CHIEF COMPLAINT: chills, hypoxic episode, fever

PRESENT ILLNESS: 57 yo M with h/o metastatic prostate cancer presents after
episode of chills and acute SOB. Patient was dx with prostate
cancer 5 yrs ago on routine screening. He had recurrence about 1
year ago, now with known liver and bone met's. Of note, he
started an estrogen based chemotherapy (Estramustine) on Wed. of
last week with concurrent coumadin for possible hypercoagulable
state.
.
Patient had been at baseline prior to 1 day PTA when he
describes first feeling very cold and then developing severe SOB
after walking to bathroom. He attempted to get into bed, but
legs gave out and he fell onto floor. No LOC. Denies chest pain,
fever, leg pain, N/V/D. + leg swelling few weeks ago, but none
recently.  Denies any cough or hemoptysis. He has had nosebleeds
with clots when he blows his nose. Also had hemorrhoidal
bleeding 1 month ago and was admitted for endoscopy.
.
Called EMS and was noted to be hypoxic to 80s on RA, tachy to
150s initially. EMS gave him 40mg IV lasix en route for ? flash
pulmonary edema as he was on lasix at home.
.
In the ED, initial VS:97, 153, 112/68, 100% NRB. Shortly
thereafter spiked to 104 . Noted to have a lactate to 4.2.
Initial CXR was unimpressive, CTA was a suboptimal study but no
large central PE. Recieved levofloxacin/zosyn, 1.5L NS, Zofran
x1 and one unit of platelets. Noted to have guaiac positive red
stool in ED and one episode of hemoptysis. Groin central line
was placed. Given obstructive pattern on LFTs, got non-con CT
abd with no obvious obstruction, only a multinodular liver.
.
Transferred to ICU, transfused 2 units PRBC given low hct, HCT
went up 2 points only and has remained stable.
On interview in the MICU, patient endorses sharp R subcostal
pain this AM, but states that it occurs when he misses his
neurontin and it has not recurred since. He currently denies any
SOB or CP, is comfortable on room air.

MEDICAL HISTORY: Hypertension
gout
right shoulder fracture,
history of chlamydia and gonorrhea
prostate CA with mets to bone, liver and spine, status post
prostatectomy with Lupron injection
umbilical hernia
status post arthroscopy of the knee.
hemorrhoidectomy, with hx of anal fissures
Recent lower GIB with negative [**Last Name (un) **] and EGD
Depression/Anxiety

MEDICATION ON ADMISSION: Celebrex 200mg [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Coumadin 3mg PO daily
Clonazepam 0.5mg PO BID
Dexamethasone 1mg TID
Estramustine 140mg TID
Fentanyl patch 75mcg/hr q72, last changed [**10-31**]
Hydromorphone 4mg PO BID PRN
Lasix 20mg PO as needed daily
Neurontin 400mg PO TID
Omeprazole 20mg PO BID
Senna 2 Tabs [**Hospital1 **]
Wellbutrin 100mg TID
Lupron 22.5 q3mon, last [**2135-7-13**]
Taxotere 20mg, last infustion [**2135-10-19**]
Zometa 4mg, last shot [**2135-9-27**]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GEN: obese, NAD
HEENT: MMM, JVP not visible due to body habitus
CV: tachy, no m/r/g
PULM: CTAB
AB: positive BS, NT/ND, no HSM
EXT: 1+ non-pitting pedal edema to shins
NEURO: CN II-XII intact (q/o L facial droop but resolves with
smiling), strength 5/5 throughout, sensation intact, reflexes 1+
throughout.

FAMILY HISTORY: sister with [**Name2 (NI) 499**] CA

SOCIAL HISTORY: lives with wife, has children and step-children. Had twice
weekly VNA. No tobacco or EtOH.
Pneumonia, organism unspecified,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of liver, secondary,Other and unspecified coagulation defects,Alkalosis,Bacteremia,Acute posthemorrhagic anemia,Unspecified pleural effusion,Pulmonary collapse,Hypoxemia,Personal history of venous thrombosis and embolism,Cirrhosis of liver without mention of alcohol,Personal history of malignant neoplasm of prostate,Unspecified essential hypertension,Gout, unspecified,Dysthymic disorder,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other specified antibiotics causing adverse effects in therapeutic use,Epistaxis,Thrombocytopenia, unspecified,Edema,Other specified cardiac dysrhythmias,Hypotension, unspecified,Gross hematuria,Retention of urine, unspecified,Neoplasm related pain (acute) (chronic),Unspecified hemorrhoids with other complication
Pneumonia, organism NOS,Secondary malig neo bone,Second malig neo liver,Coagulat defect NEC/NOS,Alkalosis,Bacteremia,Ac posthemorrhag anemia,Pleural effusion NOS,Pulmonary collapse,Hypoxemia,Hx-ven thrombosis/embols,Cirrhosis of liver NOS,Hx-prostatic malignancy,Hypertension NOS,Gout NOS,Dysthymic disorder,Mth sus Stph aur els/NOS,Adv eff antibiotics NEC,Epistaxis,Thrombocytopenia NOS,Edema,Cardiac dysrhythmias NEC,Hypotension NOS,Gross hematuria,Retention urine NOS,Neoplasm related pain,Hemrrhoid NOS w comp NEC
Admission Date:  [**2135-10-31**]              Discharge Date:   [**2135-11-7**]

Date of Birth:  [**2078-5-13**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
chills, hypoxic episode, fever

Major Surgical or Invasive Procedure:
none

History of Present Illness:
57 yo M with h/o metastatic prostate cancer presents after
episode of chills and acute SOB. Patient was dx with prostate
cancer 5 yrs ago on routine screening. He had recurrence about 1
year ago, now with known liver and bone met's. Of note, he
started an estrogen based chemotherapy (Estramustine) on Wed. of
last week with concurrent coumadin for possible hypercoagulable
state.
.
Patient had been at baseline prior to 1 day PTA when he
describes first feeling very cold and then developing severe SOB
after walking to bathroom. He attempted to get into bed, but
legs gave out and he fell onto floor. No LOC. Denies chest pain,
fever, leg pain, N/V/D. + leg swelling few weeks ago, but none
recently.  Denies any cough or hemoptysis. He has had nosebleeds
with clots when he blows his nose. Also had hemorrhoidal
bleeding 1 month ago and was admitted for endoscopy.
.
Called EMS and was noted to be hypoxic to 80s on RA, tachy to
150s initially. EMS gave him 40mg IV lasix en route for ? flash
pulmonary edema as he was on lasix at home.
.
In the ED, initial VS:97, 153, 112/68, 100% NRB. Shortly
thereafter spiked to 104 . Noted to have a lactate to 4.2.
Initial CXR was unimpressive, CTA was a suboptimal study but no
large central PE. Recieved levofloxacin/zosyn, 1.5L NS, Zofran
x1 and one unit of platelets. Noted to have guaiac positive red
stool in ED and one episode of hemoptysis. Groin central line
was placed. Given obstructive pattern on LFTs, got non-con CT
abd with no obvious obstruction, only a multinodular liver.
.
Transferred to ICU, transfused 2 units PRBC given low hct, HCT
went up 2 points only and has remained stable.
On interview in the MICU, patient endorses sharp R subcostal
pain this AM, but states that it occurs when he misses his
neurontin and it has not recurred since. He currently denies any
SOB or CP, is comfortable on room air.

Past Medical History:
Hypertension
gout
right shoulder fracture,
history of chlamydia and gonorrhea
prostate CA with mets to bone, liver and spine, status post
prostatectomy with Lupron injection
umbilical hernia
status post arthroscopy of the knee.
hemorrhoidectomy, with hx of anal fissures
Recent lower GIB with negative [**Last Name (un) **] and EGD
Depression/Anxiety

Social History:
lives with wife, has children and step-children. Had twice
weekly VNA. No tobacco or EtOH.

Family History:
sister with [**Name2 (NI) 499**] CA

Physical Exam:
GEN: obese, NAD
HEENT: MMM, JVP not visible due to body habitus
CV: tachy, no m/r/g
PULM: CTAB
AB: positive BS, NT/ND, no HSM
EXT: 1+ non-pitting pedal edema to shins
NEURO: CN II-XII intact (q/o L facial droop but resolves with
smiling), strength 5/5 throughout, sensation intact, reflexes 1+
throughout.

Pertinent Results:
CBC:
     8.5
7.6 >---< 31
    25.9
NEUTS-71* BANDS-9* LYMPHS-7* MONOS-4 EOS-0 BASOS-0 ATYPS-2*
METAS-3* MYELOS-3* PROMYELO-1* NUC RBCS-23*
HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-NORMAL
MICROCYT-1+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL
OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
.
CHEM:
138 | 106 | 21  / 141
4.6 | 16  | 0.8 \
ALBUMIN-2.8* CALCIUM-9.1 PHOSPHATE-2.7 MAGNESIUM-2.0
.
COAGS:
PT-21.4* PTT-30.3 INR(PT)-2.0*
.
LFTS:
ALT(SGPT)-74* AST(SGOT)-261* LD(LDH)-4440* CK(CPK)-447* ALK
PHOS-1129* TOT BILI-5.1*
LIPASE-64*
.
TOX SCREEN:
SERUM: ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
URINE: bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
.
CE:
[**2135-10-31**] 09:20PM   cTropnT-0.03*, CK-MB-3
.
fibrinogen 873
retic count 2.0
ferritin >[**2125**]
haptoglobin 169
TRF 148
TIBC 192
.
PSA 223.8
.
ABG:
TYPE-ART TEMP-37.6 RATES-/21 O2-15 PO2-234* PCO2-25* PH-7.46*
TOTAL CO2-18* BASE XS--3 INTUBATED-NOT INTUBA COMMENTS-GREEN TOP
.
UA
URINE  BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2
.
MICRO:
URINE CX- NEG
.
BLOOD CX:
[**10-31**]: 1 bottle growing MSSA
repeat daily blood cx neg
.
urine Legionella neg
influenza swab neg
.
ECG: Probable sinus tachycardia. ST-T wave changes are
non-specific.
.
IMAGING:
Portable CXR: 1. Low lung volumes which accentuate the
bronchovascular markings.
2. Widened mediastinum, which could in part be due to low lung
volumes and AP technique. However, if clinical concern for acute
aortic syndrome, recommend chest CTA for further evaluation.
3. Hilar prominence may be due to vascular engorgement.
4. Subtle opacities in both lung fields may be due to edema,
infection and/or metastases.
5. Bilateral, right greater than left pleural thickening versus
less likely effusions.

Chest CTA [**2135-10-31**]:
1. Suboptimal evaluation for pulmonary embolus, as above,
although no large, central embolus identified.
2. Extensive osseous metastatic disease due to prostate cancer.
3. Central interstitial thickening in upper lobes may be due to
pulmonary
edema, but given fever, also consider infectious source. Due to
history of
malignancy, malignant component is also possible. Recommend
follow-up to
resolution.
.
CTA chest [**2135-11-2**]
1. No evidence of central pulmonary embolism or aortic
dissection, but
limited study due to timing of contrast and motion.
2. New peripancreatic fat stranding. Clinical correlation for
acute
pancreatitis is recommended.
3. Pulmonary edema vs atypical pneumonia, slightly improved.
Multiple
pulmonary nodular opacities are incompletely evaluated on the
background of ground-glass opacity and a followup chest CT after
the acute pulmonary process resolves is recommended on an
outpatient.
4. 1.6-cm mediastinal lymph node, which may also be reassessed
at the time
of follow up CT.
5. Stable extensive osseous metastasis.
.
ECHO
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF 60-70%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
CT AB/PELV
1. No evidence of colitis or acute abdominal process.
2. Cirrhosis.
3. Left base small effusion/atelectasis. Upper lobe interstitial
changes; see chest CT.
4. Extensive osseous prostate metastases; e.g. vertebral body
destruction.
.
RUQ U/S:
Innumerable echogenic masses throughout the liver without
biliary
ductal dilatation. This is an unusual pattern for metastatic
prostate cancer, and if appropriate, biopsy can be considered.
.
LENIS
No deep venous thrombosis identified in the lower extremities
bilaterally. Of note, the right common femoral vein was not
interrogated due to overlying dressing.
.
HEAD CT
1. No evidence of hemorrhage, edema or mass effect.
2. No acute fractures are identified.
3. Soft tissue swelling is noted over the left parieto-occipital
region.
.
.
.
DISCHARGE LABS:
LFTS:
.
COAGS:
.
vancomycin trough [**11-6**]: 18.5

Brief Hospital Course:
57 yo M with metastatic prostate cancer (bone, liver mets)
presents with episode of hypoxia and tachycardia, fever after
starting estrogen-based therapy.
.
#. HYPOXIA/TACHYCARDIA/FEVER: Patient's initial presentation
with acute dyspnea, hypoxia and tachycardia concerning for PE,
especially in setting of pro-coagulable state on
estrogen-chemotherapy. Patient had been started on coumadin [**2-20**]
days prior, and also INR was 2/0 on presentation, it may have
been subtherapeutic when his decompensation began. Patient
underwent CTA which was non-diagnostic due to respiration
artifact and poor contrast timing. There was no e/o RV strain on
EKG or TTE. LENIS were negative for DVT. Patient was admitted to
MICU, where he was treated empirically for PE with heparin gtt.
Infection was also on the differential given high fever to 104
after presentation to the ED and CT chest showed upper lobe
infiltrates. Patient was started on broad spectrum antibiotics
(vancomycin, cefepime, levaquin) to cover for healthcare
associated PNA, since his last hospital admission was less than
1 month prior.
He was ruled out for flu. Legionella antigen was negative.
In the MICU, patient improved on this treatment regimen, and he
had stable 02 sat on room air.
.
Patient will need repeat chest CT once infection resolves ([**2-21**]
weeks) to rule out underlying malignancy.
.
Patient was transferred to medical floor after stabilization.
Heme-onc was consulted and recommended repeat CTA to rule out
PE, since this diagnosis would be a contraindication for
estramustine therapy. Patient's primary oncologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 23509**], was also contact[**Name (NI) **] and remained involved in our
treatment plan.
Repeat CTA showed no PE. Heparin gtt was stopped and patient was
restarted on home dose coumadin. However, INR became
supratherapeutic, likely because of interaction with levaquin,
and coumadin was held, vitamin K given. Dr.[**Name (NI) 24775**] plan is
to start patient on therapeutic dose Lovenox when he reinitiates
estramustine (likely after 10 days antibiotics). Patient was
placed on prophylactic dose Lovenox once INR normalized.
.
Patient had one positive blood cx, with MSSA, and all repeat
blood cx were negative. He will therefore be treated with a HAP
course (10 days of vancomycin and cefepime, 5 days of Levaquin)
with 4 additional days of vancomycin for bacteremia (14 days
total). PICC was placed. Patient remained afebrile after
receiving initial abx on HD# 1.
.
#. ANEMIA: Admission Hct 25.9 from prior 28. Had h/o LGIB 1
month ago with neg [**Last Name (un) **]. Guiaic positive in ED and started on IV
PPI. Had intermittent hemorrhoidal bleeding and
epistaxis/hemoptysis [**12-20**] anticoagulation and thrombocytopenia.
No evidence of significant GI bleeding. Received 3 total units
PRBC and Hct remained stable. No e/o hemolysis. Likely [**12-20**]
baseline anemia due to bone marrow replacement by cancer, with
minimal acute bleeding.
.
#. HYPOTENSION: Patient was hypotensive in ED, but stabilized
with antibiotics and fluids. He remained normotensive and
stable, lactate trended down. Patient received stress dose
steroids for since he was on a chronic dexamethasone regimen at
home. After HD#2, his home dose of dexamethason 1 mg TID was
resumed.
.
#. Thrombocytopenia: Most likely etiology is bone marrow
replacement by malignancy in addition to past XRT/chemo. Patient
was transfused platelets for count <50 and minor bleeding.
.
#. PROSTATE CA: Patient has prostate cancer with met's to liver,
bone. Dr. [**Last Name (STitle) 23509**] was contact[**Name (NI) **] and agreed with holding
estramutine during acute illness and infection. Our heme/onc was
also consulted. PSA was 223. Home dexamethasone was continued.
Patient had signs of worsening widespread disease, including
worsening LFTs elevation, tachycardia, and decreased alertness.
.
#. TRANSAMINITIS: LFTs increased likely [**12-20**] met's, although
there were no hepatitis serologies in our system so these were
repeated. Results pending at transfer.
.
#. LOWER EXTREMITY EDEMA: Patient developed LE edema on HD# 2,
likely due to high dose steroids and fluid resusitation. Patient
was continued on home dose Lasix and tapered to home dose
dexamethasone. Patient had no evidence of CHF on TTE, and
patient appeared otherwise euvolemic.
.
#. TACHYCARDIA: Patient remained tachycardic 100-120s despite
adequate hydration and no other signs of uncontrolled infection.
 Tachycardia was attributed to underlying malignancy, since
heart rate seemed to increase with increase in LFT's, indicative
of worsening disease. Telemetry and EKGs showed sinus
tachycardia. He also had one episode atrial tachycardia vs.
AVNRT on [**11-6**], which lasted <3 seconds and was asymptomatic and
did not recur so was not treated.
.
#. Depression/anxiety: Patient became extremely fatigued and
remained largely inactive. His alertness level seemed to
decrease in days prior to discharge. Unclear if this was due to
worsening underlying illness vs. depression. Con't Wellbutrin
and clonazepam
.
*Patient was transferred to [**Hospital6 **] per request of
family, with his primary oncologist Dr. [**Last Name (STitle) 27542**] as the
accepting physician.


Medications on Admission:
Celebrex 200mg [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Coumadin 3mg PO daily
Clonazepam 0.5mg PO BID
Dexamethasone 1mg TID
Estramustine 140mg TID
Fentanyl patch 75mcg/hr q72, last changed [**10-31**]
Hydromorphone 4mg PO BID PRN
Lasix 20mg PO as needed daily
Neurontin 400mg PO TID
Omeprazole 20mg PO BID
Senna 2 Tabs [**Hospital1 **]
Wellbutrin 100mg TID
Lupron 22.5 q3mon, last [**2135-7-13**]
Taxotere 20mg, last infustion [**2135-10-19**]
Zometa 4mg, last shot [**2135-9-27**]

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
4. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
11. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours).
12. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
13. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1)  Subcutaneous
DAILY (Daily).
14. Cefepime 2 gram Recon Soln Sig: Two (2) g Injection Q12H
(every 12 hours) for 2 days: end date [**11-9**].
15. Vancomycin 500 mg Recon Soln Sig: 1250 (1250) g Intravenous
Q 12H (Every 12 Hours) for 6 days: end date [**11-13**].
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Discharge Diagnosis:
primary:
healthcare associated pneumonia
prostate cancer
.
secondary:
thrombocytopenia (low platelets)


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


Discharge Instructions:
It was a pleasure taking care of you. You were admitted for
difficulty breathing and fevers. You were found to have
pneumonia. You underwent tests for blood clots, and you did not
have a blood clot. You were treated with intravenous antibiotics
and a PICC line was placed so you can continue these antibiotics
at rehab.
Your coumadin was stopped at the recommendation of Dr.
[**Last Name (STitle) 23509**], and you will start a different bloodthinner (Lovenox)
when you restart your estramustine chemotherapy.
You received blood and platelet transfusions since you had small
amounts of bleeding.
.
There following changes were made to your medications:
- You should have infusions of vancomycin and cefepime through
the PICC line.
- You should take Lasix every other day until you are evaluated
by a doctor.


Followup Instructions:
Dr. [**Last Name (STitle) 23509**] will see you at [**Hospital1 **].
{'Pneumonia, organism unspecified,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of liver, secondary,Other and unspecified coagulation defects,Alkalosis,Bacteremia,Acute posthemorrhagic anemia,Unspecified pleural effusion,Pulmonary collapse,Hypoxemia,Personal history of venous thrombosis and embolism,Cirrhosis of liver without mention of alcohol,Personal history of malignant neoplasm of prostate,Unspecified essential hypertension,Gout, unspecified,Dysthymic disorder,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other specified antibiotics causing adverse effects in therapeutic use,Epistaxis,Thrombocytopenia, unspecified,Edema,Other specified cardiac dysrhythmias,Hypotension, unspecified,Gross hematuria,Retention of urine, unspecified,Neoplasm related pain (acute) (chronic),Unspecified hemorrhoids with other complication'}


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: chills, hypoxic episode, fever

PRESENT ILLNESS: 57 yo M with h/o metastatic prostate cancer presents after
episode of chills and acute SOB. Patient was dx with prostate
cancer 5 yrs ago on routine screening. He had recurrence about 1
year ago, now with known liver and bone met's. Of note, he
started an estrogen based chemotherapy (Estramustine) on Wed. of
last week with concurrent coumadin for possible hypercoagulable
state.
.
Patient had been at baseline prior to 1 day PTA when he
describes first feeling very cold and then developing severe SOB
after walking to bathroom. He attempted to get into bed, but
legs gave out and he fell onto floor. No LOC. Denies chest pain,
fever, leg pain, N/V/D. + leg swelling few weeks ago, but none
recently.  Denies any cough or hemoptysis. He has had nosebleeds
with clots when he blows his nose. Also had hemorrhoidal
bleeding 1 month ago and was admitted for endoscopy.
.
Called EMS and was noted to be hypoxic to 80s on RA, tachy to
150s initially. EMS gave him 40mg IV lasix en route for ? flash
pulmonary edema as he was on lasix at home.
.
In the ED, initial VS:97, 153, 112/68, 100% NRB. Shortly
thereafter spiked to 104 . Noted to have a lactate to 4.2.
Initial CXR was unimpressive, CTA was a suboptimal study but no
large central PE. Recieved levofloxacin/zosyn, 1.5L NS, Zofran
x1 and one unit of platelets. Noted to have guaiac positive red
stool in ED and one episode of hemoptysis. Groin central line
was placed. Given obstructive pattern on LFTs, got non-con CT
abd with no obvious obstruction, only a multinodular liver.
.
Transferred to ICU, transfused 2 units PRBC given low hct, HCT
went up 2 points only and has remained stable.
On interview in the MICU, patient endorses sharp R subcostal
pain this AM, but states that it occurs when he misses his
neurontin and it has not recurred since. He currently denies any
SOB or CP, is comfortable on room air.

MEDICAL HISTORY: Hypertension
gout
right shoulder fracture,
history of chlamydia and gonorrhea
prostate CA with mets to bone, liver and spine, status post
prostatectomy with Lupron injection
umbilical hernia
status post arthroscopy of the knee.
hemorrhoidectomy, with hx of anal fissures
Recent lower GIB with negative [**Last Name (un) **] and EGD
Depression/Anxiety

MEDICATION ON ADMISSION: Celebrex 200mg [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Coumadin 3mg PO daily
Clonazepam 0.5mg PO BID
Dexamethasone 1mg TID
Estramustine 140mg TID
Fentanyl patch 75mcg/hr q72, last changed [**10-31**]
Hydromorphone 4mg PO BID PRN
Lasix 20mg PO as needed daily
Neurontin 400mg PO TID
Omeprazole 20mg PO BID
Senna 2 Tabs [**Hospital1 **]
Wellbutrin 100mg TID
Lupron 22.5 q3mon, last [**2135-7-13**]
Taxotere 20mg, last infustion [**2135-10-19**]
Zometa 4mg, last shot [**2135-9-27**]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GEN: obese, NAD
HEENT: MMM, JVP not visible due to body habitus
CV: tachy, no m/r/g
PULM: CTAB
AB: positive BS, NT/ND, no HSM
EXT: 1+ non-pitting pedal edema to shins
NEURO: CN II-XII intact (q/o L facial droop but resolves with
smiling), strength 5/5 throughout, sensation intact, reflexes 1+
throughout.

FAMILY HISTORY: sister with [**Name2 (NI) 499**] CA

SOCIAL HISTORY: lives with wife, has children and step-children. Had twice
weekly VNA. No tobacco or EtOH. 

### Response:
{'Pneumonia, organism unspecified,Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of liver, secondary,Other and unspecified coagulation defects,Alkalosis,Bacteremia,Acute posthemorrhagic anemia,Unspecified pleural effusion,Pulmonary collapse,Hypoxemia,Personal history of venous thrombosis and embolism,Cirrhosis of liver without mention of alcohol,Personal history of malignant neoplasm of prostate,Unspecified essential hypertension,Gout, unspecified,Dysthymic disorder,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other specified antibiotics causing adverse effects in therapeutic use,Epistaxis,Thrombocytopenia, unspecified,Edema,Other specified cardiac dysrhythmias,Hypotension, unspecified,Gross hematuria,Retention of urine, unspecified,Neoplasm related pain (acute) (chronic),Unspecified hemorrhoids with other complication'}
