CHIEF COMPLAINT: 

PRESENT ILLNESS: This patient is a 38-year-old
female three years status post right lumpectomy and axillary
dissection and chemotherapy and radiation now diagnosed with
ductal carcinoma in situ in the right breast on needle
localization of a mammographically-located
microcalcifications here at [**Hospital6 2018**]. This was done on [**2186-3-12**].

MEDICAL HISTORY: Hyperthyroidism treated with
radioactive iodine and the above breast cancer described.
Cesarean section. Appendectomy.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Carcinoma in situ of breast,Other complications due to other internal prosthetic device, implant, and graft,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Iodine hypothyroidism,Personal history of malignant neoplasm of breast
Ca in situ breast,Comp-int prost devic NEC,Abn react-surg proc NEC,Iodine hypothyroidism,Hx of breast malignancy
Admission Date: [**2186-4-24**]        Discharge Date: [**2186-5-1**]

Date of Birth:  [**2147-9-24**]        Sex:  F

Service:  PSU


HISTORY OF PRESENT ILLNESS:  This patient is a 38-year-old
female three years status post right lumpectomy and axillary
dissection and chemotherapy and radiation now diagnosed with
ductal carcinoma in situ in the right breast on needle
localization of a mammographically-located
microcalcifications here at [**Hospital6 2018**]. This was done on [**2186-3-12**].

PAST MEDICAL HISTORY:  Hyperthyroidism treated with
radioactive iodine and the above breast cancer described.
Cesarean section. Appendectomy.

PHYSICAL EXAMINATION:  Vital signs: Stable. The patient was
afebrile. General: She was generally a well-appearing woman
in no apparent distress. Lungs: Clear to auscultation
bilaterally. Heart: Regular, rate, and rhythm without
murmurs, rubs, or gallops. Breasts: There was a scar from a
right lumpectomy with volume loss consistent with surgery,
and there were no dominant masses noted on palpation. She had
no adenopathy. Extremities: No clubbing, cyanosis, or edema.

HOSPITAL COURSE:  The patient was admitted to the [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] for further treatment and
evaluation. The plan at this point was to bring the patient
to the operating room for total mastectomy. In addition she
would also undergo an immediate reconstruction with possible
[**Last Name (un) 5884**] flap that would be performed by Dr. [**Last Name (STitle) **] and Dr.
[**First Name (STitle) 3228**], a combination procedure between the breast surgery
service and the plastic surgery service.

On the day of admission, the patient was brought to the
operating room, [**2186-4-24**], and the operation was
performed; a skin-sparing right total mastectomy and
reconstruction using an SIEA flap. The patient tolerated the
procedure well and received 5.7 L of Crystalloid fluid, and
her estimated blood loss was 250 ml.

In the immediate postoperative period, there was noted loss
of Doppler signal over the SIEA flap requiring an immediate
return to the operating room. After heparin was bolused at
5000 units, a signal was retrieved, and the arm had been
abducted, and temperature was elevated.

The patient was intensive care unit at this time being
monitored carefully, and heparin drip was started at 500
units/hour with checks of PTT to make sure that she not in a
supratherapeutic range, and plan was to keep the body in room
temperature, warm.

In the period after this, the patient was noted to be stable,
and this plan continued to be followed. On postoperative day
#1, the patient was able to be extubated, and the heparin
drip was continued. Also of note, the patient was able to
start taking clears on postoperative day #1.

Flap checks were continued at this time and were unchanged
while the patient was in the intensive care unit. The patient
was receiving IV cephazolin at this point for prophylactic
coverage.

In the early morning of postoperative day #4, the house
officer was called to the bed side in regard to the patient's
lost Doppler signal at the 1 a.m. check. The arm was
abducted, and supportive maneuvers were made, but the flap
was still noted to be pale and cool at this time. Heparin
subcutaneously was started stat, and IV heparin was resumed,
and Lovenox was started as well at this time while flap
monitoring was continued.

The plan was for possible return to the operating room for
debridement versus excision of tissue that could possibly
become nonviable, and on [**2186-4-30**], postoperative day #6,
the patient was without complaint and was being monitored
closely for any signs of infection or imminent sloughing of
the flap. On postoperative day #7, the patient that she was
feeling better, and that her pain was very well controlled,
and she was tolerating a diet.

On exam, the flap was explored with the Doppler, and it
revealed good arterial signal and good venous signal at this
time. There was some blistering and some signs of congestion,
but the flap did not look to be in imminent concern at this
time. Thus there was a question of whether we were dealing
with epidermolysis versus deeper tissue necrosis and whether
there would be need for return to the operating room due to
the equivocal nature of our exam.

Thus the plan at this time was to discharge the patient to
home and bring back to the clinic within 48 hours for further
assessment and reevaluation of the plan. The patient was
continued on Keflex, continued on Lovenox, and continued on
oral pain medicine.

DISCHARGE INSTRUCTIONS:  The patient is to call the ER or
return to the surgery clinic if she experiences increased
pain, swelling, bleeding, discharge from the wounds, fevers,
chills, nausea or vomiting, or if there are any questions or
concerns. Purulent output is to be recorded daily. The
patient is to avoid driving or operating heavy machinery
while taking narcotic pain medicine. The patient is to resume
her home medications as she had been previously taking.

FOLLOW UP:  The patient is to follow-up with Dr. [**First Name (STitle) 3228**]
within two days. She is to call his clinic to confirm this
appointment.

DISCHARGE MEDICATIONS:  Acetaminophen 325-650 mg p.o. q.4-6
hours as needed for pain, aspirin 162 mg delayed release p.o.
daily, levothyroxine 25 mcg p.o. daily, Percocet 5/325 [**1-1**]
tab p.o. q.4-6 hours as needed for pain, ferrous sulfate 325
mg p.o. daily, Colace 100 mg p.o. b.i.d., Protonix delayed
release 40 mg p.o. daily, zolpidem tartrate 5 mg p.o. hs,
cephalexin 500 mg p.o. q.6 hours for 7 days.

DISPOSITION:  The patient is to be discharged to home and is
to follow-up with Dr. [**First Name (STitle) 3228**] within two days.



                        [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**], M.D. [**MD Number(2) 8076**]

Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D:  [**2186-5-1**] 10:09:31
T:  [**2186-5-1**] 10:54:02
Job#:  [**Job Number 59116**]
{'Carcinoma in situ of breast,Other complications due to other internal prosthetic device, implant, and graft,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Iodine hypothyroidism,Personal history of malignant neoplasm of breast'}


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: This patient is a 38-year-old
female three years status post right lumpectomy and axillary
dissection and chemotherapy and radiation now diagnosed with
ductal carcinoma in situ in the right breast on needle
localization of a mammographically-located
microcalcifications here at [**Hospital6 2018**]. This was done on [**2186-3-12**].

MEDICAL HISTORY: Hyperthyroidism treated with
radioactive iodine and the above breast cancer described.
Cesarean section. Appendectomy.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Carcinoma in situ of breast,Other complications due to other internal prosthetic device, implant, and graft,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Iodine hypothyroidism,Personal history of malignant neoplasm of breast'}
