CHIEF COMPLAINT: Hypotension, shortness of breath

PRESENT ILLNESS: 50-year-old woman with adenoid cystic carcinoma s/p left
pneumonectomy with metastasis to liver, kidney. Carboplatin
[**8-19**]. presented for follow up today at Heme-onc when patient
complained of chest pain [**5-4**]. 3 PM pale, diaphoretic BP
60/palp. P 145-150. 02 sat waxing [**Doctor Last Name 688**] 80-90% RA. 4 L NC
placed. Referred to the ED from outpatient chemotherapy session
due to shortness of breath, chest pain, low O2 sats, tachycardia
and hypotension.
.
In the ED her vital signs were: T 100.9, HR 140s, BP 99/58, RR
20, O2 sat 98% on 2L NC. EKG showed sinus tachycardia with ?
<1mm ST segment elevation, otherwise no ST-T segment
abnormalities. She was given approx 2L NS, Cefepime 2gm IV, and
Tylenol. She [**Doctor Last Name 1834**] CTA which showed no evidence of PE, but
did show new bilateral right upper and lower lobe opacities.
.
She was initially diagnosed with adenoid cystic carcinoma in [**Month (only) 116**]
[**2102**] after presenting for an eight-month history of cough. Chest
CAT scan showed left lower lobe collapse and mediastinal
enlargement encroaching on the left mainstem bronchus. She was
evaluated by Dr. [**Last Name (STitle) **] who performed an exploration with
bronchoscopy in early [**2103-3-26**]. This showed that the mainstem
bronchus was involved and obstructed by mass. Left pneumonectomy
was performed and path consistent with adenoid cystic carcinoma.
She received postoperative radiation. Discussion of palliative
care, decision to attempt chemotherpay. Chemo as stated below
with worsening mets as apparent by CT scan, last carboplatin
[**8-19**].
.
ROS:
(+) fever, chills, nausea, 75 pound weight loss over several yrs
since diagnosis. Decreased PO intake x 1 wk since chemotherapy.
No diarrhea, chest pain at this time. Improved shortness of
breath.

MEDICAL HISTORY: Oncological History:
Initially diagnosed with adenoid cystic carcinoma in 5/00 after
presenting with eight-month history of cough. Chest CT showed
left lower lobe collapse and mediastinal enlargement encroaching
on the left mainstem bronchus. Bronchoscopy at that time showed
that the mainstem bronchus was involved and obstructed by mass.
Left pneumonectomy was performed and pathology demonstrated a 6
x 5.5-cm adenoid cystic carcinoma. It had invaded the visceral
pleura and had perineural invasion. The 3 lobar nodes were
involved. The bronchial margin was positive. In 06/00, she
[**Month/Year (2) 1834**] a carinal resection. Pathology demonstrated a
microscopic focus of residual adenoid cystic carcinoma in a
bronchial wall in the submucosal area.

MEDICATION ON ADMISSION: Meds as per pt:
Pt unaware of doses
Zofran q8 hrs
Prilosec
Oxycodone q 6 hrs
Neurontin TID
Megace [**Hospital1 **]
fentanyl patch
Decadron QD as per steroid taper
.
Meds ([**3-31**]) note:
COMPAZINE 10 mg po q8h prn nausea
COUMADIN po daily as directed (held since [**8-22**] for elevated INR)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 99.2 BP 94/67 HR 111 RR 17 O2 100%
Gen: Cachectic, chronically ill-appearing woman
HEENT: MMD. non elevated JVP. OP clear.
Neck: supple. no neck stiffness
Heart: tachycardic, regular rate and rhythm
Lungs: Absent left side, clear apically right. Sparse crackles
left base
Abd: soft, non tender, non distended, + BS
Extrem: No edema, cyanosis of clubbing
Neuro: alert oriented x 3. Strenght [**2-27**] throughout. Warm well
perfused. No echymoses or other lesions noted.

FAMILY HISTORY: Her mother is alive and healthy at age 68. Her
father died at age 80 from a stroke and heart attack. She has 5

SOCIAL HISTORY: She does not smoke cigarettes or drink alcohol.
She moved from [**Country 3594**] to [**State 350**] in [**2091**]. She has a
daughter who lives in [**Name (NI) 17065**]. She also has a brother and
sister who live in the Greater [**Name (NI) 86**] area. She denies  tobacco
or alcohol use and is currently not working. In the  past, she
has worked in a bakery.
Pneumonitis due to inhalation of food or vomitus,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of posterior wall of nasopharynx,Stricture and stenosis of esophagus,Unilateral paralysis of vocal cords or larynx, partial,Dehydration,Hypotension, unspecified,Cerebral thrombosis without mention of cerebral infarction,Anemia, unspecified,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants
Food/vomit pneumonitis,Second malig neo liver,Secondary malig neo bone,Mal neo post nasopharynx,Esophageal stricture,Vocal paral unilat part,Dehydration,Hypotension NOS,Crbl thrmbs wo infrct,Anemia NOS,Hx-ven thrombosis/embols,Long-term use anticoagul
Admission Date:  [**2110-8-26**]              Discharge Date:   [**2110-9-1**]

Date of Birth:  [**2060-5-13**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
Hypotension, shortness of breath

Major Surgical or Invasive Procedure:
Video swallow study.


History of Present Illness:
 50-year-old woman with adenoid cystic carcinoma s/p left
pneumonectomy with metastasis to liver, kidney. Carboplatin
[**8-19**]. presented for follow up today at Heme-onc when patient
complained of chest pain [**5-4**]. 3 PM pale, diaphoretic BP
60/palp. P 145-150. 02 sat waxing [**Doctor Last Name 688**] 80-90% RA. 4 L NC
placed. Referred to the ED from outpatient chemotherapy session
due to shortness of breath, chest pain, low O2 sats, tachycardia
and hypotension.
.
In the ED her vital signs were: T 100.9, HR 140s, BP 99/58, RR
20, O2 sat 98% on 2L NC. EKG showed sinus tachycardia with ?
<1mm ST segment elevation, otherwise no ST-T segment
abnormalities. She was given approx 2L NS, Cefepime 2gm IV, and
Tylenol. She [**Doctor Last Name 1834**] CTA which showed no evidence of PE, but
did show new bilateral right upper and lower lobe opacities.
.
She was initially diagnosed with adenoid cystic carcinoma in [**Month (only) 116**]
[**2102**] after presenting for an eight-month history of cough. Chest
CAT scan showed left lower lobe collapse and mediastinal
enlargement encroaching on the left mainstem bronchus. She was
evaluated by Dr. [**Last Name (STitle) **] who performed an exploration with
bronchoscopy in early [**2103-3-26**]. This showed that the mainstem
bronchus was involved and obstructed by mass. Left pneumonectomy
was performed and path consistent with adenoid cystic carcinoma.
She received postoperative radiation. Discussion of palliative
care, decision to attempt chemotherpay. Chemo as stated below
with worsening mets as apparent by CT scan, last carboplatin
[**8-19**].
.
ROS:
(+) fever, chills, nausea, 75 pound weight loss over several yrs
since diagnosis. Decreased PO intake x 1 wk since chemotherapy.
No diarrhea, chest pain at this time. Improved shortness of
breath.


Past Medical History:
Oncological History:
Initially diagnosed with adenoid cystic carcinoma in 5/00 after
presenting with eight-month history of cough. Chest CT showed
left lower lobe collapse and mediastinal enlargement encroaching
on the left mainstem bronchus. Bronchoscopy at that time showed
that the mainstem bronchus was involved and obstructed by mass.
Left pneumonectomy was performed and pathology demonstrated a 6
x 5.5-cm adenoid cystic carcinoma. It had invaded the visceral
pleura and had perineural invasion. The 3 lobar nodes were
involved. The bronchial margin was positive. In 06/00, she
[**Month/Year (2) 1834**] a carinal resection. Pathology demonstrated a
microscopic focus of residual adenoid cystic carcinoma in a
bronchial wall in the submucosal area.

She received postoperative radiation. A CT scan in [**2105-2-23**]
showed no evidence of recurrence and a bronchoscopy at that time
was unremarkable. In [**2106-2-23**], she presented with some weight

loss, fatigue, and pain. CAT scan showed increased soft tissue
thickening in the left pneumonectomy site especially near the
diaphragm. On [**2106-8-5**] follow up CT scan showed increased soft
tissue throughout in the pneumonectomy cavity, especially in the
apex and medially adjacent to the descending aorta. A liver
hemangioma was identified.

Ms. [**Known lastname 14502**] [**Last Name (Titles) 1834**] a biopsy of the pleural thickening
([**2106-10-13**]). Pathology showed adenocarcinoma in fibrous tissue.
The pathology was compared to her primary resection from [**3-/2103**]
and felt to be consistent with her primary tumor.

She then [**Month/Year (2) 1834**] chemotherapy with Taxotere. Repeat CT after
therapy showed recurrent adenoid cystic carcinoma of the
trachea, now involving the lungs, pleura, and liver. She was
then started on regimen of doxorubicin and cisplatin for goal of
4 cycles. 2 cycles of carboplatin/taxol for stabilization of
liver lesions. In [**1-28**], she developed left arm pain and
weakness with tenderness along the medial aspect of the
extremity.  Spinal MRI was negative, but brachial plexus MRI
showed tumor in the left paraspinal region from T2-T5.

Most recently, from [**2109-2-23**] until [**2109-4-25**] she received four
cycles of dose-reduced cisplatin and Navelbine with stable
disease radiographically, but resolution of arm pain and
improvement in arm strength. CT torso from [**2109-9-19**] showed
progression in the liver and kidney, and she was started on
gemcitabine on [**2109-10-8**]. Her schedule has been changed to
three week cycles with gemcitabine given on days 1 and 8.

-low-dose Taxotere in [**11-28**]
-four cycles of cisplatin and Adriamycin from [**10-28**] to [**12-30**]
with initial radiographic improvement, but a CT scan in [**9-29**]
revealed progression in the lungs and liver.
-Two cycles of carboplatin and Taxol were given ([**9-29**]) with
stabilization of her liver lesions but continued progression in
the left lung
- four cycles of dose-reduced cisplatin and Navelbine
([**Date range (1) 31896**])
- Gemcitabine ([**2109-10-8**]); limited by progressive myelosuppresion
- Carboplatin in [**7-/2110**]
.
PAST MEDICAL HISTORY:
Adenoid cystic carcinoma as above.
Paralyzed left true vocal cord with hoarseness.
GERD
s/p left pneumonectomy

Social History:
She does not smoke cigarettes or drink alcohol.
She moved from [**Country 3594**] to [**State 350**] in [**2091**]. She has a
daughter who lives in [**Name (NI) 17065**]. She also has a brother and
sister who live in the Greater [**Name (NI) 86**] area. She denies  tobacco
or alcohol use and is currently not working. In the  past, she
has worked in a bakery.


Family History:
Her mother is alive and healthy at age 68. Her
father died at age 80 from a stroke and heart attack. She has 5

sisters and 2 brothers, and some of them have hypertension,
hypercholesterolemia, and diabetes. She has 6 daughters and a
son; they are all healthy.

Physical Exam:
VS: T 99.2 BP 94/67 HR 111 RR 17 O2 100%
Gen: Cachectic, chronically ill-appearing woman
HEENT: MMD. non elevated JVP. OP clear.
Neck: supple. no neck stiffness
Heart: tachycardic, regular rate and rhythm
Lungs: Absent left side, clear apically right. Sparse crackles
left base
Abd: soft, non tender, non distended, + BS
Extrem: No edema, cyanosis of clubbing
Neuro: alert oriented x 3. Strenght [**2-27**] throughout. Warm well
perfused. No echymoses or other lesions noted.


Pertinent Results:
136 105 12 73 AGap=11
3.2 23 0.5
CK: 30 MB: Pnd Trop-T: Pnd
Source: Line-portacath
80
7.8 10.1 D 215

28.6 D
Comments: Hgb: Verified
Source: [**Name (NI) 31897**]
PT: 28.8 PTT: 48.8 INR: 3.0
.
Lactate: 2.4
.
Na 136, K 4.5, Cl 92, HCO3 25, BUN 17, Creat 0.9, Mg 1.5, Phos
5.8
WBC 9.9, Hgb 14.8, HCT 43.5, Plt 339, Gran-CT 8900
.
PT: 19.3, INR 1.8
CK 34, MB 3, Trop-T<0.01
.
Blood cx pending
.
Studies:
CXR ([**8-26**]):Changes from prior left-sided pneumonectomy with
calcification along the remaining cystic cavity within the left
hemithorax is unchanged when compared to [**2110-4-1**]. A right
subclavian CVL tip within the mid SVC is unchanged. There is
scarring at the right lung apex with post-surgical changes
within the mid right lung. There is no definite pleural effusion
or focal pulmonary opacity. Shift of the mediastinum to the left
is stable.
IMPRESSION: Stable post-surgical changes involving the left
hemithorax. No acute cardiopulmonary process identified within
the right lung.
.
CTA CHEST ([**8-26**]): No filling defects in the pulmonary arteries
to suggest pulmonary embolism. The patient is status post left
pneumonectomy. There is no significant change in appearance of
fluid filling the left hemithorax with peripheral
calcifications. There is no pericardial effusion.
There has been interval development of multiple patchy alveolar
opacities throughout most of the right upper and lower lobe,
most consistent with appearance of pneumonia. Again seen is a
right lower lobe pleural-based mass, measuring 2.1 cm,
essentially stable in size compared to the previous examination.

The appearance of the right apical, paramediastinal and right
middle lobe linear densities suggestive of scar/radiation change
is stable.
Limited evaluation of upper abdominal organs demonstrates
incompletely imaged hepatic lesions.
BONE WINDOWS: There is no significant change in appearance of
multiple sclerotic lesions in thoracic spine as well as a
deformity of the left hemithorax secondary to pneumonectomy.
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Interval development of right upper and lower lobe patchy
alveolar opacities, most consistent with pneumonia.
3. Essentially unchanged size and appearance of right lower lobe

pleural-based pulmonary nodule.
.
MRI Head [**2110-8-29**]:
MPRESSION:
1.  No evidence of acute infarction.
2.  No enhancing lesions within the brain parenchyma to suggest
metastases.
3.  Improved appearance of the vein of Trolard, and evolution of
the
previously described right frontal hemorrhage.  The status of
the superior
sagittal sinus is not delineated on this non-MRV exam, in the
area of
attenuation seen on [**2109-12-9**].  The posterior portion of
the superior
sagittal sinus demonstrates a normal flow void.
.
Video Swallow Study [**2110-8-29**]:
FINDINGS:  The oral phase demonstrated mildly impaired bolus
formation and
bolus control.  There was mild-to-moderate premature spillover
into the
piriform sinuses with thin liquids via spoon and cup in mixed
consistencies.

The pharyngeal phase was within the normal limits.  Minimal
residue in the
vallecula and piriform sinuses was seen.

Mild aspiration of occurred with cup sips of thin liquids before
swallow with
her head held in the neutral position.  Mild penetration was
also seen with
thin liquids during swallow.  A 13 mm barium pill was
administered with holdup
at the distal esophagus.

Mild-to-moderate oropharyngeal dysphagia with moderately
impaired bolus
control for thin liquids with mild-to-moderate premature
spillover into the
piriform sinuses with all thin liquids with the head in neutral
position.  The
barium pill was held up at the level of the distal esophagus.

Brief Hospital Course:
Patient is a 50 year old female with metastatic adenoid cystic
lung cancer who presented with shortness of breath, tachycardia
and hypotension found to have new right upper and lower lung
opacities suspicious for pneumonia.
.
#) Shortness of breath: Findings on imaging studies
demonstrating abnormalities in right upper and lower lobes are
most suspicious for community acquired pneumonia. On history and
exam, there was no evidence of fluid overload. Initially there
was no history aspiration, as she had nausea with no vomiting
after chemotherapy, however speech and swallow studies
demonstrated aspiration, so she was also treated for an
aspiration pneumonia. Patient was not currently not neutropenic,
though CT scan with possible spreading of metastasis. She had no
recent hospitalizations to suggest other causes of pneumonia.
- Patient's shortness of breath resolved during her stay, and
nasal cannula oxygen was weaned.
- She was initially treated with Cefepime and Vancomycin, then
switched over to levofloxacin and flagyl, and eventually
switched to oral antibiotics at time of discharge.
- Nebulized bronchodilators were also used to help clear
secretions.
.
#) Hypotension: Initially there was concern for sepsis, however,
the patient's blood pressure stabilized in response to fluid
boluses.
- It was felt that the patient's baseline blood pressure was on
the lower side, with systolic in the mid 80s to low 100's, and
she was mentating well without any evidence of end organ damage.
- Patient was encouraged to drink plenty of fluids.
.
#) History pulmonary embolism and cerebral vein thrombosis:
Patient has been on Coumadin for antiocoagulation, which was
recently held due to supratherapeutic INR. Her INR remained
elevated during much of her stay, and her Coumadin was initially
restarted, however held due to high levels, likely due to
concurrent antibiotic use.
- At her follow up appointment just after discharge, her INR was
to be re-checked, and Coumadin re-started as necessary. Prior to
admission, she had been taking alternating 2 and 3 mg doses.
.
#) Adenoid cystic carcinoma: See detailed history above. Patient
recently completed course of carboplatin on [**2110-8-19**]. She has
received chemotherapy, surgical resection and radiation, however
continues to have spread of disease. Currently full code
- Supportive care was continued, and follow-up with oncology
clinic was arranged for just after discharge.
.
#) Chest pain: Her chest pain was chronic and pleuritic in
nature. The patient described it as dull, and has been present
intermittently since development of her malignancy and sugeries.
Her EKG demonstrated ST segment changes, however her cardiac
enzymes were followed and remained within normal limits.
- She continued on her home dose of Fentanyl for pain control,
along with oral morphine and neurontin.
.
#) Tachycardia: Patient has had history of baseline tachycardia,
with heart range in 120's. Her increased heart rate was likely
in part due to infection, further complicated by component of
hypovolemia, and reflexive given hypotension. She had no
evidence of pulmonary embolism.
- Patient's tachycardia improved with fluid resuscitation and
treatment of her infection, and was in the 90's-110's range at
time of discharge.
.
#) GERD: She continued on a proton pump inhibitor.
.
#) Dysphagia/Poor PO intake: Patient related that she has had
continued difficulty eating and swallowing, and has been eating
primarily softs and fluids. Her main difficulty remains a poor
appetite which she felt was the primary reason she has not been
eating very much.
- Restarted megace for assistance with appetite, discontinued
dexamethasone as no longer had nausea.
- Speech and swallow evaluated the patient and assisted with
evaluating her dysphagia. She had previously been worked up with
EGD, which demomstrated extrinsic stricture. Final video swallow
results demonstrated signs of aspiration-- recommendations made
to crush pills and have pt tuck chin while eating to avoid
aspiration.
- MRI did not demonstrate any central process responsible for
dysphagia.
- Gastroenterology consulted to evaluate and assist with
coordinating outpatient EGD with possible esophageal stent
placement for her dysphagia and aspiration. Follow up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for evaluation and possible placement of a stent to
help was in process of being set up at time of discharge, and
the gastroenterology service was to contact the patient.
.
#) Prophylaxis: Patient received proton pump inhibitor,
initially subcutaneous heparin (which was held due to elevated
coagulation studies, which resolved with d/c of heparin), and a
bowel regimen.
.

#) Code Status: Full, patient confirmed her wishes for full code
status during stay via interpreter.
.


Medications on Admission:
Meds as per pt:
Pt unaware of doses
Zofran q8 hrs
Prilosec
Oxycodone q 6 hrs
Neurontin TID
Megace [**Hospital1 **]
fentanyl patch
Decadron QD as per steroid taper
.
Meds ([**3-31**]) note:
COMPAZINE 10 mg po q8h prn nausea
COUMADIN po daily as directed (held since [**8-22**] for elevated INR)

EMEND [**Medical Record Number 31898**] mg (taken on days 1,2,3 of chemotherapy)
FENTANYL 225 mcg/hour q72 hours
Megace Oral 400 mg/10 mL--10 ml po daily
NEURONTIN 300mg po tid
OXYCODONE 5 mg - 1 to 2 tabs q6hr prn
PRILOSEC 20mg po daily
ZOFRAN 8 mg po q8h prn
DECADRON 4 mg po daily


Discharge Medications:
1. Fentanyl 100 mcg/hr Patch 72 hr [**Medical Record Number **]: Two (2)  Transdermal
Q72H (every 72 hours).
Disp:*10 patches* Refills:*2*
2. Megestrol 40 mg/mL Suspension [**Medical Record Number **]: One (1)  PO DAILY (Daily).
Disp:*1 bottle* Refills:*2*
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
4. Gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: One (1)  PO TID (3 times
a day).
Disp:*1 bottle* Refills:*2*
5. Morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: One (1)  PO q4-6 hours PRN
as needed for pain.
Disp:*1 bottle* Refills:*0*
6. Augmentin 250-62.5 mg/5 mL Suspension for Reconstitution [**Last Name (STitle) **]:
Ten (10) ml PO every eight (8) hours for 4 days.
Disp:*1 bottle* Refills:*0*
7. Fentanyl 25 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1)  Transdermal
every seventy-two (72) hours.
Disp:*10 patches* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Caregroup VNA

Discharge Diagnosis:
Primary Diagnosis:
- Pneumonia
Secondary Diagnoses:
- Cystic Adenoid Carcinoma
- GERD
- Vocal cord paralysis
- History of pulmonary emboli
- Cerebral vein thrombosis


Discharge Condition:
Stable, ambulating at baseline without assistance.


Discharge Instructions:
You were admitted due to shortness of breath, low blood
pressure, and fever. It was thought that these were all due to a
pneumonia that was seen on the CT scan. You were given
antibiotics and intravenous fluids to treat the infection and
replete your fluids to improve your blood pressure. Your blood
pressure remained stable, and your fevers resolved. While you
were hospitalized, the speech and swallow pathologists also
further evaluated your difficulty with eating, along with the
gastroenterologists. You will need follow up care in the
gastroenterology clinic to evaluate if a stent in your esophagus
would be of benefit.
.
Please contact your oncologist or primary care physician, [**Name10 (NameIs) **] go
to the emergency room, if you experience fever, chills, new or
worsening chest pain, difficulty breathing, abdominal pain,
nausea, vomiting, or other concerning symptoms.
.
You should not take your Comadin until further instructed, due
to a high level noted while hospitalized. You may be instructed
to take an injected medication called Lovenox at your follow
appointment with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **].

Followup Instructions:
Please follow up at the appointments made for you as noted
below:
-Oncology:
You have an appointment with Drs. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] on [**9-3**] at 12:30 pm. The number for the clinic
is [**Telephone/Fax (1) 22**]. You also have an appointment with [**Name6 (MD) **]
[**Name8 (MD) **], RN on [**9-3**] at 1:30 pm.
.
-Gastroenterology:
You will need to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for evaluation
and possible placement of a stent to help improve your ability
to eat and swallow. He has been contact[**Name (NI) **] about your case, and
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] [**Name5 (PTitle) **] assist with getting this further
evaluated.
.
You will need to have your INR (Coumadin level) checked on
Wednesday [**2110-9-3**].


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
{'Pneumonitis due to inhalation of food or vomitus,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of posterior wall of nasopharynx,Stricture and stenosis of esophagus,Unilateral paralysis of vocal cords or larynx, partial,Dehydration,Hypotension, unspecified,Cerebral thrombosis without mention of cerebral infarction,Anemia, unspecified,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants'}


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: Hypotension, shortness of breath

PRESENT ILLNESS: 50-year-old woman with adenoid cystic carcinoma s/p left
pneumonectomy with metastasis to liver, kidney. Carboplatin
[**8-19**]. presented for follow up today at Heme-onc when patient
complained of chest pain [**5-4**]. 3 PM pale, diaphoretic BP
60/palp. P 145-150. 02 sat waxing [**Doctor Last Name 688**] 80-90% RA. 4 L NC
placed. Referred to the ED from outpatient chemotherapy session
due to shortness of breath, chest pain, low O2 sats, tachycardia
and hypotension.
.
In the ED her vital signs were: T 100.9, HR 140s, BP 99/58, RR
20, O2 sat 98% on 2L NC. EKG showed sinus tachycardia with ?
<1mm ST segment elevation, otherwise no ST-T segment
abnormalities. She was given approx 2L NS, Cefepime 2gm IV, and
Tylenol. She [**Doctor Last Name 1834**] CTA which showed no evidence of PE, but
did show new bilateral right upper and lower lobe opacities.
.
She was initially diagnosed with adenoid cystic carcinoma in [**Month (only) 116**]
[**2102**] after presenting for an eight-month history of cough. Chest
CAT scan showed left lower lobe collapse and mediastinal
enlargement encroaching on the left mainstem bronchus. She was
evaluated by Dr. [**Last Name (STitle) **] who performed an exploration with
bronchoscopy in early [**2103-3-26**]. This showed that the mainstem
bronchus was involved and obstructed by mass. Left pneumonectomy
was performed and path consistent with adenoid cystic carcinoma.
She received postoperative radiation. Discussion of palliative
care, decision to attempt chemotherpay. Chemo as stated below
with worsening mets as apparent by CT scan, last carboplatin
[**8-19**].
.
ROS:
(+) fever, chills, nausea, 75 pound weight loss over several yrs
since diagnosis. Decreased PO intake x 1 wk since chemotherapy.
No diarrhea, chest pain at this time. Improved shortness of
breath.

MEDICAL HISTORY: Oncological History:
Initially diagnosed with adenoid cystic carcinoma in 5/00 after
presenting with eight-month history of cough. Chest CT showed
left lower lobe collapse and mediastinal enlargement encroaching
on the left mainstem bronchus. Bronchoscopy at that time showed
that the mainstem bronchus was involved and obstructed by mass.
Left pneumonectomy was performed and pathology demonstrated a 6
x 5.5-cm adenoid cystic carcinoma. It had invaded the visceral
pleura and had perineural invasion. The 3 lobar nodes were
involved. The bronchial margin was positive. In 06/00, she
[**Month/Year (2) 1834**] a carinal resection. Pathology demonstrated a
microscopic focus of residual adenoid cystic carcinoma in a
bronchial wall in the submucosal area.

MEDICATION ON ADMISSION: Meds as per pt:
Pt unaware of doses
Zofran q8 hrs
Prilosec
Oxycodone q 6 hrs
Neurontin TID
Megace [**Hospital1 **]
fentanyl patch
Decadron QD as per steroid taper
.
Meds ([**3-31**]) note:
COMPAZINE 10 mg po q8h prn nausea
COUMADIN po daily as directed (held since [**8-22**] for elevated INR)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 99.2 BP 94/67 HR 111 RR 17 O2 100%
Gen: Cachectic, chronically ill-appearing woman
HEENT: MMD. non elevated JVP. OP clear.
Neck: supple. no neck stiffness
Heart: tachycardic, regular rate and rhythm
Lungs: Absent left side, clear apically right. Sparse crackles
left base
Abd: soft, non tender, non distended, + BS
Extrem: No edema, cyanosis of clubbing
Neuro: alert oriented x 3. Strenght [**2-27**] throughout. Warm well
perfused. No echymoses or other lesions noted.

FAMILY HISTORY: Her mother is alive and healthy at age 68. Her
father died at age 80 from a stroke and heart attack. She has 5

SOCIAL HISTORY: She does not smoke cigarettes or drink alcohol.
She moved from [**Country 3594**] to [**State 350**] in [**2091**]. She has a
daughter who lives in [**Name (NI) 17065**]. She also has a brother and
sister who live in the Greater [**Name (NI) 86**] area. She denies  tobacco
or alcohol use and is currently not working. In the  past, she
has worked in a bakery. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of posterior wall of nasopharynx,Stricture and stenosis of esophagus,Unilateral paralysis of vocal cords or larynx, partial,Dehydration,Hypotension, unspecified,Cerebral thrombosis without mention of cerebral infarction,Anemia, unspecified,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants'}
