CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname 21991**] is a 77 year old male with past medical history of
COPD on 3L nasal cannula at home, OSA, thyroid cancer, chronic
renal insufficiency, and large-cell lung cancer who presents
with an episode of shortness of breath overnight. He reported to
his PCP and sleep physicians that he awoke in the middle of the
night "gasping" for air. He feels he nearly died. The dyspnea
lasted about 3 minutes in total. He did not have any other
asssociated symptoms such as chest pain, fevers, chills, or
productive cough. No wheezing. Given the complexity of his
medical problems, he was referred in for further evaluation.

MEDICAL HISTORY: - COPD, on 3L nasal cannula at home

MEDICATION ON ADMISSION: ALBUTEROL SULFATE -  (Prescribed by Other Provider) - 90 mcg HFA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 97.6 72 170/83 14 92%RA

FAMILY HISTORY: non-cont

SOCIAL HISTORY: Quit smoking >8 yrs ago but smoke and drank significantly prior
to that time
Obstructive chronic bronchitis with (acute) exacerbation,Malignant neoplasm of bronchus and lung, unspecified,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Malignant neoplasm of thyroid gland,Obstructive sleep apnea (adult)(pediatric),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Dysphagia, oropharyngeal phase,Stricture and stenosis of esophagus,Cardiac pacemaker in situ,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Bilateral paralysis of vocal cords or larynx, partial,Other dependence on machines, supplemental oxygen,Personal history of tobacco use,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health
Obs chr bronc w(ac) exac,Mal neo bronch/lung NOS,Mal neo lymph-intrathor,Malign neopl thyroid,Obstructive sleep apnea,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Dysphagia, oropharyngeal,Esophageal stricture,Status cardiac pacemaker,BPH w/o urinary obs/LUTS,Vocal paral bilat part,Depend-supplement oxygen,History of tobacco use,Hx antineoplastic chemo,Hx of irradiation
Admission Date:  [**2135-10-24**]              Discharge Date:   [**2135-10-27**]

Date of Birth:  [**2058-8-4**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Known lastname 21991**] is a 77 year old male with past medical history of
COPD on 3L nasal cannula at home, OSA, thyroid cancer, chronic
renal insufficiency, and large-cell lung cancer who presents
with an episode of shortness of breath overnight. He reported to
his PCP and sleep physicians that he awoke in the middle of the
night "gasping" for air. He feels he nearly died. The dyspnea
lasted about 3 minutes in total. He did not have any other
asssociated symptoms such as chest pain, fevers, chills, or
productive cough. No wheezing. Given the complexity of his
medical problems, he was referred in for further evaluation.

.

In the ED, his initial vital signs were:  99.1 73 143/81 22 97%
3L

He was given 325 mg of aspirin. A chest x-ray was completed and
unchanged from prior. An EKG was also unchanged atrial paced
rhythm. from prior. His initial cardiac enzymes revealed an
elevated troponin of 0.02, with a CK of 59. He is being admitted
for further evaluation and to complete a rule out for myocardial
ischemia.  He is being admitted to ICU for new dx of OSA and
initiation of Bipap.  Sleep sent him in. Looked well. No SOB
here felt fine. Satting 97% on 3L. Asymmetric swelling in left
left, negative LENI. 97.5 71 165/77 18 93%L upon departure from
ED.

.

On the floor, patient endorsed cough productive of sputum that
usually happens at night but has never woken him up from sleep.
For the past 2 months he has had increased shortness of breath
with exertion, unable to ambulate >10-15ft without shortness of
breath and a cough productive of clear mucous.  He denies fever,
chills, dysuria, chest pain, palpatitions or shortness of breath
at rest. Also reports orthopnea and sleeps sitting propped up on
wedge pillow. Denies recent sick contacts. In past notes, med
compliance has been questioned but patient endorses that his
wife has been giving him recent nebs.


Past Medical History:
- COPD, on 3L nasal cannula at home

- OSA, on BiPAP 10/5- Moderate OSA AHI 11 O2 sat nadir 76% who
failed BIAP titration

- Large-cell lung cancer- could not be resected status post
chemotherapy and XRT [**2122**]

- Anaplastic thyroid cancer status-post failed resection of
extensive tumor- [**8-11**] PET CT FDG avid left thyroid mass has
increased in size and mass effect since [**2135-6-23**]. Mets to right
upper lobe pulmonary nodule and  3. 1 cm FDG avid left parotid
lymph ? mets.

- Stage III chronic renal insufficiency, baseline 2.0-2.6

- Status-post dual-chamber pacemaker placement for
bradycardia/Wenkebach [**2133**]

-? MI

-Aflutter s/p ablation [**8-10**]

- BPH

- Pulmonary artery hypertension (40-50mmHg)

- vocal cord paralysis

- aspiration pna


Social History:
Quit smoking >8 yrs ago but smoke and drank significantly prior
to that time

Occupation: retired software engineer

Drugs: denies

Tobacco: 100pack year history

Alcohol: none recent, used to drink heavily

Other:


Family History:
non-cont

Physical Exam:
VS T 97.6 72 170/83 14 92%RA

General Appearance: Well nourished, Overweight / Obese

Eyes / Conjunctiva: PERRL, Pupils dilated, No(t) Conjunctiva
pale

Head, Ears, Nose, Throat: Normocephalic

Cardiovascular: (S1: Normal), (S2: Normal)

Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)

Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Hyperresonant: ), (Breath Sounds: Clear : , Wheezes : early
inspiratory), prolonged expiratory phase

Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent

Skin:  Not assessed, No(t) Rash:

Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): AAOx3, Movement: Not assessed, Tone:
Not assessed


Brief Hospital Course:
MICU Course:  The patient was admitted to the medical intensive
care unit for initiation and titration of BIPAP support. In
parallel, he was treated for a COPD exacerbation with oral
steroids and azithromycin, and continued on spiriva. He did not
tolerate the BIPAP through the evening, and the plan was to
discontinue this (notably, he did not tolerate bipap in sleep
lab either). Further workup of his pulmonary status was pursued
with CT scanning of neck and chest to look for progressive local
invasion of medullary thyroid CA. Plan was also put in place for
ENT evaluation of his vocal cords to look for vocal cord
dysfunction potentially related to tumor involvement.  There was
no further apneic events in the MICU and the patient continued
to do well on room air and was transferred to the floor for
further management.

On the floor, Mr [**Known lastname 21991**] was managed for the following issues:

# SOB: Patient has history of COPD with FEV1 68% on 3L at
baseline.  Was not hypoxic on the floor but was continued on a 3
day steroid course for possibility of COPD exacerbation as well
as azithromycin for five days.  Given the possibility of spread
of his cancer, a CT scan was obtained which did show a new
nodule.  He was also treated with his home nebulizers and
guiafensin to mobilize sputum.  On ambulation, he was stable on
his home O2 requirement.  He was set up for pulmonary follow-up
for his new lung nodule.

2. Leukocytosis: Patient was afebrile. Has history of aspiration
pneumonia and vocal cord paralysis. CXR clear but increased
sputum production. No other localizing signs of infection.
Leukocytosis was thought to be secondary to prednisone course
and the PCP was notified to follow up on his WBC count post
discharge.

3.  Dysphagia - The patient did complain of difficulty
swallowing foods, not liquids.  Complained of sensation of "food
getting stuck" and pointed to proximal throat. CT scan revealed
impingement of the esophagus at the level of the thyroid, likely
secondary to thyroid enlargement from hx of thyroid malignancy.
Speech and swallow was consulted; they recommended a soft solids
diet.  His oncologists were contact[**Name (NI) **] who felt that he could
benefit from a radiation therapy consult as an outpatient; he
was set up with a radiation oncology appointment for this.
.
# HTN: The patient was hypertensive on admission; on home
regimen he stabilized but pressures were still mildly elevated
likely secondary to his prednisone course.
.
#CRI: Cr at 1.9 was at his baseline.  Medications were renally
dosed.  Ct was done without contrast.
.
# BPH: Cont home meds.
.
# FEN: No IVF, replete electrolytes, regular diet
.
# Prophylaxis: Subcutaneous heparin, bowel reg
.
# Access: peripherals
.
# Code: full
.
# Communication: Patient and wife [**Name (NI) **] (HCP)[**Telephone/Fax (1) 92848**]
.
# Disposition: ICU for now


Medications on Admission:
ALBUTEROL SULFATE -  (Prescribed by Other Provider) - 90 mcg HFA

Aerosol Inhaler - 2 puffs IH three times a day as needed for prn

ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for

Nebulization - 1 nebulizer by mouth up to every four hours as

needed for shortness of breath / wheezing use with nebulizer

machine

AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth once a day

CETIRIZINE [ZYRTEC] - 5 mg Tablet - 1 Tablet(s) by mouth once a

day

FINASTERIDE [PROSCAR] - 5 mg Tablet - 1 Tablet(s) by mouth daily

GABAPENTIN -  (Prescribed by Other Provider) - 100 mg Capsule -
2

Capsule(s) by mouth three times a day

LEVOTHYROXINE [LEVOXYL] - 75 mcg Tablet - 1 Tablet(s) by mouth

once a day for 6 days weekly and [**2-4**] tablet daily for one day

weekly. - No Substitution

PORTABLE OXYGEN TANK -   - use 3 L/min O2 when walking  Dx:

COPD, hypoxia with exertion

SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth one

hour before intercourse as needed

TAMSULOSIN [FLOMAX] - 0.4 mg Capsule, Sust. Release 24 hr - 1

Capsule(s) by mouth twice a day

TIOTROPIUM BROMIDE - 18 mcg Capsule, w/Inhalation Device - 1 inh

inh once a day

ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by

mouth once a day


Discharge Medications:
1. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*150 ML(s)* Refills:*0*
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO 6 days per
week. On 7th day, take 0.5 tablet.
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-4**] Sprays Nasal
QID (4 times a day) as needed for dry.
Disp:*1 month supply* Refills:*0*
11. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
12. Outpatient Lab Work
Please have a CBC checked on [**2135-10-27**] at your appointment with
Dr. [**Last Name (STitle) **].


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
1. COPD exacerbation
2. Obstructive sleep apnea
2. Dysphagia related to esophageal compression from thyroid
cancer


Discharge Condition:
Ambulatory. Hemodynamically stable. Requires 2-3L via nasal
cannula (baseline). Maintains oxygen saturation with ambulation,
with supplemental oxygen.


Discharge Instructions:
You were admitted with shortness of breath.  Initially, you went
to the ICU because we felt that your shortness of breath could
be related to sleep apnea.  Once we found your breathing had
normalized in the ICU, we brought you to the regular medical
floor.  Since you continued to have a cough, we treated you for
worsening of your COPD.  We gave you three days of steroids and
an antibiotic called azithromycin.  You should continue
azithromycin for two more days.

You also told us that you had some trouble swallowing.  We did a
CT scan which showed that some of your esophagus, or swallowing
tube, was being compressed probably because you have a history
of thyroid cancer.  We did a test that measures your swallowing
ability and found that you should try to eat softer foods and
your pills should be crushed before you take them.

You need to see your primary care doctor 1 week following
discharge.
You should also see radiation oncology and ear-nose-throat for
the problem you'[**Name2 (NI) **] had with swallowing.  You have appointments
set up (see below).

Please return to the emergency room or contact your physician
for chest pain, shortness of breath, increased difficulty with
swallowing, difficulty with breathing, or for any other symptoms
which are concerning to you.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **], your primary care physician, [**Name10 (NameIs) **]
[**Name11 (NameIs) 766**], [**2135-10-31**] at 11:50am. His phone number is ([**Telephone/Fax (1) 1921**].

Please follow-up with the Ear, Nose, and Throat service on
[**2135-11-16**] at 9:00am. The office phone number is ([**Telephone/Fax (1) 21740**].
The office is in the [**Hospital Unit Name **], [**Location (un) **].

Please follow-up with the radiation oncology team. You will be
contact[**Name (NI) **] by the radiation oncology service with an appointment
next week. If you do not hear from them by Tuesday, [**2135-11-1**],
please call ([**Telephone/Fax (1) 70038**].

Provider: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD (endocrinology)
Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2135-11-21**] 3:00
Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD (Chest Disease Center)
Phone:[**0-0-**] Date/Time:[**2135-11-29**] 2:00
Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD (Chest Disease Center)
Phone:[**0-0-**] Date/Time:[**2135-12-6**] 1:00
{'Obstructive chronic bronchitis with (acute) exacerbation,Malignant neoplasm of bronchus and lung, unspecified,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Malignant neoplasm of thyroid gland,Obstructive sleep apnea (adult)(pediatric),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Dysphagia, oropharyngeal phase,Stricture and stenosis of esophagus,Cardiac pacemaker in situ,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Bilateral paralysis of vocal cords or larynx, partial,Other dependence on machines, supplemental oxygen,Personal history of tobacco use,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: Mr. [**Known lastname 21991**] is a 77 year old male with past medical history of
COPD on 3L nasal cannula at home, OSA, thyroid cancer, chronic
renal insufficiency, and large-cell lung cancer who presents
with an episode of shortness of breath overnight. He reported to
his PCP and sleep physicians that he awoke in the middle of the
night "gasping" for air. He feels he nearly died. The dyspnea
lasted about 3 minutes in total. He did not have any other
asssociated symptoms such as chest pain, fevers, chills, or
productive cough. No wheezing. Given the complexity of his
medical problems, he was referred in for further evaluation.

MEDICAL HISTORY: - COPD, on 3L nasal cannula at home

MEDICATION ON ADMISSION: ALBUTEROL SULFATE -  (Prescribed by Other Provider) - 90 mcg HFA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 97.6 72 170/83 14 92%RA

FAMILY HISTORY: non-cont

SOCIAL HISTORY: Quit smoking >8 yrs ago but smoke and drank significantly prior
to that time 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Malignant neoplasm of bronchus and lung, unspecified,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Malignant neoplasm of thyroid gland,Obstructive sleep apnea (adult)(pediatric),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Dysphagia, oropharyngeal phase,Stricture and stenosis of esophagus,Cardiac pacemaker in situ,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Bilateral paralysis of vocal cords or larynx, partial,Other dependence on machines, supplemental oxygen,Personal history of tobacco use,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health'}
