CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: 57 yo F with past medical history significant for HIV, heroin
abuse, tobacco abuse, presents to the ED with dyspnea two hours
after leaving AMA from [**Hospital6 **]. Was picked up by
son, who brought her to [**Hospital1 18**] emergency room. Patient originally
presented to [**Hospital6 **] after 2 months of loss of
appetite and a 20 weight loss. In the last month she had a
progressive dyspnea which worsened to the point that she was
admitted to [**Hospital6 **] 4 days prior to presentation
here. The patient reports that she left [**Hospital6 **] AMA
because she was unsatisfied with her work-up there. When asked
what her expectations were for her visit, she stated, "Help me!"

MEDICAL HISTORY: 1) Lung mass (identified at recent admission to [**Hospital3 **])
2) HIV (patient does not report, though son notes treatment on
and off for 20 years. Unknown recent viral load.)
3) Heroin abuse (patient reports last use 6-12 months ago, on
methadone maintenance)

MEDICATION ON ADMISSION: Methadone 93 mg daily (Confirmed with [**Hospital3 19386**] clinic
[**Telephone/Fax (1) 85228**])

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.8, HR 109, BP 117/78, RR 19, O2Sat 100% NRB
GEN: Appears emaciated
HEENT: Bitemporal wasting, sclera anicteric, oral mucosa dry, no
evidence of thrush
NECK: Supple, thin, no cervical or supraclavicular [**Doctor First Name **]
PULM: right posterior lung field with basilar crackles, left
posterior lung field with scant breath sounds, entire left
posterior lung field dull to percussion
CARD: Tachycardic, nl S1, nl S2, no M/R/G
GI: BS+, protuberant out of proportion to body habitus
EXT: Digital clubbing present, bilateral LE with 1+ pitting
edema to level of knees, DP and PT pulses 2+ bilaterally
NEURO: Oriented x 3, difficulty hearing
PSYCH: Patient uninterested in examination and exhibits
frustration toward examiner

FAMILY HISTORY: Father - Diabetes

SOCIAL HISTORY: Patient lives alone and is independent in all ADLs.
Tobacco: Patient reports 40 + pack-year smoking history and quit
1 month ago
Alcohol: Denies any prior use
Illicits: Longstanding history of heroin abuse, last was [**6-21**]
months ago, now on methadone maintenance from [**Location (un) 85226**]
methadone clinic. Patient reports that current dose is 90 mg
daily, though has not yet been confirmed with her clinic.
Malignant neoplasm of upper lobe, bronchus or lung,Acute and chronic respiratory failure,Other severe protein-calorie malnutrition,Secondary malignant neoplasm of bone and bone marrow,Malignant pleural effusion,Hyposmolality and/or hyponatremia,Other emphysema,Opioid type dependence, continuous,Asymptomatic human immunodeficiency virus [HIV] infection status,Encounter for palliative care,Tobacco use disorder
Mal neo upper lobe lung,Acute & chronc resp fail,Oth severe malnutrition,Secondary malig neo bone,Malignant pleural effusn,Hyposmolality,Emphysema NEC,Opioid dependence-contin,Asymp hiv infectn status,Encountr palliative care,Tobacco use disorder
Admission Date:  [**2177-6-30**]              Discharge Date:   [**2177-7-6**]

Date of Birth:  [**2119-11-21**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
none

History of Present Illness:
57 yo F with past medical history significant for HIV, heroin
abuse, tobacco abuse, presents to the ED with dyspnea two hours
after leaving AMA from [**Hospital6 **]. Was picked up by
son, who brought her to [**Hospital1 18**] emergency room. Patient originally
presented to [**Hospital6 **] after 2 months of loss of
appetite and a 20 weight loss. In the last month she had a
progressive dyspnea which worsened to the point that she was
admitted to [**Hospital6 **] 4 days prior to presentation
here. The patient reports that she left [**Hospital6 **] AMA
because she was unsatisfied with her work-up there. When asked
what her expectations were for her visit, she stated, "Help me!"

.
In the ED, initial VS were: T 99.2, HR 140, BP 162/115, RR 32,
O2Sat 99% on NRB. CXR showed white-out of left chest. Thoracic
surgery was called for consultation. Bedside thoracentesis by IP
was productive of 400 mL of serous fluid. Was ordered for a CT
chest, though refused to travel to scanner. Labs returned with
WBC count of 14.7 with 80% neutrophils and 6% bands. Was ordered
for Vancomycin and Cefepime due to concern for HCAP. UA was
performed and was negative for evidence of infection. Concerning
tachycardia, EKG showed sinus tach. Vitals signs prior to
transfer to the ICU were: T 98.6, HR 110, BP 122/80, RR 16,
O2Sat 100% on NRB.


Past Medical History:
1) Lung mass (identified at recent admission to [**Hospital3 **])
2) HIV (patient does not report, though son notes treatment on
and off for 20 years. Unknown recent viral load.)
3) Heroin abuse (patient reports last use 6-12 months ago, on
methadone maintenance)


Social History:
Patient lives alone and is independent in all ADLs.
Tobacco: Patient reports 40 + pack-year smoking history and quit
1 month ago
Alcohol: Denies any prior use
Illicits: Longstanding history of heroin abuse, last was [**6-21**]
months ago, now on methadone maintenance from [**Location (un) 85226**]
methadone clinic. Patient reports that current dose is 90 mg
daily, though has not yet been confirmed with her clinic.


Family History:
Father - Diabetes

Physical Exam:
VS: T 97.8, HR 109, BP 117/78, RR 19, O2Sat 100% NRB
GEN: Appears emaciated
HEENT: Bitemporal wasting, sclera anicteric, oral mucosa dry, no
evidence of thrush
NECK: Supple, thin, no cervical or supraclavicular [**Doctor First Name **]
PULM: right posterior lung field with basilar crackles, left
posterior lung field with scant breath sounds, entire left
posterior lung field dull to percussion
CARD: Tachycardic, nl S1, nl S2, no M/R/G
GI: BS+, protuberant out of proportion to body habitus
EXT: Digital clubbing present, bilateral LE with 1+ pitting
edema to level of knees, DP and PT pulses 2+ bilaterally
NEURO: Oriented x 3, difficulty hearing
PSYCH: Patient uninterested in examination and exhibits
frustration toward examiner


Pertinent Results:
[**2177-6-30**] 03:22PM    WBC-14.7*  LYMPH-7* ABS LYMPH-1029 CD3-38
ABS CD3-396* CD4-1 ABS CD4-7* CD8-38 ABS CD8-388 CD4/CD8-0.0*
[**2177-6-30**] 03:22PM   PT-12.8 PTT-24.7 INR(PT)-1.1
[**2177-6-30**] 03:22PM   PLT SMR-NORMAL PLT COUNT-190
[**2177-6-30**] 03:22PM   HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+
POLYCHROM-OCCASIONAL OVALOCYT-1+ TEARDROP-OCCASIONAL
[**2177-6-30**] 03:22PM   NEUTS-80* BANDS-6* LYMPHS-7* MONOS-6 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0 NUC RBCS-1*
[**2177-6-30**] 03:22PM   WBC-14.7* RBC-4.15* HGB-11.7* HCT-35.0*
MCV-84 MCH-28.2 MCHC-33.4 RDW-17.3*
[**2177-6-30**] 03:22PM   ALBUMIN-4.2
[**2177-6-30**] 03:22PM   ALT(SGPT)-26 AST(SGOT)-61* LD(LDH)-704* ALK
PHOS-64 TOT BILI-0.3
[**2177-6-30**] 03:22PM   GLUCOSE-113* UREA N-11 CREAT-0.5 SODIUM-129*
POTASSIUM-4.3 CHLORIDE-83* TOTAL CO2-30 ANION GAP-20
[**2177-6-30**] 04:15PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2177-6-30**] 08:50PM PLEURAL  WBC-50* RBC-1655* POLYS-40* LYMPHS-30*
MONOS-10* MACROPHAG-20*

Brief Hospital Course:
ICU COURSE

1) Dyspnea:
Patient presented to ED with limited medical history and report
of a new diagnosis of a lung mass prior to leaving AMA from [**Hospital **] hosptial. Was noted to have a complete opacification of
left lung field on CXR with minimal lung markings. CT scan was
suggested, though patient refused. Root cause of patient's more
acute dyspnea is the pleural effusion. Patient's dyspnea
improved greatly following removal of 400 mL fluid during
thoracentesis. A broad differential was entertained given 20
year history of HIV and smoking history: left side lung mass and
associated malignant pleural effusion, lymphoma,
post-obstructive pneumonia and resulting parapneumonic effusion.
This was supported somewhat by leukocytosis and bandemia of 6%.
Empiric therapy with vancomycin and cefepime was started.
Sputum cultures were procured, as well as fluid cell counts,
chemistries, cytology, gram stain, and culture.  The analysis of
the effusion was abnormal, but nondiagnostic.  Chest CT on [**7-1**]
showed mass (BAC) that was "head-sized", invading the left
hilus, mediastinum, bronchus and PA. Many spinal mets were
noted.  Given the picture of Stage IV Ca, discussion with family
and patient resulted in change to comfort measures only.
Patient was maintained on nasal cannula and later non-rebreather
to support oxygenation.  Sedation also helped with tachypnea,
that seemed to worsen when patient was more alert.
.
2.)  Hyponatremia:
Patient had Na of 129 upon admission.  Was thought to be likely
a hypovolemic hyponatremia given patient's hypovolemia, though
other processes could not be exluded until the patient was
euvolemic.  The patient was treated empiraclly with volume
replacement with subsequent checks in sodium and urine
lytes/osms.  Resolved with volume replacement.
.
3.)  HIV:
Patient and son reported that she has been on and off therapy
for years, though they did not know her current disease state
upon admission.  HIV antibodies and viral load were taken to
assess disease state.  CD4 count of 7, not enough blood for
viral load.  Patient was started on azithro for MAC ppx and
bactrim for PCP [**Name Initial (PRE) **].  These were stopped as patient transitioned
to CMO.
.
4.)  Heroin abuse:
Patient noted last use 6-12 months prior to admission.  Patient
reported her methadone maintenance dose to be 90 mg daily.
Attempts were made to contact [**Name2 (NI) 85227**] clinic in
[**Location (un) 5503**], MA to confirm the dose.  Methadone was administered
at the confirmed dose.  These were held intermittently when the
patient seemed overly sedated.

.
Medicine Floor Course:
Patient was transferred to the floor on [**2177-7-5**].  Upon arrival,
she was sedated, had a respiratory rate of 44 and coarse breath
sounds.  Given patient's CMO status, she was continued on 5L O2
by NC, morphine drip, ativan, and scopolamine and hyoscyamine
for oral secretions.  At 05:10 the next morning [**2177-7-6**], house
officer was informed of patient's death.  Exam revealed
nonreactive pupils, no respirations or heart sounds, no
Babinski, and no response to pain.  Family was notified.


Medications on Admission:
Methadone 93 mg daily (Confirmed with [**Hospital3 19386**] clinic
[**Telephone/Fax (1) 85228**])

Discharge Disposition:
Expired

Discharge Diagnosis:
Stage IV Lung CA

Discharge Condition:
Expired

Discharge Instructions:
Expired

Followup Instructions:
Expired


Completed by:[**2177-7-6**]
{'Malignant neoplasm of upper lobe, bronchus or lung,Acute and chronic respiratory failure,Other severe protein-calorie malnutrition,Secondary malignant neoplasm of bone and bone marrow,Malignant pleural effusion,Hyposmolality and/or hyponatremia,Other emphysema,Opioid type dependence, continuous,Asymptomatic human immunodeficiency virus [HIV] infection status,Encounter for palliative care,Tobacco use disorder'}


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: Dyspnea

PRESENT ILLNESS: 57 yo F with past medical history significant for HIV, heroin
abuse, tobacco abuse, presents to the ED with dyspnea two hours
after leaving AMA from [**Hospital6 **]. Was picked up by
son, who brought her to [**Hospital1 18**] emergency room. Patient originally
presented to [**Hospital6 **] after 2 months of loss of
appetite and a 20 weight loss. In the last month she had a
progressive dyspnea which worsened to the point that she was
admitted to [**Hospital6 **] 4 days prior to presentation
here. The patient reports that she left [**Hospital6 **] AMA
because she was unsatisfied with her work-up there. When asked
what her expectations were for her visit, she stated, "Help me!"

MEDICAL HISTORY: 1) Lung mass (identified at recent admission to [**Hospital3 **])
2) HIV (patient does not report, though son notes treatment on
and off for 20 years. Unknown recent viral load.)
3) Heroin abuse (patient reports last use 6-12 months ago, on
methadone maintenance)

MEDICATION ON ADMISSION: Methadone 93 mg daily (Confirmed with [**Hospital3 19386**] clinic
[**Telephone/Fax (1) 85228**])

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.8, HR 109, BP 117/78, RR 19, O2Sat 100% NRB
GEN: Appears emaciated
HEENT: Bitemporal wasting, sclera anicteric, oral mucosa dry, no
evidence of thrush
NECK: Supple, thin, no cervical or supraclavicular [**Doctor First Name **]
PULM: right posterior lung field with basilar crackles, left
posterior lung field with scant breath sounds, entire left
posterior lung field dull to percussion
CARD: Tachycardic, nl S1, nl S2, no M/R/G
GI: BS+, protuberant out of proportion to body habitus
EXT: Digital clubbing present, bilateral LE with 1+ pitting
edema to level of knees, DP and PT pulses 2+ bilaterally
NEURO: Oriented x 3, difficulty hearing
PSYCH: Patient uninterested in examination and exhibits
frustration toward examiner

FAMILY HISTORY: Father - Diabetes

SOCIAL HISTORY: Patient lives alone and is independent in all ADLs.
Tobacco: Patient reports 40 + pack-year smoking history and quit
1 month ago
Alcohol: Denies any prior use
Illicits: Longstanding history of heroin abuse, last was [**6-21**]
months ago, now on methadone maintenance from [**Location (un) 85226**]
methadone clinic. Patient reports that current dose is 90 mg
daily, though has not yet been confirmed with her clinic. 

### Response:
{'Malignant neoplasm of upper lobe, bronchus or lung,Acute and chronic respiratory failure,Other severe protein-calorie malnutrition,Secondary malignant neoplasm of bone and bone marrow,Malignant pleural effusion,Hyposmolality and/or hyponatremia,Other emphysema,Opioid type dependence, continuous,Asymptomatic human immunodeficiency virus [HIV] infection status,Encounter for palliative care,Tobacco use disorder'}
