CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: This is an 87-year-old man with colon cancer who presents with
several months of shortness of breath, dyspnea on exertion, and
leg edema.  He was initially noted to have a right pleural
effusion back on [**2188-2-25**] when his cardiologist ordered a chest CT
scan.  He was seen today in the oncology clinic for evaluation
of this possible malignant effusion, and he was noted to be
hypoxic in the mid to high 80's on room air and he desaturated
to 81% with ambulation.  He was referred to the ED.

MEDICAL HISTORY: 1) sick sinus syndrome and bifascicular block s/p pacemaker [**2184**]
2) paroxysmal atrial fibrillation not on coumadin, SVT [**2185**] and
atrial flutter status post ablation
3) cataracts. declined surgery
4) Echo [**2186**]: mild-to-moderate mitral regurgitation, RA and LA
5) BPH s/p TURMP [**2187**]
6) b/l edema with skin changes
7) hard of hearing
8) hx of guiaic positive stools/GI bleeding
9) osteoarthritis
10) osteoporosis
11) subclinical hypothyroid state as per record
12) hx of syncope
13) renal insufficiency
14) right pleural effusion

MEDICATION ON ADMISSION: AMIODARONE 200 mg--1 tablet(s) by mouth daily
ASPIRIN 81 mg--1 tablet(s) by mouth daily
LASIX 20 mg--2 tablet(s) by mouth daily
METOPROLOL SUCCINATE 25 mg--1 tablet(s) by mouth daily
TERAZOSIN 5 mg--1 capsule(s) by mouth daily
Tylenol 650 mg daily
MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 98.0, HR 70, BP 120/81, RR 16, O2 sat 88-93% on 3-4L NC
GEN: Alert and oriented.  NAD.
HEENT: Supple neck.  Anicteric sclera.  Slightly dry MM.  No
cervical LAD.
CV: RRR, II/VI systolic murmur at LLSB
LUNGS: Decreased BS and + dullness at right base.  Some coarse
BS at the left base.
ABD: Soft, mildly protuberant. Nontender.
EXT: Chronic venous stasis changes in both legs with 1+
bilateral pitting edema of the legs.
NEURO: A+O. Non-focal.

FAMILY HISTORY: brother had [**Name2 (NI) 500**] marrow stem cell transplant at age 82
Sister died from heart attack. Also had an unknown cancer.
Mother died from an unknown cancer.
Neice has unknown cancer.

SOCIAL HISTORY: Lives alone.  Former smoker with 35-pk-yrs.  No longer drinking
alcohol, formerly had a couple of drinks a week.
Septic shock,Acute kidney failure, unspecified,Primary pulmonary hypertension,Malignant neoplasm of other specified sites of large intestine,Congestive heart failure, unspecified,Retention of urine, unspecified,Atrial fibrillation,Chronic kidney disease, Stage III (moderate),Iron deficiency anemia secondary to blood loss (chronic),Chronic airway obstruction, not elsewhere classified,Bacterial pneumonia, unspecified,Septicemia due to escherichia coli [E. coli],Severe sepsis
Septic shock,Acute kidney failure NOS,Prim pulm hypertension,Malignant neo colon NEC,CHF NOS,Retention urine NOS,Atrial fibrillation,Chr kidney dis stage III,Chr blood loss anemia,Chr airway obstruct NEC,Bacterial pneumonia NOS,E coli septicemia,Severe sepsis
Admission Date:  [**2188-3-5**]              Discharge Date:   [**2188-3-31**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
central line placement


History of Present Illness:
This is an 87-year-old man with colon cancer who presents with
several months of shortness of breath, dyspnea on exertion, and
leg edema.  He was initially noted to have a right pleural
effusion back on [**2188-2-25**] when his cardiologist ordered a chest CT
scan.  He was seen today in the oncology clinic for evaluation
of this possible malignant effusion, and he was noted to be
hypoxic in the mid to high 80's on room air and he desaturated
to 81% with ambulation.  He was referred to the ED.

He states that he has actually had slowly progressive dyspnea
over the past year or more, and that he has also had leg edema
for that same time period.  He has noticed a recent worsening,
but more with fatigue, poor appetite, and decreased ability to
ambulate the same distances he was able to do before.  he cannot
go up stairs.  he has not had any urinary symptoms, abdominal
pain, fevers, or chills.  he has had a midly productive cough.
He has brown stools, but occasionally sees a little blood.

Past Medical History:
1) sick sinus syndrome and bifascicular block s/p pacemaker [**2184**]
2) paroxysmal atrial fibrillation not on coumadin, SVT [**2185**] and
atrial flutter status post ablation
3) cataracts. declined surgery
4) Echo [**2186**]: mild-to-moderate mitral regurgitation, RA and LA
5) BPH s/p TURMP [**2187**]
6) b/l edema with skin changes
7) hard of hearing
8) hx of guiaic positive stools/GI bleeding
9) osteoarthritis
10) osteoporosis
11) subclinical hypothyroid state as per record
12) hx of syncope
13) renal insufficiency
14) right pleural effusion

Social History:
Lives alone.  Former smoker with 35-pk-yrs.  No longer drinking
alcohol, formerly had a couple of drinks a week.

Family History:
brother had [**Name2 (NI) 500**] marrow stem cell transplant at age 82
Sister died from heart attack. Also had an unknown cancer.
Mother died from an unknown cancer.
Neice has unknown cancer.


Physical Exam:
T 98.0, HR 70, BP 120/81, RR 16, O2 sat 88-93% on 3-4L NC
GEN: Alert and oriented.  NAD.
HEENT: Supple neck.  Anicteric sclera.  Slightly dry MM.  No
cervical LAD.
CV: RRR, II/VI systolic murmur at LLSB
LUNGS: Decreased BS and + dullness at right base.  Some coarse
BS at the left base.
ABD: Soft, mildly protuberant. Nontender.
EXT: Chronic venous stasis changes in both legs with 1+
bilateral pitting edema of the legs.
NEURO: A+O. Non-focal.

Pertinent Results:
CT ABD:
1.  No definite evidence of central venous thrombosis although
the
opacifications of the veins is suboptimal.
2.  Probable "apple core" lesion in the hepatic flexure of the
colon, which may be the area of suspected cancer.  Please
correlate with other history.
3.  New patchy opacity in the left lower lobe could represent
aspiration or developing pneumonia.
4.  Large right-sided pleural effusion with associated lower
lobe atelectasis, similar in appearance to the prior study.
5.  Bilateral kidney cysts, the largest of which are simple
fluid attenuation.
6.  Enlarged prostate with central calcifications

CXR: Two views are compared with radiographs dated [**2-26**] and the
recent
[**2188-2-25**] chest CT.  There is cardiomegaly with pulmonary vascular
congestion and blurring and interstitial edema, as before.  The
moderately large layering right pleural effusion is not much
changed.  The moderately severe centrilobular emphysema and
several bilateral upper lobe pulmonary nodules are better
appreciated on the cross-sectional study.

CXR [**2188-3-24**]: IMPRESSION: PA and lateral chest compared to
[**3-5**] through [**3-22**]. Small bilateral pleural effusions
have both decreased since [**3-22**], but severe right basal
atelectasis has worsened. Top normal heart size unchanged.
Transvenous right atrial and right ventricular pacer leads are
unchanged in their respective positions. Upper lungs clear. No
pneumothorax.

CXR [**2188-3-27**]: IMPRESSION: Slight improvement in pleural effusions
and left lower lobe atelectasis, but persistent right middle and
lower lobe atelectasis.

CXT [**2188-3-31**]: IMPRESSION: Stable unchanged bilateral
small-to-moderate pleural effusions and persistent unchanged
left lower lobe atelectasis and right middle and lower lobe
atelectasis.

[**2188-3-28**] VQ Scan: IMPRESSION: Stable unchanged bilateral
small-to-moderate pleural effusions and persistent unchanged
left lower lobe atelectasis and right middle and lower lobe
atelectasis.

GLUCOSE-97 UREA N-26* CREAT-1.3* SODIUM-145 POTASSIUM-4.8
CHLORIDE-108 TOTAL CO2-31 ANION GAP-11
WBC-4.9 HCT-34.1* MCV-93 [**2188-3-5**] PLT 225
(NEUTS-69.6 LYMPHS-19.0 MONOS-8.6 EOS-2.3 BASOS-0.5)


Brief Hospital Course:
87 y/o male w/ multiple medical problems including untreated
colon ca, BPH, severe PHTN, admitted from [**Hospital **] clinic w/ hypoxia
of 81% on room air, transferred from floors w/ worsened hypoxia,
hypotension, fevers, and leukocytosis consistent with urosepsis
due to prolonged manipulation and trauma during Foley insertion.
Patient grew our ceftriaxone sensitive e.coli and treated for a
2 week course with ceftriaxone. Patient s/p continuous bladder
irrigation with resolution of his hematuria. Patient required
pressors initially but was successfully weaned. Patient was
hypoxic at baseline with known transudative pleural effusions
requiring tap on [**3-18**]. Etiology likely heart failure.

Hospital Course by Problem:

Hypoxia:
- Patient w/ significant dyspnea for last few months, had been
seen in oncology clinic to work up possible malignant pleural
effuions. Etiology of the effusions unclear. [**Name2 (NI) **] had 2
pleural tap while in the hospital, the first one [**3-6**] with over
1L fluid, and the second one [**2188-3-18**] with 1.2L of fluids
removed. Both taps c/w transudate, w/ negative cytology. TTE
showed severe PHTN and RV diastolic dysfunction w/ fluid
overload. No WML or EKG abn to suggest IMI. High suspicion of PE
in this cancer patient, but still does not explain etiology of
effusions. Degree of effusions seemed disproportionate to degree
of RV diastolic HF. Patient also has centrolobular emphysema on
CT scan in the past. Patient transferred to the oncology medical
unit from the ICU.. He was aggressively diuresed with IV lasix
with drastic improvement of lower extremity edema. Mild to
moderate pulmonary effussions persistent on follow up CXRs. The
etiology of the initial edema is [**Last Name (un) 8787**] likely heart failure
related. He is being discharged with persistent oxygen
requirement that has been weaned down from 5-6L NC to 2-3L NC,
and will go home on this. The Oxygen reqirement is likely
multifactorial and related to heart failure, COPD, and ? PE
causing RLL persistent effussion and atelectasis.
- No CTA [**2-23**] to ARF, V/Q scan not an option [**2-23**] to effusions
- no empiric anticoagulation [**2-23**] h/o GI bleed
- Pleurodesis not a good option given transudative etiology
- VQ scan indeterminent because of persistent stable effusion,
atelectasis and underlying emphysema.
.
# Septic Shock:
- acute sepsis from GU source in setting of prolonged urologic
manipulation during foley insertion. Patient intitially w/
fevers and leukocytosis.
- Was on vanc/zosyn/cipro for double coverage to intial growth
of GNR from Ucx.  Sensitivities back, cipro/vanc d/c??????d and zosyn
switched to CTX on [**3-19**], continued through [**2188-3-31**].
- Hypotension w/ infection and concominant diursesis. Started on
neo/levo/vaso for pressors, subsequently d/c??????d and pressures
stable.
.
# Hematuria/BPH: Patient with tramautic foley insertion as
above. He is s/p CBI with resolution of hematuria. Pt
transferred from ICU to oncology floor with foley catheter. Pt
failed voiding trial on [**3-27**], and foley resinserted on [**3-28**]. He
has an outpatient follow appointment made with urology for
several days after discharge. continue terazosin
.
# Diarrhea: Patient with multiple, loose bowel movements. C diff
negative x6. Likely antibiotics related diarrhea given multiple
abx for sepsis. Treated with Imodium PRN, now without diarrhea.
.
# PAF, sick sinus syndrome:  on amiodarone at home, no RVR.
Continue home dose, currently in sinus.  Not anticoagulated
given fungating colon CA.

# Colon Ca:  fungating mass dx in [**2184**], patient declined
treatment.  Was in [**Hospital **] clinic to evaluate pleural effusions. No
malignant cells on cytology. While palliative resection was one
therapeutic option given pencil thin stools, patient declining
further work up /treatment. Stools guaiac positive.
.
# ARF:  Acute on chronic.  Worsened Cr of 1.1 on admission, 2.4
now and stable.  Pre renal from septic shock/ diuresis vs ATN
from hypotension.  Renal u/s r/o??????d post-renal obstruction.  Not
that CBI complete, will monitor urine output.

Medications on Admission:
AMIODARONE 200 mg--1 tablet(s) by mouth daily
ASPIRIN 81 mg--1 tablet(s) by mouth daily
LASIX 20 mg--2 tablet(s) by mouth daily
METOPROLOL SUCCINATE 25 mg--1 tablet(s) by mouth daily
TERAZOSIN 5 mg--1 capsule(s) by mouth daily
Tylenol 650 mg daily
MVI

Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Terazosin 5 mg Capsule Sig: One (1) Capsule PO once a day.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1)  Inhalation Q6H (every 6 hours).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Hypoxia
2. Urosepsis
3. Urinary Retention
4. Acute Exacerbation of Congestive Heart Failure
5. Pneumonia
6. COPD
7. diarrhea
.
SECONDARY DIAGNOSIS:
- sick sinus syndrome


Discharge Condition:
Stable, no shortness of breath, requiring 3L O2 for sats >90%.


Discharge Instructions:
You were admitted to the hospital with shortness of breath. This
was thought most likely due to lung disease from smoking, heart
failure, atelectasis (collapsed lung), fluid in your lung, and
pneumonia. We treated you for pneumonia with antibiotics, we
also removed fluid from your lungs and this has not
re-accumulated, and we have treated you with diuretics (water
pills) to help remove fluid from your lungs. Your breathing has
improved significantly, although you are still requiring 3L of
oxygen. We would recommend that you continue to use 3L of
oxygen.
.
While you were here, you also developed a very serious blood
infection related to your bladder. You were treated with
antibiotics in the intensive care unit and you recovered very
well from this infection.
.
Please continue to take all your medications as prescribed. The
following changes have been made:
- Nebulizer treatments: you should take albuterol and
ipratroprium nebulizers every 6 hours
- oxygen: you should use at least 3L of oxygen for daily
activity
.
If you have symptoms of worsening fevers, chills, night sweats,
chest pain, abdominal pain, light-headedness, pain or burning
with urination, shortness of breath, or worsened lower extremity
swelling, please seek immediate medical attention.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

Followup Instructions:
Please follow up with Urology on THursday [**4-3**] at 9:45am
in [**Hospital Ward Name 23**] 3.

[**Last Name (un) 6267**] follow up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 1713**] in
[**2-24**] weeks.



Completed by:[**2188-3-31**]
{'Septic shock,Acute kidney failure, unspecified,Primary pulmonary hypertension,Malignant neoplasm of other specified sites of large intestine,Congestive heart failure, unspecified,Retention of urine, unspecified,Atrial fibrillation,Chronic kidney disease, Stage III (moderate),Iron deficiency anemia secondary to blood loss (chronic),Chronic airway obstruction, not elsewhere classified,Bacterial pneumonia, unspecified,Septicemia due to escherichia coli [E. coli],Severe sepsis'}


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

PRESENT ILLNESS: This is an 87-year-old man with colon cancer who presents with
several months of shortness of breath, dyspnea on exertion, and
leg edema.  He was initially noted to have a right pleural
effusion back on [**2188-2-25**] when his cardiologist ordered a chest CT
scan.  He was seen today in the oncology clinic for evaluation
of this possible malignant effusion, and he was noted to be
hypoxic in the mid to high 80's on room air and he desaturated
to 81% with ambulation.  He was referred to the ED.

MEDICAL HISTORY: 1) sick sinus syndrome and bifascicular block s/p pacemaker [**2184**]
2) paroxysmal atrial fibrillation not on coumadin, SVT [**2185**] and
atrial flutter status post ablation
3) cataracts. declined surgery
4) Echo [**2186**]: mild-to-moderate mitral regurgitation, RA and LA
5) BPH s/p TURMP [**2187**]
6) b/l edema with skin changes
7) hard of hearing
8) hx of guiaic positive stools/GI bleeding
9) osteoarthritis
10) osteoporosis
11) subclinical hypothyroid state as per record
12) hx of syncope
13) renal insufficiency
14) right pleural effusion

MEDICATION ON ADMISSION: AMIODARONE 200 mg--1 tablet(s) by mouth daily
ASPIRIN 81 mg--1 tablet(s) by mouth daily
LASIX 20 mg--2 tablet(s) by mouth daily
METOPROLOL SUCCINATE 25 mg--1 tablet(s) by mouth daily
TERAZOSIN 5 mg--1 capsule(s) by mouth daily
Tylenol 650 mg daily
MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 98.0, HR 70, BP 120/81, RR 16, O2 sat 88-93% on 3-4L NC
GEN: Alert and oriented.  NAD.
HEENT: Supple neck.  Anicteric sclera.  Slightly dry MM.  No
cervical LAD.
CV: RRR, II/VI systolic murmur at LLSB
LUNGS: Decreased BS and + dullness at right base.  Some coarse
BS at the left base.
ABD: Soft, mildly protuberant. Nontender.
EXT: Chronic venous stasis changes in both legs with 1+
bilateral pitting edema of the legs.
NEURO: A+O. Non-focal.

FAMILY HISTORY: brother had [**Name2 (NI) 500**] marrow stem cell transplant at age 82
Sister died from heart attack. Also had an unknown cancer.
Mother died from an unknown cancer.
Neice has unknown cancer.

SOCIAL HISTORY: Lives alone.  Former smoker with 35-pk-yrs.  No longer drinking
alcohol, formerly had a couple of drinks a week. 

### Response:
{'Septic shock,Acute kidney failure, unspecified,Primary pulmonary hypertension,Malignant neoplasm of other specified sites of large intestine,Congestive heart failure, unspecified,Retention of urine, unspecified,Atrial fibrillation,Chronic kidney disease, Stage III (moderate),Iron deficiency anemia secondary to blood loss (chronic),Chronic airway obstruction, not elsewhere classified,Bacterial pneumonia, unspecified,Septicemia due to escherichia coli [E. coli],Severe sepsis'}
