CHIEF COMPLAINT: Dyspnea, hemodynamic monitoring

PRESENT ILLNESS: Ms. [**Known lastname 80827**] is a 74 year-old woman with a history of CHF, COPD
on home O2, transferred from [**Hospital6 **] for further
management of a newly diagnosed, 20 cm hepatic lesion, and also
found to be dyspneic. She has been doing poorly at home for the
past several months, with worsening Pickwickian syndrome. Her
son states that she has been falling alseep at meals and sleeps
approximately 16 hours per day. This pattern was gradually
worsening until two days prior to arrival when she developed a
nonproductive cough and more labored breathing. Her son brought
her to the [**Name (NI) **], however, because she had an episode of possible
uterine bleeding where they noted dried blood on a chair after
she stood up. She has a history of significant uterine bleeding
and her son was concerned that she was having a recurrence so he
brought her to the ED. At the OSH, she was noted to have left
sided chest pain and LUQ pain. She was also found to be
hypotensive to the 90s and a Hct was found to be 26. A
non-contrast CT torso was attained and demonstrated a 20cm low
attenuation mass with possible areas of bleeding, a small amount
of perihepatic fluid, and ?new bibasilar atelectasis. However,
her management also addressed her dyspnea, and the initial
impression was that she was also experiencing a COPD
exacerbation secondary to pneumonia. She was therefore given
levofloxacin, solumedrol, and 1 unit of blood, and transferred
to [**Hospital1 18**] for hepatology management, hemodynamic monitoring, and
possible IR procedure for hemostasis.

MEDICAL HISTORY: Atrial fibrillation ([**2121**]; briefly anticoagulated in [**2121**] but
not currently)
CHF
COPD
DM2 ([**2113**])
CVA ([**2-/2121**]) w/ left sided weakness (resolved)
S/p cholecystectomy ([**2086**])
Uterine fibroid

MEDICATION ON ADMISSION: Colace 100 mg po qd
MVIA 1 tab qd
Aspirin 81 mg po qd
Synthroid 0.175 mg po qd
Glipizide 10mg po bid
Prozac 20 mg po qd
Lisinopril 5 mg po qd
Toprol 50 mg po bid
Cardizem 180 mg po qd
Lasix 60 mg po bid
Lyrica 100 mg tid
Omeprazole 20 mg po qd
Potassium chloride 40 mg [**Hospital1 **]
Digoxin 0.125 mq po qSMW (not Tues/Thurs)
Zocor 20 mg po qhs
Ipratroprium and albuterol nebs
Albuterol inhaler
Flovent/Advair

ALLERGIES: Ambien

PHYSICAL EXAM: General Appearance: Overweight / Obese

FAMILY HISTORY: NC

SOCIAL HISTORY: She has a 75-100 pack year smoking history (~2 packs per day for
50 years) but quit smoking 15 years ago. She does not drink
alcohol or use any other drugs. She lives with her son, who also
has COPD, and her husband. [**Name (NI) **] son notes increasing problems
with [**Name2 (NI) 80828**] and alertness and states that she has been
falling asleep at the dinner table.
Acute and chronic respiratory failure,Chronic diastolic heart failure,Acute kidney failure, unspecified,Hemangioma of intra-abdominal structures,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation
Acute & chronc resp fail,Chr diastolic hrt fail,Acute kidney failure NOS,Hemangioma intra-abdom,Chr airway obstruct NEC,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,DMII wo cmp nt st uncntr,Atrial fibrillation
Admission Date:  [**2122-3-13**]              Discharge Date:   [**2122-3-19**]

Date of Birth:  [**2047-3-21**]             Sex:   F

Service: MEDICINE

Allergies:
Ambien

Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Dyspnea, hemodynamic monitoring

Major Surgical or Invasive Procedure:
PICC line placement and removal


History of Present Illness:
Ms. [**Known lastname 80827**] is a 74 year-old woman with a history of CHF, COPD
on home O2, transferred from [**Hospital6 **] for further
management of a newly diagnosed, 20 cm hepatic lesion, and also
found to be dyspneic. She has been doing poorly at home for the
past several months, with worsening Pickwickian syndrome. Her
son states that she has been falling alseep at meals and sleeps
approximately 16 hours per day. This pattern was gradually
worsening until two days prior to arrival when she developed a
nonproductive cough and more labored breathing. Her son brought
her to the [**Name (NI) **], however, because she had an episode of possible
uterine bleeding where they noted dried blood on a chair after
she stood up. She has a history of significant uterine bleeding
and her son was concerned that she was having a recurrence so he
brought her to the ED. At the OSH, she was noted to have left
sided chest pain and LUQ pain. She was also found to be
hypotensive to the 90s and a Hct was found to be 26. A
non-contrast CT torso was attained and demonstrated a 20cm low
attenuation mass with possible areas of bleeding, a small amount
of perihepatic fluid, and ?new bibasilar atelectasis. However,
her management also addressed her dyspnea, and the initial
impression was that she was also experiencing a COPD
exacerbation secondary to pneumonia. She was therefore given
levofloxacin, solumedrol, and 1 unit of blood, and transferred
to [**Hospital1 18**] for hepatology management, hemodynamic monitoring, and
possible IR procedure for hemostasis.

On arrival, her VS were 98.8 100/62 120 22 93%4L (on home O2 at
baseline). She was found to be mildly dyspneic and was given
nebs. Our Radiology department assessed his OSH scans and
provided the read described above. The liver transplant service
was also contact[**Name (NI) **] and concluded that they did not feel that
this was an acute bleed, and that there was no role for acute
operative or IR intervention. The surgical service was also
consulted were concerned about a PE given her dyspnea; they also
felt that anticoagulation with heparin would be reasonable.

Review of systems is otherwise negative for N/V/D/F/C.


Past Medical History:
Atrial fibrillation ([**2121**]; briefly anticoagulated in [**2121**] but
not currently)
CHF
COPD
DM2 ([**2113**])
CVA ([**2-/2121**]) w/ left sided weakness (resolved)
S/p cholecystectomy ([**2086**])
Uterine fibroid


Social History:
She has a 75-100 pack year smoking history (~2 packs per day for
50 years) but quit smoking 15 years ago. She does not drink
alcohol or use any other drugs. She lives with her son, who also
has COPD, and her husband. [**Name (NI) **] son notes increasing problems
with [**Name2 (NI) 80828**] and alertness and states that she has been
falling asleep at the dinner table.

Family History:
NC

Physical Exam:
General Appearance: Overweight / Obese

Eyes / Conjunctiva: PERRL

Head, Ears, Nose, Throat: Normocephalic

Lymphatic: Cervical WNL, Supraclavicular WNL

Cardiovascular: (S1: Normal), (S2: Normal)

Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse: Not
assessed)

Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Diminished: )

Abdominal: Soft, Non-tender, Bowel sounds present, Obese

Extremities: Right: 1+, Left: 1+

Skin:  Warm

Neurologic: Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed, Very
sedated and moving slowly, appears encephalopathic


Pertinent Results:
cxr [**3-12**]: Bibasilar atelectasis, however, no evidence of CHF
exacerbation.
.
ct abd:
Suggestion of lipomatous deposition in the interatrial septum of
the heart. Clincial correlation advised as this can be
associated with
arrhythmias. MRI would be a more definitve examination to
confirm this
finding.
2. Vascular atherosclerotic calcifications.
3. Large, 20-cm predominantly low-density mass occupying the
majority of the right lobe of the liver, with internal regions
of hyperattenuation consistent with blood. Calcified rim
suggests a slow growing lesion. Based on the characteristics,
giant hemangioma is favored, but this remains incompletely
characterized on this non-contrast study. Further evaluation
with multiphasic CT or MRI is recommended as allowed by the
patient's renal function.
4. Additional hypoattenuating lesions within the caudate and the
left lobe of the liver are incompletely characterized.
5. Small amount of perisplenic and perihepatic free fluid.
6. Degenerative changes of the spine with grade 1
anterolisthesis of L4 on
L5.
.
[**3-12**] echo: The left atrium is markedly dilated. The right atrium
is moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is mildly dilated
with normal free wall contractility. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. Moderate (2+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a small pericardial effusion. The effusion appears
circumferential.
IMPRESSION: Suboptimal technical quality. Global left
ventricular function is probably normal, but a focal wall motion
abnormality cannot be fully excluded. Mild right ventricular
dilation with normal systolic function. Moderate mitral
regurgitation. Mild pulmonary hypertension. Small pericardial
effusion without echocardiographic signs of tamponade.
.
LENI: Slightly limited exam without evidence of DVT.
.
CXR: As compared to the previous radiograph, there is a minimal
increase of bilateral basal parenchymal opacities suggestive to
represent atelectasis. No clear evidence of overhydration. No
focal parenchymal opacity suggestive of pneumonia. Unchanged
position of the right PICC line.
.


Brief Hospital Course:
Ms. [**Known lastname 80827**] is a 74 year-old woman with a history of CHF, COPD
on home O2, transferred from [**Hospital6 **] for further
management of a newly diagnosed, 20 cm hepatic lesion, and also
found to be dyspneic.
.
#. Acute on chronic hypoxic respiratory failure: Initially,
multiple etiologies were considered including CHF exacerbation
vs pneumonia/COPD exacerbation vs PE.  Despite the fact she had
no wheezing suggesting worsening COPD and was afebrile, as she
appeared quite ill she was initially treated for pneumonia/CHF
exacerbation with furosemide for diuresis as well as
levofloxacin.  There was considerable concern for PE as well but
due to concern about her liver mass as well as possible vaginal
bleeding anticoagulation was held.  On hospital day two,
however, her respiratory status began to improve significantly
with diuresis and further control of her atrial fibrillation
(see below).  As she had had no fevers and there was no clear
infiltrate on chest radiograph with no wheezing antibiotics were
stopped and she was just kept on inhalers.  She diuresed greater
than two liters over her first 18 hours in the hospital and
this, along with improved rate control in the setting of her
probable diastolic dysfunction, significantly improved her
subjective dyspnea and O2 requirement so that she was having
reasonable O2 sats of 92-97 on 2 L by NC. Initially there were
some attempts to increase her to greater than 95 % and she
received increasing O2 but this seemed to contribute to a
depressed respiratory drive (attributed to her COPD and
appearance of chronic CO2 retention) so this was stopped.  As of
her second hospital day given negative LENIS, resolution of her
chest pain, and improvement of her respiratory status to near
her baseline the primary team felt comfortable not empirically
treating for PE, and her respiratory status eventually returned
to near baseline.

#Chronic hypercarbic respiratory failure: The patient has COPD
and Pickwickian syndrome and a chronically elevated bicarbonate
suggesting an ongoing respiratory acidosis.  As she had no
significant wheezing steroids were held though she did continue
to receive her home meds.  After falling asleep in a chair on
her second night in the hospital she was extremely difficult to
arouse the following morning with ABG showing a worsening of her
chronic respiratory acidosis.  This was thought due to
hypoventilation due to habitus and perhaps increased O2 provided
during the night due to fear of ACS (as the patient complained
of some chest pain), which could cause decreased respiratory
drive in a chronic CO2 retainer such as this.  This improved
with BiPAP as did her mental status. She would benefit from a
BiPAP trial as an outpatient; this was not done as an inpatient
because she will not be following up at [**Hospital1 18**] so CPAP will be
continued until then.

#. ?Congestive heart failure: The patient was dyspneic on
presentation and has evidence of chronic diastolic CHF on TTE.
She was empirically diuresed with some improvement in her
symptoms. She was discharged to rehab on her home dose of Lasix
that may continue to be titrated.

#. A. fib with RVR: Was in SVT on arrival to [**Hospital Unit Name 153**] and
ventricular rate slowed with metoprolol 5mg IV x 1 and diltiazem
10mg IV x 2.  Eventually, she was placed on a diltiazem drip for
improved rate control which led to improvement in her chest
discomfort and dyspnea.  On her second hospital day she was
transitioned back to her PO diltiazem with good effect.
Metoprolol and digoxin were also continued with good rate
control.

#Chest Pain: The patient had chest pain on her first and second
hospital nights.  These incidents of pain were atypical, there
were no EKG changes, and cardiac enzymes remained flat.   The
first night this improved with diuresis and rate control.  On
the second this resolved with positioning and was thought
largely due to the patient's habitus and difficult positioning
herself in bed.

#. Hepatic hemangioma: Surgery and her primary team remained
convinced this lesion was an incidental finding that had
probably developed slowly.  No specific management was attempted
though transplant surgery did follow her and recommended
outpatient followup.

#. Chronic kidney disease: The patient reported a history of CKD
of unclear etiology.  Her Cr was 2.4 at presentation and
improved over her hospital course to 1.3 on the day of
discharge.  All medications were renally dosed.

#. History of uterine bleeding: The patient had a history of
uterine bleeding and had a questionable incident of bleeding
prior to presentation.  Obstetrics and gynecology was consulted
on the morning after admission and managed to find records
indicating the patient was undergoing a significant post
menopausal bleeding work-up at Brown.  They deferred pelvic exam
as there was no further bleeding noted and her Hct remained
stable.


Medications on Admission:
Colace 100 mg po qd
MVIA 1 tab qd
Aspirin 81 mg po qd
Synthroid 0.175 mg po qd
Glipizide 10mg po bid
Prozac 20 mg po qd
Lisinopril 5 mg po qd
Toprol 50 mg po bid
Cardizem 180 mg po qd
Lasix 60 mg po bid
Lyrica 100 mg tid
Omeprazole 20 mg po qd
Potassium chloride 40 mg [**Hospital1 **]
Digoxin 0.125 mq po qSMW (not Tues/Thurs)
Zocor 20 mg po qhs
Ipratroprium and albuterol nebs
Albuterol inhaler
Flovent/Advair


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. DILT-XR 120 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
10. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
11. Pregabalin 25 mg Capsule Sig: Four (4) Capsule PO TID (3
times a day).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 5X/WEEK
([**Doctor First Name **],MO,WE,FR,SA).
14. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
16. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) ML Inhalation q4h ().
17. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
18. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
21. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale  Injection ASDIR (AS DIRECTED).
22. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
23. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
24. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
25. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.


Discharge Disposition:
Extended Care

Facility:
Southeastern MA Health & Rehabilitation Center

Discharge Diagnosis:
Primary: hepatic hemangioma, COPD, atrial fibrillation with RVR
Secondary: chronic diastolic CHF, DM2, h/o CVA


Discharge Condition:
good, stable, mental status at baseline, not somnolent,
breathing comfortably at rest with 0-2L O2


Discharge Instructions:
You were evaluated for consideration of treatment of a hepatic
hemangioma as well as for respiratory distress. The surgeons do
not feel any intervention for the hemangioma is warranted at
this time. Your respiratory status improved with control of your
heart rate, nebulizers, and gentle diuresis. You would benefit
from a trial of BiPAP, but as you are not going to follow up
here at [**Hospital1 18**], this may be done as an outpatient.

If you have worsening shortness of breath, fevers, chills, chest
pain, confusion, or any other concerning symptoms, have the
doctors at rehab [**Name5 (PTitle) 4656**] you.

Followup Instructions:
Follow up with your primary care physician 1-2 weeks after being
discharged from rehab. You should undergo a trial of BiPAP that
your primary care phsyician can set up for you. Call Dr. [**Name (NI) 80829**] office at [**Telephone/Fax (1) 9674**] to make an appointment.

You may follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of surgery regarding
your hepatic hemangioma. Call his office at ([**Telephone/Fax (1) 3618**] to
make an appointment. If you would rather follow up with a
surgeon closer to home, have your primary care physician refer
you.
{'Acute and chronic respiratory failure,Chronic diastolic heart failure,Acute kidney failure, unspecified,Hemangioma of intra-abdominal structures,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation'}


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, hemodynamic monitoring

PRESENT ILLNESS: Ms. [**Known lastname 80827**] is a 74 year-old woman with a history of CHF, COPD
on home O2, transferred from [**Hospital6 **] for further
management of a newly diagnosed, 20 cm hepatic lesion, and also
found to be dyspneic. She has been doing poorly at home for the
past several months, with worsening Pickwickian syndrome. Her
son states that she has been falling alseep at meals and sleeps
approximately 16 hours per day. This pattern was gradually
worsening until two days prior to arrival when she developed a
nonproductive cough and more labored breathing. Her son brought
her to the [**Name (NI) **], however, because she had an episode of possible
uterine bleeding where they noted dried blood on a chair after
she stood up. She has a history of significant uterine bleeding
and her son was concerned that she was having a recurrence so he
brought her to the ED. At the OSH, she was noted to have left
sided chest pain and LUQ pain. She was also found to be
hypotensive to the 90s and a Hct was found to be 26. A
non-contrast CT torso was attained and demonstrated a 20cm low
attenuation mass with possible areas of bleeding, a small amount
of perihepatic fluid, and ?new bibasilar atelectasis. However,
her management also addressed her dyspnea, and the initial
impression was that she was also experiencing a COPD
exacerbation secondary to pneumonia. She was therefore given
levofloxacin, solumedrol, and 1 unit of blood, and transferred
to [**Hospital1 18**] for hepatology management, hemodynamic monitoring, and
possible IR procedure for hemostasis.

MEDICAL HISTORY: Atrial fibrillation ([**2121**]; briefly anticoagulated in [**2121**] but
not currently)
CHF
COPD
DM2 ([**2113**])
CVA ([**2-/2121**]) w/ left sided weakness (resolved)
S/p cholecystectomy ([**2086**])
Uterine fibroid

MEDICATION ON ADMISSION: Colace 100 mg po qd
MVIA 1 tab qd
Aspirin 81 mg po qd
Synthroid 0.175 mg po qd
Glipizide 10mg po bid
Prozac 20 mg po qd
Lisinopril 5 mg po qd
Toprol 50 mg po bid
Cardizem 180 mg po qd
Lasix 60 mg po bid
Lyrica 100 mg tid
Omeprazole 20 mg po qd
Potassium chloride 40 mg [**Hospital1 **]
Digoxin 0.125 mq po qSMW (not Tues/Thurs)
Zocor 20 mg po qhs
Ipratroprium and albuterol nebs
Albuterol inhaler
Flovent/Advair

ALLERGIES: Ambien

PHYSICAL EXAM: General Appearance: Overweight / Obese

FAMILY HISTORY: NC

SOCIAL HISTORY: She has a 75-100 pack year smoking history (~2 packs per day for
50 years) but quit smoking 15 years ago. She does not drink
alcohol or use any other drugs. She lives with her son, who also
has COPD, and her husband. [**Name (NI) **] son notes increasing problems
with [**Name2 (NI) 80828**] and alertness and states that she has been
falling asleep at the dinner table. 

### Response:
{'Acute and chronic respiratory failure,Chronic diastolic heart failure,Acute kidney failure, unspecified,Hemangioma of intra-abdominal structures,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation'}
