CHIEF COMPLAINT: Hypoxia

PRESENT ILLNESS: HPI: Mr [**Known lastname 7168**] is a 63 yo male with h/o COPD, asthma, Afib, CAD
s/p MI who was transferred to [**Hospital1 18**] from [**Hospital3 **]
yesterday. He went to [**Hospital3 **] after being found to be
hypoxic at home by VNA nurse (per MICU note was 68%). At [**Hospital1 2519**] he was found to have respiratory acidosis with hypoxia
(last ABG 7.31/79/75) and transferred to [**Hospital1 18**]. Patient notes
that he is SOB at baseline and wears 2 L O2 NC at home. He notes
that he had become increasingly SOB with exertion since Sunday
([**10-28**]). He denied chest pain but did notice he had fevers. He
has also had a productive cough with yellow/white sputum for [**4-6**]
days. He denies nasal congestion or sore throat. Patient was
discharge from [**Known lastname 7168**] Rehab one week ago, after spending one
month there. He had previously spent a week hospitalized at
[**Hospital **] hospital for "a [**Last Name **] problem". Per MICU note is apperas he
had COPD with PNA that required intubation in [**Month (only) 205**]. During that
hospitalization he was started on prednisone and was tapering
off it.

MEDICAL HISTORY: PMH:
COPD (on home O2)
Pulm HTN
CAD s/p MI and Cath
AFib
CVA
Bipolar Disorder
Carotid Stenosis (90% on one side)
PVD

MEDICATION ON ADMISSION: MEDS: Warfarin 7.5 Daily; Predisone 10 Daily; Zyprexa 15 HS;
Advair 250/50 [**Hospital1 **]; Combivent INH Q6; Tikosyn (Dofetilide) 0.25
daily; Wellbutrin 100 [**Hospital1 **]; Cardizem 60 4x/day; Pepcid 20 Daily;
Glucophage

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE on [**2181-11-1**]:
96.6 127/55 79 15 ranging 94-95% on NC O2 (recent episode 86%
but O2 was off)
Gen: Well appearing man sitting in chair, NAD
HEENT: MMM, PERRL, EOMI, no oral ulcers
CV: irregularly irregular rhythm, No M/R/G, nl S1, S2
Lung: Crackles bilateraly with wheezes throughout.
Abd: Obese, Soft, + BS, mildy distended, NT, No Masses
Ext: [**3-8**]+ pitting edema bilaterally, dusky erythema bilaterally
on shins L>R, open blister draining serous fluid on medial
aspect of left shin, area was cold to touch, 1+ PT pulses
bilaterally

FAMILY HISTORY: FH: N/C

SOCIAL HISTORY: SH: 100 Pack year smoker (50 years x 2 ppd), quit in [**Month (only) 205**];
Ex-alcoholic, quit a few years ago; retired engineer, lives at
home with wife and two grown children
Pneumonia, organism unspecified,Acute respiratory failure,Chronic obstructive asthma with (acute) exacerbation,Acidosis,Unspecified pleural effusion,Atrial fibrillation,Long-term (current) use of anticoagulants,Other chronic pulmonary heart diseases,Other specified disorders of pancreatic internal secretion,Old myocardial infarction,Anemia, unspecified
Pneumonia, organism NOS,Acute respiratry failure,Ch obst asth w (ac) exac,Acidosis,Pleural effusion NOS,Atrial fibrillation,Long-term use anticoagul,Chr pulmon heart dis NEC,Pancreatic disorder NEC,Old myocardial infarct,Anemia NOS
Admission Date:  [**2181-10-30**]              Discharge Date:   [**2181-11-8**]

Date of Birth:  [**2117-8-26**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 33596**]
Chief Complaint:
Hypoxia

Major Surgical or Invasive Procedure:
None

History of Present Illness:
HPI: Mr [**Known lastname 7168**] is a 63 yo male with h/o COPD, asthma, Afib, CAD
s/p MI who was transferred to [**Hospital1 18**] from [**Hospital3 **]
yesterday. He went to [**Hospital3 **] after being found to be
hypoxic at home by VNA nurse (per MICU note was 68%). At [**Hospital1 2519**] he was found to have respiratory acidosis with hypoxia
(last ABG 7.31/79/75) and transferred to [**Hospital1 18**]. Patient notes
that he is SOB at baseline and wears 2 L O2 NC at home. He notes
that he had become increasingly SOB with exertion since Sunday
([**10-28**]). He denied chest pain but did notice he had fevers. He
has also had a productive cough with yellow/white sputum for [**4-6**]
days. He denies nasal congestion or sore throat. Patient was
discharge from [**Known lastname 7168**] Rehab one week ago, after spending one
month there. He had previously spent a week hospitalized at
[**Hospital **] hospital for "a [**Last Name **] problem". Per MICU note is apperas he
had COPD with PNA that required intubation in [**Month (only) 205**]. During that
hospitalization he was started on prednisone and was tapering
off it.

Past Medical History:

PMH:
COPD (on home O2)
Pulm HTN
CAD s/p MI and Cath
AFib
CVA
Bipolar Disorder
Carotid Stenosis (90% on one side)
PVD


Social History:
SH: 100 Pack year smoker (50 years x 2 ppd), quit in [**Month (only) 205**];
Ex-alcoholic, quit a few years ago; retired engineer, lives at
home with wife and two grown children

Family History:

FH: N/C


Physical Exam:
PE on [**2181-11-1**]:
96.6 127/55 79 15 ranging 94-95% on NC O2 (recent episode 86%
but O2 was off)
Gen: Well appearing man sitting in chair, NAD
HEENT: MMM, PERRL, EOMI, no oral ulcers
CV: irregularly irregular rhythm, No M/R/G, nl S1, S2
Lung: Crackles bilateraly with wheezes throughout.
Abd: Obese, Soft, + BS, mildy distended, NT, No Masses
Ext: [**3-8**]+ pitting edema bilaterally, dusky erythema bilaterally
on shins L>R, open blister draining serous fluid on medial
aspect of left shin, area was cold to touch, 1+ PT pulses
bilaterally


Pertinent Results:
[**2181-10-30**] 04:50PM BLOOD WBC-12.8* RBC-3.50* Hgb-10.1* Hct-32.4*
MCV-93 MCH-28.7 MCHC-31.0 RDW-16.5* Plt Ct-328
[**2181-10-31**] 03:21AM BLOOD WBC-9.0 RBC-3.15* Hgb-9.0* Hct-29.0*
MCV-92 MCH-28.6 MCHC-31.1 RDW-16.3* Plt Ct-319
[**2181-10-31**] 08:02PM BLOOD Hct-26.6*
[**2181-10-31**] 09:04PM BLOOD Hct-26.6*
[**2181-11-1**] 05:09AM BLOOD Hct-29.9*
[**2181-11-2**] 06:35AM BLOOD WBC-13.6*# RBC-3.38* Hgb-9.8* Hct-30.7*
MCV-91 MCH-29.0 MCHC-32.0 RDW-15.9* Plt Ct-333
[**2181-11-3**] 07:11AM BLOOD WBC-13.2* RBC-3.41* Hgb-10.0* Hct-31.2*
MCV-92 MCH-29.3 MCHC-32.0 RDW-15.9* Plt Ct-346
[**2181-11-6**] 07:40AM BLOOD WBC-16.7* RBC-3.55* Hgb-10.5* Hct-32.7*
MCV-92 MCH-29.6 MCHC-32.1 RDW-16.0* Plt Ct-343
[**2181-10-30**] 04:50PM BLOOD Neuts-93.6* Lymphs-5.2* Monos-1.1*
Eos-0.1 Baso-0.1
[**2181-11-6**] 07:40AM BLOOD Plt Ct-343
[**2181-11-6**] 07:40AM BLOOD PT-17.7* PTT-26.5 INR(PT)-2.2
[**2181-10-30**] 04:50PM BLOOD PT-31.1* PTT-43.4* INR(PT)-7.3
[**2181-10-31**] 03:21AM BLOOD PT-32.0* PTT-44.5* INR(PT)-7.7
[**2181-11-1**] 05:09AM BLOOD PT-23.4* PTT-31.7 INR(PT)-4.0
[**2181-10-30**] 04:50PM BLOOD Glucose-299* UreaN-19 Creat-1.2 Na-134
K-4.5 Cl-90* HCO3-34* AnGap-15
[**2181-10-31**] 03:21AM BLOOD Glucose-289* UreaN-23* Creat-1.2 Na-136
K-4.3 Cl-92* HCO3-35* AnGap-13
[**2181-11-1**] 05:04AM BLOOD Glucose-285* UreaN-29* Creat-1.3* Na-134
K-6.0* Cl-90* HCO3-33* AnGap-17
[**2181-11-1**] 06:35AM BLOOD Glucose-287* UreaN-27* Creat-1.2 Na-134
K-4.1 Cl-90* HCO3-37* AnGap-11
[**2181-11-2**] 06:35AM BLOOD Glucose-270* UreaN-32* Creat-1.0 Na-137
K-4.3 Cl-94* HCO3-36* AnGap-11
[**2181-11-3**] 07:11AM BLOOD Glucose-234* UreaN-27* Creat-1.1 Na-137
K-5.1 Cl-94* HCO3-37* AnGap-11
[**2181-11-4**] 07:28AM BLOOD Glucose-308* UreaN-28* Creat-1.1 Na-139
K-5.0 Cl-93* HCO3-35* AnGap-16
[**2181-11-5**] 07:11AM BLOOD Glucose-261* UreaN-27* Creat-1.1 Na-139
K-5.0 Cl-94* HCO3-39* AnGap-11
[**2181-11-6**] 07:40AM BLOOD Glucose-243* UreaN-34* Creat-1.1 Na-138
K-4.8 Cl-94* HCO3-38* AnGap-11
[**2181-10-30**] 04:50PM BLOOD CK(CPK)-33*
[**2181-10-31**] 03:21AM BLOOD LD(LDH)-222 CK(CPK)-16*
[**2181-10-30**] 04:50PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2181-10-31**] 03:21AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2181-11-5**] 07:11AM BLOOD calTIBC-289 Ferritn-148 TRF-222
[**2181-10-31**] 03:21AM BLOOD Hapto-392*
[**2181-10-30**] 06:23PM BLOOD pO2-59* pCO2-70* pH-7.35 calHCO3-40* Base
XS-9
[**2181-10-30**] 05:00PM BLOOD Lactate-1.7
.
Diagnostic studies:
CXR [**10-30**]: IMPRESSION: Right lower lobe pneumonia and a small
right-sided pleural effusion.
.
chest CT [**10-31**]: IMPRESSION:
1. Diffuse ground glass opacity, small loculated right pleural
effusion, and fluid in the left minor fissure findings secondary
to diffuse pulmonary edema.
2. Right lower lobe subsegmental consolidation most consistent
with pneumonia and/or resolving pneumonia. Repeat examination in
[**5-9**] weeks to ensure resolution is recommended.
3. Diffuse mild centrilobular and paraseptal emphysema.
4. Probable anterior chest wall sebaceous cyst.
(there was a lung nodule seen on this by the MICU team that was
not reported in the official report. Dr. [**Last Name (STitle) 60152**], outpatient
pulmonologist is aware and will follow)

Brief Hospital Course:
Assessment: 63 yo male with COPD on home O2, h/o recent PNA,
Afib, CVA, HTN, CAD s/p MI who presented with hypoxia and
metabolic acidosis and found to have RLL. Currently clinically
stable with stable O2 sats and in and out of Afib but
hemodynamically stable and asymptomatic.
.
*Hypoxia: The patient was transferred to [**Hospital1 18**] from [**Hospital1 **] for hypoxia. Per the MICU note, in the ED the pt was
febrile to 101, and found to be in A-flutter with a HR 112 and
BP 112/65. His ABG was 7.35/70/59 and WBC was elevated at 12.8.
A CXR showed RLL pNA and small right sided pleural effusion. He
was transferred to the MICU for observation and remained stable
with mild SOB, CP, dizziness. He was treated with Prednisone,
Levaquin, albuterol and ipratropium nebs and advair for the PNA
and COPD. Nebs elevated sat to 90-100% on O2. Cardiac echo
revealed LVEF=55%. He was also found to be in afib/aflutter,
which could have contributed to his SOB, thought patient claimed
he was asymptomatic.  He was treated with dofetilide and PO
diltiazem to help control his rate.  On transfer to the medicine
service the patient was not SOB at rest though he could only
walk a short while without getting SOB (says this is a big
change from last week). Denied dizziness, chest pain, abd pain,
N/V. The hypoxia was thought to be secondary to the pneumonia in
addition to underlying COPD. Patient was continued on Levaquin
and completed a 10 day course.  He was also continued on nebs
and 40 mg prednisone and improved.  He was additionally given
several doses of lasix which appeared to improve his functional
ability. He was discharged on a prednisone taper of 30 mg for 5
days and 25 mg for 5 days, with instructions to follow-up with
his PCP within one week to have his taper adjusted.
.
*Afib: Patient was fluctuating in and out of rapid afib
throughout his stay. He was asymptomatic, though occasionally he
felt more SOB.  He was treated with dofetolide and PO diltiazem
with some rate control.  However patient would trend into the
120s-160s and required IV diltiazem to bring his rate down. EP
was consulted and recommended increasing the PO diltiazem to 90
mg and continuing with dofetolide.  If his rate was not
controlled they suggested loading with digoxin or amiodarone.
Since dofetilide prolongs QT, daily EKGs were obtained to make
sure the pt did not have QTc greater than 500.  No additional QT
prolonging medications were to be added to his regimen (levaquin
and dilt had already been started).  Cr was also closely
monitored per pharmacy recs.  He was stable on diltiazem and
difetolide and occasionally went back into NSR.  He also had
occasional bursts to HR 120s-140s but came back down on his own
after several minutes.  He was started on digoxin one day prior
to admission and was to follow-up with his PCP for [**Name Initial (PRE) **]/u on his
dig levels.  Additionally, his home coumadin was initially
stopped b/c he had an INR of >7 at admission.  After INR was
below 2, it was re-started at a low dose (5 mg) b/c levaquin can
potentiate the effects of coumadin.  He was discharged on 5 mg
coumadin qd.
.
*Anemia: Pt's hct was 26-32 during this admission. Baseline hct
was not known.  Iron studies showed a normocytic anemia with nl
iron, ferritin, TIBC and retics. Patient did not require a
transfusion during his stay.

.
*Pleural effusion: Patient was found to have a right pleural
effusion.In the MICU a diagnostic tap was considered but CT
suggested fluid collection too small.
.
*Pulmonary nodule:  A pulmonary nodule was seen by the MICU team
on the patient's chest CT.  This was not noted in the CT report.
 The patient's outpatient pulmonologist, Dr. [**Last Name (STitle) 60152**], was
contact[**Name (NI) **] and noted the nodule was new.  He will follow the
nodule as an outpatient.  The patient was sent home with CDs of
his radiology images so that Dr. [**Last Name (STitle) 60152**] could review the chest
CT.
.
*Hyperglycemia- Patient was hyperglycemic on steroids. Fixed
dose insulin was started, initially NPH and then lantus.
Metformin was continued.  Patient was discharged on 30 units of
lantus sc at bedtime.
.
*Slightly elevated Cr: Cr was 1.2-1.3 initially. Baseline was
unknown but was 1.1 later in the admission and not trending up
with dofetilide.
.
*FEN: Cardiac diet. Lytes were repleted PRN.
.
*PPX: Protonix, coumadin, PT


Medications on Admission:
MEDS: Warfarin 7.5 Daily; Predisone 10 Daily; Zyprexa 15 HS;
Advair 250/50 [**Hospital1 **]; Combivent INH Q6; Tikosyn (Dofetilide) 0.25
daily; Wellbutrin 100 [**Hospital1 **]; Cardizem 60 4x/day; Pepcid 20 Daily;
Glucophage

Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1)  Inhalation twice a day.
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Olanzapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours.
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*1*
9. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*1*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
11. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 5 days: Please take 30 mg qd for 5 days then take 25
mg qd for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
12. Lantus 100 unit/mL Solution Sig: 30  units Subcutaneous at
bedtime: Titrate down as prednisone dose is decreased.
Disp:*qs one month* Refills:*1*
13. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Insulin Sliding Scale
Please follow the Regular Insulin sliding scale in the post
discharge instructions
15. Outpatient Lab Work
Please have your digoxin level, electrolytes and creatinine
checked in one week
16. Lancets,Ultra Thin     Misc Sig: One (1)  Miscell.  four
times a day: Please give patient lancets for First Touch
Glucometer.
Disp:*qs one month* Refills:*2*
17. strips  Sig: One (1)   four times a day: Please give patient
test strips for First Touch glucometer.
Disp:*qs one month* Refills:*2*
18. Outpatient Lab Work
Please resume having your INR checked as you were doing prior to
admission.  Your first level should be checked on [**2181-11-12**].
19. Prednisone 5 mg Tablet Sig: Five (5) Tablet PO once a day
for 5 days: Please take the 30mg of prednisone qd for 5 days
followed by 25 mg prednisone for 5 days.
Disp:*25 Tablet(s)* Refills:*0*
20. Insulin Syringe 0.5cc/28G     Syringe Sig: One (1)  Miscell.
 once a day.
Disp:*qs one month* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Community VNA

Discharge Diagnosis:
Pneumonia
COPD
Atrial Fibrillation


Discharge Condition:
Stable on 2L NC O2, with DOE, though able to walk a short
distance.


Discharge Instructions:
Please take your medications as prescribed.
Please return to the ER or call your doctor if you have
increasing shortness of breath, chest pain, palpitations,
dizziness or lightheadedness.
Please follow up with your primary care doctor by early next
week.  He will need to follow your insulin regimen, your
prednisone dosing and check your digoxin level.

Followup Instructions:
Please follow-up with your pulmonologist, Dr. [**Last Name (STitle) 60152**], in [**2-4**]
weeks.  You will need to take your radiology CD with you to this
appointment.
.
Please follow up with your primary care doctor., Dr. [**Last Name (STitle) 7516**], by
early next week.  He will need to follow your insulin regimen,
your prednisone dosing and check your digoxin level..
.
Please resume your prior regimen of having your INR checked.
.
{'Pneumonia, organism unspecified,Acute respiratory failure,Chronic obstructive asthma with (acute) exacerbation,Acidosis,Unspecified pleural effusion,Atrial fibrillation,Long-term (current) use of anticoagulants,Other chronic pulmonary heart diseases,Other specified disorders of pancreatic internal secretion,Old myocardial infarction,Anemia, 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: Hypoxia

PRESENT ILLNESS: HPI: Mr [**Known lastname 7168**] is a 63 yo male with h/o COPD, asthma, Afib, CAD
s/p MI who was transferred to [**Hospital1 18**] from [**Hospital3 **]
yesterday. He went to [**Hospital3 **] after being found to be
hypoxic at home by VNA nurse (per MICU note was 68%). At [**Hospital1 2519**] he was found to have respiratory acidosis with hypoxia
(last ABG 7.31/79/75) and transferred to [**Hospital1 18**]. Patient notes
that he is SOB at baseline and wears 2 L O2 NC at home. He notes
that he had become increasingly SOB with exertion since Sunday
([**10-28**]). He denied chest pain but did notice he had fevers. He
has also had a productive cough with yellow/white sputum for [**4-6**]
days. He denies nasal congestion or sore throat. Patient was
discharge from [**Known lastname 7168**] Rehab one week ago, after spending one
month there. He had previously spent a week hospitalized at
[**Hospital **] hospital for "a [**Last Name **] problem". Per MICU note is apperas he
had COPD with PNA that required intubation in [**Month (only) 205**]. During that
hospitalization he was started on prednisone and was tapering
off it.

MEDICAL HISTORY: PMH:
COPD (on home O2)
Pulm HTN
CAD s/p MI and Cath
AFib
CVA
Bipolar Disorder
Carotid Stenosis (90% on one side)
PVD

MEDICATION ON ADMISSION: MEDS: Warfarin 7.5 Daily; Predisone 10 Daily; Zyprexa 15 HS;
Advair 250/50 [**Hospital1 **]; Combivent INH Q6; Tikosyn (Dofetilide) 0.25
daily; Wellbutrin 100 [**Hospital1 **]; Cardizem 60 4x/day; Pepcid 20 Daily;
Glucophage

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE on [**2181-11-1**]:
96.6 127/55 79 15 ranging 94-95% on NC O2 (recent episode 86%
but O2 was off)
Gen: Well appearing man sitting in chair, NAD
HEENT: MMM, PERRL, EOMI, no oral ulcers
CV: irregularly irregular rhythm, No M/R/G, nl S1, S2
Lung: Crackles bilateraly with wheezes throughout.
Abd: Obese, Soft, + BS, mildy distended, NT, No Masses
Ext: [**3-8**]+ pitting edema bilaterally, dusky erythema bilaterally
on shins L>R, open blister draining serous fluid on medial
aspect of left shin, area was cold to touch, 1+ PT pulses
bilaterally

FAMILY HISTORY: FH: N/C

SOCIAL HISTORY: SH: 100 Pack year smoker (50 years x 2 ppd), quit in [**Month (only) 205**];
Ex-alcoholic, quit a few years ago; retired engineer, lives at
home with wife and two grown children 

### Response:
{'Pneumonia, organism unspecified,Acute respiratory failure,Chronic obstructive asthma with (acute) exacerbation,Acidosis,Unspecified pleural effusion,Atrial fibrillation,Long-term (current) use of anticoagulants,Other chronic pulmonary heart diseases,Other specified disorders of pancreatic internal secretion,Old myocardial infarction,Anemia, unspecified'}
