CHIEF COMPLAINT: Hypoxia

PRESENT ILLNESS: 77F h/o diastolic CHF, CRI, recurrent pleural effusions,
transferred from [**Hospital6 5016**] on [**2115-2-4**] for further w/u
of persistent pleural effusions.  Pt had undergone L
thoracentesis on [**2115-1-30**], which demonstrated nonmalignant
effusions with exudative protein count but otherwise
transudative markers.  After the thoracentesis, pt became
hypoxic on RA, decreasing to 74% with slight improvement after
receivng 2-3L O2 NC.
.
On presentation to the ED after her thoracentesis, pt was
diagnosed with "reexpansion pulmonary edema," placed on BIPAP,
and received levofloxacin but switched to clindamycin on [**1-31**]
due to prolonged QT interval and concomitant sotalol use.
Subsequently, pt appeared to have developed flash pulmonary
edema on [**2-2**] to which she responded to furosemide 40 mg IV with
900 cc urine output, with oxygen saturation 94-95% on 50%
facemask.  She later vomited x2, and then sotalol was held for
QTc 510 ms.
.
Pt was later transferred to [**Hospital1 18**] to undergo pleuroscopy in the
IP suite.  During IP, pt desaturated to mid-70s on 5L NC after
being placed on her R side, and improved to mid-80s with
repositioning.  She was then transferred to the MICU for closer
management, where she was treated with clindamycin for
presumptive asp PNA, and albuterol/ipratropium nebulizers.  A
pigtail catheter was placed to drain L pleural effusion.  CTA PE
was held given elevated creatinine.  Pt's oxygen saturations
stabilized on 1L NC, and pt was transferred to the floor.

MEDICAL HISTORY: # COPD
# Chronic pleural effusions
--[**11-10**]: Transudative effusions s/p R thoracentesis
--[**2114-12-10**]: Transudative effusions s/p B thoracentesis
# CRI (baseline creat ~2.5) [**1-5**] hypertensive nephrosclerosis
# Diastolic CHF (EF 55%)
# MVP (3+ MR)
# Sick sinus syndrome s/p pacemaker
# HTN
# Anemia of chronic disease
# Hyperlipidemia
# Rheumatoid arthritis
# Osteoarthritis
# Osteoporosis

MEDICATION ON ADMISSION: Meds at home:
Sotalol 40 mg [**Hospital1 **]
Pravastatin 20 mg daily
Multivitamin
Furosemide 20 mg QOD
Lisinopril 40 mg [**Hospital1 **]
Hydralazine 50 mg [**Hospital1 **]
Verapamil 240 mg daily
Hydroxychloroquine 200 mg daily
Aspirin 81 mg daily
Caltrate
Oxygen via nasal cannula, 2 L
.
Medications on transfer to [**Hospital1 18**]:
Esomeprazole 40 mg IV daily
Hydralazine 50 mg PO q6h
Verapamil SR 240 mg PO daily
Hydroxychloroquine 200 mg PO daily
Aspirin 81 mg daily
Clindamycin 600 mg IV q8h
Alprazolam 0.5 mg PO prn
.
Meds on transfer to MICU:
Ondansetron
Pantoprazole 40 mg daily
Verapamil 240 mg daily
Plaquenil 200 mg [**Hospital1 **]
Clindamycin 600 mg IV q8h
Alprazolam 0.5 mg Qhs prn
Acetaminophen PRN
Heparin SC TID
.
Allergies: PCN / erythromycin

ALLERGIES: Penicillins / Erythromycin Base

PHYSICAL EXAM: VS: Temp 97.8, BP 160/59, HR 88, RR 25, O2sat 94 on 1L NC --> 88
on 1L NC when repositioned in bed
GEN: NAD
HEENT: PERRL, EOMI, anicteric, MMM, OP clear
NECK: No LAD, no JVD
RESP: Dullness to percussion and no breath sounds noted at
bilateral bases to ~1/2 up lung fields, B apices clear, no
wheezing
CV: RRR, S1 and S2, no m/r/g
ABD: Soft, ND, NT, BS+
EXT: W/W/P, no edema

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: # Professional: Retired nurse.
# Tobacco: Prior 20+ year smoking history.
# Alcohol: None.
Unspecified pleural effusion,Acute on chronic diastolic heart failure,Chronic airway obstruction, not elsewhere classified,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Iatrogenic pneumothorax,Pressure ulcer, lower back,Hypopotassemia,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary tract infection, site not specified,Chronic kidney disease, unspecified,Hypoxemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Surgical or other procedure not carried out because of contraindication,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Mitral valve disorders,Other and unspecified hyperlipidemia,Rheumatoid arthritis,Personal history of tobacco use,Other dependence on machines, supplemental oxygen,Cardiac pacemaker in situ
Pleural effusion NOS,Ac on chr diast hrt fail,Chr airway obstruct NEC,Food/vomit pneumonitis,Acute kidney failure NOS,Iatrogenic pneumothorax,Pressure ulcer, low back,Hypopotassemia,React-indwell urin cath,Urin tract infection NOS,Chronic kidney dis NOS,Hypoxemia,Abn react-procedure NEC,Accid in resident instit,No proc/contraindication,Hy kid NOS w cr kid I-IV,Mitral valve disorder,Hyperlipidemia NEC/NOS,Rheumatoid arthritis,History of tobacco use,Depend-supplement oxygen,Status cardiac pacemaker
Admission Date:  [**2115-2-4**]              Discharge Date:   [**2115-2-11**]

Date of Birth:  [**2038-1-22**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Erythromycin Base

Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Hypoxia

Major Surgical or Invasive Procedure:
Ultrasound-guided placement of left pigtail catheter

History of Present Illness:
77F h/o diastolic CHF, CRI, recurrent pleural effusions,
transferred from [**Hospital6 5016**] on [**2115-2-4**] for further w/u
of persistent pleural effusions.  Pt had undergone L
thoracentesis on [**2115-1-30**], which demonstrated nonmalignant
effusions with exudative protein count but otherwise
transudative markers.  After the thoracentesis, pt became
hypoxic on RA, decreasing to 74% with slight improvement after
receivng 2-3L O2 NC.
.
On presentation to the ED after her thoracentesis, pt was
diagnosed with "reexpansion pulmonary edema," placed on BIPAP,
and received levofloxacin but switched to clindamycin on [**1-31**]
due to prolonged QT interval and concomitant sotalol use.
Subsequently, pt appeared to have developed flash pulmonary
edema on [**2-2**] to which she responded to furosemide 40 mg IV with
900 cc urine output, with oxygen saturation 94-95% on 50%
facemask.  She later vomited x2, and then sotalol was held for
QTc 510 ms.
.
Pt was later transferred to [**Hospital1 18**] to undergo pleuroscopy in the
IP suite.  During IP, pt desaturated to mid-70s on 5L NC after
being placed on her R side, and improved to mid-80s with
repositioning.  She was then transferred to the MICU for closer
management, where she was treated with clindamycin for
presumptive asp PNA, and albuterol/ipratropium nebulizers.  A
pigtail catheter was placed to drain L pleural effusion.  CTA PE
was held given elevated creatinine.  Pt's oxygen saturations
stabilized on 1L NC, and pt was transferred to the floor.

Past Medical History:
# COPD
# Chronic pleural effusions
--[**11-10**]: Transudative effusions s/p R thoracentesis
--[**2114-12-10**]: Transudative effusions s/p B thoracentesis
# CRI (baseline creat ~2.5) [**1-5**] hypertensive nephrosclerosis
# Diastolic CHF (EF 55%)
# MVP (3+ MR)
# Sick sinus syndrome s/p pacemaker
# HTN
# Anemia of chronic disease
# Hyperlipidemia
# Rheumatoid arthritis
# Osteoarthritis
# Osteoporosis

Social History:
# Professional: Retired nurse.
# Tobacco: Prior 20+ year smoking history.
# Alcohol: None.

Family History:
Noncontributory

Physical Exam:
VS: Temp 97.8, BP 160/59, HR 88, RR 25, O2sat 94 on 1L NC --> 88
on 1L NC when repositioned in bed
GEN: NAD
HEENT: PERRL, EOMI, anicteric, MMM, OP clear
NECK: No LAD, no JVD
RESP: Dullness to percussion and no breath sounds noted at
bilateral bases to ~1/2 up lung fields, B apices clear, no
wheezing
CV: RRR, S1 and S2, no m/r/g
ABD: Soft, ND, NT, BS+
EXT: W/W/P, no edema


Pertinent Results:
Notable labs:
.
[**2115-2-5**] 07:35AM BLOOD Glucose-111* UreaN-46* Creat-2.3* Na-136
K-4.3 Cl-100 HCO3-24 AnGap-16
[**2115-2-5**] 01:58PM BLOOD Type-ART pO2-51* pCO2-47* pH-7.38
calTCO2-29 Base XS-1 Intubat-NOT INTUBA
.
Imaging:
.
# OSH CT chest ([**1-30**]): Post left thoracentesis with considerable
edema in the lower half of the left lung felt to be related to
re-expansion. left upper lung and right lung are clear although
chronic changes are present. small amounts of residual bilateral
pleural fluid. less than 10% left sided pneumothorax.
.
# OSH CXR ([**1-31**]): Dense left lower lob infiltrate with patchy
right lower lobe infiltrate, left pleural effusion suspected.
.
# CHEST (PORTABLE AP)  [**2115-2-6**] 5:27 AM
1.  Status post left pigtail catheter placement in left upper
chest with new left-sided pneumothorax at the base.
2.  More severe right-sided pleural effusion.
3.  Stable increased retrocardiac opacity likely representing
compressive atelectasis.
.
# RENAL U.S.  [**2115-2-7**] 3:27 PM: Small, symmetrical kidneys with
thin cortex. No hydronephrosis and no stones or solid masses.
Bilateral pleural effusion.
.
# CHEST (PORTABLE AP)  [**2115-2-10**] 3:04 PM: Bilateral pleural
effusions, slightly increased with the greater portion of the
fluid loculated within the mid lung fields.

Brief Hospital Course:
77F h/o HTN, CRI [**1-5**] hypertensive nephropathy, diastolic CHF,
chronic pleural effusions, transferred to [**Hospital1 18**] from OSH to
undergo pleuroscopy, then transferred to MICU from IP suite
after hypoxia during aborted pleuroscopy, s/p pigtail catheter
to drain L pleural effusion, s/p talc pleurodesis, treated for
aspiration PNA, COPD, and CHF.
.
# Hypoxia: Pt became hypoxic after OSH thoracentesis, and again
later during attempted pleuroscopy at [**Hospital1 18**].  Hypoxia was
considered likely [**1-5**] underlying COPD, volume overload, chronic
pleural effusions, and aspiration PNA given history of vomiting
and report of opacity on CXR at OSH.  Pt was administered
clindamycin for aspiration PNA, and albuterol/ipratropium
nebulizers for COPD.  Pigtail cathether was placed to drain
effusions; L pneumothorax was then also noted, which resolved.
Pt completed clindaymycin x10 days for aspiration pneumonia,
with improvement in her respiratory status.
.
# Pleural effusions: Pt underwent talc pleurodesis at L pleura
per IP, with no further interventions anticipated.
.
# Diastolic CHF: Pt had known significant MR [**First Name (Titles) 151**] [**Last Name (Titles) 61935**] EF.
On transfer to floor from MICU, pt appeared euvolemic, with no
JVD and no peripheral edema.  Pt's home regimen of furosemide 20
mg QOD, lisinopril 40 mg [**Hospital1 **] were continued.
.
# HTN:  Pt was initially continued on home regimen of verapamil
240 mg daily and lisinopril 40mg [**Hospital1 **], and was restarted on
hydralazine 50 mg PO BID per home regimen upon transfer to the
floor.  Given no known h/o ventricular or supraventricular
arrhythmias, as well as development of long QTc, sotalol was
discontinued permanently.  Pt was started on HCTZ and metoprolol
50mg TID, to be uptitrated as an outpatient.
.
# UTI: Pt was noted to have a pan-sensitive E. Coli UTI, and was
started on ciprofloxacin x10 days given Foley instrumentation.
.
# Chronic renal insufficiency: Pt was noted to develop prerenal
ARF [**1-5**] poor PO and overdiuresis; this resolved after adequate
hydration.
.
# Hyperlipidemia: Pt continued on pravastatin 20mg PO daily, and
ASA 81mg daily.
.
# DNR/DNI

Medications on Admission:
Meds at home:
Sotalol 40 mg [**Hospital1 **]
Pravastatin 20 mg daily
Multivitamin
Furosemide 20 mg QOD
Lisinopril 40 mg [**Hospital1 **]
Hydralazine 50 mg [**Hospital1 **]
Verapamil 240 mg daily
Hydroxychloroquine 200 mg daily
Aspirin 81 mg daily
Caltrate
Oxygen via nasal cannula, 2 L
.
Medications on transfer to [**Hospital1 18**]:
Esomeprazole 40 mg IV daily
Hydralazine 50 mg PO q6h
Verapamil SR 240 mg PO daily
Hydroxychloroquine 200 mg PO daily
Aspirin 81 mg daily
Clindamycin 600 mg IV q8h
Alprazolam 0.5 mg PO prn
.
Meds on transfer to MICU:
Ondansetron
Pantoprazole 40 mg daily
Verapamil 240 mg daily
Plaquenil 200 mg [**Hospital1 **]
Clindamycin 600 mg IV q8h
Alprazolam 0.5 mg Qhs prn
Acetaminophen PRN
Heparin SC TID
.
Allergies: PCN / erythromycin

Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation Q4H (every 4 hours) as needed.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
12. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
13. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
15. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
18. Ondansetron 4 mg IV Q8H:PRN


Discharge Disposition:
Extended Care

Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57850**] Healthcare Center - [**Location (un) **]

Discharge Diagnosis:
Primary:
Hypoxia
Congestive Heart Failure (acute on chronic diastolic)
Chronic Pleural Effusions
COPD
Chronic Renal Insufficiency
Mitral Valve Prolapse with 3+MR
Hypertension
.
Secondary:
Sick Sinus Syndrome s/p pacer
Rheumatoid Arthritis
Anemia of Chronic Disease
Hyperlipidemia


Discharge Condition:
Stable, blood pressures still running high, actively uptitrating
metoprolol for further control.


Discharge Instructions:
You were admitted with hypoxia during pleuroscopy, and were
maintained with a pigtail catheter to drain a left sided pleural
effusion, and were treated for aspiration pneumonia, UTI, COPD,
and CHF.
.
During this admission, Sotalol was stopped. Please do not take
this medication anymore. Because you blood pressure was running
high, we increased your dose of metoprolol to 50 three times
daily on discharge, but this should be continued to be increased
to better control your blood pressure. Additionally, you will
remain on the following medications: lisinopril 40mg daily, HTCZ
25mg daily, hydralazine 50 mg PO Q6H for your blood pressure.
.
Additionally, you were noted to have hematuria on this
admission, which resolved by the time of discharge. We believe
that this was secondary to a UTI (catheter related), so you will
complete a 10 day course of ciprofloxacin for this (this will
also treat a presumed aspiration pneumonia as well).
.
Please return to hospital for fevers, shortness of breath, chest
pain or other symptoms that concern you.


Followup Instructions:
Please follow up with your primary care physician.



Completed by:[**2115-2-17**]
{'Unspecified pleural effusion,Acute on chronic diastolic heart failure,Chronic airway obstruction, not elsewhere classified,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Iatrogenic pneumothorax,Pressure ulcer, lower back,Hypopotassemia,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary tract infection, site not specified,Chronic kidney disease, unspecified,Hypoxemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Surgical or other procedure not carried out because of contraindication,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Mitral valve disorders,Other and unspecified hyperlipidemia,Rheumatoid arthritis,Personal history of tobacco use,Other dependence on machines, supplemental oxygen,Cardiac pacemaker in situ'}


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: 77F h/o diastolic CHF, CRI, recurrent pleural effusions,
transferred from [**Hospital6 5016**] on [**2115-2-4**] for further w/u
of persistent pleural effusions.  Pt had undergone L
thoracentesis on [**2115-1-30**], which demonstrated nonmalignant
effusions with exudative protein count but otherwise
transudative markers.  After the thoracentesis, pt became
hypoxic on RA, decreasing to 74% with slight improvement after
receivng 2-3L O2 NC.
.
On presentation to the ED after her thoracentesis, pt was
diagnosed with "reexpansion pulmonary edema," placed on BIPAP,
and received levofloxacin but switched to clindamycin on [**1-31**]
due to prolonged QT interval and concomitant sotalol use.
Subsequently, pt appeared to have developed flash pulmonary
edema on [**2-2**] to which she responded to furosemide 40 mg IV with
900 cc urine output, with oxygen saturation 94-95% on 50%
facemask.  She later vomited x2, and then sotalol was held for
QTc 510 ms.
.
Pt was later transferred to [**Hospital1 18**] to undergo pleuroscopy in the
IP suite.  During IP, pt desaturated to mid-70s on 5L NC after
being placed on her R side, and improved to mid-80s with
repositioning.  She was then transferred to the MICU for closer
management, where she was treated with clindamycin for
presumptive asp PNA, and albuterol/ipratropium nebulizers.  A
pigtail catheter was placed to drain L pleural effusion.  CTA PE
was held given elevated creatinine.  Pt's oxygen saturations
stabilized on 1L NC, and pt was transferred to the floor.

MEDICAL HISTORY: # COPD
# Chronic pleural effusions
--[**11-10**]: Transudative effusions s/p R thoracentesis
--[**2114-12-10**]: Transudative effusions s/p B thoracentesis
# CRI (baseline creat ~2.5) [**1-5**] hypertensive nephrosclerosis
# Diastolic CHF (EF 55%)
# MVP (3+ MR)
# Sick sinus syndrome s/p pacemaker
# HTN
# Anemia of chronic disease
# Hyperlipidemia
# Rheumatoid arthritis
# Osteoarthritis
# Osteoporosis

MEDICATION ON ADMISSION: Meds at home:
Sotalol 40 mg [**Hospital1 **]
Pravastatin 20 mg daily
Multivitamin
Furosemide 20 mg QOD
Lisinopril 40 mg [**Hospital1 **]
Hydralazine 50 mg [**Hospital1 **]
Verapamil 240 mg daily
Hydroxychloroquine 200 mg daily
Aspirin 81 mg daily
Caltrate
Oxygen via nasal cannula, 2 L
.
Medications on transfer to [**Hospital1 18**]:
Esomeprazole 40 mg IV daily
Hydralazine 50 mg PO q6h
Verapamil SR 240 mg PO daily
Hydroxychloroquine 200 mg PO daily
Aspirin 81 mg daily
Clindamycin 600 mg IV q8h
Alprazolam 0.5 mg PO prn
.
Meds on transfer to MICU:
Ondansetron
Pantoprazole 40 mg daily
Verapamil 240 mg daily
Plaquenil 200 mg [**Hospital1 **]
Clindamycin 600 mg IV q8h
Alprazolam 0.5 mg Qhs prn
Acetaminophen PRN
Heparin SC TID
.
Allergies: PCN / erythromycin

ALLERGIES: Penicillins / Erythromycin Base

PHYSICAL EXAM: VS: Temp 97.8, BP 160/59, HR 88, RR 25, O2sat 94 on 1L NC --> 88
on 1L NC when repositioned in bed
GEN: NAD
HEENT: PERRL, EOMI, anicteric, MMM, OP clear
NECK: No LAD, no JVD
RESP: Dullness to percussion and no breath sounds noted at
bilateral bases to ~1/2 up lung fields, B apices clear, no
wheezing
CV: RRR, S1 and S2, no m/r/g
ABD: Soft, ND, NT, BS+
EXT: W/W/P, no edema

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: # Professional: Retired nurse.
# Tobacco: Prior 20+ year smoking history.
# Alcohol: None. 

### Response:
{'Unspecified pleural effusion,Acute on chronic diastolic heart failure,Chronic airway obstruction, not elsewhere classified,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Iatrogenic pneumothorax,Pressure ulcer, lower back,Hypopotassemia,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary tract infection, site not specified,Chronic kidney disease, unspecified,Hypoxemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Surgical or other procedure not carried out because of contraindication,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Mitral valve disorders,Other and unspecified hyperlipidemia,Rheumatoid arthritis,Personal history of tobacco use,Other dependence on machines, supplemental oxygen,Cardiac pacemaker in situ'}
