CHIEF COMPLAINT: SOB

PRESENT ILLNESS: 39 y/o M with PMHx of HTN, iritis, who presented to his PCP's
office with a 2 days of worsening SOB, and dizziness on standing
after going to the gym.

MEDICAL HISTORY: 1)HTN
2)Iritis

MEDICATION ON ADMISSION: Lisinopril 20mg QD
Claritin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission to ICU...
Vitals: T 99 BP 106/63 HR 95 RR 22 O2: 98% on 2L
Gen:  Well appearing male in NAD; able to talk in complete
sentences
HEENT: Anicteric sclera. O/P clear. MMM.
Neck:  No elev JVP. No cervical or supraclavicular LAD.
Cardio: Regular, nml s1,s2. No murmurs
Resp:  CTAB.  No c/w/r.
Abd: Soft. NTND. No TTP. No inguinal LAD
Ext: 2+ pulses bilat, no edema. No erythema. (-) [**Last Name (un) 5813**] sign
Neuro:  AAOx3
GU: No testicular masses palpated.
RECTAL: Guiaic (-) in ED per notes.
.
on floor:
Vitals: 98.4, 104/70, 96, 16, 95% RA
Gen: Well appearing male in NAD
HEENT: Anicteric sclera. O/P clear. MMM.
Neck: No JVD noted, no [**Doctor First Name **], no bruit noted
Cardio: Regular, nml s1,s2. No murmurs
Resp: CTAB. No c/w/r.
Abd: Soft. NTND. + BS
Ext: 2+ pulses bilat, no edema. No erythema. no calf tenderness.
IVC filter in right thigh
Neuro: AAOx3
RECTAL: Guiaic (-) in ED per notes.

FAMILY HISTORY: Mother has hypercholesterolemia and history of alcohol abuse;
diagnosed with breast cancer one year ago.  His father has
nonmelanoma skin cancer.  No other fam hx of blood clots or
malignancy.

SOCIAL HISTORY: The patient grew up in a farm in [**Location (un) 3844**], currently works
for EScription Services for the past 3 years. There is a lot of
traveling around the country for up to a week at a time.  He
works pretty hard but likes his job.  He has no history of
alcohol, drug abuse, or smoking.  He currently lives in the
[**Location (un) 4398**].  He lives alone.  He has an occasional male partner
with whom he is sexually active.  He does use condoms.  He has
no history of sexually transmitted diseases.
Other pulmonary embolism and infarction,Acute kidney failure, unspecified,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Hypovolemia,Unspecified essential hypertension,Other specified anemias,Heart disease, unspecified
Pulm embol/infarct NEC,Acute kidney failure NOS,Ac DVT/emb distl low ext,Hypovolemia,Hypertension NOS,Anemia NEC,Heart disease NOS
Admission Date:  [**2135-7-15**]              Discharge Date:   [**2135-7-25**]

Date of Birth:  [**2096-2-16**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
[**2135-7-17**] IVC Filter Placed

History of Present Illness:
39 y/o M with PMHx of HTN, iritis, who presented to his PCP's
office with a 2 days of worsening SOB, and dizziness on standing
after going to the gym.

Patient said on tuesday he noticed left calf "knot" after
swimming, with no other symptoms. On weds/thurs. he noticed he
was sob, dizzy and diaphoretic with normal exertion (walked [**1-3**]
block). Finally, on friday, his left calf "knot" was not
resolved with vigorous massage, and his symptoms of SOB,
dizziness and diaphoresis were not improved so he saw his PCP.
[**Name10 (NameIs) **] arrived to his PCP's office who found him to be hypotensive
and tachycardic, and he was sent into the ED. Interestingly,
patient notes ~ 5 weeks ago he had some sob while boxing, and 3
weeks ago he also had sob after a long flight.
.
Brief hospital course: In the ED, VS: T98.1, HR116, BP96/80,
RR16 o2sat: 97% RA. His CT scan showed bilateral PEs and he was
given ASA 325 x1, & started on hep gtt.  The patient was
admitted to the ICU, and for his saddle emboli he was continued
on heparin gtt, and had an IVC filter placed. He will start
coumadin. His ARF was treated with fluids, which led to
improvement. In the setting of PE/hypotension, his blood
pressure meds were held and he was aggressively hydrated

Past Medical History:
1)HTN
2)Iritis


Social History:
The patient grew up in a farm in [**Location (un) 3844**], currently works
for EScription Services for the past 3 years. There is a lot of
traveling around the country for up to a week at a time.  He
works pretty hard but likes his job.  He has no history of
alcohol, drug abuse, or smoking.  He currently lives in the
[**Location (un) 4398**].  He lives alone.  He has an occasional male partner
with whom he is sexually active.  He does use condoms.  He has
no history of sexually transmitted diseases.




Family History:
Mother has hypercholesterolemia and history of alcohol abuse;
diagnosed with breast cancer one year ago.  His father has
nonmelanoma skin cancer.  No other fam hx of blood clots or
malignancy.


Physical Exam:
On Admission to ICU...
Vitals: T 99 BP 106/63 HR 95 RR 22 O2: 98% on 2L
Gen:  Well appearing male in NAD; able to talk in complete
sentences
HEENT: Anicteric sclera. O/P clear. MMM.
Neck:  No elev JVP. No cervical or supraclavicular LAD.
Cardio: Regular, nml s1,s2. No murmurs
Resp:  CTAB.  No c/w/r.
Abd: Soft. NTND. No TTP. No inguinal LAD
Ext: 2+ pulses bilat, no edema. No erythema. (-) [**Last Name (un) 5813**] sign
Neuro:  AAOx3
GU: No testicular masses palpated.
RECTAL: Guiaic (-) in ED per notes.
.
on floor:
Vitals: 98.4, 104/70, 96, 16, 95% RA
Gen: Well appearing male in NAD
HEENT: Anicteric sclera. O/P clear. MMM.
Neck: No JVD noted, no [**Doctor First Name **], no bruit noted
Cardio: Regular, nml s1,s2. No murmurs
Resp: CTAB. No c/w/r.
Abd: Soft. NTND. + BS
Ext: 2+ pulses bilat, no edema. No erythema. no calf tenderness.
IVC filter in right thigh
Neuro: AAOx3
RECTAL: Guiaic (-) in ED per notes.


Pertinent Results:
[**2135-7-15**] Chest CT: Massive bilateral pulmonary emboli involving
the bilateral distal, lobar and multiple proximal segmental
pulmonary arteries.  Focal gound glass opacity in the left upper
lobe may represent focal infarction, although follow up films
are recommended to ensure resolution.

[**2135-7-15**] CXR:  The heart size and mediastinal contours are
normal.  There is no pleural effusion or pneumothorax.  The
lungs are clear.

[**2135-7-16**] ECHO - Right ventricular cavity enlargement with free
wall hypokinesis and preserved apical function c/w acute RV
pressure overload/pulmonary embolism.

[**2135-7-16**] LE Doppler - Occlusive intraluminal thrombus is seen
within the right distal superficial femoral vein extending
inferiorly into the right popliteal and calf veins.
.
EKG on admission: Sinus tachycardia. Inferior Q of waves
doubtful significance. Since previous tracing, rate faster.
.
admission labs:

[**2135-7-15**] 11:10AM   D-DIMER-4016*
[**2135-7-15**] 11:10AM   WBC-12.2* RBC-5.80 HGB-16.1 HCT-46.8 MCV-81*
MCH-27.7 MCHC-34.4 RDW-13.3
[**2135-7-15**] 11:10AM   CK-MB-6 cTropnT-0.11
[**2135-7-15**] 11:10AM   CK(CPK)-684*
[**2135-7-15**] 11:10AM   UREA N-21* CREAT-1.4* SODIUM-137
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-27 ANION GAP-19
[**2135-7-15**] 11:10AM   GLUCOSE-68*
[**2135-7-15**] 08:30PM   D-DIMER-4256*
[**2135-7-15**] 08:30PM   NEUTS-66.6 LYMPHS-22.4 MONOS-5.5 EOS-3.4
BASOS-2.1*
[**2135-7-15**] 08:30PM   WBC-10.7 RBC-5.63 HGB-16.0 HCT-45.0 MCV-80*
MCH-28.3 MCHC-35.4* RDW-13.4
[**2135-7-15**] 08:30PM   CK-MB-5
[**2135-7-15**] 08:30PM   cTropnT-0.03*
[**2135-7-15**] 08:30PM   GLUCOSE-95 UREA N-24* CREAT-1.5* SODIUM-135
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-24 ANION GAP-18

Brief Hospital Course:
This is 39 y/o M with h/o HTN who presents with intermittant
SOB, and hypotension found to have massive bilateral saddle
emboli
.
1) Pulmonary embolism - The patient was admitted with extensive
bilateral pulmonary emboli.  As this is a very serious condition
and the patient was unstable in the ED (but responding to
fluids) the patient was admitted to the ICU and started on
heparin.  In the ICU, he was hemodynamically stable, so no lytic
therapy was started.  After transfer, the patient remained
stable, and his course on the floor was without events.  He
remained on heparin and coumadin and we waited until he became
therapeutic, by closely monitoring his PT, PTT and INR and
adjusting his coumadin dose.  As an outpatient he will remain on
coumadin and should have a hypercoaguability workup, TTE, and a
repeat chest CT.
.
2) Deep vein thrombus: The patient was noted to have an
intraluminal thrombus within the right distal superficial
femoral vein extending inferiorly into the right popliteal and
calf veins.  As above, the patient was treated with heparin and
coumadin, but due to this large clot that had potential to break
off, he was placed with an IVC filter.  The patient responded
well to the IVC filter and anticoagulation, and should have this
IVC filter in for life for protection.
.
3) Right Ventricular strain: On admission, the patient was noted
to have elevated troponins, and this was attributed to the right
ventricular strain from the pulmonary embolism. The case was
discussed with cardiology, and since he was hemodynamically
stable and responding to anticoagulation they felt lytic therapy
was unnecessary.   The right ventricle is resilient and should
recover, in time.  The patient had no problems during his
course, and will have a repeat ECHO in 3 months to revalute.
.
4) Anemia: The patient was noted to have a mild anemia.  He was
hemodynamically stable, and we felt this could be followed up
further as an outpatient.
.
5) Hypertension - The patient was hypotensive on admission, and
in the setting of a pulmonary embolism, his blood pressure
medications were held.  He remained normotensive during his
course, and therefore we continued to hold his medications as
they can be restarted as an outpatient.
.
6) Acute renal failure: On admission the patient presented with
a creatinine of 1.4, increased from his baseline of 1.0.  This
improved with hydration, although increased again during the
course to 1.3.  The Fena was calculated to be ~ 1% and therefore
assumed to be pre-renal.  Hydration was provided and the patient
improved, leading to the diagnosis of pre-renal failure.


Medications on Admission:
Lisinopril 20mg QD
Claritin

Discharge Medications:
1. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day: You
can retake your home claritin.
2. Outpatient Lab Work
Please check PT, PTT, INR
3. Warfarin 2 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime):
take 8 mg daily.
Disp:*120 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
1. Pulmonary embolism
2. Deep vein thrombosis
3. Anemia
4. Mulculoskeletal pain

Discharge Condition:
stable, tolerating medications, afebrile

Discharge Instructions:
1. Please attend all appointments
2. Please take all medications as prescribed, we are holding
your lisinopril because your blood pressure was low.  This
should be readdressed with Dr. [**Last Name (STitle) **].
3. Please return for worsening shortness of breath, chest pain,
vomiting, high fever and inability
4. Please have your labs drawn in 2 days (bring lab slip
prescription), at Dr.[**Name (NI) 6001**] office.

Followup Instructions:
1. Would have a repeat chest CT in 3 months
2. You need a repeat ECHO in 3 months
3. You need a work-up for hypercoagulability, which Dr. [**Last Name (STitle) **]
will help you coordinate.
4. You have an appointment with Dr. [**Last Name (STitle) **] (# [**Telephone/Fax (1) 250**]) on
Friday [**7-29**] at 9:50 am.
{'Other pulmonary embolism and infarction,Acute kidney failure, unspecified,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Hypovolemia,Unspecified essential hypertension,Other specified anemias,Heart disease, unspecified'}


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: SOB

PRESENT ILLNESS: 39 y/o M with PMHx of HTN, iritis, who presented to his PCP's
office with a 2 days of worsening SOB, and dizziness on standing
after going to the gym.

MEDICAL HISTORY: 1)HTN
2)Iritis

MEDICATION ON ADMISSION: Lisinopril 20mg QD
Claritin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission to ICU...
Vitals: T 99 BP 106/63 HR 95 RR 22 O2: 98% on 2L
Gen:  Well appearing male in NAD; able to talk in complete
sentences
HEENT: Anicteric sclera. O/P clear. MMM.
Neck:  No elev JVP. No cervical or supraclavicular LAD.
Cardio: Regular, nml s1,s2. No murmurs
Resp:  CTAB.  No c/w/r.
Abd: Soft. NTND. No TTP. No inguinal LAD
Ext: 2+ pulses bilat, no edema. No erythema. (-) [**Last Name (un) 5813**] sign
Neuro:  AAOx3
GU: No testicular masses palpated.
RECTAL: Guiaic (-) in ED per notes.
.
on floor:
Vitals: 98.4, 104/70, 96, 16, 95% RA
Gen: Well appearing male in NAD
HEENT: Anicteric sclera. O/P clear. MMM.
Neck: No JVD noted, no [**Doctor First Name **], no bruit noted
Cardio: Regular, nml s1,s2. No murmurs
Resp: CTAB. No c/w/r.
Abd: Soft. NTND. + BS
Ext: 2+ pulses bilat, no edema. No erythema. no calf tenderness.
IVC filter in right thigh
Neuro: AAOx3
RECTAL: Guiaic (-) in ED per notes.

FAMILY HISTORY: Mother has hypercholesterolemia and history of alcohol abuse;
diagnosed with breast cancer one year ago.  His father has
nonmelanoma skin cancer.  No other fam hx of blood clots or
malignancy.

SOCIAL HISTORY: The patient grew up in a farm in [**Location (un) 3844**], currently works
for EScription Services for the past 3 years. There is a lot of
traveling around the country for up to a week at a time.  He
works pretty hard but likes his job.  He has no history of
alcohol, drug abuse, or smoking.  He currently lives in the
[**Location (un) 4398**].  He lives alone.  He has an occasional male partner
with whom he is sexually active.  He does use condoms.  He has
no history of sexually transmitted diseases. 

### Response:
{'Other pulmonary embolism and infarction,Acute kidney failure, unspecified,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Hypovolemia,Unspecified essential hypertension,Other specified anemias,Heart disease, unspecified'}
