CHIEF COMPLAINT: Transferred for evaluation of left piriform sinus mass

PRESENT ILLNESS: 71M with multiple medical problems including a 59 pack year
smoking history, 45 year alcoholic hx and CABG, recently
discharged from [**Hospital3 **] for pneumothorax s/p chest tube
placement, now transferred from the same hospital for work-up
for a left piriform sinus mass, after presenting with difficulty
swallowing. Patient reports gradual dysphagia for 5 months,
first to solids, later to liquids. Immediately prior to
presentation to [**Hospital3 **], he was regurgitating baby food
(all he could tolerate) through his nasal passages. Subsequent
to this dysphagia, the patient experienced a 45 pound weight
loss over the past 5 months. He denied hematemesis, chest pain,
sob, palpitations, abd pain, hematuria or dysuria. CT of the
neck at [**Hospital3 **] showed a 3.6 cm mass in the L piriform
sinus. An EGD was unable to be completed due to severe
esophageal stricture. A modified barium study showed achalasia
and severe esophageal narrowing. The patient's course there was
additionally complicated by hypertension requiring IV meds,
given his intolerance for PO. The patient was transferred to
[**Hospital1 18**] for further work-up of this mass.

MEDICAL HISTORY: Diabetes
Hypertension
Coronary Artery Disease, s/p CABG x 5
Permanent Pacemaker for ?sick sinus/tachy brady
Peripheral Vascular Disease (AAA s/p repair)
COPD
Spontaneous Pneumothorax s/p chest tube
Colon Cancer s/p resection in approximately [**2102**]

MEDICATION ON ADMISSION: (Unsure of doses)
Amlodipine
Isosorbide
Digoxin
Toprol - XL
Lipitor
Actos
Metformin
KCl
Metformin
Percocet

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T98.3 BP 180/84 HR 76 R18 O2sat 92%RA
GEN Cachetic male in NAD, able to speak in full sentences
HEENT extremely poor dentition, few teeth in mouth, blackened
tongue; hardened immobile mass measuring about 2 inches can be
appreciated along the R lateral neck ( may be displacement of
anatomy)
HEART nl rate, S1S2, no gmr; due to emaciated status heart can
appreciate every heart
LUNGS CTA b/l no RRW
ABD sunken, concave, surgical scar, otherwise benign
EXT no cce

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient is not married. He does not have any children. He
reports he has been an alcoholic for the past 45 years. He now
drinks 2 glasses of wine per day. He has a 59 pack year smoking
history.
Carcinoma in situ of lip, oral cavity, and pharynx,Chronic airway obstruction, not elsewhere classified,Cachexia,Pressure ulcer, lower back,Other and unspecified alcohol dependence, unspecified,Paralytic ileus,Unspecified pleural effusion,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Fitting and adjustment of cardiac pacemaker,Anemia of other chronic disease,Aortocoronary bypass status,Tobacco use disorder,Personal history of malignant neoplasm of gastrointestinal tract, unspecified,Intestinal bypass or anastomosis status,Personal history of other diseases of circulatory system
Ca in situ oral cav/phar,Chr airway obstruct NEC,Cachexia,Pressure ulcer, low back,Alcoh dep NEC/NOS-unspec,Paralytic ileus,Pleural effusion NOS,DMII wo cmp nt st uncntr,Hypertension NOS,Ftng cardiac pacemaker,Anemia-other chronic dis,Aortocoronary bypass,Tobacco use disorder,Hx of GI malignancy NOS,Intestinal bypass status,Hx-circulatory dis NEC
Admission Date:  [**2107-7-20**]              Discharge Date:   [**2107-8-11**]

Date of Birth:  [**2036-4-3**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Transferred for evaluation of left piriform sinus mass

Major Surgical or Invasive Procedure:
Chest Tubes
Surgical Biopsy
Gastric Tube
Tracheostomy
Thoracentesis


History of Present Illness:
71M with multiple medical problems including a 59 pack year
smoking history, 45 year alcoholic hx and CABG, recently
discharged from [**Hospital3 **] for pneumothorax s/p chest tube
placement, now transferred from the same hospital for work-up
for a left piriform sinus mass, after presenting with difficulty
swallowing. Patient reports gradual dysphagia for 5 months,
first to solids, later to liquids. Immediately prior to
presentation to [**Hospital3 **], he was regurgitating baby food
(all he could tolerate) through his nasal passages. Subsequent
to this dysphagia, the patient experienced a 45 pound weight
loss over the past 5 months. He denied hematemesis, chest pain,
sob, palpitations, abd pain, hematuria or dysuria. CT of the
neck at [**Hospital3 **] showed a 3.6 cm mass in the L piriform
sinus. An EGD was unable to be completed due to severe
esophageal stricture. A modified barium study showed achalasia
and severe esophageal narrowing. The patient's course there was
additionally complicated by hypertension requiring IV meds,
given his intolerance for PO. The patient was transferred to
[**Hospital1 18**] for further work-up of this mass.


Past Medical History:
Diabetes
Hypertension
Coronary Artery Disease, s/p CABG x 5
Permanent Pacemaker for ?sick sinus/tachy brady
Peripheral Vascular Disease (AAA s/p repair)
COPD
Spontaneous Pneumothorax s/p chest tube
Colon Cancer s/p resection in approximately [**2102**]


Social History:
Patient is not married. He does not have any children. He
reports he has been an alcoholic for the past 45 years. He now
drinks 2 glasses of wine per day. He has a 59 pack year smoking
history.

Family History:
NC

Physical Exam:
VS T98.3 BP 180/84 HR 76 R18 O2sat 92%RA
GEN Cachetic male in NAD, able to speak in full sentences
HEENT extremely poor dentition, few teeth in mouth, blackened
tongue; hardened immobile mass measuring about 2 inches can be
appreciated along the R lateral neck ( may be displacement of
anatomy)
HEART nl rate, S1S2, no gmr; due to emaciated status heart can
appreciate every heart
LUNGS CTA b/l no RRW
ABD sunken, concave, surgical scar, otherwise benign
EXT no cce


Pertinent Results:
[**2107-7-21**] 06:15AM BLOOD Digoxin-0.7*
[**2107-7-21**] 06:15AM BLOOD Triglyc-72
[**2107-7-22**] 06:15AM BLOOD %HbA1c-5.7
[**2107-7-25**] 05:09AM BLOOD calTIBC-189* Hapto-155 Ferritn-300
TRF-145*
[**2107-7-29**] 06:33AM BLOOD Hapto-163
[**2107-7-21**] 06:15AM BLOOD Albumin-3.7 Calcium-9.4 Phos-2.8 Mg-1.4*
[**2107-7-22**] 12:40AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2
[**2107-7-22**] 06:15AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2
[**2107-7-23**] 09:07AM BLOOD Calcium-9.4 Phos-2.5* Mg-2.5
[**2107-7-24**] 05:28AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0
[**2107-7-25**] 05:09AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9 Iron-23*
[**2107-7-26**] 05:34AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.3
[**2107-7-27**] 04:31AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.2
[**2107-7-28**] 05:59AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.0
[**2107-7-29**] 06:33AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.9
[**2107-7-29**] 03:13PM BLOOD Calcium-PND Phos-PND Mg-PND
[**2107-7-21**] 06:15AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2107-7-21**] 03:40PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2107-7-22**] 12:40AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2107-7-21**] 06:15AM BLOOD CK(CPK)-58
[**2107-7-21**] 03:40PM BLOOD CK(CPK)-55
[**2107-7-22**] 12:40AM BLOOD CK(CPK)-86
[**2107-7-25**] 05:09AM BLOOD TotBili-0.4
[**2107-7-29**] 06:33AM BLOOD TotBili-0.5
[**2107-7-21**] 06:15AM BLOOD estGFR-Using this
[**2107-7-29**] 06:33AM BLOOD estGFR-Using this
[**2107-7-21**] 06:15AM BLOOD Glucose-129* UreaN-6 Creat-1.0 Na-139
K-2.9* Cl-101 HCO3-26 AnGap-15
[**2107-7-22**] 12:40AM BLOOD Glucose-158* UreaN-16 Creat-1.0 Na-141
K-3.9 Cl-104 HCO3-24 AnGap-17
[**2107-7-22**] 06:15AM BLOOD Glucose-146* UreaN-17 Creat-1.0 Na-141
K-3.8 Cl-105 HCO3-26 AnGap-14
[**2107-7-23**] 09:07AM BLOOD Glucose-153* UreaN-27* Creat-1.0 Na-144
K-3.6 Cl-109* HCO3-29 AnGap-10
[**2107-7-24**] 05:28AM BLOOD Glucose-195* UreaN-21* Creat-0.9 Na-141
K-3.6 Cl-106 HCO3-29 AnGap-10
[**2107-7-25**] 05:09AM BLOOD Glucose-224* UreaN-16 Creat-0.7 Na-142
K-3.5 Cl-107 HCO3-28 AnGap-11
[**2107-7-26**] 05:34AM BLOOD Glucose-193* UreaN-16 Creat-0.8 Na-141
K-4.0 Cl-109* HCO3-28 AnGap-8
[**2107-7-27**] 04:31AM BLOOD Glucose-121* UreaN-16 Creat-0.8 Na-142
K-4.0 Cl-109* HCO3-30 AnGap-7*
[**2107-7-28**] 05:59AM BLOOD Glucose-161* UreaN-15 Creat-0.8 Na-139
K-4.0 Cl-106 HCO3-30 AnGap-7*
[**2107-7-29**] 06:33AM BLOOD Glucose-160* UreaN-13 Creat-0.8 Na-137
K-4.3 Cl-104 HCO3-30 AnGap-7*
[**2107-7-29**] 03:13PM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
[**2107-7-25**] 05:09AM BLOOD Ret Aut-0.8*
[**2107-7-29**] 06:33AM BLOOD Ret Aut-1.2
[**2107-7-21**] 06:15AM BLOOD Plt Ct-209
[**2107-7-22**] 06:15AM BLOOD Plt Ct-233
[**2107-7-23**] 09:07AM BLOOD Plt Ct-175
[**2107-7-23**] 09:35PM BLOOD PT-11.5 PTT-47.5* INR(PT)-1.0
[**2107-7-24**] 05:28AM BLOOD Plt Ct-151
[**2107-7-25**] 05:09AM BLOOD PT-11.8 PTT-29.8 INR(PT)-1.0
[**2107-7-25**] 05:09AM BLOOD Plt Ct-136*
[**2107-7-26**] 05:34AM BLOOD Plt Ct-136*
[**2107-7-27**] 04:31AM BLOOD Plt Ct-158
[**2107-7-28**] 05:59AM BLOOD PT-11.6 PTT-27.8 INR(PT)-1.0
[**2107-7-28**] 05:59AM BLOOD Plt Ct-153
[**2107-7-29**] 06:33AM BLOOD Plt Ct-135*
[**2107-7-29**] 03:13PM BLOOD Plt Ct-PND
[**2107-7-21**] 06:15AM BLOOD WBC-7.2 RBC-3.90* Hgb-11.7* Hct-34.0*
MCV-87 MCH-29.9 MCHC-34.4 RDW-15.8* Plt Ct-209
[**2107-7-22**] 06:15AM BLOOD WBC-12.8*# RBC-3.62* Hgb-10.7* Hct-31.2*
MCV-86 MCH-29.6 MCHC-34.4 RDW-15.9* Plt Ct-233
[**2107-7-23**] 09:07AM BLOOD WBC-9.3 RBC-3.06* Hgb-9.2* Hct-26.7*
MCV-87 MCH-30.1 MCHC-34.5 RDW-16.1* Plt Ct-175
[**2107-7-23**] 12:00PM BLOOD Hct-30.6*
[**2107-7-23**] 09:35PM BLOOD Hct-28.0*
[**2107-7-24**] 05:28AM BLOOD WBC-7.6 RBC-3.12* Hgb-9.3* Hct-27.6*
MCV-89 MCH-29.7 MCHC-33.6 RDW-15.8* Plt Ct-151
[**2107-7-24**] 11:39AM BLOOD Hct-28.8*
[**2107-7-24**] 11:03PM BLOOD Hct-28.0*
[**2107-7-25**] 05:09AM BLOOD WBC-6.2 RBC-3.02* Hgb-9.0* Hct-26.8*
MCV-89 MCH-29.7 MCHC-33.4 RDW-15.7* Plt Ct-136*
[**2107-7-25**] 04:47PM BLOOD Hct-28.5*
[**2107-7-26**] 05:34AM BLOOD WBC-6.0 RBC-2.64* Hgb-7.7* Hct-23.3*
MCV-88 MCH-29.2 MCHC-33.1 RDW-15.8* Plt Ct-136*
[**2107-7-26**] 09:37AM BLOOD Hct-22.0*
[**2107-7-27**] 12:13AM BLOOD Hct-25.7*
[**2107-7-27**] 04:31AM BLOOD WBC-7.5 RBC-2.82* Hgb-8.4* Hct-25.7*
MCV-91 MCH-29.9 MCHC-32.9 RDW-16.1* Plt Ct-158
[**2107-7-28**] 05:59AM BLOOD WBC-7.6 RBC-2.89* Hgb-9.1* Hct-25.6*
MCV-89 MCH-31.4 MCHC-35.4* RDW-15.8* Plt Ct-153
[**2107-7-28**] 12:54PM BLOOD Hct-27.4*
[**2107-7-29**] 06:33AM BLOOD WBC-5.7 RBC-2.68* Hgb-8.2* Hct-23.7*
MCV-88 MCH-30.5 MCHC-34.6 RDW-16.0* Plt Ct-135*
[**2107-7-29**] 03:13PM BLOOD WBC-PND RBC-PND Hgb-PND Hct-PND MCV-PND
MCH-PND MCHC-PND Plt Ct-PND
.
CXR ([**7-21**]): Single chest AP performed to evaluate pneumothorax,
the heart and mediastinum are midline. A pacer  pack is noted in
the left infraclavicular area. The left lung is expanded. There
is the large pneumothorax on the right with total collapse of
the right lower lobe, partial collapse of the left middle lobe
and the right upper lobe. There has not been a significant shift
in the mediastinum however. There are no previous films for
comparison.
.
CXR ([**7-23**]): Two views. Comparison with the previous study done
[**2107-7-22**]. A second chest tube has been inserted on the right. The
second chest tube terminates medially near the right lung apex.
A right pneumothorax is no longer apparent. There is interval
increase in subcutaneous emphysema on that side. The lungs
appear clear. There is interval decrease in a small right
effusion. The heart and mediastinal structures are unchanged. A
bipolar transvenous pacemaker remains in place. A PICC line has
been pulled back and now terminates at the level of the superior
vena cava.

IMPRESSION: Right pneumothorax no longer apparent post placement
of a second right chest tube. PICC line has been pulled back.
.
CXR ([**7-29**]): CHEST, PA AND LATERAL: Comparison is made to the
prior day. Patient is status post CABG. A right-sided PICC line
and dual lead pacemaker are unchanged. Cardiac and mediastinal
contours are also unchanged. There is no pneumothorax.

Density along the right lateral chest wall, at the site of the
recent catheter tract, has a similar appearance. More
inferiorly, there is greater right lower lobe opacity which may
represent loculated effusion, atelectasis, or consolidation. In
addition, free-flowing bilateral pleural effusions are
increased.

IMPRESSION: No evidence of pneumothorax. Increased effusions and
right lower lobe opacity.
.
Rest MIBI ([**2107-7-22**]): Following injection of MIBI while patient
was at rest and experiencing chest pain, static and gated SPECT
images were obtained and analyzed. Gated images and the rest of
the test including stress images were not performed due to
patients pulmonary and blood pressure problems.

Imaging Protocol:

This study was interpreted using the 17-segment myocardial
perfusion model. The image quality is good. The left ventricular
cavity size is normal. There are no perfusion defects seen in
the rest images.

IMPRESSION: Normal rest myocardial perfusion. Ejection fraction
and stress
images not obtained.
.
CT Neck ([**2107-7-27**]): FINDINGS: There is an ill-defined,
heterogeneous, enhancing mass filling the left piriform sinus
with the bulk centered at the C5 level on the lateral scout
film. This mass extends into the left tonsillar space and has
several central areas of hypodensity consistent with necrosis.
There is associated narrowing and compression of the airway at
the level of the hyoid bone and more inferiorly at the
valleculae. At its largest size at the C5 level, this mass
measures 4.8 x 3.0 cm in the axial plane. The inferior portion
of the mass abuts the superior aspect of the thyroid gland.
There is no associated neck pathologic lymphadenopathy. There is
diffuse atherosclerotic calcification at the aortic arch and of
the carotid arteries bilaterally. The cavernous portions of the
carotid arteries are especially calcified. Limited views of the
inferior portion of the brain are unremarkable. Incidental note
is made of extensive degenerative, multilevel disease with mild
narrowing of the spinal canal at the C5 level secondary to
posterior osteophytosis. Limited views of the lung apices
demonstrate striking centrilobular emphysematous changes with
several peripheral bullae noted. Furthermore, there is a
partially imaged tubular structure extending along the anterior
aspect of the right lobe.

IMPRESSION: Large, heterogeneously enhancing suspicious mass
centered within the left piriform sinus at the C5 level
suspicious for underlying malignancy such as squamous cell
carcinoma. Encroachment of the airway at the inferior border of
the hyoid bone. No pathologic associated lymphadenopathy within
the neck.
.
CTA Abdomen & Pelvis ([**2107-7-27**]): IMPRESSION:
1. No evidence for retroperitoneal hematoma.
2. Status post abdominal aneurysm repair. This likely explains
the unusual appearance of the aorta at the level of the renal
arteries where a waist is seen as well as a left lateral
wide-mouthed focal outpouching. Comparison with prior outside
studies would be helpful to ensure stability of this finding.
High grade stenosis of the left renal artery and celiac trunc as
described above.
3. Small-to-moderate bilateral pleural effusions.
4. Small left kidney with perfusion abnormality likely due to
compromise of the left renal artery by the aneurysm.
5. Calcified granulomas in the spleen and liver.
6. Left hydrocele and presacral fluid of uncertain clinical
significance.
7. 3D reformations were not available at the time of this
dictation. An addendum will be added once they have become
available.
.
Echo ([**2107-7-26**]): Conclusions:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
5-10 mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size and systolic function (LVEF>55%).
Regional left ventricular wall motion is normal. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. 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 to
moderate ([**2-8**]+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.

IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved
biventricular systolic function. Mild-moderate mitral
regurgitation. Moderate pulmonary hypertension. Mildly dilated
ascending aorta.

PLEURAL FLUID: exudative, negative for malignant cells.



Brief Hospital Course:
71 y.o. male w/ MMP including extensive alcohol and smoking hx,
transferred from an outside hospital with a 3.5 cm piriform
sinus mass and right tension PTX. The following issues were
investigated during this hospitalization:
.
# PTX: Patient had had a spontaneous PTX at the OSH, which per
CXR report on transfer, had resolved s/p chest tube placement.
Thus, the PTX observed on arrival was felt to be recurrent
rather than persistent. Thoracic surgery was consulted and the
patient eventually received two chest tubes with resolution of
the pneumothorax after removal of the chest tubes. Patient was
maintained on supplemental oxygen with appropriate saturation
for the remainder of his hospitalization.
.
# Pirifrom Mass: Per pathology, squamous cell carcinoma, patient
has history of heavy smoking and alcohol. ENT was consulted and
though determined to be a high risk surgical candidate given
cardiac history, but otherwise medically cleared, the patient
underwent biopsy. Tracheostomy was perfomed as well. Given the
patient's inability to swallow, he was made NPO and started on
TPN before eventual G tube placement.  The tracheostomy was
uncomplicated; but it was decided to transfer the patient to the
MICU for close oxygen monitoring given his multiple
comorbidities. Upon transfer back to the floor, he underwent
several speech and swallow evaluations. Although initially he
was deemed safe for comfort POs (coffee, water sips), subsequent
evaluations demonstrated that he has a high risk of aspiration.
Thus, he is NPO with only mouth swabs and ice chips.

  The patient must see radiation oncology (Dr [**Last Name (STitle) 35885**] [**Telephone/Fax (1) 73095**]), Dr [**First Name (STitle) **] (ENT) and Dr [**Last Name (STitle) **] (Oncology) at discharge.
.
Respiratory failure: The patient did well after his tracheostomy
and quickly transitioned to trach mask.  There was concern for
developing pneumonia on the R lobe of the lung and for this
reason unasyn and vancomycin were started. He completed a 10
course of vancomycin and zosyn, although all cultures remained
negative: urine, blood, sputum, and pleural fluid. He underwent
thoracentesis which yielded exudative fluid with [**Numeric Identifier 73096**] RBCs and
no malignant cells.
.
# Anemia: Hematocrit gradually trended down from admission with
no clear source. Patient had brown, heme negative stool. He did
not have hematemesis or hemoptysis. Hemolysis labs were
negative. Given abdominal bruit on exam with history of AAA s/p
repair, an endoleak was considered, but there was no evidence of
RP bleed on CTA. Iron studies pointed to anemia of chronic
disease. The patient received several blood transfusions for
continuously dropping hematocrit. For the past 14 days prior to
discharge, his hematocrit stabilized and had no further changes.
.
# HTN: Poorly-controlled and chronically elevated. Furthermore,
patient was unable to tolerate PO medications [**3-11**] mass. Patient
was not symptomatic with this hypertension and was continued on
IV/TD antihypertensives with SBP goal of 160-
170: permissive hypertension given chronic elevation as an
outpatient.
.
# Arrythmia: Patient has pacemaker and was on Digoxin. The
indication was not documented in his transfer paperwork, but
according to the history given by the patient, the indication
appeared to be tachy-brady/sick sinus. Patient was on Digoxin as
an outpatient and serum levels were appropriate. The patient
remained rate-controlled and in sinus on successive EKGs. On
telemetry, he had occasional PVCs. He had one run of 7 beats VT
which resolved spontaneously and during which the patient
remained asymptomatic.
.
# Diabetes: Well-controlled with HbA1C of 5.7 during this
hospitalization. Patient was continued on an Insulin sliding
scale as well as received Insulin in his TPN. After TPN was
discontinued, once his tube feeds were at goal, his sugars
became elevated >200. He was then transitioned to glargine as
well as RISS, with better sugar control.
.
# Fevers: In the week prior to d/c, he spiked fevers to 101
twice. He was pancultured but all cultures were negative. He was
asymptomatic. It was thought that these were most likely tumor
fevers. He has remained afebrile for >48 hours and is ready for
discharge.


Medications on Admission:
(Unsure of doses)
Amlodipine
Isosorbide
Digoxin
Toprol - XL
Lipitor
Actos
Metformin
KCl
Metformin
Percocet


Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: One (1)  PO Q8H
(every 8 hours) as needed for fever,pain.
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours).
3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q2H (every 2 hours) as needed.
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 14 days.
5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
6. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. HydrALAzine 20 mg IV Q6H:PRN SBP > 160
8. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Nitroglycerin 2 % Ointment Sig: One (1)  Transdermal Q6H
(every 6 hours) as needed for BP>150.
13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
15. Budesonide 0.25 mg/2 mL Solution for Nebulization Sig: One
(1) ML Inhalation [**Hospital1 **] ().
16. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily) for 14 days.
17. Insulin sliding scale
18. Tracheostomy care per protocol
19. Lortab Elixir 2.5-167 mg/5 mL Solution Sig: [**2-8**]  PO every
4-6 hours as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]

Discharge Diagnosis:
Left Piriform Sinus Mass: Squamous Cell Carcinoma
Right Pneumothorax
Diabetes
Hypertension


Discharge Condition:
Stable


Discharge Instructions:
You were seen and evaluated for a tumor in your throat as well
as a collapsed lung. A biopsy was performed of this tumor and it
is a cancer that has not spread (squamous cell carcinoma). You
had two chest tubes placed in order to treat your collapsed lung
and this was successful. A tracheostomy was placed in your
throat so you can breathe easily. You cannot take anything per
mouth except ice chips, as you run the risk of a fatal pneumonia
if you do that. You are now being discharged.

Take all of your medications as directed. You need to see
radiation oncology as directed, as well as the other doctors
that saw [**Name5 (PTitle) **] in the hospital. See the appointments below.

Keep all of your follow-up appointments.

Call your doctor or go to the ER for any of the following:
fevers/chills, nausea/vomiting, chest pain, shortness of breath
or any other concerning symptoms.

Followup Instructions:
Call your primary care physician and schedule an appointment in
[**8-16**] days.

You need also to see:
DR [**Last Name (STitle) **] (radiation Oncology) [**Telephone/Fax (1) 73097**]

DR [**First Name (STitle) **] : [**8-25**], at 1 pm. (ENT) An appointment has been made
for you.
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2107-8-18**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7706**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2107-8-18**] 10:30





Name:  [**Known lastname 12362**],[**Known firstname **] J              Unit No:   [**Numeric Identifier 12363**]

Admission Date:  [**2107-7-20**]              Discharge Date:   [**2107-8-11**]

Date of Birth:  [**2036-4-3**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 161**]
Addendum:
Re- Patient's fevers of unknown source: these occurred while the
patient was still on his regimen of vancomycin and zosyn for ten
days as documented above under respiratory. AS stated above,
they were intermittent, and resolved spontaneously. The patient
was afebrile and asymptomatic for > 48 hours prior to discharge.

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2215**] Northeast - [**Location (un) **]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**]

Completed by:[**2107-8-12**]
{'Carcinoma in situ of lip, oral cavity, and pharynx,Chronic airway obstruction, not elsewhere classified,Cachexia,Pressure ulcer, lower back,Other and unspecified alcohol dependence, unspecified,Paralytic ileus,Unspecified pleural effusion,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Fitting and adjustment of cardiac pacemaker,Anemia of other chronic disease,Aortocoronary bypass status,Tobacco use disorder,Personal history of malignant neoplasm of gastrointestinal tract, unspecified,Intestinal bypass or anastomosis status,Personal history of other diseases of circulatory system'}


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: Transferred for evaluation of left piriform sinus mass

PRESENT ILLNESS: 71M with multiple medical problems including a 59 pack year
smoking history, 45 year alcoholic hx and CABG, recently
discharged from [**Hospital3 **] for pneumothorax s/p chest tube
placement, now transferred from the same hospital for work-up
for a left piriform sinus mass, after presenting with difficulty
swallowing. Patient reports gradual dysphagia for 5 months,
first to solids, later to liquids. Immediately prior to
presentation to [**Hospital3 **], he was regurgitating baby food
(all he could tolerate) through his nasal passages. Subsequent
to this dysphagia, the patient experienced a 45 pound weight
loss over the past 5 months. He denied hematemesis, chest pain,
sob, palpitations, abd pain, hematuria or dysuria. CT of the
neck at [**Hospital3 **] showed a 3.6 cm mass in the L piriform
sinus. An EGD was unable to be completed due to severe
esophageal stricture. A modified barium study showed achalasia
and severe esophageal narrowing. The patient's course there was
additionally complicated by hypertension requiring IV meds,
given his intolerance for PO. The patient was transferred to
[**Hospital1 18**] for further work-up of this mass.

MEDICAL HISTORY: Diabetes
Hypertension
Coronary Artery Disease, s/p CABG x 5
Permanent Pacemaker for ?sick sinus/tachy brady
Peripheral Vascular Disease (AAA s/p repair)
COPD
Spontaneous Pneumothorax s/p chest tube
Colon Cancer s/p resection in approximately [**2102**]

MEDICATION ON ADMISSION: (Unsure of doses)
Amlodipine
Isosorbide
Digoxin
Toprol - XL
Lipitor
Actos
Metformin
KCl
Metformin
Percocet

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T98.3 BP 180/84 HR 76 R18 O2sat 92%RA
GEN Cachetic male in NAD, able to speak in full sentences
HEENT extremely poor dentition, few teeth in mouth, blackened
tongue; hardened immobile mass measuring about 2 inches can be
appreciated along the R lateral neck ( may be displacement of
anatomy)
HEART nl rate, S1S2, no gmr; due to emaciated status heart can
appreciate every heart
LUNGS CTA b/l no RRW
ABD sunken, concave, surgical scar, otherwise benign
EXT no cce

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient is not married. He does not have any children. He
reports he has been an alcoholic for the past 45 years. He now
drinks 2 glasses of wine per day. He has a 59 pack year smoking
history. 

### Response:
{'Carcinoma in situ of lip, oral cavity, and pharynx,Chronic airway obstruction, not elsewhere classified,Cachexia,Pressure ulcer, lower back,Other and unspecified alcohol dependence, unspecified,Paralytic ileus,Unspecified pleural effusion,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Fitting and adjustment of cardiac pacemaker,Anemia of other chronic disease,Aortocoronary bypass status,Tobacco use disorder,Personal history of malignant neoplasm of gastrointestinal tract, unspecified,Intestinal bypass or anastomosis status,Personal history of other diseases of circulatory system'}
