CHIEF COMPLAINT: Nausea

PRESENT ILLNESS: 74 year-old man with glottic squamous cell carcinomal s/p chemo
and XRT as well as T3N0Mx poorly differentiated carcinoma of the
lung in remission presenting after a recent hospitalization for
dysphagia with continued dysphagia and poor PO intake leading to
weakness.  He was discharged approximately a week before this
presentation and at that time was admitted for dysphagia.  He
had dilation of a relativley quite minor esophageal stricture
during that hospitalization and afterwards improved and was
discharged.  He reports that his swallowing is slightly better
but he is not able to take much food at all.  He reports his
appetite is very poor.  In the context of this poor intake he
reports he has gotten very week and though he reports a month or
so ago he could walk several blocks over the last weeks he does
not think he could do this. Aside from his weakness and poor
intake he reports chronic back pain on his left side, where he
had a previous surgery.  He has subjective fevers and chills and
reports chronic cough but this is nonproductive.  He does have
chronic production of sputum in his mouth that he does not feel
he can handle and swallow and spits in a basin throughout our
interview.  He denies odynophagia.  He also endorses chronic
anorexia and more recently having had some subjective fevers or
chills though he reports dysuria or localizing singns except for
his chronic, nonproductive cough and approximately two episodes
of loose stool a day, which he reports are immediately after he
eats.  He has mild headache. He denies abdominal pain, dysuria,
or flank pain.  He very rarely has nausea and will vomit with
dyspnea after vomiting.  He denies dyspnea at any other time.
Because of inability to manage these symptoms at home he
presented to the ED.

MEDICAL HISTORY: - Diabetes mellitus, type II
- Hypertension
- T3 N0 M0 glottic squamous cell carcinoma s/p chemoradiation
therapy
- Tracheostomy on [**2134-11-3**]
- PEG tube placed on [**2134-11-17**].
- Poorly differentiated large cell carcinoma T3N0MX in the left
upper lobe s/p left thoracotomy, partial decortication of lung,
left upper lobectomy, mediastinal lymphadenectomy, en bloc
resection of pericardium on [**2136-6-12**].
- Hospitalization for dysphagia a week previous with very minor
stricture that was dilated

MEDICATION ON ADMISSION: -Metformin  1000 mg PO twice a day.
-Omeprazole  20 mg PO DAILY
-Dilaudid  2-4 mg PO every four hours as needed for pain.
-Colace 100 mg PO twice a day as needed for constipation.
-Senna  8.6 mg :  1-2 Tablets PO twice a day as needed for
constipation.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
VS:  T 99.1, P 94, BP 116/60, RR 18, O2 99% on RA
Appearance: Thin elderly man appearing uncomfortable and
frequently spitting in a basin but non-toxic
Eyes: EOMI, Conjunctiva Clear
ENT: Dry appearing, Edentulous,no ulcers or erythema, no JVD,
chronic fibrotic changes of anterior throat (presumably from
radiation)
CV: Regular, normal S1 and S2, no systolic or diastolic murmurs,
no lower extremity edema appreciated
Respiratory: Breathing appears comfortable, diminished breath
sounds over the left upper chest, , diminished breath sounds at
the bases bilaterally with a few crackles at the left base on
auscultation, lidocaine patches on left back
GI: Soft, Nontender, nondistended, bowel sounds positive, No
hepatomegaly or splenomegaly
MSK: Tone WNL, Bulk WNL, Upper Extremity Strength 5/5 and
symmetrical, Lower Extremity Strength 4+/5 and symmetrical, No
cyanosis, No clubbing, No joint swelling
Neuro: CNII-XII intact, Normal attention, Fluent heavily
accented speech
Integument:  Warm,  dry, no rash
Psychiatric: Appears anxious but generally pleasant
Hematologic / Lymphatic: No Cervical [**Doctor First Name **], Thyroid WNL

FAMILY HISTORY: His mother died at age 85 of unclear causes.  Father died in
Siberia after being taken from family, unclear medical history.
Sisters and sons without notable problems at this time.

SOCIAL HISTORY: He quit smoking three years ago after 150-pack-year history.
Previously a teacher in [**Country 5881**].  History of heavy alcohol use
but quit in his 50s.   He used to be a teacher in [**Country 5881**]. Former
ETOH use, quit 20 years ago. Lives with his wife and son.
Persistent vomiting,Unspecified septicemia,Acute kidney failure, unspecified,Other severe protein-calorie malnutrition,Pneumonia due to Klebsiella pneumoniae,Acquired coagulation factor deficiency,Malignant pleural effusion,Intestinal infection due to Clostridium difficile,Malignant neoplasm of liver, secondary,Severe sepsis,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of other parts of bronchus or lung,Pathologic fracture of vertebrae,Other ascites,Malignant neoplasm of glottis,Helicobacter pylori [H. pylori],Unilateral paralysis of vocal cords or larynx, partial,Other specified disorders of penis,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Unspecified essential hypertension,Atrial fibrillation,Chronic post-thoracotomy pain,Acute gastritis, without mention of hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Stricture and stenosis of esophagus,Other dysphagia,Late effect of radiation,Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Redundant prepuce and phimosis,Thrombocytopenia, unspecified
Persistent vomiting,Septicemia NOS,Acute kidney failure NOS,Oth severe malnutrition,K. pneumoniae pneumonia,Acq coagul factor defic,Malignant pleural effusn,Int inf clstrdium dfcile,Second malig neo liver,Severe sepsis,Secondary malig neo bone,Mal neo bronch/lung NEC,Path fx vertebrae,Ascites NEC,Malignant neo glottis,Helicobacter pylori,Vocal paral unilat part,Disorder of penis NEC,DMII wo cmp uncntrld,Hypertension NOS,Atrial fibrillation,Chron post-thoracot pain,Acute gastrtis w/o hmrhg,Chr blood loss anemia,Esophageal stricture,Dysphagia NEC,Late effect of radiation,Abn react-radiotherapy,Redun prepuce & phimosis,Thrombocytopenia NOS
Admission Date:  [**2136-9-24**]              Discharge Date:   [**2136-11-15**]

Date of Birth:  [**2062-5-27**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
Nausea

Major Surgical or Invasive Procedure:
Video swallow study
EGD
Insertion of Pigtail catheter in R pleural space


History of Present Illness:
74 year-old man with glottic squamous cell carcinomal s/p chemo
and XRT as well as T3N0Mx poorly differentiated carcinoma of the
lung in remission presenting after a recent hospitalization for
dysphagia with continued dysphagia and poor PO intake leading to
weakness.  He was discharged approximately a week before this
presentation and at that time was admitted for dysphagia.  He
had dilation of a relativley quite minor esophageal stricture
during that hospitalization and afterwards improved and was
discharged.  He reports that his swallowing is slightly better
but he is not able to take much food at all.  He reports his
appetite is very poor.  In the context of this poor intake he
reports he has gotten very week and though he reports a month or
so ago he could walk several blocks over the last weeks he does
not think he could do this. Aside from his weakness and poor
intake he reports chronic back pain on his left side, where he
had a previous surgery.  He has subjective fevers and chills and
reports chronic cough but this is nonproductive.  He does have
chronic production of sputum in his mouth that he does not feel
he can handle and swallow and spits in a basin throughout our
interview.  He denies odynophagia.  He also endorses chronic
anorexia and more recently having had some subjective fevers or
chills though he reports dysuria or localizing singns except for
his chronic, nonproductive cough and approximately two episodes
of loose stool a day, which he reports are immediately after he
eats.  He has mild headache. He denies abdominal pain, dysuria,
or flank pain.  He very rarely has nausea and will vomit with
dyspnea after vomiting.  He denies dyspnea at any other time.
Because of inability to manage these symptoms at home he
presented to the ED.

In the ED all vital signs were stable.  T 98, P 108, BP 92/65,
RR 18, O2 Sat 100% RA.  He had labs and cultures, which revealed
a leukocytosis but UA and chest radiograph were both without
signs of acute infection and he was afebrile.  He was admitted
for further management.

Currently, he discusses his litany of complaints and is very
irritated by how poorly he is feeling.  He is particularly
concerned about how little he is eating and mentioned to a nurse
he would die without IVF.  He does ask for supplements, however,
and is very concerned with his PO intake.

REVIEW OF SYSTEMS:
Positive per HPI.
Notably negative for abdominal pain, shortness of breath (except
immediately following emesis), and vomiting with liquids.
Otherwise review of systems performed and unremarkable.

Past Medical History:
- Diabetes mellitus, type II
- Hypertension
- T3 N0 M0 glottic squamous cell carcinoma s/p chemoradiation
therapy
- Tracheostomy on [**2134-11-3**]
- PEG tube placed on [**2134-11-17**].
- Poorly differentiated large cell carcinoma T3N0MX in the left
upper lobe s/p left thoracotomy, partial decortication of lung,
left upper lobectomy, mediastinal lymphadenectomy, en bloc
resection of pericardium on [**2136-6-12**].
- Hospitalization for dysphagia a week previous with very minor
stricture that was dilated

Social History:
He quit smoking three years ago after 150-pack-year history.
Previously a teacher in [**Country 5881**].  History of heavy alcohol use
but quit in his 50s.   He used to be a teacher in [**Country 5881**]. Former
ETOH use, quit 20 years ago. Lives with his wife and son.

Family History:
His mother died at age 85 of unclear causes.  Father died in
Siberia after being taken from family, unclear medical history.
Sisters and sons without notable problems at this time.

Physical Exam:
ADMISSION EXAM:
VS:  T 99.1, P 94, BP 116/60, RR 18, O2 99% on RA
Appearance: Thin elderly man appearing uncomfortable and
frequently spitting in a basin but non-toxic
Eyes: EOMI, Conjunctiva Clear
ENT: Dry appearing, Edentulous,no ulcers or erythema, no JVD,
chronic fibrotic changes of anterior throat (presumably from
radiation)
CV: Regular, normal S1 and S2, no systolic or diastolic murmurs,
no lower extremity edema appreciated
Respiratory: Breathing appears comfortable, diminished breath
sounds over the left upper chest, , diminished breath sounds at
the bases bilaterally with a few crackles at the left base on
auscultation, lidocaine patches on left back
GI: Soft, Nontender, nondistended, bowel sounds positive, No
hepatomegaly or splenomegaly
MSK: Tone WNL, Bulk WNL, Upper Extremity Strength 5/5 and
symmetrical, Lower Extremity Strength 4+/5 and symmetrical, No
cyanosis, No clubbing, No joint swelling
Neuro: CNII-XII intact, Normal attention, Fluent heavily
accented speech
Integument:  Warm,  dry, no rash
Psychiatric: Appears anxious but generally pleasant
Hematologic / Lymphatic: No Cervical [**Doctor First Name **], Thyroid WNL

Discharge Exam (prior to death)

VS: 98.1 90s/40s 90s AF 98% on FiO2 35% Trach collar
General: non-alert, cachectic man sitting in bed, in distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, trach site without
oozing
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi. Transmitted upper airway sounds from trach.
CV: Irreg irreg. Rate approx 80s. Normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: PEG dressing and wound C/D/I. Abdomen soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley drainaing dark yellow urine
Ext: Diffuse anasarca with 2-3+ pitting edema. Warm, well
perfused, 2+ pulses, no clubbing, cyanosis. RUE PICC without
erythema or purulence

Pertinent Results:
===================
LABORATORY RESULTS
===================
WBC-14.1* RBC-3.50* Hgb-9.8* Hct-29.2* MCV-84 RDW-13.7 Plt
Ct-514*
---Neuts-88* lymphs-4* Monos-8
Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL
Microcy-NORMAL Polychr-OCCASIONAL
Glucose-196* UreaN-23* Creat-0.8 Na-134 K-4.1 Cl-96 HCO3-25

==============
OTHER STUDIES
==============
Chest radiograph PA and lateral [**2136-9-24**] (my read): General
greater density over the left lung field, likely due to volume
loss (chronic).  No infiltrate or pulmonary edema appreciated.
No effusions.  There is a circular lucency of the left clavicle
that appears new from previous chest radiographs though
radiograph from [**Month (only) 216**] shows a circular lucency likely linked to
the lung.  No acute intrapulmonary process, ? lytic lesion in
left clavicle.

Bed Side Swallow Study
SUMMARY / IMPRESSION:
Mr. [**Known lastname 84573**] is well known to me from previous swallowing
evaluations. He had been tolerating thin liquids and ground
solids before his recent left thoracotomy, Left upper lobectomy
and pericardial resection for biopsy proven non-small cell lung
cancer.  We repeated his video swallow after that procedure
before d/c but swallow function was c/w previous exams and he
remained safe for thin liquids and soft foods with extra sauce
and gravy. He was given a 10 days course of antibiotics for H
pylori but was only able to take 3 1/2 days of the medication
and
did not finish the prescription.

It is unlikely his oral and pharyngeal have changed since [**Month (only) 205**]
when we did his last video swallow and he has been recently
dilated which rules out the possibility he restrictured. My
guess
is that the biggest change is likely continued H pylori, as he
vomited up most of the medication and stoped taking it after 3
days. Suggest considering restarting meds for H pylori (not sure
if it needs to be rediagnosed before starting meds) to try to
improve comfort.

He remains safe to drink his liquid supplements, and takes 5
cans
of Nutren 2.0, 500 calories each which he should be ordered for
here. He can also take water safely, which can keep him
hydrated.
We will plan to f/u with him after treatment for H pylori to see
if he feels his oral and pharyngeal swallow has improved
further.

This swallowing pattern correlates to a Functional Oral Intake
Scale (FOIS) rating of 5.
.
TTE ([**2136-10-12**]):
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2136-6-15**], no
change.
.
Gastric biopsy ([**2136-10-3**]):
Gastric antrum and body, mucosal biopsies:
Antral and corpus mucosa with focal intestinal metaplasia, focal
regeneration of gastric pits and minimal inflammation; see note.
Note: The findings are non-specific, but are most suggestive of
a chemical-type gastropathy.  At the request of the clinician, a
Helicobacter immunostain is performed and is negative for H.
pylori, with satisfactory controls.
.
EGD ([**2136-10-3**])
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered MAC
anesthesia. Supplemental oxygen was used. The patient was placed
in the left lateral decubitus position and an endoscope was
introduced through the mouth and advanced under direct
visualization until the third part of the duodenum was reached.
Careful visualization of the upper GI tract was performed. The
procedure was not difficult. The patient tolerated the procedure
well. There were no complications.
Findings: Esophagus:
 Mucosa: stricture seen near upper esophogeal sphincter as
previously described. The scope was able to traverse the lesion.

Stomach:
 Lumen: A medium size hiatal hernia was seen.
 Mucosa: Erythema of the mucosa was noted in the stomach. This
was worse in the antrum. Consistent with pan gastritis.
Duodenum: Normal duodenum.
Impression: Abnormal mucosa in the esophagus
Erythema in the stomach
Medium hiatal hernia
Otherwise normal EGD to third part of the duodenum
.
Gastric emptying study ([**10-5**]): IMPRESSION: Normal gastric
emptying study.
.
[**2136-10-30**]   Radiology CHEST (PORTABLE AP)
1. Moderate bilateral pleural effusions, likely stable.
2. Bibasilar opacities, probable compressive atelectasis.
Pneumonia and
aspiration are within the differential, though less likely.
4. Widened mediastinum corresponding with fluid and adenopathy
seen on recent
chest CT.
5. Known pulmonary nodules not well characterized.

[**2136-10-29**]   Radiology MR [**Name13 (STitle) 6452**]/T-SPINE W & W/O CONT
1. Severe compression deformity of T6 vertebral body with mild
retropulsion,
but no cord compression. This finding is compatible with either
a pathologic fracture secondary to a metastasis, or an
osteoporotic fracture. No additional metastases are seen in the
thoracic or lumbar spine.
2. Chronic moderate compression deformity of the L2 vertebral
body with mild retropulsion, but no nerve root compression

[**2136-10-29**]   Radiology N-G TUBE PLACEMENT/PERC G/G-J TUBE PLMT
Prelim report not available

[**2136-10-27**]   Radiology [**Last Name (un) **]-INTESTINAL TUBE PL
Unsuccessful attempted passage of a nasogastric tube despite
fluoroscopy. Findings discussed with Dr. [**Last Name (STitle) **] by Dr. [**Last Name (STitle) **] at
1510 hours on [**10-27**]. Please note this precludes gastrostomy
by the IR team. Surgical consult suggested.

[**2136-10-26**]   Radiology CT NECK W/CONTRAST
1. Status post tracheostomy. No evidence of recurrent laryngeal
tumor. 2. 2. Upper mediastinal lymphadenopathy and right pleural
effusion, better evaluated on the dedicated chest CT examination
performed on the same day.
3. Persistent left hydrothorax.
ATTENDING NOTE: 1. A right sided level 2 lymphnode (2:19) has
increased in
size since [**2136-7-1**] and measures 13-mm and has hetrogenous
density suggestive of metastasis. 2. Right pleural effusion is
new since [**2136-7-1**], correlate with Chest CT. 3. There is
increased glottic and supra-glottic edema likely related to
treatment changes

[**2136-10-26**]   Radiology CT CHEST W/CONTRAST
1. Incompletely-imaged multiple liver masses, new since the
[**2136-8-16**] CT examination, compatible with malignancy.
Further evaluation with abdominal and pelvic CT is recommended.
2. See neck CT report assessment for any recurrent right
laryngeal tumor.
3. Interval complete collapse of the T6 vertebral body since the
[**2136-8-16**] examination may be pathologic given the findings of new
hepatic
malignancy.
4. Enlarging right upper lobe pulmonary nodule, new left lower
lobe nodule, and equivocal left pleural-based nodule.
5. Status post tracheostomy, with patent airways to the
subsegmental levels.
6. Moderate-sized bilateral pleural effusions, greater on the
right, with
adjacent compressive atelectasis.
7. Persistent left hydrothorax, with resolution of a previously
seen small
loculated pneumothorax.
8. New small amount of intra-abdominal ascites.
9. New prominent upper mediastinal lymph nodes, suspicious for
malignancy.

[**2136-10-26**]   Radiology CHEST (PORTABLE AP)
1. Developing retrocardiac opacity compatible with aspiration,
pneumonia, or atelectasis.
2. Small left pleural effusion

[**2136-10-25**]   Radiology VIDEO OROPHARYNGEAL SWA
Aspiration of thin liquids and nectar-thick liquids. Pharyngeal
residue with pudding. Please refer to note from speech and
swallow division in the OMR for further details.

[**2136-10-24**]   Radiology CHEST (PORTABLE AP)     [**Last Name (LF) 2437**],[**First Name3 (LF) **]
Approved
1. Diffuse increase in left lung opacity, compatible with
worsening pleural effusion.
2. Right lower lung atelectasis.

[**2136-10-23**]   Radiology RIB UNILAT, W/ AP CHEST     [**Last Name (LF) **],[**First Name3 (LF) **]
Approved
No definite rib fx or rib lesion. Gallstones noted. Changes in
left lung, as described

Microbiology
[**2136-10-28**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2136-10-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {PSEUDOMONAS AERUGINOSA, STAPH AUREUS COAG
+} INPATIENT
[**2136-10-28**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2136-10-28**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-10-24**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-10-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-10-24**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2136-10-21**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL {CLOSTRIDIUM DIFFICILE} INPATIENT
[**2136-10-21**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2136-10-18**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-10-17**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-10-17**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-10-17**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2136-10-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-10-13**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-10-13**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-10-2**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-10-2**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-10-2**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-9-29**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-9-29**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2136-9-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2136-9-28**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-9-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]

=
================================================================

[**2136-11-7**] 10:20 am SPUTUM     Site: ENDOTRACHEAL
      Source: Endotracheal.

   GRAM STAIN (Final [**2136-11-7**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2136-11-10**]):
      Commensal Respiratory Flora Absent.
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup will be performed appropriate to the isolates
recovered from
      this site.
      PSEUDOMONAS AERUGINOSA.
         MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES.
      STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.    SPARSE
GROWTH.
      GRAM NEGATIVE ROD #3.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |          STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
                             |          |
CEFEPIME--------------    16 I
CEFTAZIDIME-----------    16 I
CIPROFLOXACIN---------     1 S
GENTAMICIN------------     4 S
LEVOFLOXACIN----------                2 S
MEROPENEM-------------     2 S
PIPERACILLIN/TAZO-----       S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----                2 S

   LEGIONELLA CULTURE (Final [**2136-11-14**]):    NO LEGIONELLA
ISOLATED.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   ACID FAST SMEAR (Final [**2136-11-8**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.

===========================================================

[**2136-9-24**] 11:00AM BLOOD WBC-14.1* RBC-3.50* Hgb-9.8* Hct-29.2*
MCV-84 MCH-28.1 MCHC-33.7 RDW-13.7 Plt Ct-514*
[**2136-9-27**] 06:55AM BLOOD WBC-13.1* RBC-2.94* Hgb-8.1* Hct-24.6*
MCV-84 MCH-27.6 MCHC-33.0 RDW-14.3 Plt Ct-452*
[**2136-10-2**] 07:20AM BLOOD WBC-15.0* RBC-2.97* Hgb-8.0* Hct-24.7*
MCV-83 MCH-26.9* MCHC-32.2 RDW-14.0 Plt Ct-481*
[**2136-10-5**] 01:59PM BLOOD WBC-15.1* RBC-2.75* Hgb-7.5* Hct-23.0*
MCV-84 MCH-27.4 MCHC-32.8 RDW-14.1 Plt Ct-452*
[**2136-10-18**] 03:23AM BLOOD WBC-18.5* RBC-2.57* Hgb-6.8* Hct-22.5*
MCV-87 MCH-26.3* MCHC-30.1* RDW-15.2 Plt Ct-565*
[**2136-10-27**] 04:33AM BLOOD WBC-22.4* RBC-2.75* Hgb-7.2* Hct-23.8*
MCV-87 MCH-26.1* MCHC-30.1* RDW-15.4 Plt Ct-230
[**2136-10-28**] 03:32AM BLOOD WBC-22.5* RBC-2.77* Hgb-7.3* Hct-24.0*
MCV-87 MCH-26.2* MCHC-30.3* RDW-16.6* Plt Ct-144*
[**2136-11-6**] 03:53AM BLOOD WBC-12.3* RBC-2.33* Hgb-6.4* Hct-20.1*
MCV-86 MCH-27.4 MCHC-31.8 RDW-16.5* Plt Ct-106*
[**2136-11-7**] 06:00AM BLOOD WBC-11.9* RBC-2.70* Hgb-7.1* Hct-23.2*
MCV-86 MCH-26.4* MCHC-30.7* RDW-17.1* Plt Ct-107*
[**2136-11-15**] 05:23AM BLOOD WBC-10.8 RBC-2.69* Hgb-7.5* Hct-23.6*
MCV-88 MCH-27.8 MCHC-31.7 RDW-16.9* Plt Ct-49*
[**2136-11-11**] 06:00AM BLOOD Glucose-135* UreaN-21* Creat-0.6 Na-139
K-3.5 Cl-100 HCO3-33* AnGap-10
[**2136-11-12**] 06:00AM BLOOD Glucose-125* UreaN-21* Creat-0.6 Na-141
K-3.6 Cl-101 HCO3-31 AnGap-13
[**2136-11-12**] 02:35PM BLOOD Glucose-112* UreaN-21* Creat-0.6 Na-141
K-4.3 Cl-103 HCO3-32 AnGap-10
[**2136-11-13**] 05:50AM BLOOD Glucose-139* UreaN-27* Creat-0.9 Na-141
K-4.0 Cl-102 HCO3-30 AnGap-13
[**2136-11-14**] 05:28AM BLOOD Glucose-154* UreaN-39* Creat-1.1 Na-143
K-3.4 Cl-104 HCO3-30 AnGap-12
[**2136-11-15**] 05:23AM BLOOD Glucose-220* UreaN-52* Creat-1.6* Na-141
K-4.7 Cl-104 HCO3-28 AnGap-14
[**2136-11-15**] 05:23AM BLOOD Albumin-1.5* Calcium-7.0* Phos-4.8*
Mg-2.6
[**2136-11-13**] 05:50AM BLOOD Calcium-7.7* Phos-3.8 Mg-2.3
[**2136-11-12**] 02:35PM BLOOD TotProt-3.5* Albumin-1.5* Globuln-2.0
Calcium-7.1* Phos-2.6* Mg-2.1
[**2136-11-12**] 06:00AM BLOOD Calcium-7.5* Phos-2.7 Mg-2.2
[**2136-11-11**] 06:00AM BLOOD Albumin-1.6* Calcium-7.2* Phos-3.1 Mg-2.1
[**2136-11-10**] 03:08PM BLOOD Calcium-7.6* Phos-3.4 Mg-2.1

======================================

[**Known lastname **],[**Known firstname 84574**]	[**Medical Record Number 84575**]	M  74  [**2062-5-27**]
Radiology Report	CTA CHEST W&W/O C&RECONS, NON-CORONARY	Study
Date of [**2136-11-12**] 6:22 PM

[**Last Name (LF) **],[**First Name3 (LF) **]	OMED	11R	[**2136-11-12**] 6:22 PM
CTA CHEST W&W/O C&RECONS, NON-	 	Clip # [**Clip Number (Radiology) 84576**]
Reason: ?r/o PE
Contrast: [**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION:
   74 year old man with metastatic lung cancer, glottic cancer,
presumed
   aspiration pneumonia, and acutely worsening SOB.
REASON FOR THIS EXAMINATION:
   ?r/o PE
CONTRAINDICATIONS FOR IV CONTRAST:
   None.
Wet Read: YGd MON [**2136-11-12**] 10:31 PM
Subtle filling defect involving RML subsegmental branch
(4:158-161, 402b:25,
and 3:4) could represent trace pulmonary embolism. Small right
ptx and right
posterior pleurx catheter in place. Fluid distends esophagus and
aerosolized
material in lower lobe airways and extensive aspiration
pneumonitis.
Bilateral pulmonary nodules some pleural based. Right apical
paraseptal
emphysema. Trace pleural effusions. Left 7th rib sclerosis,
probably post
traumatic. Stable severe T6 wedge compression.

d/w Dr. [**Last Name (STitle) **] at 7:30 pm and 10:00 pm on [**2136-11-12**] via
phone by [**Doctor Last Name **] x
[**Numeric Identifier 27921**]
Final Report
CTA CHEST WITH AND WITHOUT CONTRAST

DATE: [**2136-11-12**].

COMPARISON: [**2136-10-26**] CT chest; MR thoracic spine [**10-29**], [**2136**]; CT
abdomen and pelvis [**2136-10-31**].

CLINICAL INDICATION: 74 year old man with metastatic lung
cancer, glottic
cancer, presumed aspiration pneumonia, and acutely worsening
SOB. Rule out PE.

TECHNIQUE: Axial images of the chest were obtained without the
use of
intravenous contrast. Subsequently, axial images were obtained
after the
uneventful administration of 100 mL Optiray intravenous
contrast. Coronal and
sagittal reformatted images were constructed.

CHEST FINDINGS:

There is no central or segmental pulmonary embolus. Evaluation
of distal
subsegmental branches is slightly limited secondary to
incomplete
opacification with contrast. The previously described subtle
filling defect
involving the right middle lobe subsegmental branch is favored
to be
artifactual. No additional filling defects are identified.

The heart is normal in size. There is a small pericardial
effusion. Loculated
fluid in the left anterior hemithorax with peripheral
enhancement is
unchanged. There are small, left greater than right, bilateral
pleural
effusions with adjacent compressive atelectasis at the bases.
There is no
axillary lymphadenopathy. Mediastinal lymphadenopathy,
predominantly
involving the prevascular space/anterior mediastinum, is
unchanged in size.

A small right pneumothorax is new from the prior examination. A
right
posteriorly placed chest tube is in place. There is underlying
centrilobular
and periseptal emphysema. There are new and worsening areas of
scattered
ground-glass opacities with septal thickening, predominantly
involving the
right lung. On the left, there is bronchial wall thickening
involving the
lower lobe bronchi, minimally progressed from the prior
examination. Patchy
parenchymal opacity in the medial base is noted.

There is a new subpleural nodular opacity measuring 6 mm in the
left upper
lobe (3:12). A pleural-based nodule at the left base measuring
10 x 12 mm is
essentially unchanged. Also stable is the right upper lobe
pulmonary nodule
(9mm, 2:10).

The esophagus is newly distended and fluid filled.

Atherosclerotic changes are present within the normal caliber
aorta. There is
focal narrowing of mild degree in the left main pulmonary
artery, unchanged
from prior examinations (3:16).

The patient has a tracheostomy tube which is unchanged in
appearance.

An enlarging liver lesion in the left hepatic lobe measures 6.1
x 8.2 cm. This
is incompletely imaged. There is abdominal ascites.

MUSCULOSKELETAL FINDINGS: There is asymmetric left greater than
right
subcutaneous fat stranding in the chest wall. Compression
deformity of T6
vertebral body is redemonstrated and stable. Post-surgical
changes are
present in the left posterior ribs. Incompletely healed fracture
with callus
formation is present in the left fifth lateral rib.

IMPRESSION:
1. New small right pneumothorax. Right chest tube is posteriorly
positioned.
Please ensure chest tube is to suction.
2. No definite evidence of pulmonary embolus.
3. Stable pleural/parenchymal nodules, left hydrothorax and
small left
pleural effusion.
4. New areas of scattered ground-glass opacities with septal
thickening,
predominantly on the right, related to inflammatory or
infectious etiology.
5. Bronchial wall thickening at the left base with patchy
consolidation,
minimally progressed, possibly secondary to aspiration.
6. Fluid-filled and dilated esophagus, new from the prior
examination which
may relate to esophagitis or possibly early stricture formation.
Please
correlate for symptoms of esophagitis.
7. Enlarging incompletely imaged liver metastasis.
8. Stable T6 wedge compression deformity.

The study and the report were reviewed by the staff radiologist.

DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: TUE [**2136-11-13**] 5:09 PM
 	Imaging Lab

Brief Hospital Course:
74 year-old man with laryngeal cancer and NSCLC s/p chemo and
XRT, history of chronic dysphagia (to solids), and H.pylori
infection presents with progressive nausea and resulting
decreased PO intake.
.
#ICU course #1: He was first admitted to the ICU shortly after
admission when he looked very sleepy, with tachypnia and labored
breathing. In the ICU, he was started on heliox, racemic
epinephrine and IV dedacrdone. He was kept strict NPO and some
of his meds were switched to IV form. He was evaluated by ENT
who placed tracheostomy on the day of the admission with no
complications. CXR post trach showed no complications with
larger lung volumes.
.
# ICU course #2: Patient was readmitted to the ICU on [**10-23**] for
AFib with RVR. He was initially placed on a diltiazem drip and
amiodarone infusion was also started to obtain rhythm control.
Heart rate was better controlled with amiodarone, but attempts
to transition to po amiadorone were hindered by persistent
dysphagia. Patient failed video swallow study and patient had G
tube placed by IR on [**10-29**]. He was then transitioned to po dilt.
During this stay, he complained of persistent dyspnea and CXR
showed a new worsening pleural effusion on the right. CT of the
chest on [**10-26**] showed multiple liver mets, T6 collapse,
enlarging rt upper pulm nodule, new LLL nodule, equivocal lft
pleural based nodule, prominent mediastinal nodes, and moderate
sized bilateral pleural effusions, greater on the right.
Heme/onc was consulted who did not feel chemotherapy or further
imaging was indicated. Diagnostic thoracentesis of rt pleural
effusion was considered, but patient could not be properly
positioned. Additionally, radiation oncology was consulted for
palliative XRT, but again, patient positioning limited treatment
options. MRI of the spine was ordered, and spine consult planned
at this time. He was called out to the floor [**10-30**].
.
# Metastatic disease: Patient with glottic SCC (T3N0)s/p
chemoradiation in [**2134**] and stage IIB NSCLC s/p left upper
lobectomy in [**2136-5-13**]. Following surgery in [**Month (only) 116**], patient was
told he was 'cancer free'. Patient developed persistent dyspnea
during hospital stay, and CXR noted bilateral pleural effusions.
CT of the chest on [**10-26**] showed multiple liver mets, T6
collapse, enlarging rt upper pulm nodule, new LLL nodule,
equivocal lft pleural based nodule, prominent mediastinal nodes,
and moderate sized bilateral pleural effusions, greater on the
right. Heme/onc was consulted who did not feel chemotherapy or
further imaging was indicated. Diagnostic thoracentesis of rt
pleural effusion was considered, but patient could not be
properly positioned. Additionally, radiation oncology was
consulted for palliative XRT, but again, patient positioning
limited treatment options. MRI of the spine was ordered, and
spine consult planned at this time.

# Nausea, heartburn: Initially an attempt at H.pylori
eradication was done to eliminate that as a potential cause of
his nausea. However, he was unable to tolerate sequential
therapy and was taken off of it. He was therefore started on PPI
[**Hospital1 **] and given antiemetics, particularly zofran. He then had an
EGD and gastric emptying study. His gastric emptying study was
normal. EGD showed stricture in his upper esophageal sphincter,
abnormal mucosa in the esophagus, erythema in the stomach,
medium hiatal hernia. His UES was dilated. He also had
heartburn, which was treated as above and with zofran, which
would aid in gastric motility given his lack of a LES. His
nausea and heartburn gradually improved. However, due to
persistent dysphagia, he was made NPO and G tube was placed on
[**10-29**].
.
# CDiff: During his hospital course, he began having low grade
fevers and diarrhea.  CXR, blood cultures, urine culture were
unrevealing. CDiff antigen was positive on [**10-21**] and patient was
started on IV flagyl. Due to his high risk, vancomycin enemas
were added on [**10-26**] as he could not tolerate po vancomycin. PO
vancomycin was added to regimen following successful placement
of G tube on [**10-29**].
.
# Dysphagia: He has history of glottic cancer s/p chemo XRT, s/p
trach with course complicated by chronic dysphagia with dilation
esophageal stricture [**2136-9-16**]. Pt had an EGD approximately one
week prior to admission that did not show a significant
narrowing and patient had dilation with improvement and even
acknowledges this improvement in the dysphagia component of his
symptoms. To ensure that esophageal stricture was not still
contributing to his symptoms, he had a video swallow study which
was none revealing of contributory pathology. He was
supplemented with nutren given his risk for malnutrition.
However, as his hospital course prolonged, his dysphagia
progressed and he failed a second video swallow study on [**10-25**].
He was made NPO with TPN until a G-tube was placed by IR on
[**10-29**].
.
#Chronic pain, like post-thoracotomy pain: He was seen by the
chronic pain service as well as the pain and palliative care
service. He was treated with a lidocaine patch, prn dilaudid,
basal fentanyl patch, and gabapentin. Plain films of right ribs
were negative for fracture. CT scan of thorax to eval
progression of pleural effusion noted compression fracture of
T6. He was previously being considered by pain clinic for nerve
block for post-thoracotomy pain; he may follow with them. He
will also follow with palliative care upon outpt referral by
oncology. Given newly found metastatic disease, may also
consider bone scan to r/o mets as outpt.

# Atrial fibrillation: He was noted to have asymptomatic atrial
fibrillation with RVR on [**10-11**]. TSH was checked and normal; TTE
showed elongated LA but was unchanged from prior TTE. On [**10-23**],
he again developed RVR and attempts to control with IV nodal
agents resulted in decreased blood pressure. He was transferred
to the ICU where diltiazem gtt was started to control rate.
During this time, amiadarone infusion was started and rhythm
control was adequately obtained. He was transitioned to po
amiadarone following placement of G tube.

#Normocytic Anemia: Pt with poor po may also be component of
iron deficiency although normocytic. He may also have some mild
gastric blood loss due to his severe gastritis. Studies included
levated ferritin, ESR, CRP markedly elevated, pointing to anemia
of chronic disease. His Hct responded appropriately to 1 unit
PRBC [**10-8**]. He again received 1 unit PRBC on [**10-21**] and [**10-29**].
.
# Thrombocytopenia: Plt count began trending down from 403 on
[**10-21**] to 120 on [**10-30**]. Etiology was thought to be due to platelet
clumping seen on smear, although CDiff infection and amiadarone
therapy could not be ruled out.
.
# Cough, dry mouth, upper airway secretions: Various other
complaints were addressed, including cepacol prn cough; mouth
swabs for dry mouth (may consider artificial saliva); albuterol
nebulizers for thick secretions from upper airway chronic
disease. He should follow up with PPC as an outpt (to be
referred by outpt oncology).
.
Status: full code

OMED COURSE ([**10-31**] - [**2136-11-15**]):
# fevers/PNA: Pt febrile on [**11-11**] with CXR concerning for
pneumonia, witnessed aspiration of bilious content. IV vanc and
zosyn restarted on [**2136-11-7**]. Zosyn coverage obtained because of
risk for aspiration pneumonia and better coverage of anaerobes.
Furthermore, prior pseudomonas cultures were intermediate to
cefepime and sensitive to zosyn. Sputum Cx positive gram
negative rods (pseudomonas-[**Last Name (un) 36**] to zosyn and
stenotrophomonas-[**Last Name (un) 36**] to levo/bactrim). IV zosyn and bactrim
discontinued on [**2136-11-15**] due to renal toxicity and worsening
thrombocytopenia, levofloxacin started for
pseudomonas/stenotrophomonas coverage. Mr. [**Known lastname 84573**] was
eventually made CMO by his family on [**2136-11-15**] and passed that
evening. The family declined an autopsy.
.
# Dyspnea: A pigtail pleural drain was placed by IR on [**11-12**] for
palliation of shortness of breath. 1200 cc of pleural fluid was
drained. The tube was capped from [**11-14**] - 3 for hypotension.
.
# AF with RVR: rate was well controlled eventually on amiodarone
200mg daily.
.
# Anasarca: Likely secondary to hypoalbuminuria. Attempts were
made to diurese daily ~500 cc. However hypotension from [**11-7**] to
[**11-15**] made diuresis impossible during these dates. Albumin
administration from [**Date range (1) **] did little to improve anasarca and
pulmonary edema. Mr. [**Known lastname 84573**] was eventually made CMO by his
family on [**2136-11-15**] and passed that evening.
.
# [**Last Name (un) **]: Mr. [**Known lastname 84573**] developed renal failure on [**11-12**] with
progressive worsening over the next 4 days. Given his
hypotension, he was not a candidate for hemodialysis. The family
ultimately decided against initiating CVVH in the ICU, he was
made CMO on [**2136-11-15**] and passed that evening.
.
#. Metastatic disease (Glottic SCC and NSCLC; s/p trach): Pt has
two underlying malignancies and evidence of likely metastatic
disease with liver lesions and spine lesions. ortho spine rec'd
TLSO brace when OOB. No liver biopsy was obtained per family
discussion. Pain control with intermittent IV morphine was
continued. Mr. [**Known lastname 84573**] was eventually made CMO by his family
on [**2136-11-15**] and passed that evening.
.
# C diff: Mr. [**Known lastname 84573**] was maintained on PO vanc/IV flagyl
with persistent diarrhea.
.
# Anemia: Given guiac positive bilious secretions and stool,
coupled with slow drop in hct, likely slow bleeding from glottic
carcinoma. Mr. [**Known lastname 84573**] was transfused intermittently for hct
< 25.
.
# Thrombocytopenia: Drop to 90s by date of demise from 600 on
admission. Likely [**2-15**] tumor invasion, but initially could not
rule out HIT given heparin use. 4T's score was 3 and workup with
HIT antibody was currently not indicated. On [**11-12**], Mr.
[**Known lastname 84573**] complained of acute worsening shortness of breath. A
CTA was obtained and a HIT antibody was sent. The CTA was
negative for pulmonary embolism, and the HIT antibody was
negative.  Thrombocytopenia likely [**2-15**] tumor invasion of marrow
vs. drug effect. On date of demise, given thrombocytopenia,
zosyn was discontinued.
.
# Gastritis: Continue PPI and sucrafate, triggered [**2136-11-9**] for
emesis of bilious secretions with aspiration. Guiac positivity
is expected given gastritis/SCC. Standing antiemetics were
started and tube feeds were slowed.
.
# Penile lesion: On [**11-12**], a stage 3 penile ulcer was noted.
Urology and wound consults were obtained. Likely secondary to
anasarca and paraphimosis. [**Hospital1 **] wet-to-dry dressings were
started.

Medications on Admission:
-Metformin  1000 mg PO twice a day.
-Omeprazole  20 mg PO DAILY
-Dilaudid  2-4 mg PO every four hours as needed for pain.
-Colace 100 mg PO twice a day as needed for constipation.
-Senna  8.6 mg :  1-2 Tablets PO twice a day as needed for
constipation.

Discharge Medications:
NONE, patient died

Discharge Disposition:
Expired

Discharge Diagnosis:
Metastatic Non-Small Cell Lung Cancer
Glottic Squamous Cell Carcinoma
Sepsis secondary to HCAP
C diff infection

Discharge Condition:
Deceased

Discharge Instructions:
Deceased

Followup Instructions:
Deceased

                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
{'Persistent vomiting,Unspecified septicemia,Acute kidney failure, unspecified,Other severe protein-calorie malnutrition,Pneumonia due to Klebsiella pneumoniae,Acquired coagulation factor deficiency,Malignant pleural effusion,Intestinal infection due to Clostridium difficile,Malignant neoplasm of liver, secondary,Severe sepsis,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of other parts of bronchus or lung,Pathologic fracture of vertebrae,Other ascites,Malignant neoplasm of glottis,Helicobacter pylori [H. pylori],Unilateral paralysis of vocal cords or larynx, partial,Other specified disorders of penis,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Unspecified essential hypertension,Atrial fibrillation,Chronic post-thoracotomy pain,Acute gastritis, without mention of hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Stricture and stenosis of esophagus,Other dysphagia,Late effect of radiation,Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Redundant prepuce and phimosis,Thrombocytopenia, unspecified'}


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: Nausea

PRESENT ILLNESS: 74 year-old man with glottic squamous cell carcinomal s/p chemo
and XRT as well as T3N0Mx poorly differentiated carcinoma of the
lung in remission presenting after a recent hospitalization for
dysphagia with continued dysphagia and poor PO intake leading to
weakness.  He was discharged approximately a week before this
presentation and at that time was admitted for dysphagia.  He
had dilation of a relativley quite minor esophageal stricture
during that hospitalization and afterwards improved and was
discharged.  He reports that his swallowing is slightly better
but he is not able to take much food at all.  He reports his
appetite is very poor.  In the context of this poor intake he
reports he has gotten very week and though he reports a month or
so ago he could walk several blocks over the last weeks he does
not think he could do this. Aside from his weakness and poor
intake he reports chronic back pain on his left side, where he
had a previous surgery.  He has subjective fevers and chills and
reports chronic cough but this is nonproductive.  He does have
chronic production of sputum in his mouth that he does not feel
he can handle and swallow and spits in a basin throughout our
interview.  He denies odynophagia.  He also endorses chronic
anorexia and more recently having had some subjective fevers or
chills though he reports dysuria or localizing singns except for
his chronic, nonproductive cough and approximately two episodes
of loose stool a day, which he reports are immediately after he
eats.  He has mild headache. He denies abdominal pain, dysuria,
or flank pain.  He very rarely has nausea and will vomit with
dyspnea after vomiting.  He denies dyspnea at any other time.
Because of inability to manage these symptoms at home he
presented to the ED.

MEDICAL HISTORY: - Diabetes mellitus, type II
- Hypertension
- T3 N0 M0 glottic squamous cell carcinoma s/p chemoradiation
therapy
- Tracheostomy on [**2134-11-3**]
- PEG tube placed on [**2134-11-17**].
- Poorly differentiated large cell carcinoma T3N0MX in the left
upper lobe s/p left thoracotomy, partial decortication of lung,
left upper lobectomy, mediastinal lymphadenectomy, en bloc
resection of pericardium on [**2136-6-12**].
- Hospitalization for dysphagia a week previous with very minor
stricture that was dilated

MEDICATION ON ADMISSION: -Metformin  1000 mg PO twice a day.
-Omeprazole  20 mg PO DAILY
-Dilaudid  2-4 mg PO every four hours as needed for pain.
-Colace 100 mg PO twice a day as needed for constipation.
-Senna  8.6 mg :  1-2 Tablets PO twice a day as needed for
constipation.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
VS:  T 99.1, P 94, BP 116/60, RR 18, O2 99% on RA
Appearance: Thin elderly man appearing uncomfortable and
frequently spitting in a basin but non-toxic
Eyes: EOMI, Conjunctiva Clear
ENT: Dry appearing, Edentulous,no ulcers or erythema, no JVD,
chronic fibrotic changes of anterior throat (presumably from
radiation)
CV: Regular, normal S1 and S2, no systolic or diastolic murmurs,
no lower extremity edema appreciated
Respiratory: Breathing appears comfortable, diminished breath
sounds over the left upper chest, , diminished breath sounds at
the bases bilaterally with a few crackles at the left base on
auscultation, lidocaine patches on left back
GI: Soft, Nontender, nondistended, bowel sounds positive, No
hepatomegaly or splenomegaly
MSK: Tone WNL, Bulk WNL, Upper Extremity Strength 5/5 and
symmetrical, Lower Extremity Strength 4+/5 and symmetrical, No
cyanosis, No clubbing, No joint swelling
Neuro: CNII-XII intact, Normal attention, Fluent heavily
accented speech
Integument:  Warm,  dry, no rash
Psychiatric: Appears anxious but generally pleasant
Hematologic / Lymphatic: No Cervical [**Doctor First Name **], Thyroid WNL

FAMILY HISTORY: His mother died at age 85 of unclear causes.  Father died in
Siberia after being taken from family, unclear medical history.
Sisters and sons without notable problems at this time.

SOCIAL HISTORY: He quit smoking three years ago after 150-pack-year history.
Previously a teacher in [**Country 5881**].  History of heavy alcohol use
but quit in his 50s.   He used to be a teacher in [**Country 5881**]. Former
ETOH use, quit 20 years ago. Lives with his wife and son. 

### Response:
{'Persistent vomiting,Unspecified septicemia,Acute kidney failure, unspecified,Other severe protein-calorie malnutrition,Pneumonia due to Klebsiella pneumoniae,Acquired coagulation factor deficiency,Malignant pleural effusion,Intestinal infection due to Clostridium difficile,Malignant neoplasm of liver, secondary,Severe sepsis,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of other parts of bronchus or lung,Pathologic fracture of vertebrae,Other ascites,Malignant neoplasm of glottis,Helicobacter pylori [H. pylori],Unilateral paralysis of vocal cords or larynx, partial,Other specified disorders of penis,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Unspecified essential hypertension,Atrial fibrillation,Chronic post-thoracotomy pain,Acute gastritis, without mention of hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Stricture and stenosis of esophagus,Other dysphagia,Late effect of radiation,Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Redundant prepuce and phimosis,Thrombocytopenia, unspecified'}
