CHIEF COMPLAINT: hypoxia

PRESENT ILLNESS: 75 YOM with history of HTN who had progressive DOE and fatigue
over the fall with two courses of ABX for PNA with no
improvement.  He was sent for a CT of the chest [**2182-1-18**] which
revealed findings consistent with lung cancer in the left field
with metastases to the right lung, liver, bones and likely
adrenal glands.  He underwent a left sided thoracentesis on
[**2182-1-24**] with removal of 2L of fluid.  The cytology from the
pleural effusion showed adenocarcinoma with immunostains of the
tumor cells positive for CK7, [**Last Name (un) **]-31 and TTF-1.  He subsequently
underwent MR of the head and thoracic spine on [**2182-1-30**] which
showed diffuse metastasis.
.
He went to [**Hospital **] clinic this afternoon with progressive worsening
of dyspnea. Had 2 L taken off and was direct admitted to floor
for observation overnight and plan for pleuradesis or possible
pleurex cath placement in the morning with subsequent transfer
to OMED.
.
On arrival to the floor he was sattign 84% on NRB and nursing
triggered and transferred the patient to MICU six.
.
On arrival to the MICU he is comfortable lying on his right side
with O2 sats of 955 on NRB. He had minimal pain at the site of
the thoracentesis.
.
.
Review of systems:
(+) Per HPI

MEDICAL HISTORY: Prostate cancer s/p XRT ~[**2172**] treated at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 47**] Oncology
Center
Hypertension
Hyperlipidemia
Stage IV lung adenocarcinoma (as described above)

MEDICATION ON ADMISSION: AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily
CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - [**12-31**] tsp(s) by
mouth up to q 4 hrs prn cough
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth
daily
HYDROCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**12-31**] Tablet(s)
by
mouth po q6hrs prn pain
LATANOPROST [XALATAN] - 0.005 % Drops - 1 ou hs
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth every 8 hrs prn
anxiety
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
Tmax: 37.4 ??????C (99.3 ??????F)
Tcurrent: 37.4 ??????C (99.3 ??????F)
HR: 108 (96 - 108) bpm
BP: 113/51(75) {113/45(62) - 122/54(75)} mmHg
RR: 25 (17 - 25) insp/min
SpO2: 98%
Heart rhythm: ST (Sinus Tachycardia)
Height: 68 Inch
General Appearance: Well nourished, Anxious
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: No(t) Symmetric), (Percussion:
Dullness : left lung fields), (Breath Sounds: Clear : right lung
fields, Diminished: left lung [**Last Name (un) 8434**])
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin:  Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed

FAMILY HISTORY: Sister - breast cancer in her 70s.
Mother is 95 and in good health.
Father is 94 and in good health.

SOCIAL HISTORY: Mr. [**Known lastname 18418**] is married to [**Doctor First Name 15359**] who is his second wife.  [**Name (NI) **] has
a daughter and 2 sons.  [**Name (NI) 15359**] has 2 children.  Quit smoking
~[**2154**].  Smoked 2 packs per day X 25-30 years.  Was a heavy
drinker until [**2149**]; required detox at that time.  He is a
painter
by profession and was working until he got sick. Was in the
marines.
Malignant pleural effusion,Acute and chronic respiratory failure,Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Malignant neoplasm of bronchus and lung, unspecified,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of brain and spinal cord,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Other chronic pulmonary heart diseases,Encounter for palliative care,Unspecified essential hypertension,Nausea alone,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Do not resuscitate status,Anemia, unspecified,Neoplasm related pain (acute) (chronic),Insomnia, unspecified,Constipation, unspecified,Adjustment disorder with anxiety,Personal history of malignant neoplasm of prostate
Malignant pleural effusn,Acute & chronc resp fail,Pulm embol/infarct NEC,Ac DVT/emb distl low ext,Mal neo bronch/lung NOS,Secondary malig neo lung,Sec mal neo brain/spine,Acute kidney failure NOS,Hyposmolality,Chr pulmon heart dis NEC,Encountr palliative care,Hypertension NOS,Nausea alone,Adv eff antineoplastic,Hyperlipidemia NEC/NOS,Do not resusctate status,Anemia NOS,Neoplasm related pain,Insomnia NOS,Constipation NOS,Adjustment dis w anxiety,Hx-prostatic malignancy
Admission Date:  [**2182-1-31**]              Discharge Date:   [**2182-2-12**]

Date of Birth:  [**2106-5-9**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
hypoxia

Major Surgical or Invasive Procedure:
thoracentesis

History of Present Illness:
75 YOM with history of HTN who had progressive DOE and fatigue
over the fall with two courses of ABX for PNA with no
improvement.  He was sent for a CT of the chest [**2182-1-18**] which
revealed findings consistent with lung cancer in the left field
with metastases to the right lung, liver, bones and likely
adrenal glands.  He underwent a left sided thoracentesis on
[**2182-1-24**] with removal of 2L of fluid.  The cytology from the
pleural effusion showed adenocarcinoma with immunostains of the
tumor cells positive for CK7, [**Last Name (un) **]-31 and TTF-1.  He subsequently
underwent MR of the head and thoracic spine on [**2182-1-30**] which
showed diffuse metastasis.
.
He went to [**Hospital **] clinic this afternoon with progressive worsening
of dyspnea. Had 2 L taken off and was direct admitted to floor
for observation overnight and plan for pleuradesis or possible
pleurex cath placement in the morning with subsequent transfer
to OMED.
.
On arrival to the floor he was sattign 84% on NRB and nursing
triggered and transferred the patient to MICU six.
.
On arrival to the MICU he is comfortable lying on his right side
with O2 sats of 955 on NRB. He had minimal pain at the site of
the thoracentesis.
.
.
Review of systems:
(+) Per HPI


Past Medical History:
Prostate cancer s/p XRT ~[**2172**] treated at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 47**] Oncology
Center
Hypertension
Hyperlipidemia
Stage IV lung adenocarcinoma (as described above)


Social History:
Mr. [**Known lastname 18418**] is married to [**Doctor First Name 15359**] who is his second wife.  [**Name (NI) **] has
a daughter and 2 sons.  [**Name (NI) 15359**] has 2 children.  Quit smoking
~[**2154**].  Smoked 2 packs per day X 25-30 years.  Was a heavy
drinker until [**2149**]; required detox at that time.  He is a
painter
by profession and was working until he got sick. Was in the
marines.


Family History:
Sister - breast cancer in her 70s.
Mother is 95 and in good health.
Father is 94 and in good health.


Physical Exam:
ADMISSION EXAM
Tmax: 37.4 ??????C (99.3 ??????F)
Tcurrent: 37.4 ??????C (99.3 ??????F)
HR: 108 (96 - 108) bpm
BP: 113/51(75) {113/45(62) - 122/54(75)} mmHg
RR: 25 (17 - 25) insp/min
SpO2: 98%
Heart rhythm: ST (Sinus Tachycardia)
Height: 68 Inch
General Appearance: Well nourished, Anxious
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: No(t) Symmetric), (Percussion:
Dullness : left lung fields), (Breath Sounds: Clear : right lung
fields, Diminished: left lung [**Last Name (un) 8434**])
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin:  Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed

DISCHARGE EXAM
VS:  98.1  120/56  68  18  98% on 6L face mask
General:  ill-appearing man in NAD, wearing face mask
HEENT:  EOMI, PERRL, MMM, OP clear
CV:  RRR, nl S1 S2, no MRG
Resp:  Left lung decreased breath sounds to top [**1-1**] of lung,
right lung rales at bottom [**1-1**].  No wheezes.
Abd:  soft, non-tender, non-distended
Ext:  warm, well-perfused, no edema
Neuro:  awake and alert, strength 5/5 throughout, sensation
grossly normal

Pertinent Results:
ADMISSION LABS
[**2182-1-31**] 09:20PM BLOOD WBC-10.3# RBC-3.67* Hgb-10.8* Hct-30.9*
MCV-84 MCH-29.5 MCHC-35.0 RDW-12.2 Plt Ct-296
[**2182-1-31**] 09:20PM BLOOD PT-11.9 PTT-28.3 INR(PT)-1.1
[**2182-1-31**] 09:20PM BLOOD Glucose-116* UreaN-19 Creat-1.0 Na-135
K-4.6 Cl-97 HCO3-27 AnGap-16
[**2182-1-31**] 09:20PM BLOOD Calcium-9.0 Phos-4.0 Mg-1.8
[**2182-2-1**] 05:40PM BLOOD CK-MB-4 cTropnT-0.05* proBNP-4089*
[**2182-2-1**] 04:30PM BLOOD Lactate-1.7

DISCHARGE LABS:
[**2182-2-11**] 07:07AM BLOOD WBC-8.5# RBC-3.42* Hgb-9.8* Hct-29.1*
MCV-85 MCH-28.7 MCHC-33.7 RDW-13.1 Plt Ct-334
[**2182-2-11**] 07:07AM BLOOD Glucose-100 UreaN-30* Creat-1.0 Na-133
K-4.5 Cl-95* HCO3-32 AnGap-11
[**2182-2-11**] 07:07AM BLOOD Calcium-8.6 Phos-4.7* Mg-1.8

Microbiology:  MRSA SCREEN (Final [**2182-2-3**]):    No MRSA
isolated.

CTA CHEST [**2182-2-1**]
1. Acute pulmonary embolus in the right main pulmonary artery
with extension
to the right upper, right middle, and right lower lobe segmental
and
subsegmental pulmonary arteries. Additionally, there is a focal
opacity in
the right lower lobe which can be representative of a developing
infarct
versus a developing pneumonia.
2. Large left perihilar mass with extension and circumscription
to all lobes of the left lung and complete collapse of the left
lower lobe. Additionally, hypodense foci within the collapsed
left lower lobe are highly suggestive of tumor. Evidence of
lymphangitic carcinomatosis is visualized in the left upper
lobe. Hilar and mediastinal lymphadenopathy is associated with
this tumor.
3. Two right lower lobe nodules which may be representative of
metastatic
foci, but are of unclear etiology. Additionally, there is
thickening of the anterior right pleura, which may be
representative of a metastatic focus.
4. Bilateral small pleural effusions.
5. Although severely limited evaluation of the abdominal
structures, the
non-opacified visualized portion of the upper abdomen
demonstrates a
hypodensity in the right lobe of the liver which may be
representative of a metastatic focus. Further characterization
with a dedicated abdominal study is recommended.

[**2182-2-1**] LENIs
Left peroneal vein thrombosis. Right lesser saphenous
(superficial) vein thrombosis.

[**2182-2-2**] TTE
The left atrium is elongated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. The right ventricular
cavity is moderately dilated with mild global free wall
hypokinesis. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
Severe pulmonary hypertension. Moderately dilated right
ventricle with mild global systolic dysfunction. Normal global
left ventricular systolic function. Moderate tricuspid
regurgitation.

[**2182-2-1**] CXR:
FINDINGS: There continues to be large left pleural effusion and
there is a new right pleural effusion. There is hazy vasculature
bilaterally, left greater than right, compatible with fluid
overload. There continues to be some rightward mediastinal shift
similar compared to the film from the prior day.

[**2182-2-2**] CXR:
FINDINGS: There is complete opacification of the left hemithorax
with mediastinal shift towards the left. This is compatible with
increased fluid and associated volume loss. Right lung is clear
with the exception of some lower lobe alveolar infiltrate
medially similar in appearance to the CT scan from the prior
day.
IMPRESSION: Increased collapse of the left lung with complete
opacification of the left hemithorax.

[**2182-2-3**] CXR:
Compared to the prior study, there is no significant interval
change in complete opacification of the left hemithorax and
mediastinal shift to the left. There is a right lower lobe
infiltrate, similar in size compared to the study from the prior
day.

[**2182-2-11**] CT Head:
FINDINGS: There is no evidence of hemorrhage, edema, mass
effect, or infarction. The scattered small metastases which were
previously seen on MRI are not visualized on CT, even after the
administration of intravenous contrast. The ventricles and sulci
are normal in size and configuration. The basal cisterns are
patent. The dural venous sinuses in the vessels of the circle of
[**Location (un) 431**] enhance normally and symmetrically. No fracture is
identified. The visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The soft tissues are
unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Known small metastases which were visualized on the recent
MRI are not visualized on this exam.

Brief Hospital Course:
75 year-old male with stage IV lung CA with brain metastases
initially admitted directly from [**Hospital **] clinic for enlarging
left-sided malignant effusion and hypoxemia, admitted to the ICU
for management of hypoxemic respiratory failure, then
transferred to the oncology service.
.
# Stage IV lung adenocarcinoma:  Cytology-confirmed diagnosis
with widespread metastases, a tumor in the perihilar region of
the left lung causing collapse and recurrent malignant effusions
made his prognosis particularly poor.  In addition to an
essentially non-functional left lung, his right lung was
compromised with a pulmonary embolism in the main right
pulmonary artery (see below). In addition to management of his
hypoxia and shortness of breath, the patient was initiated on
chemotherapy with carboplatin and pemetrexed in an attempt to
reduce his disease burden in the lung and thus reduce his
symptoms.
.
# Nausea:  The patient experienced nausea for several days
following chemotherapy.  This was treated with dexamethasone for
a three day course and Zofran pre-medication prior to meals.  He
continued to have nausea, but was able to tolerate a regular
diet.
.
# Pleural effusion:  The patient was first noted to have a left
pleural effusion in late [**Month (only) 404**].  On admission this was noted
to have reaccumulated and was again removed via thoracentesis.
Placement of a Pleurex catheter was considered, however the
patient preferred to wait to determine if chemotherapy could
reduce his symptoms.  He was provided high-flow oxygen and
nebulizer treatments.
.
# Pulmonary embolism:  The patient was found to have a pulmonary
embolism in the right lung.  TTE showed severe pulmonary artery
hypertension, likely representing the conditions in both lungs
creating back-pressure.  After weighing the risks/benefits of
starting anticoagulation, it was determined that starting a
heparin gtt with close monitoring was indicated at this time
despite the known risk of intracranial bleeding from metastases.
 His blood pressure was maintained below SBP 140 and DBP 110 to
help prevent intracranial bleeding.
.
# Acute kidney injury: Creatinine was found to be elevated to
1.3, thought to be due to hypovolemia.  Urine electrolytes were
consistent with pre-renal process.  Resolved to 1.0 with
hydration.
.
# Hypertension:  Good SBP control will be important for him to
prevent catastrophic ICH.  Continued home medications, with
uptitration for SBP<140s, DBP<110.  In the two days prior to
discharge, his BP dropped slightly necessitating reduced
regimen.
.
# CODE: DNR/DNI, confirmed with family
# COMM: patient, wife
.
Transitional Issues:
- follow BP and restart HCTZ, amlodipine as necessary to
maintain SBP < 140, DBP < 110

Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily
CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - [**12-31**] tsp(s) by
mouth up to q 4 hrs prn cough
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth
daily
HYDROCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**12-31**] Tablet(s)
by
mouth po q6hrs prn pain
LATANOPROST [XALATAN] - 0.005 % Drops - 1 ou hs
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth every 8 hrs prn
anxiety
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth daily

Medications - OTC
ASPIRIN - 81 mg Tablet - 1 Tablet(s) by mouth daily
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth hs


Discharge Medications:
1. Hospital bed
Semi-electric hospital bed with gel overlay.
Patient has a medical condition which requires positioning of
the body not feasible in an ordinary bed to alleviate pain.
Dx:  stage IV lung cancer with metastasis to liver and bone,
malignant pleural effusion with impaired nutritional status
2. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H
(every 4 hours) as needed for cough.
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): both eyes.
4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for anxiety, insomnia, nausea.
6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. docusate sodium 100 mg Tablet Sig: One (1) Capsule PO at
bedtime.
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Home Oxygen
Please provide high-flow oxygen supplementation at 6-10L per
minute continous flow via face mask.  Dx:  malignant pleural
effusion due to lung cancer, pulmonary embolism
11. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg
Subcutaneous Q12H (every 12 hours).
Disp:*60 syringes* Refills:*2*
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
13. Wheelchair
Standard wheelcair with elevated footrests, seat and back
cushion.  Dx:  Stage IV lung cancer with mets to liver and bone.
 Patient cannot be mobile inside home without the use of a
wheelchair.
14. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*2*
15. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
16. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
17. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*15 Tablet(s)* Refills:*2*
18. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for groin.
Disp:*qs tube* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
vna and hospice of greater [**Location (un) **]

Discharge Diagnosis:
primary:
pleural effusion
pulmonary embolism
.
secondary:
stage IV lung cancer

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

Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**].  You were admitted to the hospital with
shortness of breath caused by fluid on the lungs (pleural
effusion).  The effusion was drained by a thoracentesis.  You
were also found to have a blood clot in the lung, a pulmonary
embolism.  This was treated with heparin, an anti-coagulant.
Your shortness of breath required oxygen support.  You were
transferred to the Intensive Care Unit, but after the
thoracentesis procedure your breathing improved and you were
able to be transferred back to the regular medical floor.

During your admission you were started on chemotherapy.
Following chemotherapy you had problems with nausea,
particularly in the mornings.  We treated this with anti-nausea
medications prior to each meal and on an as-needed basis.

We made the following changes to your medications:
- STOP Percocet
- START oxycodone for pain.  This is similar to Percocet.  If
you need more pain medication, please contact [**Name (NI) 24185**]
office.
- STOP hydrochlorothiazide and amlodipine, both blood pressure
medications, as your pressures have been low.  Continue
lisinopril.
- START folic acid
- START Lovenox injections, an anti-coagulant
- START senna for constipation
- START Zofran for nausea.  Please use this medication three
times a day before meals.
- START Zyprexa for nausea.
- START miconazole powder for groin rash

Please follow-up with your physicians as listed below.

Followup Instructions:
Department: INTERVENTIONAL PULMONOLOGY
When: THURSDAY [**2182-2-21**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2182-2-21**] at 4:00 PM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2182-2-21**] at 4:00 PM
With: DR. [**First Name8 (NamePattern2) 24186**] [**Last Name (NamePattern1) 24187**] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Malignant pleural effusion,Acute and chronic respiratory failure,Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Malignant neoplasm of bronchus and lung, unspecified,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of brain and spinal cord,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Other chronic pulmonary heart diseases,Encounter for palliative care,Unspecified essential hypertension,Nausea alone,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Do not resuscitate status,Anemia, unspecified,Neoplasm related pain (acute) (chronic),Insomnia, unspecified,Constipation, unspecified,Adjustment disorder with anxiety,Personal history of malignant neoplasm of prostate'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: hypoxia

PRESENT ILLNESS: 75 YOM with history of HTN who had progressive DOE and fatigue
over the fall with two courses of ABX for PNA with no
improvement.  He was sent for a CT of the chest [**2182-1-18**] which
revealed findings consistent with lung cancer in the left field
with metastases to the right lung, liver, bones and likely
adrenal glands.  He underwent a left sided thoracentesis on
[**2182-1-24**] with removal of 2L of fluid.  The cytology from the
pleural effusion showed adenocarcinoma with immunostains of the
tumor cells positive for CK7, [**Last Name (un) **]-31 and TTF-1.  He subsequently
underwent MR of the head and thoracic spine on [**2182-1-30**] which
showed diffuse metastasis.
.
He went to [**Hospital **] clinic this afternoon with progressive worsening
of dyspnea. Had 2 L taken off and was direct admitted to floor
for observation overnight and plan for pleuradesis or possible
pleurex cath placement in the morning with subsequent transfer
to OMED.
.
On arrival to the floor he was sattign 84% on NRB and nursing
triggered and transferred the patient to MICU six.
.
On arrival to the MICU he is comfortable lying on his right side
with O2 sats of 955 on NRB. He had minimal pain at the site of
the thoracentesis.
.
.
Review of systems:
(+) Per HPI

MEDICAL HISTORY: Prostate cancer s/p XRT ~[**2172**] treated at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 47**] Oncology
Center
Hypertension
Hyperlipidemia
Stage IV lung adenocarcinoma (as described above)

MEDICATION ON ADMISSION: AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily
CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - [**12-31**] tsp(s) by
mouth up to q 4 hrs prn cough
HYDROCHLOROTHIAZIDE - 12.5 mg Tablet - 1 Tablet(s) by mouth
daily
HYDROCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**12-31**] Tablet(s)
by
mouth po q6hrs prn pain
LATANOPROST [XALATAN] - 0.005 % Drops - 1 ou hs
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth daily
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth every 8 hrs prn
anxiety
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
Tmax: 37.4 ??????C (99.3 ??????F)
Tcurrent: 37.4 ??????C (99.3 ??????F)
HR: 108 (96 - 108) bpm
BP: 113/51(75) {113/45(62) - 122/54(75)} mmHg
RR: 25 (17 - 25) insp/min
SpO2: 98%
Heart rhythm: ST (Sinus Tachycardia)
Height: 68 Inch
General Appearance: Well nourished, Anxious
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: No(t) Symmetric), (Percussion:
Dullness : left lung fields), (Breath Sounds: Clear : right lung
fields, Diminished: left lung [**Last Name (un) 8434**])
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin:  Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed

FAMILY HISTORY: Sister - breast cancer in her 70s.
Mother is 95 and in good health.
Father is 94 and in good health.

SOCIAL HISTORY: Mr. [**Known lastname 18418**] is married to [**Doctor First Name 15359**] who is his second wife.  [**Name (NI) **] has
a daughter and 2 sons.  [**Name (NI) 15359**] has 2 children.  Quit smoking
~[**2154**].  Smoked 2 packs per day X 25-30 years.  Was a heavy
drinker until [**2149**]; required detox at that time.  He is a
painter
by profession and was working until he got sick. Was in the
marines. 

### Response:
{'Malignant pleural effusion,Acute and chronic respiratory failure,Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Malignant neoplasm of bronchus and lung, unspecified,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of brain and spinal cord,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Other chronic pulmonary heart diseases,Encounter for palliative care,Unspecified essential hypertension,Nausea alone,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Do not resuscitate status,Anemia, unspecified,Neoplasm related pain (acute) (chronic),Insomnia, unspecified,Constipation, unspecified,Adjustment disorder with anxiety,Personal history of malignant neoplasm of prostate'}
