CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 54-year-old
Asian male who originally presented on [**2133-5-29**]
complaining of a several day history of shortness of breath,
cough with the production of yellow sputum, with bilateral
lower extremity edema times three weeks (which is new for the
patient).  He described as sudden in onset and worse with
exertion.

MEDICAL HISTORY: 1.  Lung cancer; status post right lower lobectomy.
Chemotherapy and radiation therapy in [**2126**] for adenocarcinoma
of the lung.
2.  History of fibrosis and bronchiectasis of the right lung.
3.  History of pericarditis; status post radiation therapy.
4.  History of pulmonary tuberculosis as a teenager; treated.
5.  History of glaucoma.
6.  History of supraventricular tachycardia.

MEDICATION ON ADMISSION: 1.  Ciprofloxacin 500 mg by mouth twice per day.
2.  Augmentin 125 mg by mouth three times per day
3.  Protonix 40 mg by mouth once per day.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient denies tobacco, alcohol, and
drug use.  He is engaged and employed as an engineer.  He
immigrated from [**Location (un) 6847**] in [**2098**].  The patient reportedly
works in a Navy shipping yard and has had a history of
asbestos exposure.
Unspecified pleural effusion,Acute respiratory failure,Acute kidney failure, unspecified,Iatrogenic pneumothorax,Pneumonia, organism unspecified,Congestive heart failure, unspecified
Pleural effusion NOS,Acute respiratry failure,Acute kidney failure NOS,Iatrogenic pneumothorax,Pneumonia, organism NOS,CHF NOS
Admission Date:  [**2133-5-29**]     Discharge Date:  [**2133-6-19**]

Date of Birth:   [**2079-4-27**]     Sex:  M

Service:  ACOVE Medicine Service

HISTORY OF PRESENT ILLNESS:  The patient is a 54-year-old
Asian male who originally presented on [**2133-5-29**]
complaining of a several day history of shortness of breath,
cough with the production of yellow sputum, with bilateral
lower extremity edema times three weeks (which is new for the
patient).  He described as sudden in onset and worse with
exertion.

In the Emergency Department, a chest x-ray showed a large
left pleural effusion.  Negative for pulmonary embolism.  He
reports a chronic cough for three years (occasionally
blood-tinged).

At the time of admission, the patient denied chest pain,
nausea, vomiting, diarrhea, constipation, fevers, chills, or
sick contacts.  [**Name (NI) **] reports a prior history of a left pleural
effusion consistent with pneumonia which was not tapped and
resolved on its own.

In the Emergency Department, the patient's urine noted to be
light brown with dark tinge in color which was new for him.
Blood urea nitrogen and creatinine were 32 and 1.8.  His
baseline creatinine is 0.8.  Originally felt to be prerenal
secondary to dehydration.  The patient was hydrated with
resolution.  Urinalysis revealed microhematuria.

For pleural effusion, underwent thoracentesis on [**2133-5-30**]
with 4000 cc removed.  The patient reportedly felt transient
relief of shortness of breath; however, he had an episode of
chest tightness.  Tachypnea overnight; from [**2133-5-30**] to
[**2133-5-31**] with decreasing oxygen saturations to 89% to 90%
on 3 liters nasal cannula.

On [**2133-5-31**] the patient underwent ultrasound-guided
thoracentesis with 1400 cc of pleural fluid removed.  A small
left apical pneumothorax was noted after repeat
thoracentesis.  The patient was transferred to the Intensive
Care Unit on [**2133-5-31**] for increased work of breathing,
hypoxia, and tachypnea.  Felt need for closer oxygen
monitoring by Pulmonary Intensive Care Unit team.

PAST MEDICAL HISTORY:
1.  Lung cancer; status post right lower lobectomy.
Chemotherapy and radiation therapy in [**2126**] for adenocarcinoma
of the lung.
2.  History of fibrosis and bronchiectasis of the right lung.
3.  History of pericarditis; status post radiation therapy.
4.  History of pulmonary tuberculosis as a teenager; treated.
5.  History of glaucoma.
6.  History of supraventricular tachycardia.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON ADMISSION:
1.  Ciprofloxacin 500 mg by mouth twice per day.
2.  Augmentin 125 mg by mouth three times per day
3.  Protonix 40 mg by mouth once per day.

SOCIAL HISTORY:  The patient denies tobacco, alcohol, and
drug use.  He is engaged and employed as an engineer.  He
immigrated from [**Location (un) 6847**] in [**2098**].  The patient reportedly
works in a Navy shipping yard and has had a history of
asbestos exposure.

PHYSICAL EXAMINATION ON PRESENTATION:  Vital signs revealed
temperature was 98.3, blood pressure was 166/93, heart rate
was 84, respiratory rate was 25 to 30, and oxygen saturation
was 99% on 4 liters nasal cannula.  In general, an Asian
male, age appropriate, well-nourished, comfortable, and in no
apparent distress.  Head, eyes, ears, nose, and throat
examination revealed pupils were equal, round, and reactive
to light.  Extraocular muscles were intact.  Sclerae were
anicteric.  Oral mucosa were moist.  The neck was supple.  No
masses.  No lymphadenopathy.  Positive jugular venous
distention to the angle of the jaw at 45 degrees.  Lung
examination revealed right bronchial breath sounds.  Left
lobe with decreased breath sounds at the bases.  Crackles to
one-third of the way up.  Cardiovascular examination revealed
tachycardia.  First heart sound and second heart sound.  No
audible murmurs, rubs, or gallops.  Question third heart
sound.  The abdomen was soft, nontender, and nondistended.
Positive bowel sounds.  No hepatosplenomegaly.  Extremity
examination revealed positive lower extremity edema.  No
clubbing or cyanosis noted.

PERTINENT LABORATORY VALUES ON PRESENTATION:   Laboratories
on admission revealed white blood cell count was 12.5,
hematocrit was 26.7, and platelets were 441.  Sodium was 136,
potassium was 4.4, bicarbonate was 23, blood urea nitrogen
was 30, creatinine was 1.9, and blood glucose was 106.
Lactate dehydrogenase was 192.  Total protein was 7.8.
Albumin was 3.  Calcium was 8.3, magnesium was 1.8, and
phosphorous was 4.1.  Iron was 24.  Reticulocyte count was
1.4.  Total iron-binding capacity was 173.  Ferritin was 203.
Urine creatinine was 74.  Urine sodium was 21.  Urine
osmolalities were 377.  FeNa was 0.4%.  Pleural fluid #1
revealed 12,750 white blood cells, neutrophils of 70,
lymphocytes of 6, monocytes of 20, red blood cells of 20,750,
pH was 7.7, total protein was 2.2, lactate dehydrogenase was
71, glucose was 108, albumin was 1.  Gram stain was negative.
Pleural fluid #2 revealed 625 white blood cells, 7% polys,
13% monocytes, red blood cells of 37,250, total protein was
2.4, lactate dehydrogenase was 110, glucose was 110, albumin
was 1.  Gram stain revealed 2+ polymorphonuclear leukocytes.
Cultures negative for growth.

PERTINENT RADIOLOGY/IMAGING:  Electrocardiogram revealed
sinus tachycardia [**Company 104132**] wave inversions in V1.  No ST
changes.

A chest x-ray on [**5-31**] revealed apical left pneumothorax,
right opacification of hemithorax, a small pleural effusion
(decreased from [**2133-5-29**] study).

A renal ultrasound revealed both kidneys were swollen and
echogenic in appearance; in keep with the patient's stated
history of acute renal failure.  A small amount of fluid in
the pelvis. No hydronephrosis.

A computed tomography angiogram on [**5-29**] showed no pulmonary
embolism.  Stable right axillary lymphadenopathy.  Multiple
patchy opacities in the left upper lobe with ground-glass
basilar opacities.  Moderate left pleural effusion.

SIGNIFICANT HOSPITAL STUDIES:  (During the patient's stay,
the patient had numerous radiologic studies performed)

1.  A computed tomography angiogram of the chest with and
without contrast and reconstruction with findings which
demonstrated an interval development of left-sided pleural
effusion and patchy opacities in the left lung.  Clinical
picture could represent infectious cause although there was
concern for the development of metastases.  No pulmonary
embolism.  Multiple cavitated vegetations of the right lung.

2.  Multiple chest x-rays repeatedly showing a left-sided
pleural effusion with opacification of the right chest wall.
Most studies were used to gage the extent and reaccumulation
of pleural fluid.

3.  A renal ultrasound showed swollen echogenic kidneys; in
keeping with a history of possible acute renal failure.  No
evidence of hydronephrosis.  No evidence of a mass or stone.

4.  A magnetic resonance imaging of the chest and mediastinum
with and without contrast following was recent ultrasound
examination demonstrated thrombosis of the left internal
jugular vein, occlusion versus narrowing of the left
brachiocephalic vein, consolidation of the left upper lobe
and lingula, multiple cavitations in the right upper lobe,
and a large left pleural effusion.

5.  Bilateral lower extremity Doppler studies showed no
evidence of deep venous thrombosis.

6.  Magnetic resonance imaging/magnetic resonance angiography
of the abdomen, pelvis, and kidneys showed no evidence of
tumor within the abdomen, pelvis, or kidneys.  It showed a
moderate left-sided pleural effusion.  No evidence of renal
vein thrombosis.  This was considered negative for
malignancy.

7.  Cardiac magnetic resonance imaging was obtained to
evaluate for pericardial constriction showed a normal left
ventricular cavity size, with normal regional and global
ventricular systolic function, normal right ventricular
cavity size.  No myocardial infarction evidence, pericardial
thickening, adhesions, or reconstruction.  A large left
pleural effusion and evidence of increased intravascular
pressure.  Overall, no evidence of pericardial constriction.

8.  The patient refused two additional studies that were
requested; a renal biopsy and cystoscopy.  Both were
suggested during inpatient admission; however, the patient
denied the procedures and will be scheduled as an outpatient.

9.  The patient underwent three different thoracentesis
procedures.  The patient also underwent a Pleur-X catheter
drainage placement.

CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:  The
patient is a 54-year-old Asian male with a history of
adenocarcinoma of the right lung (status post lung resection)
and history of pulmonary tuberculosis as a teenager who
presented to the hospital on [**2133-5-29**] complaining of a
several day history of shortness of breath, cough, dyspnea on
exertion, and bilateral lower extremity edema; who was
ultimately discharged on [**2133-6-19**].

Consequently, the patient had a complicated medical course
during his stay.  The patient was discharged in stable
condition with instructions to return as needed.

1.  PULMONARY ISSUES:   The patient continued to have
shortness of breath secondary to a recurrent left-sided
pleural effusion.  During his hospital stay he was tapped
with thoracentesis three times with relief of symptoms;
however, the patient had repeated fluid reaccumulation.

Ultimately, the etiology of the pleural effusion remained
unclear.  The patient was treated for a pneumonia early in
his hospital course with azithromycin for seven days with no
apparent change.

The patient had a bronchoscopy on [**6-5**] which was highly
suggestive of atypical cells; consistent with adenocarcinoma
of the lung.  However, no biopsy was performed as no mass was
identified.

A cardiac magnetic resonance imaging showed a large pleural
effusion; however, there was no constriction (based on the
Cardiology interpretation).

The thoracentesis procedures demonstrated a mixed picture.
However, in the end, it was determined to be an exudative
effusion.

The patient also had multiple chest magnetic resonance
imaging studies and computed tomographies which demonstrated
no obvious cause for the recurrent pleural effusions;
however, a further study will be complained on [**6-24**] when
the patient undergoes a positron emission tomography of the
chest.

At this time, the suspicion of malignancy cells needs to be
confirmed, and the recurrent pleural effusion seemed most
probably related to a malignancy.  However, the patient's
complex course also included kidney disease with a diagnosis
of probable immunoglobulin A nephropathy; question
nephritis versus nephrosis possibly leading to the
accumulation of the effusion.  However, the effusion was
exudative not transudative.

Prior to admission, the Interventional Pulmonology Clinic
placed a Pleur-X drain which will need to be repeatedly
drained to help improve shortness of breath.  A pleurodesis
was determined to be a risky procedure in a patient with
limited pulmonary reserve and only one functioning lung.

From a pulmonary standpoint, the patient was discharged home
on oxygen, Lovenox for seven days (covering his internal
jugular deep venous thrombosis with no evidence of pulmonary
embolism) with followup to be coordinated with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 217**] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (his pulmonologist and
oncologist) following completion of the positron emission
tomography scan.

2.  RENAL ISSUES:  The patient initially presented with what
was thought to be a picture consistent with acute renal
failure.  However, the patient's kidney function failed to
respond to simple hydration.

A magnetic resonance imaging and magnetic resonance
angiography of the abdomen and pelvis showed that there was
no deep venous thrombosis or renal vein thrombosis.  The
patient was given a tentative diagnosis of probable
immunoglobulin A nephropathy and/or nephritic versus
nephrotic syndrome.  However, the patient refused an
inpatient renal biopsy which hindered a confirmatory
pathological diagnosis.

The patient was markedly proteinuric and had marked hematuria
in his urine.  He had elevated blood pressures.  He was
treated with an ACE inhibitor which he initially responded to
quite well with his protein decreasing from approximately 8
grams per day down to 2.5 grams per day on lisinopril 20.
However, by discharge his urine protein to creatinine ratio
had increased back to 5, and he remained moderately
hypertensive in the 140s with proteinuria and hematuria in
his urine.

The plan on discharge was to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1366**] in his clinic for scheduling of a renal biopsy.  The
patient also refused a cystoscopy while in house to evaluate
the bladder (per a Urology consultation).

3.  HEMATOLOGIC ISSUES:  The patient had marked anemia which
progressed throughout his hospital course.  Hematocrit levels
typically ran in the mid 20s to high 20s.  However, near the
end of his hospital course his hematocrit started trending
downward.  He ultimately had a hematocrit of 23.  Two units
were transfused, and his hematocrit jumped to 26 and was
transfused elevating his hematocrit to above 28.  On
discharge, his hematocrit was 30.7.

However, the patient did continue to have hematuria and has
been instructed to have close followup for his hematocrit.

In addition, the patient was discharged on Lovenox and
Coumadin.  The patient was initiated on his Coumadin
treatment today for treatment of his internal jugular deep
venous thrombosis.  The patient was to follow up in the
[**Hospital 197**] Clinic on Monday and was to continue Lovenox
treatment until he is therapeutic.

4.  CARDIOVASCULAR SYSTEM:  The patient ruled out for any
evidence of constrictive pericarditis.  The patient's
hypertension was treated with Lopressor 50 mg three times per
day, hydralazine initially which was then discontinued prior
to discharge in order to improve compliance, and lisinopril
20 mg which was ultimately increased to 30 mg by mouth once
per day.

There was marked discrepancy in the notes in terms of blood
pressure recordings.  The patient often had recorded blood
pressures in his thigh which were often 30 to 40 points above
his left arm level.  The patient had a peripherally inserted
central catheter line in his right arm which prevented blood
pressure measurements.  However, in the left arm his blood
pressures were consistently in the 120s to 140s, and was
135/80 on discharge.

5.  OTHER ISSUES:  In terms of the patient's treatment, the
patient was extremely discouraged that a final definitive
diagnosis was not made.  The patient was often seen with his
fiance and his sister who both were combative during multiple
discussions.

There was a lot of concern and questions whether the patient
was treated well during this hospital stay, and I believe
that during the translation process (as the patient and his
sister did not speak English as a first language) that there
may have been some confusion.

Ultimately, it was explained to the patient that he was
treated to the best of all of the consultants and primary
team ability, and I believe that the fiance and the patient
were satisfied with his care.  However, they were considering
a second opinion on discharge.

CONDITION AT DISCHARGE:  The patient was hemodynamically
stable on discharge.

PRIMARY DISCHARGE DIAGNOSES:
1.  Dyspnea and shortness of breath.
2.  Recurrent left pleural effusion.
3.  Adenocarcinoma of unknown primary.

SECONDARY DISCHARGE DIAGNOSES:
1.  Deep venous thrombosis.
2.  Acute renal failure.
3.  Nephritic syndrome.
4.  Nephrotic syndrome.
5.  Hematuria.
6.  Anemia.

MEDICATIONS ON DISCHARGE:  (The patient was discharged on the
following medications)
 1.  Metoprolol 50 mg by mouth three times per day
 2.  Iron sulfate 325 mg by mouth twice per day.
 3.  Colace 100 mg by mouth twice per day.
 4.  Dulcolax 5 mg by mouth twice per day as needed (for
constipation).
 5.  Protonix 40 mg by mouth once per day.
 6.  Lisinopril 20 mg by mouth once per day.
 7.  Warfarin 4 mg by mouth once per day (until [**Hospital 197**]
Clinic visit in two to three days).
 8.  Lovenox 60 mg subcutaneously twice per day (times seven
days).
 9.  Albuterol inhaler.
10.  Ambien 5 mg by mouth q.h.s. as needed (for insomnia).
11.  Vicodin 5/500-mg tablets by mouth q.4-6h. as needed (for
pain).

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient was to follow up with his primary care
physician (Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 452**]) over the next week.
2.  The patient was to follow up at [**Company 5620**] in two
to three days (located at [**Street Address(2) 104133**] in [**Location (un) **],
[**State 350**]) to assess Coumadin level, anemia, and kidney
function.
3.  Appointment in approximately one month with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1366**] (telephone number [**Telephone/Fax (1) 104134**]) to monitor renal
function and potential biopsy.
4.  The patient was to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 217**] (from Pulmonary) for management of pulmonary
symptoms.
5. The patient was to follow up with Urology for cystoscopy.
6.  The patient was to follow up with oncologist (Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]) after positron emission tomography scan.
7.  Positron emission tomography scan on the fourth floor of
the [**Last Name (un) 469**] Building and Nuclear Medicine on [**6-24**].
8.  The patient was to follow up with Interventional
Pulmonology Clinic as needed for Pleur-X drain management.

POST DISCHARGE SERVICES:
1.  Home oxygen.
2.  Physical therapy.
3.  Teaching for Lovenox injections.
4.  Activity as tolerated.






                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7937**], M.D.  [**MD Number(1) 7938**]

Dictated By:[**Last Name (NamePattern1) 1303**]

MEDQUIST36

D:  [**2133-6-19**]  20:01
T:  [**2133-7-1**]  07:37
JOB#:  [**Job Number 104135**]
{'Unspecified pleural effusion,Acute respiratory failure,Acute kidney failure, unspecified,Iatrogenic pneumothorax,Pneumonia, organism unspecified,Congestive heart failure, unspecified'}


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: The patient is a 54-year-old
Asian male who originally presented on [**2133-5-29**]
complaining of a several day history of shortness of breath,
cough with the production of yellow sputum, with bilateral
lower extremity edema times three weeks (which is new for the
patient).  He described as sudden in onset and worse with
exertion.

MEDICAL HISTORY: 1.  Lung cancer; status post right lower lobectomy.
Chemotherapy and radiation therapy in [**2126**] for adenocarcinoma
of the lung.
2.  History of fibrosis and bronchiectasis of the right lung.
3.  History of pericarditis; status post radiation therapy.
4.  History of pulmonary tuberculosis as a teenager; treated.
5.  History of glaucoma.
6.  History of supraventricular tachycardia.

MEDICATION ON ADMISSION: 1.  Ciprofloxacin 500 mg by mouth twice per day.
2.  Augmentin 125 mg by mouth three times per day
3.  Protonix 40 mg by mouth once per day.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient denies tobacco, alcohol, and
drug use.  He is engaged and employed as an engineer.  He
immigrated from [**Location (un) 6847**] in [**2098**].  The patient reportedly
works in a Navy shipping yard and has had a history of
asbestos exposure. 

### Response:
{'Unspecified pleural effusion,Acute respiratory failure,Acute kidney failure, unspecified,Iatrogenic pneumothorax,Pneumonia, organism unspecified,Congestive heart failure, unspecified'}
