CHIEF COMPLAINT: admitted from [**Hospital 191**] clinic w/ 5 days worsening SOB, DOE

PRESENT ILLNESS: Pt is a 63M w/ h/o metastatic carcinoid tumor, HTN,
hyperlipidemia who reports increasing SOB and DOE starting about
a month ago but worsening significantly within the last 5 days.
It has recently gotten so bad he can barely get up out of a
chair without getting short of breath. He reports orthopnea but
no PND. In clinic today, he was using accessory muscles of
respiration and was mildly diaphoretic, and his O2 sat on room
air was 97%, dropping to 94% with ambulation. He reports no
fever or chills, no URI symptoms, no recent travel, no changes
in his medications.
Pt also reports ~5 episodes of chest pain in the last few weeks
which he describes as pressure on his mid-sternum and usually
occurs during exertion. There is no associated nausea or
vomiting. He says he takes a [**12-29**] tablet of Xanax when he gets
this pain sometimes which seems to help. He cannot take
nitroglycerin because of his Viagra.

MEDICAL HISTORY: 1. metastatic carcinoid tumor, Dx'ed [**2123**]
-was on a study drug for a year and a half (ended about a year
ago) and was on octreotide for a few months earlier this year
but stopped because of diarrhea
2. hypertension
3. hyperlipidemia
4. carotid endarterectomy [**2120**]
5. depression/anxiety
6. cellulitis 2 weeks ago, given Keflex IV at [**Hospital3 **], now resolved
7. DM2/prediabetic state: random blood sugar was high, was on
glyburide for a brief time but made his sugars low so stopped
8. anxiety attack [**2110**] (collapsed), diagnosed in [**2120**] as MI
9. basal cell carcinoma (chest, low back, MOHS on cheek [**3-31**] and
[**7-1**])

MEDICATION ON ADMISSION: ASA 81mg po qd
Lipitor 20mg po qpm
Norvasc 5mg po qd
Paxil 30mg po qd
ranitidine 150mg po bid
Viagra 25mg po qd
[**Doctor First Name **] 180mg po qd
Xanax 0.25 mg po qd prn

ALLERGIES: Nitroglycerin

PHYSICAL EXAM: VS: T 97.7, HR 97, BP 140/52, RR 20, O2sat 97% on RA
Gen: awake, alert, conversant, elderly man, mildly short of
breath
HEENT: PERRL, EOMI, MMM
Neck: supple, JVP elevated (~8cm)
Chest: fine cracles at left base, otherwise CTA
CV: RRR, nl S1S2, no m/r/g, distant heart sounds
Abd: S/ND, mildy tender to palpation in LLQ
Ext: WWP, 1+ LE edema bilaterally, no c/c
Neuro: nonfocal

FAMILY HISTORY: early CAD

SOCIAL HISTORY: Lives alone, has two daughters
Distant tobacco use (25 pack-years, quit 30 years ago), distant
EtOH use (quit 28 yrs ago), no drugs
Congestive heart failure, unspecified,Pneumonia, organism unspecified,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Acute and subacute necrosis of liver,Acquired coagulation factor deficiency,Malignant neoplasm of liver, secondary,Aortic valve disorders,Diseases of tricuspid valve,Acidosis,Other chronic pulmonary heart diseases,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of large intestine,Hypotension, unspecified
CHF NOS,Pneumonia, organism NOS,Acute respiratry failure,Ac kidny fail, tubr necr,Acute necrosis of liver,Acq coagul factor defic,Second malig neo liver,Aortic valve disorder,Tricuspid valve disease,Acidosis,Chr pulmon heart dis NEC,Hypertension NOS,DMII wo cmp nt st uncntr,Hx of colonic malignancy,Hypotension NOS
Admission Date:  [**2127-8-1**]              Discharge Date:   [**2127-8-21**]

Date of Birth:  [**2063-11-28**]             Sex:   M

Service: MEDICINE

Allergies:
Nitroglycerin

Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
admitted from [**Hospital 191**] clinic w/ 5 days worsening SOB, DOE


Major Surgical or Invasive Procedure:
thoracentesis
cardiac catheterization


History of Present Illness:
Pt is a 63M w/ h/o metastatic carcinoid tumor, HTN,
hyperlipidemia who reports increasing SOB and DOE starting about
a month ago but worsening significantly within the last 5 days.
It has recently gotten so bad he can barely get up out of a
chair without getting short of breath. He reports orthopnea but
no PND. In clinic today, he was using accessory muscles of
respiration and was mildly diaphoretic, and his O2 sat on room
air was 97%, dropping to 94% with ambulation. He reports no
fever or chills, no URI symptoms, no recent travel, no changes
in his medications.
Pt also reports ~5 episodes of chest pain in the last few weeks
which he describes as pressure on his mid-sternum and usually
occurs during exertion. There is no associated nausea or
vomiting. He says he takes a [**12-29**] tablet of Xanax when he gets
this pain sometimes which seems to help. He cannot take
nitroglycerin because of his Viagra.


Past Medical History:
1. metastatic carcinoid tumor, Dx'ed [**2123**]
-was on a study drug for a year and a half (ended about a year
ago) and was on octreotide for a few months earlier this year
but stopped because of diarrhea
2. hypertension
3. hyperlipidemia
4. carotid endarterectomy [**2120**]
5. depression/anxiety
6. cellulitis 2 weeks ago, given Keflex IV at [**Hospital3 **], now resolved
7. DM2/prediabetic state: random blood sugar was high, was on
glyburide for a brief time but made his sugars low so stopped
8. anxiety attack [**2110**] (collapsed), diagnosed in [**2120**] as MI
9. basal cell carcinoma (chest, low back, MOHS on cheek [**3-31**] and
[**7-1**])


Social History:
Lives alone, has two daughters
Distant tobacco use (25 pack-years, quit 30 years ago), distant
EtOH use (quit 28 yrs ago), no drugs

Family History:
early CAD


Physical Exam:
VS: T 97.7, HR 97, BP 140/52, RR 20, O2sat 97% on RA
Gen: awake, alert, conversant, elderly man, mildly short of
breath
HEENT: PERRL, EOMI, MMM
Neck: supple, JVP elevated (~8cm)
Chest: fine cracles at left base, otherwise CTA
CV: RRR, nl S1S2, no m/r/g, distant heart sounds
Abd: S/ND, mildy tender to palpation in LLQ
Ext: WWP, 1+ LE edema bilaterally, no c/c
Neuro: nonfocal


Pertinent Results:
[**2127-8-1**] 03:30PM   PLT COUNT-201
[**2127-8-1**] 03:30PM   NEUTS-69.9 LYMPHS-23.5 MONOS-4.8 EOS-1.1
BASOS-0.7
[**2127-8-1**] 03:30PM   WBC-9.2 RBC-4.68 HGB-14.6 HCT-42.0 MCV-90
MCH-31.3 MCHC-34.8 RDW-13.7
[**2127-8-1**] 03:30PM   TSH-4.0

[**2127-8-1**] 03:30PM   CK-MB-NotDone cTropnT-<0.01
[**2127-8-1**] 03:30PM   CK(CPK)-50
[**2127-8-1**] 03:30PM   GLUCOSE-125* UREA N-14 CREAT-1.0 SODIUM-138
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-22 ANION GAP-19

Brief Hospital Course:
1. SOB: likely from CHF
The patient was initially diuresed for mild pulmonary edema: he
received 20 IV Lasix on night of admission and 40mg [**8-2**], with
good UOP. On [**8-2**], pt was reporting improvement of symptoms and
able to walk around his room with 4L O2 NC. The following day he
reported feeling worse, with increasing SOB, and was found to
now be in oliguric renal failure. CXR [**8-3**] 8am showed showed
atelectasis with possible superimposed pneumonia. Emergent TTE
showed decreased EF (30%), anteroapical infarct with
moderate-to-severe overall left ventricular contractile
dysfunction; bicusapid aortic valve with at least mild aortic
stenosis. He was sent to the MICU [**8-3**] to [**8-10**] (see below for
course).
.
On transfer back from the MICU, SOB was much improved, and he
was on 2L NC intermittently for comfort. After his ARF resolved,
he was cathed [**8-15**], showing persisting right heart failure [**1-29**]
tricuspid regurg. He was monitored in the CCU post-cath and
diuresed 1.3L until transfer back to the floor on [**8-17**]. There,
diuresis was continued with stable Cr, and the pt was weaned off
O2, able to maintain O2 saturation throughout PT exercise and
reporting much improvement from initial symptoms.
.
2. chest pain
-MI (no ischemic changes on EKG) vs. GERD vs. anxiety vs. PE
(CTA negative)
Cardiac enzymes were negative. Viagra was discontinued while
in-house so nitrates could be used if necessary. He was
monitored on tele, with no abnormalities. Xanax was continued
0.25mg prn.
.
3. HTN/hyperlipidemia/CAD
Norvasc and Lipitor were continued initially, but the
anti-hypertensive regimen was changed in MICU (see below), and
lipitor was stopped due to transaminitis. He had clean
coronaries on cath [**8-15**]. A repeat TTE on [**8-18**] showed no change
from [**8-3**]. On [**8-19**], given restoration of renal and hepatic
function, he was restarted on lipitor, and hydralazine and
nitrate were replaced with toprol XL 25qd per cardiology recs.
He may benefit from lisinopril in the future. Aspirin was
continued throughout his hospital course.
.
4. diabetes/pre-diabetic state
-diabetic diet, RISS
.
5. depression/anxiety
-continued Paxil, Xanax
.
6. PPx: subq heparin, H2B/PPI
.
7. PT: pt was started on physical therapy during his hospital
stay. By the time of discharge, he was tolerating [**12-29**] physical
therapy sessions a day and maintaining O2 sats in high 90s. PT
felt he would be able to tolerate a total of [**2-28**] hours of PT per
day spread across multiple sessions in an acute rehab setting.
.
.
MICU Course

1. Hypoxic respiratory failure:  On hospital day 3, the patient
began to have desaturations requiring 100% NRB to maintain
oxygen saturation.  His hypoxia was attributed to a right lower
lobe pneumonia and congestive heart failure given his new wall
motion abnormality with an EF of 35-40%.  He completed a 7-day
course of Levofloxacin and Vancomycin for empiric treatment of
hospital acquired pneumonia.  He was also given lasix for
diuresis given his positive fluid status.  Several times during
his ICU stay, he desaturated to the low 70% for brief episodes.
Some of these episodes were attributed to anxiety since his
saturations improved with ativan.  However, anxiety alone could
not explain his persistent oxygen requirement.  A chest CT was
performed to look for parenchymal disease that was not evident
on plain films.  The CT showed bilateral pleural effusions with
the right greated than the left.  The effusions were attributed
to CHF.  He was started on hydralazine and insosorbide
mononitrate for afterload reduction.  Given his persistent
oxygen requirement a diagnostic and therapeutic thoracentesis
was performed to rule out a malignant or infected effusion.
Approximately 1 litre of clear yellow fluid that was consistent
with a transudate was removed from the right.  Pleural cultures
showed no growth at the time of transfer from the ICU.  His
oxygenation improved post-thoracentesis and he was able to
tolerate being on room air.

2. Hypotension:  His hypotension was concerning for SIRS/early
sepsis given his intial concurrent leukocytosis and elevated
lactate.  His pressure stabilized after fluid boluses during his
first 24 hours in the ICU.  After resolution of the hypotension,
his blood pressure was elevated and he required metoprolol to
maintain adequate blood pressure control.
.
3.  Metabolic acidosis:  His initial metabolic acidosis was
likely due to lactic acidosis secondary to hypoperfusion.  He
received bicarbonate infusion with correction of the acidosis
during the first 24 hours of his ICU stay.
.
4.  ARF:  The acute renal failure was likely secondary to
contrast nephropathy and overdiuresis with lasix given his
intial presentation with CHF.   His FeUrea was consistent with
pre-renal.  Renal felt that he had a resolving ATN in the
setting of hypotension and recommended repleting half his urine
output with 1/2NS for a resolving ATN.  He initially appeared to
be volume overloaded on exam and aggressive diuresis was
attempted once his creatinie returned to [**Location 213**].  However, he
experience a bump in his creatinine.  Subsequently, lasix was
used sparingly and his creatinine and electrolytes were followed
closely.  His ARF was resolving upon transfer from the MICU.
.
5.   Hepatitis:  He had normal LFTs prior to his episode of
hypotension.  His LFTs drastically increased.  An ultrasound
showed old metastasis and fluid overload.  Initially, the
possibility of cyanide toxicity was thought to contribute to his
presentation give his herbal supplements.  He received one dose
of mucomyst and sodium thiosulfate.  Per Toxicology consult, his
hepatitis was unlikely from his medications/supplements.  His
hepatitis serologies were negative.  His AST/ALT peaked on ICU
day 2 and his tbili peaked on ICU day 6.  This pattern is
consistent with shock liver.
.
6.  Coagulopathy:  His elevated PT/PTT was likely secondary to
acute liver failure.  There was no evidence of aute bleeding
initially, but his hematocrit decreased 48 to 39 after two
liters iv fluids.  His platelets and fibrinogen also trended
down.  His coagulopathy could be attributed to live dysfunction,
however, a mild DIC could not be ruled out.  He was given a
total of 20 mg vitamin K, 5 units of 6 units FFP, and 1 unit
cryoprecipitate to decrease INR prior to placing central line on
the day of transfer to the ICU.  He was also given 3 Units of
FFP prior to performing a thoracentesis for an elevated INR.
Upon transfer from the ICU, his platelets, fibrinogen, and INR
were returning to normal levels.
.
7.  CAD:  He had a history of a previous MI and now has new
anterior wall hypokinesis on echo and reduced EF 35%.  He ruled
out for an acute MI by serial enzymes.  His ASA and statin were
held in the setting of liver dysfuntion.  On ICU day 4, low dose
metoprolol was started once his blood pressure was stable.  He
will need a stress MIBI once stable.
.
8. DM:  He initially required an insulin drip for glycemic
control and was transitioned to an insulin SS on ICU day 3.  His
blood glucose remained in good control generally between
110-160.
.
9.  FEN:  He was intially NPO.  His diet was advanced as
tolerated.  He initially required fluid resucitation to maintain
his blood pressure.  On admission to the ICU, he had an elevated
potassium to 7.0.  He received calcium gluconate, insulin with
D50, kayexelate, and bicarb.  His potassium overcorrected and he
required repletion.  His magnesium and calcium were also
repleted.
.
10.  Access:  He had a left IJ central line.
.
11.  Prophylaxis:  He was maintained on a PPI and pneumoboots.


Medications on Admission:
ASA 81mg po qd
Lipitor 20mg po qpm
Norvasc 5mg po qd
Paxil 30mg po qd
ranitidine 150mg po bid
Viagra 25mg po qd
[**Doctor First Name **] 180mg po qd
Xanax 0.25 mg po qd prn


Discharge Medications:
1. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
4. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-29**] Sprays Nasal
TID (3 times a day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
12. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily). Tablet(s)


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Primary: congestive heart failure
Secondary: metastatic carcinoid tumor, hypertension,
hyperlipidemia, diabetes mellitus type 2, basal cell carcinoma


Discharge Condition:
good, stable


Discharge Instructions:
If you experience worsening shortness of breath, fevers/chills,
chest pain, seek medical attention immediately.

If you gain more than 3 lbs, contact Dr. [**First Name (STitle) **].

Your anti-hypertensive medications have been changed while you
were in the hospital. You are currently prescribed for Toprol XL
25mg daily. You may benefit from an ACE inhibitor in the future.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2127-9-10**] 4:15
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2127-9-10**] 6:40
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] VASCULAR [**Name12 (NameIs) 3628**] (NHB) Where: VASCULAR
[**Name12 (NameIs) 3628**] (NHB) Date/Time:[**2127-12-2**] 2:00


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]
{'Congestive heart failure, unspecified,Pneumonia, organism unspecified,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Acute and subacute necrosis of liver,Acquired coagulation factor deficiency,Malignant neoplasm of liver, secondary,Aortic valve disorders,Diseases of tricuspid valve,Acidosis,Other chronic pulmonary heart diseases,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of large intestine,Hypotension, 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: admitted from [**Hospital 191**] clinic w/ 5 days worsening SOB, DOE

PRESENT ILLNESS: Pt is a 63M w/ h/o metastatic carcinoid tumor, HTN,
hyperlipidemia who reports increasing SOB and DOE starting about
a month ago but worsening significantly within the last 5 days.
It has recently gotten so bad he can barely get up out of a
chair without getting short of breath. He reports orthopnea but
no PND. In clinic today, he was using accessory muscles of
respiration and was mildly diaphoretic, and his O2 sat on room
air was 97%, dropping to 94% with ambulation. He reports no
fever or chills, no URI symptoms, no recent travel, no changes
in his medications.
Pt also reports ~5 episodes of chest pain in the last few weeks
which he describes as pressure on his mid-sternum and usually
occurs during exertion. There is no associated nausea or
vomiting. He says he takes a [**12-29**] tablet of Xanax when he gets
this pain sometimes which seems to help. He cannot take
nitroglycerin because of his Viagra.

MEDICAL HISTORY: 1. metastatic carcinoid tumor, Dx'ed [**2123**]
-was on a study drug for a year and a half (ended about a year
ago) and was on octreotide for a few months earlier this year
but stopped because of diarrhea
2. hypertension
3. hyperlipidemia
4. carotid endarterectomy [**2120**]
5. depression/anxiety
6. cellulitis 2 weeks ago, given Keflex IV at [**Hospital3 **], now resolved
7. DM2/prediabetic state: random blood sugar was high, was on
glyburide for a brief time but made his sugars low so stopped
8. anxiety attack [**2110**] (collapsed), diagnosed in [**2120**] as MI
9. basal cell carcinoma (chest, low back, MOHS on cheek [**3-31**] and
[**7-1**])

MEDICATION ON ADMISSION: ASA 81mg po qd
Lipitor 20mg po qpm
Norvasc 5mg po qd
Paxil 30mg po qd
ranitidine 150mg po bid
Viagra 25mg po qd
[**Doctor First Name **] 180mg po qd
Xanax 0.25 mg po qd prn

ALLERGIES: Nitroglycerin

PHYSICAL EXAM: VS: T 97.7, HR 97, BP 140/52, RR 20, O2sat 97% on RA
Gen: awake, alert, conversant, elderly man, mildly short of
breath
HEENT: PERRL, EOMI, MMM
Neck: supple, JVP elevated (~8cm)
Chest: fine cracles at left base, otherwise CTA
CV: RRR, nl S1S2, no m/r/g, distant heart sounds
Abd: S/ND, mildy tender to palpation in LLQ
Ext: WWP, 1+ LE edema bilaterally, no c/c
Neuro: nonfocal

FAMILY HISTORY: early CAD

SOCIAL HISTORY: Lives alone, has two daughters
Distant tobacco use (25 pack-years, quit 30 years ago), distant
EtOH use (quit 28 yrs ago), no drugs 

### Response:
{'Congestive heart failure, unspecified,Pneumonia, organism unspecified,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Acute and subacute necrosis of liver,Acquired coagulation factor deficiency,Malignant neoplasm of liver, secondary,Aortic valve disorders,Diseases of tricuspid valve,Acidosis,Other chronic pulmonary heart diseases,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of large intestine,Hypotension, unspecified'}
