CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 57 year old male with HTN, hypercholesterolemia, OSA, who
presents with one week of cough and shortness of breath with
exertion for 2 days. He also complains of one episode of nausea,
vomiting and 3-4 days of watery diarrhea, denies any blood in
emesis or stool. He was seen in [**Location (un) **] Urgent Care Clinic
and sent here. Patient reports cough has been non-productive,
but coughing to the point of dry heaves. No known fevers or
chills at home. Denies muscle aches or pains, able to go to work
for the past few days, but became very concerned when he became
dyspneic with minimal exertion at work. Denies any associated
chest pain, dizziness, or feeling LH with the SOB. No recent
antibiotics, no recent travel, multiple sick contacts at home.
Did receive the flu vaccine this year. Remembers having a stress
test over five years ago, believes he had an echo within the
past two years, cannot recall specific results.
.
ED vitals: HR 110's, O2 sat 100%/3L. The patient given dose of
Levofloxacin and aspirin, CXR with small left pleural effusion.
Blood cultures sent.

MEDICAL HISTORY: HTN
hypercholesterolemia
OSA
GERD

MEDICATION ON ADMISSION: Lipitor 20 daily
Colace 100 [**Hospital1 **]
Lisinopril 5 daily
Ranitidine 150 mg [**Hospital1 **]
Aspirin 81 daily
Ibuprofen
HCTZ 25 daily
Nafazodone 150 mg [**Hospital1 **]
CPAP- does not know his settings

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: V: 99.7/ bp 143/72/ hr 107/ rr 22/ 90% on RA-> 96% on 2L
Gen: obese male, speaking full sentences but w/ labored
breathing
HEENT: atraumatic, anicteric, EOMI, dry mucosa
Neck: no JVP, no LAD
CV: tachy, no murmurs or rubs appreciated
Pulm: decreased BS on left with rhonchi, mild wheeze throughout

FAMILY HISTORY: Mother deceased from a MI at age 75, Father deceased from
pneumonia at 81

SOCIAL HISTORY: Lives with his wife, two children, and father in law. Works as a
bus driver for mass transit. Non-smoker, occasional ETOH, no
illicits
Acute idiopathic pericarditis,Iron deficiency anemia secondary to blood loss (chronic),Dehydration,Unspecified disease of pericardium,Esophageal reflux,Unspecified essential hypertension,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric)
Ac idiopath pericarditis,Chr blood loss anemia,Dehydration,Pericardial disease NOS,Esophageal reflux,Hypertension NOS,Pure hypercholesterolem,Obstructive sleep apnea
Admission Date:  [**2192-1-17**]              Discharge Date:   [**2192-1-20**]

Date of Birth:  [**2134-9-22**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 458**]
Chief Complaint:
shortness of breath


Major Surgical or Invasive Procedure:
Pericardiocentesis


History of Present Illness:
57 year old male with HTN, hypercholesterolemia, OSA, who
presents with one week of cough and shortness of breath with
exertion for 2 days. He also complains of one episode of nausea,
vomiting and 3-4 days of watery diarrhea, denies any blood in
emesis or stool. He was seen in [**Location (un) **] Urgent Care Clinic
and sent here. Patient reports cough has been non-productive,
but coughing to the point of dry heaves. No known fevers or
chills at home. Denies muscle aches or pains, able to go to work
for the past few days, but became very concerned when he became
dyspneic with minimal exertion at work. Denies any associated
chest pain, dizziness, or feeling LH with the SOB. No recent
antibiotics, no recent travel, multiple sick contacts at home.
Did receive the flu vaccine this year. Remembers having a stress
test over five years ago, believes he had an echo within the
past two years, cannot recall specific results.
.
ED vitals: HR 110's, O2 sat 100%/3L. The patient given dose of
Levofloxacin and aspirin, CXR with small left pleural effusion.
Blood cultures sent.


Past Medical History:
HTN
hypercholesterolemia
OSA
GERD


Social History:
Lives with his wife, two children, and father in law. Works as a
bus driver for mass transit. Non-smoker, occasional ETOH, no
illicits


Family History:
Mother deceased from a MI at age 75, Father deceased from
pneumonia at 81


Physical Exam:
V: 99.7/ bp 143/72/ hr 107/ rr 22/ 90% on RA-> 96% on 2L
Gen: obese male, speaking full sentences but w/ labored
breathing
HEENT: atraumatic, anicteric, EOMI, dry mucosa
Neck: no JVP, no LAD
CV: tachy, no murmurs or rubs appreciated
Pulm: decreased BS on left with rhonchi, mild wheeze throughout

Abd: soft, nt, nd, nabs
Ext: warm, dry. Mild trace pretibial edema, DP pulses full and
symmetric B/L


Pertinent Results:
.
EKG:
.
Labs:
142.|.100.|.24 111
--------------
3.5.|.29.|.0.9
.
WBC 11.1 Hct 32.4 Plt 359
N:70.4 L:20.7 M:7.7 E:0.5 Bas:0.6
.
[**1-17**] 7:45p.m. CK: 136 MB: Pnd Trop < 0.01
.
Lactate:2.7
.
Studies:
[**1-17**] CXR: Cardiomegaly with small left pleural effusion.
.
Echo:
Left ventricular wall thickness, cavity size, and systolic
function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion
abnormality cannot be fully excluded. The aortic valve leaflets
(3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are
mildly thickened. There is no mitral valve prolapse. There is a
small
pericardial effusion subtending the posterolateral wall. The
effusion is echo
dense, consistent with blood, inflammation or other cellular
elements. There
are no echocardiographic signs of tamponade.
.
Pericardial fluid:
GRAM STAIN (Final [**2192-1-19**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2192-1-22**]):    NO GROWTH.

   ANAEROBIC CULTURE (Final [**2192-1-25**]):    NO GROWTH.

   ACID FAST SMEAR (Final [**2192-1-19**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

   ACID FAST CULTURE (Pending):

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
.
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
NEGATIVE FOR CMV IgM ANTIBODY BY EIA


Brief Hospital Course:
A/P: 57 year old male with HTN, hypercholesterolemia presents
with cough x 1 week, SOB x 2 days.
.
# SOB- Patient was found to have pericardial effusion. No
tamponade physiuology observed. The fluid was drained and a
drain was placed. Pt's breathing improved a lot after the fluid
was removed. The echo was repeated after the drainage. It showed
decreased amount of fluid as compared to the previous ECHO. Pt
was on O2 by NC during the day and was using his CPAP machine
during night. He was monitored on telemetry. The pt remained
stable after pericardial drain removal, required no oxygen and
was discharged in stable condidtion.  A follow up cardiology
appointment and a follow up echo was scheduled. The CXR showed
LLL infiltrate. Hence he was treated with a course of
levofloxacin
.
# [**Name (NI) 3674**] pt had normocytic anemia. unclear baseline hct. Pt did
not report any signs or symptoms of GIB, reported having a
colonoscopy three years ago that was normal.
.
# hypercholesterolemia- continued statin
.
# OSA- CPAP overnight
.
# FEN-  heart healthy diet
.
# Proph- heparin SC


Medications on Admission:
Lipitor 20 daily
Colace 100 [**Hospital1 **]
Lisinopril 5 daily
Ranitidine 150 mg [**Hospital1 **]
Aspirin 81 daily
Ibuprofen
HCTZ 25 daily
Nafazodone 150 mg [**Hospital1 **]
CPAP- does not know his settings


Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
5. Nefazodone 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 1 weeks.
Disp:*24 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary
pericardial effusion
.
Secondary
hypercholesterolemia
OSA uses CPAP
GERD
chronic blood loss anemia
obesity
psoriasis


Discharge Condition:
Stable


Discharge Instructions:
You had fluid accumulation around your heart. We removed the
fluid. You need to follow up with your cardiologist. You also
need to get an [**Hospital1 461**] before seeing your cardiologist.
The appointments for both these things have been made.
.
We stopped you lisinopril and HCTZ. Your PCP needs to assess
your BP and decide whether to restart these medications.
.
You need to get a test known as PPD. Please talk to your PCP
regarding this.
.
If you have chest pain, shortness of breath, dizziness,
palpitaions, nausea, vomitting, pain in stomach please call your
doctor or go to the emergency room

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2192-2-8**]
2:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2192-1-30**]
9:00

Please make a follow up appointment with your primary care
provider Dr [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **] early next week. You need to get a
test known as PPD. Please talk to your PCP regarding this. Also
we stopped you lisinopril and HCTZ. Your PCP needs to assess
your BP and decide whether to restart these medications.



Completed by:[**2192-2-1**]
{'Acute idiopathic pericarditis,Iron deficiency anemia secondary to blood loss (chronic),Dehydration,Unspecified disease of pericardium,Esophageal reflux,Unspecified essential hypertension,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric)'}


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: 57 year old male with HTN, hypercholesterolemia, OSA, who
presents with one week of cough and shortness of breath with
exertion for 2 days. He also complains of one episode of nausea,
vomiting and 3-4 days of watery diarrhea, denies any blood in
emesis or stool. He was seen in [**Location (un) **] Urgent Care Clinic
and sent here. Patient reports cough has been non-productive,
but coughing to the point of dry heaves. No known fevers or
chills at home. Denies muscle aches or pains, able to go to work
for the past few days, but became very concerned when he became
dyspneic with minimal exertion at work. Denies any associated
chest pain, dizziness, or feeling LH with the SOB. No recent
antibiotics, no recent travel, multiple sick contacts at home.
Did receive the flu vaccine this year. Remembers having a stress
test over five years ago, believes he had an echo within the
past two years, cannot recall specific results.
.
ED vitals: HR 110's, O2 sat 100%/3L. The patient given dose of
Levofloxacin and aspirin, CXR with small left pleural effusion.
Blood cultures sent.

MEDICAL HISTORY: HTN
hypercholesterolemia
OSA
GERD

MEDICATION ON ADMISSION: Lipitor 20 daily
Colace 100 [**Hospital1 **]
Lisinopril 5 daily
Ranitidine 150 mg [**Hospital1 **]
Aspirin 81 daily
Ibuprofen
HCTZ 25 daily
Nafazodone 150 mg [**Hospital1 **]
CPAP- does not know his settings

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: V: 99.7/ bp 143/72/ hr 107/ rr 22/ 90% on RA-> 96% on 2L
Gen: obese male, speaking full sentences but w/ labored
breathing
HEENT: atraumatic, anicteric, EOMI, dry mucosa
Neck: no JVP, no LAD
CV: tachy, no murmurs or rubs appreciated
Pulm: decreased BS on left with rhonchi, mild wheeze throughout

FAMILY HISTORY: Mother deceased from a MI at age 75, Father deceased from
pneumonia at 81

SOCIAL HISTORY: Lives with his wife, two children, and father in law. Works as a
bus driver for mass transit. Non-smoker, occasional ETOH, no
illicits 

### Response:
{'Acute idiopathic pericarditis,Iron deficiency anemia secondary to blood loss (chronic),Dehydration,Unspecified disease of pericardium,Esophageal reflux,Unspecified essential hypertension,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric)'}
