CHIEF COMPLAINT: Shortness of breath/fevers/HA

PRESENT ILLNESS: PCP:
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) 1730**] O.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Fax: [**Telephone/Fax (1) 29683**]
.
Date/Time: [**2112-2-27**]: 4:00 am
.
History obtained with the assistance of a [**Name6 (MD) 8003**] speaking RN
84M with h/o recurrent pleural effusions s/p pigtail catheter
placement, VATS with talc pleurodesis. His thoracoscopy was
complicated by a right pneumothorax requiring a chest tube. He
also has CKD, DM, AS and presents with a HA x 24 hours but
resolved on presentation to the ED.  He also here with SOBOE and
fever to 101.2 on presentation. He felt febrile so she took his
temperature which was 99.3. He then took 1 gm of tylenol. Even
though per the ED he presented with worsening SOB per pt he did
not have difficulties breathing, solely a headache. No visual
changes. No slurred speech. On 3L NC. CXR c/w PNA. S/p L US
guided thoracentesis 4 days PTP which produced clear
serosanguinous fluid. He felt very weak and tired after his
thoracentesis and there was no change in his breathing. Not on
oxygen at home. His breathing improved dramatically after his
recent surgery such that he was able to climb stairs without
difficulty.  He is not very active at home but he is able to
walk from one room to another.
101.2 83 207/89-> BP improved without intervention 18 94
Meds Given: azithromycin and ceftriaxone, Fluids given:
Radiology Studies:, consults called.
[x] IVF (dry on exam, increased creatinine)
[x] Cx and abx (ceftx, azithro)
- admit medicine
+ 10 pt crit drop- guiac negative in ED.
Rsided PNA and L pleural effusion.
IVF, cultures before abx.
99F 70 162/68 17 99% 2L 02
.
ROS:
-Constitutional: []WNL [+]Weight gain 8 lb []Fatigue/Malaise
[+]Fever []Chills/Rigors []Nightweats [-]Anorexia
-Eyes: [X]WNL []Blurry Vision []Diplopia []Loss of Vision
[]Photophobia
-ENT: []WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose
[]Tinnitus []Sinus pain []Sore throat
-Cardiac: []WNL [-]Chest pain []Palpitations []LE edema
[]Orthopnea/PND []DOE
-Respiratory: []WNL [+]SOB [-]Pleuritic  pain []Hemoptysis
[-]Cough
-Gastrointestinal: []WNL [-]Nausea [-]Vomiting [-]Abdominal pain
[]Abdominal Swelling [-]Diarrhea-  [-]Constipation []Hematemesis
[]Hematochezia []Melena
-Heme/Lymph: [X]WNL []Bleeding []Bruising []Lymphadenopathy
-GU: []WNL [-]Incontinence/Retention [-]Dysuria []Hematuria
[]Discharge []Menorrhagia  [+]dribbling with urination
-Skin: [X]WNL []Rash []Pruritus
-Endocrine: [X]WNL []Change in skin/hair []Loss of energy
[]Heat/Cold intolerance
-Musculoskeletal: [X]WNL []Myalgias []Arthralgias []Back pain
-Neurological: [X]WNL []Numbness of extremities []Weakness of
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo
[]Confusion []Headache
-Psychiatric: [X]WNL []Depression []Suicidal Ideation
-Allergy/Immunological: [] WNL []Seasonal Allergies
All other ROS negative.
.

MEDICAL HISTORY: HTN
DM2
CRI, baseline creatinine 2.5-3.0
hypothyroidism
GERD
antral ulceration with GI bleeding
diverticulosis
proctitis
pancreatitis
BPH
colon polyps
dperession
AS
chronic anemia
.
PSH:
right VATS, talc pleurodesis, and pleural biopsise on [**2112-1-1**].
s/p colectomy

MEDICATION ON ADMISSION: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 97.8, 181/83L , 181/81, 64, 20, 88-89% RA, 96% 2L
GENERAL: Thin, chronically ill appearing male in NAD.
Nourishment: At risk
Grooming: OK
Mentation: Alert, speaks in full setences
Eyes:NC/AT, EOMI without nystagmus, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Lungs CTA bilaterally without R/R/W
Cardiovascular: RRR, nl. S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
Genitourinary:
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or
inguinal lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor, dysdiadochokinesia noted. FNF and HKS WNL bilaterally.
-DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+
ankle jerks bilaterally. Plantar response was flexor
bilaterally.
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy

FAMILY HISTORY: sister and mother had stomach cancer. Daughter has CAD s/p
PCIx3.

SOCIAL HISTORY: Lives with wife and 1 of his daughters. From [**Country **] republic,
worked on farm there, last visit [**5-29**]. denies tobacco, alcohol,
drug use.
- No visual aides
- no dentures
- independent of ADLS
- continues to drive, no memory problems, no falls, walks
without cane or walker.
grandaughter Daughter [**Name (NI) 8314**] is HCP
Bacterial pneumonia, unspecified,Acute kidney failure, unspecified,Acute respiratory failure,Chronic diastolic heart failure,Unspecified pleural effusion,Acidosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Aortic valve disorders,Depressive disorder, not elsewhere classified,Diverticulosis of colon (without mention of hemorrhage),Esophageal reflux,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Other specified cardiac dysrhythmias,Anemia, unspecified
Bacterial pneumonia NOS,Acute kidney failure NOS,Acute respiratry failure,Chr diastolic hrt fail,Pleural effusion NOS,Acidosis,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Aortic valve disorder,Depressive disorder NEC,Dvrtclo colon w/o hmrhg,Esophageal reflux,DMII renl nt st uncntrld,Nephritis NOS in oth dis,Cardiac dysrhythmias NEC,Anemia NOS
Admission Date:  [**2112-2-27**]              Discharge Date:   [**2112-3-1**]

Date of Birth:  [**2027-4-7**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
Shortness of breath/fevers/HA

Major Surgical or Invasive Procedure:
IP service thoracentesis

History of Present Illness:
PCP:
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) 1730**] O.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Fax: [**Telephone/Fax (1) 29683**]
.
Date/Time: [**2112-2-27**]: 4:00 am
.
History obtained with the assistance of a [**Name6 (MD) 8003**] speaking RN
84M with h/o recurrent pleural effusions s/p pigtail catheter
placement, VATS with talc pleurodesis. His thoracoscopy was
complicated by a right pneumothorax requiring a chest tube. He
also has CKD, DM, AS and presents with a HA x 24 hours but
resolved on presentation to the ED.  He also here with SOBOE and
fever to 101.2 on presentation. He felt febrile so she took his
temperature which was 99.3. He then took 1 gm of tylenol. Even
though per the ED he presented with worsening SOB per pt he did
not have difficulties breathing, solely a headache. No visual
changes. No slurred speech. On 3L NC. CXR c/w PNA. S/p L US
guided thoracentesis 4 days PTP which produced clear
serosanguinous fluid. He felt very weak and tired after his
thoracentesis and there was no change in his breathing. Not on
oxygen at home. His breathing improved dramatically after his
recent surgery such that he was able to climb stairs without
difficulty.  He is not very active at home but he is able to
walk from one room to another.
101.2 83 207/89-> BP improved without intervention 18 94
Meds Given: azithromycin and ceftriaxone, Fluids given:
Radiology Studies:, consults called.
[x] IVF (dry on exam, increased creatinine)
[x] Cx and abx (ceftx, azithro)
- admit medicine
+ 10 pt crit drop- guiac negative in ED.
Rsided PNA and L pleural effusion.
IVF, cultures before abx.
99F 70 162/68 17 99% 2L 02
.
ROS:
-Constitutional: []WNL [+]Weight gain 8 lb []Fatigue/Malaise
[+]Fever []Chills/Rigors []Nightweats [-]Anorexia
-Eyes: [X]WNL []Blurry Vision []Diplopia []Loss of Vision
[]Photophobia
-ENT: []WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose
[]Tinnitus []Sinus pain []Sore throat
-Cardiac: []WNL [-]Chest pain []Palpitations []LE edema
[]Orthopnea/PND []DOE
-Respiratory: []WNL [+]SOB [-]Pleuritic  pain []Hemoptysis
[-]Cough
-Gastrointestinal: []WNL [-]Nausea [-]Vomiting [-]Abdominal pain
[]Abdominal Swelling [-]Diarrhea-  [-]Constipation []Hematemesis
[]Hematochezia []Melena
-Heme/Lymph: [X]WNL []Bleeding []Bruising []Lymphadenopathy
-GU: []WNL [-]Incontinence/Retention [-]Dysuria []Hematuria
[]Discharge []Menorrhagia  [+]dribbling with urination
-Skin: [X]WNL []Rash []Pruritus
-Endocrine: [X]WNL []Change in skin/hair []Loss of energy
[]Heat/Cold intolerance
-Musculoskeletal: [X]WNL []Myalgias []Arthralgias []Back pain
-Neurological: [X]WNL []Numbness of extremities []Weakness of
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo
[]Confusion []Headache
-Psychiatric: [X]WNL []Depression []Suicidal Ideation
-Allergy/Immunological: [] WNL []Seasonal Allergies
All other ROS negative.
.

Past Medical History:
HTN
DM2
CRI, baseline creatinine 2.5-3.0
hypothyroidism
GERD
antral ulceration with GI bleeding
diverticulosis
proctitis
pancreatitis
BPH
colon polyps
dperession
AS
chronic anemia
.
PSH:
right VATS, talc pleurodesis, and pleural biopsise on [**2112-1-1**].
s/p colectomy


Social History:
Lives with wife and 1 of his daughters. From [**Country **] republic,
worked on farm there, last visit [**5-29**]. denies tobacco, alcohol,
drug use.
- No visual aides
- no dentures
- independent of ADLS
- continues to drive, no memory problems, no falls, walks
without cane or walker.
grandaughter Daughter [**Name (NI) 8314**] is HCP


Family History:
sister and mother had stomach cancer. Daughter has CAD s/p
PCIx3.


Physical Exam:
97.8, 181/83L , 181/81, 64, 20, 88-89% RA, 96% 2L
GENERAL: Thin, chronically ill appearing male in NAD.
Nourishment: At risk
Grooming: OK
Mentation: Alert, speaks in full setences
Eyes:NC/AT, EOMI without nystagmus, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Lungs CTA bilaterally without R/R/W
Cardiovascular: RRR, nl. S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
Genitourinary:
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or
inguinal lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor, dysdiadochokinesia noted. FNF and HKS WNL bilaterally.
-DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+
ankle jerks bilaterally. Plantar response was flexor
bilaterally.
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy

*
Physical exam on discharge: Patient now has good breath sounds
on the left, but still has rhoncherous breath sounds on the
right. No LE edema. JVP 6.


Pertinent Results:
[**2112-2-27**] 01:22AM   LACTATE-0.7
[**2112-2-26**] 11:20PM   GLUCOSE-179* UREA N-55* CREAT-2.9* SODIUM-136
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-23 ANION GAP-12
[**2112-2-26**] 11:20PM   estGFR-Using this
[**2112-2-26**] 11:20PM   WBC-10.8 RBC-3.31*# HGB-8.5*# HCT-25.8*#
MCV-78* MCH-25.6* MCHC-32.9 RDW-17.4*
[**2112-2-26**] 11:20PM   NEUTS-82.4* LYMPHS-13.1* MONOS-4.2 EOS-0.2
BASOS-0.1
[**2112-2-26**] 11:20PM   PLT COUNT-223
[**2112-2-26**] 11:20PM   PT-13.2 PTT-30.8 INR(PT)-1.1
.
Procedure date     Tissue received     Report Date    Diagnosed
by
[**2112-1-1**] [**2112-1-1**] [**2112-1-5**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **],DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/stu
Previous biopsies:    [**-9/4084**]  PLEURAL FLUID (1 VIAL)
  [**-9/4043**]  Slides referred for consultation.
  [**-5/2031**]  EGD

DIAGNOSIS:
Pleural biopsies (A):
Granulation tissue with acute and chronic inflammation;
organizing fibrinous exudate.
Some degree of atypicality is seen, probably reactive.
Polarizable material present.
No malignancy identified.
.

PLEURAL
 PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos Meso Macro
Other
[**2112-2-23**] 09:39AM    275* 185* 6* 53* 27* 9* 1*   4*1
[**2111-12-25**] 09:34AM    505* 30* 34* 16* 0 17*   31* 2*2
[**2111-11-4**] 10:30AM    50* 3* 4* 56* 0 1* 6* 30* 3*3

ATYPICAL CELLS, REFER TO CYTOLOGY
REVIEWED BY [**Last Name (NamePattern4) 39834**], MD [**2112-2-24**]

MESOTHELIAL CELLS,FAVOR REACTIVE
REFER TO CYTOLOGY
REVIEWED BY [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ON [**2111-12-28**]

ATYPICAL CELLS,REFER TO CYTOLOGY
REVIEWED BY [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3157**],MD ON [**2111-11-6**]


 PLEURAL CHEMISTRY TotProt Glucose Creat LD(LDH)
[**2112-2-23**] 09:39AM    3.0 156   108
[**2111-12-25**] 09:34AM    4.1 116 2.3 151
[**2111-11-4**] 10:30AM    1.8 92   74

OTHER BODY FLUID
 OTHER BODY FLUID  pH
[**2112-2-23**] 10:06AM    7.451
[**2111-12-25**] 09:48AM    7.421

PLEURAL FLUID




Brief Hospital Course:
The patient is an 84 year old male with HTN, DM, recurrent
pleural effusions who presented with new hypoxemia(not on home
O2)

Primary Diagnosis: 482.9 PNEUMONIA, BACTERIAL NOS
Secondary Diagnosis: 786.05 SHORTNESS OF BREATH
Secondary Diagnosis: 780.60 FEVER, UNSPECIFIED
Secondary Diagnosis: 799.02 HYPOXEMIA
Secondary Diagnosis: 428.32 HEART FAILURE, (B3) CHRONIC
DIASTOLIC
The patient was found on admission to have fever and new
infiltrate on the right. this was in addition to the recurrent
pleural effusion that had formed on the left, even after being
drained just a few days before. With both problems he had
significant resp comprimise and went to the ICU. There he was
given broad spectrum antibiotics after having a rising WBC's and
recurrant fever with CAP therapy. His fever improved and the
fluid was drained. he is now down to 2L by NC. he will need to
complete 10 days of broad abx therapy(until [**3-6**]). His
vancomycin b/c of his renal function was dosed once, with vanc
levels checked daily and given again for level <20(first dose
lasted >72hrs). He will also need close monitoring of his i/o's
to make sure he stays even and gets IV lasix if needed. he was
previously on 40 mg of lasix prior to admission and the effusion
returned. We are not entirely sure that this effusion is from
CHF, so even if his volume status is maintained it may return.
If his O2 worsens he should get CXR's to monitor that left lung.
he will need f/u with the interventional pulmonary clinic 2
weeks after discharge. they will be scheduleing him an appt the
day after discharge. He will also need pulm rehab as he lives up
2 flights of stairs.
.
Secondary Diagnosis: 585.4 CHRONIC KIDNEY DISEASE, STAGE IV
(15-29)
ACUTE RENAL FAILURE- b/l 2.4 now increased to 2.9. will need
monitoring frequently. pls avoid nephrotoxins and dose
vancomycin by level.
.
Secondary Diagnosis: 424.1 AORTIC STENOSIS-INSUFFICIENCY
moderate aortic valve stenosis (valve area 1.0-1.2cm2). the
patient may be preload dependent so euvolemia is difficult but
important to maintain.
.
Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN
When ill, the patient had all his hypertension meds held. We
recommend restarting his BB the night of discharge and the
nifedipine if needed.
.
Secondary Diagnosis: 249.40 SECONDARY DIABETES MELLITUS WITH
RENAL MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED

-stopped o/p DM meds and using only insulin. had to add NPH for
better control
.
Secondary Diagnosis: 600.90 HYPERPLASIA OF PROSTATE,
UNSPECIFIED, WITHOUT URINARY
OBSTRUCTION AND OTHER LOWER URINARY SYMPTOMS (LUTS)
-continued flomax.
.
Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE
(GERD)
Continue o/p PPI
.
Code Status: FULL CODE, discussed with patient/family on
admission.
.
HCP is [**Name (NI) **] [**Name (NI) 28942**] (dtr) [**Telephone/Fax (1) 39835**]

Medications on Admission:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

times a day) as needed for constipation.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
scoop PO once a day.
Disp:*1 can* Refills:*2*
9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet

Sustained Release PO DAILY (Daily). recently discontinued.
10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lasix 20 mg PO BID
13. Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection TID (3 times a day): to stop when ambulating.
2. Ferrous Sulfate 300  mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Five (5)
UNITS Subcutaneous twice a day.
6. Insulin Aspart 100 unit/mL Cartridge Sig: sliding scale
Subcutaneous AC&HS.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB or wheezing.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOb or wheezing.
9. Nifediac CC 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
10. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours) for 5 days: until
[**3-6**].
11. Vancomycin 1,000 mg Recon Soln Sig: One (1) dose Intravenous
level <20.
12. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
qdaily to [**Hospital1 **] if i/o are positive or weight +>3lbs.
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Primary Diagnosis: 518.81 RESPIRATORY FAILURE, ACUTE
Secondary Diagnosis: 424.1 AORTIC STENOSIS-INSUFFICIENCY
Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN
Secondary Diagnosis: 585.4 CHRONIC KIDNEY DISEASE, STAGE IV
(15-29)
Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE
(GERD)
Secondary Diagnosis: 428.32 HEART FAILURE, (B3) CHRONIC
DIASTOLIC
Secondary Diagnosis: 250.82 DIABETES TYPE II, UNCONTROLLED W/
COMPLICATIONS
Secondary Diagnosis: 482.9 PNEUMONIA, BACTERIAL NOS


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


Discharge Instructions:
Patient being transferred to facility

Followup Instructions:
with [**Hospital **] clinic in 2 weeks(appt to be made 1 day after discharge)
also need f/u with PCP upon discharge(he has been updated on the
hospital course).
{'Bacterial pneumonia, unspecified,Acute kidney failure, unspecified,Acute respiratory failure,Chronic diastolic heart failure,Unspecified pleural effusion,Acidosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Aortic valve disorders,Depressive disorder, not elsewhere classified,Diverticulosis of colon (without mention of hemorrhage),Esophageal reflux,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Other specified cardiac dysrhythmias,Anemia, unspecified'}


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



### Clinical text :
CHIEF COMPLAINT: Shortness of breath/fevers/HA

PRESENT ILLNESS: PCP:
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) 1730**] O.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Fax: [**Telephone/Fax (1) 29683**]
.
Date/Time: [**2112-2-27**]: 4:00 am
.
History obtained with the assistance of a [**Name6 (MD) 8003**] speaking RN
84M with h/o recurrent pleural effusions s/p pigtail catheter
placement, VATS with talc pleurodesis. His thoracoscopy was
complicated by a right pneumothorax requiring a chest tube. He
also has CKD, DM, AS and presents with a HA x 24 hours but
resolved on presentation to the ED.  He also here with SOBOE and
fever to 101.2 on presentation. He felt febrile so she took his
temperature which was 99.3. He then took 1 gm of tylenol. Even
though per the ED he presented with worsening SOB per pt he did
not have difficulties breathing, solely a headache. No visual
changes. No slurred speech. On 3L NC. CXR c/w PNA. S/p L US
guided thoracentesis 4 days PTP which produced clear
serosanguinous fluid. He felt very weak and tired after his
thoracentesis and there was no change in his breathing. Not on
oxygen at home. His breathing improved dramatically after his
recent surgery such that he was able to climb stairs without
difficulty.  He is not very active at home but he is able to
walk from one room to another.
101.2 83 207/89-> BP improved without intervention 18 94
Meds Given: azithromycin and ceftriaxone, Fluids given:
Radiology Studies:, consults called.
[x] IVF (dry on exam, increased creatinine)
[x] Cx and abx (ceftx, azithro)
- admit medicine
+ 10 pt crit drop- guiac negative in ED.
Rsided PNA and L pleural effusion.
IVF, cultures before abx.
99F 70 162/68 17 99% 2L 02
.
ROS:
-Constitutional: []WNL [+]Weight gain 8 lb []Fatigue/Malaise
[+]Fever []Chills/Rigors []Nightweats [-]Anorexia
-Eyes: [X]WNL []Blurry Vision []Diplopia []Loss of Vision
[]Photophobia
-ENT: []WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose
[]Tinnitus []Sinus pain []Sore throat
-Cardiac: []WNL [-]Chest pain []Palpitations []LE edema
[]Orthopnea/PND []DOE
-Respiratory: []WNL [+]SOB [-]Pleuritic  pain []Hemoptysis
[-]Cough
-Gastrointestinal: []WNL [-]Nausea [-]Vomiting [-]Abdominal pain
[]Abdominal Swelling [-]Diarrhea-  [-]Constipation []Hematemesis
[]Hematochezia []Melena
-Heme/Lymph: [X]WNL []Bleeding []Bruising []Lymphadenopathy
-GU: []WNL [-]Incontinence/Retention [-]Dysuria []Hematuria
[]Discharge []Menorrhagia  [+]dribbling with urination
-Skin: [X]WNL []Rash []Pruritus
-Endocrine: [X]WNL []Change in skin/hair []Loss of energy
[]Heat/Cold intolerance
-Musculoskeletal: [X]WNL []Myalgias []Arthralgias []Back pain
-Neurological: [X]WNL []Numbness of extremities []Weakness of
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo
[]Confusion []Headache
-Psychiatric: [X]WNL []Depression []Suicidal Ideation
-Allergy/Immunological: [] WNL []Seasonal Allergies
All other ROS negative.
.

MEDICAL HISTORY: HTN
DM2
CRI, baseline creatinine 2.5-3.0
hypothyroidism
GERD
antral ulceration with GI bleeding
diverticulosis
proctitis
pancreatitis
BPH
colon polyps
dperession
AS
chronic anemia
.
PSH:
right VATS, talc pleurodesis, and pleural biopsise on [**2112-1-1**].
s/p colectomy

MEDICATION ON ADMISSION: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 97.8, 181/83L , 181/81, 64, 20, 88-89% RA, 96% 2L
GENERAL: Thin, chronically ill appearing male in NAD.
Nourishment: At risk
Grooming: OK
Mentation: Alert, speaks in full setences
Eyes:NC/AT, EOMI without nystagmus, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Lungs CTA bilaterally without R/R/W
Cardiovascular: RRR, nl. S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
Genitourinary:
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or
inguinal lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor, dysdiadochokinesia noted. FNF and HKS WNL bilaterally.
-DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+
ankle jerks bilaterally. Plantar response was flexor
bilaterally.
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy

FAMILY HISTORY: sister and mother had stomach cancer. Daughter has CAD s/p
PCIx3.

SOCIAL HISTORY: Lives with wife and 1 of his daughters. From [**Country **] republic,
worked on farm there, last visit [**5-29**]. denies tobacco, alcohol,
drug use.
- No visual aides
- no dentures
- independent of ADLS
- continues to drive, no memory problems, no falls, walks
without cane or walker.
grandaughter Daughter [**Name (NI) 8314**] is HCP 

### Response:
{'Bacterial pneumonia, unspecified,Acute kidney failure, unspecified,Acute respiratory failure,Chronic diastolic heart failure,Unspecified pleural effusion,Acidosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Aortic valve disorders,Depressive disorder, not elsewhere classified,Diverticulosis of colon (without mention of hemorrhage),Esophageal reflux,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Other specified cardiac dysrhythmias,Anemia, unspecified'}
