CHIEF COMPLAINT: Shortness of Breath

PRESENT ILLNESS: 55 year old woman s/p L4-L5 laminectomy and fusion on [**2172-4-7**],
discharged [**2172-4-12**], who presented to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**Hospital **] hospital with 3
days of SOB on [**2172-4-23**]. Pt states that she developed SOB three
days prior to admission. She denies CP, palpitations, but does
endorse DOE with recent difficulty reaching the top of her
stairs. Following dinner on [**4-22**] the pt developed worsening SOB
at rest and the pt called EMS. En route to hospital pt was
initally bradycardic, hypotensive and with low sats, BP improved
with non-rebreather and the pt became tachycardic in the low
100's. At OSH pt was given 3L NS and 1u pRBCs for tachycardia
and anemia (OSH hct 26), and pt had a CTA PE protocol that
revealed a large left main pulmonary artery PE extending to
segmental arteries involving all lobes of the left lung, as well
as a right upper lobe apical segmental artery PE, and an
occlusive embolus in the right lower lobe pulmonary artery. The
pt was started on a heparin gtt and transfered to [**Hospital1 18**] ED for
further management. ABG at OSH showed: 7.46/30/53/21.
.
In the [**Hospital1 18**] ED, initial vs were: T 98.6 P 88 BP 135/88 R 28 O2
sat 91% NRB. Patient was given morphine and ondansetron and
heparin was continued. Patient was admitted to ICU for further
management.
.
On the floor, patient appears comfortable but tachypnic on NRB.
Reports that she is thirsty.
.
Review of systems:
(+) Per HPI
Also, patient endorses non-productive, non-bloody cough for
three days, constipation (no BM since she was discharged from
the hospital [**2172-4-12**]), and abdominal pain at the site of the
surgical incision.
.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.

MEDICAL HISTORY: Obesity
Gastric Bypass
s/p anterior L4-S1 fusion
Depression/Anxiety

MEDICATION ON ADMISSION: Oxycodone 5 mg [**2-8**] Tablet(s) every 4 hours, as needed
Docusate Sodium 100 mg Tab Twice Daily
Tizanidine 4 mg Tab Daily, at bedtime
Quetiapine 50 mg Tab Daily, at bedtime
Cyanocobalamin 50 mcg Tab Daily
Multivitamin Tab Daily
Clonazepam 0.5 mg Tab Daily, at bedtime
Venlafaxine ER 225 mg 24 hr Tab Daily
Doxidan (bisacodyl) 5 mg Tab Oral 2 Tablet Once Daily, as needed

ALLERGIES: Ambien

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, R single lumen EJ in
place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, + ttp, non-distended, midline incision C/D/I
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Lives with husband, runs food service.
- Tobacco: Denies.
- Alcohol: Denies.
- Illicits: Denies.
Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Acute posthemorrhagic anemia,Other chronic pulmonary heart diseases,Other diseases of spleen,Tricuspid valve disorders, specified as nonrheumatic,Iron deficiency anemia, unspecified,Other iatrogenic hypotension,Other alteration of consciousness,Other opiates and related narcotics causing adverse effects in therapeutic use,Essential thrombocythemia,Backache, unspecified,Obesity, unspecified,Constipation, unspecified,Dysthymic disorder,Bariatric surgery status,Arthrodesis status
Pulm embol/infarct NEC,Ac DVT/emb prox low ext,Ac posthemorrhag anemia,Chr pulmon heart dis NEC,Spleen disease NEC,Nonrheum tricusp val dis,Iron defic anemia NOS,Iatrogenc hypotnsion NEC,Other alter consciousnes,Adv eff opiates,Essntial thrombocythemia,Backache NOS,Obesity NOS,Constipation NOS,Dysthymic disorder,Bariatric surgery status,Arthrodesis status
Admission Date:  [**2172-4-23**]              Discharge Date:   [**2172-5-4**]

Date of Birth:  [**2117-2-7**]             Sex:   F

Service: MEDICINE

Allergies:
Ambien

Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Shortness of Breath

Major Surgical or Invasive Procedure:
None

History of Present Illness:
55 year old woman s/p L4-L5 laminectomy and fusion on [**2172-4-7**],
discharged [**2172-4-12**], who presented to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**Hospital **] hospital with 3
days of SOB on [**2172-4-23**]. Pt states that she developed SOB three
days prior to admission. She denies CP, palpitations, but does
endorse DOE with recent difficulty reaching the top of her
stairs. Following dinner on [**4-22**] the pt developed worsening SOB
at rest and the pt called EMS. En route to hospital pt was
initally bradycardic, hypotensive and with low sats, BP improved
with non-rebreather and the pt became tachycardic in the low
100's. At OSH pt was given 3L NS and 1u pRBCs for tachycardia
and anemia (OSH hct 26), and pt had a CTA PE protocol that
revealed a large left main pulmonary artery PE extending to
segmental arteries involving all lobes of the left lung, as well
as a right upper lobe apical segmental artery PE, and an
occlusive embolus in the right lower lobe pulmonary artery. The
pt was started on a heparin gtt and transfered to [**Hospital1 18**] ED for
further management. ABG at OSH showed: 7.46/30/53/21.
.
In the [**Hospital1 18**] ED, initial vs were: T 98.6 P 88 BP 135/88 R 28 O2
sat 91% NRB. Patient was given morphine and ondansetron and
heparin was continued. Patient was admitted to ICU for further
management.
.
On the floor, patient appears comfortable but tachypnic on NRB.
Reports that she is thirsty.
.
Review of systems:
(+) Per HPI
Also, patient endorses non-productive, non-bloody cough for
three days, constipation (no BM since she was discharged from
the hospital [**2172-4-12**]), and abdominal pain at the site of the
surgical incision.
.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.


Past Medical History:
Obesity
Gastric Bypass
s/p anterior L4-S1 fusion
Depression/Anxiety

Social History:
Lives with husband, runs food service.
- Tobacco: Denies.
- Alcohol: Denies.
- Illicits: Denies.


Family History:
Noncontributory.

Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, R single lumen EJ in
place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, + ttp, non-distended, midline incision C/D/I
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema


Pertinent Results:
[**2172-4-23**] 09:28PM   PTT-54.2*
[**2172-4-23**] 02:37PM   GLUCOSE-109* UREA N-14 CREAT-0.7 SODIUM-139
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11
[**2172-4-23**] 02:37PM   CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-2.1
[**2172-4-23**] 06:17AM   GLUCOSE-96 LACTATE-1.3 NA+-141 K+-3.2*
CL--102 TCO2-24

Iron: 20
calTIBC: 274
Ferritn: 64
TRF: 211

LE Ultrasound:
Grayscale and Doppler son[**Name (NI) **] of the bilateral common femoral,
superficial femoral, and popliteal veins were performed. Within
the right distal femoral vein, inferior to the bifurcation
(SFV), an echogenic clot is seen. Flow was seen around this
clot. The remaining vessels demonstrate normal compressibility,
flow and augmentation.

Outside Hospital CTA Scan:  massive b/l PE

TTE [**4-23**]: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The right ventricular cavity is
dilated with mild global free wall hypokinesis. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.

CTA Chest [**4-30**]: IMPRESSION:
1. Minimally increase in large pulmonary artery clot burden on
the right
since 1 week prior. The pulmonary artery remains almost the same
diameter as the aorta suggesting mild pulmonary hypertension.
There are no other signs to suggest right ventricular strain.
2. Left upper lung ground glass opacities may represent
infectious etiology, asymmetric ventilation from pulmonary
embolus or foci of hemorrhage.
3. New small, left greater than right pleural effusions.
4. No RP bleed.
5. Small splenic infarct.


Brief Hospital Course:
55 y/o F with hx of gastric bypass and recent spinal fusion on
[**2172-4-7**] who presents with acute pulmonary embolism.

# Pulmonary embolism (provoked): Per reports from OSH, and per
discussion with radiologists at [**Hospital1 18**] and review of the images,
pt has diffuse PE's bilaterally, with very little lung
perfusion. Pt was started on oxygen and a heparin drip (with
which there was initially some difficulty in obtaining
therapeutic PTT) as well as coumadin. Upon admission she was on
a nonrebreather, but was weaned to facemask and then to nasal
cannula and, on discharge, was on room air during the day with
desaturations overnight requiring her to get home oxygen for
overnight only.
-could consider outpt sleep study
-pt discharged c therapeutic INR, will need close f/u

# s/p laminectomy (Dr. [**Last Name (STitle) 363**]: Midline incision healing well,
pt still having pain in abdomen, low back.  She was initially
controlled with IV pain medication, but transitioned back to her
home regimen of PO oxycontin and oxycodone.  Ortho recommended
A/P and lateral L-spine films during her admission.  These were
obtained and showed no change in alignment.
-pt to f/u with Dr [**Last Name (STitle) 363**] as outpt

# Pain Management s/p laminectomy: Midline incision healing
well, pt still having pain in abdomen, low back. Ortho is
following along.  Left back pain perhaps due to small splenic
infarct seen on chest CT. Pain service consulted. Tizanidine
continued. Started gabapentin and lidocaine patch.

# Depression/Anxiety:  Pt. was very tearful during admission as
she was not expecting this and has had tremendous stress at home
(her son is in prison).  Social work was consulted for support.
Home anxiety regimen continued. Seroquel increased to 50 qhs. Pt
able to discuss her anxiety and depression at length with this
provider. [**Name10 (NameIs) **] also states that she has never considered hurting
herself and that she believes she is here for a reason.

# splenic infact: unclear etiology
-recommend outpt heme eval

# anemia: iron studies c/w iron deficiency plus anemia of
chronic inflammation. Would recommend starting iron when pt on
less opiates (pt had issues c constipation during
hospitalization, did not want to start iron at this time).
- recommend start iron as outpt


Medications on Admission:
Oxycodone 5 mg [**2-8**] Tablet(s) every 4 hours, as needed
Docusate Sodium 100 mg Tab Twice Daily
Tizanidine 4 mg Tab Daily, at bedtime
Quetiapine 50 mg Tab Daily, at bedtime
Cyanocobalamin 50 mcg Tab Daily
Multivitamin Tab Daily
Clonazepam 0.5 mg Tab Daily, at bedtime
Venlafaxine ER 225 mg 24 hr Tab Daily
Doxidan (bisacodyl) 5 mg Tab Oral 2 Tablet Once Daily, as needed

OxyContin 20 mg 12 hr Tab every 12 hours


Discharge Medications:
1. oxygen
oxygen 2L per minute continuous for portability pulse dose
system
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
5. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Clonazepam 1 mg Tablet Sig: [**2-8**] Tablet PO QHS (once a day (at
bedtime)).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): do NOT
take at the same time as oxycontin as it may make you sleepy. Do
NOT drive or operate machinery or drink alcohol while taking
this medicine.
Disp:*14 Tablet Sustained Release 12 hr(s)* Refills:*0*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Put on
for 12 hours then MUST be removed for 12 hours (cannot wear 24
hours per day).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
12. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
13. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: take on Monday and Thursday only.
Disp:*30 Tablet(s)* Refills:*0*
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Take
on Tue, Wed, Fri, Sat, Sun (take the other dose on Mon and
Thurs).
Disp:*30 Tablet(s)* Refills:*0*
15. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours.
Disp:*90 Capsule(s)* Refills:*0*
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain: do NOT take at the same time as oxycontin as
it may make you sleepy. Do NOT drive or operate machinery or
drink alcohol while taking this medicine.
Disp:*20 Tablet(s)* Refills:*0*
17. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1)  Inhalation every six (6) hours as needed for shortness
of breath or wheezing for 2 weeks.
Disp:*1 inhaler* Refills:*0*
18. Mirapex  Oral


Discharge Disposition:
Home With Service

Facility:
Homemakers of [**Location (un) 33810**]

Discharge Diagnosis:
Primary
Pulmonary Embolus


Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent


Discharge Instructions:
You came to the hospital after having a blood clots in your
lungs (pulmonary embolus) in the context of recovering from back
surgery. You required intravenous heparin and coumadin was
started - when this drug reached a good level, the heparin was
discontinued. You will need to take coumadin for a year. You
will need to have your coumadin levels checked carefully so you
will see Dr [**Last Name (STitle) 10023**] on Wednesday. Please use your oxygen at
night while sleeping.

Please continue your medications with the following changes:
1. STOP percocet
2. STOP flexoril
3. START colace and senna and bisacodyl for constipation as pain
meds can be constipating
4. START oxycontin twice daily for pain
5. START oxycodone as needed for pain
6. START gabapentin
7. START lidocaine patch (12 hours on, 12 hours off)
8. START albuterol inhaler
9. START coumadin

Followup Instructions:
Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
When: [**Last Name (LF) 2974**], [**2173-5-22**]:30 am
Location: [**Hospital3 **] [**Hospital **] MEDICAL CENTER
Address: [**Last Name (LF) **], [**First Name3 (LF) **] BLDG. [**Location (un) **]
Phone: [**Telephone/Fax (1) 3573**]

Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
When: This Wednesday [**5-6**] 11:30a
Location: [**Location (un) **] INTERNAL MEDICINE
Address: [**Apartment Address(1) 83581**], [**Location (un) **],[**Numeric Identifier 62963**]
Phone: [**Telephone/Fax (1) 10026**]



Completed by:[**2172-5-6**]
{'Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Acute posthemorrhagic anemia,Other chronic pulmonary heart diseases,Other diseases of spleen,Tricuspid valve disorders, specified as nonrheumatic,Iron deficiency anemia, unspecified,Other iatrogenic hypotension,Other alteration of consciousness,Other opiates and related narcotics causing adverse effects in therapeutic use,Essential thrombocythemia,Backache, unspecified,Obesity, unspecified,Constipation, unspecified,Dysthymic disorder,Bariatric surgery status,Arthrodesis status'}


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: Shortness of Breath

PRESENT ILLNESS: 55 year old woman s/p L4-L5 laminectomy and fusion on [**2172-4-7**],
discharged [**2172-4-12**], who presented to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**Hospital **] hospital with 3
days of SOB on [**2172-4-23**]. Pt states that she developed SOB three
days prior to admission. She denies CP, palpitations, but does
endorse DOE with recent difficulty reaching the top of her
stairs. Following dinner on [**4-22**] the pt developed worsening SOB
at rest and the pt called EMS. En route to hospital pt was
initally bradycardic, hypotensive and with low sats, BP improved
with non-rebreather and the pt became tachycardic in the low
100's. At OSH pt was given 3L NS and 1u pRBCs for tachycardia
and anemia (OSH hct 26), and pt had a CTA PE protocol that
revealed a large left main pulmonary artery PE extending to
segmental arteries involving all lobes of the left lung, as well
as a right upper lobe apical segmental artery PE, and an
occlusive embolus in the right lower lobe pulmonary artery. The
pt was started on a heparin gtt and transfered to [**Hospital1 18**] ED for
further management. ABG at OSH showed: 7.46/30/53/21.
.
In the [**Hospital1 18**] ED, initial vs were: T 98.6 P 88 BP 135/88 R 28 O2
sat 91% NRB. Patient was given morphine and ondansetron and
heparin was continued. Patient was admitted to ICU for further
management.
.
On the floor, patient appears comfortable but tachypnic on NRB.
Reports that she is thirsty.
.
Review of systems:
(+) Per HPI
Also, patient endorses non-productive, non-bloody cough for
three days, constipation (no BM since she was discharged from
the hospital [**2172-4-12**]), and abdominal pain at the site of the
surgical incision.
.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.

MEDICAL HISTORY: Obesity
Gastric Bypass
s/p anterior L4-S1 fusion
Depression/Anxiety

MEDICATION ON ADMISSION: Oxycodone 5 mg [**2-8**] Tablet(s) every 4 hours, as needed
Docusate Sodium 100 mg Tab Twice Daily
Tizanidine 4 mg Tab Daily, at bedtime
Quetiapine 50 mg Tab Daily, at bedtime
Cyanocobalamin 50 mcg Tab Daily
Multivitamin Tab Daily
Clonazepam 0.5 mg Tab Daily, at bedtime
Venlafaxine ER 225 mg 24 hr Tab Daily
Doxidan (bisacodyl) 5 mg Tab Oral 2 Tablet Once Daily, as needed

ALLERGIES: Ambien

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, R single lumen EJ in
place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, + ttp, non-distended, midline incision C/D/I
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Lives with husband, runs food service.
- Tobacco: Denies.
- Alcohol: Denies.
- Illicits: Denies. 

### Response:
{'Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Acute posthemorrhagic anemia,Other chronic pulmonary heart diseases,Other diseases of spleen,Tricuspid valve disorders, specified as nonrheumatic,Iron deficiency anemia, unspecified,Other iatrogenic hypotension,Other alteration of consciousness,Other opiates and related narcotics causing adverse effects in therapeutic use,Essential thrombocythemia,Backache, unspecified,Obesity, unspecified,Constipation, unspecified,Dysthymic disorder,Bariatric surgery status,Arthrodesis status'}
