CHIEF COMPLAINT: Hypoxia.

PRESENT ILLNESS: Mr. [**Known lastname 8040**] is a 77-year-old male
with a medical history significant for coronary disease
status post myocardial infarction in [**2108**], multiple
transient ischemic attacks, hypertension, gastrointestinal
bleed, type 2 diabetes mellitus, renal cell carcinoma with
metastases to the lungs, status post partial left nephrectomy
and end stage renal disease on hemodialysis who presented
with progressive dyspnea on exertion for the past four weeks.

MEDICAL HISTORY: 1.  Renal cell carcinoma.  Renal cell carcinoma was
discovered during a work-up for abdominal pain in [**2135-5-30**], which revealed bilateral renal masses.  CT and MI scan
revealed 3 cm mass in left upper pole and a 4 cm mass in
upper right pole and patient is now status post left partial
nephrectomy for cancer treatment as of [**2135-6-30**].
2.  End stage renal disease.  Patient's end stage renal
disease is likely secondary to type 2 diabetes mellitus, as
well as renal cell carcinoma status post left partial
nephrectomy.  He is currently on hemodialysis treatment at
[**Location (un) 1468**] Dialysis Unit on a Tuesday, Thursday, Saturday
schedule.
3.  Type 2 diabetes mellitus.  Diabetes is currently
controlled with diet.
4.  Coronary disease.  Patient is status post myocardial
infarction in the [**2108**] and had recent chest pain in the past
which has been worked up.
5.  Hypertension.
6.  History of transient ischemic attack.  First demonstrated
in [**2135-6-30**] postoperatively from nephrectomy, which was
partial on the left kidney.  There has also been an episode
where he became unresponsive with straining and extension of
his right arm.  MI and MRA of the head showed small vessel
disease and evidence for an old left-sided cerebral
infarction.  This work-up was done on previous admissions.
7.  Gout.
8.  Sciatica.
9.  Cataracts.  Patient is status post bilateral cataract
surgery.
10. Benign prostatic hypertrophy.  He is status post
suprapubic prostatectomy in [**2139-7-31**].
11. Paroxysmal atrial fibrillation.
12. Hypercholesterolemia.
13. Hemicolectomy for massive gastrointestinal bleed
secondary to CMV colitis exacerbated by aspirin.

MEDICATION ON ADMISSION: (Medications on admission were as
follows)
 1.  Celexa 20 mg p.o. once per day.
 2.  Digoxin 0.125 mg p.o. once per day.
 3.  Metoprolol 75 mg p.o. once per day.
 4.  Isosorbide mononitrate 90 mg p.o. once per day.
 5.  Zantac 150 mg p.o. once per day.
 6.  Zestril 20 mg p.o. once per day.
 7.  Clarinex 5 mg p.o. once per day.
 8.  Ticlid 250 mg p.o. once per day.
 9.  Renagel 21 mg p.o. twice per day.
10.  Phos-Lo 3 p.o. three times per day.
11.  Nephrocaps one tablet p.o. once per day.

ALLERGIES: Penicillin causes rashes.  Aspirin exacerbates
gastrointestinal bleed.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for renal cell carcinoma in both
father and brother.

SOCIAL HISTORY: Significant for no alcohol or tobacco abuse.
Patient also denies illicit drug use.  He lives with his wife
of 55 years and is a War World II veteran.
Congestive heart failure, unspecified,Secondary malignant neoplasm of lung,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Alkalosis,Other pulmonary insufficiency, not elsewhere classified,Primary pulmonary hypertension
CHF NOS,Secondary malig neo lung,Hyp kid NOS w cr kid V,Abn react-renal dialysis,Alkalosis,Other pulmonary insuff,Prim pulm hypertension
Admission Date:  [**2142-6-11**]     Discharge Date:  [**2142-6-15**]

Date of Birth:   [**2064-9-22**]     Sex:  M

Service:  [**Hospital1 **]

HISTORY OF PRESENT ILLNESS:  Mr. [**Known lastname 8040**] is a 77-year-old male
with a medical history significant for coronary disease
status post myocardial infarction in [**2108**], multiple
transient ischemic attacks, hypertension, gastrointestinal
bleed, type 2 diabetes mellitus, renal cell carcinoma with
metastases to the lungs, status post partial left nephrectomy
and end stage renal disease on hemodialysis who presented
with progressive dyspnea on exertion for the past four weeks.

On the day of presentation, [**2142-6-11**], the patient was at
his [**Hospital **] Clinic appointment where he was found to be
dyspneic with just short walking and found to have an oxygen
saturation of 83% on room air.  Of note, just one month prior
in clinic, the patient had an oxygen saturation of 99% on
room air.  He denied history of orthopnea, or paroxysmal
nocturnal dyspnea and reported no chest pain at the time.
Mr. [**Known lastname 8040**] was subsequently transferred to the [**Hospital6 1760**] Emergency Department, where
his breathing became more labored requiring 100%
nonrebreather, which resulted in an oxygen saturation in the
low 90s.  His initial vitals were as follows:  Temperature of
98.1.  Heart rate of 76.  Blood pressure 160/80. Respiratory
rate of 14.  His oxygen saturation was in the low 90s with
100% nonrebreather.

He had diffuse rhonchi and crackles on his lung exam and
evidence of volume overload on physical examination.  His
chest x-ray demonstrated findings consistent with congestive
heart failure, bilateral pleural effusion, bibasilar
collapse, consolidation, and mediastinal hilar
lymphadenopathy with diffuse bilateral small nodules,
consistent with metastatic disease.

A repeat chest x-ray revealed worsening pulmonary edema
consistent with congestive heart failure.  Patient's blood
pressure also rose to 230/120 requiring intravenous
nitroglycerin drip.  Once the patient was stabilized, he was
transferred to the floor for further care and management.

PAST MEDICAL HISTORY:
1.  Renal cell carcinoma.  Renal cell carcinoma was
discovered during a work-up for abdominal pain in [**2135-5-30**], which revealed bilateral renal masses.  CT and MI scan
revealed 3 cm mass in left upper pole and a 4 cm mass in
upper right pole and patient is now status post left partial
nephrectomy for cancer treatment as of [**2135-6-30**].
2.  End stage renal disease.  Patient's end stage renal
disease is likely secondary to type 2 diabetes mellitus, as
well as renal cell carcinoma status post left partial
nephrectomy.  He is currently on hemodialysis treatment at
[**Location (un) 1468**] Dialysis Unit on a Tuesday, Thursday, Saturday
schedule.
3.  Type 2 diabetes mellitus.  Diabetes is currently
controlled with diet.
4.  Coronary disease.  Patient is status post myocardial
infarction in the [**2108**] and had recent chest pain in the past
which has been worked up.
5.  Hypertension.
6.  History of transient ischemic attack.  First demonstrated
in [**2135-6-30**] postoperatively from nephrectomy, which was
partial on the left kidney.  There has also been an episode
where he became unresponsive with straining and extension of
his right arm.  MI and MRA of the head showed small vessel
disease and evidence for an old left-sided cerebral
infarction.  This work-up was done on previous admissions.
7.  Gout.
8.  Sciatica.
9.  Cataracts.  Patient is status post bilateral cataract
surgery.
10. Benign prostatic hypertrophy.  He is status post
suprapubic prostatectomy in [**2139-7-31**].
11. Paroxysmal atrial fibrillation.
12. Hypercholesterolemia.
13. Hemicolectomy for massive gastrointestinal bleed
secondary to CMV colitis exacerbated by aspirin.

ALLERGIES:  Penicillin causes rashes.  Aspirin exacerbates
gastrointestinal bleed.

MEDICATIONS:  The patient on previous admissions was on:
1.  Claritin 10 mg po q.d.
2.  Digoxin 125 mcg po q.d.
3.  Imdur 90 mg po q.d.
4.  Isosorbide 60-90 mg po q.d.
5.  Metoprolol 75 mg po b.i.d.
6.  Nephrocaps 1 mg po q.d.
7.  Nifedipine ER 60 mg po q.h.s.
8.  Phos-Lo.
9.  Ranitidine 75-250 mg po q.h.s.
10. Ticlid 250 mg po q.d.
11. Zestril 20 mg po q.d.

FAMILY HISTORY:  Significant for renal cell carcinoma in both
father and brother.

SOCIAL HISTORY:  Significant for no alcohol or tobacco abuse.
Patient also denies illicit drug use.  He lives with his wife
of 55 years and is a War World II veteran.

PHYSICAL EXAMINATION:  On initial physical examination in the
Emergency Department, the patient was breathing heavily in
mild distress in a bed.  He appeared his stated age and
cachectic, otherwise, he was pleasant, alert and oriented
times three.  His vitals were a temperature of 98.1.  Heart
rate of 76.  Blood pressure 160/80 with intermittent rise to
systolic blood pressure of 230 and a respiratory rate of 14.
His initial weight was approximately 73 kg.  His head, eyes,
ears, nose and throat exam:  Normocephalic, atraumatic.
Anicteric and noninjected sclera.  No lesions in the
oropharynx and upper dentures were noted.  Pupils are equal,
round, and reactive to light and accommodation.  His
Extraocular muscles were intact.  No rhinorrhea was
appreciated.  Neck exam:  Soft, trachea midline.  Jugular
venous pressure was 8-9 cm and no thyromegaly was noted.
Pulmonary chest exam:  Rhonchi on expiration bilaterally with
mild crackles, left greater than right.  heart exam:
Regular, audible, but distant S1, S2, 1-2/6 systolic murmur
heard loudest at the base, no rubs or gallops were
appreciated.  Abdominal exam:  Nondistended, positive bowel
sounds, soft and nontender, no hepatosplenomegaly.  Back
exam:  No CVA tenderness bilaterally.  Genitourinary exam:
Deferred.  Rectal exam:  Deferred.  Pulses:  2+ radial pulses
and palpable, 1+ pedal pulses bilaterally.  Extremity exam:
[**11-30**]+ pitting peripheral edema, especially in the lower
extremities.  AV fistula noted in the left upper extremity
with good thrill.  Neurological exam:  Alert and oriented
times three.  Cranial nerves II through XII tested and were
intact.  Dermatology exam:  Very mild psoriatic rash on
scalp, face and extensor surfaces.  There is also some brown
discoloration of skin noted on anterior tibial aspect on the
right leg.

LABORATORY DATA:  The patient's initial CBC showed white
blood cell count of 8.0, hematocrit 38.0, and a platelet
count of 280.  His Chem-7 demonstrated sodium of 139,
potassium 3.9, chloride 92, bicarbonate 35, BUN of 34,
creatinine 7.2 and blood sugar of 111.  His first CK enzyme
came back 65 which was within normal limits.  His first
troponin T came back as 0.21.  Second set was 0.27.  Third
set was 0.27.  Fourth set was 0.22 and a fifth set was 0.19.
His calcium level was 9.0, phosphate of 4.4 and magnesium of
1.9.  His digoxin level was found to be 1.3.  His blood gas
was shown to have PO2 of 38, pCO2 of 41, and a pH of 7.56.
His lactate level was 1.0.

His first chest x-ray revealed findings consistent with
previous heart failure with bilateral pleural effusions,
bibasilar collapsing consolidation in mediastinal hilar
lymphadenopathy with diffuse bilateral small nodules
consistent with metastases.

The patient also had an electrocardiogram done which showed
no acute changes from previous studies.  There were still
signs of left ventricular hypertrophy strain, but otherwise,
no clear evidence for myocardial infarction.

An echocardiogram on [**6-12**] demonstrated left ventricular
ejection fraction of greater than 55% and a small right to
left intracardiac shunt, most likely consistent with atrial
septal defect.  Pulmonary artery systolic hypertension was
noted, but there was preserved global and regional
biventricular systolic function.  There was mild aortic
regurgitation and mild mitral regurgitation.

HOSPITAL COURSE:

1.  Shortness of breath:  The patient was transferred to the
floor on the day of admission for further care and
management, however, after a couple hours, he complained of
increased dyspnea on exertion and had an oxygen saturation of
approximately 80% on 100% nonrebreather with systolic blood
pressure in the 160s.  He was subsequently transferred to the
Medical Intensive Care Unit for further treatment.  At the
Medical Intensive Care Unit, Mr. [**Known lastname 8040**] was continued on
oxygen saturation with nonrebreather and face tent.  At
admission, he was ruled out for PE with CT angiogram.  He
received hemodialysis on [**2142-6-12**] under the care of Dr.
[**Last Name (STitle) 1860**] and had three liters of fluid removed with significant
improvement of his shortness of breath, but still complained
of productive green-yellow cough.  Given his rapid
improvement, the patient was transferred to the floor on [**2142-6-13**] with further management.  On [**6-14**], the patient
received another hemodialysis session with 2.6 kg of fluid
removed to a dry weight of 66 kg and Epogen administered.
However, three hours into the session, the patient
experienced a dull pressure type of chest pain with no
radiation, however, it resolved with oral nitroglycerin and
morphine.  The chest pain only lasted a few minutes and there
was no recurrence of chest pain throughout the hospital
course.

His most recent echocardiogram was otherwise normal except
for a mild right to left shunt atrial septal defect and his
latest electrocardiogram indicated a possible new T wave
inversion, however, Cardiology Consult was requested and the
evaluation indicated no evidence of myocardial infarction or
acute myocardial ischemia process, instead, they felt the
electrocardiogram was consistent with left ventricular
hypertrophy strain patterns.

Patient's shortness of breath continued to improve to the
point where his oxygen saturation on room air was 92%.  His
pulmonary function appeared to have returned to baseline and
he was seen by Physical Therapy.  Physical Therapy walked the
patient around the hospital floor and found him to be in the
low 90s on room air with ambulation.  They felt that he was
clear to go home with home Physical Therapy.  Pulmonary also
evaluated the patient and felt that he did not need an
interventional pulmonary procedures done at this time as his
pulmonary function had returned to baseline and seemed to be
continually improving.

2.  Coronary disease/Cardiovascular:  Patient's blood
pressure on initial examination at the Emergency Department
was a systolic blood pressure as high at 230, however, a
nitroglycerin drip was able to control his blood pressure
throughout the Medical Intensive Care Unit course and his
medication was adjusted with increase in Lopressor and
hydralazine dosage throughout the Medical Intensive Care Unit
course helped keep his blood pressure in the 140s to 150s.
He did complain of a dull pressure like substernal chest pain
on the 17th after three hours of hemodialysis.  He has had
episodes of chest pain in the past during hemodialysis as per
Dr.[**Name (NI) 129**] notes.  He was seen by Cardiology Consult, Dr.
[**First Name (STitle) 2572**], and he was evaluated.  His troponin and CKs were
within his baseline.  His troponin T was in the low 0.20
range, however, this has been his consistent levels
throughout this hospital course with no acute rises
throughout this admission.  He was continued on his current
cardiac regimen which included Lopressor, hydralazine and ACE
inhibitor.  His electrocardiogram was consistent with a left
ventricular hypertrophy pattern, but showed no acute evidence
of acute myocardial infarction or process.  He also had his
medications filtered through a PVO filter given his new
discovery of a right to left shunt on echocardiogram.

3.  End stage renal disease:  The patient most likely
presented due to volume overload secondary to end stage renal
disease.  Hemodialysis sessions were done twice with total
removal of approximately 6.6 kg of fluid.  It seems that he
may not have had sufficient fluid removal in the past,
therefore, we aggressively tested his lowest possible dry
weight as tolerated and it seems that he may need to have a
new setting for his optimal dry weight given his recent
weight loss secondary to his metastatic renal cell carcinoma.
However, he continued to improve and his volume status
improved and at the time of discharge he appeared to be
euvolemic.

CONDITION ON DISCHARGE:  Good.

DISCHARGE STATUS:  To home with services, primarily home
Physical Therapy.

DISCHARGE DIAGNOSES:
1.  Dyspnea.
2.  Hypoxia.
3.  Chronic renal failure.
4.  Congestive heart failure.
5.  Metastatic renal cell carcinoma.

DISCHARGE MEDICATIONS:
1.  Citalopram 20 mg q.d.
2.  Ranitidine 150 mg q.h.s.
3.  Nephrocaps 1 mg q.d.
4.  Plavix 75 mg po q.d.
5.  Lisinopril 40 mg po q.h.s.
6.  Toprol XL 150 mg t.i.d.
7.  Renagel 800 mg t.i.d. with meals.
8.  Claritin 10 mg po q.d.
9.  Digoxin 125 mcg q.d.
10. Imdur 90 mg q.d.

FOLLOW-UP PLANS:  The patient's follow-up plans include:
Continuation of Dialysis schedule at [**Location (un) 1468**] Dialysis Unit on
[**6-16**] at 11:15 a.m.  He will also follow-up with Dr. [**Last Name (STitle) 1860**]
as necessary.  He will also contact his oncologist to
schedule a follow-up appointment.  He will also call his
primary care physician or return to the hospital if he has
any new symptoms of shortness of breath or chest pain.

FOLLOW-UP APPOINTMENTS:
1.  Follow-up in [**Hospital **] Clinic on Saturday, [**6-16**] at
11:15 a.m.
2.  Primary care physician [**Name9 (PRE) 702**] within one week.
3.  Follow-up appointment with oncologist.









                          [**Name6 (MD) 251**] [**Name8 (MD) **], M.D.  [**MD Number(1) 1197**]

Dictated By:[**First Name3 (LF) 8041**]

MEDQUIST36

D:  [**2142-6-15**]  06:14
T:  [**2142-6-22**]  20:28
JOB#:  [**Job Number 8042**]


Admission Date:  [**2142-6-11**]     Discharge Date:  [**2142-6-15**]

Date of Birth:   [**2064-9-22**]     Sex:  M

Service:  MICU Green

CHIEF COMPLAINT:  Hypoxia.

HISTORY OF PRESENT ILLNESS:  The patient is a 77-year-old
gentleman with renal cell carcinoma originally diagnosed in
[**2134**].  The patient had bilateral partial nephrectomies at
that time for chromophobe oocytic component tumor (grade II
to III) with 4.5 cm skin size with capillary penetration but
negative margins.

Cancer was quiescent until two months ago when metastases
were noted in the patient's lungs.  The patient presents with
progressive dyspnea on exertion over the past two weeks and
an oxygen saturation in the 80s on the day of admission at
his oncologist's office.  Prior oxygen saturation in [**Month (only) **] had
been 99%.  As noted, a chest x-ray in [**2142-3-29**] showed
hilar lymphadenopathy and a bronchoscopy with biopsy showed
metastatic renal cell carcinoma.

The patient denies fevers, chills, nausea, vomiting, chest
pain, and palpitations.  The patient has had a chronic cough
for months which has been intermittently productive of yellow
and green sputum.  The patient has complained of anorexia
over the past several weeks.  The patient notes orthopnea
requiring him to sleep on two pillows, but no paroxysmal
nocturnal dyspnea.

The patient went to his oncologist on [**6-11**] for an
appointment and had low oxygen saturations to 83% and was
sent to the Emergency Department.

In the Emergency Department, the patient responded to 3
liters of oxygen with oxygen saturations coming up to 92% but
had an increasing oxygen requirement.  The patient was seen
by the Primary Medicine team at 4 a.m. and was short of
breath on 100% nonrebreather but was mentating well.  An
arterial blood gas at that time revealed pH was 7.56, PCO2
was 38, and PO2 was 38.

The patient was transferred to the Medical Intensive Care
Unit for further evaluation.  The chest x-ray on admission
was consistent with congestive heart failure with small
bilateral pleural effusions.  The patient's last dialysis had
been on [**2142-6-9**].

PAST MEDICAL HISTORY:
 1.  Renal cell carcinoma diagnosed in [**2134**] with bilateral
partial nephrectomies; chromophobe oocytic component tumor
(grade II to III); 4.5 cm; capillary penetration; and
negative margins.  The patient has been on dialysis since
[**2135**].
 2.  Paroxysmal atrial fibrillation.
 3.  Hypertension.
 4.  Coronary artery disease with a myocardial infarction in
[**2108**] and a normal echocardiogram in [**2138**].
 5.  Seizure disorder (however the patient is no longer on
Dilantin).
 6.  History of transient ischemic attacks.
 7.  Vascular dementia.
 8.  Gout.
 9.  History of gastrointestinal bleed resulting in a
hemicolectomy.
10.  Psoriasis.
11.  Type 2 diabetes.

MEDICATIONS ON ADMISSION:  (Medications on admission were as
follows)
 1.  Celexa 20 mg p.o. once per day.
 2.  Digoxin 0.125 mg p.o. once per day.
 3.  Metoprolol 75 mg p.o. once per day.
 4.  Isosorbide mononitrate 90 mg p.o. once per day.
 5.  Zantac 150 mg p.o. once per day.
 6.  Zestril 20 mg p.o. once per day.
 7.  Clarinex 5 mg p.o. once per day.
 8.  Ticlid 250 mg p.o. once per day.
 9.  Renagel 21 mg p.o. twice per day.
10.  Phos-Lo 3 p.o. three times per day.
11.  Nephrocaps one tablet p.o. once per day.

ALLERGIES:  Allergy to ASPIRIN (which causes bleeding) and to
PENICILLIN (which causes a rash).

SOCIAL HISTORY:  The patient was a building wrecker for about
20 to 30 years beginning in the [**2078**] and then a salesman.
The patient does not have a smoking history.

FAMILY HISTORY:   Family history was noncontributory.

PHYSICAL EXAMINATION ON PRESENTATION:  Physical examination
on admission revealed temperature was 96.3, heart rate was
76, blood pressure was 190/80, the respiratory rate was 21,
and the oxygen saturation was 80% to 92% on a 100%
nonrebreather mask.  In general, the patient was in no acute
distress.  Alert and oriented times three.  Head, eyes, ears,
nose, and throat examination revealed pupils were equal,
round, and reactive to light.  Extraocular movements were
intact.  The neck was supple with no jugular venous
distention.  Pulmonary examination revealed the patient's
lungs were clear to auscultation bilaterally/anteriorly.
Cardiovascular examination revealed a regular rate and
rhythm.  No murmurs appreciated.  The abdomen was soft,
nontender, and nondistended with positive bowel sounds.
Extremity examination revealed no edema.  Dorsalis pedis
pulses were 2+ bilaterally.  Neurologic examination revealed
no gross deficits.  Skin examination revealed multiple
psoriatic plaques on the scalp.

PERTINENT LABORATORY VALUES ON PRESENTATION:   Laboratories
on admission revealed white blood cell count was 8,
hematocrit was 38, and platelets were 280.  Sodium was 139,
potassium was 3.9, chloride was 92, bicarbonate was increased
at 35, blood urea nitrogen was 34, creatinine was 7.2, and
blood glucose was 111.  Arterial blood gas initially revealed
pH was 7.56, PCO2 was 38, and PO2 was 38.  Arterial blood gas
then improved to a pH of 7.42, PCO2 of 43, and PO2 of 62;
this was on 100% nonrebreather mask.

PERTINENT RADIOLOGY/IMAGING:  A chest x-ray from [**6-11**]
showed bulky lymphadenopathy with diffuse reticular nodular
pattern and bilateral pleural effusions; consistent with
congestive heart failure and metastatic disease.

Electrocardiogram was compared with [**2139-11-30**] with a
rate of 75, normal sinus, left axis deviation, and normal
intervals.  Left ventricular hypertrophy with a flipped T
wave in leads V4, V5, and III (which were new).

Just noting a computed tomography scan from [**6-8**], prior to
admission, showed extensive mediastinal adenopathy with a
node as large as 3.3 cm X 2.9 cm (which has increased in
size).  Also, small bilateral pleural effusions.  Also with
new nodular densities and an increased size of metastases in
the left lobe with one nodule measuring 12 mm in diameter.

HOSPITAL COURSE BY ISSUE/SYSTEM:

1.  HYPOXIA ISSUES:  The patient was admitted with hypoxia
with an oxygen requirement, but his saturations improved on
100% nonrebreather mask to the 90s.  He was breathing
comfortably.  It seemed that the patient encountered sputum
that he could not clear.  His saturations dropped, but when
he coughed his saturations would improve.

Of note, the patient came to the Intensive Care Unit on a
nitroglycerin drip and had been taking isosorbide
mononitrate, and this may have worsened his respiratory
status as it may have dilated pulmonary vasculature that was
contracting to try and keep his V/Q match.  Also, the patient
had been anorexic over the past several weeks and had
probably lost wean by mask, though his dialysis was being
maintained at the same dry weight.  When the patient was
dialyzed off 3 liters later in the morning on the day of
admission, the patient's respiratory status improved.  The
patient will most likely require establishment of a new lower
dry weight.

There was an immediate suspicion for a pulmonary embolism on
admission; however, given the patient's metastatic status,
history of bleeds, and improving oxygen saturations, the
patient was not fully heparinized at that time.  However, on
day two of admission the patient was sent for a computed
tomography angiogram to rule out a pulmonary embolism.

In the Medical Intensive Care Unit, the patient continued to
improve his oxygenation and was switched to 6 liters nasal
cannula and was breathing comfortably.

2.  METABOLIC ALKALOSIS ISSUES:  The patient was admitted
with a bicarbonate of 35.  This may have enhanced his
respiratory distress as the patient is oliguric.  This likely
was an iatrogenic elevated bicarbonate level due to either
over bicarbonated dialysis solution and/or his Phos-Lo and/or
Renagel.  Those two medications were held in the Medical
Intensive Care Unit, and he was dialyzed again with a low
bicarbonate solution, and his bicarbonate resolved down to 27
after that.  It seemed that this may no longer be an issue
for this patient.

3.  HYPERTENSIVE ISSUES:  The patient was hypertensive to
200/80s to 90s on admission to the Medical Intensive Care
Unit.  The patient was initially placed on a labetalol drip
with good affect.  This was after the nitroglycerin drip was
stopped.  The next day we attempted to take the patient off
the labetalol drip and maintain him on his metoprolol 75 mg
p.o. twice per day; however, this was not sufficient
overnight, and the patient was placed on hydralazine 20 mg
intravenously every six hours for blood pressure maintenance
which worked well.

4.  END-STAGE RENAL DISEASE ISSUES:  The patient was last
dialyzed on [**6-9**].  He was dialyzed again on [**6-12**] with 3
liters removed.  The patient seemed to have an improvement in
his respiratory status after this and had no signs of being
overly dried out by this dialysis.  It was very likely that
due to the patient's recent anorexia he had lost dry weight
and needed to be dialyzed to a lower dry weight.

5.  CORONARY ARTERY DISEASE ISSUES:  The patient had a
distant history of a myocardial infarction.  A recent
echocardiogram from [**2138**] showed a preserved ejection fraction
and left ventricular function.

The patient did have a small troponin leak by enzymes at
approximately 0.2, but his creatine kinase levels were flat
at around 50 to 60.  We had a low suspicion that the patient
had a cardiac event and thought that this was more likely due
to his respiratory distress and his end-stage renal disease.

However, the patient received another echocardiogram with a
bubble study.  This echocardiogram on [**6-12**] showed a small
right-to-left shunt across the atrium, left ventricular
function was preserved and normal size, normal ejection
fraction of greater than 55%, mild aortic regurgitation, and
mild mitral regurgitation.  The patient did have moderate
pulmonary artery systolic hypertension.  The patient was also
switched from Ticlid to Plavix for an anti-platelet [**Doctor Last Name 360**]
which the patient is presumably on in lieu of aspirin which
he is allergic to.

6.  TYPE 2 DIABETES MELLITUS ISSUES:  The patient was placed
on an insulin sliding-scale and a diabetic diet with
fingersticks four times per day.

7.  RENAL CELL CARCINOMA ISSUES:  The patient recently
learned that he had metastases to his lungs.  His family and
outpatient oncologist were notified of this situation.

8.  PROPHYLAXIS ISSUES:  The patient was maintained on
subcutaneous heparin and ranitidine for gastrointestinal
prophylaxis.





                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], M.D.  [**MD Number(2) 8038**]

Dictated By:[**Last Name (NamePattern1) 6006**]

MEDQUIST36

D:  [**2142-6-13**]  13:39
T:  [**2142-6-20**]  10:55
JOB#:  [**Job Number 8039**]
{'Congestive heart failure, unspecified,Secondary malignant neoplasm of lung,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Alkalosis,Other pulmonary insufficiency, not elsewhere classified,Primary pulmonary hypertension'}


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: Mr. [**Known lastname 8040**] is a 77-year-old male
with a medical history significant for coronary disease
status post myocardial infarction in [**2108**], multiple
transient ischemic attacks, hypertension, gastrointestinal
bleed, type 2 diabetes mellitus, renal cell carcinoma with
metastases to the lungs, status post partial left nephrectomy
and end stage renal disease on hemodialysis who presented
with progressive dyspnea on exertion for the past four weeks.

MEDICAL HISTORY: 1.  Renal cell carcinoma.  Renal cell carcinoma was
discovered during a work-up for abdominal pain in [**2135-5-30**], which revealed bilateral renal masses.  CT and MI scan
revealed 3 cm mass in left upper pole and a 4 cm mass in
upper right pole and patient is now status post left partial
nephrectomy for cancer treatment as of [**2135-6-30**].
2.  End stage renal disease.  Patient's end stage renal
disease is likely secondary to type 2 diabetes mellitus, as
well as renal cell carcinoma status post left partial
nephrectomy.  He is currently on hemodialysis treatment at
[**Location (un) 1468**] Dialysis Unit on a Tuesday, Thursday, Saturday
schedule.
3.  Type 2 diabetes mellitus.  Diabetes is currently
controlled with diet.
4.  Coronary disease.  Patient is status post myocardial
infarction in the [**2108**] and had recent chest pain in the past
which has been worked up.
5.  Hypertension.
6.  History of transient ischemic attack.  First demonstrated
in [**2135-6-30**] postoperatively from nephrectomy, which was
partial on the left kidney.  There has also been an episode
where he became unresponsive with straining and extension of
his right arm.  MI and MRA of the head showed small vessel
disease and evidence for an old left-sided cerebral
infarction.  This work-up was done on previous admissions.
7.  Gout.
8.  Sciatica.
9.  Cataracts.  Patient is status post bilateral cataract
surgery.
10. Benign prostatic hypertrophy.  He is status post
suprapubic prostatectomy in [**2139-7-31**].
11. Paroxysmal atrial fibrillation.
12. Hypercholesterolemia.
13. Hemicolectomy for massive gastrointestinal bleed
secondary to CMV colitis exacerbated by aspirin.

MEDICATION ON ADMISSION: (Medications on admission were as
follows)
 1.  Celexa 20 mg p.o. once per day.
 2.  Digoxin 0.125 mg p.o. once per day.
 3.  Metoprolol 75 mg p.o. once per day.
 4.  Isosorbide mononitrate 90 mg p.o. once per day.
 5.  Zantac 150 mg p.o. once per day.
 6.  Zestril 20 mg p.o. once per day.
 7.  Clarinex 5 mg p.o. once per day.
 8.  Ticlid 250 mg p.o. once per day.
 9.  Renagel 21 mg p.o. twice per day.
10.  Phos-Lo 3 p.o. three times per day.
11.  Nephrocaps one tablet p.o. once per day.

ALLERGIES: Penicillin causes rashes.  Aspirin exacerbates
gastrointestinal bleed.

PHYSICAL EXAM: 

FAMILY HISTORY: Significant for renal cell carcinoma in both
father and brother.

SOCIAL HISTORY: Significant for no alcohol or tobacco abuse.
Patient also denies illicit drug use.  He lives with his wife
of 55 years and is a War World II veteran. 

### Response:
{'Congestive heart failure, unspecified,Secondary malignant neoplasm of lung,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Alkalosis,Other pulmonary insufficiency, not elsewhere classified,Primary pulmonary hypertension'}
