CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: 72 year old male with past medical history of COPD on 3L home
oxygen, CAD, hypertension, and s/p endovascular repair of
abdominal aortic aneurysm on [**2145-5-19**] and a left femoral
endarterectomy on [**2145-5-22**] complicated by respiratory failure,
myocardial infarction, and left lower extremity ischemia, now
presenting with two day history of shortness of breath without
any new sputum production or other upper respiratory symptoms.
.
He was extremely short of breath per EMS had O2 sats of 73% on 3
L oxygen. He denied fever chills headache or chest pain. He has
been nauseous without vomiting.

MEDICAL HISTORY: - COPD- baseline home O2 3LCN
- Morbid Obesity
- HTN
- HL
- AAA
- Pulm. nodule
- Edema
- S/P abd. hernia repair

MEDICATION ON ADMISSION: albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler
aspirin 325 mg po qdaily
clopidogrel 75 mg po qdaily
iron 325 mg po qdaily
enalapril maleate 5 mg po qdaily
fluticasone 110 mcg/Actuation Aerosol 2 puffs [**Hospital1 **]
furosemide 20 mg po qdaily
metoprolol succinate 100 mg po qdaily
rosuvastatin 20 mg po qdaily
tiotropium bromide 18 mcg po qdaily

ALLERGIES: scallops

PHYSICAL EXAM: On Admission:
Vitals: T:96.7 BP:119/51(69) P:65 R:22 O2:93% FiO270%
General: Intubated, sedated
HEENT: MMM, oropharynx clear, PERRL
Neck: no obvious JVD, difficulty to assess due to size
CV: Regular rate and rhythm, no m/r/g
Lungs: Mild wheezes bilaterally, no rales, ronchi.
Abdomen: Obese, protuberant, nontender, nondistended
GU: Foley in place
Ext: warm, well perfused, 1+ pulses equal in all extremities,
lower extremity swelling bilaterally RLE > LLE

FAMILY HISTORY: CAD/PVD - father and mother, died in their 70s
CVA - brother in 60s.  Brother diagnosed with alzheimers at age
60.

SOCIAL HISTORY: Lives at home with wife, daughter, son-in-law and 3
grandchildren.  Used to work as a office equipment repairman.
Tobacco - quit [**2136**], was a lifetime smoker - 1-2ppd for 43 years
EtOH - occasional ethanol
drug use - denies.
Acute respiratory failure,Chronic obstructive asthma with (acute) exacerbation,Acute diastolic heart failure,Other shock without mention of trauma,Body Mass Index 40.0-44.9, adult,Hyperosmolality and/or hypernatremia,Other iatrogenic hypotension,Morbid obesity,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Old myocardial infarction,Leukocytosis, unspecified,Peripheral vascular disease, unspecified,Benign neoplasm of skin of lower limb, including hip,Other and unspecified hyperlipidemia,Other dependence on machines, supplemental oxygen,Other postprocedural status,Personal history of tobacco use,Intravenous anesthetics causing adverse effects in therapeutic use
Acute respiratry failure,Ch obst asth w (ac) exac,Ac diastolic hrt failure,Shock w/o trauma NEC,BMI 40.0-44.9, adult,Hyperosmolality,Iatrogenc hypotnsion NEC,Morbid obesity,Crnry athrscl natve vssl,Hypertension NOS,Old myocardial infarct,Leukocytosis NOS,Periph vascular dis NOS,Benign neo skin leg,Hyperlipidemia NEC/NOS,Depend-supplement oxygen,Post-proc states NEC,History of tobacco use,Adv eff intraven anesth
Admission Date:  [**2146-1-17**]              Discharge Date:   [**2146-1-22**]

Date of Birth:  [**2073-9-20**]             Sex:   M

Service: MEDICINE

Allergies:
scallops

Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
72 year old male with past medical history of COPD on 3L home
oxygen, CAD, hypertension, and s/p endovascular repair of
abdominal aortic aneurysm on [**2145-5-19**] and a left femoral
endarterectomy on [**2145-5-22**] complicated by respiratory failure,
myocardial infarction, and left lower extremity ischemia, now
presenting with two day history of shortness of breath without
any new sputum production or other upper respiratory symptoms.
.
He was extremely short of breath per EMS had O2 sats of 73% on 3
L oxygen. He denied fever chills headache or chest pain. He has
been nauseous without vomiting.

Initial vitals in the ED were: 95 111 192/124 24 92% 15L.  Labs
notable for WBC of 15.1, ABG of 7.15/114/203 and normal UA.  CXR
showed worsening pulmonary edema and blunted costodiaphragmatic
angles. He was intubated for hypercarbic respiratory distress,
after satting 90%s on NRB and dropping his sats to 86% with
increasing nausea preventing tolerance of BiPAP.  He was treated
for COPD exacerbation with IV methylprednisone, ceftriaxone and
azithromycin along with magnesium and duonebs x2.  He was
started on propofol in setting of intubation, which was
subsequently switched to fentanyl and versed due to hypotension,
but never required levophed (ordered in system).  Of note,
increasing respiratory rates on the ventilator seem to cause
hypotension as well. On transfer, vitals were: 60s, 96% O2 on
Fi02 70%, 112/60
.
He was transferred to MICU for evaluation and management of
hypercarbic respiratory failure.
.
On arrival to the MICU, he arrived sedated and ventilated. He
was hypotensive to 74/37, R IJ CVL was placed and he was started
on norepinephrine. His initial ABG in the MICU was
7.08/120/89/38.
.
Review of systems:
Patient intubated, unable to complete review of systems, please
see ED documentation for ROS obtained prior to intubation, will
review with patient once extubated.

Past Medical History:
- COPD- baseline home O2 3LCN
- Morbid Obesity
- HTN
- HL
- AAA
- Pulm. nodule
- Edema
- S/P abd. hernia repair


Social History:
Lives at home with wife, daughter, son-in-law and 3
grandchildren.  Used to work as a office equipment repairman.
Tobacco - quit [**2136**], was a lifetime smoker - 1-2ppd for 43 years
EtOH - occasional ethanol
drug use - denies.


Family History:
CAD/PVD - father and mother, died in their 70s
CVA - brother in 60s.  Brother diagnosed with alzheimers at age
60.


Physical Exam:
On Admission:
Vitals: T:96.7 BP:119/51(69) P:65 R:22 O2:93% FiO270%
General: Intubated, sedated
HEENT: MMM, oropharynx clear, PERRL
Neck: no obvious JVD, difficulty to assess due to size
CV: Regular rate and rhythm, no m/r/g
Lungs: Mild wheezes bilaterally, no rales, ronchi.
Abdomen: Obese, protuberant, nontender, nondistended
GU: Foley in place
Ext: warm, well perfused, 1+ pulses equal in all extremities,
lower extremity swelling bilaterally RLE > LLE

Prior to discharge:
96.0 124/64 77 20 97% on 3L
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - decreased breath sounds diffusely. no rhonchi, resp
unlabored, no accessory muscle use
HEART - distant heart sounds [**3-10**] body habitus, RRR, no MRG, nl
S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, bilateral lower extremity edema, +1 pitting
2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moving all 4
extremities


Pertinent Results:
Admission Labs:
[**2146-1-19**] 02:30AM BLOOD WBC-16.3*# RBC-3.75* Hgb-11.0* Hct-36.1*
MCV-96 MCH-29.5 MCHC-30.6* RDW-14.6 Plt Ct-212
[**2146-1-18**] 03:43AM BLOOD WBC-10.1 RBC-3.78* Hgb-11.2* Hct-35.4*
MCV-94 MCH-29.6 MCHC-31.5 RDW-14.5 Plt Ct-206
[**2146-1-17**] 05:07PM BLOOD WBC-9.1 RBC-3.83* Hgb-11.5* Hct-36.9*
MCV-96 MCH-30.0 MCHC-31.2 RDW-14.4 Plt Ct-175
[**2146-1-17**] 08:25AM BLOOD WBC-15.1*# RBC-4.52* Hgb-13.4* Hct-43.2
MCV-96# MCH-29.6 MCHC-30.9* RDW-14.2 Plt Ct-242
[**2146-1-19**] 02:30AM BLOOD Neuts-91.0* Lymphs-4.3* Monos-4.3 Eos-0.4
Baso-0.1
[**2146-1-17**] 05:07PM BLOOD Neuts-95.1* Lymphs-3.8* Monos-0.6*
Eos-0.3 Baso-0.1
[**2146-1-17**] 08:25AM BLOOD Neuts-71.8* Lymphs-21.8 Monos-5.0 Eos-0.9
Baso-0.4
[**2146-1-19**] 02:30AM BLOOD Plt Ct-212
[**2146-1-18**] 08:15AM BLOOD PTT-150*
[**2146-1-18**] 03:43AM BLOOD Plt Ct-206
[**2146-1-18**] 03:43AM BLOOD PT-11.5 PTT-138.3* INR(PT)-1.1
[**2146-1-17**] 05:07PM BLOOD PT-10.8 PTT-44.2* INR(PT)-1.0
[**2146-1-19**] 04:11PM BLOOD Glucose-111* UreaN-31* Creat-1.0 Na-145
K-4.1 Cl-96 HCO3-43* AnGap-10
[**2146-1-19**] 02:30AM BLOOD Glucose-158* UreaN-26* Creat-1.2 Na-143
K-4.2 Cl-98 HCO3-39* AnGap-10
[**2146-1-18**] 05:20PM BLOOD Glucose-148* UreaN-25* Creat-1.2 Na-140
K-5.6* Cl-98 HCO3-36* AnGap-12
[**2146-1-18**] 03:43AM BLOOD Glucose-154* UreaN-22* Creat-1.1 Na-143
K-4.7 Cl-101 HCO3-31 AnGap-16
[**2146-1-17**] 05:07PM BLOOD Glucose-151* UreaN-19 Creat-1.1 Na-142
K-6.8* Cl-105 HCO3-32 AnGap-12
[**2146-1-17**] 08:25AM BLOOD Glucose-162* UreaN-18 Creat-1.1 Na-145
K-4.9 Cl-97 HCO3-40* AnGap-13
[**2146-1-19**] 02:30AM BLOOD ALT-23 AST-40 LD(LDH)-272* AlkPhos-84
TotBili-0.3
[**2146-1-19**] 04:11PM BLOOD Calcium-8.3* Phos-4.0 Mg-2.5
[**2146-1-19**] 02:30AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.4
[**2146-1-18**] 05:20PM BLOOD Calcium-8.1* Phos-3.2 Mg-2.3
[**2146-1-18**] 03:43AM BLOOD Calcium-8.1* Phos-2.4*# Mg-2.2
[**2146-1-17**] 05:07PM BLOOD Albumin-4.0 Calcium-6.9* Phos-4.2 Mg-2.2
[**2146-1-17**] 08:36AM BLOOD Lactate-1.7 Na-144 K-4.6 Cl-89*
calHCO3-42*
[**2146-1-19**] 09:16AM BLOOD freeCa-1.04*
[**2146-1-19**] 02:55AM BLOOD freeCa-1.12

Notable Studies:
CTA chest:
As compared to the previous examination, there is slightly
improved contrast filling, currently no evidence of pulmonary
embolism, but a filling inhomogeneity in the lingular artery.
Bilateral mild-to-moderate pleural effusions, bilateral areas of
dorsal and perifissural atelectasis. No evidence of right heart
strain. No enlarged mediastinal lymph nodes. Saber-sheath
trachea.

[**2146-1-18**] TTE:
Conclusions
The left atrium is elongated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are not well seen. Physiologic mitral regurgitation is
seen (within normal limits). There is an anterior space which
most likely represents a prominent fat pad.

IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size and global systolic function.

Compared with the report of the prior study (images unavailable
for review) of [**2145-5-24**], there is no significant tricuspid
regurgitation detected on the current study.

LENIs [**2146-1-17**]:
IMPRESSION: No evidence of DVT.

[**1-20**] CXR: FINDINGS: As compared to the previous radiograph, the
patient has been  extubated and the central venous access line
has been removed. Lung volumes are relatively large. There is
evidence of cardiomegaly and mild fluid overload. Unchanged
right basal atelectasis and presence of a small left pleural
effusion with subsequent left retrocardiac atelectasis.

Discharge Labs:
[**2146-1-22**] 07:30AM BLOOD WBC-8.1 RBC-3.87* Hgb-11.2* Hct-35.5*
MCV-92 MCH-29.0 MCHC-31.6 RDW-14.4 Plt Ct-167
[**2146-1-22**] 07:30AM BLOOD Glucose-84 UreaN-31* Creat-1.0 Na-142
K-3.2* Cl-91* HCO3-40* AnGap-14
[**2146-1-19**] 12:53PM BLOOD Type-ART FiO2-50 pO2-112* pCO2-66*
pH-7.41 calTCO2-43* Base XS-14 Intubat-NOT INTUBA Comment-FACE
TENT

Studies Pending at Discharge:
None

Brief Hospital Course:
72M with Chronic Obstructive Pulmonary Disease (on home O2 at
3L), coronary artery disease s/p AMI, hypertension, AAA s/p EVAR
([**2145-5-7**]), peripheral vascular disease s/p left femoral
endarterectomy admitted with hypercarbic respiratory failure due
to severe COPD exacerbation.
.
# Hypercarbic respiratory failure/Severe exacerbation of COPD:
Patient was admitted to the Intensive Care Unit with hypercarbic
respiratory failure requiring intubation. Imaging did not show
evidence of pneumonia and no pulmonary embolism was seen on CTA.
LENIs were negative for DVT. Patient was treated with steroids
and azithromycin for severe exacerbation of COPD. Patient was
extubated, finished course of azithromycin in-house, and was
discharged on 3L of oxygen by nasal canula to complete a two
week course of prednisone taper.

#Acute Diastolic Heart Failure:
While on the ventilator patient was diuresed for volume overload
with improvement in oxygenation. It was felt that stress of COPD
exacerbation had led to mild heart failure exacerbation. TTE
showed a preserved EF.

# Hypotension:
Patient was transiently on vasopressors while intubated.
.
# Lower extremity edema: RLE > LLE, unknown duration of
symptoms, high concern for DVT/PE given clinical presentation.
Bilateral duplex U/S: negative for DVT, initially treated with
heparin drip that was discontinued when evaluation was negative
for DVT and PE.
.
CAD s/p STEMI: Continued ASA, clopidogrel
.
HTN: Placed on home BP medications.
.
HLD: Continued on home statin.
.
Transitional issues:
-2 week prednisone taper
-may benefit from sleep study and night time NIPPV
-nevus on leg was evaluated by dermatology, no concern for
melanoma

Medications on Admission:
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler
aspirin 325 mg po qdaily
clopidogrel 75 mg po qdaily
iron 325 mg po qdaily
enalapril maleate 5 mg po qdaily
fluticasone 110 mcg/Actuation Aerosol 2 puffs [**Hospital1 **]
furosemide 20 mg po qdaily
metoprolol succinate 100 mg po qdaily
rosuvastatin 20 mg po qdaily
tiotropium bromide 18 mcg po qdaily

Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One
(1) Tablet PO once a day.
5. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
9. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. prednisone 20 mg Tablet Sig: as directed below Tablet PO
once a day for 10 days: take 2 tabs for the first 2 days, 1 tab
for the next 4 days, and half a tab for the last 2 days.
Disp:*10 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 1468**] VNA

Discharge Diagnosis:
COPD exacerbation


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname 88137**],
You were admitted to the hospital because you had an
exacerbation of your COPD/emphysema. You were found to be in
respiratory failure and you were intubated in the emergency
department. You were admitted to the intensive care unit and
started on antibiotics and steroids. You were extubated,
improved clinically, and transferred to the floor.

The following medication has been added to your regimen:
Prednisone: Please take 2 pills (40 mg) for the first two days,
1 pill (20 mg) for the next 4 days, and half of a pill (10 mg)
for the last 4 days.


Followup Instructions:
Please be sure to keep all of your followup appointments as
listed below:

Primary Care appointment:
Dr. [**Last Name (STitle) 88138**],CANDAN
 ** Friday, [**1-28**] at 12:40pm
26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 11562**]
Phone: [**Telephone/Fax (1) 31019**]
Fax: [**Telephone/Fax (1) 6808**]

Department: VASCULAR SURGERY
When: FRIDAY [**2146-2-11**] at 10:15 AM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: VASCULAR SURGERY
When: FRIDAY [**2146-2-11**] at 11:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2146-1-25**]
{'Acute respiratory failure,Chronic obstructive asthma with (acute) exacerbation,Acute diastolic heart failure,Other shock without mention of trauma,Body Mass Index 40.0-44.9, adult,Hyperosmolality and/or hypernatremia,Other iatrogenic hypotension,Morbid obesity,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Old myocardial infarction,Leukocytosis, unspecified,Peripheral vascular disease, unspecified,Benign neoplasm of skin of lower limb, including hip,Other and unspecified hyperlipidemia,Other dependence on machines, supplemental oxygen,Other postprocedural status,Personal history of tobacco use,Intravenous anesthetics 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: Shortness of breath

PRESENT ILLNESS: 72 year old male with past medical history of COPD on 3L home
oxygen, CAD, hypertension, and s/p endovascular repair of
abdominal aortic aneurysm on [**2145-5-19**] and a left femoral
endarterectomy on [**2145-5-22**] complicated by respiratory failure,
myocardial infarction, and left lower extremity ischemia, now
presenting with two day history of shortness of breath without
any new sputum production or other upper respiratory symptoms.
.
He was extremely short of breath per EMS had O2 sats of 73% on 3
L oxygen. He denied fever chills headache or chest pain. He has
been nauseous without vomiting.

MEDICAL HISTORY: - COPD- baseline home O2 3LCN
- Morbid Obesity
- HTN
- HL
- AAA
- Pulm. nodule
- Edema
- S/P abd. hernia repair

MEDICATION ON ADMISSION: albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler
aspirin 325 mg po qdaily
clopidogrel 75 mg po qdaily
iron 325 mg po qdaily
enalapril maleate 5 mg po qdaily
fluticasone 110 mcg/Actuation Aerosol 2 puffs [**Hospital1 **]
furosemide 20 mg po qdaily
metoprolol succinate 100 mg po qdaily
rosuvastatin 20 mg po qdaily
tiotropium bromide 18 mcg po qdaily

ALLERGIES: scallops

PHYSICAL EXAM: On Admission:
Vitals: T:96.7 BP:119/51(69) P:65 R:22 O2:93% FiO270%
General: Intubated, sedated
HEENT: MMM, oropharynx clear, PERRL
Neck: no obvious JVD, difficulty to assess due to size
CV: Regular rate and rhythm, no m/r/g
Lungs: Mild wheezes bilaterally, no rales, ronchi.
Abdomen: Obese, protuberant, nontender, nondistended
GU: Foley in place
Ext: warm, well perfused, 1+ pulses equal in all extremities,
lower extremity swelling bilaterally RLE > LLE

FAMILY HISTORY: CAD/PVD - father and mother, died in their 70s
CVA - brother in 60s.  Brother diagnosed with alzheimers at age
60.

SOCIAL HISTORY: Lives at home with wife, daughter, son-in-law and 3
grandchildren.  Used to work as a office equipment repairman.
Tobacco - quit [**2136**], was a lifetime smoker - 1-2ppd for 43 years
EtOH - occasional ethanol
drug use - denies. 

### Response:
{'Acute respiratory failure,Chronic obstructive asthma with (acute) exacerbation,Acute diastolic heart failure,Other shock without mention of trauma,Body Mass Index 40.0-44.9, adult,Hyperosmolality and/or hypernatremia,Other iatrogenic hypotension,Morbid obesity,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Old myocardial infarction,Leukocytosis, unspecified,Peripheral vascular disease, unspecified,Benign neoplasm of skin of lower limb, including hip,Other and unspecified hyperlipidemia,Other dependence on machines, supplemental oxygen,Other postprocedural status,Personal history of tobacco use,Intravenous anesthetics causing adverse effects in therapeutic use'}
