CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: The patient is a 83 yo female w/ h/o bilateral pe's, pneumonia,
pulmonary hypertension and emphysema who presents with dyspnea.
The patient has chronic dyspnea that has steadily worsened such
that she has been breathing very heavy in the last 3 days. She
has no cp, cough, pleuritic pain, or fevers with dyspnea and
dyspnea is worse with activity. She only notes she may have had
chills lately. With this she has felt very weak and tired
lately, and the night prior to admission she felt as if she was
going to collapse. Patient did not lose consciousness, and may
have had some palpitations prior to this episode. In addition to
the above, the patient has had decreased po intake, nausea x 1
week (and 2 episodes of non-bloody vomitius), associated with po
intake. She denies abd pain, dysuria, hematuria, diarrhea
(although chronically she stools ~ 3x/day). She has had no sick
contacts to her knowledge either. Per the family, it seems as if
the patient has many issues, that have recently escalated and
they are most concerned with her recent fatigue and inablility
to do activities given her sob.
.
In ed pt. was hypoxic and placed on nrb. She was given 40 iv
lasix and 60 prednisone x 1. In ED she underwent CTA Chest,
which ruled out PE. CT Abdomen showed gallbladder wall
thickening, confirmed by RUQ US. Surgery was consulted to
consider HIDA scan.

MEDICAL HISTORY: 1. s/p THR 22 years ago complicated by clot in leg
2. s/p cataract surgery
3. Back pain s/p corticosteroid injections
4. PFTs [**8-13**]- FEv1- 52; FVC- 54%, FEV1/FVC 104: restrictive
ventilatory defect
5. CHF: diastolic dysfunction ef 50%
6. Emphysema (2 L home oxygen)
7. Bilateral PE's ([**Date range (1) 96188**])
8. Multiple pna's recent in [**12-13**]
9. Pulmonary hypertension
10. Recent right arm fx

MEDICATION ON ADMISSION: 1. toprol xl 25 qd
2. albuterol 2 puffs q 6 hr prn
3. ipratroprium 2 puffs qid prn
4. timolol 0.5 % one drop right eye qd
5. coumadin 3 mg qhs
6. lisinopril 5 mg qd

ALLERGIES: Clindamycin / Vancomycin

PHYSICAL EXAM: VS: T: 96.5; BP: 120/80; HR: 114; RR: 22; O2: 93-94% on 10 L FM

FAMILY HISTORY: No heart or lung disease in family.

SOCIAL HISTORY: pt. is from [**Country **] and lives in an independent senior facility
with vna 2 x/week. Son in area very involved in her care. No
smoking (now or history), etoh or drugs
Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute on chronic diastolic heart failure,Chronic kidney disease, unspecified,Diseases of tricuspid valve,Acute kidney failure, unspecified,Acute respiratory failure,Other chronic pulmonary heart diseases,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Iron deficiency anemia, unspecified,Long-term (current) use of anticoagulants
Pneumonia, organism NOS,Obs chr bronc w(ac) exac,Ac on chr diast hrt fail,Chronic kidney dis NOS,Tricuspid valve disease,Acute kidney failure NOS,Acute respiratry failure,Chr pulmon heart dis NEC,Pancreatic disorder NEC,Adv eff corticosteroids,Iron defic anemia NOS,Long-term use anticoagul
Admission Date:  [**2153-2-6**]              Discharge Date:   [**2153-2-17**]


Service: MEDICINE

Allergies:
Clindamycin / Vancomycin

Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
intubation


History of Present Illness:
The patient is a 83 yo female w/ h/o bilateral pe's, pneumonia,
pulmonary hypertension and emphysema who presents with dyspnea.
The patient has chronic dyspnea that has steadily worsened such
that she has been breathing very heavy in the last 3 days. She
has no cp, cough, pleuritic pain, or fevers with dyspnea and
dyspnea is worse with activity. She only notes she may have had
chills lately. With this she has felt very weak and tired
lately, and the night prior to admission she felt as if she was
going to collapse. Patient did not lose consciousness, and may
have had some palpitations prior to this episode. In addition to
the above, the patient has had decreased po intake, nausea x 1
week (and 2 episodes of non-bloody vomitius), associated with po
intake. She denies abd pain, dysuria, hematuria, diarrhea
(although chronically she stools ~ 3x/day). She has had no sick
contacts to her knowledge either. Per the family, it seems as if
the patient has many issues, that have recently escalated and
they are most concerned with her recent fatigue and inablility
to do activities given her sob.
.
In ed pt. was hypoxic and placed on nrb. She was given 40 iv
lasix and 60 prednisone x 1. In ED she underwent CTA Chest,
which ruled out PE. CT Abdomen showed gallbladder wall
thickening, confirmed by RUQ US. Surgery was consulted to
consider HIDA scan.



Past Medical History:
1. s/p THR 22 years ago complicated by clot in leg
2. s/p cataract surgery
3. Back pain s/p corticosteroid injections
4. PFTs [**8-13**]- FEv1- 52; FVC- 54%, FEV1/FVC 104: restrictive
ventilatory defect
5. CHF: diastolic dysfunction ef 50%
6. Emphysema (2 L home oxygen)
7. Bilateral PE's ([**Date range (1) 96188**])
8. Multiple pna's recent in [**12-13**]
9. Pulmonary hypertension
10. Recent right arm fx


Social History:
pt. is from [**Country **] and lives in an independent senior facility
with vna 2 x/week. Son in area very involved in her care. No
smoking (now or history), etoh or drugs

Family History:
No heart or lung disease in family.

Physical Exam:
VS: T: 96.5; BP: 120/80; HR: 114; RR: 22; O2: 93-94% on 10 L FM

mask.
Gen: fatigued pale female, appears frail
HEENT: Right surgical pupil. Left pupil ERRLA, sclera anicteric,
pale conjunctiva, mm dry, no oral lesions
Neck: JVD 8-10 cm. No LAD
CV: Tachy no m/r/g
Lungs: wheezes throughout but no crackles noted. no accessory
muscle use. moving air well.
Abd: NABS. soft, nt, nd
Ext: 1+ pitting edema b/l to knees
Neuro: non-focal, cn intact


Pertinent Results:
admission labs:
[**2153-2-5**] 08:45PM   PT-32.8* PTT-31.8 INR(PT)-3.5*
[**2153-2-5**] 08:45PM   PLT COUNT-193
[**2153-2-5**] 08:45PM   WBC-7.8 RBC-3.57* HGB-10.8* HCT-31.7* MCV-89
MCH-30.2 MCHC-33.9 RDW-17.1*
[**2153-2-5**] 08:45PM   CK-MB-NotDone cTropnT-<0.01
[**2153-2-5**] 08:45PM   CK(CPK)-66
[**2153-2-5**] 08:45PM   GLUCOSE-126* UREA N-30* CREAT-1.2* SODIUM-134
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-20* ANION GAP-17
[**2153-2-5**] 08:56PM   PO2-27* PCO2-34* PH-7.40 TOTAL CO2-22 BASE
XS--3
[**2153-2-5**] 09:49PM   TYPE-ART O2 FLOW-5 PO2-52* PCO2-23* PH-7.44
TOTAL CO2-16* BASE XS--5 INTUBATED-NOT INTUBA
[**2153-2-6**] 05:50AM   CK-MB-NotDone
[**2153-2-6**] 05:50AM   cTropnT-<0.01
[**2153-2-6**] 05:50AM   LIPASE-56
[**2153-2-6**] 05:50AM   ALT(SGPT)-18 AST(SGOT)-31 CK(CPK)-55 ALK
PHOS-87 AMYLASE-71 TOT BILI-0.7
.
results:
cta:
IMPRESSION:
1) No evidence of PE.
2) Persistent multifocal ground glass opacities with interval
resolution of peribronchiolar patchy opacities and multifocal
nodular opacities seen on the prior CT of [**2152-12-16**],
suggesting a resolving infectious process.
3) Significant atherosclerotic burden of the aorta and its major
tributaries,
4) Thickened gallbladder wall, with hyperenhancing gallbladder
mucosa.
.
CxR: [**2-5**]: .Interval improvement of multifocal patchy opacities,
likely consistent with resolving pneumonia
.
[**2-6**] US ruq:
CONCLUSION: Edematous gallbladder wall without significant
luminal distention and without gallstones. There was no focal
tenderness directly over the gallbladder.

The lack of a more distended gallbladder lumen plus the
prominent hepatic veins, and the appearance of the lungs on
today's CTA study suggests the gallbladder edema may be due to
third spacing of fluid secondary to congestive heart failure.
Clinical correlation is recommended, but in nearly all cases of
acute cholecystitis, the lumen is much more distended than we
see in this patient. If necessary, this could be further
evaluated with a radionuclide biliary scan.
.
ct head [**2-11**]:
IMPRESSION: No evidence of acute intracranial hemorrhage or
significant change from prior study. MRI with diffusion-weighted
images is more sensitive in the evaluation for acute
ischemia/infarct and for vascular detail.
.
echo [**2153-2-12**]:
Conclusions:
The left atrium is normal in size. There is asymmetric left
ventricular hypertrophy. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade I (mild) LV diastolic dysfunction. The right
ventricular cavity is dilated with borderline depressed right
ventricular function (not full visualized). [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The tricuspid valve leaflets are
mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no


Brief Hospital Course:
1. Dyspnea: The patient presented with acute on chronic dyspnea
and given her history of multiple pneumonias, chills and per
patient's family low temperatures the concern was for a
recurrent pneumonia. Another concern originally was for COPD
exacerbation.  The patient was treated with azithromycin and
ceftriaxone for presumed pneumonia and prednisone and nebulizers
for COPD exacerbation.  The pulmonary team was consulted and
felt most of this was due to fluid overload so th patient was
diuresed.  The patient improved, but on [**2153-2-10**] she was noted to
be cyanotic off oxygen so placed on 4L and became unresponsive,
with junctional rhythm (AV dissociation ?). A code blue was
called for unresponsiveness and hypoxia (80%). She was intubated
and placed on dopamine drip due to hypotension and sent to CCU.
Her course in the CCU involved being weaned off pressors and her
hypotension resolved. She was extubated on [**2-12**] without any
issues. She was treated with high dose steroids for her
pulmonary status and also treated for presumed aspiration
pneumonia with ceftriaxone and flagyl. She had a CTA that was
negative for PE.  She was transferred back to the floor, and at
that time she was weaned off steroids and completed a 7 day
course of ceftriaxone and flagyl for aspiration pneumonia.  The
patient improved on the floor and pulmonary felt most of her
symptoms were related to her pulmonary hypertension and some
fluid overload.  She was started on sildenafil and diuresed.
She was doing well at discharge and will continue her inhalers,
sildenafil and will have close follow-up as an outpatient with
pulmonary.
.
2. Nausea: The patient's nausea and abdominal discomfort was
attributed to her enlarged gallbladder.  With diruesis this
improved.  Surgery saw the patient and did not see the need for
a HIDA scan.  Her urine was negative for infection, and with
diuresis she no longer complained of nausea or pain.
.
3. SVT: On tele the patient had several episodes of SVT and
remained asymptomatic.  The abnormal rhythm always broke without
intervetion, and she was treated with a beta-blocker that helped
to keep her in a normal rate.  She will continue the
beta-blocker as an outpatient, and should have it titrated up if
her pressure can tolerate this.
.
4. presyncope: The patient described presyncope, and this could
have been due to a number of factors.  Her vitals revealed
orthostasis and with fluids she improved.  She was ruled out for
MI, and the only other possible cause was her SVT, which
resolved with a beta-blocker.  The patient felt better at
discharge and will continue her beta-blocker and will work with
physical therapy at rehab.
.
5. Diastolic dysfunction: The patient presented with volume
overload and improved with diuresis, a low sodium diet and with
a beta-blocker.  She should have her weight followed at
discharge and if she appears overloaded may need more lasix.
She will be discharged with a low dose of lasix and a
beta-blocker.
.
6. Bilateral PE's: The patient has a history of PE, but 2 CTA's
were performed and were negative for PE.  She was maintained on
her coumadin and this was held for several days due to
supratherapeutic INR.  As an outpatient she should continue to
have her INR checked and have her [**Month/Day (1) **] between [**2-10**].  She should
have her coumadin adjusted accordingly.
.
7. anemia: The patient's baseline hematocrit is around 30-33.
While in the CCU she had a  HCT drop of 4 points, but the
recheck was back at her baseline.  She had iron studies
consistent with iron deficiency anemia but iron was held and may
need to be started as an outpatient.  Her hematocrit remained
fairly stable during her course and should be followed as an
outpatient.  She never required transfusions during her course.
.
8. Acute on chronic renal insufficiency:  The patient was never
formally diagnosed with renal insufficiency though her baseline
was noted to be around~ 1.2-1.5. In the unit her creatinine
increased to 1.8 and this was attributed her hypotension, as
once her hypotension improved so did her creatinine.  Her renal
function normalized at discharge and should continue to be
followed as an outpatient.
.
9. leukocytosis: The patient had leukocytosis for most of her
course and this was attributed to steroids.  She remained on
antibiotics for a possible pulmonary source and blood and urine
cultures were sent.  All cultures are negative to date, though
some are still pending and should be followed at rehab.
.
10. Steroid induced hyperglycemia: The patient required insulin
while on steroids and may have some underlying diabetes.  The
patient will have ssi written for at rehab, but a formal
diagnosis of diabetes may be immenent and should be addressed as
an outpatient.


Medications on Admission:
1. toprol xl 25 qd
2. albuterol 2 puffs q 6 hr prn
3. ipratroprium 2 puffs qid prn
4. timolol 0.5 % one drop right eye qd
5. coumadin 3 mg qhs
6. lisinopril 5 mg qd


Discharge Medications:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Inhalation four times a day.
2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
coumadin.
5. Outpatient Lab Work
Please have your INR checked in 2 days.  Your [**Month/Day (3) **] is [**2-10**]
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q1-2H () as needed for wheezing.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Sildenafil 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day): hold for sbp < 100.
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for sbp <100 and hr < 55.
14. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
15. Humalog 100 unit/mL Cartridge Sig: follow ss  Subcutaneous
per ss.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]

Discharge Diagnosis:
1. Hypoxia
2. Pneumonia
3. CHF
4. Acute on chronic renal insufficiency
5. COPD exacerbation
6. Steroid induced hyperglycemia
7. Anemia
8. Pulmonary hypertension
9. SVT


Discharge Condition:
stable, tolerating medications


Discharge Instructions:
You were admitted for hypoxia, which was related to your fluid
status and possibly an infection with a COPD exacerbation.  The
most likely cause though is your pulmonary hypertension.  You
were diuresed, treated with antibiotics, and treated with
steroids.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet, to maintain fluid balance.
.
You also will need your INR checked 2 days after discharge to
verify you are on the appropriate dose of coumadin.
.
You will continue all home medications, except the toprol xl.
New medications include metoprolol, pantoprazole, aspirin,
colace, senna, lasix and sildenafil.  You will no longer take
lisinopril.
.
Call your doctor or go to the emergency room for vomiting,
worsened dizziness, fainting, new headache, chest pain or
worsened shortness of breath.

Followup Instructions:
1. You have a pulmonary appointment as follows: Provider:
[**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2153-3-15**]
4:10
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2153-3-15**] 4:30
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] /DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2153-3-15**] 4:30
2. You have an appointment with your primary doctor as follows:
Thursday [**2153-2-22**] at 10:45 am with Dr. [**First Name (STitle) **] #[**Telephone/Fax (1) 133**].
{'Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute on chronic diastolic heart failure,Chronic kidney disease, unspecified,Diseases of tricuspid valve,Acute kidney failure, unspecified,Acute respiratory failure,Other chronic pulmonary heart diseases,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Iron deficiency anemia, unspecified,Long-term (current) use of anticoagulants'}


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: The patient is a 83 yo female w/ h/o bilateral pe's, pneumonia,
pulmonary hypertension and emphysema who presents with dyspnea.
The patient has chronic dyspnea that has steadily worsened such
that she has been breathing very heavy in the last 3 days. She
has no cp, cough, pleuritic pain, or fevers with dyspnea and
dyspnea is worse with activity. She only notes she may have had
chills lately. With this she has felt very weak and tired
lately, and the night prior to admission she felt as if she was
going to collapse. Patient did not lose consciousness, and may
have had some palpitations prior to this episode. In addition to
the above, the patient has had decreased po intake, nausea x 1
week (and 2 episodes of non-bloody vomitius), associated with po
intake. She denies abd pain, dysuria, hematuria, diarrhea
(although chronically she stools ~ 3x/day). She has had no sick
contacts to her knowledge either. Per the family, it seems as if
the patient has many issues, that have recently escalated and
they are most concerned with her recent fatigue and inablility
to do activities given her sob.
.
In ed pt. was hypoxic and placed on nrb. She was given 40 iv
lasix and 60 prednisone x 1. In ED she underwent CTA Chest,
which ruled out PE. CT Abdomen showed gallbladder wall
thickening, confirmed by RUQ US. Surgery was consulted to
consider HIDA scan.

MEDICAL HISTORY: 1. s/p THR 22 years ago complicated by clot in leg
2. s/p cataract surgery
3. Back pain s/p corticosteroid injections
4. PFTs [**8-13**]- FEv1- 52; FVC- 54%, FEV1/FVC 104: restrictive
ventilatory defect
5. CHF: diastolic dysfunction ef 50%
6. Emphysema (2 L home oxygen)
7. Bilateral PE's ([**Date range (1) 96188**])
8. Multiple pna's recent in [**12-13**]
9. Pulmonary hypertension
10. Recent right arm fx

MEDICATION ON ADMISSION: 1. toprol xl 25 qd
2. albuterol 2 puffs q 6 hr prn
3. ipratroprium 2 puffs qid prn
4. timolol 0.5 % one drop right eye qd
5. coumadin 3 mg qhs
6. lisinopril 5 mg qd

ALLERGIES: Clindamycin / Vancomycin

PHYSICAL EXAM: VS: T: 96.5; BP: 120/80; HR: 114; RR: 22; O2: 93-94% on 10 L FM

FAMILY HISTORY: No heart or lung disease in family.

SOCIAL HISTORY: pt. is from [**Country **] and lives in an independent senior facility
with vna 2 x/week. Son in area very involved in her care. No
smoking (now or history), etoh or drugs 

### Response:
{'Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Acute on chronic diastolic heart failure,Chronic kidney disease, unspecified,Diseases of tricuspid valve,Acute kidney failure, unspecified,Acute respiratory failure,Other chronic pulmonary heart diseases,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Iron deficiency anemia, unspecified,Long-term (current) use of anticoagulants'}
