CHIEF COMPLAINT: sudden onset dyspnea

PRESENT ILLNESS: Mr. [**Known lastname 5057**] is a 77yo M with HTN, HL, COPD, and newly diagnosed
NSCLC , now s/p his first round of chemotherapy. He was
transferred to the [**Hospital1 18**] ED in the midst of a RBC transfusion
when he developed sudden shortness of breath that was
interpreted as a possible transfusion reaction.
.
He appears to have severe COPD caused by an extensive smoking
history. He has poor exercise tolerance which has only worsened
in the preceding months. Any exertion, including walking down
the street, can cause increased RR and profound SOB. Albuterol
can help stop these episodes. He has been pursed-lip breathing
for years. He recently underwent TTE evaluation of his exercise
intolerance, at which point a relatively large pericardial
effusion with tamponade physiology was seen. He was admitted to
the CCU [**9-2**]- [**9-6**] and underwent pericardiocentesis, which
revealed malignant cells. He recently underwent his first chemo
session with taxol for NSCLC. His oncologist is Dr. [**Last Name (STitle) 349**] at
[**Location (un) 2274**].
.
His fatigue and poor exercise tolerance persisted. He was found
to be anemic to 25 and subsequently was brought to 7 [**Hospital Ward Name 1826**]
for blood transfusion. Midway through the transfusion, he
developed worsening SOB and increased RR. He thinks this episode
was similar to his usual bouts of breathlessness, and he
admittedly was upset with how long the transfusion was taking.
Fearing a transfusion reaction, he was brought to the [**Hospital1 18**] ED
for further evaluation.
.
In the ED, he was found to be tachycardic and tachypneic.
Received 20mg IV lasix and underwent BiPAP trial, which was
poorly tolerated. Of note, he continued to saturate in the
upper90s on 3-4LNC, though remained tachypneic. A bedside echo
was done which showed no pericardial effusion per the ED read.
He was transferred to the MICU for concern of increased WOB. VS
prior to transfer were 97.9 108 150/80 36 99/4L.
.
On arrival to the MICU, his intial VS were 96.5, 107, 153/63, 95
3LNC. He continues to purse-lip breath. He describes frequent
episodes similar to his breathlessness on transfusion, which
often pass after coughing or spitting. He otherwise feels well
aside from fatigue. He notes no recent couging or cold-like
smpyotms, no sore throat, fevers, chills, chest pains or
pressure. He has lower extremity edema but no PND, orthopnea. No
recent F/C. In the midst of our interview, he had the urge to
urinate and abruptly stood to use his urinal- he developed
respiratory distress with saturations dipping to the 80s and
tachypnea to 50. This episode resolved with supplemental 02. He
felt it was similar to the events surrounding his infusion.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: - Non-small cell lung cancer
- squamous cell carcinoma, s/p MOHS
- colonic polyps, last colonoscopy 1 year ago
- COPD
- gastritis
- h/o gout
- h/o nephrolithiasis
- hypertension
- Hyperlipidemia

MEDICATION ON ADMISSION: 1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)

ALLERGIES: Beta-Blockers (Beta-Adrenergic Blocking Agts)

PHYSICAL EXAM: Admission Exam:
Vitals: 96.5, 107, 153/63, 95 3LNC
General: Alert, oriented, pursed-lip breathing in the 30s
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse wheezing heard throughout anterior and posterior
lung fields. Fair air movement. No crackles or rhonchi.
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Abdominal
musculature used in exhalation.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death
- Mother: chronic leukemia, died at age 89
- Father: h/o MI, pancreatic cancer, died at age 69

SOCIAL HISTORY: Lives with his wife in [**Location (un) **]. Retired hardware store
owner. Has two boys, both live in [**State **], and one
grandson.
- Tobacco history: 97.5 pack-year history, still smokes 1.5 ppd
Subendocardial infarction, initial episode of care,Acute respiratory failure,Acute systolic heart failure,Bacterial pneumonia, unspecified,Malignant neoplasm of other parts of bronchus or lung,Obstructive chronic bronchitis with (acute) exacerbation,Malignant pleural effusion,Unspecified essential hypertension,Dysthymic disorder,Coronary atherosclerosis of native coronary artery,Antineoplastic chemotherapy induced anemia,Raynaud's syndrome,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Gout, unspecified,Personal history of colonic polyps,Personal history of other malignant neoplasm of skin,Long-term (current) use of other medications
Subendo infarct, initial,Acute respiratry failure,Ac systolic hrt failure,Bacterial pneumonia NOS,Mal neo bronch/lung NEC,Obs chr bronc w(ac) exac,Malignant pleural effusn,Hypertension NOS,Dysthymic disorder,Crnry athrscl natve vssl,Anemia d/t antineo chemo,Raynaud's syndrome,Adv eff antineoplastic,Hyperlipidemia NEC/NOS,Gout NOS,Prsnl hst colonic polyps,Hx-skin malignancy NEC,Long-term use meds NEC
Admission Date:  [**2132-10-7**]              Discharge Date:   [**2132-10-14**]

Date of Birth:  [**2054-12-31**]             Sex:   M

Service: MEDICINE

Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)

Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
sudden onset dyspnea

Major Surgical or Invasive Procedure:
Intubation x2 days;

History of Present Illness:
Mr. [**Known lastname 5057**] is a 77yo M with HTN, HL, COPD, and newly diagnosed
NSCLC , now s/p his first round of chemotherapy. He was
transferred to the [**Hospital1 18**] ED in the midst of a RBC transfusion
when he developed sudden shortness of breath that was
interpreted as a possible transfusion reaction.
.
He appears to have severe COPD caused by an extensive smoking
history. He has poor exercise tolerance which has only worsened
in the preceding months. Any exertion, including walking down
the street, can cause increased RR and profound SOB. Albuterol
can help stop these episodes. He has been pursed-lip breathing
for years. He recently underwent TTE evaluation of his exercise
intolerance, at which point a relatively large pericardial
effusion with tamponade physiology was seen. He was admitted to
the CCU [**9-2**]- [**9-6**] and underwent pericardiocentesis, which
revealed malignant cells. He recently underwent his first chemo
session with taxol for NSCLC. His oncologist is Dr. [**Last Name (STitle) 349**] at
[**Location (un) 2274**].
.
His fatigue and poor exercise tolerance persisted. He was found
to be anemic to 25 and subsequently was brought to 7 [**Hospital Ward Name 1826**]
for blood transfusion. Midway through the transfusion, he
developed worsening SOB and increased RR. He thinks this episode
was similar to his usual bouts of breathlessness, and he
admittedly was upset with how long the transfusion was taking.
Fearing a transfusion reaction, he was brought to the [**Hospital1 18**] ED
for further evaluation.
.
In the ED, he was found to be tachycardic and tachypneic.
Received 20mg IV lasix and underwent BiPAP trial, which was
poorly tolerated. Of note, he continued to saturate in the
upper90s on 3-4LNC, though remained tachypneic. A bedside echo
was done which showed no pericardial effusion per the ED read.
He was transferred to the MICU for concern of increased WOB. VS
prior to transfer were 97.9 108 150/80 36 99/4L.
.
On arrival to the MICU, his intial VS were 96.5, 107, 153/63, 95
3LNC. He continues to purse-lip breath. He describes frequent
episodes similar to his breathlessness on transfusion, which
often pass after coughing or spitting. He otherwise feels well
aside from fatigue. He notes no recent couging or cold-like
smpyotms, no sore throat, fevers, chills, chest pains or
pressure. He has lower extremity edema but no PND, orthopnea. No
recent F/C. In the midst of our interview, he had the urge to
urinate and abruptly stood to use his urinal- he developed
respiratory distress with saturations dipping to the 80s and
tachypnea to 50. This episode resolved with supplemental 02. He
felt it was similar to the events surrounding his infusion.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
- Non-small cell lung cancer
- squamous cell carcinoma, s/p MOHS
- colonic polyps, last colonoscopy 1 year ago
- COPD
- gastritis
- h/o gout
- h/o nephrolithiasis
- hypertension
- Hyperlipidemia


Social History:
Lives with his wife in [**Location (un) **]. Retired hardware store
owner. Has two boys, both live in [**State **], and one
grandson.
- Tobacco history: 97.5 pack-year history, still smokes 1.5 ppd

- ETOH: 1 glass of wine/night
- Illicit drugs: denies


Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death
- Mother: chronic leukemia, died at age 89
- Father: h/o MI, pancreatic cancer, died at age 69


Physical Exam:
Admission Exam:
Vitals: 96.5, 107, 153/63, 95 3LNC
General: Alert, oriented, pursed-lip breathing in the 30s
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse wheezing heard throughout anterior and posterior
lung fields. Fair air movement. No crackles or rhonchi.
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Abdominal
musculature used in exhalation.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

At the time of his discharge, the patient's vital signs were
stable and he had O2 sats of 96% on 2L NC.  While he continued
to have wheezes with fair air movement on lung exam, there were
no basilar crackles.  THere was no edema or elevation of the
JVP. The Foley had been removed.

Pertinent Results:
Admission Labs:
[**2132-10-7**] 08:23PM URINE  HOURS-RANDOM UREA N-679 CREAT-97
SODIUM-71 POTASSIUM-81 CHLORIDE-86
[**2132-10-7**] 08:23PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2132-10-7**] 08:23PM URINE  BLOOD-SM  NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2132-10-7**] 08:23PM URINE  RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2132-10-7**] 08:23PM URINE  GRANULAR-2* HYALINE-14*
[**2132-10-7**] 08:23PM URINE  MUCOUS-RARE
[**2132-10-7**] 06:36PM   LACTATE-1.3
[**2132-10-7**] 06:30PM   GLUCOSE-124* UREA N-30* CREAT-1.5* SODIUM-141
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17
[**2132-10-7**] 06:30PM   estGFR-Using this
[**2132-10-7**] 06:30PM   LD(LDH)-395* CK(CPK)-115 TOT BILI-0.8
[**2132-10-7**] 06:30PM   cTropnT-1.00*
[**2132-10-7**] 06:30PM   CK-MB-5 proBNP-[**Numeric Identifier 91421**]*
[**2132-10-7**] 06:30PM   IRON-83
[**2132-10-7**] 06:30PM   WBC-3.2*# RBC-2.79*# HGB-9.1*# HCT-25.2*#
MCV-90# MCH-32.7* MCHC-36.2* RDW-20.8*
[**2132-10-7**] 06:30PM   NEUTS-22* BANDS-2 LYMPHS-47* MONOS-19* EOS-7*
BASOS-1 ATYPS-0 METAS-0 MYELOS-2* NUC RBCS-3*
[**2132-10-7**] 06:30PM   HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-1+ SCHISTOCY-2+
BITE-1+ ACANTHOCY-1+
[**2132-10-7**] 06:30PM   PLT SMR-LOW PLT COUNT-132*
[**2132-10-7**] 06:30PM   PT-17.8* PTT-26.5 INR(PT)-1.6*

Notable Labs:
[**2132-10-9**] 05:15AM BLOOD FDP-40-80*
[**2132-10-7**] 06:30PM BLOOD cTropnT-1.00*
[**2132-10-8**] 04:41AM BLOOD CK-MB-6 cTropnT-0.99*
[**2132-10-8**] 05:24PM BLOOD CK-MB-5 cTropnT-0.65*
[**2132-10-7**] 06:30PM BLOOD calTIBC-257* Hapto-<5* Ferritn-590*
TRF-198*
[**2132-10-7**] 06:36PM BLOOD Lactate-1.3

EKG [**2132-10-7**]:
Sinus tachycardia. Left axis deviation. Right bundle-branch
block. Probable small R waves in leads II, III and aVF but
consider prior inferior myocardial infarction. ST-T wave
abnormalities. Low precordial voltage. Compared to the previous
tracing of [**2132-9-3**] the rate is faster. ST-T wave abnormalities
are more prominent. Precordial voltage is less prominent.
Clinical correlation is suggested

CXR [**2132-10-7**]:
1. Moderate enlargement of the cardiac silhouette, similar
compared to the
prior PET-CT.
2. Dilated and tortuous ascending thoracic aorta.
3. Patchy opacities within the lung bases, which could reflect
atelectasis, infection, or aspiration.
4. Known spiculated nodule in the right upper lobe is better
appreciated on the recent PET CT.

TTE [**2132-10-8**]:
The left atrium is elongated. The right atrium is markedly
dilated. The estimated right atrial pressure is 5-10 mmHg. The
estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses and cavity size are normal. There
is mild global left ventricular hypokinesis (LVEF = 40-45 %).
Right ventricular chamber size is normal. with borderline normal
free wall function. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
([**1-13**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**1-13**]+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a very small
pericardial effusion.
IMPRESSION: Mild global left and right ventricular hypokinesis.
Mild to moderate mitral regurgitation. Mild to moderate aortic
regurgitation. Very small pericardial effusion. Moderate
pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2132-9-6**],
biventricular function is now impaired. Valvular regurgitation
is now apparent (previous study was focused). Pulmonary
hypertension is identified.
.
Labs on Discharge:

[**2132-10-14**] 09:45AM BLOOD WBC-7.0 RBC-3.15* Hgb-9.8* Hct-31.2*
MCV-99* MCH-31.2 MCHC-31.6 RDW-20.8* Plt Ct-135*
[**2132-10-14**] 09:45AM BLOOD Plt Ct-135*
[**2132-10-14**] 09:45AM BLOOD Glucose-131* UreaN-45* Creat-1.3* Na-143
K-3.7 Cl-99 HCO3-34* AnGap-14
[**2132-10-14**] 09:45AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8

Brief Hospital Course:
Mr. [**Known lastname 5057**] is a 77yoM with COPD, HTN, HLD, and a recent
hospitalization for cardiac tamponade who presents from [**Hospital Ward Name **]
7 transfusion unit with acute SOB during transfusion.

1. ACUTE HYPOXIC RESPIRATORY FAILURE:
--PNEUMONIA and ACUTE SYSTOLIC CHF: He developed acute shortness
of breath early into his blood transfusion which he was
receiving for anemia.  Transfusion reaction/TRALI was initially
suspected though he lacked severe pulmonary edema or hypoxia to
support this diagnosis.  He was admitted to the MICU due to
apparent increased WOB, and was briefly tried on BiPAP in the ED
despite normal saturations. Tamponade was ruled out with US in
ED. He initially was stable on room air with saturations in the
90s upon admission to the ICU.  He related numerous similar
episodes of shortness of breath at home and related a
progressive worsening of his overall respiratory status and
exercise stamina over the preceding months.  His CXR showed mild
edema and RLL haziness. Widespread wheezing prompted treatment
for COPD exacerbation.  He decompensated quickly in the unit
after getting agitated during a foley adjustment.  He
desaturated to the 70s-80s and had an increased WOB refractory
to nebs, lasix, and NRB.  He was urgently intubated.  The cause
of his decompensation was felt to be multifactorial.  He had a
trop of 1.00 on admission with flat CK/MB, but new
LAD-distributed TWI on EKG, and new onset systolic dysfunction
with EF to 40-45% on TTE (new since last month).  A cardiac
event could have potentially caused his deterioration and CHF
exacerbation.  Pneumonia was possible based on his RLL
infiltrate, and he was treated for HCAP with
vanco/cefepime/levaquin.  Sputum culture revealed commensal resp
flora and sparse GNR.  He was started on nebs and steroids for
possible COPD exacerbation as well,though these were quickly
tapered due to suspicion for more of a CHF etiology.  He was
aggressively diuresed.  He was extubated on [**2132-10-9**] and
transfered to the floor on [**2132-10-10**].
.
On the floor he was initially saturating in the 90's on 4L NC.
He continued to be diuresed gently with PO and occasional IV
lasix. His oxygen was weaned as tolerated with a goal of 02 sat
of 92%. His steroids were discontinued on [**2132-10-13**] as the
etiology of his SOB was thought to be related to pulmonary edema
and a possible pneumonia rather than a COPD exacerbation.  His
vancomycin was discontinued based on sputum data and cefepime
and levaquin were continued until further speciation was
available. His nebulizers were continued throughout his hospital
stay. On the day prior to discharge, cefipime was discontinued
as the patient had remained afebrile and without leukocytosis;
prednisone was also discontinued since COPD flare appears to not
have been the primary etiology of SOB and his symptoms were
resolving. PT was consulted and worked with the patient on
improving functional status.  He was discharged home with home
PT services, home 02, and cardiac telemonitoring.
.
2)NSTEMI: His troponin elevation to 1.00 is without any similar
MB or CK elevation. He had some nonspecific lateral T wave
changes, but no chst pain or pressure to suggest ACS. TTE
revealed new onset systolic dysfunction with EF 45-50%.
Cardiology was consulted, who felt that the chemotherapy
(taxol/cisplatin) is not likely to blame and that he had a
recent MI.  Based on EKG and echo data, there was a possible
partial occlusion in the LAD and that the patient may benefit
from elective cathetrization. However, based on the absence of
symptoms and the comorbidities in the patient, oncology,
medicine and the patient's family were in agreement with medical
management.  On [**2132-10-12**] the patient had an 8 beat run of
v-tach. An EKG was essentially unchanged and troponins showed a
continued downward trend.
.
3. ANEMIA: HCT to 25 of unclear source, though inflammatory
disease from malignancy  or myelosupression from chemo are both
possible. Though his hematrocrit trended downwards in the days
prior to discharge, a transfusion was not thought to be
necessary by cardiology (goal 25).
.
4. NON SMALL CELL LUNG CANCER: currently undergoing taxol chemo;
will resume as outpatient. Atrius oncology service followed
while the patient was in house.

5. HYPERTENSION: The patient had recently been taken off his
dose of 20 mg linisnopril QAM due to low blood pressures. Based
on his new diagnosis of CHF, lisinopril was restarted at a dose
of 10 mg QAM; his blood pressures remained stable with systolics
greater than 110 while in house.
.
6. GOUT: Allopurinol and colchicine were continued, this was not
an active issue on this admission.


Medications on Admission:
1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)

Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation q4-6 hours as needed for SOB, wheezing.
4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.

6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable

PO DAILY (Daily).


Discharge Medications:
1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).

2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. beclomethasone dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) Spray Inhalation twice a day.
4. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Capsule Inhalation once a day.
Disp:*30 capsules* Refills:*2*
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-13**] puff Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
8. lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Home Oxygen
1-4 liters per minute continuous oxygen via nasal cannula [**Male First Name (un) **]:
99 months
Diagnosis: COPD
11. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
12. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every
other day for 1 doses.
Disp:*1 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Congestive Heart Failure, Possible Pneumonia, COPD, Non-Small
Cell Lung Cancer, Anemia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(walker).


Discharge Instructions:
Dear Mr. [**Known lastname 5057**],

It was a pleasure participating in your care at [**Hospital1 18**].  You were
admitted to the medical ICU after presenting to the emergency
department for acute onset shortness of breath during a blood
transfusion.  A reaction to the blood transfusion itself was
ruled out. A chest xray showed possible signs of a pneumomia and
you were started on broad spectrum antibiotics.  It is possible
that yoru COPD was contributing to your shortness of breath and
you were also given a steroid as well as your usual inhalers.
In the MICU you had a second acute episode of shortness of
breath that was not responsive to oxygen. Because of your
worsening respiratory status you were intubated (given a
breathing tube).  Laboratory results and an EKG suggested that
you may have had a heart attack prior to the hospitalization.
An echo cardiogram showed that you had a new onset of congestive
heart failure (CHF).  It is likely that your shortness of breath
was due to too much volume backing up in your lungs. You were
given lasix to help reduce the volume in your lungs and your
respiratory status improved to the point that you were extubated
(breathing tube was removed) two days after you were intubated.
Cardiology was consulted to help with your care and suggested
the possibility of a cardiac cathetrization to look at the
vessels of your heart.  However, along with your oncolgy team,
it was determined to be best to try to manage your heart disease
with medical management.
Due to your continued improvement you were transferred to the
general medical floor where we continued to monitor your
respiratory status and give you lasix to manage your fluid
balance. Your steroids were stopped on the medical floor and the
medicines for your pneumonia were narrowed to treat the most
likely organism. Your regular inhalers were continued.
We followed your blood counts throughout your stay and it was
not deemed necessary to transfuse additional blood at this time.

You will return home with home nursing, oxygen, and physical
therapy services. You should keep your oxygen saturation bewteen
88-92% and should use 3L of oxygen when active.  You will also
have cardiac telemonitoring to assist with monitoring your daily
weights and blood pressures. The results of this will
automitically be sent to Dr.[**Name (NI) 17793**] office.
You should resume the medicines you were previously taking at
home with the following changes:

START: lisinopril 10 mg QD (daily)

START: lasix 20 mg PO (by mouth) QD

START: atorvastatin 80 PO QD

START: Spiriva 1 puff [**Hospital1 **] (twice daily)

CONTINUE: Levofloxacin 750 mg x1 dose ([**10-16**])

Followup Instructions:
Please follow up with the appointments below after your
discharge from the hospital:

Name: [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) **], NP
Specialty: Internal Medicine
When: Tuesday [**10-21**] at 9:30am
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 23943**]
Phone: [**Telephone/Fax (1) 17530**]
Dr. [**Last Name (STitle) **] is out of the office next week so you will see
his nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) **] at this visit.

Name: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**], MD
Specialty: Hematology/Oncology
When: Thursday [**10-23**] at 1:30p
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3468**]

Name: [**Doctor First Name 30513**] [**Doctor First Name 88276**], PA
Specialty: Cardiology
When: Wednesday [**10-29**] at 11:30am
Location: [**Hospital1 641**]
Address: [**Hospital1 **], [**University/College **], [**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 72622**]
You will see Dr. [**Last Name (STitle) 91422**] physicians assistant [**First Name5 (NamePattern1) 30513**] [**Last Name (NamePattern1) 88276**] at
this visit.



Completed by:[**2132-10-15**]
{"Subendocardial infarction, initial episode of care,Acute respiratory failure,Acute systolic heart failure,Bacterial pneumonia, unspecified,Malignant neoplasm of other parts of bronchus or lung,Obstructive chronic bronchitis with (acute) exacerbation,Malignant pleural effusion,Unspecified essential hypertension,Dysthymic disorder,Coronary atherosclerosis of native coronary artery,Antineoplastic chemotherapy induced anemia,Raynaud's syndrome,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Gout, unspecified,Personal history of colonic polyps,Personal history of other malignant neoplasm of skin,Long-term (current) use of other medications"}


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: sudden onset dyspnea

PRESENT ILLNESS: Mr. [**Known lastname 5057**] is a 77yo M with HTN, HL, COPD, and newly diagnosed
NSCLC , now s/p his first round of chemotherapy. He was
transferred to the [**Hospital1 18**] ED in the midst of a RBC transfusion
when he developed sudden shortness of breath that was
interpreted as a possible transfusion reaction.
.
He appears to have severe COPD caused by an extensive smoking
history. He has poor exercise tolerance which has only worsened
in the preceding months. Any exertion, including walking down
the street, can cause increased RR and profound SOB. Albuterol
can help stop these episodes. He has been pursed-lip breathing
for years. He recently underwent TTE evaluation of his exercise
intolerance, at which point a relatively large pericardial
effusion with tamponade physiology was seen. He was admitted to
the CCU [**9-2**]- [**9-6**] and underwent pericardiocentesis, which
revealed malignant cells. He recently underwent his first chemo
session with taxol for NSCLC. His oncologist is Dr. [**Last Name (STitle) 349**] at
[**Location (un) 2274**].
.
His fatigue and poor exercise tolerance persisted. He was found
to be anemic to 25 and subsequently was brought to 7 [**Hospital Ward Name 1826**]
for blood transfusion. Midway through the transfusion, he
developed worsening SOB and increased RR. He thinks this episode
was similar to his usual bouts of breathlessness, and he
admittedly was upset with how long the transfusion was taking.
Fearing a transfusion reaction, he was brought to the [**Hospital1 18**] ED
for further evaluation.
.
In the ED, he was found to be tachycardic and tachypneic.
Received 20mg IV lasix and underwent BiPAP trial, which was
poorly tolerated. Of note, he continued to saturate in the
upper90s on 3-4LNC, though remained tachypneic. A bedside echo
was done which showed no pericardial effusion per the ED read.
He was transferred to the MICU for concern of increased WOB. VS
prior to transfer were 97.9 108 150/80 36 99/4L.
.
On arrival to the MICU, his intial VS were 96.5, 107, 153/63, 95
3LNC. He continues to purse-lip breath. He describes frequent
episodes similar to his breathlessness on transfusion, which
often pass after coughing or spitting. He otherwise feels well
aside from fatigue. He notes no recent couging or cold-like
smpyotms, no sore throat, fevers, chills, chest pains or
pressure. He has lower extremity edema but no PND, orthopnea. No
recent F/C. In the midst of our interview, he had the urge to
urinate and abruptly stood to use his urinal- he developed
respiratory distress with saturations dipping to the 80s and
tachypnea to 50. This episode resolved with supplemental 02. He
felt it was similar to the events surrounding his infusion.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: - Non-small cell lung cancer
- squamous cell carcinoma, s/p MOHS
- colonic polyps, last colonoscopy 1 year ago
- COPD
- gastritis
- h/o gout
- h/o nephrolithiasis
- hypertension
- Hyperlipidemia

MEDICATION ON ADMISSION: 1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)

ALLERGIES: Beta-Blockers (Beta-Adrenergic Blocking Agts)

PHYSICAL EXAM: Admission Exam:
Vitals: 96.5, 107, 153/63, 95 3LNC
General: Alert, oriented, pursed-lip breathing in the 30s
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse wheezing heard throughout anterior and posterior
lung fields. Fair air movement. No crackles or rhonchi.
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Abdominal
musculature used in exhalation.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death
- Mother: chronic leukemia, died at age 89
- Father: h/o MI, pancreatic cancer, died at age 69

SOCIAL HISTORY: Lives with his wife in [**Location (un) **]. Retired hardware store
owner. Has two boys, both live in [**State **], and one
grandson.
- Tobacco history: 97.5 pack-year history, still smokes 1.5 ppd 

### Response:
{"Subendocardial infarction, initial episode of care,Acute respiratory failure,Acute systolic heart failure,Bacterial pneumonia, unspecified,Malignant neoplasm of other parts of bronchus or lung,Obstructive chronic bronchitis with (acute) exacerbation,Malignant pleural effusion,Unspecified essential hypertension,Dysthymic disorder,Coronary atherosclerosis of native coronary artery,Antineoplastic chemotherapy induced anemia,Raynaud's syndrome,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Gout, unspecified,Personal history of colonic polyps,Personal history of other malignant neoplasm of skin,Long-term (current) use of other medications"}
