CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: 65 yo m with hx restrictive lung dz, CAD, distolic HF, OSA, HTN,
BPH, type II DM p/w progressively worsening shortness of breath
and LE edema. Pt reports that for the last 1 week has been
having worsening dyspnea both at rest and on exertion. Also with
~15 lb weight gain in 1 week. Usually weighs 265 lbs, today
280lbs. Home VNA contact[**Name (NI) **] cardiology and lasix titrated from 60
mg [**Hospital1 **] to 80 mg [**Hospital1 **] yesterday. However without improvement of
sxs.
.
Also reports worsening LE edema, left greater than right.
Apparent trauma to L toe and knee after fall. Also with dry
productive cough and nasal congestion. Denies orthopnea, PND. At
baseline with very limited ET to ~several steps, limited mostly
by chronic back and leg pain. Per wife, during recent travel to
[**Location (un) **], did not adhere to low sodium diet for several days.
Chronic L sided CP radiating to the neck, approximately 2
episodes per week. Last episode was yesterday. These episodes
are usually non-exertional, non-radiating, and self resolves
over 2-3 minutes.
.
His inital vitals were: 97.4 98/59 HR 71 75% on RA, 97% 2L NC.
In the ED he was given 80mg IV lasix and was then admitted to
the floor for treatment of CHF exacerbation.
.
Of note Mr. [**Name14 (STitle) 34888**] has had his pain medications titrated up
recently with his methadone being doubled to 10mg tid.  He had
taken 2 doses at this increased dose and upon admission to the
floor was found to be somnolent, developing shallow respirations
with worsening obtundation.  He then desatted to 70's on N/C and
was placed on a 100% NRB.  ABG at that time was 7.03/103/241.
He was given 0.4mg IV narcan with improved consciousness and
subsequently became cold/uncomfortable with hypertension to SBP
160.  He was transferred to the CCU for narcan drip and closer
monitoring.

MEDICAL HISTORY: 1) CHF, EF 45% from most recent echo [**6-5**], mixed LV systolic and

MEDICATION ON ADMISSION: HOME MEDICATIONS:
Oxycodone 5/325 2 tabs TID
Methadone 10 mg TID
Tylenol
Lasix 80 [**Hospital1 **]-->increased on [**7-12**] from 60 [**Hospital1 **]
Lexapro [**9-16**]
ASA 325
Colace
ISS
Flomax 0.8 daily
cozaar 50 daily
Toprol xl 25 daily
Proscar 5 daily
Imdur 30 daily
Calcitriol 0.5 daily
Protonix 40 daily
Mirapex 0.125 daily
BIPAP 16 cm insp, 13 cm exp pressure with 4 L O2

ALLERGIES: Vicodin / Ms Contin

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VS - 97.8 136/63 HR 79 100% on 100% NRB
Gen: WDWN middle aged male in NAD. Somnolent but arousable.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
Neck: Supple with JVP of 10 cm
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were shallow, but unlabored without accessory muscle use.
+Bibasilar crackles, decreased BS in bases
Abd: Protuberant, soft, NTND. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
Ext: 2+ edema b/l left grossly more edematous than right, FROM
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.

FAMILY HISTORY: DM, CVA - brother
Breast [**Name (NI) 3730**] - mother
emphysema - father

SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] never smoked. Only minimal
Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Acute on chronic diastolic heart failure,Acute respiratory failure,Other primary cardiomyopathies,Chronic kidney disease, Stage III (moderate),Acute kidney failure, unspecified,Methadone causing averse effects in therapeutic use,Obstructive sleep apnea (adult)(pediatric),Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Old myocardial infarction,Atherosclerosis of native arteries of the extremities with intermittent claudication,Cellulitis and abscess of toe, unspecified
Hyp ht/kd NOS I-IV w hf,Ac on chr diast hrt fail,Acute respiratry failure,Prim cardiomyopathy NEC,Chr kidney dis stage III,Acute kidney failure NOS,Adv eff methadone,Obstructive sleep apnea,BPH w/o urinary obs/LUTS,DMII neuro nt st uncntrl,Neuropathy in diabetes,Nephritis NOS in oth dis,Diabetic retinopathy NOS,Old myocardial infarct,Ath ext ntv at w claudct,Cellulitis, toe NOS
Admission Date:  [**2143-7-13**]              Discharge Date:   [**2143-7-18**]

Date of Birth:  [**2078-1-6**]             Sex:   M

Service: MEDICINE

Allergies:
Vicodin / Ms Contin

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
None


History of Present Illness:
65 yo m with hx restrictive lung dz, CAD, distolic HF, OSA, HTN,
BPH, type II DM p/w progressively worsening shortness of breath
and LE edema. Pt reports that for the last 1 week has been
having worsening dyspnea both at rest and on exertion. Also with
~15 lb weight gain in 1 week. Usually weighs 265 lbs, today
280lbs. Home VNA contact[**Name (NI) **] cardiology and lasix titrated from 60
mg [**Hospital1 **] to 80 mg [**Hospital1 **] yesterday. However without improvement of
sxs.
.
Also reports worsening LE edema, left greater than right.
Apparent trauma to L toe and knee after fall. Also with dry
productive cough and nasal congestion. Denies orthopnea, PND. At
baseline with very limited ET to ~several steps, limited mostly
by chronic back and leg pain. Per wife, during recent travel to
[**Location (un) **], did not adhere to low sodium diet for several days.
Chronic L sided CP radiating to the neck, approximately 2
episodes per week. Last episode was yesterday. These episodes
are usually non-exertional, non-radiating, and self resolves
over 2-3 minutes.
.
His inital vitals were: 97.4 98/59 HR 71 75% on RA, 97% 2L NC.
In the ED he was given 80mg IV lasix and was then admitted to
the floor for treatment of CHF exacerbation.
.
Of note Mr. [**Name14 (STitle) 34888**] has had his pain medications titrated up
recently with his methadone being doubled to 10mg tid.  He had
taken 2 doses at this increased dose and upon admission to the
floor was found to be somnolent, developing shallow respirations
with worsening obtundation.  He then desatted to 70's on N/C and
was placed on a 100% NRB.  ABG at that time was 7.03/103/241.
He was given 0.4mg IV narcan with improved consciousness and
subsequently became cold/uncomfortable with hypertension to SBP
160.  He was transferred to the CCU for narcan drip and closer
monitoring.


Past Medical History:
1) CHF, EF 45% from most recent echo [**6-5**], mixed LV systolic and

diastolic dysfunction, cardiomyopathy
2) CAD, NSTEMI in [**3-6**] during admission for urosepsis with
hypotension and coma.
3) Type II DM c/b neuropathy, nephropathy, retinopathy
4) HTN
5) CRI, baseline creatinine of 1.7
6) Anemia of chronic disease.
7) Sleep apnea on BiPAP, currently 16/13 on 4L O2
8) Chronic restrictive ventilatory disease secondary to a bile
duct leak with pulmonary fibrosis requiring decortication
9) Neuropathy - hands and feet
10) Lower extremity claudication
11) BPH.
12) Glaucoma; on carbonic anhydrase inhibitor
13) Bilateral cataracts s/p surgical removal
14) Depression
15) Osteoarthritis
16) Erectile dyscunction s/p Penile implant [**11-6**]
.
.
Past surgical history:
1) [**2138**] Roux-en-y reconstruction after laparoscopic
cholecystectomy c/b damage to CBD
2) [**2139**] Decortication for fibrothorax complicated by
respiratory failure requiring tracheostomy.
3) Appendectomy.
4) Left knee/hip replacement
5) L shoulder AC recection


Social History:
The patient lives with his wife. [**Name (NI) **] never smoked. Only minimal

ethanol. Retired. Lives a sedentary lifestyle.


Family History:
DM, CVA - brother
Breast [**Name (NI) 3730**] - mother
emphysema - father

Physical Exam:
PHYSICAL EXAMINATION:
VS - 97.8 136/63 HR 79 100% on 100% NRB
Gen: WDWN middle aged male in NAD. Somnolent but arousable.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
Neck: Supple with JVP of 10 cm
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were shallow, but unlabored without accessory muscle use.
+Bibasilar crackles, decreased BS in bases
Abd: Protuberant, soft, NTND. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
Ext: 2+ edema b/l left grossly more edematous than right, FROM
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.

Pertinent Results:
LABS:
BNP 7352 on admission.
WBC 9.3 on admission down to 6.0 on discharge.
HCT 33 on admission and 34 on discharge.
BUN 68 on admission down to 49 at discharge.
Cr 2.5 on admission down to 1.7 on discharge.
Blood gas on admission pH 7.03 CO2 102 O2 241.
Blood gas before discharge pH 7.38 CO3 53 O2 97.
.
CXR on admission:
The appearance of the chest is similar to [**2143-5-4**]. Mild
cardiomegaly is unchanged. Pulmonary vasculature appears similar
and remains prominent, consistent with a mild degree of edema.
Left lateral pleural thickening has not changed. There is no
evident pleural effusion or new airspace consolidation. Again
seen is prior right rib resection. Clips in the right upper
quadrant compatible with prior cholecystectomy.
.
Cardiology Report ECG Study Date of [**2143-7-13**]  12:15:04 PM
Sinus rhythm. Frequent atrial ectopy. Probable old
inferoposterior wall
myocardial infarction. Non-specific T wave changes. Compared to
tracing
of [**2143-5-4**] there is no significant diagnostic change.
.
RENAL U/S:
The right kidney measures 10.9 cm. The left kidney measures 10.7
cm. There is no evidence of hydronephrosis, nephrolithiasis or
renal mass. The corticomedullary differentiation in the kidneys
is preserved.
.
LEFT LOWER EXTREMITY ULTRASOUND:
No evidence of left lower extremity deep vein thrombosis.
.
ECHO:
The left atrium is normal in size. The estimated right atrial
pressure is 5-10 mmHg. Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.

Brief Hospital Course:
65 male w/ questionable diastolic dsyfunction CKD, CAD, DM2, HTN
admitted with dyspnea and volume overload and hypercarbic
respiratory failure from prescribed narotics.
.
# Volume Overload: Patient diuresed nicely and was 2.4L negative
in first 24 hrs of admission, with minimal rales on exam. Volume
overload improving although still with b/l pitting edema.
Presumed CHF (with scant evidence), with preserved EF >55% in
[**5-8**]. Diastolic dysfunction was not evident on echo (only echo
abnormality is altered e:a ration). Precipitant for current
decompensation not entirely clear. Possibilities include dietary
indiscretion per wife and possible URI/infectious precipitant.
Treated with lasix drip and restarted on PO lasix at more
frequent dosing of 60mg TID (up from his home dose of 60 mg [**Hospital1 **])
with good effect. O2 sat was 97% on discharge.
.
# Hypercarbic respiratory failure: Likely due prescribed
narcotic use.  Presented with dangerous hypercarbia and
respiratory acidosis. His home narcotics were initially held and
then decreased on discharge. He remained on bipap over length of
stay and had good Oxygen saturation (97% on room air).
.
# CAD: With apparently chronic non-exertional self-resolving CP.
Cath in [**2138**] showed minimal dz. ROMI at admission. His
metoprolol was continued at 12.5 [**Hospital1 **]. His ASA was decreased from
325 to 81 for secondary prophylaxis because he has not had
stents. Consider stress test when symptomatically improved as an
outpatient.
.
# CKD: CKD Stage 3, secondary to diabetic nephropathy. Acute on
chronic renal failure likely due to poor forward flow which
improved greatly with diuresis. Renal ultrasound was normal.
Etiology includes pre-renal vs renal dysfunction (diabetic
complication possibly). Initially high creatinine (2.4) and was
stable at 1.7 on discharge. Nephrology followed patient during
hospitalization.
.
# HTN: Stopped his home regimen of Imdur 30 because no clear
indication given good blood pressure control and normal echo.
Metoprolol 12.5 [**Hospital1 **] and Cozzar 50 mg were continued at home
dose.
.
# LE edema: Consistent with volume overload. Was asymmetric with
left greater than right. NEG Dopplers for DVT.  Cellulitis at
left great toe treated with amox / clavulanate 500mg [**Hospital1 **] (7 day
course started on [**7-14**]).
.
# DM 2: Diet controlled. Acceptable HgbA1c of 6.7 in [**12-9**].
.
# Nasal congestion/dry cough: Clinical picture suggestive of
viral URI sxs.
.
# Osteoarthritis: At baseline with severe lower back pain and LE
pain.  We restarted methadone at reduced dose given his
respiratory suppression at his prior doses.
.
# OSA: BIPAP 16 cm insp, 13 cm exp pressure with 4 L O2
continued.
.
He is full code.

Medications on Admission:
HOME MEDICATIONS:
Oxycodone 5/325 2 tabs TID
Methadone 10 mg TID
Tylenol
Lasix 80 [**Hospital1 **]-->increased on [**7-12**] from 60 [**Hospital1 **]
Lexapro [**9-16**]
ASA 325
Colace
ISS
Flomax 0.8 daily
cozaar 50 daily
Toprol xl 25 daily
Proscar 5 daily
Imdur 30 daily
Calcitriol 0.5 daily
Protonix 40 daily
Mirapex 0.125 daily
BIPAP 16 cm insp, 13 cm exp pressure with 4 L O2

Discharge Medications:
1. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Methadone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
Disp:*45 Tablet(s)* Refills:*2*
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Escitalopram 10 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).

8. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO once a
day.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day.
11. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
13. Mirapex 0.125 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Respiratory Insufficiency due to Narcotics
Volume Overload
Left First Toe Cellulitis
Acute Renal Failure


Discharge Condition:
Good. Weight 121.7 kg. Oxygen saturation 97% on room air.


Discharge Instructions:
Please remember to take your medications as described in the
instructions. If you develop increasing shortness of breath,
increasing weight, chest pains, high fever, nausea,
palpitations, light-headedness, or loss of consciousness, or any
other concerning signs, please contact your physician
[**Name Initial (PRE) 2227**].

Followup Instructions:
Please follow up with your primary care provider [**Name Initial (PRE) 176**] 2 weeks
of discharge. Please call your primary care provider to schedule
this. The following other appointments have been made for you:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2143-9-2**]
2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3172**] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2143-9-5**] 3:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2144-5-26**] 11:30



Completed by:[**2143-7-20**]
{'Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Acute on chronic diastolic heart failure,Acute respiratory failure,Other primary cardiomyopathies,Chronic kidney disease, Stage III (moderate),Acute kidney failure, unspecified,Methadone causing averse effects in therapeutic use,Obstructive sleep apnea (adult)(pediatric),Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Old myocardial infarction,Atherosclerosis of native arteries of the extremities with intermittent claudication,Cellulitis and abscess of toe, unspecified'}


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

PRESENT ILLNESS: 65 yo m with hx restrictive lung dz, CAD, distolic HF, OSA, HTN,
BPH, type II DM p/w progressively worsening shortness of breath
and LE edema. Pt reports that for the last 1 week has been
having worsening dyspnea both at rest and on exertion. Also with
~15 lb weight gain in 1 week. Usually weighs 265 lbs, today
280lbs. Home VNA contact[**Name (NI) **] cardiology and lasix titrated from 60
mg [**Hospital1 **] to 80 mg [**Hospital1 **] yesterday. However without improvement of
sxs.
.
Also reports worsening LE edema, left greater than right.
Apparent trauma to L toe and knee after fall. Also with dry
productive cough and nasal congestion. Denies orthopnea, PND. At
baseline with very limited ET to ~several steps, limited mostly
by chronic back and leg pain. Per wife, during recent travel to
[**Location (un) **], did not adhere to low sodium diet for several days.
Chronic L sided CP radiating to the neck, approximately 2
episodes per week. Last episode was yesterday. These episodes
are usually non-exertional, non-radiating, and self resolves
over 2-3 minutes.
.
His inital vitals were: 97.4 98/59 HR 71 75% on RA, 97% 2L NC.
In the ED he was given 80mg IV lasix and was then admitted to
the floor for treatment of CHF exacerbation.
.
Of note Mr. [**Name14 (STitle) 34888**] has had his pain medications titrated up
recently with his methadone being doubled to 10mg tid.  He had
taken 2 doses at this increased dose and upon admission to the
floor was found to be somnolent, developing shallow respirations
with worsening obtundation.  He then desatted to 70's on N/C and
was placed on a 100% NRB.  ABG at that time was 7.03/103/241.
He was given 0.4mg IV narcan with improved consciousness and
subsequently became cold/uncomfortable with hypertension to SBP
160.  He was transferred to the CCU for narcan drip and closer
monitoring.

MEDICAL HISTORY: 1) CHF, EF 45% from most recent echo [**6-5**], mixed LV systolic and

MEDICATION ON ADMISSION: HOME MEDICATIONS:
Oxycodone 5/325 2 tabs TID
Methadone 10 mg TID
Tylenol
Lasix 80 [**Hospital1 **]-->increased on [**7-12**] from 60 [**Hospital1 **]
Lexapro [**9-16**]
ASA 325
Colace
ISS
Flomax 0.8 daily
cozaar 50 daily
Toprol xl 25 daily
Proscar 5 daily
Imdur 30 daily
Calcitriol 0.5 daily
Protonix 40 daily
Mirapex 0.125 daily
BIPAP 16 cm insp, 13 cm exp pressure with 4 L O2

ALLERGIES: Vicodin / Ms Contin

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VS - 97.8 136/63 HR 79 100% on 100% NRB
Gen: WDWN middle aged male in NAD. Somnolent but arousable.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
Neck: Supple with JVP of 10 cm
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were shallow, but unlabored without accessory muscle use.
+Bibasilar crackles, decreased BS in bases
Abd: Protuberant, soft, NTND. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
Ext: 2+ edema b/l left grossly more edematous than right, FROM
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.

FAMILY HISTORY: DM, CVA - brother
Breast [**Name (NI) 3730**] - mother
emphysema - father

SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] never smoked. Only minimal 

### Response:
{'Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Acute on chronic diastolic heart failure,Acute respiratory failure,Other primary cardiomyopathies,Chronic kidney disease, Stage III (moderate),Acute kidney failure, unspecified,Methadone causing averse effects in therapeutic use,Obstructive sleep apnea (adult)(pediatric),Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Old myocardial infarction,Atherosclerosis of native arteries of the extremities with intermittent claudication,Cellulitis and abscess of toe, unspecified'}
