.
Multi-vitamins.
Folate.
Atacand 32 mg p.o. q. day.

SOCIAL HISTORY:  The patient reports a 10 pack year history
of cigarette smoking which she stopped in [**2124**].  The patient
denies having used any alcohol.  The patient is currently
living alone.

FAMILY HISTORY:  Patient reports her mother having died of
complications of pneumonia and chronic obstructive pulmonary
disease.  Father also had emphysema and had hypertension and
died at the age of 86.  There is a questionable history of
valve replacement in her mother.

The patient was seen at Dr.[**Name (NI) 1482**] office and evaluated.
The patient's pathology slides from her
esophagogastroduodenoscopy on [**2137-11-22**] was diagnosed
with squamous cell carcinoma, invasive.  The slide was
reviewed by the pathology staff at [**Hospital1 190**] which concurred with the diagnosis of invasive
squamous cell carcinoma of the esophagus.

The patient underwent preoperative testing, including
pulmonary function tests.  After an extensive discussion with
Dr. [**Last Name (STitle) **] regarding the benefit and risks of surgical
intervention, the patient consented to undergo Ivor-[**Doctor Last Name **]
resection with neck anastomosis , given the irradiated
mediastinum.  This was a high risk procedure due to the prior
operation and radiation and comorbidities, but other options were
very limited.  The patient presented to the operating room on
[**2137-12-20**] with the following physical examination
findings.

PHYSICAL EXAMINATION:  The patient was afebrile. Temperature
of 97.3.  Heart rate of 108; sinus tachycardia.  Blood
pressure was 150/66.  respiratory rate of 16. Saturating 97%
on room air.  The patient was alert, oriented times three,
appearing cachectic but otherwise not in apparent distress.
HEAD, EYES, EARS, NOSE AND THROAT:  Within normal limits at
the time.  Cardiovascular examination:  Rate and rhythm were
regular with S1 and S2, in mild sinus tachycardia, with grade
III out of VI systolic ejection murmur, heard greatest in the
aortic area.  Respiratory examination:  Clear to auscultation
bilaterally, despite given history of chronic right sided
pleural effusion.

Examination of the chest showed a well healed median
sternotomy site with a small amount of scarring. Abdominal
examination was with bowel sounds, soft, nontender,
nondistended, without evidence of hepatosplenomegaly.  The
patient did not have any inguinal hernias and the rectal
examination was negative for occult blood.  Neurologically,
the patient was alert and oriented times three, with
appropriate mood and affect.  Cranial nerves were grossly
intact from 2 to 12.  There were no gross anomalies in
sensory modalities and the upper and lower extremities were
with full range of motion with bilaterally equal 5/5
strength. The patient's gait and stance was within normal
limits.

LABORATORY DATA:  The patient's preoperative laboratory
studies showed a white count of 6.3; hemoglobin of 11.7;
hematocrit of 36.2.  Platelet count of 298.  The patient's
preoperative radiologic studies showed right sided chronic
pleural effusion.  The patient presented to the operating
room on [**12-21**] and underwent Ivor-[**Doctor Last Name **] resection of the
esophageal cancer.  Please see the operative report for
specific details.

Immediately after the surgery, the patient was successful
extubate din the operating room and was transferred to the
Post Anesthesia Care Unit in stable condition.  While in the
Post Anesthesia Care Unit, on postoperative day number zero,
the patient was found to have CVP of 2; slight decrease from
the baseline of 6 to 9, and decrease in the urine output,
trailing from 100 cc per hour to 30 cc per hour.  The
patient's blood pressure remained in the 90's systolically.
The patient was assessed to be volume depleted and was given
lactated Ringers solution bolus with elevation in blood
pressure to 100 systolic.  Urine output was at 35 cc per
hour.

The patient was noted to be in respiratory distress by the
nursing staff.  The surgical and anesthesia teams were called
stat.  The patient was examined by the anesthesia resident
and was found to have a left vocal cord in paramedian
position and the right vocal cord fully extended out.  The
patient was found to have stable vital signs; however, the
patient was breathing rapidly with stridor and with
difficulty.  The patient was intubated by the anesthesia team
with 7.0 endotracheal tube, taped at 21 cm.  The patient was
given Etomidate and succylcholine prior to intubation and was
successfully intubated using MAC-3 blade.  The intubation was
confirmed with bilateral breath sounds and tidal C02 being
positive.

Chest x-ray done showed no evidence of pneumothorax or
pulmonary edema.  The patient's respiratory status was
followed with frequent physical examination and serial
arterial blood gases.  The patient was also cycled with
cardiac enzymes, to rule out myocardial events.  She ruled
out negative.  Electrocardiogram done at the time also did
not show any evidence of myocardial ischemia.  The patient
remained intubated overnight on postoperative day number zero
and on ventilatory support.  On the morning of postoperative
day number one, the patient's sedation was turned off.  The
patient awoke without any difficulty and the patient was
extubated uneventfully.  The patient was seen by the ENT team
for the finding of left vocal cord paralysis seen on
intubation the day prior.  This finding was confirmed by ENT
services.  Fiberoptic examination was done. However, it
wasn't clear whether this was a new finding after the surgery
given her prior history of thymic resection. However, on further
questioning , the patient described the finding as a known
sequela of her prior treatments, to which she had compensated
over time. The patient did relatively well through the day of
postoperative day number one. However, she was found to have
increased shortness of breath during the night of postoperative
day number one.  The patient became tachycardiac with sinus
rhythm on electrocardiogram; however, she was found to have a new
right bundle branch block.  Breath sounds were decreased
bilaterally with expiratory wheezes and the patient's
arterial blood gases worsened with base deficit of negative
three from prior value of negative one.

The patient was treated with aggressive pulmonary toilette
and was monitored very carefully.  Cardiac enzymes were being
cycled at the time and as previously noted, came back
negative with troponins less than 0.01.  With availability of
an Intensive Care Unit bed, the patient was transferred on
postoperative day number two to the surgical Intensive Care
Unit.  The patient's Intensive Care Unit stay ranged from
[**2137-12-22**] to [**2138-1-9**] and the Intensive Care Unit
course will be summarized by systems as follows:

Neurologic:  The patient's postoperative pain was initially
addressed with epidural combination of Bupivacaine and
Dilaudid; however, this was turned off with ensuing events in
the Post Anesthesia Care Unit and the patient's Dilaudid was
split off from the epidural and was administered with PCA.
Having achieved good pain control with Dilaudid PCA alone,
epidural was discontinued on [**2137-12-23**].  Otherwise,
the patient's neurologic status remained intact, without any
changes, except when the patient was sedated for respiratory
issues, to be detailed below.

Cardiovascularly, the patient remained stable throughout her
Intensive Care Unit stay. The patient was treated with low
dose intravenous Lopressor, given the nature of the surgery
and the propensity for development of atrial fibrillation
postoperatively.  The patient had occasional low grade
tachycardia which was attributed to other issues going on
during her Intensive Care Unit stay.  Otherwise,
cardiovascularly, she remained stable.  The patient did rule
out of myocardial infarction with four different troponin
levels less than 0.01.  In terms of electrocardiogram, the
patient was noted to have right bundle branch block which was
new prior to her Intensive Care Unit admission.  There was
also a left anterior fascicular block that was noted on the
previous electrocardiogram noted [**2137-12-12**].

Respiratory:  The patient's Intensive Care Unit stay involved
events and issues mostly involving her respiratory system and
is summarized below.  Prior to her Intensive Care Unit on
admission on postoperative day number two, the patient had
been reintubated in the Post Anesthesia Care Unit and then
extubated on postoperative day number one.  She had an
episode of respiratory difficultly which had resolved with
aggressive chest physical therapy.  However, on postoperative
day number three, [**12-24**], the patient was again found to
have respiratory distress.  At this time, her PC02 was found
to be rising and the patient was reintubated for her safety
with 7.0 endotracheal tube and was placed on ventilatory
support.  The patient did well on SMV support and was put on
C-Pap trial which she tolerated well on postoperative day
number five, [**12-26**], with arterial blood gases of
7.41/42/145/28/+2.  On C-Pap FI02 was 40% with pressure
support of 15 and PEEP of 5.  The patient's pressure support
was weaned down further and the patient was gently diuresed
with intravenous Lasix drip given her positive volume status
through this time on postoperative day number six, [**2137-12-26**]. Throughout that day, the patient was also given a
T-piece trial for two hours which she tolerated. Having been
weaned successfully and having tolerated T-piece trial, the
patient was extubated on postoperative day number 7, [**2137-12-27**].  However, during that day, the patient was found to
have respiratory distress with clear stridor and tachypnea.
The patient was put on increased oxygen with improvement in
saturation; however, because the patient was breathing with
much significant amount of work, the patient underwent a
direct laryngoscopy which showed the same findings as prior
with paramedian position of the left vocal cord and a
subglottic edema that was visible.  The patient was
reintubated on postoperative day number seven, [**2137-12-27**], with 7.0 endotracheal tube.  Also on [**2137-12-27**],
postoperative day number seven, the patient was noted to have
changed in the quality of her right sided chest tube with
suspicion for chylothorax.  Please see the gastrointestinal
section for the intervention pursuant to this finding.  On
[**2137-12-29**], postoperative day number nine, the patient
successfully underwent a tracheostomy at the bedside.  Please
see the operative report for further details.  The patient
received a #7 Por-Tex trach tube for failure to be weaned off
the vent and respiratory distress requiring reintubation
three times postoperatively.

On [**2137-12-30**], postoperative day number 10 and 1, the
patient's right sided chest tube fell out accidentally;
however, there were no respiratory complications resulting
from that event and there was no pneumothorax seen on the
chest x-ray.  From then on to the end of her Intensive Care
Unit stay, on [**2138-1-9**], the patient did not have any
significant respiratory issues.  The patient did experience
occasional subjective shortness of breath, associated with
tachypnea and tachycardia, which resolved with aggressive
chest physical therapy and good tracheostomy care. The
patient tolerated having trach mask and, on transfer to the
floor on [**2138-1-9**], the patient tolerated being on
trach mask, breathing spontaneously without respiratory
difficulty.

Gastrointestinal:  On [**2137-12-20**], as part of her
Ivor-[**Doctor Last Name **] procedure, the patient also received J tube
placement and postoperatively, tube feeds were started
without any problems.  On [**2137-12-27**], on postoperative
day number seven as noted above, the patient was noted to
have change in her right chest tube output and the patient
was diagnosed as having chylothorax.  The patient's tube
feeds were changed to Vivonex and the patient was started on
Somatostatin.  Despite these interventions, the patient's
chylothorax continued with increased right sided chest tube
output and thorax surgery consult was called.  The patient
was evaluated by the thoracic team and Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**].
Based on the recommendation of the thoracic surgery team, the
patient's tube feeds were discontinued and the patient was
started on total parenteral nutrition on [**2137-12-30**],
postoperative day number ten and one.  The patient continued
to be treated with Octreotide (Simvastatin).  As noted above,
also on that day, the patient's right sided chest tube
accidentally fell out; however, there was no pneumothorax
noted and the right sided chylothorax persisted with drainage
out of the former chest tube site, in excess of 700 cc per
day.

With continuing chylothorax, the patient was taken to the
operating room on [**2138-1-3**] by the thoracic surgery
team and Dr. [**Last Name (STitle) 952**] for right sided thoracoscopy with
evacuation of pleural effusion and talc pleurodesis.  Please
see the operative report for further details.  In summary,
the thoracic team tried to locate the leak of the chylus,
given that the thoracic duct was ligated in the previous
surgery on [**2137-12-20**], when the patient underwent
Ivor-[**Doctor Last Name **] resection.  However, there was no obvious point of
leakage of chyle from the surgical site and some oozing from
around the area of the aortic arch was noted. The patient
succesfully underwent a right sided VATS with evacuation of
pleural effusion and talc pleurodesis and replacement of the
right sided chest tube on [**2138-1-3**].

Postoperatively, the patient was continued on her TPN and
Octreotide and continued n.p.o.  The patient was also given
medium chain triglyceride supplement as part of her TPN.  The
right sided chest tube was kept to wall suction and the
significant right sided chest tube output was replaced cc per
cc with intravenous fluids/TPN.  On transfer out of the
Intensive Care Unit on [**2138-1-9**], the patient's right
sided chest tube continued to be relatively high but no longer
was chylous, with a very low lymphocyte count and triglyceride
level.  this seemed to be a pure lymph leak from disruption of
the multiple collaterals which had formed following her
radiation.   The patient remained n.p.o. and
was receiving TPN without fat supplement with a medium chain
triglyceride and the patient did not receive any tube feeds.

Genitourinary:  The patient's urine output was monitored with
Foley catheter and given her high right sided chest tube
output, the patient's urine output was followed carefully and
was replaced, as mentioned above, with intravenous
fluids/TPN.  There was an episode of urinary tract infection
to be described in detail under the infectious disease
section, which was treated appropriately with antibiotics and
resolved.

Hematology:  The patient was transfused one unit of PRBC on
[**2137-12-24**], postoperative day number four, for
decrease in hematocrit to 24.8.  There was no evidence of
acute bleeding.  The patient was stable.  The patient
responded after transfusion to a hematocrit of 31.6. This was
attributed mostly to aggressive fluid hydration. The patient
was transfused two units of PRBC on [**2138-1-7**] on
postoperative day number 18/9/4, when her hematocrit acutely
changed to 21 from 33.  There was no evidence of active
bleeding and no evidence of oozing from the surgical sites.
It wasn't clear where the loss of the blood volume may have
been.  The patient did have red blood cells that were noted
coming out of the pleural fluid and there were concerns that
the patient may be having hemolysis and DIC.  The patient's
laboratory values were checked and there were no indications
that the patient was having DIC or had been in septic shock.
The patient received two units of PRBC with appropriate rise
in hematocrit to 34. After that point, the patient did not
require any blood product transfusion.

On [**2138-1-7**], the patient was noted to have right upper
extremity swelling and received ultrasound of the right upper
extremity.  The patient was found to have a non occlusive
thrombus involving the right internal jugular vein, which was
the site of a previous central venous line.  The current
central venous line at that time was located in the right
subclavian vein and did not have any evidence of thrombosis.
Based on these findings, the patient was started on heparin
drip and was titrated to a PTT value between 50 to 60 and
eventually, the patient stabilized to a heparin drip with a
value between 500 to 600 units per hour.

Infectious disease:  When the patient's chylothorax was noted
on [**2138-12-28**], postoperative day number seven, the
pleural fluid was also sent off for gram stain and culture,
with positive urine culture.  Gram stain showed 3+
polymorphonuclear leukocytes and no micro organisms.  The
culture did grow out Staphylococcus coagulase negative
species and alphastreptococci; however, given that the
patient did not have any rise in white blood cell count and
did not show any evidence of infection on physical
examination, these findings were credited to be contaminants.
However, the patient did have a rise in white count on
[**1-1**], postoperative day number [**11-4**] with jump in white
count from 9 to 15.  The patient was pan cultured and her
urine was found to grow pan sensitive E. coli and
enterococcus species. The patient blood culture, also from
the same day, showed Staph coagulase negative; however, this
was considered a contaminant, given that the catheter tip was
negative.  The pleural fluid was recultured on [**2138-1-2**], which showed pan sensitive enterococcus, staph
coagulase negative species and bacterium species as well as a
probable micrococcus species.  Also, by this time, the urine
culture from [**1-1**], came back with E. coli and
Enterococcus and the patient was started on intravenous
Levaquin and intravenous Vancomycin.  After the patient
underwent left sided video thoracoscopy on [**2138-1-3**],
the patient continued on Vancomycin and Levaquin.  The
patient received a full course treatment of Levaquin for her
urinary tract infection and continued on her Vancomycin
through her stay in Intensive Care Unit.

Her white blood cell count continued to rise with peak value
of 22.5 cells per cc and on discharge from Intensive Care
Unit, was still at 16.8.  During those times, the patient did
not have any fevers and did not exhibit any signs of sepsis.
Repeat cultures done after [**1-2**] were negative for any
micro organisms with negative blood cultures on [**1-3**],
[**1-5**] and negative catheter tip culture on [**1-5**] as
well.  The patient's urine was negative for microorganisms on
[**1-5**] and despite negative cultures, the patient
continued to have elevated white count of 16 on discharge
from Intensive Care Unit.

With the patient having been stable for some time, without
further respiratory issues after her tracheostomy, was
transferred out of the Intensive Care Unit on [**2138-1-9**]. Because the patient's right sided chest tube output
continued to remain relatively high, despite having undergone
talc pleurodesis on [**2138-1-3**], the thoracic surgery
team performed a bedside talc pleurodesis on [**2138-1-9**].
However, the second talc pleurodesis was not effective and
the patient continued to have relatively high chest tube
output.  The patient's right sided chest tube output was
matched cc per cc by intravenous fluids/total parenteral
nutrition and the patient was maintained relatively euvolemic
with only minimal pedal edema on physical examination.

Soon after her transfer out of the unit, on postoperative day
number 20/11/6, [**2138-1-9**], the patient's pleural fluid
was reanalyzed and the patient was found to be losing
approximately 10 grams of protein in her pleural fluid.  The
TPN was adjusted so that the patient will be receiving an
additional 10 grams of amino acid in her TPN.  On the floor,
the patient continued on her intravenous Vancomycin that she
had started on [**2138-1-1**].  She was found to have some
tachycardia on [**2138-12-12**] without evidence of
respiratory distress.  Chest x-ray was checked, which showed
a right sided pleural effusion, which was not dramatically
different from previous chest x-rays done in the Intensive
Care Unit.  The patient's chest tube output had also cleared
up with clear yellow color and quality and it was suspected
that the patient's chylothorax was resolving despite
relatively high output by the chest tube.  The patient's
pleural fluid triglyceride was rechecked with level of 17 on
transfer out from the Intensive Care Unit, which was
significantly decreased from the finding of 627 on [**2137-12-27**].  Based on these findings, the patient was restarted
on her tube feeds, which was 2/3 strength Impact with 5 to 10
cc per hour.  The patient continued on these tube feeds.
Because her levels had only increased mildly to 76 despite
having been on tube feeds, she was slowly advanced.

As mentioned above, the patient was noted to be tachycardia
in 110's despite any respiratory distress.  The patient was
cultured and was found to have a positive urine culture
growing out yeast.  The patient was started on Fluconazole.
The patient also was started on Levaquin on [**2138-1-12**]
for suspicion of aspiration pneumonia.  The gram stain
initially showed 3+ gram negative rods; 1+ gram positive
cocci in pairs and 1+ gram positive rods; however, the final
culture only grew out sparse oropharyngeal flora.  Through
these times, the patient was also noted to have increase in
her white count to 21,000. The patient was continued on her
Vancomycin, Levaquin and Fluconazole.  Repeat urine culture
on [**1-15**] showed a 10 to 100,000 organisms per cc of
yeast as well as sputum culture which showed rare growth of
yeast.  However, preliminary fungal culture did not isolate
any fungus.  Mycotic and fungal blood cultures were done on
[**1-15**] and these cultures were no growth to date, on the
day of expiration of the patient and were also no growth to
date on day of dictation.

It should be noted that the patient's central venous line was
changed on [**2138-1-14**], over a guide wire and the
catheter tip was sent for culture; however.   On
[**2138-1-15**], postoperative day number 27/17/12, the
chest tube was discontinued by the thoracic surgery team.
The patient was found to have leakage of clear, serous,
pleural fluid around the former chest tube site; however, the
patient remained afebrile with vital signs stable with very
mild tachycardia.  The patient was not in apparent distress
at the time. With good oxygen saturations, with 100% on
tracheostomy mask at 35% oxygen.

Given the patient's persistent elevated white count, despite
being on Vancomycin, Levaquin and Fluconazole, other source
of infection were investigated.  The patient would
occasionally complain of right sided chest/right upper
quadrant pain, which were considered to be pleuritic in
origin given her chest tube there which was recently
discontinued.  However, given the elevated white count, the
patient did receive a right upper quadrant ultrasound to rule
out any gallbladder disease and she did not have any evidence
of cholecystitis.

The infectious disease consult was called for rocommendations
and their findings were to continue with Vancomycin and to
discontinue the Levaquin and Fluconazole.  They also
recommended reculturing the right pleural fluid, if it could
be done sterilely.  The WBC in the pleural fluid was very
low,  however. Also, there were questions as to a fluid
collection seen next to the esophagus.  The infectious
disease service was questioning a potential source of
infection; however, the surgical team, based on the operative
findings, did not find this to be a potential source of
infection.  The infectious disease service also recommended
ruling out for Clostridium difficile colitis, despite no
evidence of abdominal pain or distention and this was
started.

On the evening of [**2138-1-17**], postoperative day number
29/19/14, the thoracic surgery team came by around 6 p.m. and
because the former chest tube site was leaking a good amount
of pleural fluid, the area was stitched as per instructions
of Dr. [**Last Name (STitle) 952**].  Also, the trach collar was changed to #4
cuffless by the thoracic team.  The patient was found to be
breathing comfortably with oxygen saturation remaining over
97% on two liters nasal cannula.  The patient was also given
a Passe-mural valve for trial, which she tolerated without
any problems.  The valve was removed by the nursing staff
prior to sleep; tracheostomy mask was replaced on the patient
with 35% oxygen, with saturations greater than 97%.  As per
patient's request, the patient was suctioned three times and
was found to have minimal secretions.  Trach mask was
replaced on the patient's trach and she stated that she felt
"better."  The patient received her usual doses of
intravenous Dilaudid with good relief of pain.  Her last
recorded temperature was 95.6 degrees F at 9 p.m. and was
noted to have oxygen saturation of 97%.  The last recorded
blood pressure was 146/60 at 7 p.m. with heart rate of 99 and
regular, and respiratory rate of 22, saturating 97%. Last
recorded finger stick was 141 at 9 p.m.

Early in the morning of [**2138-1-18**], the patient was
found by nursing staff to be unresponsive during early
morning rounds for vitals check.  At that time, the patient
was cyanotic without heart rate, apneic and without blood
pressure.  ACLS protocol was initiated at 3:40 a.m. and
hospital wide code blue was called promptly. The surgical
staff, including the chief resident responded promptly. The
patient's trach tube was bagged with Ambu-bag and the patient
was respirated.  Chest compressions were started.  Automatic
external defibrillator was applied. The patient was found to
be in asystole.  The patient was given an amp of Atropine and
an amp of epinephrine with continued ventilation and chest
compression.  No shock was applied.  Right sided chest tube
was reinserted at 3:52 a.m.  The patient received additional
amp of Atropine and epinephrine and received another dose of
Atropine and epinephrine.  Despite these efforts, the patient
did not have any cardiac rhythm and the patient was
pronounced dead at 3:58 a.m.

Dr. [**Last Name (STitle) **], the attending surgeon, notified the family of
the patient's death.  The family refused post mortem
examination.




                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]

Dictated By:[**Last Name (NamePattern1) 10201**]
MEDQUIST36

D:  [**2138-2-26**]  08:41
T:  [**2138-1-27**]  05:11
JOB#:  [**Job Number 53445**]
{'Malignant neoplasm of middle third of esophagus,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Unspecified pleural effusion,Bacteremia,Cardiac arrest,Urinary tract infection, site not specified,Other complications due to other vascular device, implant, and graft,Other noninfectious disorders of lymphatic channels'}


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: 

PRESENT ILLNESS: The patient is a 74 year old
female with past medical history of thymic cancer, status
post resection at [**Hospital6 1129**] in [**2125**];
status post chemotherapy times 18 sessions, who presented to
Dr.[**Name (NI) 1482**] office after having undergone a work-up of
her dysphagia for one month's duration. The patient found
that she was having difficulty swallowing which was
progressively worsening over the course of one month.  The
difficulty swallowing was primarily solid foods, resulting in
frequent regurgitation. The patient denies having any
hematemesis.  Over a course of six months prior to admission,
the patient reported having a 12 pound weight loss.  The
patient denied having any other symptoms such as fever,
chills, diaphoresis, chest pain; denied having other
significant pulmonary symptoms.  Despite reporting history of
chronic right sided pleural effusion, status post radiation
therapy for thymic cancer.

MEDICAL HISTORY: As noted above, significant for thymic
cancer, diagnosed in [**2125**].  Status post resection at
[**Hospital6 1129**].  Status post chemotherapy
times 18 rounds.  The patient's last follow-up at
[**Hospital6 1129**] was three years prior to
current admission.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Patient reports her mother having died of
complications of pneumonia and chronic obstructive pulmonary
disease.  Father also had emphysema and had hypertension and
died at the age of 86.  There is a questionable history of
valve replacement in her mother.

SOCIAL HISTORY: The patient reports a 10 pack year history
of cigarette smoking which she stopped in [**2124**].  The patient
denies having used any alcohol.  The patient is currently
living alone. 

### Response:
{'Malignant neoplasm of middle third of esophagus,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Unspecified pleural effusion,Bacteremia,Cardiac arrest,Urinary tract infection, site not specified,Other complications due to other vascular device, implant, and graft,Other noninfectious disorders of lymphatic channels'}
