CHIEF COMPLAINT: Nausea, Vomiting

PRESENT ILLNESS: 40 yo F with unresectable esophageal cancer who was recently
discharged from the hospital secondary to right neck pain. She
was then discharged on [**12-1**]. Notes indicate the patient
re-presented on [**12-4**] with the chief complaint of "strange
sounding airway" and dyspnea. She was found to have a soft
tissue infection lateral to the esophagus that likely represents
microperforation, for which she was started on abx, and she
required surgical tracheostomy for upper airway obstruction
caused by her esophageal cancer.
.
Additionally, her MICU course was remarkable for persistent
tachycardia and mild hypotension. Her heart rate remains 120s at
rest with brief episodes of rates as high as 150 when she is out
of bed, sinus tachycardia at all times. Her blood pressure has
ranged from 70s-90s systolic, which does not appear to be new,
as OMR notes document systolic blood pressures in the high
80s-low 90s at multiple visits. Evaluation as to the cause of
tachycardia has included TSH (low normal), with fT4 pending;
echo (nml LV and RV function, no echocardiographic signs of
hemodynamically significant PE); ABG 7.46/41/114 was with pt
breathing room air for 10 minutes, indicating that there is no
apparent A-a gradient; a random cortisol level was low, but
responded appropriately to cosyntropin. Since she appears well,
with good skin turgor and adequate urine output, despite the
tachycardia and hypotension, she was transferred out of the ICU.

MEDICAL HISTORY: #. Invasive Esophageal Squamous Squamous Cell Carcinoma:
- [**2129-11-1**]: Pt arrived in America from [**Country 3587**]
- [**2129-11-2**]: Pt evaluated for Odynophagia, tx with Prilosec
- 11/26-30/07: Admitted fo Esophageal Web Dilations that
relieved symptoms
- [**1-4**]: Symptoms of odynophagia returned
- [**2130-2-12**]: Referred to ENT for recurrent cervial web at C4-5
- [**2130-4-14**]: Esophageal Dilation under general anesthesia
- [**5-4**]: ENT consult for bilateral submandibular pain
- 5/29-30/08: Two subsequent attempts at dilation unsucessful
- [**6-4**]: PEG placed for FTT
- [**2130-6-7**]: Bx confirms Invasive Squamous Cell CA
- [**2130-6-20**]:
diagnosed [**2130-5-28**] in
setting of esophageal stricture
- high cervical esophageal lesion not resectable
- completed therapy with Cetuximab and radiation therapy
# Anemia
# Upper esophageal and pharyngeal stricture; s/p PEG
# Shoulder Pain
# Lung lesion - NOS
# Chronic pain from radiation.
# Nausea and vomiting.
# PEG tube site candidiasis

MEDICATION ON ADMISSION: Tylenol occasionaly
Lactulose 30 cc tid prn
Methadone 2.5 mg [**Hospital1 **]
.
Upon transfer out of the MICU:
.
Heparin 5000 UNIT SC TID
Insulin SC
Lactulose 30 mL PO Q8H:PRN  Order date: [**12-12**] @ 0050
Levofloxacin 750 mg IV Q24H day 1 = [**12-6**]
Methadone 2.5 mg PO BID
Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H day 1 = [**12-6**]
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Nortriptyline 25 mg NG HS
Ondansetron 8 mg IV Q 8H
Pantoprazole 40 mg IV Q12H
Docusate Sodium (Liquid) 100 mg PO BID PRN
Prochlorperazine 25 mg PR Q12H
Fluconazole 200 mg NG Q24H day 1 = [**12-6**]
Gabapentin 300 mg PO QAM & 600 mg PO QPM
Vancomycin 1000 mg IV Q 12H day 1 = [**12-6**]

ALLERGIES: Roxicet

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
VS: T = 99.4 P = 120 BP = 108/60 RR 16, O2Sat:100%
GENERAL: Young female who appears older than her stated age.
She is appears tired and worn.
Mentation: Alert but restricted affect. Does not smile.
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Bibasilar crackles
Cardiovascular: tachy, nl. S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
PEG site C/D/I no odor. Appears better than during previous
admission.
Genitourinary:
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-DTRs: 2+ biceps, triceps,
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
Psychiatric:  Very limited affect with rare brightening.
.
PHYSICAL EXAM UPON ARRIVAL TO THE FLOOR: [**12-11**]
Vitals: T97.9 BP96/50 HR126 RR19 O2Sat100% on 35% trach collar
GEN: Thin, tired-appearing [**Location 7972**] woman
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea with sutured trach cannula
COR: tachy, no M/G/R, normal S1 S2, radial pulses +2
PULM: bronchial [**Location 1440**] sounds throughout
ABD: Soft, NT, ND, +BS, no HSM, no masses. PEG in place in LUQ
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: Normal turgor. No jaundice, cyanosis, or gross dermatitis.
No ecchymoses.

FAMILY HISTORY: There is no history in her family of heart disease, gastric
cancer, esophageal cancer or colon cancer or inflammatory bowel
disease.

SOCIAL HISTORY: The patient lives in [**Location 686**], MA with her cousin [**Name (NI) **] [**Name (NI) **],
who is her HCP. The patient is initially from [**Country 11660**]
islands, she is not currently working.
Tobacco: None
ETOH: None
Illicits: None
Malignant neoplasm of cervical esophagus,Perforation of esophagus,Secondary malignant neoplasm of lung,Malignant pleural effusion,Parapharyngeal abscess,Pneumonia, organism unspecified,Unspecified disease of the jaws,Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Anemia in neoplastic disease,Drug induced neutropenia,Penicillins causing adverse effects in therapeutic use
Mal neo cervical esophag,Perforation of esophagus,Secondary malig neo lung,Malignant pleural effusn,Parapharyngeal abscess,Pneumonia, organism NOS,Jaw disease NOS,Abn react-radiotherapy,Accident in place NEC,Anemia in neoplastic dis,Drug induced neutropenia,Adv eff penicillins
Admission Date:  [**2130-12-4**]              Discharge Date:   [**2131-1-19**]

Date of Birth:  [**2090-5-18**]             Sex:   F

Service: MEDICINE

Allergies:
Roxicet

Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
Nausea, Vomiting

Major Surgical or Invasive Procedure:
Tracheostomy
thoracentesis
Left VATS
Mechanical Ventilation


History of Present Illness:
40 yo F with unresectable esophageal cancer who was recently
discharged from the hospital secondary to right neck pain. She
was then discharged on [**12-1**]. Notes indicate the patient
re-presented on [**12-4**] with the chief complaint of "strange
sounding airway" and dyspnea. She was found to have a soft
tissue infection lateral to the esophagus that likely represents
microperforation, for which she was started on abx, and she
required surgical tracheostomy for upper airway obstruction
caused by her esophageal cancer.
.
Additionally, her MICU course was remarkable for persistent
tachycardia and mild hypotension. Her heart rate remains 120s at
rest with brief episodes of rates as high as 150 when she is out
of bed, sinus tachycardia at all times. Her blood pressure has
ranged from 70s-90s systolic, which does not appear to be new,
as OMR notes document systolic blood pressures in the high
80s-low 90s at multiple visits. Evaluation as to the cause of
tachycardia has included TSH (low normal), with fT4 pending;
echo (nml LV and RV function, no echocardiographic signs of
hemodynamically significant PE); ABG 7.46/41/114 was with pt
breathing room air for 10 minutes, indicating that there is no
apparent A-a gradient; a random cortisol level was low, but
responded appropriately to cosyntropin. Since she appears well,
with good skin turgor and adequate urine output, despite the
tachycardia and hypotension, she was transferred out of the ICU.



Past Medical History:
#. Invasive Esophageal Squamous Squamous Cell Carcinoma:
- [**2129-11-1**]: Pt arrived in America from [**Country 3587**]
- [**2129-11-2**]: Pt evaluated for Odynophagia, tx with Prilosec
- 11/26-30/07: Admitted fo Esophageal Web Dilations that
relieved symptoms
- [**1-4**]: Symptoms of odynophagia returned
- [**2130-2-12**]: Referred to ENT for recurrent cervial web at C4-5
- [**2130-4-14**]: Esophageal Dilation under general anesthesia
- [**5-4**]: ENT consult for bilateral submandibular pain
- 5/29-30/08: Two subsequent attempts at dilation unsucessful
- [**6-4**]: PEG placed for FTT
- [**2130-6-7**]: Bx confirms Invasive Squamous Cell CA
- [**2130-6-20**]:
diagnosed [**2130-5-28**] in
setting of esophageal stricture
- high cervical esophageal lesion not resectable
- completed therapy with Cetuximab and radiation therapy
# Anemia
# Upper esophageal and pharyngeal stricture; s/p PEG
# Shoulder Pain
# Lung lesion - NOS
# Chronic pain from radiation.
# Nausea and vomiting.
# PEG tube site candidiasis


Social History:
The patient lives in [**Location 686**], MA with her cousin [**Name (NI) **] [**Name (NI) **],
who is her HCP. The patient is initially from [**Country 11660**]
islands, she is not currently working.
Tobacco: None
ETOH: None
Illicits: None


Family History:
There is no history in her family of heart disease, gastric
cancer, esophageal cancer or colon cancer or inflammatory bowel
disease.


Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T = 99.4 P = 120 BP = 108/60 RR 16, O2Sat:100%
GENERAL: Young female who appears older than her stated age.
She is appears tired and worn.
Mentation: Alert but restricted affect. Does not smile.
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Bibasilar crackles
Cardiovascular: tachy, nl. S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
PEG site C/D/I no odor. Appears better than during previous
admission.
Genitourinary:
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-DTRs: 2+ biceps, triceps,
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
Psychiatric:  Very limited affect with rare brightening.
.
PHYSICAL EXAM UPON ARRIVAL TO THE FLOOR: [**12-11**]
Vitals: T97.9 BP96/50 HR126 RR19 O2Sat100% on 35% trach collar
GEN: Thin, tired-appearing [**Location 7972**] woman
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea with sutured trach cannula
COR: tachy, no M/G/R, normal S1 S2, radial pulses +2
PULM: bronchial [**Location 1440**] sounds throughout
ABD: Soft, NT, ND, +BS, no HSM, no masses. PEG in place in LUQ
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: Normal turgor. No jaundice, cyanosis, or gross dermatitis.
No ecchymoses.

Pertinent Results:
[**2130-12-4**] Neck CT:
1. No mass lesions are detected within the airway to explain
stridorous
breathing.
2. Fluid again noted within the esophagus in the region of the
thyroid gland. Also noted on prior study, possibly relating to
region of stricture.
3. Slight increase in cavitary lesion within the left lung apex.


NOTE ADDED AT ATTENDING REVIEW: There is a collection of air in
the right
neck, apparently just lateral to the esophagus, but possibly
within a dilated esophagus, best seen on images 34-37 of series
2. In this location it raises the possibility of an esophageal
perforation. Since it is difficult to determine the location of
the lateral margin of the esophagus, it is difficult to
distinguish an extraluminal collection from dilatation of the
organ. An MR examination may be helpful.

There is induration of the adjacent tissues, which could be a
consequence of local infection, but also could arise as a result
of prior radiation.
.
[**2130-12-4**] CT CHEST
1. Small pharyngeal or paralaryngeal abscess, phlegmon or
malignancy has
grown over two weeks. If the lesion is inflammatory it suggests
ulceration in the hypopharynx/upper esohagus. Please see report
of today's neck CT.
2. Slow growth of small left upper lobe lung cavity and a tiny
right lower
lobe lesion as well as a new left lower lobe lesion are
concerning for
multifocal metastases, or slow spread of an indolent infection.
Small growing
left pleural mass is more characteristic of metastasis.
.
[**2130-12-6**] MRI SOFT TISSUE NECK, W/O & W/CONTRAST
IMPRESSION: 12 x 8 mm collection of air with small amount of
fluid just
anterior to the right aspect of the esophagus at the level of
the thyroid
gland which likely represents esophageal perforation and/or
abscess.
Additional considerations include esophageal diverticulum,
although less
likely.
.
TTE (Complete) Done [**2130-12-11**] at 2:38:57 PM
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-5 mmHg. 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 aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2130-2-28**], no
change.
.
[**2130-12-12**] CTA CHEST
1. No pulmonary embolism.
2. New left posterior pleural lesion. Although this would be an
atypical
location for an esophageal carcinoma metastasis, the possibility
of malignancy cannot be totally excluded and PET CT may provide
additional diagnostic information.
3. Increase in right lower lobe and left upper lobe opacities
and new left
lower lobe opacity most likely represent infectios process; from
the same or different [**Doctor Last Name 360**]
4. Resolution of fluid collection in the posterior
parapharyngeal space
compared to the CT of [**2130-12-4**]., now fluid filled
.
[**2130-12-17**] CXR
Tracheostomy tube is again visualized. There is new left small
pleural effusion with volume loss in the left lower lobe. An
early infiltrate in this region cannot be totally excluded.
Otherwise, the lungs are clear.
.
LABWORK:
[**2130-12-4**] 08:42PM   GLUCOSE-112* UREA N-13 CREAT-0.5 SODIUM-133
POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-29 ANION GAP-17
[**2130-12-4**] 08:42PM   estGFR-Using this
[**2130-12-4**] 08:42PM   HCG-<5
[**2130-12-4**] 08:42PM   CALCIUM-9.2 PHOSPHATE-2.4* MAGNESIUM-2.0
[**2130-12-4**] 08:42PM   WBC-9.6 RBC-3.35* HGB-9.8* HCT-28.8* MCV-86
MCH-29.2 MCHC-34.0 RDW-14.7
[**2130-12-4**] 08:42PM   NEUTS-81.3* LYMPHS-12.0* MONOS-5.8 EOS-0.8
BASOS-0.1
[**2130-12-4**] 08:42PM   PLT COUNT-672*
[**2130-12-4**] 08:42PM   PT-14.3* PTT-25.5 INR(PT)-1.2*
.
Hematology
  COMPLETE BLOOD COUNT	WBC	RBC	Hgb	Hct	MCV	MCH	MCHC	RDW	Plt Ct
[**2131-1-19**] 12:00AM
	4.8	3.02*	9.5*	26.6*	88	31.4	35.8*	13.4	377
Source: Line-PICC
[**2131-1-18**] 12:00AM
	4.7	3.14*	9.5*	26.8*	85	30.4	35.6*	13.9	356
Source: Line-TLCVL
[**2131-1-17**] 12:00AM
	5.4	3.38*	10.2*	29.4*	87	30.1	34.6	13.8	368
Source: Line-PICC
[**2131-1-16**] 12:00AM
	4.0	3.51*	10.6*	30.7*	88	30.2	34.6	14.0	359
Source: Line-PICC
[**2131-1-15**] 02:04AM
	5.0	3.17*	9.5*	26.8*	85	30.0	35.5*	14.8	352
Source: Line-arterial
[**2131-1-14**] 04:41AM
	7.8	3.28*	10.2*	27.7*	84	31.1	36.9*	14.6	358
Source: Line-arterial
[**2131-1-13**] 10:21PM
	10.6	3.44*#	10.9*#	29.0*#1	84	31.6	37.5*	14.0	425
Source: Line-arterial
[**2131-1-13**] 02:24AM
	7.3	2.70*	8.2*	23.1*	85	30.4	35.6*	14.3	415
Source: Line-aline
[**2131-1-12**] 06:20PM
	7.4#	2.71*	8.1*	23.2*	86	30.1	35.1*	14.3	356
Source: Line-arterial ulnar
[**2131-1-12**] 01:00AM  	4.2	2.93*	8.8*	25.7*	88	29.9	34.1	13.9	389
[**2131-1-10**] 05:45AM
	3.7*	3.08*	9.1*	26.7*	87	29.6	34.2	13.9	420
[**2131-1-9**] 06:15AM
	3.7*	3.09*	9.2*	26.3*	85	29.9	35.2*	14.0	430
[**2131-1-8**] 05:35AM
	3.9*	3.26*	9.8*	28.2*	87	30.1	34.8	13.9	431
[**2131-1-6**] 05:40AM
	3.3*	3.24*	9.8*	27.5*	85	30.4	35.8*	14.5	409
[**2131-1-5**] 07:20AM
	3.2*	3.24*	10.1*	28.1*	87	31.1	35.9*	14.4	386
[**2131-1-4**] 06:30AM
	3.4*	3.60*	11.0*	31.1*	86	30.6	35.5*	14.5	431
[**2131-1-3**] 01:45PM
	4.3#	3.70*	11.3*	32.2*	87	30.6	35.1*	14.5	441*
[**2131-1-2**] 07:45AM
	2.5*	3.06*	9.1*	27.2*	89	29.7	33.5	14.5	363
[**2131-1-1**] 06:50AM
	2.4*	3.11*	9.3*	27.0*	87	29.8	34.4	14.6	386
[**2130-12-31**] 05:50AM
	2.2*	3.11*	9.3*	27.2*	88	29.9	34.2	14.3	372
[**2130-12-30**] 06:00AM
	2.3*	3.26*	9.9*	29.0*	89	30.4	34.2	13.9	376
[**2130-12-29**] 06:45AM
	2.1*	3.07*	9.2*	27.1*	88	29.8	33.8	13.8	344
[**2130-12-28**] 05:55AM
	2.1*	3.17*	9.7*	28.2*	89	30.7	34.6	14.6	381
[**2130-12-27**] 10:00AM
	2.0*	3.19*	9.6*	28.2*	88	29.9	33.9	14.5	420
SPECIMNE ARRIVED IN LAB AT 12:41PM
[**2130-12-26**] 06:40AM
	1.7*	3.10*	9.8*	27.5*	89	31.5	35.6*	13.9	320
[**2130-12-25**] 06:15AM
	2.3*	2.92*	8.9*	25.3*	87	30.4	35.1*	13.9	340
[**2130-12-24**] 05:50AM
	2.7*	2.97*	9.1*	25.4*	86	30.6	35.8*	14.7	331
[**2130-12-22**] 05:35AM
	2.7*	2.98*	8.8*	26.2*	88	29.4	33.5	14.9	337
[**2130-12-21**] 06:00AM
	2.4*	3.03*	9.2*	26.6*	88	30.4	34.6	14.4	303
[**2130-12-20**] 05:50AM
	2.3*	3.00*	8.9*	25.8*	86	29.7	34.5	15.3	308
[**2130-12-19**] 07:00AM
	3.0*	3.30*	10.1*	29.2*	89	30.5	34.5	15.3	302
[**2130-12-16**] 09:05AM
	3.4*	3.46*#	10.3*#	30.0*	87	29.9	34.5	15.9*	327
[**2130-12-15**] 03:35PM  	 	 	 	29.9*	 	 	 	 	
[**2130-12-14**] 07:40AM
	5.4	2.75*	8.2*	24.6*	90	29.8	33.3	15.7*	358
[**2130-12-13**] 08:00AM
	9.0	2.99*	9.0*	26.0*	87	30.1	34.7	15.6*	378
[**2130-12-12**] 07:45AM  	6.0	2.92*	8.7*	25.7*	88	29.9	34.0	15.3	387
[**2130-12-11**] 04:22AM  	6.9	2.97*	8.9*	26.1*	88	30.0	34.1	15.3	415
[**2130-12-10**] 04:26AM
	8.4	3.08*	9.1*	26.7*	87	29.4	33.9	15.1	457*
[**2130-12-9**] 04:54AM
	9.1	2.88*	8.8*	25.0*	87	30.6	35.3*	15.1	466*
[**2130-12-8**] 06:10AM
	7.0	3.10*	9.0*	26.8*	87	29.1	33.6	14.6	514*
[**2130-12-7**] 03:47AM
	12.8*#	3.43*	10.4*	30.3*	88	30.2	34.2	15.2	645*
[**2130-12-6**] 03:18AM
	7.9	3.23*	9.7*	27.8*	86	30.2	35.0	15.0	633*
[**2130-12-5**] 10:00AM
	7.4	3.19*	9.1*	27.9*	87	28.4	32.5	15.2	553*
[**2130-12-4**] 08:42PM
	9.6	3.35*	9.8*	28.8*	86	29.2	34.0	14.7	672*

VERIFIED LABEL

D
IFFERENTIAL	Neuts	Bands	Lymphs	Monos	Eos	Baso	Atyps	Metas	Myelos
[**2131-1-12**] 06:20PM  	89.5*	 	6.6*	2.6	1.2	0	 	 	
Source: Line-arterial ulnar
[**2131-1-6**] 05:40AM  	57	2	20	13*	4	0	2*	1*	1*
[**2131-1-5**] 07:20AM  	60.3	 	21.8	10.3	7.5*	0.1	 	 	
[**2131-1-4**] 06:30AM  	62.9	 	25.3	7.3	4.4*	0.2	 	 	
[**2131-1-3**] 01:45PM  	70.2*	 	16.9*	7.7	5.1*	0.1	 	 	
[**2131-1-1**] 06:50AM  	53.0	 	27.4	10.5	8.7*	0.4	 	 	
[**2130-12-31**] 05:50AM  	56	0	36	4	1	0	3*	0	0
[**2130-12-30**] 06:00AM  	39.8*	 	42.9*	11.6*	5.4*	0.3	 	 	
[**2130-12-29**] 06:45AM  	45.6*	 	32.4	13.0*	8.7*	0.3	 	 	
[**2130-12-28**] 05:55AM  	27*	3	56*	9	3	0	2*	0	0
[**2130-12-27**] 10:00AM  	31*	0	40	18*	10*	1	0	0	0
SPECIMNE ARRIVED IN LAB AT 12:41PM
[**2130-12-26**] 06:40AM  	52.8	 	28.4	9.4	8.8*	0.6	 	 	
[**2130-12-25**] 06:15AM  	50	0	28	14*	5*	2	1*	0	0
[**2130-12-21**] 06:00AM  	51.6	 	34.1	8.6	5.4*	0.3	 	 	
[**2130-12-8**] 06:10AM  	84.1*	 	9.3*	5.7	0.7	0.1	 	 	
[**2130-12-4**] 08:42PM  	81.3*	 	12.0*	5.8	0.8	0.1	 	 	
  RED CELL
M
O
R
P
H
O
L
O
G
Y	Hypochr	Anisocy	Poiklo	Macrocy	Microcy	Polychr	Ovalocy	Schisto
[**2131-1-6**] 05:40AM
	NORMAL1	1+	1+	NORMAL	1+	OCCASIONAL	1+	OCCASIONAL

NORMAL
MANUALLY COUNTED
  BASIC COAGULATION (PT, PTT, PLT, INR)	PT	PTT	Plt Smr	Plt
Ct	INR(PT)
[**2131-1-19**] 12:00AM  	 	 	 	377	
Source: Line-PICC
[**2131-1-18**] 12:00AM  	 	 	 	356	
Source: Line-TLCVL
[**2131-1-17**] 12:00AM  	 	 	 	368	
Source: Line-PICC
[**2131-1-16**] 12:00AM  	 	 	 	359	
Source: Line-PICC
[**2131-1-15**] 02:04AM  	 	 	 	352	
Source: Line-arterial
[**2131-1-14**] 04:41AM  	 	 	 	358	
Source: Line-arterial
[**2131-1-13**] 10:21PM  	 	 	 	425	
Source: Line-arterial
[**2131-1-13**] 02:24AM  	 	 	 	415	
Source: Line-aline
[**2131-1-12**] 06:20PM  	 	 	 	356	
Source: Line-arterial ulnar
[**2131-1-12**] 01:00AM  	 	 	 	389	
[**2131-1-12**] 01:00AM  	14.5*	28.3	 	 	1.3*
[**2131-1-10**] 05:45AM  	 	 	 	420	
[**2131-1-9**] 06:15AM  	 	 	 	430	
[**2131-1-8**] 05:35AM  	 	 	 	431	
[**2131-1-6**] 05:40AM  	 	 	NORMAL	409	
[**2131-1-5**] 07:20AM  	 	 	 	386	
[**2131-1-4**] 06:30AM  	 	 	 	431	
[**2131-1-3**] 01:45PM  	 	 	 	441*	
[**2131-1-3**] 01:45PM  	13.0	27.7	 	 	1.1
[**2131-1-2**] 07:45AM  	 	 	 	363	
[**2131-1-1**] 06:50AM  	 	 	 	386	
[**2130-12-31**] 05:50AM  	 	 	NORMAL	372	
[**2130-12-30**] 06:00AM  	 	 	 	376	
[**2130-12-29**] 06:45AM  	 	 	 	344	
[**2130-12-28**] 05:55AM  	 	 	 	381	
[**2130-12-27**] 10:00AM  	 	 	NORMAL	420	
SPECIMNE ARRIVED IN LAB AT 12:41PM
[**2130-12-26**] 06:40AM  	 	 	 	320	
[**2130-12-25**] 06:15AM  	 	 	NORMAL	340	
[**2130-12-24**] 05:50AM  	 	 	 	331	
[**2130-12-22**] 05:35AM  	 	 	 	337	
[**2130-12-21**] 06:00AM  	 	 	 	303	
[**2130-12-20**] 05:50AM  	 	 	 	308	
[**2130-12-19**] 07:00AM  	 	 	 	302	
[**2130-12-16**] 09:05AM  	 	 	 	327	
[**2130-12-14**] 07:40AM  	 	 	 	358	
[**2130-12-13**] 08:00AM  	 	 	 	378	
[**2130-12-12**] 07:45AM  	 	 	 	387	
[**2130-12-11**] 04:22AM  	 	 	 	415	
[**2130-12-10**] 04:26AM  	 	 	 	457*	
[**2130-12-9**] 04:54AM  	 	 	 	466*	
[**2130-12-8**] 06:10AM  	 	 	 	514*	
[**2130-12-8**] 04:25AM  	17.0*	29.6	 	 	1.5*
[**2130-12-7**] 03:47AM  	 	 	 	645*	
[**2130-12-6**] 03:18AM  	 	 	 	633*	
[**2130-12-5**] 10:00AM  	 	 	 	553*	
[**2130-12-4**] 08:42PM  	 	 	 	672*	
[**2130-12-4**] 08:42PM  	14.3*1	25.5	 	 	1.2*

HEMOLYZED, MODERATELY
INTERPRET RESULTS WITH CAUTION
Chemistry
  RENAL & GLUCOSE	Glucose	UreaN	Creat	Na	K	Cl	HCO3	AnGap
[**2131-1-19**] 12:00AM  	99	15	0.4	134	4.6	96	29	14
Source: Line-PICC
[**2131-1-18**] 12:00AM  	96	17	0.4	140	4.6	102	29	14
Source: Line-TLCVL
[**2131-1-17**] 12:00AM  	96	12	0.4	133	4.4	97	27	13
Source: Line-PICC
[**2131-1-16**] 12:00AM  	129*	7	0.4	133	4.5	95*	28	15
Source: Line-PICC
[**2131-1-15**] 02:04AM  	129*	7	0.4	138	3.6	105	26	11
Source: Line-arterial
[**2131-1-14**] 04:41AM  	160*	5*	0.5	137	4.2	104	25	12
Source: Line-arterial
[**2131-1-13**] 10:21PM  	192*	5*	0.4	135	3.6	100	27	12
Source: Line-arterial
[**2131-1-13**] 02:24AM  	87	4*	0.4	133	3.9	102	27	8
Source: Line-aline
[**2131-1-12**] 06:20PM  	99	5*	0.4	134	3.6	103	27	8
Source: Line-arterial ulnar
[**2131-1-12**] 01:00AM  	94	8	0.5	137	4.1	102	29	10
[**2131-1-2**] 07:45AM  	104	4*	0.5	139	3.8	101	32	10
[**2131-1-1**] 06:50AM  	101	4*	0.6	136	4.2	99	31	10
[**2130-12-31**] 05:50AM  	77	5*	0.5	136	4.31	100	30	10
[**2130-12-30**] 06:00AM  	82	4*	0.6	138	4.1	101	32	9
[**2130-12-29**] 06:45AM  	118*	4*	0.6	136	4.1	99	31	10
[**2130-12-28**] 05:55AM  	83	5*	0.5	137	4.0	100	31	10
[**2130-12-27**] 10:00AM  	49*2	5*	0.5	138	4.1	101	31	10
SPECIMEN ARRIVED IN LAB AT 12:41PM
[**2130-12-26**] 06:40AM  	122*	5*	0.5	134	3.8	100	28	10
[**2130-12-25**] 06:15AM  	78	6	0.5	137	3.9	102	30	9
[**2130-12-24**] 05:50AM  	79	6	0.4	137	4.0	101	30	10
[**2130-12-22**] 05:35AM  	83	6	0.5	138	4.3	102	32	8
[**2130-12-21**] 06:00AM  	78	6	0.5	139	4.0	102	30	11
[**2130-12-20**] 05:50AM  	77	7	0.5	136	3.7	101	30	9
[**2130-12-19**] 07:00AM  	105	7	0.7	139	4.2	101	30	12
[**2130-12-16**] 09:05AM  	106*	8	0.6	137	4.2	100	30	11
[**2130-12-14**] 07:40AM  	96	6	0.5	138	4.3	104	29	9
[**2130-12-13**] 08:00AM  	124*	7	0.5	134	4.2	97	31	10
[**2130-12-12**] 07:45AM  	110*	7	0.5	136	4.0	102	30	8
[**2130-12-11**] 04:22AM  	107*	6	0.5	137	4.0	102	29	10
[**2130-12-10**] 04:26AM  	116*	7	0.6	131*	3.5	98	27	10
ADDED TSH [**12-10**] 4:40PM; [**Last Name (un) **] ADDED [**12-10**] 5:05PM
[**2130-12-9**] 08:38AM  	 	 	 	 	3.3	 	 	
[**2130-12-9**] 04:54AM  	97	8	0.6	132*	5.9*3	98	28	12
GROSS HEMOLYSIS
[**2130-12-8**] 04:25AM  	97	13	0.7	135	3.9	99	30	10
[**2130-12-7**] 03:47AM  	142*	15	0.6	133	4.5	97	29	12
[**2130-12-6**] 03:18AM  	138*	10	0.5	136	4.2	98	29	13
[**2130-12-5**] 10:00AM  	115*	10	0.5	132*	4.3	95*	29	12
[**2130-12-4**] 08:42PM  	112*	13	0.5	133	5.04	92*	29	17
MODERATELY HEMOLYZED SPECIMEN

HEMOLYSIS FALSELY ELEVATES K
HEMOLYZED, SLIGHTLY
VERIFIED BY REPLICATE ANALYSIS
NOTIFIED T. [**Doctor Last Name **] AT 131PM ON [**2130-12-27**]
HEMOLYSIS FALSELY INCREASES THIS RESULT
HEMOLYSIS FALSELY ELEVATES K.
  ESTIMATED GFR (MDRD CALCULATION)	estGFR
[**2131-1-12**] 01:00AM  	Using this1

Using this patient's age, gender, and serum creatinine value of
0.5,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 40-49 is 99 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
  ENZYMES &
B
ILIRUBIN	ALT	AST	LD(LDH)	CK(CPK)	AlkPhos	Amylase	TotBili	DirBili
[**2131-1-14**] 04:41AM  	 	 	 	172*	 	 	 	
Source: Line-arterial
[**2131-1-13**] 10:21PM  	 	 	 	217*	 	 	 	
Source: Line-arterial
[**2131-1-2**] 07:45AM  	 	 	129	 	 	 	 	
[**2130-12-5**] 09:10AM  	 	 	 	52	 	 	 	
[**2130-12-5**] 01:35AM  	 	 	 	48	 	 	 	
  CPK ISOENZYMES	CK-MB	cTropnT
[**2131-1-14**] 04:41AM  	2	<0.011
Source: Line-arterial
[**2131-1-13**] 10:21PM  	2	<0.011
Source: Line-arterial
[**2130-12-5**] 09:10AM  	1	<0.011
[**2130-12-5**] 01:35AM  	1	LESS THAN 2

<0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
LESS THAN 0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
  CHEMISTRY	TotProt	Albumin	Globuln	Calcium	Phos	Mg	UricAcd	Iron
[**2131-1-19**] 12:00AM  	 	3.9	 	9.0	2.5*	2.1	 	
Source: Line-PICC
[**2131-1-18**] 12:00AM  	 	 	 	9.4	2.5*	2.1	 	
Source: Line-TLCVL
[**2131-1-17**] 12:00AM  	 	 	 	9.1	3.1	2.2	 	
Source: Line-PICC
[**2131-1-16**] 12:00AM  	 	 	 	9.2	2.9	2.1	 	
Source: Line-PICC
[**2131-1-15**] 02:04AM  	 	 	 	8.2*	1.9*	1.8	 	
Source: Line-arterial
[**2131-1-14**] 04:41AM  	 	 	 	8.8	1.3*	1.8	 	
Source: Line-arterial
[**2131-1-13**] 10:21PM  	 	 	 	8.6	1.6*	1.7	 	
Source: Line-arterial
[**2131-1-13**] 02:24AM  	 	 	 	8.3*	2.8	2.1	 	
Source: Line-aline
[**2131-1-12**] 06:20PM  	 	2.3*	 	7.8*	3.1	1.2*	 	
Source: Line-arterial ulnar
[**2131-1-12**] 01:00AM  	 	 	 	8.7	2.9	2.0	 	
[**2131-1-2**] 07:45AM  	6.0*	 	 	9.2	3.8	2.0	 	
[**2131-1-1**] 06:50AM  	 	 	 	9.3	3.7	1.9	 	
[**2130-12-31**] 05:50AM  	 	 	 	8.9	3.5	2.01	 	
[**2130-12-30**] 06:00AM  	 	 	 	9.6	3.5	2.0	 	
[**2130-12-29**] 06:45AM  	 	 	 	8.9	3.4	1.9	 	
[**2130-12-27**] 10:00AM  	 	 	 	9.0	3.3	2.0	 	
SPECIMEN ARRIVED IN LAB AT 12:41PM
[**2130-12-25**] 06:15AM  	 	 	 	9.0	3.2	1.9	 	
[**2130-12-24**] 05:50AM  	 	 	 	 	 	1.9	 	
[**2130-12-21**] 06:00AM  	 	 	 	 	 	1.9	 	
[**2130-12-20**] 05:50AM  	 	 	 	9.0	3.4	1.9	 	
[**2130-12-19**] 07:00AM  	 	 	 	9.5	3.4	2.0	 	
[**2130-12-16**] 09:05AM  	 	 	 	 	 	1.9	 	
[**2130-12-14**] 07:40AM  	 	 	 	8.6	3.3	1.8	 	
[**2130-12-13**] 08:00AM  	 	 	 	8.9	3.1	1.9	 	
[**2130-12-12**] 07:45AM  	 	 	 	8.5	2.3*	1.9	 	
[**2130-12-11**] 04:22AM  	 	 	 	9.0	2.7	1.8	 	
[**2130-12-10**] 04:26AM  	 	 	 	8.9	2.5*	1.8	 	
ADDED TSH [**12-10**] 4:40PM; [**Last Name (un) **] ADDED [**12-10**] 5:05PM
[**2130-12-9**] 08:38AM  	 	 	 	 	 	1.8	 	
[**2130-12-9**] 04:54AM  	 	 	 	9.0	3.5	1.81	 	
GROSS HEMOLYSIS
[**2130-12-8**] 04:25AM  	 	 	 	9.1	3.2	1.8	 	
[**2130-12-7**] 03:47AM  	 	 	 	9.8	3.1	2.0	 	
[**2130-12-6**] 03:18AM  	 	 	 	10.0	3.8	1.9	 	
[**2130-12-5**] 10:00AM  	 	 	 	8.5	2.9	1.8	 	
[**2130-12-4**] 08:42PM  	 	 	 	9.2	2.4*	2.02	 	
MODERATELY HEMOLYZED SPECIMEN

HEMOLYSIS FALSELY ELEVATES Mg
HEMOLYSIS FALSELY ELEVATES MG.
OTHER CHEMISTRY	Osmolal
[**2131-1-13**] 10:21PM  	277
Source: Line-arterial
  PITUITARY	TSH
[**2130-12-31**] 05:50AM  	1.5
[**2130-12-11**] 04:22AM  	0.12*
[**2130-12-10**] 04:26AM  	0.29
ADDED TSH [**12-10**] 4:40PM; [**Last Name (un) **] ADDED [**12-10**] 5:05PM
  THYROID	T4	T3	calcTBG	TUptake	T4Index	Free T4
[**2130-12-13**] 08:00AM  	12.9*	 	1.02	0.98	12.6*	
[**2130-12-12**] 07:45AM  	13.1*	122	 	 	 	1.9*
  OTHER ENDOCRINE	Cortsol
[**2131-1-13**] 03:34PM  	31.3*1
PLEASE MEASURE THIRTY MINUTES AFTER COSYNTROPIN
[**2131-1-13**] 02:59PM  	21.0*1
[**2130-12-10**] 11:17PM  	25.6*1
[**2130-12-10**] 10:57PM  	17.91
[**2130-12-10**] 10:14PM  	4.11
[**2130-12-10**] 04:26AM  	0.9*1
ADDED TSH [**12-10**] 4:40PM; [**Last Name (un) **] ADDED [**12-10**] 5:05PM

NORMAL DIURNAL PATTERN: 7-10AM 6.2-19.4 / 4-8PM 2.3-11.9
GYNECOLOGIC	HCG
[**2130-12-4**] 08:42PM  	<51
MODERATELY HEMOLYZED SPECIMEN

<5
<5 IS NEGATIVE; 5 - 25 IS EQUIVOCAL; >25 IS POSITIVE
LAB USE ONLY	RedHold
[**2131-1-6**] 05:40AM  	HOLD
Blood Gas
  BLOOD GASES	Type	Temp	Rates	Tidal V	PEEP	FiO2	O2
Flow	pO2	pCO2	pH	calTCO2	Base XS	Intubat	Comment
[**2131-1-13**] 02:36AM  	ART	 	 	 	 	 	 	201*	48*	7.40	31*	4	 	
[**2131-1-12**] 08:41PM  	ART	 	 	 	 	35	 	156*	44	7.42	30	4	NOT
INTUBA1	TRACH MASK
[**2130-12-11**] 08:46PM  	ART	 	 	 	 	 	 	114*	41	7.46*	30	5	 	
[**2130-12-8**] 12:33PM  	ART	 	 	 	 	 	 	159*	38	7.48*	29	5	 	

NOT INTUBATED
WHOLE BLOOD, MISCELLANEOUS CHEMISTRY	Lactate
[**2131-1-12**] 08:41PM  	0.8
.

Pathology Examination
Name	Birthdate   	Age   	Sex	Pathology #    	[**Hospital1 18**] [**Known lastname 71385**],[**Known firstname **] [**Last Name (NamePattern1) 71386**]      	[**2090-5-18**]   	40	Female
	[**-7/4872**]	[**Numeric Identifier 71387**]
Report to: 	DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1533**]
Gross Description by: 	DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] GOODELL/dif

SPECIMEN SUBMITTED: Tracheal Tissue.

Procedure date    	Tissue received    	Report Date   	Diagnosed
by
[**2130-12-8**]	[**2130-12-8**]	[**2130-12-13**]	DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl
Previous biopsies:   	[**-7/2145**]  G I BIOPSY (1 JAR).
 	[**-6/4630**]  GASTRIC BX.
 	[**Numeric Identifier 71388**]  RIGHT AND LEFT SEGMENT OF FALLOPIAN TUBES (2).

DIAGNOSIS:

Trachea, biopsy:
1.  Unremarkable cartilage.
2.  Paratracheal soft tissue with acute and chronic
inflammation; no malignancy identified.
.
Pathology Examination
Name	Birthdate   	Age   	Sex	Pathology #    	[**Hospital1 18**] [**Known lastname 71385**],[**Known firstname **] [**Last Name (NamePattern1) 71386**]      	[**2090-5-18**]   	40	Female
	[**Numeric Identifier 71389**]	[**Numeric Identifier 71387**]
Report to: 	DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1533**]
Gross Description by: 	DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/dif

SPECIMEN SUBMITTED: posterior pleural plaque, inferior pleural
plaque, upper lobe wedge.

Procedure date    	Tissue received    	Report Date   	Diagnosed
by
[**2131-1-12**]	[**2131-1-12**]	[**2131-1-16**]	DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dwc??????
Previous biopsies:   	[**-7/4872**]  Tracheal Tissue.
 	[**-7/2145**]  G I BIOPSY (1 JAR).
 	[**-6/4630**]  GASTRIC BX.
 	[**Numeric Identifier 71388**]  RIGHT AND LEFT SEGMENT OF FALLOPIAN TUBES (2).

DIAGNOSIS:
Pleura, left posterior plaque, biopsy (A-B):

     Metastatic squamous cell carcinoma.

Pleura, left inferior plaque, biopsy (C-D):

     Metastatic squamous cell carcinoma.

Lung, left upper lobe, wedge resection (E-J):

     Metastatic squamous cell carcinoma (see note).


Note:
(E-J): Apart from the largest tumor nodule (2 cm in greatest
dimension), multiple small foci of metastatic squamous cell
carcinoma are present along the pleural surface. The surgical
margin of resection appears to be free of tumor.

Clinical:  Esophageal mass, neck pain.
Gross:

The specimen is received fresh labeled with the patient's name,
"[**Known lastname 19688**], [**Known firstname **] [**Last Name (NamePattern1) **]", the medical record number and
"pleural plaque." It consists of a fragment of white - tan firm
tissue measuring 2.5 x 1.5 x 0.6 cm, serially sectioned and
partially frozen.  Intraoperative exam was performed. A frozen
section was performed on tissue. The frozen section diagnosis by
Dr. [**Last Name (STitle) **] is "posterior pleural plaque: metastatic carcinoma."


The remainder of the specimen is entirely submitted in A, frozen
section in B.

Part 2 is additionally labeled "inferior pleural plaque." It
consists of a fragment of firm pink-tan tissue measuring 1.0 x
0.9 x 0.2 cm. The specimen is serially sliced and submitted in
C-D.

Part 3 is additionally labeled "left upper lobe wedge RUSH." It
consists of a wedge resection of lung measuring 6.0 x 3.4 x 1.5
cm with a stapled margin that measures 8.0 cm in length. The
pleural surface is smooth and shiny, and involved by a white
mass measuring 3.0 x 1.5 cm.  This area is firm on palpation.
The specimen is serially sliced to reveal a 2.0 x 2.0 x 1.0 cm
white tan cystic well circumscribed, nodule, located 0.4 cm from
the nearest stapled margin. The mass involves the pleura. The
remainder of the lung parenchyma is unremarkable.   The specimen
is represented as follows: E-F = pulmonary resection margin, G-I
= tumor in relation to parietal pleura, J = unremarkable lung.
.


Brief Hospital Course:
The following summary is divided into sections due to the
patients prolonged hospital course:

# Esophageal Cancer/Cough/SOB: The patient presented with cough
and SOB.  Her symptoms progressed and ENT was consulted.  The
patient was found to have superglottic swellling and she was
transferred to the ICU for concern of possible iminent airway
obstruction.  A CT of the neck was concerning for perforation
and this finding was reassessed with MRI which raised the
possibility of abcess formation.  Given these findings, throacic
surgery was consulted and it was felt that the patient would
benefit from tracheostomy placement for airway protection.  A
trach was placed by thoracics on [**2130-12-8**] which was tolerated
well.  Speech and swallow followed for assessment for passy muir
valve.

[**Hospital Unit Name 71390**] COURSE [**12-6**] through [**12-11**]
.
[**12-6**]
- ENT - advised continued MICU care, trachea 3 mm at narrowest
point and supraglottic edema, R vocal cord paralysis
- Thoracics consult- likely not a tear; advised barium swallow
and broad spectrum coverage, ddx perforation vs TE fistula;
- Pt did not tolerate barium swallow
- Added Vanco/Levo/Flagyl/Fluconazole
- MR Neck - read PENDING (wet read by surgery - no ET fistula,
no extaluminal air)
- TFs - restart Ensure
- Evaluated for worsening stridor at 0400; Inspiratory stridor
noted on exam in all lung fields, but pt saturating well. Denies
worsening pain. Thoracics informed.
.
[**Date range (3) 71391**]
- MRI suggestive of micro-esophagael perf, +/- infection
- (Started on Vanco Levo Fluc yesterday [**12-6**])
- ?Worsening stridor this Morning ([**12-7**]) around 4AM, self
resolved.
- Unless team observes persistent stridor, plan for continuing
Abx, no surgical (trach) intervention at this time.
- had rhoncorous [**Month/Year (2) 1440**] sounds, 3am, cleared on own.
[**12-8**]
- Had trachyostomy; tolerated procedure well. Weaned off vent
overnight and placed on trach mask.
- Per Thoracics, would attempt passy miur valve today.
.
[**12-9**]
- c/od but no bed
- ENT s/o
- CXR shows trach well palced
- tolerated trach proecedure well
- no stridor, no n/v
- restarted tube feeds
- thoracics - 2 wks antibx but will follow on the floor
- patient somewhat confused about cancer dx and prognosis - will
need to have [**Doctor Last Name **]/[**Doctor Last Name **] to explain to patient what to
expect for the future
- continues to be tachycardic
.
12/14-15/08
-Assessment update: noting low suspicion for esophagael cancer
per Dr. [**Last Name (STitle) 174**]. Concern that chest lesion is met, but not
confirmed. Re: reversibility of trach--if this was esoph perf
[**1-29**] vomiting or [**1-29**] to radiation, likely temporary and may be
removed s/p f/u bronch.
-Refusing depression meds, psychiatry, social work
-Speech and Swallow tomorrow
-Gave 1 L for tachychardia
.
[**2130-12-10**]
Spoke to oncology team re: transfer. Concern that hemodynamics
are slightly worse than on admission. On admission SBPs in 90s,
HR in low 100s, now SBP in 80s, HR 110s. Documented baseline
blood pressures in all discharge summaries from [**2129**] have been
baseline SBPs in the 80s but without tachycardia. Will check
cortisol, TSH.
-Cortisol noted to be quite low. Have ordered supression test.
Will likely need to start treatment steroids s/p test.

[**2130-12-11**]
-Continuing cough apprecaited. Secretions noted.
-In general, "still"-appearing, as if in pain, but repeatedly
denies.
- hypotensive to 70's but not symptomatic. Tachy with normal
echo. Good UOP.
Summary of ICU Course:
Briefly, Mrs [**Known lastname 19688**] is a 40 yo F with unresectable esophageal
cancer who was recently discharged from the hospital secondary
to right neck pain. She was then discharged on [**12-1**]. Notes
indicate the patient re-presented on [**12-4**] with the chief
complaint of "strange sounding airway" and dyspnea. She was
found to have a soft tissue infection lateral to the esophagus
that likely represents microperforation, for which she was
started on abx, and she required surgical tracheostomy for upper
airway obstruction caused by her esophageal cancer.
.
Additionally, her MICU course was remarkable for persistent
tachycardia and mild hypotension. Her heart rate remains 120s at
rest with brief episodes of rates as high as 150 when she is out
of bed, sinus tachycardia at all times. Her blood pressure has
ranged from 70s-90s systolic, which does not appear to be new,
as OMR notes document systolic blood pressures in the high
80s-low 90s at multiple visits. Evaluation as to the cause of
tachycardia has included TSH (low normal), with fT4 pending;
echo (nml LV and RV function, no echocardiographic signs of
hemodynamically significant PE); ABG 7.46/41/114 was with pt
breathing room air for 10 minutes, indicating that there is no
apparent A-a gradient; a random cortisol level was low, but
responded appropriately to cosyntropin. Since she appears well,
with good skin turgor and adequate urine output, despite the
tachycardia and hypotension, she was transferred out of the ICU.

The following section summarizes the patients OMED course
including VATS and SICU transfer:
.
40 y/o F with esophageal SCC s/p XRT, s/p tracheostomy for upper
airway compromise with parapharyngeal abscess, now s/p VATs for
LUL cavitary lesion and found to have metastatic esophageal CA.
.
#. Metastatic Esophageal CA: Patient s/p chemo and radiation.
The patient was noted to have a LUL cavitary lesion on CT scan
in early [**Month (only) **]. This was found to have grown by Janurary.
Concern that new lung lesion is secondary to metastatic disease.
A new left sided pleural effusion was seen on CT on [**1-1**]. The
patient underwent thoracentesis on [**1-2**] with 700cc of clear
yellow fluid drained without complication. Cytology and cultures
were sent and the patient was found to have an exudative
effusion. ID was consulted, fungal serologies and stool O&P were
sent. The patient was ruled out for TB on two separate
occasions. Sputum from [**1-5**] grew back Klebsiella Oxytoca, and on
[**1-6**] Acinetobacter both of which were thought to be a
contaminant. The patient was transfered to the [**Hospital Ward Name 516**] on
[**2131-1-12**] to undergo a VATS resection of the the cavitary lesion.
The patient underwent VATS on [**2130-1-11**] which unfortunately
revealed carcinomatous plaques on the pleural wall which were
confirmed frozen section. A chest tube was placed. The patient
briefly required pressers while in the SICU. These were weaned
and the patient was subsequently transfered back to the [**Hospital Ward Name 5074**] on [**1-15**]. Fungal serologies revealed strogyloides and the
patient was given two days of Ivermectin. The patient will
follow-up with Dr. [**Last Name (STitle) **] as an outpatient.
.
#. s/p Trach: The patient was trached on [**12-8**] secondary to
airway compromise. The patient has been breathing comfortably
with trach on 35% trach mask FM; ambulating without supplemental
oxygen; transient dyspnea improves with nebs, anxiolytics. The
patient did not tolerate a PMV on [**1-2**] following completion of a
28 day course of Unasyn and Clindamycin (previously Augmentin).
The patient did not tolerate her PMV mask on [**1-3**]. On [**1-4**]
respiratory therapy attempted to use inhaled fluticasone to
improve her symptoms. The patient was tolerating her PMV
incrementaly more each day. On [**1-7**] the patient was noted to
have increased TM requirements up to 50%. This was thought to be
potentially secondary to reaccumulation of her L pleural
effusion. The patients trach was changed to a 6.0 fenestrated
trach on [**1-16**]. The patient was decannulated by thoracics on [**1-17**]
which she tolerated. Supportive care should be continued upon
discharge.
.
# Healthcare Associated PNA: The patient developed fevers and
had continued cough following her VATS. The patient was placed
empirically on Cefepime on [**1-15**], this was later changed to
Levaquin upon discharge for a planned 10 day total duration of
antibiotics. Cultures were NGTD at the time of discharge.
.
# Parapharygneal Abscess. The patient was placed initially on
Augmentin. This was changed to Unasyn / Clindamycin for which
she subsequently completed 28 days of treatement. ENT evaluated
patient [**1-1**] no upper airway abnormality other than copious
secretions. A CT Neck and Chest on [**1-2**] revealed both
tetropharyngeal and retrotracheal swelling as well as soft
tissue density encompassing the esophagus. This was thought to
potentially represent post-radiation changes and phlegmon. No
evidence of a drainable fluid collection.
.
#. Neutropenia: Initially thought to be secondary to patients
being on augmentin. This was subsequently changed to
Clindamycin/Unasyn or compazine. ANC subsequenrly resolved to
1278 [**1-1**].
.
#. Anemia: Currently at baseline, no signs of active bleeding.
Con't to monitor. There was question of benefit of higher
transfusion threshold to reduce tachycardia.
.
#. Tachycardia: The patient has been persistently in sinus
tachycardia 110-130 bpm. The patient was evaluate while in the
ICU that indicated a low probibility for PE, no signs of CHF,
and potentially subclinical hyperthyroidism although TSH WNL.
There was thought that part of the ST was secondary to anxiety.
Anemia also potentially played a role.
- Cont Tele
.
#. Hypotension: Asymptomatic and maintaining MAP >= 60. Responds
well to fluid bolus when systolics drift down to 70s. Continue
vol challenge prn. Was briefly on pressers while in the unit,
now weaned off.
.
#. Pain: The patients pain was well-controlled with gabapentin
and methadone. The patient was written for Morphine PRN.
.
# Depression: The patient remains on nortriptyline for depressed
mood and will not take additional treatment. Likely that some of
this is related to coping with general medical illness as well
as underlying depression and being away from her children.
- SW will cont to follow
- cont nortriptyline
.
#. Steroid-Induced DM: continue SSI; if requirements trend down
now that off steroids, can D/C insulin

Medications on Admission:
Tylenol occasionaly
Lactulose 30 cc tid prn
Methadone 2.5 mg [**Hospital1 **]
.
Upon transfer out of the MICU:
.
Heparin 5000 UNIT SC TID
Insulin SC
Lactulose 30 mL PO Q8H:PRN  Order date: [**12-12**] @ 0050
Levofloxacin 750 mg IV Q24H day 1 = [**12-6**]
Methadone 2.5 mg PO BID
Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H day 1 = [**12-6**]
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Nortriptyline 25 mg NG HS
Ondansetron 8 mg IV Q 8H
Pantoprazole 40 mg IV Q12H
Docusate Sodium (Liquid) 100 mg PO BID PRN
Prochlorperazine 25 mg PR Q12H
Fluconazole 200 mg NG Q24H day 1 = [**12-6**]
Gabapentin 300 mg PO QAM & 600 mg PO QPM
Vancomycin 1000 mg IV Q 12H day 1 = [**12-6**]


Discharge Medications:
1. Nortriptyline 10 mg/5 mL Solution [**Month/Year (2) **]: One (1)  PO HS (at
bedtime).
2. Methadone 5 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO BID (2 times a day).

3. Lactulose 10 gram/15 mL Syrup [**Month/Year (2) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
Disp:*300 ML(s)* Refills:*2*
4. Senna 8.8 mg/5 mL Syrup [**Month/Year (2) **]: Five (5) ML PO BID (2 times a
day).
Disp:*300 ML(s)* Refills:*2*
5. Acetaminophen 160 mg/5 mL Solution [**Month/Year (2) **]: [**12-29**] tsp PO Q6H (every
6 hours) as needed for fever or pain.
Disp:*1 Bottle* Refills:*2*
6. Guaifenesin 100 mg/5 mL Syrup [**Month/Day (2) **]: Fifteen (15) ML PO Q6H
(every 6 hours) as needed for cough.
Disp:*200 ML(s)* Refills:*1*
7. 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*
8. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO BID (2
times a day).
Disp:*600 mL* Refills:*2*
9. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
10. Compazine 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every 4-6 hours as
needed for nausea: crush & mix with water.  .
Disp:*30 Tablet(s)* Refills:*0*
11. Ativan 1 mg Tablet [**Hospital1 **]: [**12-29**] - 1 Tablet PO every 4-6 hours as
needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
12. Levofloxacin 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital **] hospice care

Discharge Diagnosis:
Primary Diagnosis
- Metastatic Esophageal CA
- Parapharyngeal Abcess
- Left Pleural Effusison
- Health-Care Acquired PNA


Discharge Condition:
good. Patient abulating. PEG in place. Tolerating
De-Cannulation.


Discharge Instructions:
You were admitted to hospital with shortness of [**Hospital 1440**] and
wheezing. You were found to have an infection in your throat for
which you received antibiotics. A breathing tracheostomy was
placed so that you were able to [**Hospital 1440**]. This infection was
treated and you are now able to breathe without the tube.  The
hole in your neck should close up on its own, you do not need to
do anything about this.

You were found to have a growning lesion in your left lung and
you underwent an operation to removed the lesion as well as
fluid. You were found to have recurrence of your esophageal
cancer. Dr. [**Last Name (STitle) **] will see you in clinic to discuss chemotherapy.

You were also treated for a pneumonia.  You need to take 5 more
days of an antibiotic called levofloxacin.

Please continue to take all of your medications as listed below.
A number of changes have been made.

Please keep all of your appointments.

Please call your doctor if you experience continued fevers,
chills, shortness of [**Last Name (STitle) 1440**], chest pain, nausea, vomitting,
diarrhea.

Followup Instructions:
With Dr. [**Last Name (STitle) 71392**] on [**1-30**] at 1:30 PM on [**Hospital Ward Name 23**] 9.

Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2131-1-25**] 12:45
Provider: [**Name10 (NameIs) 4617**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 7976**] Date/Time:[**2131-1-26**]
2:15
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 8268**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2131-1-29**]
10:30

Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2131-2-8**] 9:00
{'Malignant neoplasm of cervical esophagus,Perforation of esophagus,Secondary malignant neoplasm of lung,Malignant pleural effusion,Parapharyngeal abscess,Pneumonia, organism unspecified,Unspecified disease of the jaws,Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Anemia in neoplastic disease,Drug induced neutropenia,Penicillins causing adverse effects in therapeutic use'}


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, Vomiting

PRESENT ILLNESS: 40 yo F with unresectable esophageal cancer who was recently
discharged from the hospital secondary to right neck pain. She
was then discharged on [**12-1**]. Notes indicate the patient
re-presented on [**12-4**] with the chief complaint of "strange
sounding airway" and dyspnea. She was found to have a soft
tissue infection lateral to the esophagus that likely represents
microperforation, for which she was started on abx, and she
required surgical tracheostomy for upper airway obstruction
caused by her esophageal cancer.
.
Additionally, her MICU course was remarkable for persistent
tachycardia and mild hypotension. Her heart rate remains 120s at
rest with brief episodes of rates as high as 150 when she is out
of bed, sinus tachycardia at all times. Her blood pressure has
ranged from 70s-90s systolic, which does not appear to be new,
as OMR notes document systolic blood pressures in the high
80s-low 90s at multiple visits. Evaluation as to the cause of
tachycardia has included TSH (low normal), with fT4 pending;
echo (nml LV and RV function, no echocardiographic signs of
hemodynamically significant PE); ABG 7.46/41/114 was with pt
breathing room air for 10 minutes, indicating that there is no
apparent A-a gradient; a random cortisol level was low, but
responded appropriately to cosyntropin. Since she appears well,
with good skin turgor and adequate urine output, despite the
tachycardia and hypotension, she was transferred out of the ICU.

MEDICAL HISTORY: #. Invasive Esophageal Squamous Squamous Cell Carcinoma:
- [**2129-11-1**]: Pt arrived in America from [**Country 3587**]
- [**2129-11-2**]: Pt evaluated for Odynophagia, tx with Prilosec
- 11/26-30/07: Admitted fo Esophageal Web Dilations that
relieved symptoms
- [**1-4**]: Symptoms of odynophagia returned
- [**2130-2-12**]: Referred to ENT for recurrent cervial web at C4-5
- [**2130-4-14**]: Esophageal Dilation under general anesthesia
- [**5-4**]: ENT consult for bilateral submandibular pain
- 5/29-30/08: Two subsequent attempts at dilation unsucessful
- [**6-4**]: PEG placed for FTT
- [**2130-6-7**]: Bx confirms Invasive Squamous Cell CA
- [**2130-6-20**]:
diagnosed [**2130-5-28**] in
setting of esophageal stricture
- high cervical esophageal lesion not resectable
- completed therapy with Cetuximab and radiation therapy
# Anemia
# Upper esophageal and pharyngeal stricture; s/p PEG
# Shoulder Pain
# Lung lesion - NOS
# Chronic pain from radiation.
# Nausea and vomiting.
# PEG tube site candidiasis

MEDICATION ON ADMISSION: Tylenol occasionaly
Lactulose 30 cc tid prn
Methadone 2.5 mg [**Hospital1 **]
.
Upon transfer out of the MICU:
.
Heparin 5000 UNIT SC TID
Insulin SC
Lactulose 30 mL PO Q8H:PRN  Order date: [**12-12**] @ 0050
Levofloxacin 750 mg IV Q24H day 1 = [**12-6**]
Methadone 2.5 mg PO BID
Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H day 1 = [**12-6**]
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Nortriptyline 25 mg NG HS
Ondansetron 8 mg IV Q 8H
Pantoprazole 40 mg IV Q12H
Docusate Sodium (Liquid) 100 mg PO BID PRN
Prochlorperazine 25 mg PR Q12H
Fluconazole 200 mg NG Q24H day 1 = [**12-6**]
Gabapentin 300 mg PO QAM & 600 mg PO QPM
Vancomycin 1000 mg IV Q 12H day 1 = [**12-6**]

ALLERGIES: Roxicet

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
VS: T = 99.4 P = 120 BP = 108/60 RR 16, O2Sat:100%
GENERAL: Young female who appears older than her stated age.
She is appears tired and worn.
Mentation: Alert but restricted affect. Does not smile.
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Bibasilar crackles
Cardiovascular: tachy, nl. S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
PEG site C/D/I no odor. Appears better than during previous
admission.
Genitourinary:
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-DTRs: 2+ biceps, triceps,
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
Psychiatric:  Very limited affect with rare brightening.
.
PHYSICAL EXAM UPON ARRIVAL TO THE FLOOR: [**12-11**]
Vitals: T97.9 BP96/50 HR126 RR19 O2Sat100% on 35% trach collar
GEN: Thin, tired-appearing [**Location 7972**] woman
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea with sutured trach cannula
COR: tachy, no M/G/R, normal S1 S2, radial pulses +2
PULM: bronchial [**Location 1440**] sounds throughout
ABD: Soft, NT, ND, +BS, no HSM, no masses. PEG in place in LUQ
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: Normal turgor. No jaundice, cyanosis, or gross dermatitis.
No ecchymoses.

FAMILY HISTORY: There is no history in her family of heart disease, gastric
cancer, esophageal cancer or colon cancer or inflammatory bowel
disease.

SOCIAL HISTORY: The patient lives in [**Location 686**], MA with her cousin [**Name (NI) **] [**Name (NI) **],
who is her HCP. The patient is initially from [**Country 11660**]
islands, she is not currently working.
Tobacco: None
ETOH: None
Illicits: None 

### Response:
{'Malignant neoplasm of cervical esophagus,Perforation of esophagus,Secondary malignant neoplasm of lung,Malignant pleural effusion,Parapharyngeal abscess,Pneumonia, organism unspecified,Unspecified disease of the jaws,Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Anemia in neoplastic disease,Drug induced neutropenia,Penicillins causing adverse effects in therapeutic use'}
