CHIEF COMPLAINT: hypoxia

PRESENT ILLNESS: 56yo man with history of renal cell cancer s/p nephrectomy and
renal transplant, asthma, hypertension who presents with
shortness of breath s/p nasal polypectomy.  During the
procedure, patient receieved 800cc fluid, with estimated blood
loss 200cc.  In the PACU the patient was slow to recover from
anesthesia with saturations were 85-88% on 6L, heart rate 70s,
SBP 160-180 as patient did not take his antihypertensives prior
to surgery.  In PACU, CXR obtained showing diffuse patchy
infiltrate on right and slightly denser infiltrate on left,
concerning for pulmonary edema vs aspiration pneumonia.  Oxygen
saturation improved to 92-93% on NRB after 20mg iv lasix and
nebulizers.

MEDICAL HISTORY: Renal cell ca s/p nephrectomy [**2093**]
s/p cadaveric renal transplant [**8-8**]
diabetes mellitus type 2
asthma- not treated, hospitalized as child
s/p left AV graft
h/o ciguatera poisening from barracuda ingestion
nasal polyps
hypertension
DM type 2
Barrett's esophagus
mild pulmonary hypertension
trivial MR

MEDICATION ON ADMISSION: Norvasc 5mg daily
Metoprolol 100mg [**Hospital1 **]
Cellcelpt 250mg [**Hospital1 **]
prednisone 5mg daily
furosemide 40mg daily
clonidine 0.2mg daily
avandia 4mg daily
lisinopril 5mg daily
ecotrin 81mg daily

ALLERGIES: Vancomycin

PHYSICAL EXAM: T 97.2  HR 71  BP  156/63   RR 30  93%NRB
Gen:  seating in chair, lethargic but arousable, using accessory
muscles, expiratory grunting
HEENT:  PERRL, anicteric, MMM, OP clear, nasal packing B
Neck:  no JVP, supple, no LAD
CV:  RRR, II/VI SEM at LSB
Pulm:  B rales, L>R
Abd:  obese, soft, NT, ND, well healed scar, +BS
Ext:  no edema, 2+DP pulses B
Neuro:  A&Ox3, nonfocal
Skin:  warm, dry, intact

FAMILY HISTORY: mother with renal disease

SOCIAL HISTORY: married, works in nutrition at [**Hospital1 18**]
remote tob hs, no EtOH, no IVDA
Other polyp of sinus,Other pulmonary insufficiency, not elsewhere classified,Kidney replaced by transplant,Other and unspecified coagulation defects,Chronic ethmoidal sinusitis,Personal history of malignant neoplasm of kidney,Unspecified essential hypertension,Unspecified sleep apnea,Other diseases of pharynx, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Nasal sinus polyp NEC,Other pulmonary insuff,Kidney transplant status,Coagulat defect NEC/NOS,Chr ethmoidal sinusitis,Hx of kidney malignancy,Hypertension NOS,Sleep apnea NOS,Disease of pharynx NEC,DMII wo cmp nt st uncntr
Admission Date:  [**2102-12-4**]              Discharge Date:   [**2102-12-8**]

Date of Birth:  [**2045-12-2**]             Sex:   M

Service: MEDICINE

Allergies:
Vancomycin

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

Major Surgical or Invasive Procedure:
- nasal polypectomy


History of Present Illness:
56yo man with history of renal cell cancer s/p nephrectomy and
renal transplant, asthma, hypertension who presents with
shortness of breath s/p nasal polypectomy.  During the
procedure, patient receieved 800cc fluid, with estimated blood
loss 200cc.  In the PACU the patient was slow to recover from
anesthesia with saturations were 85-88% on 6L, heart rate 70s,
SBP 160-180 as patient did not take his antihypertensives prior
to surgery.  In PACU, CXR obtained showing diffuse patchy
infiltrate on right and slightly denser infiltrate on left,
concerning for pulmonary edema vs aspiration pneumonia.  Oxygen
saturation improved to 92-93% on NRB after 20mg iv lasix and
nebulizers.

Past Medical History:
Renal cell ca s/p nephrectomy [**2093**]
s/p cadaveric renal transplant [**8-8**]
diabetes mellitus type 2
asthma- not treated, hospitalized as child
s/p left AV graft
h/o ciguatera poisening from barracuda ingestion
nasal polyps
hypertension
DM type 2
Barrett's esophagus
mild pulmonary hypertension
trivial MR

Social History:
married, works in nutrition at [**Hospital1 18**]
remote tob hs, no EtOH, no IVDA

Family History:
mother with renal disease

Physical Exam:
T 97.2  HR 71  BP  156/63   RR 30  93%NRB
Gen:  seating in chair, lethargic but arousable, using accessory
muscles, expiratory grunting
HEENT:  PERRL, anicteric, MMM, OP clear, nasal packing B
Neck:  no JVP, supple, no LAD
CV:  RRR, II/VI SEM at LSB
Pulm:  B rales, L>R
Abd:  obese, soft, NT, ND, well healed scar, +BS
Ext:  no edema, 2+DP pulses B
Neuro:  A&Ox3, nonfocal
Skin:  warm, dry, intact

Pertinent Results:
CXR:  fluffy, infiltrates B, L>R, patchy on R
ECG:  sinus rhythm at 80bpm, intervals nml, axes nml, prominent
J point elevation

Echo [**3-9**]:  EF >55%, mild pulm htn, trivial MR

Brief Hospital Course:
56yo man with history of renal cell cancer, s/p nephrectomy, s/p
renal transplant, asthma, and hypertension who presented with
hypoxia following nasal polypectomy.  During hospitalization the
following problems were addressed:
1.  Hypoxia:  The patient was slow to awake from anesthesia and
desaturated requiring supplemental oxygen by mask.  CXr showed
large left infiltrate and patchy right opacities.  The
differential included CHF exacerbation vs. aspiration
pneumonititis vs. aspiration pneumonia vs. chronic hypercapnea
and slow recovery from anesthetics.  He was initially started on
levofloxacin and flagyl, but this was d/c'd as there was little
evidence of pneumonia.  He was given lasix, but did not respond
with adequate diuresis.  Despite the lack of diuresis he
improved clinically, suggesting pulmonary edema was not the
cause.  An echocardiogram was unchanged from his previous exam,
showing diastolic dysfunction with severe LVH and an EF >55%.
He most likely suffered from a pneumonitis following anesthesia.
 Additionally, he was found to desaturate while sleeping and
likely suffers from obstructive sleep apnea.  It is recommended
that he follow up for outpatient evaluation for OSA.
2.  Hypertension:  the patient had some labile blood pressures.
His ACEI was initially held as he was in ARF and his metoprolol
was held out of concern for acute CHF.  These were restarted and
he was continued on his home regimen.  His blood pressures
remained elevated, and the lisinopril dose was subsequently
increased to 10mg daily.
3.  Diabetes mellitus type 2:  The patient had previously been
followed at [**Last Name (un) **], but had not been seen for a year.  [**Last Name (un) **]
was consulted.  His avandia was d/c'd out of concern for causing
pulmonary edema.  He was started on Lantus and maintained on
sliding scale insulin.  His lantus dose was titrated up prior to
discharge.  He has outpatient follow-up scheduled with [**Last Name (un) **].
4.  Polypectomy:  ENT continued to follow the patient.  He was
initially treated with Ancef, which was subsequently changed to
Keflex for infection prophylaxis.  The packing was removed on
[**2102-12-8**].  He was discharged on 10-day course of keflex, and is
to follow-up with ENT as outpatient.
5.  Renal Transplant:  Renal transplant service was consulted.
The patient was initially continued on his home regimen of
CellCept and prednisone.  At time of discharge, he was started
on rapimmune, in addition to continuing cellcept/prednisone.
6.  Dispo:  he will follow up with ENT, his primary care
physician, [**Name10 (NameIs) **] [**Name11 (NameIs) **] clinic, and renal transplant service.  He
is a full code.

Medications on Admission:
Norvasc 5mg daily
Metoprolol 100mg [**Hospital1 **]
Cellcelpt 250mg [**Hospital1 **]
prednisone 5mg daily
furosemide 40mg daily
clonidine 0.2mg daily
avandia 4mg daily
lisinopril 5mg daily
ecotrin 81mg daily

Discharge Medications:
1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
2. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous at bedtime: monitor FSG while on insulin.
3. Insulin Regular Human 100 unit/mL Cartridge Sig: per SS units
Injection four times a day: monitor FSG QID, w/ insulin as per
sliding scale.
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
5. Rapamune 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Clonidine HCl 0.2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Percocet 2.5-325 mg Tablet Sig: One (1) Tablet PO every [**4-11**]
hours as needed for pain for 7 days.
Disp:*10 Tablet(s)* Refills:*0*
12. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
primary
- nasal polyps s/p polypectomy
- hypoxia
- perioperative aspiration pneumonitis
- obstructive sleep apnea
- s/p renal transplant
- hypertension
- DM type 2
secondary
- renal cell cancer s/p nephrectomy
- s/p cadaveric kidney transplant
- glucose intolerence
- Barrett's esophagus
- asthma
- s/p left AV graft
- h/o ciguatera poisoning
- mild pulmonary hypertension
- trivial MR

Discharge Condition:
- stable to home

Discharge Instructions:
- Take medications as directed.  Please note your insulin has
been adjusted, and you have been started on rapammune, and your
lasix and lisinopril doses have been adjusted.  In addition, you
are to complete 10 days of antibiotics.
- Follow up as scheduled.
- [**Name8 (MD) **] MD or go to ER for nose bleeding or discomfort,
difficulty breathing, chest pain, difficulty urinating, flank or
abdominal pain, fevers, or other concerning symptoms.

Followup Instructions:
- Follow up with ENT Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in [**Hospital Unit Name 40**] (ENT) on [**2102-12-12**] at 2:00 pm.  Call [**Telephone/Fax (1) 41**]
with questions.
- Follow up with Dr. [**Last Name (STitle) 5717**] in [**1-6**] weeks.  You will need flu shot
at this appointment.
- Follow up with [**Last Name (un) **] in [**2-7**] weeks.
- Follow up with renal transplant surgery on [**12-18**] for labs as
scheduled, and then for regular appointments.
- Recommend outpatient sleep study to evaluate for sleep apnea.



Completed by:[**2102-12-11**]
{'Other polyp of sinus,Other pulmonary insufficiency, not elsewhere classified,Kidney replaced by transplant,Other and unspecified coagulation defects,Chronic ethmoidal sinusitis,Personal history of malignant neoplasm of kidney,Unspecified essential hypertension,Unspecified sleep apnea,Other diseases of pharynx, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: 56yo man with history of renal cell cancer s/p nephrectomy and
renal transplant, asthma, hypertension who presents with
shortness of breath s/p nasal polypectomy.  During the
procedure, patient receieved 800cc fluid, with estimated blood
loss 200cc.  In the PACU the patient was slow to recover from
anesthesia with saturations were 85-88% on 6L, heart rate 70s,
SBP 160-180 as patient did not take his antihypertensives prior
to surgery.  In PACU, CXR obtained showing diffuse patchy
infiltrate on right and slightly denser infiltrate on left,
concerning for pulmonary edema vs aspiration pneumonia.  Oxygen
saturation improved to 92-93% on NRB after 20mg iv lasix and
nebulizers.

MEDICAL HISTORY: Renal cell ca s/p nephrectomy [**2093**]
s/p cadaveric renal transplant [**8-8**]
diabetes mellitus type 2
asthma- not treated, hospitalized as child
s/p left AV graft
h/o ciguatera poisening from barracuda ingestion
nasal polyps
hypertension
DM type 2
Barrett's esophagus
mild pulmonary hypertension
trivial MR

MEDICATION ON ADMISSION: Norvasc 5mg daily
Metoprolol 100mg [**Hospital1 **]
Cellcelpt 250mg [**Hospital1 **]
prednisone 5mg daily
furosemide 40mg daily
clonidine 0.2mg daily
avandia 4mg daily
lisinopril 5mg daily
ecotrin 81mg daily

ALLERGIES: Vancomycin

PHYSICAL EXAM: T 97.2  HR 71  BP  156/63   RR 30  93%NRB
Gen:  seating in chair, lethargic but arousable, using accessory
muscles, expiratory grunting
HEENT:  PERRL, anicteric, MMM, OP clear, nasal packing B
Neck:  no JVP, supple, no LAD
CV:  RRR, II/VI SEM at LSB
Pulm:  B rales, L>R
Abd:  obese, soft, NT, ND, well healed scar, +BS
Ext:  no edema, 2+DP pulses B
Neuro:  A&Ox3, nonfocal
Skin:  warm, dry, intact

FAMILY HISTORY: mother with renal disease

SOCIAL HISTORY: married, works in nutrition at [**Hospital1 18**]
remote tob hs, no EtOH, no IVDA 

### Response:
{'Other polyp of sinus,Other pulmonary insufficiency, not elsewhere classified,Kidney replaced by transplant,Other and unspecified coagulation defects,Chronic ethmoidal sinusitis,Personal history of malignant neoplasm of kidney,Unspecified essential hypertension,Unspecified sleep apnea,Other diseases of pharynx, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
