CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: 73yo male w/ stage IIIB squamous cell lung cancer, s/p recent
chemo and radiation, coming from a [**Hospital1 1501**] with dyspnea since
yesterday. No reported fevers, but also developed lower
extremity edema. EMS found him with shortness of breath, with
oxygen saturations in low 80s, put on non-rebreather, then CPAP
for transfer. No history of CHF. Appears cachectic.

MEDICAL HISTORY: - Stage IIIB squamous cell cancer diagnosed [**6-/2179**] with large
right lower lobe [**Location (un) 21851**] extending into the subcarina.
Right supraclavicular and R paratracheal lymphadenopathy.
Lesions in the stomach and liver suspicious for mets being
worked up. Has been on carboplatin and paclitaxel, as well as
completing a full course radiation.
- hypertension
- hyperlipidemia

MEDICATION ON ADMISSION: - dexamethasone 8mg daily (supposed to be only day prior and day
of chemo)
- omeprazole 10mg daily
- Zofran 4mg TID PRN
- Oxycodone 5mg TID PRN
- Sucralfate 10mL QID

ALLERGIES: No Allergies/ADRs on File

PHYSICAL EXAM: ADMISSION EXAM:
General: Intubated, sedated.
HEENT: Sclera anicteric, PERRL
Neck: JVP not elevated, no LAD
Lungs: Bilateral R>L coarse breath sounds.
CV: Tachy, regular, no audible murmurs
Abdomen: soft, non-tender, non-distended
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: - Tobacco: 12 pack year smoking history, has quit
- Alcohol: none
- Illicits: none
Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute respiratory failure,Empyema without mention of fistula,Encephalopathy, unspecified,Other pneumothorax,Malignant neoplasm of lower lobe, bronchus or lung,Anemia, unspecified,Other esophagitis,Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified essential hypertension,Diarrhea,Other and unspecified hyperlipidemia,Enlargement of lymph nodes,Other specified disorders of stomach and duodenum,Other specified disorders of liver
Meth sus pneum d/t Staph,Acute respiratry failure,Empyema w/o fistula,Encephalopathy NOS,Other pneumothorax,Mal neo lower lobe lung,Anemia NOS,Other esophagitis,Abn react-radiotherapy,Hypertension NOS,Diarrhea,Hyperlipidemia NEC/NOS,Enlargement lymph nodes,Gastroduodenal dis NEC,Liver disorders NEC
Admission Date:  [**2179-9-21**]              Discharge Date:   [**2179-9-28**]

Date of Birth:  [**2106-3-1**]             Sex:   M

Service: MEDICINE

Allergies:
No Allergies/ADRs on File

Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
Chest tube placement and removal
Endotracheal Intubation ([**9-21**]) and extubation ([**9-23**])
PICC placement


History of Present Illness:
73yo male w/ stage IIIB squamous cell lung cancer, s/p recent
chemo and radiation, coming from a [**Hospital1 1501**] with dyspnea since
yesterday. No reported fevers, but also developed lower
extremity edema. EMS found him with shortness of breath, with
oxygen saturations in low 80s, put on non-rebreather, then CPAP
for transfer. No history of CHF. Appears cachectic.

Of note, the patient was recently admitted from [**9-13**] to
[**2179-9-17**] to [**Hospital 3278**] medical center with dysphagia and diagnosed
with radiation esophagitis. He was started on a PPI and
carafate, as well as Percocet. He tolerated a diet and was
discharged with follow-up with his oncologist. Attending was Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Etten.

In the ED, initial vitals were 99.0 151 113/87 30 93% on CPAP.
Patient was found to have a right-sided pneumothorax, so a
right-sided chest tube was placed, which drained 300cc of
foul-smelling purulent fluid after a large gush of air. Repeat
CXR showed incomplete expansion of the right lung. Chest tube
has put out another 300cc. Initially on BiPAP, then weaned to
non-rebreather. Given vanc/Zosyn. Labs notable for anemia of
33.8, lactate 3.3, WBC 7.3 with 33% bands. 2 PIV placed.  To get
CT scan, and on return to the ED had worsening hypoxia and
respiratory distress and was intubated. Received total 3L IV
fluid. Prior to transfer were 99, 73, 142/88, 24, 98%
non-rebreather.

Intubated and sedated, cannot provide further history.

Past Medical History:
- Stage IIIB squamous cell cancer diagnosed [**6-/2179**] with large
right lower lobe [**Location (un) 21851**] extending into the subcarina.
Right supraclavicular and R paratracheal lymphadenopathy.
Lesions in the stomach and liver suspicious for mets being
worked up. Has been on carboplatin and paclitaxel, as well as
completing a full course radiation.
- hypertension
- hyperlipidemia

Social History:
- Tobacco: 12 pack year smoking history, has quit
- Alcohol: none
- Illicits: none


Family History:
Non-contributory

Physical Exam:
ADMISSION EXAM:
General: Intubated, sedated.
HEENT: Sclera anicteric, PERRL
Neck: JVP not elevated, no LAD
Lungs: Bilateral R>L coarse breath sounds.
CV: Tachy, regular, no audible murmurs
Abdomen: soft, non-tender, non-distended
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

DISCHARGE EXAM:
VS: RR 20 (16-22), pain 0/10
General: NAD, though restless. Not-intubated. Interactive.
Lungs: Decreased breath sounds in the R lung field, coarse
breath sounds throughout the left lung field
GU: no foley
Ext: cool, 2+ pulses, no clubbing, cyanosis, edema
Otherwise physical exam upon discharge is unchanged from
admission.


Pertinent Results:
ADMISSION LABS:
[**2179-9-21**] 10:54AM BLOOD WBC-7.3 RBC-3.80* Hgb-10.9* Hct-33.8*
MCV-89 MCH-28.7 MCHC-32.2 RDW-15.3 Plt Ct-228
[**2179-9-21**] 10:54AM BLOOD Neuts-58 Bands-32* Lymphs-6* Monos-3
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2179-9-21**] 10:54AM BLOOD PT-12.4 PTT-26.7 INR(PT)-1.0
[**2179-9-21**] 10:54AM BLOOD Glucose-131* UreaN-24* Creat-0.7 Na-141
K-4.2 Cl-100 HCO3-28 AnGap-17
[**2179-9-21**] 04:34PM BLOOD ALT-14 AST-22 LD(LDH)-267* CK(CPK)-68
AlkPhos-70 TotBili-0.6
[**2179-9-21**] 04:34PM BLOOD CK-MB-3 cTropnT-<0.01
[**2179-9-21**] 11:07AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.0
[**2179-9-21**] 11:27AM BLOOD Type-ART pO2-270* pCO2-44 pH-7.42
calTCO2-30 Base XS-4 Intubat-INTUBATED
[**2179-9-21**] 10:59AM BLOOD Glucose-124* Lactate-3.3* K-4.4
[**2179-9-21**] 05:31PM BLOOD freeCa-0.98*

DISCHARGE LABS:
[**2179-9-24**] 03:08AM BLOOD WBC-4.6 RBC-2.79* Hgb-7.6* Hct-23.4*
MCV-84 MCH-27.2 MCHC-32.4 RDW-14.9 Plt Ct-145*
[**2179-9-24**] 03:08AM BLOOD Glucose-114* UreaN-13 Creat-0.4* Na-135
K-3.7 Cl-99 HCO3-31 AnGap-9
[**2179-9-24**] 03:08AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.8

URINE:
[**2179-9-21**] 12:41PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2179-9-21**] 12:41PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2179-9-21**] 12:41PM URINE RBC-<1 WBC-5 Bacteri-NONE Yeast-NONE
Epi-0 TransE-<1

PLEURAL FLUID:
[**2179-9-21**] 04:15PM PLEURAL WBC-[**Numeric Identifier 42344**]* RBC-7000* Polys-100*
Lymphs-0 Monos-0 Macro-0
[**2179-9-21**] 04:15PM PLEURAL TotProt-2.1 Glucose-21 LD(LDH)-9470

MICRO:
[**2179-9-21**] BCx: NEGATIVE
[**2179-9-21**] UCx: NEGATIVE
[**2179-9-21**] MRSA screen: NEGATIVE
[**2179-9-21**] Pleural fluid Cx:
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
      GAMMA(I.E. NON-HEMOLYTIC) STREPTOCOCCUS.    SPARSE GROWTH.

      VIRIDANS STREPTOCOCCI.
         SPARSE GROWTH OF THREE COLONIAL MORPHOLOGIES.
      GRAM NEGATIVE ROD(S).    RARE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------   0.5 S

[**2179-9-21**] Sputum Cx: GRAM STAIN (Final [**2179-9-21**]): >25 PMNs, 4+
PMNs    RESPIRATORY CULTURE (Final [**2179-9-23**]): GNRs SPARSE
GROWTH.
NO LEGIONELLA ISOLATED.

STUDIES:
[**2179-9-21**] EKG: Sinus tachycardia with non-specific ST-T wave
changes in the lateral precordial leads.

[**2179-9-21**] CXR:
1. Large right-sided pneumothorax with deviation of mediastinal
structures to the left concerning for tension.
2. Hazy density in the left mid and lower lung zones which may
represent infectious process.

[**2179-9-21**] CT chest:
1. Per clinical concern for empyema, there is minimal layering
fluid within the right hemithorax without organization or
enhancing walls to suggest underlying empyema. There are dense
consolidations, worse in the right lower lobe with central areas
of hypoattenuation and air which are most compatible with
necrotizing pneumonia. Multifocal pneumonia is suspected with
extensive patchy opacities also noted in the right upper, left
upper and left lower lobes. Only the consolidation of the right
lower lobe demonstrates areas of necrosis. Given the
distribution, aspiration is a consideration.
2. Persistent right pneumothorax with indwelling chest tube.
Chest tube course as described above. There is baseline
pneumonia. No significant mediastinal shift is seen to suggest
recurrence of tension physiology.
3. Marked visceral pleural thickening, particularly of the lower
right hemithorax. This is of indeterminate etiology or
chronicity. This could be related to underlying infection. Given
the lack of parietal pleural thickening or other abnormality,
malignancy is felt less likely but is not excluded.

[**2179-9-24**] CHEST (PORTABLE AP): Diffuse abnormality in the right
lung continues to clear, particularly following removal of the
right pleural tube suggesting that most of this abnormality was
due to combination of edema and hemorrhage rather than
pneumonia. On the other hand consolidation in the left lower
lung has increased progressively since [**9-22**] and may well
be pneumonia. Small-to-moderate right pleural effusion remains.
There is no pneumothorax. Heart size is top normal, improved
since earlier in the day. Left PIC line  ends in the upper SVC.

Brief Hospital Course:
Mr. [**Known lastname **] is a 73M with stage IIIB squamous cell lung cancer, s/p
chemo and palliative radiation, coming from a [**Hospital1 1501**] with SOB,
found to have MSSA multifocal pneumonia, empyema, and
pneumothorax, s/p chest tube placement and now removal.

# Goals of Care: Family meeting was held with pt's daughter and
wife. It was decided to make the patient comfort measures only,
with the exception of keeping antibiotics on board. Pt will be
transitioning to hospice, at which point antibiotics will be
discontinued. Pt had no further lab draws.

# Respiratory failure: Patient was admitted with pneumothorax,
pneumonia, and empyema. He was intubated for respiratory
distress on admission, extubated on [**2179-9-23**]. Chest tube was in
place for empyema, removed on [**2179-9-24**]. Culture growing coag +
staph (pan-sensitive), GNR, Strep viridans, and Gamma strep. He
was treated with Zosyn from [**2179-9-21**] to [**2179-9-28**] and Tobramycin
from [**2179-9-21**] to [**2179-9-27**], after which they were discontinued as
pt was transitioned to hospice. He was on morphine and
nebulizers for comfort.

# Lung cancer, stage 3b: MRI was negative for brain mets.
Patient s/p palliative radiation with adjuvant weekly
[**Doctor Last Name **]/taxol x3 cycles in [**Month (only) 359**]. However, pt is no longer a
candidate for palliative chemo and his overall prognosis poor.
Patient's dexamethasone was tapered off.

# Esophagitis: Secondary to recent radiation. He was continued
on a PPI and sucralfate for comfort.

Medications on Admission:
- dexamethasone 8mg daily (supposed to be only day prior and day
of chemo)
- omeprazole 10mg daily
- Zofran 4mg TID PRN
- Oxycodone 5mg TID PRN
- Sucralfate 10mL QID

Discharge Medications:
1. sucralfate 1 gram Tablet [**Month (only) **]: One (1) Tablet PO QID (4 times
a day).
2. guaifenesin 100 mg/5 mL Syrup [**Month (only) **]: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
3. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for sob or wheezing.
5. Lorazepam 0.5-1 mg IV Q3H:PRN anxiety/distress
6. acetaminophen 650 mg Suppository [**Last Name (STitle) **]: One (1) suppository
Rectal three times a day as needed for pain or tactile fever.
7. scopolamine base 1.5 mg Patch 72 hr [**Last Name (STitle) **]: One (1) patch
Transdermal every seventy-two (72) hours as needed for nausea or
secretions.
8. morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: 2.5-7.5 mL PO q2h as needed
for pain.
Disp:*1 bottle* Refills:*1*
9. Dulcolax 10 mg Suppository [**Last Name (STitle) **]: One (1) suppository Rectal
once a day as needed for constipation.

Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]

Discharge Diagnosis:
Primary Diagnoses:
Pneumothorax
Necrotizing multifocal pneumonia
Empyema

Secondary Diagnosis:
Stage IIIB squamous cell lung cancer

Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure taking care of you during your hospital stay
at [**Hospital1 69**]. You were admitted with
shortness of breath, but then then found to have a small hole in
your lung, pneumonia, and empyema (an infection in the fluid
that surrounds your lungs). The small hole in your lung was
treated with placement of a chest tube and its subsequent
removal, which helped to seal the hole. The pneumonia and
empyema were treated with antibiotics.

After a discussion with your family it was decided to shift the
focus of your care to comfort, as well as complete a course of
antibiotics. Therefore, any intervention that would cause
discomfort was held or discontinued.

With regards to your medications, please make the following
changes.
Please START taking:
1. Albuterol - for difficulty breathing
2. Acetaminophen - for pain and fever
3. Docusate - to help with bowel movements
4. Lansoprazole - to help with heartburn
5. Lorazepam - for anxiety or distress
6. Morphine elixir - for pain

Please STOP taking:
1. Dexamethasone
2. Omeprazole
3. Zofran
4. Oxycodone

Otherwise, please take your home medications as prescribed in
your discharge paperwork.

Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (tel:
[**Telephone/Fax (1) 8236**]), as needed.



Completed by:[**2179-9-28**]
{'Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute respiratory failure,Empyema without mention of fistula,Encephalopathy, unspecified,Other pneumothorax,Malignant neoplasm of lower lobe, bronchus or lung,Anemia, unspecified,Other esophagitis,Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified essential hypertension,Diarrhea,Other and unspecified hyperlipidemia,Enlargement of lymph nodes,Other specified disorders of stomach and duodenum,Other specified disorders of liver'}


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: 73yo male w/ stage IIIB squamous cell lung cancer, s/p recent
chemo and radiation, coming from a [**Hospital1 1501**] with dyspnea since
yesterday. No reported fevers, but also developed lower
extremity edema. EMS found him with shortness of breath, with
oxygen saturations in low 80s, put on non-rebreather, then CPAP
for transfer. No history of CHF. Appears cachectic.

MEDICAL HISTORY: - Stage IIIB squamous cell cancer diagnosed [**6-/2179**] with large
right lower lobe [**Location (un) 21851**] extending into the subcarina.
Right supraclavicular and R paratracheal lymphadenopathy.
Lesions in the stomach and liver suspicious for mets being
worked up. Has been on carboplatin and paclitaxel, as well as
completing a full course radiation.
- hypertension
- hyperlipidemia

MEDICATION ON ADMISSION: - dexamethasone 8mg daily (supposed to be only day prior and day
of chemo)
- omeprazole 10mg daily
- Zofran 4mg TID PRN
- Oxycodone 5mg TID PRN
- Sucralfate 10mL QID

ALLERGIES: No Allergies/ADRs on File

PHYSICAL EXAM: ADMISSION EXAM:
General: Intubated, sedated.
HEENT: Sclera anicteric, PERRL
Neck: JVP not elevated, no LAD
Lungs: Bilateral R>L coarse breath sounds.
CV: Tachy, regular, no audible murmurs
Abdomen: soft, non-tender, non-distended
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: - Tobacco: 12 pack year smoking history, has quit
- Alcohol: none
- Illicits: none 

### Response:
{'Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute respiratory failure,Empyema without mention of fistula,Encephalopathy, unspecified,Other pneumothorax,Malignant neoplasm of lower lobe, bronchus or lung,Anemia, unspecified,Other esophagitis,Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified essential hypertension,Diarrhea,Other and unspecified hyperlipidemia,Enlargement of lymph nodes,Other specified disorders of stomach and duodenum,Other specified disorders of liver'}
