CHIEF COMPLAINT: 

PRESENT ILLNESS: 

MEDICAL HISTORY: Her previous medical history as above.

MEDICATION ON ADMISSION: Her medications preoperatively
were Plavix, aspirin, Hydrea, Levoxyl, hydrochlorothiazide,
and metoprolol.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Malignant neoplasm of other parts of bronchus or lung,Cardiac complications, not elsewhere classified,Atrial fibrillation,Unilateral paralysis of vocal cords or larynx, partial,Other specified anomalies of respiratory system,Benign neoplasm of thymus,Acute bronchitis
Mal neo bronch/lung NEC,Surg compl-heart,Atrial fibrillation,Vocal paral unilat part,Respiratory anomaly NEC,Benign neoplasm thymus,Acute bronchitis
Admission Date:  [**2184-9-13**]     Discharge Date:  [**2184-10-16**]


Service:

PREOPERATIVE DIAGNOSIS:
 1.  Left upper lobe mass.

SECONDARY DIAGNOSES:
1.  Polycythemia [**Doctor First Name **].
2.  Thyroid cancer.
3.  History of atypical transient ischemic attacks.
4.  Carotid stenosis.
5.  Hypertension.
6.  Status post thyroidectomy.
7.  Status post total abdominal hysterectomy.
8.  Status post cholecystectomy.

POSTOPERATIVE DIAGNOSES:
 1.  Left upper lobe mass.
 2.  Polycythemia [**Doctor First Name **].
 3.  Thyroid cancer.
 4.  History of atypical transient ischemic attacks.
 6.  Carotid stenosis.
 7.  Hypertension.
 8.  Status post thyroidectomy.
 9.  Status post total abdominal hysterectomy.
10.  Status post cholecystectomy.

PROCEDURES PERFORMED:  (On [**2184-9-13**])
1.  Left upper lobe wedge resection.
2.  Bronchoscopy.
3.  Completion of left upper lobectomy.
4.  Mediastinal lymph node dissection.
5.  Excision of thymoma.
6.  Pleural flap pedicle closure.

INDICATIONS FOR ADMISSION:  Ms. [**Known lastname **] is a fairly active
82-year-old woman who presented with a history of chest pain.
She was evaluated and ruled out for a myocardial infarction.

Her workup included radiographs that demonstrated a mass in
the left upper lobe and was confirmed by computed tomography
scan.  The risk, benefits, and alternatives were discussed
with her at length.  We felt that this was most likely a lung
cancer of some type, and she might benefit from resection
even given her advanced age.  She had some concerns about
this, and was discussed them for quite some time.  She also
has a history of some atypical visual changes; possibly
transient ischemic attacks, and a history of polycythemia
[**Doctor First Name **].

She underwent a preoperative evaluation including attempted
snipping of her carotid artery by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] here.
Eventually, she was felt not to be a safe candidate during
the angiogram.  She was placed on aspirin and Plavix at that
time.  After this procedure, her lung mass was again
addressed with her.  She consented to undergo definitive
treatment.

PAST MEDICAL HISTORY:  Her previous medical history as above.

MEDICATIONS ON ADMISSION:  Her medications preoperatively
were Plavix, aspirin, Hydrea, Levoxyl, hydrochlorothiazide,
and metoprolol.

PHYSICAL EXAMINATION ON PRESENTATION:  Her physical
examination was otherwise unremarkable.

HOSPITAL COURSE:  Please note that this dictation is being
performed several months after the patient's date of death.
It was difficult to determine who the responsible resident
was for dictating this Discharge Summary, and I am going to
complete it at this time.  My recollection at this time is
being reinforced by the patient's chart; although, for the
exact details I would refer to the medical record.

The patient underwent the above-mentioned procedure on
[**2184-9-13**].  Postoperatively, she was monitored in the
Intensive Care Unit.

For the first two postoperative days, she was monitored in
the Postanesthesia Care Unit for some (1) respiratory
lability and (2) relative hypotension requiring
[**Name (NI) 103585**] drip at low-to-moderate doses to maintain her
blood pressure.  We were especially aggressive about this
given her previous history of atypical transient ischemic
attacks.

On or about the third postoperative day, the patient
manifested signs of respiratory distress.  A chest x-ray
demonstrated collapse of the remaining left lower lobe, and
the patient was intubated.  The patient was transferred to
the Cardiac Surgery Recovery Unit, and full monitoring was
performed.

Over approximately the subsequent second to nine days, the
patient showed steady slow improvement.  She did not show any
evidence of multiorgan failure, and her pulmonary symptoms
slowly resolved.  She was bronchoscoped on a daily basis with
the finding of thick secretions as well as mucosal edema.

Interventional Pulmonology was consulted at this time, and
they performed the majority of the bronchoscopies.  She
treated with prophylactic antibiotics, and several cultures
did not prove her to have a pneumonia.

She was slowly weaned from ventilatory support by
approximately postoperative day nine, and she was extubated.

At this point, we re-evaluated her swallowing given the
prolonged intubation and previous surgery, and thought this
would be prudent.  Her swallowing evaluation showed gross
aspiration.  She was made nothing by mouth and treated with
nutrition alternatives.

Around postoperative day twelve, she still manifested an
increased white blood cell count despite being afebrile.  She
was treated with prophylactic antibiotics.  However,
increasingly over the next one to two weeks, this was felt
actually to be related to withdrawal of her Hydrea medication
for polycythemia [**Doctor First Name **].  We had a long discussion with her
hematologist about this, and this was felt eventually to be
the most likely cause of her leukocytosis.  Clinically, she
did not appear infected nor septic.

Her pulmonary status, however, continued to be tenuous
requiring aggressive pulmonary toilet.  Because of
intermittent left lower lobe collapse and effusion on that
side, Interventional Radiology was consulted and placed a
small drain in the left pleural space on postoperative day
fourteen for effusion.  The culture did not grow out any
bacteria on final analysis.

Around this time, Ear/Nose/Throat was consulted for her
swallowing difficulties, and she was found to have bilateral
vocal cord paresis.  They felt that this would improve with
time and simply keeping her nothing by mouth would suffice.

Over the subsequent two weeks, the patient showed gradual
improvement; although, she was not yet able to swallow.

At the end of [**Month (only) 359**] (around [**9-30**]), Gastroenterology
was consulted for placement of percutaneous endoscopic
gastrostomy tube.  It was around this time she also had
manifest signs of increasing blood pressure lability.  She
had an acute decompensation around [**10-1**] or [**10-2**],
and a percutaneous endoscopic gastrostomy tube was deferred
for a later date.

Cardiology was involved in her management, and pressors were
needed to support her blood pressure.  The patient had an
elevation in her troponin to a level of 18, and an
echocardiogram which showed severe global dysfunction of her
left ventricle.  This was a significant change from her
preoperative which essentially showed a normal ventricle.
She also had some arrhythmias at this time with some
ventricular as well as atrial arrhythmias.

A cardiac catheterization was performed at that time which
surprisingly showed completely normal coronary arteries.  It
was unclear as to the etiology of her acute decompensation in
cardiac function, and this may have been related to some
adverse reaction to a drug (which eventually remained
undetermined).

By [**10-6**], the patient was showing steady progress.  Her
repeat echocardiogram actually showed a normal left
ventricle.  She was re-evaluation at this time by
Ear/Nose/Throat and felt to still be at high risk and was
kept nothing by mouth at this time.

Again, at this time, the patient had no signs of sepsis or
infection.

On or about [**10-9**], the patient had an episode of
monocular blindness and was consulted by the Neurology
Service.  She had previously had a workup for this; both as
an inpatient earlier in her hospital stay and as mentioned
preoperatively (including an aborted attempt at stenting her
carotid).

At this time, the treatment recommended was maintaining her
blood pressure at a higher rate; and this was done with a
dopamine infusion.  Neurologically, she was otherwise fairly
nonfocal and was gaining strength each day.

By [**10-13**], the patient was showing improvement with
Physical Therapy, and Speech and Swallow evaluation showed
significant improvement and no evidence of aspiration, and
she was placed on a diet with aspiration maneuvers as
described by the Speech Therapy Department.

It should be mentioned that the patient had an increasing
interstitial pattern on her chest x-rays.  It was unclear as
to the etiology of this.  The differential included infection
versus inflammatory connective tissue versus lymphatic spread
of tumor.  Her pathology showed bronchoalveolar carcinoma
well differentiated as well as a noninvasive thymoma.
Therefore, we felt that neoplasm was probably unlikely.

She was eventually started on prophylactic antibiotics, but
on [**10-14**] the patient had an acute decompensation of an
extremely severe nature.

The patient showed evidence of respiratory distress and was
intubated immediately by Anesthesia.  Her hemodynamics became
progressively/rapidly decompensated, and fluids and pressors
were necessary for support.  Immediately, invasive
hemodynamic monitoring lines were placed including a
Swan-Ganz catheter that was consistent with septic
physiology.  Aggressive treatment was performed at this time
to optimize her cardiac, respiratory, pulmonary, and renal
function.

We had a long discussion with her family at this time as to
the events that occurred, and sought their opinion as to what
she would prefer for her management.  We agreed that
aggressive management would continue to see if she showed
dramatic improvement.  If not, we would consider alternative
strategies.

Over the subsequent two day, the patient showed absolutely no
improvement with progression to multiorgan dysfunction.
After a long discussion with the patient's family (including
her son who was her health care proxy), they felt that the
patient would not want to persist with this mode of life
support given her age and extremely poor prognosis.

At this time, withdrawal of support was initiated and comfort
measures made, and the patient expired.  The family was
present during this time.  Dr. [**Last Name (STitle) 175**] was present and
participated throughout all the decision making processes.

DISCHARGE DISPOSITION:  Death.





                          [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D.  [**MD Number(1) 179**]

Dictated By:[**Last Name (NamePattern1) 44639**]

MEDQUIST36

D:  [**2185-1-7**]  15:51
T:  [**2185-1-11**]  11:51
JOB#:  [**Job Number **]
{'Malignant neoplasm of other parts of bronchus or lung,Cardiac complications, not elsewhere classified,Atrial fibrillation,Unilateral paralysis of vocal cords or larynx, partial,Other specified anomalies of respiratory system,Benign neoplasm of thymus,Acute bronchitis'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: 

PRESENT ILLNESS: 

MEDICAL HISTORY: Her previous medical history as above.

MEDICATION ON ADMISSION: Her medications preoperatively
were Plavix, aspirin, Hydrea, Levoxyl, hydrochlorothiazide,
and metoprolol.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Malignant neoplasm of other parts of bronchus or lung,Cardiac complications, not elsewhere classified,Atrial fibrillation,Unilateral paralysis of vocal cords or larynx, partial,Other specified anomalies of respiratory system,Benign neoplasm of thymus,Acute bronchitis'}
