CHIEF COMPLAINT: recurrent right pleural effsuion admitted w/ dyspnea

PRESENT ILLNESS: 84 YO M w/ metastatic colon ca to liver and pleura. Last
thoracentesis in [**Month (only) 216**] for 1100cc. Recently admitted for
CHF/COPD exaccerbation and seen by palliative care.
Admitted w/ recurrent right pleural effusion.

MEDICAL HISTORY: ONC HISTORY:
Per Heme/Onc fellow note: Metastatic colon cancer first
diagnosed [**2-28**] after labs revealing low HCT and Iron 19,
ferritin 30, TIBC within normal limits.
- CT scan [**2114-3-20**]: No colon mass visualized. Liver lesions
demonstrated, as seen on ultrasound. Pleural effusions, right
greater than left.
- [**2114-3-15**] CT scan: No evidence of pulmonary embolus or
thoracic aortic dissection. Bilateral pleural effusions and
diffuse ground-glass opacity which may be seen in the setting of
congestive heart
failure, central lobular emphysema. Multiple new low-attenuating

MEDICATION ON ADMISSION: coumadin 3mg-stopped [**9-30**], advair 500/50', albuterol nebs, dilt
240', lasix 80", lisinopril 40', kcl 20', prednisone 40' (on
taper to baseline dose 20', senna, serax 15 qhs, spiriva 18mcg

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ROS: c/o 2 days of unequal leg swelling w/ left leg pain per
wife. Dyspnea w/ exertion. No cough, fever, chills or other
constitional symptoms.
general: frail appearing elderly male when sitting in NAD
wearing oxygen and SOB w/ movement.
HEENT: slight JVD otherwise unremarkable
COR: Irreg, Irreg
abd: soft, round, NT, ND, +BS
extrem: bilat LE edema left >right.

FAMILY HISTORY: The patient's parents lived to be elderly.  His sister has a
history of colon cancer, diagnosed in her 70s.

SOCIAL HISTORY: Lives at home w/wife of 50+ [**Name2 (NI) 1686**], has 2 children who are involved
in his care. Former smoker (40 pk [**Name2 (NI) 1686**]) quit approx 20 [**Name2 (NI) 1686**] pta.
No ETOH, no IVDU. Retired.
Secondary malignant neoplasm of pleura,Acute and chronic respiratory failure,Personal history of malignant neoplasm of large intestine,Congestive heart failure, unspecified,Other chronic pulmonary heart diseases,Macular degeneration (senile), unspecified,Unspecified essential hypertension,Atrial fibrillation,Long-term (current) use of anticoagulants,Chronic airway obstruction, not elsewhere classified
Second malig neo pleura,Acute & chronc resp fail,Hx of colonic malignancy,CHF NOS,Chr pulmon heart dis NEC,Macular degeneration NOS,Hypertension NOS,Atrial fibrillation,Long-term use anticoagul,Chr airway obstruct NEC
Admission Date:  [**2114-10-4**]              Discharge Date:   [**2114-10-8**]


Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 281**]
Chief Complaint:
recurrent right pleural effsuion admitted w/ dyspnea

Major Surgical or Invasive Procedure:
thoracentesis and pleurex catheter placement


History of Present Illness:
84 YO M w/ metastatic colon ca to liver and pleura. Last
thoracentesis in [**Month (only) 216**] for 1100cc. Recently admitted for
CHF/COPD exaccerbation and seen by palliative care.
Admitted w/ recurrent right pleural effusion.

Past Medical History:
ONC HISTORY:
Per Heme/Onc fellow note: Metastatic colon cancer first
diagnosed [**2-28**] after labs revealing low HCT and Iron 19,
ferritin 30, TIBC within normal limits.
- CT scan [**2114-3-20**]: No colon mass visualized. Liver lesions
demonstrated, as seen on ultrasound. Pleural effusions, right
greater than left.
- [**2114-3-15**] CT scan: No evidence of pulmonary embolus or
thoracic aortic dissection. Bilateral pleural effusions and
diffuse ground-glass opacity which may be seen in the setting of
congestive heart
failure, central lobular emphysema. Multiple new low-attenuating

lesions within the liver, concerning for metastatic disease.
- [**2114-3-16**] Right upper quadrant ultrasound: Innumerable liver

lesions, concerning for metastatic disease.
- CT scan of the abdomen and pelvis [**2114-3-20**]: No overt
concentric apple-core mass lesion or stricture. Multiple liver
lesions as described in prior ultrasound study, incompletely
assessed without IV contrast. Large right and small left pleural
effusions.
- Colonscopy [**2114-3-19**]: A single sessile polyp of benign
appearance is found in the descending colon, a single piece
polypectomy was performed using a hot smear. The polyp is
completely removed.
- Ultrasound-guided liver biopsy, [**2114-3-21**]: Metastatic
adenocarcinoma consistent with colonic origin. Immunostain for
CK-20 positive, CK-7 negative, consistent with colonic origin.
Please note that it is not clear whether this is an ultrasound
or
CT-guided biopsy.
- CEA: [**2-/2114**] 14, [**3-/2114**] 18, [**4-/2114**] 27, [**5-/2114**] 20.
- [**2114-6-12**] CT: One moderate sized right pleural effusion with

small loculated pneumothorax. The age of the pneumothorax is not

clear, but it was present on the CT of [**2114-3-20**]. Innumerable
liver metastases which are larger than on prior CT, large
necrotic lymph node in the portahepatis.
.
PMH
--Atrial fibrillation
--Severe COPD
--Secondary pulmonary HTN
--CHF
--macular degeneration since his 40's
--torn R rotator cuff
--HTN


Social History:
Lives at home w/wife of 50+ [**Name2 (NI) 1686**], has 2 children who are involved
in his care. Former smoker (40 pk [**Name2 (NI) 1686**]) quit approx 20 [**Name2 (NI) 1686**] pta.
No ETOH, no IVDU. Retired.


Family History:
The patient's parents lived to be elderly.  His sister has a
history of colon cancer, diagnosed in her 70s.


Physical Exam:
ROS: c/o 2 days of unequal leg swelling w/ left leg pain per
wife. Dyspnea w/ exertion. No cough, fever, chills or other
constitional symptoms.
general: frail appearing elderly male when sitting in NAD
wearing oxygen and SOB w/ movement.
HEENT: slight JVD otherwise unremarkable
COR: Irreg, Irreg
abd: soft, round, NT, ND, +BS
extrem: bilat LE edema left >right.

Pertinent Results:
Portable AP chest radiograph compared to [**2114-10-4**].

Additional increase in already large right pleural effusion is
demonstrated. New left retrocardiac opacity might represent a
focal area of atelectasis or aspiration. The patient is in mild
volume overload. There is no pneumothorax and there is no overt
failure.


Brief Hospital Course:
pt was admitted for dyspnea (O2 dependent)and placement of
pleurex catheter for recurrent right effusion. Pt's coumadin had
been on hold x1 day PTA. He will have pleurex cathter when INR
<1.4.
HD#2 pt found w/ sat of 70%; ABG 7.27-PCO2 117, PaO2 66%. CXR w/
increased right effusion. Given 40mg IVP lasix, 100% NRB and
then transferred to the SICU for non-invasive ventilation. Pt
could not [**Last Name (un) 1815**] CPAP but sats improved to mid 90's on venti
mask. INR was 1.3 and interventional pulmonology was able to
place a pleurex catheter and drained 2.4 liters. Pt's resp
status improved signficantly and he was transferred from the ICU
to the floor. He was d/c'd to home on the following day. His
family declined hospice services and VNA services were set up.

Medications on Admission:
coumadin 3mg-stopped [**9-30**], advair 500/50', albuterol nebs, dilt
240', lasix 80", lisinopril 40', kcl 20', prednisone 40' (on
taper to baseline dose 20', senna, serax 15 qhs, spiriva 18mcg

Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1)  Inhalation twice a day.
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 5 days: take 30mg starting [**10-9**] x5days then 20mg daily
ongoing.
Disp:*15 Tablet(s)* Refills:*0*
9. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day:
dr. [**Last Name (STitle) 2168**] will advise you futher.
Disp:*60 Tablet(s)* Refills:*2*
10. Serax 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day.
12. Outpatient Lab Work
have your INR checked on thursday and then as directed by your
primary doctor
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
metastatic colon ca to liver and pleura, COPD-O2 dependent,
chronic CHF, pul HTN, Macular degeneration, HTN, torn right
rotator cuff, AFIB on coumadin


Discharge Condition:
improved


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc
Please call Dr.[**Initials (NamePattern4) 14680**] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 10084**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Call immediately if drain comes out.  Cover site immediately
with a clean dressing
-[**Month (only) 116**] shower with water-proof occlusive dressing.
-No bathing or swimming
Pleurax site keep covered with a clean dressing.
Drain every other day: keep log of drainage
Do not drain more than 1 liter at a single drainage.
Call IP if have questions or concerns, drainage around tube or
if drainage less than 50 cc for 3 consecutive drains.
[**Telephone/Fax (1) 10084**]

Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **]- pls call to schedule an apointment.
You have a follow up appointment with interventional pulmonology
on [**10-16**] at 11am on [**Hospital1 **] one to have your sutures removed.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]

Completed by:[**2114-10-10**]

Admission Date: [**2114-10-4**]        Discharge Date: [**2114-10-8**]


Service:  [**Last Name (un) 7081**]


ADMISSION DIAGNOSES:
1. Right pleural effusion.
2. Stage IV colon cancer (metastases to liver, pleura).
3. Chronic obstructive pulmonary disease (home oxygen
    dependent, steroid dependent).
4. Congestive heart failure.
5. Pulmonary hypertension.
6. Macular degeneration.
7. Hypertension.
8. Status post torn right rotator cuff.
9. Atrial fibrillation.

DISCHARGE DIAGNOSES:
1. Acute respiratory failure.
2. Status post insertion of right thoracic PleurX catheter.
3. Right pleural effusion.
4. Stage IV colon cancer (metastases to liver, pleura).
5. Chronic obstructive pulmonary disease (home oxygen
    dependent, steroid dependent).
6. Congestive heart failure.
7. Pulmonary hypertension.
8. Macular degeneration.
9. Hypertension.
10.Status post torn right rotator cuff.
11.Atrial fibrillation.

ADMISSION HISTORY AND PHYSICAL:  Mr. [**Known lastname 30984**] is an 84-year-old
man with stage IV colon cancer with metastases to his liver
and his pleura, who has been accumulating large right-sided
pleural effusions. He underwent a thoracentesis late in the
summer of [**2113**], which drained over a liter of fluid. The
cytology at that time was negative for malignancy. He had
reaccumulated a large pleural effusion on his right side and
was therefore admitted for elective drainage of this
effusion, and insertion of a PleurX catheter for future
management of his effusion. He was admitted electively in
order to allow his INR to become subtherapeutic, as he had
been on Coumadin for atrial fibrillation.

HOSPITAL COURSE:  The patient was admitted on [**2114-10-4**]. His INR had come down to 1.4 by then and the plan was
for him to undergo an elective drainage of his effusion on
[**10-5**]. The patient became acutely hypoxic on the evening
of [**2114-10-4**] secondary to what was felt to be
worsening pulmonary edema, given the patient had not been
taking his Lasix for several days. He was diuresed
aggressively with Lasix at which time his oxygenation
improved, and his mental status and respiratory status
improved. On the morning of [**2114-10-5**] the patient
became increasingly confused and agitated. An arterial blood
gas was drawn which showed a pCO2 of 112, indicating that the
patient had developed some acute on chronic CO2 retention as
his pH at that time was not significantly low (7.27). As the
patient was DNR/DNI, his only option was positive pressure
ventilation. Therefore, he was transferred to the ICU for
drainage of his effusion and possible initiation of positive
pressure ventilation if necessary. The patient stabilized
with additional diuresis not requiring a BiPAP mask, and on
that same day underwent drainage of his pleural effusion, at
that time 2.4 liters of clear fluid were drained. There was
no evidence of hemothorax or infection in the fluid. A PleurX
catheter was placed. The patient's respiratory status still
remained somewhat tenuous although he symptomatically felt
better and his mental status improved. Extensive discussions
were held with the family and eventually the palliative care
service, who had been seeing the patient, met with the family
and the decision was made that the patient would be placed in
hospice palliative care without further aggressive
intervention. He was transferred back to the floor on the
[**10-6**] and since that time has been doing well,
maintaining an oxygen saturation of 93% on 2 liters, which
was his baseline. There was no significant reaccumulation of
his catheter. He was then set up with discharge to hospice
and palliative care on the [**2114-10-8**]. He was
discharged afebrile with normal hemodynamics and as noted an
oxygen saturation of 93% on 2 liters.

DISCHARGE MEDICATIONS:  Included albuterol nebulizer
treatments q.6h. as needed, diltiazem extended release 240 mg
p.o. once daily, fluticasone, Solu-Medrol inhaler 250/50 one
inhalation b.i.d., Lasix 80 mg p.o. b.i.d., lisinopril 40 mg
p.o. once daily, prednisone 40 mg p.o. once daily until
[**10-13**], after that time taper down to 20 mg once daily
and continue taper thereafter, Senna 2 mg p.o. at bedtime,
tiotropium bromide 1 tablet inhaled daily.

DISCHARGE CODE STATUS:  DNR/DNI.



                        [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) 286**]

Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D:  [**2114-10-8**] 10:46:38
T:  [**2114-10-8**] 18:09:28
Job#:  [**Job Number 102774**]
{'Secondary malignant neoplasm of pleura,Acute and chronic respiratory failure,Personal history of malignant neoplasm of large intestine,Congestive heart failure, unspecified,Other chronic pulmonary heart diseases,Macular degeneration (senile), unspecified,Unspecified essential hypertension,Atrial fibrillation,Long-term (current) use of anticoagulants,Chronic airway obstruction, not elsewhere classified'}


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: recurrent right pleural effsuion admitted w/ dyspnea

PRESENT ILLNESS: 84 YO M w/ metastatic colon ca to liver and pleura. Last
thoracentesis in [**Month (only) 216**] for 1100cc. Recently admitted for
CHF/COPD exaccerbation and seen by palliative care.
Admitted w/ recurrent right pleural effusion.

MEDICAL HISTORY: ONC HISTORY:
Per Heme/Onc fellow note: Metastatic colon cancer first
diagnosed [**2-28**] after labs revealing low HCT and Iron 19,
ferritin 30, TIBC within normal limits.
- CT scan [**2114-3-20**]: No colon mass visualized. Liver lesions
demonstrated, as seen on ultrasound. Pleural effusions, right
greater than left.
- [**2114-3-15**] CT scan: No evidence of pulmonary embolus or
thoracic aortic dissection. Bilateral pleural effusions and
diffuse ground-glass opacity which may be seen in the setting of
congestive heart
failure, central lobular emphysema. Multiple new low-attenuating

MEDICATION ON ADMISSION: coumadin 3mg-stopped [**9-30**], advair 500/50', albuterol nebs, dilt
240', lasix 80", lisinopril 40', kcl 20', prednisone 40' (on
taper to baseline dose 20', senna, serax 15 qhs, spiriva 18mcg

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ROS: c/o 2 days of unequal leg swelling w/ left leg pain per
wife. Dyspnea w/ exertion. No cough, fever, chills or other
constitional symptoms.
general: frail appearing elderly male when sitting in NAD
wearing oxygen and SOB w/ movement.
HEENT: slight JVD otherwise unremarkable
COR: Irreg, Irreg
abd: soft, round, NT, ND, +BS
extrem: bilat LE edema left >right.

FAMILY HISTORY: The patient's parents lived to be elderly.  His sister has a
history of colon cancer, diagnosed in her 70s.

SOCIAL HISTORY: Lives at home w/wife of 50+ [**Name2 (NI) 1686**], has 2 children who are involved
in his care. Former smoker (40 pk [**Name2 (NI) 1686**]) quit approx 20 [**Name2 (NI) 1686**] pta.
No ETOH, no IVDU. Retired. 

### Response:
{'Secondary malignant neoplasm of pleura,Acute and chronic respiratory failure,Personal history of malignant neoplasm of large intestine,Congestive heart failure, unspecified,Other chronic pulmonary heart diseases,Macular degeneration (senile), unspecified,Unspecified essential hypertension,Atrial fibrillation,Long-term (current) use of anticoagulants,Chronic airway obstruction, not elsewhere classified'}
