CHIEF COMPLAINT: Respiratory distress

PRESENT ILLNESS: The patient is a 69 year old
female with no significant past medical history who presented
to [**Hospital 882**] Hospital with acute onset of respiratory
distress.  The patient had been noticing an enlarging neck
mass for the past three to four years.  As [**First Name8 (NamePattern2) **] [**Hospital 882**]
Hospital notes, the patient noticed increasing phlegm
production two days prior to admission and increasing
shortness of breath.  She was being evaluated by
Otorhinolaryngology as an outpatient and sent to [**Hospital 882**]
Hospital for head/neck/chest computerized tomography scan.
While in the Waiting Room the patient had an acute onset of
respiratory distress requiring intubation and was admitted to
the [**Hospital 882**] Hospital Intensive Care Unit.  Because the
outside hospital was unable to provide radiation, the patient
was transferred to the [**Hospital6 256**].

MEDICAL HISTORY: None.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: The patient lives with one son and her
grandson.  She quit tobacco 30 years ago and smoked less than
half a pack per day for a few years.  She denies alcohol use.
She works at [**Company **] and was working prior to her
Otorhinolaryngology visit.  Before that she worked for 14
years at a Stride-Rite Factory gluing soles to bottom of
shoes.
Malignant neoplasm of other specified part of esophagus,Other pulmonary insufficiency, not elsewhere classified,Tracheoesophageal fistula,Urinary tract infection, site not specified,Candidiasis of mouth,Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck,Acute bronchitis,Other constipation
Mal neo esophagus NEC,Other pulmonary insuff,Tracheoesophageal fstula,Urin tract infection NOS,Thrush,Mal neo lymph-head/neck,Acute bronchitis,Constipation NEC
Admission Date:  [**2119-10-18**]       Discharge Date: [**2119-11-5**]

Date of Birth:   [**2050-1-27**]       Sex:  F

Service:  Fernard Intensive Care Unit

CHIEF COMPLAINT:  Respiratory distress

HISTORY OF PRESENT ILLNESS:  The patient is a 69 year old
female with no significant past medical history who presented
to [**Hospital 882**] Hospital with acute onset of respiratory
distress.  The patient had been noticing an enlarging neck
mass for the past three to four years.  As [**First Name8 (NamePattern2) **] [**Hospital 882**]
Hospital notes, the patient noticed increasing phlegm
production two days prior to admission and increasing
shortness of breath.  She was being evaluated by
Otorhinolaryngology as an outpatient and sent to [**Hospital 882**]
Hospital for head/neck/chest computerized tomography scan.
While in the Waiting Room the patient had an acute onset of
respiratory distress requiring intubation and was admitted to
the [**Hospital 882**] Hospital Intensive Care Unit.  Because the
outside hospital was unable to provide radiation, the patient
was transferred to the [**Hospital6 256**].

100 cc of necrotic material was aspirated from the left neck
mass which by report is consistent with squamous cell
carcinoma.  Computerized tomography scan of the neck/chest
revealed a 7 by 7 cm left-sided neck mass with deviation of
the trachea to the right and compression of the trachea
around the endotracheal tube.  No obvious tumor was seen in
the chest computerized tomography scan.

PAST MEDICAL HISTORY:  None.

ALLERGIES:  No known drug allergies.

MEDICATIONS:  Medications as an outpatient, none.
Medications on transfer were Heparin subcutaneously, Morphine
and Ativan prn.

FAMILY HISTORY:  Non-contributory

SOCIAL HISTORY:  The patient lives with one son and her
grandson.  She quit tobacco 30 years ago and smoked less than
half a pack per day for a few years.  She denies alcohol use.
She works at [**Company **] and was working prior to her
Otorhinolaryngology visit.  Before that she worked for 14
years at a Stride-Rite Factory gluing soles to bottom of
shoes.

LABORATORY DATA:  Laboratory studies at an outside hospital
revealed sodium 138, potassium 3.9, chloride 101, bicarbonate
31, BUN 7, creatinine .8, glucose 128, white blood cell count
8.2, hematocrit 32.9, platelets 300, LDH 228.  Arterial blood
gases, pressor support ventilation of 10 and 5 is 7.54, 27,
and greater than 250.

PHYSICAL EXAMINATION:  On physical examination vital signs
were 100.2, heartrate 98, blood pressure 141/93, respiratory
rate 14 and oxygen saturations 100%.  In general the patient
is an elderly female in no apparent distress, awake, and
answering questions.  Head, eyes, ears, nose and throat,
extraocular muscles intact.  Pupils, equal and reactive to
light and accommodation.  Large left-sided neck mass,
nontender, approximately 8 by 8 cm.  Small 1 cm area of
ecchymosis around the biopsy site.  Heart, normal S1 and S2,
no murmurs, rubs or gallops.  Lungs clear to auscultation
bilaterally.  Abdomen obese, soft, nontender, positive bowel
sounds.  Extremities, no cyanosis, clubbing or edema.

RADIOGRAPHS:  Chest x-ray from outside hospital, large left
neck mass with questionable mediastinal lymphadenopathy,
endotracheal tube at carina.  Chest computerized tomography
scan without contrast, large neck mass, 7 by 7 in diameter,
left trachea shifted to right, trachea compressed around
endotracheal tube.  Computerized tomography scan of chest
revealed multiple anterior mediastinal lymph nodes and
para-aortic tracheal compression with deviation to the right,
no parenchymal lung lesions are seen, small left pleural
effusion.

HOSPITAL COURSE:  This is a 69 year old female with
left-sided neck mass consistent with squamous cell carcinoma,
most likely of esophageal origin, causing airway compromise,
intubated for airway protection.

1.  Left-sided neck mass - On arrival to [**Hospital6 1760**], the patient was evaluated by
Radiation [**Hospital 44889**] Medical Oncology and Otorhinolaryngology.
It was felt given the size of the mass that extubation could
not be done safely without further securing the airway.  The
patient had a computerized tomography scan of the neck and
chest with contrast and an magnetic resonance imaging scan of
the chest which revealed the following.  Computerized
tomography scan of the head revealed no evidence of
intracranial metastatic disease.  Computerized tomography
scan of the chest showed a large neck mass which tracks along
the posterior wall of the trachea into the thoracic inlet,
measuring 7 by 11 cm, multiple enlarged mediastinal lymph
nodes and a small lower thoracic vertebral body hemangioma.
The magnetic resonance imaging scan of the neck with
gadolinium showed redemonstration of an enormous neck mass
with probable infiltration in the region of the left carotid
sheath and other signs of spread.

In light of these findings, the patient was scheduled for
Operating Room placement of a tracheostomy.  The patient was
sent to the Operating Room on [**2119-10-26**], hospital day
#9.  In the Operating Room the procedure was noted to be very
difficult and a tracheoesophageal fistula was found.  The
patient's trachea was dissected to the fifth tracheal ring
and an endotracheal tube was placed instead of a stable
tracheostomy tube, given the difficulty of the procedure.  On
hospital day #10, the patient had an open gastrostomy tube
placed and a Port-A-Cath placed by General Surgery.  A
panendoscopy was done at the time of her tracheostomy
placement on hospital day #10 which showed diffuse tumor in
both the trachea and the esophagus.  Multiple biopsies were
done of the esophagus and it was felt at this time that the
tumor was originating from the cervical esophagus, although
this could not be definitely confirmed.

On the day after gastrostomy tube and Port-A-Cath placement,
extensive discussions were taken with the family.
Interventional Pulmonology was consulted for possible
stenting of the esophageal tracheal fistula, however, given
the location it was felt that no stent could be placed in
either the esophagus or the trachea at this time.  Given the
poor prognosis with the extent of disease, complicated by the
tracheoesophageal fistula, the decision on whether to pursue
radiation and chemotherapy was in question.  The patient met
with both radiation oncology and medical oncology and was
told about the risks and benefits of treatment.  Given the
fistula, it was thought that radiation and chemotherapy,
while possibly able to provide some local control of tumor
extension, would only worsen the fistula and cause
neutropenia increasing infection risk.  The patient decided
that she wanted to not pursue chemotherapy and radiation
therapy and would want to go home with home hospice care.
The patient was also made Do-Not-Resuscitate at this time.

Given the unusual nature of the patient's tracheostomy tube,
a customized tracheostomy was ordered and is currently
enroute to the hospital.  The patient is to have a more
permanent airway placed on Wednesday, [**11-8**].  If the
patient is able to tolerate the patient and her airway
remains stable, she should be able to be discharged home with
maximal home services.

During this hospitalization palliative care was consulted to
aid in placement and home services.  They are currently
following the patient and have already provided some possible
resources for the patient.

2.  Tracheobronchitis -  On hospital day #2 the patient had a
bronchoscopy to evaluate for any intrinsic compression of
airways by the neck mass.  Airways appeared patent below the
endotracheal tube, however, numerous secretions were seen.
BAL later grew out Staphylococcus aureus which was
pansensitive.  The patient completed a ten-day course of
Levaquin and Clindamycin which was later added after the
tracheal esophageal fistula was found.  Currently, the
patient has occasional secretions and lowgrade temperatures,
however, secretions overall have decreased this admission and
the patient's cough has not increased.  We will try to
observe the patient off of antibiotics but anticipate that
she may continue to have lowgrade fevers due to her
tracheoesophageal fistula and extent of tumor burden.

3.  Urinary tract infection - The patient had an urinary
tract infection during this admission which was Escherichia
coli pansensitive.  The patient was treated with Levaquin,
and subsequent cultures have remained negative.  The Foley
catheter was discontinued on hospital day #19.

4.  Thrush - It was noted that the patient has several
plaques on her tongue and was started on Nystatin Swish and
Swallow which will have to continue while at home.

5.  Constipation - It was noted that the patient had multiple
episodes of constipation in the setting of Roxicet narcotic
use for incisional pain.  This has resolved with an adequate
bowel regimen.

6.  Physical therapy - The patient was evaluated by physical
therapy who felt that the patient may be able to be
discharged home with maximal services.  The patient has been
ambulating without complications.

7.  Respiratory status - The patient was initially on vent
support, however, this was slowly weaned during her hospital
course and she is currently on a T-piece 24 hours a day
without any necessary vent support.  She should be able to go
home with a similar apparatus.  She no longer needs any vent
support.

8.  Tubes, lines and drains - The patient has had her Foley
catheter discontinued.  She has a Port-A-Cath which has been
deaccessed and has a percutaneous endoscopic gastrostomy
tube.  She is currently receiving tube feeds 24 hours a day
at 60 cc/hr.

9.  Code status - The patient is currently
Do-Not-Resuscitate.

DISCHARGE DIAGNOSIS:
1.  Stage 4 cervical esophageal cancer
2.  Airway compromise, status post tracheostomy
3.  Tracheobronchitis
4.  Urinary tract infection
5.  Thrush
6.  Constipation

An addendum will be added to this dictation summary with the
rest of the [**Hospital 228**] hospital course.  This dictation cover
the timeframe from [**2119-10-18**] to [**2119-11-5**].

Disposition will be determined at a later date.  The patient
will follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 44890**] who
is [**Location (un) 2312**].




                           DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981

Dictated By:[**Last Name (NamePattern1) 218**]
MEDQUIST36

D:  [**2119-11-5**]  16:41
T:  [**2119-11-5**]  16:50
JOB#:  [**Job Number 13948**]


Name:  [**Known lastname 8235**], [**Known firstname **]                     Unit No:  [**Numeric Identifier 8236**]

Admission Date:  [**2119-10-18**]     Discharge Date:  [**2119-11-8**]

Date of Birth:   [**2050-1-27**]     Sex:  F

Service:  [**Hospital Ward Name 5950**] ICU

This is an addendum to a Discharge Summary from [**2119-10-18**] to
[**2119-11-5**].  This addendum covers the [**Hospital 1325**] hospital course
from [**2119-11-6**] to the anticipated time of discharge on
[**2119-11-8**].

The patient was clinically stable while awaiting the arrival
of the appropriate tracheostomy tube.  She did develop a low
grade fever and a subsequent urine culture revealed 100,000
colony forming units of Enterococcus and 10,000 colony
forming units of coagulase negative Staphylococcus.  The
sensitivities for both are pending at the time of discharge.
The patient was started no Vancomycin.  She never had a rise
in her white count, dysuria nor other symptoms to follow
clinically.

On [**2119-11-6**], the patient's tracheostomy tube arrived, and
placement in the operating room is pending for [**2119-11-8**].  If
the patient is clinically stable in her post-tracheostomy
tube placement course, she will be discharged to acute
rehabilitation.

DISCHARGE DIAGNOSES:
1.  Head and neck squamous cell carcinoma presenting as
left-sided neck mass, stage 4.
2.  Urinary tract infection with Enterococcus and coagulase
negative Staphylococcus, sensitivities pending.
3.  Status post tracheobronchitis.
4.  Thrush.
5.  Status post tracheostomy tube placement.

DISCHARGE MEDICATIONS:
1.  Vancomycin 1 gram q12 hours.
2.  Bowel regimen with Senna and Lactulose.
3.  Protonix.
4.  Ativan p.r.n.
5.  Percocet elixir.

FOLLOW UP:  The patient will follow up in one to two weeks
time from acute rehab with her primary care physician.  [**Name10 (NameIs) **]
family is intermittently involved in her care and will
receive training along with the patient for proper
tracheostomy tube care at acute rehabilitation.

The patient's code status was determined on this admission to
be DNR/DNI.






                          [**Name6 (MD) 3228**] [**Last Name (NamePattern4) 4849**], M.D.  [**MD Number(1) 4850**]

Dictated By:[**Name8 (MD) 2621**]

MEDQUIST36

D:  [**2119-11-8**]  12:02
T:  [**2119-11-8**]  12:53
JOB#:  [**Job Number 8237**]


Admission Date:  [**2119-10-18**]       Discharge Date:  [**2119-11-10**]

Date of Birth:   [**2050-1-27**]       Sex:  F

Service:  INTENSIVE CARE UNIT

This is Discharge Summary Addendum to cover the [**Hospital 228**]
hospital course from [**2119-11-8**] to [**2119-11-10**].

The patient returned from tracheotomy tube placement with no
complications and clinically stable.  She was kept in house
for a period of 48 hours for monitoring with her new
electrocardiogram which had been placed.  She has a stable
oxygen requirement, stable clinical features and stable
radiographic appearance over lung parenchyma.  And she
completed a three day course of Vancomycin for enterococcal
urinary tract infection.

DISCHARGE DIAGNOSES:  See prior dictated Discharge Summary
addendum.

DISCHARGE MEDICATIONS:  Same as prior Discharge Summary
addendum except discontinue Vancomycin.

Discharge to [**Hospital 13698**] Hospital for acute rehabilitation.
Follow up with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 45410**] in [**Location (un) 2312**]
and ear, nose and throat follow up in two months for
tracheostomy tube examination.




                            [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D.  [**MD Number(1) 8285**]

Dictated By:[**Last Name (NamePattern1) 45411**]
MEDQUIST36

D:  [**2119-11-10**]  11:58
T:  [**2119-11-10**]  12:34
JOB#:  [**Job Number 18352**]
{'Malignant neoplasm of other specified part of esophagus,Other pulmonary insufficiency, not elsewhere classified,Tracheoesophageal fistula,Urinary tract infection, site not specified,Candidiasis of mouth,Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck,Acute bronchitis,Other constipation'}


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: Respiratory distress

PRESENT ILLNESS: The patient is a 69 year old
female with no significant past medical history who presented
to [**Hospital 882**] Hospital with acute onset of respiratory
distress.  The patient had been noticing an enlarging neck
mass for the past three to four years.  As [**First Name8 (NamePattern2) **] [**Hospital 882**]
Hospital notes, the patient noticed increasing phlegm
production two days prior to admission and increasing
shortness of breath.  She was being evaluated by
Otorhinolaryngology as an outpatient and sent to [**Hospital 882**]
Hospital for head/neck/chest computerized tomography scan.
While in the Waiting Room the patient had an acute onset of
respiratory distress requiring intubation and was admitted to
the [**Hospital 882**] Hospital Intensive Care Unit.  Because the
outside hospital was unable to provide radiation, the patient
was transferred to the [**Hospital6 256**].

MEDICAL HISTORY: None.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: The patient lives with one son and her
grandson.  She quit tobacco 30 years ago and smoked less than
half a pack per day for a few years.  She denies alcohol use.
She works at [**Company **] and was working prior to her
Otorhinolaryngology visit.  Before that she worked for 14
years at a Stride-Rite Factory gluing soles to bottom of
shoes. 

### Response:
{'Malignant neoplasm of other specified part of esophagus,Other pulmonary insufficiency, not elsewhere classified,Tracheoesophageal fistula,Urinary tract infection, site not specified,Candidiasis of mouth,Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck,Acute bronchitis,Other constipation'}
