CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: 54F h/o behcets, transferred from outside hospital with
bilateral PEs, including saddle. Pt has been in rehab lately.
SOB x 3 weeks. Surgery monday, yestserday worse, OSH shows CT
saddle and bilateral PEs. She has been having more dyspnea with
transfers to bed to wheelchair, and it became much worse
yesterday. She is dyspneic at rest, and much worse with
exertion. She had left foot surgery 4 days ago.  The patient
notes that she had a clot in her leg 3 yrs ago s/p a leg
fracture, for which she was on heparin for only one week.  She
notes no hx of PE, no fam hx of DVT/PE, and no known clotting
disorders.  She does not smoke or take oral contraceptives. The
patient notes that she had shortness of breath for the past week
and a half, was started on 2L NC last week, and given a new
diagnosis of heart failure last week, w/ addition of lasix and
matolazone.

MEDICAL HISTORY: Hospitalized in [**2116-8-27**] for sepsis, renal failure
Recent L first toe joint resection secondary to persistent ulcer
chronic intractable pain
Constipation
Diabetes mellitus type 2 with neurological manifestations
Foot ulceration
Opiate dependence
Seizure disorder
Depression
Behcet's disease
Hypercholesteremia
Hypothyroidism
Lupus
DVT

MEDICATION ON ADMISSION: -acidophilus
-carafate 1g tid
-duoneb tid prn -- not taking
-ferrous sulfate 325 [**Hospital1 **]
-Fentanyl 75 mcg/hr Transdermal Patch 72 hr apply one Q 72 hours

ALLERGIES: Tetracycline / doxycycline

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
afebrile, HR 100, 95/71, 97% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM,
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, obese, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, L foot in cast, edema to
mid-tibia in R lower extremity, pitting

FAMILY HISTORY: no hx of blood clots, blood disorders, DVT, PE in family

SOCIAL HISTORY: - Tobacco: none
- Alcohol: none
- Illicits: none
Pt lives in [**Location 1459**] Care and Rehab since [**9-19**] (s/p
hospitalization for sepsis, renal failure). Has gotten a bed at
an [**Hospital3 **] facility to live in starting [**2117-3-28**].
Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Chronic osteomyelitis, ankle and foot,Heart disease, unspecified,Congestive heart failure, unspecified,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Other chronic pulmonary heart diseases,Behcet's syndrome,Systemic lupus erythematosus,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified acquired hypothyroidism,Other chronic pain,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Polyneuropathy in diabetes,Depressive disorder, not elsewhere classified,Long-term (current) use of insulin,Obesity, unspecified,Anemia, unspecified,Opioid type dependence, unspecified,Pure hypercholesterolemia
Pulm embol/infarct NEC,Ac DVT/emb prox low ext,Chr osteomyelit-ankle,Heart disease NOS,CHF NOS,Proteus infection NOS,Chr pulmon heart dis NEC,Behcet's syndrome,Syst lupus erythematosus,Epilep NOS w/o intr epil,Hypothyroidism NOS,Chronic pain NEC,DMII neuro uncntrld,Neuropathy in diabetes,Depressive disorder NEC,Long-term use of insulin,Obesity NOS,Anemia NOS,Opioid dependence-unspec,Pure hypercholesterolem
Admission Date:  [**2117-2-4**]              Discharge Date:   [**2117-2-12**]

Date of Birth:  [**2062-3-19**]             Sex:   F

Service: MEDICINE

Allergies:
Tetracycline / doxycycline

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
IVC filter placement
PICC placement


History of Present Illness:
54F h/o behcets, transferred from outside hospital with
bilateral PEs, including saddle. Pt has been in rehab lately.
SOB x 3 weeks. Surgery monday, yestserday worse, OSH shows CT
saddle and bilateral PEs. She has been having more dyspnea with
transfers to bed to wheelchair, and it became much worse
yesterday. She is dyspneic at rest, and much worse with
exertion. She had left foot surgery 4 days ago.  The patient
notes that she had a clot in her leg 3 yrs ago s/p a leg
fracture, for which she was on heparin for only one week.  She
notes no hx of PE, no fam hx of DVT/PE, and no known clotting
disorders.  She does not smoke or take oral contraceptives. The
patient notes that she had shortness of breath for the past week
and a half, was started on 2L NC last week, and given a new
diagnosis of heart failure last week, w/ addition of lasix and
matolazone.

In the ED inital vitals were,  98.1 104 118/68 22 96% 2L Nasal
Cannula. Patient was initiated on a heparin drip.
Gave 1 L IVF. EKG: sinus @ 100, NA, NI, QIII and TWI in III, no
STE
Vitals on transfer: 103, RR 20, 94/66, 96% 2L

On arrival to the ICU, vital signs afebrile, HR 100, 95/71, 97%
on 3L. Pt comfortable, in no distress, and able to give a clear
and coherent medical history.

Review of systems:
(+) Per HPI, constipation, lightheadedness
(-) 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, abdominal pain. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.

Past Medical History:
Hospitalized in [**2116-8-27**] for sepsis, renal failure
Recent L first toe joint resection secondary to persistent ulcer
chronic intractable pain
Constipation
Diabetes mellitus type 2 with neurological manifestations
Foot ulceration
Opiate dependence
Seizure disorder
Depression
Behcet's disease
Hypercholesteremia
Hypothyroidism
Lupus
DVT

Social History:
- Tobacco: none
- Alcohol: none
- Illicits: none
Pt lives in [**Location 1459**] Care and Rehab since [**9-19**] (s/p
hospitalization for sepsis, renal failure). Has gotten a bed at
an [**Hospital3 **] facility to live in starting [**2117-3-28**].


Family History:
no hx of blood clots, blood disorders, DVT, PE in family


Physical Exam:
ADMISSION PHYSICAL EXAM:
afebrile, HR 100, 95/71, 97% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM,
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, obese, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, L foot in cast, edema to
mid-tibia in R lower extremity, pitting

Pertinent Results:
ADMISSION LABS:
[**2117-2-4**] 11:50PM BLOOD WBC-14.0* RBC-3.89* Hgb-12.3 Hct-37.6
MCV-97 MCH-31.5 MCHC-32.6 RDW-16.8* Plt Ct-332
[**2117-2-4**] 11:50PM BLOOD Neuts-64.6 Lymphs-32.5 Monos-1.6* Eos-0.9
Baso-0.5
[**2117-2-4**] 11:50PM BLOOD PT-10.7 PTT-37.3* INR(PT)-1.0
[**2117-2-4**] 11:50PM BLOOD Glucose-162* UreaN-31* Creat-1.2* Na-137
K-3.5 Cl-94* HCO3-29 AnGap-18
[**2117-2-4**] 11:50PM BLOOD cTropnT-0.05*
[**2117-2-4**] 11:50PM BLOOD CK-MB-4 proBNP-8296*

At OSH:
BUN 31, Cr 1.1, Na 140, K 3.3, Cl 96, CO2 29
trop t 0.02, BNP 5450, Mg 2.5
DDimer 5.64 (nl 0.5)

L foot biopsy from surgery demonstrates few polys and few gram
positive cocci: prelim proteus mirabilis, diphtheroids,
enterococcus, w/ proteus sensis in chart

Micro:  none

Images:
OSH CXR ([**2-4**]): lungs and pleura clear, cardiomediastinal
silhouette is normal. no bony abnl seen.

CTPA ([**2-4**]): Multiple pulmonary emboli including a saddle
embolus. Pulmonary emboli involve both the L and R pulmonary
arteries as well as all lobar and most segmental branches.  The
thoracic aorta is normal.  The heart is normal.  The lungs are
clear.  There is no mediastinal or hilar adenopathy.

EKG:
([**2116-3-6**]):Normal sinus rhythm. Normal ECG

BILAT LOWER EXT VEINS Study Date of [**2117-2-5**] 11:13 AM
FINDINGS: Bilateral lower extremity venous duplex.
RIGHT LOWER EXTREMITY:
The common femoral and proximal femoral shows normal flow and
compression.
The mid and distal femoral vein, the popliteal vein and the
posterior tibial veins show no flow and no compression.
The peroneal veins could not be seen.
LEFT LOWER EXTREMITY:
The common femoral vein and proximal femoral vein shows normal
flow and
compression.
Mid and distal femoral vein show partial compression and
intermittent flow
within them.
The popliteal, the posterior tibial and peroneal veins show
normal flow and compression.
IMPRESSION:
1. DVT of the right mid-to-distal femoral vein, popliteal and
PTV.
2. Partial thrombosis of the left mid and distal femoral vein.

Portable TTE (Focused views) Done [**2117-2-6**] at 1:45:05 PM
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis
and preservation of apical function ([**Last Name (un) 13367**] sign).
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.] There
is abnormal systolic septal motion/position consistent with
right ventricular pressure overload. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. There is no aortic
valve stenosis. The mitral valve leaflets are structurally
normal. No mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.

IMPRESSION: Suboptimal image quality. Right ventricular cavity
enlargement with free wall hypokinesis. Moderate pulmonary
artery hypertension.

CXR:
IMPRESSION: AP chest compared to [**2115-2-6**]:35 a.m.
Tip of the new left brachial PICC line is in the lower third of
the SVC.
Heart size top normal. Lungs clear

Repeat ECHO:
IMPRESSION: Moderately dilated and hypokinetic right ventricle.
Moderate pulmonary artery systolic hypertension. Preserved left
ventricular systolic function.


Brief Hospital Course:
Assessment and Plan: 54F h/o Beh??????et, transferred from outside
hospital with dyspnea and e/o bilateral PEs, including saddle
embolus.

# Acute PE:
Patient has had shortness of breath for approximately 3 weeks.
It is likely that pt had some PE at that point, which grew or
were exacerbated by surgery and further immobilization on
Monday. Pt w/ surgery on Monday [**2-1**].  Worsening shortness of
breath since then.  At OSH, CTA demonstrated extensive bilateral
pulmonary emboli, w/ e/o saddle embolism.  PE most likely
secondary to immobility, as patient has been in rehab for
months. No family hx of DVT/PE, clotting disorders or
malignancy.  Patient apparently had a DVT after fracturing foot
years ago. Patient is obese.  Patient is transferred on heparin
drip.  Patient has never been tested for anti-phospholipid
syndrome. Per hx, pt has lupus, which also may contribute to a
pro-thrombotic picture. Patient's systolic pressures were
occasionally low to the 80 range although responsive to fluid
boluses (500 cc at a time of LR increasing pressures to the
120s).  Echo did demonstrate right heart strain and pulmonary
hypertension.  Bilateral lower extremity ultrasound did
demonstrate bilateral DVTs and the interventional radiology team
placed an IVC filter [**2117-2-5**].  Therapeutic PTT was difficult to
achieve during the initial phase of hospitalization, with
patient eventually needing [**2104**] units of heparin / hour to keep
PTT at goal of 80.  In close consultation with cardiology team;
given that clot likely had been present for up to 3 weeks, the
decision was made to hold on catheter directed therapy and to
reserve TPA treatment in the event of acute decompensation.
Rheumatology consult deemed that Behcet's disease likely
quiescent and no need for stress dose steroids, besides to
maintain pressures in the event of adrenal insufficiency.  We
enjoyed consultation with the hematology team who also
recommended continuation of the heparin drip.  Coumadin was
started [**2-8**] with goal INR [**1-29**] for likely lifetime.  However,
after [**1-29**] doses 5 mg, INR increased rapidly to 4.  Was held then
restarted at 2mg on [**2-11**].  Will likely need 2-3 mg ultimately
once completes antibiotics.
- Patient will require Warfarin therapy, goal INR [**1-29**], for
indefinite therapy.  Please note patient is quite sensitive to
Warfarin
- Please bridge subtherapeutic INR <2 with Lovenox 1mg/kg q12 if
necessary
- Follow up with HMVA hematology
- Follow up with HMVA Cardiology: will need repeat Echo in 3
months
- Consider removal of IVC filter after 3 months.  Patient would
need to be off anticoagulation for procedure.  [**Hospital1 18**] IR:
[**Telephone/Fax (1) 8243**]

# [**2117-2-1**] podiatric operation by Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 41949**] (Left
foot 1st joint resection and 2nd toe manipulation) Per OSH
records: bone biopsy from [**2117-2-1**]: proteus resistant to Bactrim,
moxifloxacin, gentamycin and Cipro.  Sensitive to ampicillin,
cefazolin, meropenem, tobramycin.  Patient was given Bactrim 2
tabs daily for a week and switched to cefpodoxime for "mop up"
therapy until [**2-15**].  Patient will have daily dressing changes
until discharge and will need follow up approx [**2-23**] for suture
removal with Dr. [**Last Name (STitle) **].
- keep in brace

# Behcet's Disease: Rheumatology consulted and not felt to be
active during her hospitalization.  She was initially given
stress dose steroids but transitioned to her usual Prednisone
20mg [**Hospital1 **].  Cal, Vit D initiated.  Bactrim 1 DS 3/wk initiated
for PCP [**Name Initial (PRE) 1102**].  Anticardiolipin antibioties are NEGATIVE.
- Follow up with rheumatologist

# Chronic intractable pain: Pt on chronic narcotics.  Most of
intractable pain from Behcet's lesions (mucosae, vagina).  On
methadone, fentanyl and Dilaudid.  We continued fentanyl,
Dilaudid (slightly lower doses than home so as not to exacerbate
hypotension initially, then resumed usual dose 8mg q6) as well
as gabapentin.  We held oxycodone.  Continued bowel regimen

# DMII, uncontrolled: HA1c 8.4 approximately one year ago at
PCP.  [**Name10 (NameIs) **] insulin dependent.  Complicated by neuropathy
- continue home lantus and HISS
- frequent FS

# seizure disorder: stable
- continued Keppra

# Depression: stable
- continued home psych meds

# Communication: Patient
HCP [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 41950**], mother [**Telephone/Fax (1) 41951**]
# Code: Full (discussed with patient)

Also, please note LASIX on HOLD until felt medically stable to
resume.

===================
Transitional issues
===================
- will need outpatient work-up re: secondary reasons of PE like
underlying malignancy (does have chronic vaginal bleeding, etc)
although in the context of patient being immobile and in and out
of wheelchair since [**9-7**].
- IVC filter is in place, ? pull in 3 months ([**2117-5-6**])
- Follow up TTE [**5-8**] to eval for PHTN
- outpatient pulm follow up
- Pods follow up approx [**2-23**] for suture removal, need to
schedule Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 41949**], dry dressing changes until then
PRN.


Medications on Admission:
-acidophilus
-carafate 1g tid
-duoneb tid prn -- not taking
-ferrous sulfate 325 [**Hospital1 **]
-Fentanyl 75 mcg/hr Transdermal Patch 72 hr apply one Q 72 hours

-methadone 30mg q6-8hrs
-Hydromorphone (DILAUDID) 6-8 mg Oral Tablet q4-6hrs PRN
-Gabapentin 800mg qd
-gabapentin 200mg [**Hospital1 **]
-Azathioprine 50 mg 250 mg qd
-Prednisone 20mg [**Hospital1 **]
-protonix 40mg qd
-Oxycodone 15 mg Oral Tablet 1 tab q 4hrs as per patient
-Aripiprazole (ABILIFY) 2 mg Oral Tablet 2 tabs daily
-Amitriptyline 100 mg Oral Tablet 1 tab at bedtime
-Ketoconazole 2 % Topical Cream APPLY UNDER ARMS TWICE DAILY
-Furosemide 60mg [**Hospital1 **]
-Insulin Glargine (LANTUS SOLOSTAR) 10units at bedtime every
night
-Insulin Needles, Disposable, (BD INSULIN PEN NEEDLE UF SHORT)
31 X [**5-12**] " Misc.(Non-Drug; Combo Route) Needle use daily with
solstar pen
-zoloft 100mg [**Hospital1 **]
-seroquel 200qhs, 50qd, 100bid
-acetaminophen 650 q6-8hrs PRN
-Insulin Aspart (NOVOLOG) sliding scale
-Keppra 1500 [**Hospital1 **]
-metolazone 2.5mg qmonday
-mucinex 600mg [**Hospital1 **]
-MVN
-bactrim DS 800-160 mg [**Hospital1 **] until [**2-11**] post-op


Discharge Medications:
1. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
5. aripiprazole 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. sertraline 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
8. quetiapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. azathioprine 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
14. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for n/v.
15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
16. methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
17. cefpodoxime 100 mg Tablet Sig: Four (4) Tablet PO Q12H
(every 12 hours): through [**2117-2-15**].
18. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
19. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
20. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
21. prednisone 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
22. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
23. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
24. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
25. hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
26. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime.
27. Humalog 100 unit/mL Solution Sig: 1-15 units Subcutaneous
qACHS: according to sliding scale.
28. Held medication
Lasix 120 mg daily
- resume once felt to be stable
29. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: note multiple drug interactions; needs close INR monitoring.

30. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
31. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous QACHS: sliding scale as directed (see separate
sheet).
32. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
33. dextrose 50% in water (D50W)     Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.



Discharge Disposition:
Extended Care

Facility:
[**Hospital **] rehab and nursing center

Discharge Diagnosis:
Acute PE with right heart strain
Lower extremity DVT
Bechet's disease
Chronic pain
Chronic osteo, left foot, s/p debridement
Depression
Seizure disorder


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:
Patient admitted with shortness of breath, and found to have
acute saddle pulmonary embolus with lower extremity DVT.  IVC
filter placed on [**2117-2-5**]. Echocardiogram showed right heart
strain, and this will need to be repeated in three months.
Transitioned to Warfarin with Heparin bridge. Maintained on
immunosuppressants for Behcets disease.

Patient will require INR goal [**1-29**] on Warfarin, as well as
indefinite anticoagulation therapy.  She will need to follow up
with her Rheumatologists and Hematologists.  She was initiated
on Cal, Vitamin D, and Bactrim for PCP [**Name Initial (PRE) 1102**].

She will need to follow up with her Podiatrists regarding her
foot care, and complete a short course of antibiotics
(cefpodoxime through [**2-15**])

After 3 months, please consider removing IVC filter.  This will
need to be done OFF anticoagulation with Interventional
Radiology.

Lasix 120 mg daily being held until felt to be stable

Followup Instructions:
PCP: [**Name10 (NameIs) 41941**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 31019**]
- within 1 week of discharge from facility

HMVA Cardiology
- within 1 month.  Will need repeat Echo in 3 months from
discharge

HMVA Rheumatology
- within 2-4 weeks

[**Hospital1 18**] Intervention Radiology.  for consideration of removal of
IVC filter
- Please have patient call [**Telephone/Fax (1) 8243**] for an appointment after
3 months


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

Completed by:[**2117-2-12**]
{"Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Chronic osteomyelitis, ankle and foot,Heart disease, unspecified,Congestive heart failure, unspecified,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Other chronic pulmonary heart diseases,Behcet's syndrome,Systemic lupus erythematosus,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified acquired hypothyroidism,Other chronic pain,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Polyneuropathy in diabetes,Depressive disorder, not elsewhere classified,Long-term (current) use of insulin,Obesity, unspecified,Anemia, unspecified,Opioid type dependence, unspecified,Pure hypercholesterolemia"}


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: dyspnea

PRESENT ILLNESS: 54F h/o behcets, transferred from outside hospital with
bilateral PEs, including saddle. Pt has been in rehab lately.
SOB x 3 weeks. Surgery monday, yestserday worse, OSH shows CT
saddle and bilateral PEs. She has been having more dyspnea with
transfers to bed to wheelchair, and it became much worse
yesterday. She is dyspneic at rest, and much worse with
exertion. She had left foot surgery 4 days ago.  The patient
notes that she had a clot in her leg 3 yrs ago s/p a leg
fracture, for which she was on heparin for only one week.  She
notes no hx of PE, no fam hx of DVT/PE, and no known clotting
disorders.  She does not smoke or take oral contraceptives. The
patient notes that she had shortness of breath for the past week
and a half, was started on 2L NC last week, and given a new
diagnosis of heart failure last week, w/ addition of lasix and
matolazone.

MEDICAL HISTORY: Hospitalized in [**2116-8-27**] for sepsis, renal failure
Recent L first toe joint resection secondary to persistent ulcer
chronic intractable pain
Constipation
Diabetes mellitus type 2 with neurological manifestations
Foot ulceration
Opiate dependence
Seizure disorder
Depression
Behcet's disease
Hypercholesteremia
Hypothyroidism
Lupus
DVT

MEDICATION ON ADMISSION: -acidophilus
-carafate 1g tid
-duoneb tid prn -- not taking
-ferrous sulfate 325 [**Hospital1 **]
-Fentanyl 75 mcg/hr Transdermal Patch 72 hr apply one Q 72 hours

ALLERGIES: Tetracycline / doxycycline

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
afebrile, HR 100, 95/71, 97% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM,
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, obese, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, L foot in cast, edema to
mid-tibia in R lower extremity, pitting

FAMILY HISTORY: no hx of blood clots, blood disorders, DVT, PE in family

SOCIAL HISTORY: - Tobacco: none
- Alcohol: none
- Illicits: none
Pt lives in [**Location 1459**] Care and Rehab since [**9-19**] (s/p
hospitalization for sepsis, renal failure). Has gotten a bed at
an [**Hospital3 **] facility to live in starting [**2117-3-28**]. 

### Response:
{"Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Chronic osteomyelitis, ankle and foot,Heart disease, unspecified,Congestive heart failure, unspecified,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Other chronic pulmonary heart diseases,Behcet's syndrome,Systemic lupus erythematosus,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified acquired hypothyroidism,Other chronic pain,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Polyneuropathy in diabetes,Depressive disorder, not elsewhere classified,Long-term (current) use of insulin,Obesity, unspecified,Anemia, unspecified,Opioid type dependence, unspecified,Pure hypercholesterolemia"}
