CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: Pt is a 82 y/o M w/ h/o COPD, CAD, TIA who p/w progressive
dyspnea over the last few weeks. Pt. admits to not taking his
medications for the last month b/c "he ran out". He has had
worsening SOB and today he couldn't tolerate it.
.
Denied chest pain/n/v/d/urinary or bowel sx.
.
In [**Name (NI) **], pt. tight w/ min. air movement. O2 sat in 79% on RA.
Rec'd combivent nebs, steroids. Pt. w/ some improvement on nebs,
continued to desat off continous nebs.

MEDICAL HISTORY: HTN
hypercholesterolemia
NQWMI ca. [**2182**]
TIA/aphasia [**10-1**]
s/p L CEA [**2-2**]
COPD (FEV1 1.57 per [**7-1**] PFTs)
BPH s/p TURP [**5-31**]
balanitis s/p circumcision [**5-31**]
remote nephrolithiasis
former tobacco use (80 pack/year Hx)

MEDICATION ON ADMISSION: ALBUTEROL 90MCG--2 puffs four times a day as needed
ASPIRIN 325MG--One by mouth every day
ATROVENT 18MCG--2 puffs four times a day
LIPITOR 10MG--One tablet by mouth every day
LISINOPRIL 5 mg--One (1) tablet po once a day
**per pt.'s daughter, the pt really only taking lipitor.**

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 97.2, BP: 94/58 HR 93 RR: 25 89% on 6L neg >800cc for the day

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: lives with wife. 2- children, daughter very involved. Works as
case manger at [**Hospital1 18**]. 80 pack years of smoking, quit 5 years
ago. Has generally been pretty resistant to medical care, last
PCP [**Name Initial (PRE) **] ~ 2 years ago.
Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Retention of urine, unspecified,Congestive heart failure, unspecified,Candidiasis of mouth,Pure hypercholesterolemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Old myocardial infarction
Pneumonia, organism NOS,Obs chr bronc w(ac) exac,Acute respiratry failure,Acute kidney failure NOS,Chronic kidney dis NOS,Retention urine NOS,CHF NOS,Thrush,Pure hypercholesterolem,Hy kid NOS w cr kid I-IV,Old myocardial infarct
Admission Date:  [**2196-2-1**]              Discharge Date:   [**2196-2-13**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
Endotracheal intubation

History of Present Illness:
Pt is a 82 y/o M w/ h/o COPD, CAD, TIA who p/w progressive
dyspnea over the last few weeks. Pt. admits to not taking his
medications for the last month b/c "he ran out". He has had
worsening SOB and today he couldn't tolerate it.
.
Denied chest pain/n/v/d/urinary or bowel sx.
.
In [**Name (NI) **], pt. tight w/ min. air movement. O2 sat in 79% on RA.
Rec'd combivent nebs, steroids. Pt. w/ some improvement on nebs,
continued to desat off continous nebs.

Additionally in ED, EKG w/ < [**Street Address(2) 4793**] elevation in V1/2 w/ +
troponin-.  Per  cardiology intervention was limited to aspirin
and heparin was deferred no BB b/c copd; cycle enyzymes, call
them if pain recurs, repeat EKG.
.
Patient was given ceftriaxone, azithro due to multilobar pna
seen on cxr. Sputum and blood cultures were obtained. He was
given lasix 10 IV and continuous combivent nebs.


Past Medical History:
HTN
hypercholesterolemia
NQWMI ca. [**2182**]
TIA/aphasia [**10-1**]
s/p L CEA [**2-2**]
COPD (FEV1 1.57 per [**7-1**] PFTs)
BPH s/p TURP [**5-31**]
balanitis s/p circumcision [**5-31**]
remote nephrolithiasis
former tobacco use (80 pack/year Hx)


Social History:
lives with wife. 2- children, daughter very involved. Works as
case manger at [**Hospital1 18**]. 80 pack years of smoking, quit 5 years
ago. Has generally been pretty resistant to medical care, last
PCP [**Name Initial (PRE) **] ~ 2 years ago.

Family History:
Non-contributory

Physical Exam:
T 97.2, BP: 94/58 HR 93 RR: 25 89% on 6L neg >800cc for the day

GEN: NAD, speaking in full sentences, A & O X 3, no accessory
muscle use
HEENT: L CEA surgical scar, well-healed; no thyromegaly
LUNGS: poor air movement, + expiratory wheezes, minimal
expiratory rhonchi, no crackles, decreased bs at bases
HEART: RRR, nls1s2 no MRGs
ABD: sl. distended, soft, NTND +bs
EXT: 2+ pulses, no C/C/E
NEURO: nl MS; CN II-XII grossly intact, nl strength and
sensation grossly


Pertinent Results:
Portable CXR [**2-8**]: A small right pleural effusion has decreased.
Small bilateral pleural effusions persist. Mild opacification at
the lung bases is probably atelectasis. Upper lungs clear. No
pulmonary edema. Heart size normal.
.
Echo [**2-2**]: There is moderate symmetric left ventricular
hypertrophy. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated. There is
mild global right ventricular free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
No mitral regurgitation is seen. The left ventricular inflow
pattern suggests impaired relaxation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.


Brief Hospital Course:
This 82 year old gentleman with COPD and CAD, and TIA's
presented with progressive dyspnea over several weeks was
admitted to the ICU for hypoxia and need for continuous nebs.
Given wheezes and history of smoking, this was believed to be
secondary to COPD exacerbation. In addition, there was evidence
of bilateral opacities on chest X-ray suggesting a concurrent
pneumonia and pt was initially covered broadly.  He was ruled
out for MI and pulmonary embolus disease.

#hypoxia/PNA: On HD 3 the patient was found to be hypercarbic
with pCO2 of 83 and was therefore intubated.  His respiratory
function improved and he was extubated on HD 5  Sputum culture
revealed strep pneumonia and antibiotic coverage was narrowed to
levofloxacin.

After extubation, the patient had a persistently high oxygen
requirement requiring face mask with nasal cannula.  He was
weaned off face mask but continued to require 6 L nasal cannula
to maintain oxygen saturations at 88-92% (which is baseline per
patient).  When attempts were made to increase o2 saturatino, he
became hypercarbic, so the goal was made to keep his sats in the
88-92% range.  He was not in respiratory distress after
extubation.  He was transferred on HD 8 to the floor.

He was continued on nebs around the clock and required 6L NC or
35% FM intitially, with continued desats on ambulation with PT.
Over his five day stay on the floor, his lung exam improved and
his oxygenation status improved such that he could tolerate 4L
o2 while ambulating with desats onlt to 85% on discharge. We
strongly recommended pulmonary rehab, but patient repeatedly
refused.  Through this time, we continued levofloxacin and
discharged him with a prescription to take him through a full 14
day course.
.
He was discharged home with home oxygen, albuterol nebulizers
and tiotroprium, salmeterol, fluticasone
.
# Cardiac:
Pt. also had elevated trops with flat CK in context of
hypovolemic ARF, which has now resolved to baseline. Also had a
brief run of sinus arrest and junctional escape (several
seconds), so cardiology recommended avoid nodal agents for BP
control and pt. was started on lisinopril. Had Echo showing
moderate LVH, normal EF, moderate RV dilitation, hypertrophy,
and mild hypokinesis.

We started asa, continued lipitor and initially started ACE-I,
which he initially tolerated in ICU, but had to be titrated down
due to hypotension on the floor.  We ended up discontinuing it,
with plans to readress whether his blood pressures could
tolerate ACE-I as an outpatient.  Of not he was asymptomatic
during these episodes of hypotension to systolics in the 90s.
.
# Volume overload:
He also was aggressively volume resuscitated resulting in a max
of 12L positive in ICU, after which he has been aggressively
diuresed with lasix.   He responded nicely with no need for
further diuretics upon discharge
.
#CRI- baseline 1.0, admission 1.7. likely elevated in the
setting of infection.
--Resolved with fluids, clearing of infection
.

Medications on Admission:
ALBUTEROL 90MCG--2 puffs four times a day as needed
ASPIRIN 325MG--One by mouth every day
ATROVENT 18MCG--2 puffs four times a day
LIPITOR 10MG--One tablet by mouth every day
LISINOPRIL 5 mg--One (1) tablet po once a day
**per pt.'s daughter, the pt really only taking lipitor.**


Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Day (2) **]:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Day (2) **]:*30 Tablet(s)* Refills:*2*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
[**Month/Day (2) **]:*180 neb* Refills:*2*
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed.
[**Month/Day (2) **]:*100 neb* Refills:*0*
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
[**Month/Day (2) **]:*30 Cap(s)* Refills:*2*
6. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) inh Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*1 disk* Refills:*2*
7. Oxygen-Air Delivery Systems     Device Sig: One (1) system
Miscellaneous once.
[**Hospital1 **]:*1 kit* Refills:*0*
8. home oxygen
home oxygen.  Titrate on face mask or nasal cannula to oxygen
saturation of 88-91%
9. Nebulizer     Device Sig: One (1) device Miscellaneous once.
[**Hospital1 **]:*1 unit* Refills:*0*
10. Nebulizer Accessories     Kit Sig: One (1) kit Miscellaneous
once.
[**Hospital1 **]:*1 kit* Refills:*0*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for anxiety.
[**Hospital1 **]:*50 Tablet(s)* Refills:*0*
13. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: take 3 tabs po per day (30mg) for 7 days then 2 tabs per
day (20mg) for another 7 days.  After than start taper using 5mg
tablets.
[**Hospital1 **]:*35 Tablet(s)* Refills:*0*
14. Prednisone 5 mg Tablet Sig: as directed Tablet PO once a
day: after finishing 20 mg taper, start taking 3 tabs/day(15mg)
for 1 week, then 2 tabs/day until further notice from your PCP.
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*0*
15. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
[**Name Initial (NameIs) **]:*90 Capsule(s)* Refills:*0*
16. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
[**Name Initial (NameIs) **]:*1 bottle* Refills:*0*
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO bid:prn as needed
for constipation.
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*0*
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
[**Name Initial (NameIs) **]:*60 Capsule(s)* Refills:*0*
19. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
[**Name Initial (NameIs) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
[**Name Initial (NameIs) **]:*2 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
COPD exacerbation
Multilobar Pneumonia
Acute Renal Failure
_______________
Hypertension


Discharge Condition:
good, tolerating POs, ambulating without assistance, satting 88%
on Room air, desatting to low 80s on 4L NC with ambulation


Discharge Instructions:
please seek medical attention should you develop increasing
shortness of breath or desaturations to less than 85%.  Please
also seek medical attention should you develop fevers, chills,
chest pain, abdominal pain, or increased weight gain, swelling.


You have two more days of antibiotics which you should finish.
Take all other medications exactly as prescribed.  You should
attempt to adhere to a diet of <2g salt per day.  Weigh yourself
daily and call your doctor should you gain > 3 pounds or >5
pounds from today's weight.

You should follow up with Dr. [**Last Name (STitle) 5717**] within a week, as below

Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 5717**] within the next week.  His number is
[**Telephone/Fax (1) 250**].
{'Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Retention of urine, unspecified,Congestive heart failure, unspecified,Candidiasis of mouth,Pure hypercholesterolemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Old myocardial infarction'}


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: Pt is a 82 y/o M w/ h/o COPD, CAD, TIA who p/w progressive
dyspnea over the last few weeks. Pt. admits to not taking his
medications for the last month b/c "he ran out". He has had
worsening SOB and today he couldn't tolerate it.
.
Denied chest pain/n/v/d/urinary or bowel sx.
.
In [**Name (NI) **], pt. tight w/ min. air movement. O2 sat in 79% on RA.
Rec'd combivent nebs, steroids. Pt. w/ some improvement on nebs,
continued to desat off continous nebs.

MEDICAL HISTORY: HTN
hypercholesterolemia
NQWMI ca. [**2182**]
TIA/aphasia [**10-1**]
s/p L CEA [**2-2**]
COPD (FEV1 1.57 per [**7-1**] PFTs)
BPH s/p TURP [**5-31**]
balanitis s/p circumcision [**5-31**]
remote nephrolithiasis
former tobacco use (80 pack/year Hx)

MEDICATION ON ADMISSION: ALBUTEROL 90MCG--2 puffs four times a day as needed
ASPIRIN 325MG--One by mouth every day
ATROVENT 18MCG--2 puffs four times a day
LIPITOR 10MG--One tablet by mouth every day
LISINOPRIL 5 mg--One (1) tablet po once a day
**per pt.'s daughter, the pt really only taking lipitor.**

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 97.2, BP: 94/58 HR 93 RR: 25 89% on 6L neg >800cc for the day

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: lives with wife. 2- children, daughter very involved. Works as
case manger at [**Hospital1 18**]. 80 pack years of smoking, quit 5 years
ago. Has generally been pretty resistant to medical care, last
PCP [**Name Initial (PRE) **] ~ 2 years ago. 

### Response:
{'Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Retention of urine, unspecified,Congestive heart failure, unspecified,Candidiasis of mouth,Pure hypercholesterolemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Old myocardial infarction'}
