CHIEF COMPLAINT: Shortness of Breath

PRESENT ILLNESS: 81 y/o female with a hx of metastatic squamous cell carcinoma of
the L leg; she presented to her oncologists office 2 days ago
with L hip and left leg thought to be from her radiation
therapy; she had a CT scan from a week prior which revealed L
sided hydronephrosis in the presence of a urinary tract
infection.  The urology consult noted this hydro was from
external compression from L iliac chain LAD.

MEDICAL HISTORY: -Squamous Cell Carcinoma to L leg x1 year s/p radiation and
chemo
-A.fib (on warfarin, on dilt)
-HTN
-Recurrent UTI

MEDICATION ON ADMISSION: -Warfarin 2mg PO daily
-Nifedipine XL 120mg PO daily
-Fluticasone Propionate 0.05%
-Toprol XL 50mg PO daily
-Nitrofurantoin 50mg PO daily
-Diltiazem 240mg PO daily
-Alprazolam 0.25mg PO qhs
-APAP/Codeine 300/30mg PO q4h PRN pain
-Famotidine 20mg PO daily

ALLERGIES: ciprofloxacin / Percocet / Percocet

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: T: 97.7 BP: 101/59 P: 103 R: 25 O2: 95% NRB
General: Alert, oriented, no acute distress, thin
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops; Peripheral IV lines in both hands and the L AC
Lungs: Clear to auscultation bilaterally, diminished bases
bilaterally, no retractions, mild tachypnea, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE PHYSICAL EXAM:
VS: 99 94/57-111/58 75-90 18 94%RA
GENERAL - elderly female in NAD
HEENT - sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTAB, slightly decreased at bases. respirations
unlabored, no accessory muscle use. no wheezing or rales. able
to speak in full sentences
HEART - irregularly irregular, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ peripheral pulses, 2+ LLE pitting edema up
to ankle
SKIN - no rashes or lesions
NEURO - awake, A&Ox3

FAMILY HISTORY: -Father died at 97
-Mother died at 87; palpitations, DMII
-Brother died at 74; prostate CA
-Son 57, alive; DMII
-Daughter 56, alive and well
-Daughter 54, alive and well

SOCIAL HISTORY: Lives in [**Hospital1 **] Village retirement facility with husband.
Retired from work in jewelry sales.  3 grown children.  Lifelong
nonsmoker.  Drinks red wine.
Other specified forms of effusion, except tuberculous,Acute respiratory failure,Intestinal infection due to Clostridium difficile,Candidiasis of other urogenital sites,Acute pyelonephritis without lesion of renal medullary necrosis,Hydronephrosis,Acute kidney failure, unspecified,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Secondary malignant neoplasm of lung,Other fluid overload,Atrial fibrillation,Long-term (current) use of anticoagulants,Other drugs and medicinal substances causing adverse effects in therapeutic use,Hypotension, unspecified,Unspecified essential hypertension,Leukocytosis, unspecified,Other and unspecified Escherichia coli [E. coli],Anemia, unspecified,Do not resuscitate status,Insomnia, unspecified,Abdominal pain, other specified site,Constipation, unspecified,Personal history of other malignant neoplasm of skin,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health
Effusion NEC exc tb,Acute respiratry failure,Int inf clstrdium dfcile,Candidias urogenital NEC,Ac pyelonephritis NOS,Hydronephrosis,Acute kidney failure NOS,Mal neo lymph-intrathor,Secondary malig neo lung,Fluid overload NEC,Atrial fibrillation,Long-term use anticoagul,Adv eff medicinal NEC,Hypotension NOS,Hypertension NOS,Leukocytosis NOS,E.coli infection NEC/NOS,Anemia NOS,Do not resusctate status,Insomnia NOS,Abdmnal pain oth spcf st,Constipation NOS,Hx-skin malignancy NEC,Hx antineoplastic chemo,Hx of irradiation
Admission Date:  [**2185-5-7**]              Discharge Date:   [**2185-5-24**]

Date of Birth:  [**2104-3-13**]             Sex:   F

Service: MEDICINE

Allergies:
ciprofloxacin / Percocet / Percocet

Attending:[**Doctor First Name 2080**]
Chief Complaint:
Shortness of Breath


Major Surgical or Invasive Procedure:
Right thoracentesis (diagnostic and therapeutic)

History of Present Illness:
81 y/o female with a hx of metastatic squamous cell carcinoma of
the L leg; she presented to her oncologists office 2 days ago
with L hip and left leg thought to be from her radiation
therapy; she had a CT scan from a week prior which revealed L
sided hydronephrosis in the presence of a urinary tract
infection.  The urology consult noted this hydro was from
external compression from L iliac chain LAD.

She initially presented to the emergency department upon urging
from her oncologist where she received antibiotics, and was seen
by urology who requested additional imaging.  She was admitted
for a complicated urinary tract infection and seen by urology
following a reapeat CT Scan on [**5-4**]; On [**5-5**] the patient
underwent a cystoscopy, L retrograde pyelogram, and a left
double-J stent placement.

The patient tolerated the procedure well - but on [**5-7**], a rapid
response was called and the patient presented with shortness of
breath, tachycardia to 120 and SBPs in the 100's.  The patient
was found to have an INR of 6.2, and transferred to the [**Hospital1 **]
ICU.  She was noted to have progressively worsening
leukocystosis to 21,000.  Her creatinine bumped to 1.7 and began
trending down to 1.3 prior to transfer.

On arrival to the MICU, the patient was in no apparent distress,
saturating 95% on 15L via nonrebreather mask.  She was alert and
oriented to person, place, time and denies any discomfort or
subjective feelings of dyspnea.

Past Medical History:
-Squamous Cell Carcinoma to L leg x1 year s/p radiation and
chemo
-A.fib (on warfarin, on dilt)
-HTN
-Recurrent UTI


Social History:
Lives in [**Hospital1 **] Village retirement facility with husband.
Retired from work in jewelry sales.  3 grown children.  Lifelong
nonsmoker.  Drinks red wine.



Family History:
-Father died at 97
-Mother died at 87; palpitations, DMII
-Brother died at 74; prostate CA
-Son 57, alive; DMII
-Daughter 56, alive and well
-Daughter 54, alive and well


Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.7 BP: 101/59 P: 103 R: 25 O2: 95% NRB
General: Alert, oriented, no acute distress, thin
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops; Peripheral IV lines in both hands and the L AC
Lungs: Clear to auscultation bilaterally, diminished bases
bilaterally, no retractions, mild tachypnea, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE PHYSICAL EXAM:
VS: 99 94/57-111/58 75-90 18 94%RA
GENERAL - elderly female in NAD
HEENT - sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTAB, slightly decreased at bases. respirations
unlabored, no accessory muscle use. no wheezing or rales. able
to speak in full sentences
HEART - irregularly irregular, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ peripheral pulses, 2+ LLE pitting edema up
to ankle
SKIN - no rashes or lesions
NEURO - awake, A&Ox3


Pertinent Results:
ADMISSION LABS:
WBC-18.9* RBC-2.67* Hgb-9.6* Hct-29.5* MCV-110* MCH-36.1*
MCHC-32.7 RDW-14.0 Plt Ct-383
Neuts-92.7* Lymphs-2.8* Monos-3.9 Eos-0.5 Baso-0.1
PT-59.8* PTT-40.9* INR(PT)-6.0*
Glucose-98 UreaN-32* Creat-1.0 Na-136 K-3.9 Cl-103 HCO3-19*
AnGap-18
ALT-5 AST-14 LD(LDH)-197 CK(CPK)-59 AlkPhos-95 TotBili-0.4
CK-MB-3 cTropnT-<0.01 proBNP-4015*
Albumin-3.2* Calcium-8.2* Phos-3.2 Mg-1.9
Type-[**Last Name (un) **] pO2-43* pCO2-31* pH-7.46* calTCO2-23 Base XS-0
Intubat-NOT INTUBA
Lactate-1.1
freeCa-1.11*
URINALYSIS: Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.019 Blood-LG
Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.5 Leuks-MOD
RBC->182* WBC->182* Bacteri-MOD Yeast-FEW Epi-0 AmorphX-OCC
URINE WBC Clm-MANY Mucous-RARE
.
DISCHARGE LABS
[**2185-5-24**] 07:05AM BLOOD WBC-29.9* RBC-2.52* Hgb-8.4* Hct-28.0*
MCV-111* MCH-33.2* MCHC-29.9* RDW-14.8 Plt Ct-257
[**2185-5-24**] 07:05AM BLOOD Neuts-90* Bands-3 Lymphs-0 Monos-5 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2185-5-24**] 07:05AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Bite-OCCASIONAL
[**2185-5-24**] 07:05AM BLOOD PT-28.1* PTT-30.1 INR(PT)-2.7*
[**2185-5-24**] 07:05AM BLOOD Glucose-71 UreaN-13 Creat-0.4 Na-138
K-3.0* Cl-100 HCO3-26 AnGap-15
[**2185-5-24**] 07:05AM BLOOD Calcium-7.7* Phos-3.1 Mg-1.7
.
PLEURAL FLUID LABS:
-PLEURAL TotProt-1.5 Glucose-121 LD(LDH)-186 Albumin-1.1
-PLEURAL WBC-363* RBC-448* Polys-4* Lymphs-4* Monos-0 Meso-2*
Macro-90*
-CYTOLOGY: negative
-CULTURES: no growth
.
Other micro
- blood culture [**5-8**] - no growth
- blood culture [**5-17**] - no growth
- urine [**5-15**] - >100,000 yeast
- stool [**5-12**] - C. diff positive
.
CXRFINDINGS [**5-8**] :  There are no old films available for
comparison.  The heart is mildly enlarged. Both hemidiaphragms
are obscured likely due to a combination of volume loss and
effusions. An underlying infectious infiltrate cannot be
excluded. There is mild pulmonary vascular re-distribution and
some alveolar opacities. The overall impression is that of CHF.
An underlying infectious infiltrate cannot be excluded.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY  [**2185-5-8**]
IMPRESSION:
1.  No evidence of pulmonary embolism.
2.  Bilateral moderate-to-large simple pleural effusions.
3.  Bilateral consolidations associated with the pleural
effusions.  These
most likely represent atelectasis, although in the proper
clinical setting, pneumonia cannot be excluded.
4.  7-mm ground-glass nodular opacity and two sub-4-mm pulmonary
nodules in the left upper lobe.  Given the patient's history of
cancer, per the
[**Last Name (un) 8773**] guidelines, a followup CT of the chest is recommended
at 3 to 6
months.
5.  Moderate-to-severe cardiomegaly.
.
ECHO [**5-9**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. No premature appearance of agitated saline is
seen at rest. The estimated right atrial pressure is 5-10 mmHg.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened with mild posterior leaflet elongation, but no
frank systolic prolapse. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension.There is an
anterior space which most likely represents a prominent fat pad.
There is a left sided pleural effusion.
IMPRESSION: Mild mitral regurgitation without discrete
vegetation or definite systolic prolapse. No vegitations seen.
No transpulmonary shunt identified. Normal regional and global
biventricular systolic function. Mild pulmonary arterial
hypertension. .
.
CT torso [**2185-5-18**]
1.  Proctitis.  No evidence of [**Last Name (un) 2432**]-colon.
2.  Volume overload as evidenced by moderate-sized bilateral
pleural
effusions, cardiomegaly and anasarca.
3.  Mediastinal and supraclavicular lymphadenopathy with
pulmonary nodules is
concerning for metastatic disease.  Followup CT of the chest
could be
performed in three to six months to document stability of the
pulmonary
nodules.
4.  Dysmorphic liver.  In the setting of a large heart and
dilated hepatic
veins, a cardiac etiology should be considered.
.
CXR [**5-19**]
IMPRESSION:  Unchanged small left and trace right pleural
effusions since
[**2185-5-15**].


Brief Hospital Course:
81 yo F with hx of SCC, Afib, HTN who presents with UTI and L
hydronephrosis s/p stent placement found to by hypoxic with
large bilateral pleural effusions now improved after R.
thoracentesis and course complicated by [**Female First Name (un) **] cystitis and
severe C. diff infection.
.
1. Respiratory Failure/hypoxia due to pleural effusions -
Patient found to have large bilateral pleural effusions after
aggressive fluid administration during urology procedure. She
was initially admitted to the intensive care unit for hypoxia.
She underwent a thoracentesis (removed 1L of fluid) with
subsequent improvement in oxygenation. Pleural effusions were
thought to be due to volume overload related to aggressive
volume given during urology procedure combined with low albumin
state. She has no renal failure or evidence of CHF on echo to
explain volume overload. Alternatively, pleural fluid was
exudative by LDH criteria and given history of malignancy there
was also concern for possible malignant effusion.  However,
cytology and micro from sample were negative. Patient responded
well to IV diuresis (20 mg IV Lasix) and was able to wean to
low-mid 90s on room air without evidence of respiratory
distress. Her discharge weight was 116.4 lbs. She was not
discharged on oral Lasix given that she was orthostatic on exam.
If she gains more than 5 pounds, develops worsening lower
extremity edema, or respiratory distress, would restart Lasix at
either 20 mg IV or 40 mg oral.

2. Severe C. difficile colitis with leukocytosis - Patient found
to have sudden increase in her white blood cell count to 30,000
with diarrhea. She was found to have positive C. diff toxin and
initiated on IV Flagyl.  Her WBC continued to
increase and she was broadened to PO and PR Vancomycin.  Given
abdominal distention, she underwent a CT Torso which showed
proctitis likely related to C. diff infection but otherwise no
evidence of occult infection or megacolon. The imaging did
however show concern for metastatic disease. Her WBC stabilized
but did not improve with her improving symptoms.  Infectious
disease was therefore consulted who felt her WBC was consistent
with C. diff plus a leukemoid reaction, possibly related to her
malignancy.  We continued her PO Vancomycin at 500 mg, then back
to 125 mg QID.  She remained stable with soft bowel movements
with mild abdominal distention, but no pain, fever, or ileus.
We recommend continuing PO vancomycin to complete a full course
and monitoring her WBC for resolution.  Her course may need to
be extended or tapered should she not respond.  Heme/Onc eval of

her leukocytosis may also be considered.
--she was discharged on oral vancomycin every 6 hours for at
least a 14 day course (day 1 was [**5-22**]). She was discharged on
500 mg QID. However, if patient has no worsening symptoms in the
2 days following discharge, she can change the vancomycin dose
to 125 mg QID to complete her course.

2. Bacterial/Fungal UTI - Patient was admitted on antibiotics to
treat complicated urine infection. Initially she was placed on
Zosyn. Urine culture showed E. coli sensitive to cephalosporins.
She was subsequently changed to ceftriaxone. She completed a 14
day course. On repeat urine study, patient was noted to have
greater than 100,000 yeast. Given continued dysuria she was
started on fluconazole and completed a 7 day course. She will
need to follow up with urology for management of her ureteral
stents

3. AFib: Presented with supra therapeutic INR which was
subsequently reversed for thoracentesis. Coumadin dose was
titrated to maintain therapeutic INR between [**1-7**].  She will need
to have her INR checked daily after discharge. When it
falls below 2.5, would give Coumadin 0.5 mg. She will need to
have INR checked at least twice weekly until on stable dosing.
Patient was given her home diltiazem dosing. She was also
restarted on her home metoprolol however she became bradycardic
and this was discontinued. She maintained adequate rate control
between 60-80 with diltiazem alone.

4. hypertension - Patient continued on diltiazem. Her metoprolol
and nifedepine were held and blood pressures maintained in low
100s.
- Monitor for resolution of her orthostasis

5. [**Last Name (un) **]: Patient had peak creatinine of 1.7 at OSH which
subsequently resolved.

6. squamous cell carcinoma - s/p chemo and radiation with
evidence of metastatic disease on imaging, with LAD and
pulmonary nodules. Patient was started on long acting pain
control with OxyContin and continued on oxycodone prn for
breakthrough. She was also given standing Tylenol.  She should
follow up with her oncologist to discuss further treatment and
goals of care.

7. Poor Nutritional Status: Patient with poor appetite and
albumin notably was 3.2. She was encouraged to drink ensure TID
with her meals. This should be encouraged further in rehab.

transitional issues:
- C diff infection - She was discharged on 500 mg QID. However,
if patient has no worsening symptoms in the 2 days after
discharge, can change the dose of vancomycin to 125 mg QID to
complete her course.
- Goals of care: patient with clear end of life wishes,
discussed with daughter; no code/compressions, but OK to
intubate if respiratory failure
- patient will need INR checked daily. When INR less than 2.5
would start 0.5 mg of Coumadin. She will need to have her INR
checked at least twice weekly after restarting Coumadin until on
stable regimen.
- Patient's discharge weight was 116.4 lbs. If she gains more
than 5 pounds, develops worsening lower extremity edema or
respiratory distress, would restart Lasix at either 20 mg IV or
40 mg oral. Notably patient had episodes of orthostasis while
being diuresed.
- patient will need to follow up with her oncologist regarding
her leukocytosis and metastatic disease to address further
treatment and goals of care.
- Patient will need to follow up with urology for management of
her ureteral stents.


Medications on Admission:
-Warfarin 2mg PO daily
-Nifedipine XL 120mg PO daily
-Fluticasone Propionate 0.05%
-Toprol XL 50mg PO daily
-Nitrofurantoin 50mg PO daily
-Diltiazem 240mg PO daily
-Alprazolam 0.25mg PO qhs
-APAP/Codeine 300/30mg PO q4h PRN pain
-Famotidine 20mg PO daily


Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Diltiazem Extended-Release 240 mg PO DAILY
hold for SBP<100, HR<60
3. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Senna 1 TAB PO BID:PRN Constipation
8. OxycoDONE (Immediate Release)  5 mg PO Q6H:PRN pain
hold for oversedation, RR<12
9. Oxycodone SR (OxyconTIN) 10 mg PO Q8H
hold for oversedation, RR<12
10. Vancomycin Oral Liquid 500 mg PO Q6H Duration: 12 Days (can
decrease dose to 125 mg QID to complete course if patients
symptoms do not worsenen in the next 2 days)


Discharge Disposition:
Extended Care

Facility:
[**Hospital 4470**] HealthCare Center at [**Location (un) 38**]

Discharge Diagnosis:
primary diagnosis: urinary tract infection, clostridium
difficile colitis. dyspnea
secondary diagnosis: squamous cell carcinoma of the skin, atrial
fibrillation


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 Ms. [**Known lastname 112065**],

It was a pleasure participating in your care at [**Hospital1 771**]. You were admitted to the hospital with
difficulty breathing after a recent urologic procedure. You were
found to have fluid around your lungs (pleural effusions),
likely caused by getting fluids during your operation. The fluid
was removed from your right lung via thoracentesis, and your
oxygenation improved. You were also give intravenous medications
to help remove the fluid. In addition to this you were treated
for both a bacterial and yeast urine infection with medications.
You were also found to have an infection called Clostridium
difficile colitis which you started treatment for. You were
evaluated by the physical therapy team who felt that you would
benefit from rehab.
.
The following changes have been made to your medication regimen.
Please START taking
- oral vancomycin 500 mg every 6 hours for total 14 days (day 1
[**5-22**])
- lasix 40 mg as needed if weight increases by more than five
pounds
- oxycontin 10 mg three times a day
- oxycodone 5 mg every six hours as needed for pain
.
Please STOP taking
- metoprolol
- nifedipine
- tylenol #3
.
You were not discharged on a [**Month/Year (2) 1988**] coumadin dose. You will
need to have your INR checked at your facility and your dose
will be adjusted appropriately.
.
Please take the rest of your medications as prescribed and
follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].


Followup Instructions:
Department: Hematology/ Oncology
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Tuesday [**2185-6-7**] at 11:15 AM
Location: [**Location (un) **] HEMATOLOGY ONCOLOGY
Address: [**Location (un) 10726**], [**Hospital1 **],[**Numeric Identifier 10727**]
Phone: [**Telephone/Fax (1) 10728**]

Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital 1263**] Hospital
Address: [**Apartment Address(1) 112066**] [**Location (un) 686**], MA
Phone: [**Telephone/Fax (1) 64585**]
Appointment: Friday [**2185-6-10**] 10:45am



Completed by:[**2185-5-24**]
{'Other specified forms of effusion, except tuberculous,Acute respiratory failure,Intestinal infection due to Clostridium difficile,Candidiasis of other urogenital sites,Acute pyelonephritis without lesion of renal medullary necrosis,Hydronephrosis,Acute kidney failure, unspecified,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Secondary malignant neoplasm of lung,Other fluid overload,Atrial fibrillation,Long-term (current) use of anticoagulants,Other drugs and medicinal substances causing adverse effects in therapeutic use,Hypotension, unspecified,Unspecified essential hypertension,Leukocytosis, unspecified,Other and unspecified Escherichia coli [E. coli],Anemia, unspecified,Do not resuscitate status,Insomnia, unspecified,Abdominal pain, other specified site,Constipation, unspecified,Personal history of other malignant neoplasm of skin,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health'}


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: 81 y/o female with a hx of metastatic squamous cell carcinoma of
the L leg; she presented to her oncologists office 2 days ago
with L hip and left leg thought to be from her radiation
therapy; she had a CT scan from a week prior which revealed L
sided hydronephrosis in the presence of a urinary tract
infection.  The urology consult noted this hydro was from
external compression from L iliac chain LAD.

MEDICAL HISTORY: -Squamous Cell Carcinoma to L leg x1 year s/p radiation and
chemo
-A.fib (on warfarin, on dilt)
-HTN
-Recurrent UTI

MEDICATION ON ADMISSION: -Warfarin 2mg PO daily
-Nifedipine XL 120mg PO daily
-Fluticasone Propionate 0.05%
-Toprol XL 50mg PO daily
-Nitrofurantoin 50mg PO daily
-Diltiazem 240mg PO daily
-Alprazolam 0.25mg PO qhs
-APAP/Codeine 300/30mg PO q4h PRN pain
-Famotidine 20mg PO daily

ALLERGIES: ciprofloxacin / Percocet / Percocet

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Vitals: T: 97.7 BP: 101/59 P: 103 R: 25 O2: 95% NRB
General: Alert, oriented, no acute distress, thin
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops; Peripheral IV lines in both hands and the L AC
Lungs: Clear to auscultation bilaterally, diminished bases
bilaterally, no retractions, mild tachypnea, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE PHYSICAL EXAM:
VS: 99 94/57-111/58 75-90 18 94%RA
GENERAL - elderly female in NAD
HEENT - sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTAB, slightly decreased at bases. respirations
unlabored, no accessory muscle use. no wheezing or rales. able
to speak in full sentences
HEART - irregularly irregular, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ peripheral pulses, 2+ LLE pitting edema up
to ankle
SKIN - no rashes or lesions
NEURO - awake, A&Ox3

FAMILY HISTORY: -Father died at 97
-Mother died at 87; palpitations, DMII
-Brother died at 74; prostate CA
-Son 57, alive; DMII
-Daughter 56, alive and well
-Daughter 54, alive and well

SOCIAL HISTORY: Lives in [**Hospital1 **] Village retirement facility with husband.
Retired from work in jewelry sales.  3 grown children.  Lifelong
nonsmoker.  Drinks red wine. 

### Response:
{'Other specified forms of effusion, except tuberculous,Acute respiratory failure,Intestinal infection due to Clostridium difficile,Candidiasis of other urogenital sites,Acute pyelonephritis without lesion of renal medullary necrosis,Hydronephrosis,Acute kidney failure, unspecified,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Secondary malignant neoplasm of lung,Other fluid overload,Atrial fibrillation,Long-term (current) use of anticoagulants,Other drugs and medicinal substances causing adverse effects in therapeutic use,Hypotension, unspecified,Unspecified essential hypertension,Leukocytosis, unspecified,Other and unspecified Escherichia coli [E. coli],Anemia, unspecified,Do not resuscitate status,Insomnia, unspecified,Abdominal pain, other specified site,Constipation, unspecified,Personal history of other malignant neoplasm of skin,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health'}
