CHIEF COMPLAINT: Dyspnea on exertion

PRESENT ILLNESS: Mr. [**Known lastname 8467**] is a 62m with metastatic prostate ca, cad, osa, and a
history of mild doe with an unrevealing work-up who came to
oncology clinic today with complaints of worsening doe over the
past 5-6 days.  He states it began this past weekend with no
clear precipitant; he'd felt fine all last week.  Whereas
normally he could walk 80-90 feet on level ground before feeling
dyspneic, now it occurs at half that distance.  He describes the
sensation as one of having to work harder to [**Last Name (LF) 1440**], [**First Name3 (LF) **]
increased effort.  There's been minimal cough, minimal sputum
production, no hemoptysis, no wheezing, no orthopnea/pnd, no
chest pain or palpitations, no uri sx.  He also has no sick
contacts, no exposure to dusts or other strange environmental
phenomenon, no recent travel; his volunteer activities does
include work with the homeless, but a large portion of this is
office-related work, and he does not think anyone he's been
around has had a cough.  He further denies f/c (though had one
temp to 100.1 at home), abd pain, n/v/d/c, melena/hematochezia,
hematuria/frequency.  His appetite has been decreased for the
past few weeks but he's kept up with oral hydration.
In the oncology clinic, hi o2 sats were in the mid 90's on room
air at rest but he desatted to mid 80's with ambulation.

MEDICAL HISTORY: -Metastatic prostate CA -- Diagnosed [**2178**] after developing back
pain, and his PSA came back at 1567.  He has multiple osseous
metastases.  The cancer is hormone refractory, and he was
initially treated with lupron; when disease progression was
demonstrated on this regimen, he underwent 28 cycles of
taxotere/estramustine.  Then in [**12/2185**] he got mitoxantrone and
prednisone.  Most recently he's had taxotere and carboplatin for
12 cycles with good response though complicated by acute
colitis.  As he continued to progress off chemotherapy, he was
started on the ARIAD trial in 1/[**2186**].
-HTN
-CAD -- NSTEMI [**2179**], MIBI in [**2183**] with mild, fixed defects
-OSA

MEDICATION ON ADMISSION: -EC-aspirin 325 mg daily
-omeprazole 20 mg daily
-fentanyl patch 50 mcg every 48 hours
-Ditropan 10 mg b.i.d.
-doxazosin 8 mg b.i.d.
-lisinopril 20 mg daily
-multivitamin daily
-Aldactone 50 mg b.i.d.
-Lupron every 3 months
-Percocet b.i.d.
-Celebrex 200 mg b.i.d.
-Silvadene cream twice daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: t 99.4, bp 160/88, hr 80, rr 18, spo2 96%ra
gen- pleasant, mod obese male, looks slightly older than age,
non-toxic, nad
heent- anicteric sclera, op clear with mmm
neck- no jvd/lad/thyromegaly
cv- rrr, s1s2, 2/6 systolic murmur at ursb (no radiation)
pul- no resp distress/accessory muscle use; moves air well,
normal i:e, no w/r/r
abd- soft, nt, nd, nabs, no hepatosplenomegaly
back- no cva tenderness, no sacral edema, mild mid-thoracic vert
pain (baseline per pt)
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, no pitting/indentations, mildly discolored
derm- erythematous, confluent rash on elbows, hands, feet
neuro- a&ox3, no focal cn/motor deficits

FAMILY HISTORY: His mother seems to have a malignancy but bx's have been
unrevealing thus far.

SOCIAL HISTORY: Mr. [**Known lastname 8467**] lives in [**Location **] with his wife and son.  [**Name (NI) **] formerly worked
for [**Company 2676**] as a software engineer, working on the guidance
system for the Patriot missile; prior to that he was in the Air
Force.  He has an undergraduate degree in MIS and an MBA.  He
smoked 1ppd for 20 years but quit 20 years ago, has a glass of
wine occasionally with dinner, and has never used
illicit/injection drugs.  He has a labrador retriever.
Other pulmonary insufficiency, not elsewhere classified,Secondary malignant neoplasm of lung,Other specified alveolar and parietoalveolar pneumonopathies,Other pulmonary embolism and infarction,Unspecified hypertensive heart disease with heart failure,Acute diastolic heart failure,Secondary malignant neoplasm of bone and bone marrow,Acute kidney failure, unspecified,Personal history of malignant neoplasm of prostate,Obstructive sleep apnea (adult)(pediatric),Old myocardial infarction,Dermatitis due to drugs and medicines taken internally,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Disorder of bone and cartilage, unspecified,Anemia of other chronic disease,Other disorders of neurohypophysis,Benign neoplasm of cerebral meninges,Long-term (current) use of steroids
Other pulmonary insuff,Secondary malig neo lung,Alveol pneumonopathy NEC,Pulm embol/infarct NEC,Hyp ht dis NOS w ht fail,Ac diastolic hrt failure,Secondary malig neo bone,Acute kidney failure NOS,Hx-prostatic malignancy,Obstructive sleep apnea,Old myocardial infarct,Drug dermatitis NOS,Adv eff antineoplastic,Bone & cartilage dis NOS,Anemia-other chronic dis,Neurohypophysis dis NEC,Ben neo cerebr meninges,Long-term use steroids
Admission Date:  [**2187-2-1**]              Discharge Date:   [**2187-3-9**]

Date of Birth:  [**2124-6-5**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
Dyspnea on exertion


Major Surgical or Invasive Procedure:
bronchoscopy

History of Present Illness:
Mr. [**Known lastname 8467**] is a 62m with metastatic prostate ca, cad, osa, and a
history of mild doe with an unrevealing work-up who came to
oncology clinic today with complaints of worsening doe over the
past 5-6 days.  He states it began this past weekend with no
clear precipitant; he'd felt fine all last week.  Whereas
normally he could walk 80-90 feet on level ground before feeling
dyspneic, now it occurs at half that distance.  He describes the
sensation as one of having to work harder to [**Last Name (LF) 1440**], [**First Name3 (LF) **]
increased effort.  There's been minimal cough, minimal sputum
production, no hemoptysis, no wheezing, no orthopnea/pnd, no
chest pain or palpitations, no uri sx.  He also has no sick
contacts, no exposure to dusts or other strange environmental
phenomenon, no recent travel; his volunteer activities does
include work with the homeless, but a large portion of this is
office-related work, and he does not think anyone he's been
around has had a cough.  He further denies f/c (though had one
temp to 100.1 at home), abd pain, n/v/d/c, melena/hematochezia,
hematuria/frequency.  His appetite has been decreased for the
past few weeks but he's kept up with oral hydration.
In the oncology clinic, hi o2 sats were in the mid 90's on room
air at rest but he desatted to mid 80's with ambulation.


Past Medical History:
-Metastatic prostate CA -- Diagnosed [**2178**] after developing back
pain, and his PSA came back at 1567.  He has multiple osseous
metastases.  The cancer is hormone refractory, and he was
initially treated with lupron; when disease progression was
demonstrated on this regimen, he underwent 28 cycles of
taxotere/estramustine.  Then in [**12/2185**] he got mitoxantrone and
prednisone.  Most recently he's had taxotere and carboplatin for
12 cycles with good response though complicated by acute
colitis.  As he continued to progress off chemotherapy, he was
started on the ARIAD trial in 1/[**2186**].
-HTN
-CAD -- NSTEMI [**2179**], MIBI in [**2183**] with mild, fixed defects
-OSA


Social History:
Mr. [**Known lastname 8467**] lives in [**Location **] with his wife and son.  [**Name (NI) **] formerly worked
for [**Company 2676**] as a software engineer, working on the guidance
system for the Patriot missile; prior to that he was in the Air
Force.  He has an undergraduate degree in MIS and an MBA.  He
smoked 1ppd for 20 years but quit 20 years ago, has a glass of
wine occasionally with dinner, and has never used
illicit/injection drugs.  He has a labrador retriever.


Family History:
His mother seems to have a malignancy but bx's have been
unrevealing thus far.


Physical Exam:
t 99.4, bp 160/88, hr 80, rr 18, spo2 96%ra
gen- pleasant, mod obese male, looks slightly older than age,
non-toxic, nad
heent- anicteric sclera, op clear with mmm
neck- no jvd/lad/thyromegaly
cv- rrr, s1s2, 2/6 systolic murmur at ursb (no radiation)
pul- no resp distress/accessory muscle use; moves air well,
normal i:e, no w/r/r
abd- soft, nt, nd, nabs, no hepatosplenomegaly
back- no cva tenderness, no sacral edema, mild mid-thoracic vert
pain (baseline per pt)
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, no pitting/indentations, mildly discolored
derm- erythematous, confluent rash on elbows, hands, feet
neuro- a&ox3, no focal cn/motor deficits


Pertinent Results:
Admission Labs:

[**2187-2-1**] 10:44AM BLOOD WBC-4.5 RBC-3.87* Hgb-10.9* Hct-31.0*
MCV-80* MCH-28.0 MCHC-35.0 RDW-16.0* Plt Ct-163
[**2187-2-1**] 10:44AM BLOOD Neuts-66 Bands-4 Lymphs-15* Monos-7
Eos-5* Baso-2 Atyps-1* Metas-0 Myelos-0
[**2187-2-1**] 10:44AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Tear Dr[**Last Name (STitle) 833**]
[**2187-2-1**] 10:44AM BLOOD Plt Smr-NORMAL Plt Ct-163
[**2187-2-1**] 10:44AM BLOOD Ret Aut-0.7*
[**2187-2-1**] 10:44AM BLOOD Glucose-123* UreaN-21* Creat-1.4* Na-132*
K-3.8 Cl-100 HCO3-24 AnGap-12
[**2187-2-1**] 10:44AM BLOOD ALT-34 AST-69* LD(LDH)-626* CK(CPK)-145
AlkPhos-67 TotBili-0.9 DirBili-0.2 IndBili-0.7
[**2187-2-1**] 10:44AM BLOOD CK-MB-2 cTropnT-<0.01
[**2187-2-1**] 08:00PM BLOOD CK-MB-2 cTropnT-<0.01
[**2187-2-2**] 12:00AM BLOOD CK-MB-2 cTropnT-<0.01
[**2187-2-1**] 10:44AM BLOOD TotProt-5.5* Albumin-3.2* Globuln-2.3
Calcium-7.4* Phos-2.3* Mg-1.7 Cholest-213*
[**2187-2-1**] 08:00PM BLOOD Iron-35*
[**2187-2-1**] 08:00PM BLOOD calTIBC-229* VitB12-1354* Folate-14.6
Ferritn-693* TRF-176*
[**2187-2-1**] 10:44AM BLOOD Triglyc-230*
.
[**2-1**] CXR: Subtle right lower lobe posterior basilar opacity,
which may be due to atelectasis or early pneumonia. Followup
chest radiographs would be helpful. Linear retrosternal upper
lobe opacity, likely atelectasis.
.
[**2-1**] Head CT: 1. New 2.0 x 1.3 cc cm focus of hypointensity in
the right inferior frontal lobe. The appearance is nonspecific
and contusion or age indeterminate infarction cannot be
excluded. MRI is recommended for further correlation.
.
[**2-2**] LENIs: No evidence of deep venous thrombosis.
.
[**2-2**] CTA Chest: 1. Multiple segmental pulmonary emboli.
2. Patchy bilateral ground-glass opacities, likely consistent
with pulmonary edema from congestive heart failure. An
infectious process cannot be fully ruled out.
.
[**2-2**] Renal U/S: 1. No hydronephrosis.
2. Possible tiny crystal in the mid portion of the right kidney.
.
[**2-2**] CXR: Interval worsening of multifocal bilateral hazy
(ground glass) opacities, which is likely due to asymmetrical
pulmonary edema or atypical infection. Differential diagnosis
includes hemorrhage and drug toxicity.
.
[**2-5**] Echo: The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Tissue velocity imaging
demonstrates an E/e' <8 suggesting a normal left ventricular
filling pressure. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is moderately dilated.
The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is a very small
pericardial effusion (seen posteriorly). There are no
echocardiographic signs of tamponade.
.
[**2-7**] CXR: No evidence of pneumothorax. Slight worsening of
parenchymal opacities.
.
[**2-7**] Bronchial Washings: negative for malignant cells.
.
[**2-9**] CXR: Slight improvement in bilateral pulmonary opacities.
.
CTA Chest [**2187-2-21**]:
CT OF THE CHEST WITH CONTRAST, FINDINGS:  Current studies viewed
in
conjunction with the prior exam of [**2187-2-11**].  There are diffuse
ground glass opacities throughout both lung fields, most marked
in the upper lobes.  There is relative sparing of the right
lower lobe.  There is no evidence of pulmonary embolism.  There
are no effusions appreciated.  Again appreciated is some
scattered mediastinal lymphadenopathy.  Bone windows reveal some
rarified areas within scattered vertebral bodies raising the
question of metastatic foci, unchanged compared to the prior
exam.  Small bilateral pleural effusions are appreciated and
appear new since the prior study.
.
IMPRESSION:
1.  No evidence of pulmonary embolism.
2.  Marked progression in diffuse ground glass infiltrates with
relative
sparing of the right lower lobe.  This is associated with
development of new small bilateral effusions.
3.  Study is otherwise unchanged including multiple areas within
the thoracic vertebral body raising the question of bony
involvement by this patient's underlying malignancy.
.
Wedge biopsies of lung, two:
I.  (Right upper lobe):
a.  Patchy organizing pneumonitis with features of bronchiolitis
obliterans-organizing pneumonia (BOOP).
b.  Marked accumulation of intraalveolar macrophages.
c.  Subpleural fibrosis with intimal thickening of pulmonary
arteries.
.
II.  (Right middle lobe):
a.  Metastatic adenocarcinoma consistent with prostate origin,
microscopic focus (slide G). Tumor cells are positive for PSA
and keratin cocktail and negative for PSAP, keratin 7 and 20.
b.  Patchy organizing pneumonitis with features of bronchiolitis
obliterated-organizing pneumonitis (BOOP).
c.  Marked accumulation of intraalveolar macrophages.
d.  Subpleural fibrosis with intimal thickening of pulmonary
arteries.
.


Brief Hospital Course:
Shortness of [**Date Range **]:  This was initially felt to be [**1-18**] PE given
CTA findings on admission.  Initial work up ruled out cardiac
ischemia with a normal EKG and negative cardiac enzymes.
Infectious etiologies were also considered, including bacterial
pneumonia, PCP (given that that the patient had been on
chemotherapy), fungal infections, and tuberculosis.  Initially,
the patient was treated with levofloxacin for community acquired
pneumonia.  This was discontinued at the recommendation of the
infectious diseae service as it has some anti-TB activity, and
we did not want to give monotherapy for TB until it was formally
ruled out.  When the patient continued to be febrile,
ceftriaxone and azithromycin were started for community acquired
pneumonia, and coverage was then broadened to zosyn and
vancomycin to cover nosocomial pneumonia as the patient's
infiltrates on chest xray were worsening while the patient was
hospitalized.  A viral antigen screen was negative, ruling out
influenza and several other viral infections.
.
The pulmonary service was consulted, and a bronchoscopy with BAL
was performed.  The gram stain from the BAL showed no organisms,
and the respiratory culture grew oropharyngeal flora.  PCP and
AFB were negative.  However, the PCP screen in patients with
malignancy is not always reliable, so bactrim and steroids were
started to cover PCP.  [**Name10 (NameIs) **] patient was also continued on
isolation precautions for TB until additional sputum samples
could be obtained, for similar reasons.  He was eventually ruled
out for TB with 3 negative AFBs.  After PCP was ruled out
steroids were d/ced.
.
Thoracic surgery was consulted for a VATS procedure to obtain
tissue to help confirm the diagnosis.  The main concern, other
than the above differential, was lymphangitic spread of his
tumor, which could be confirmed with tissue, as well as BOOP,
which was a concern given recent chemo therapy with
tor-inhibitor, which has a known association with BOOP.
Thoracics recommended repeat Chest CT before considering VATS,
and when this showed improvement in GGO they recommended
continuing antibiotics and steroids and deferring VATS.
.
However pt had an episode of respiratory decompensation,
requiring a transfer to the [**Hospital Unit Name 153**] and non-invasive ventilation
with BiPAP.  Pt. did not require intubation.  It was felt that
this decompensation was [**1-18**] flash pulmonary edema.  After pt.
was stabilized and transferred back to the floor VATS was again
considered given uncertainty in the diagnosis (repeat CTA had
showed resolution of PEs, however pt. was still very SOB, and
the team was not confident that his SOB could be contributed to
pulmonary edema and PE alone)  It was also noted that pt's
decompensation happened after steroids were d/ced, and so a
steroid responsive process like BOOP was considered.
.
On [**3-1**] pt. was taken for VATS.  Pathology showed BOOP +
evidence of metastatic prostate CA in the lung.
.
In the end pt's SOB was felt to be multifactorial, from PE, lung
mets from prostate CA, BOOP, which was most likely [**1-18**] pt's
recent chemotherapy regimen, and from CHF with diastolic
dysfunction.  Pt. improved with steroids and diuresis, and was
discharged home with home O2 and close follow up with Dr.
[**Last Name (STitle) **], his oncologist.  Pt. was discharged on Prednisone,
Lovenox and Coumadin, a BB and ACE, and home O2.
.
#Acute renal insufficiency: Pt. had 2 episodes where his Cr
became elevated.  [**Last Name (un) **] firt, shortly after admission was felt to
be pre-renal and improved with hydration. A Renal US at that
point showed no obstruction.  The second happened several days
after Bactrim was tarted and was felt to be [**1-18**] AIN from Bactrim
and resolved with discontinuation of this.  Cr was stable around
1 for several days prior to discharge.
.
#CAD -- The patient was ruled out for MI on admission.  He was
monitored on telemetry for a few days with no significant
events.  We continued aspirin and ACE inhibitor per his
outpatient regimen, and added a beta blocker for better BP
control.
.
#HTN -- We continued lisinopril, and doxazosin, which the
patient was on as an outpatient, and added a beta blocker for
better BP control, particularly given the patient's history of
coronary artery disease.
.
#Anemia -- The patient's creatinine ranged in the high 20s, down
from his baseline of mid to high 30's.  There was no obvious
source of blood loss or hemolysis.  In the past, had no
b12/fe/fol deficiency.  The anemia was microcytic with a low
retic count.  The most probable cause seemed to be AOCD with a
contribution from chemotherapy.  Laboratory studies were
consistent with this etiology.  Given the patient's hypoxia, it
was decided to transfuse the patient to maintain hct around 30.
He received 1 unit of PRBC on [**2-3**] and another on [**2-9**].
.
#Hyponatremia -- This was considered to be likely SIADH, given
the ongoing pulmonary process.  Improved with fluid restriction.
.
#Skin rash -- This was secondary to chemotherapy.  We continued
with silvadene [**Hospital1 **] per outpatient regimen.
.
#Pain -- Continued the usual outpatient regimen.  Celebrex was
initially held due to elevated creatinine, but was restarted
after a few days.

Medications on Admission:
-EC-aspirin 325 mg daily
-omeprazole 20 mg daily
-fentanyl patch 50 mcg every 48 hours
-Ditropan 10 mg b.i.d.
-doxazosin 8 mg b.i.d.
-lisinopril 20 mg daily
-multivitamin daily
-Aldactone 50 mg b.i.d.
-Lupron every 3 months
-Percocet b.i.d.
-Celebrex 200 mg b.i.d.
-Silvadene cream twice daily


Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
4. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day).
Disp:*1 bottle* Refills:*2*
8. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*21 Capsule(s)* Refills:*0*
10. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
12. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed.
Disp:*90 Tablet(s)* Refills:*0*
13. Prednisone 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*0*
14. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
15. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2)  Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*24 mL* Refills:*0*
16. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*0*
17. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
20. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

21. Enoxaparin 100 mg/mL Syringe Sig: One (1) mL Subcutaneous
[**Hospital1 **] (2 times a day).
Disp:*14 mL* Refills:*0*
22. Carvedilol 3.125 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
Disp:*240 Tablet(s)* Refills:*2*
23. Home Oxygen
3L continuous O2 NC- O2 98% on 3L, 83-84% on RA


Discharge Disposition:
Home With Service

Facility:
Care Centrix

Discharge Diagnosis:
Metastatic Prostate Cancer
Pulmonary Embolus
Bronchiolitis Obliterans Organizing Pneumonia (BOOP)
Flash Pulmonary Edema
Hypertension
CHF with Diastolic Dysfunction, preserved EF (65-70%)
Obstructive Sleep Apnea


Discharge Condition:
Improved- breathing comfortably on 3L oxygen


Discharge Instructions:
If you experience fever, chills, shortness of [**Hospital1 1440**], chest
pain, or any other new or concerning symptoms, please call your
doctor or return to the emergency room for evaluation.
.
Please take all medications as prescribed.
.
Please attend all followup appointments.
.
Please limit your sodium intake to 2 g/day and your fluid intake
to 2L per day.

Followup Instructions:
Oncology: Please call Dr. [**Last Name (STitle) **] and Dr.[**Name (NI) 30779**] office at
[**Telephone/Fax (1) 22**] about your follow up appointment next Thursday.
.
Pulmonology: Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office at
[**Telephone/Fax (1) 612**] to set up a follow up appointment
.
Primary Care: Please call Dr.[**Name (NI) 29254**] office at [**Telephone/Fax (1) 250**]
to set up a follow up appointment in the next 2-4 weeks.
.
Please have your INR checked at a lab by your house and have the
results faxed to Dr. [**Last Name (STitle) 13933**] at [**Telephone/Fax (1) 13345**].


                             [**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]

Completed by:[**2187-5-7**]
{'Other pulmonary insufficiency, not elsewhere classified,Secondary malignant neoplasm of lung,Other specified alveolar and parietoalveolar pneumonopathies,Other pulmonary embolism and infarction,Unspecified hypertensive heart disease with heart failure,Acute diastolic heart failure,Secondary malignant neoplasm of bone and bone marrow,Acute kidney failure, unspecified,Personal history of malignant neoplasm of prostate,Obstructive sleep apnea (adult)(pediatric),Old myocardial infarction,Dermatitis due to drugs and medicines taken internally,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Disorder of bone and cartilage, unspecified,Anemia of other chronic disease,Other disorders of neurohypophysis,Benign neoplasm of cerebral meninges,Long-term (current) use of steroids'}


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 on exertion

PRESENT ILLNESS: Mr. [**Known lastname 8467**] is a 62m with metastatic prostate ca, cad, osa, and a
history of mild doe with an unrevealing work-up who came to
oncology clinic today with complaints of worsening doe over the
past 5-6 days.  He states it began this past weekend with no
clear precipitant; he'd felt fine all last week.  Whereas
normally he could walk 80-90 feet on level ground before feeling
dyspneic, now it occurs at half that distance.  He describes the
sensation as one of having to work harder to [**Last Name (LF) 1440**], [**First Name3 (LF) **]
increased effort.  There's been minimal cough, minimal sputum
production, no hemoptysis, no wheezing, no orthopnea/pnd, no
chest pain or palpitations, no uri sx.  He also has no sick
contacts, no exposure to dusts or other strange environmental
phenomenon, no recent travel; his volunteer activities does
include work with the homeless, but a large portion of this is
office-related work, and he does not think anyone he's been
around has had a cough.  He further denies f/c (though had one
temp to 100.1 at home), abd pain, n/v/d/c, melena/hematochezia,
hematuria/frequency.  His appetite has been decreased for the
past few weeks but he's kept up with oral hydration.
In the oncology clinic, hi o2 sats were in the mid 90's on room
air at rest but he desatted to mid 80's with ambulation.

MEDICAL HISTORY: -Metastatic prostate CA -- Diagnosed [**2178**] after developing back
pain, and his PSA came back at 1567.  He has multiple osseous
metastases.  The cancer is hormone refractory, and he was
initially treated with lupron; when disease progression was
demonstrated on this regimen, he underwent 28 cycles of
taxotere/estramustine.  Then in [**12/2185**] he got mitoxantrone and
prednisone.  Most recently he's had taxotere and carboplatin for
12 cycles with good response though complicated by acute
colitis.  As he continued to progress off chemotherapy, he was
started on the ARIAD trial in 1/[**2186**].
-HTN
-CAD -- NSTEMI [**2179**], MIBI in [**2183**] with mild, fixed defects
-OSA

MEDICATION ON ADMISSION: -EC-aspirin 325 mg daily
-omeprazole 20 mg daily
-fentanyl patch 50 mcg every 48 hours
-Ditropan 10 mg b.i.d.
-doxazosin 8 mg b.i.d.
-lisinopril 20 mg daily
-multivitamin daily
-Aldactone 50 mg b.i.d.
-Lupron every 3 months
-Percocet b.i.d.
-Celebrex 200 mg b.i.d.
-Silvadene cream twice daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: t 99.4, bp 160/88, hr 80, rr 18, spo2 96%ra
gen- pleasant, mod obese male, looks slightly older than age,
non-toxic, nad
heent- anicteric sclera, op clear with mmm
neck- no jvd/lad/thyromegaly
cv- rrr, s1s2, 2/6 systolic murmur at ursb (no radiation)
pul- no resp distress/accessory muscle use; moves air well,
normal i:e, no w/r/r
abd- soft, nt, nd, nabs, no hepatosplenomegaly
back- no cva tenderness, no sacral edema, mild mid-thoracic vert
pain (baseline per pt)
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, no pitting/indentations, mildly discolored
derm- erythematous, confluent rash on elbows, hands, feet
neuro- a&ox3, no focal cn/motor deficits

FAMILY HISTORY: His mother seems to have a malignancy but bx's have been
unrevealing thus far.

SOCIAL HISTORY: Mr. [**Known lastname 8467**] lives in [**Location **] with his wife and son.  [**Name (NI) **] formerly worked
for [**Company 2676**] as a software engineer, working on the guidance
system for the Patriot missile; prior to that he was in the Air
Force.  He has an undergraduate degree in MIS and an MBA.  He
smoked 1ppd for 20 years but quit 20 years ago, has a glass of
wine occasionally with dinner, and has never used
illicit/injection drugs.  He has a labrador retriever. 

### Response:
{'Other pulmonary insufficiency, not elsewhere classified,Secondary malignant neoplasm of lung,Other specified alveolar and parietoalveolar pneumonopathies,Other pulmonary embolism and infarction,Unspecified hypertensive heart disease with heart failure,Acute diastolic heart failure,Secondary malignant neoplasm of bone and bone marrow,Acute kidney failure, unspecified,Personal history of malignant neoplasm of prostate,Obstructive sleep apnea (adult)(pediatric),Old myocardial infarction,Dermatitis due to drugs and medicines taken internally,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Disorder of bone and cartilage, unspecified,Anemia of other chronic disease,Other disorders of neurohypophysis,Benign neoplasm of cerebral meninges,Long-term (current) use of steroids'}
