CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 65M with hx of hypertension, hypothyroidism presenting with
shortness of breath and fever. He was in his usual state of
health until ~2 weeks ago at which time he developed mild
shortness of breath and cough. He described cough as the
dominant symptom when he first came to the MICU; on transfer to
the medicine service he emphasized the history of dyspnea on
exertion. He denied sinus congestion, headache, rhinorrhea or
sore throat. His dyspnea on exertion continued; he says that
today he came to the emergency department because "my wife made
me" come. He had chest wall pain bilaterally by his history with
me (described as left-sided when he first came in), which he
says was worsened by deep breathing and coughing.
.
In the ED, his initial vital signs were 100.7 132 230/80 42 99%
NRB. He was initially placed on nitroglycerin gtt for blood
pressure control. A CXR was inconclusive for edema vs.
infiltrate. His BNP returned low so the nitroglycerin gtt was
discontinued in favor of labetalol. He received ceftriaxone and
levofloxacin; he grew out GPCs so was started on vancomycin;
these returned as pan-sensitive pneumococcus, so vanco was
d/c'ed and IV penicillin G was started while the patient was in
the MICU. He was called out to the floor as his clinical
condition improved.
.
ROS: no HA, abd pain, no dysuria, no rash, no leg swelling. no
weight gain. no increasing abd girth. + snores, no known apneic
spells during sleep.

MEDICAL HISTORY: hypertension
past hypothyroidism
?newly detected ascites

MEDICATION ON ADMISSION: benadryl prn
advil 400 mg [**Hospital1 **] (for past 2 weeks)
.
previously prescribed: metoprolol, synthroid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On arrival at [**Hospital1 18**]/MICU
VS: 99.6 96 120/72 28 100% (15L mask)
GEN: tachypneic. speaking in full sentences, obese male
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, dry MM, Neck supple, no LAD, no carotid
bruits, JVP not seen due to body habitus
CV: distant heart sounds RRR, nl s1, s2, no m/r/g. chest pain
reproduced with palpation.
PULM: late crackles at the bases with faint wheeze bilat.
ABD: soft, NT, mod distension, + BS, no HSM, + fluid
EXT: warm, dry, +2 distal pulses BL, no femoral bruits
NEURO: alert & oriented x3, no right/left neglect, CN II-XII
grossly intact, 5/5 strength throughout upper and lower
extremities. No sensory deficits to light touch appreciated. No
asterixis
PSYCH: appropriate affect
.
Additional findings on transfer from the MICU:
PULM: Egophony at the left lower half of lung field; bronchial
breath sounds from right middle to bottom of lung field. Fair
air movement above these findings.
GENITAL: macerated, depigmented area on underpart of foreskin,
appears to be some constriction of foreskin around distal
portion of penis shaft; no isolated lesions

FAMILY HISTORY: Father - deceased hx of stroke. Mother - deceased hx of
alzheimers. No cancers. no MI, no DM2

SOCIAL HISTORY: Lives with wife and 18 year old grandson. distant smoking
history >40 years ago. On admission: Says he drinks alcohol
(shots Bourbon or vodka) 2-3x/week unless celebrating; last
drink 2 weeks ago. Later: history suggested a much heavier
consumption pattern prior to one year ago, and possibly heavier
at present.
Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute kidney failure, unspecified,Other pulmonary insufficiency, not elsewhere classified,Bacteremia,Unspecified pleural effusion,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Bullous myringitis,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Anemia of other chronic disease,Alcoholic cirrhosis of liver
Pneumococcal pneumonia,Acute kidney failure NOS,Other pulmonary insuff,Bacteremia,Pleural effusion NOS,Other streptococcus,Bullous myringitis,Hypothyroidism NOS,Hypertension NOS,Anemia-other chronic dis,Alcohol cirrhosis liver
Admission Date:  [**2175-6-4**]              Discharge Date:   [**2175-6-9**]

Date of Birth:  [**2110-2-25**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 603**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
none

History of Present Illness:
65M with hx of hypertension, hypothyroidism presenting with
shortness of breath and fever. He was in his usual state of
health until ~2 weeks ago at which time he developed mild
shortness of breath and cough. He described cough as the
dominant symptom when he first came to the MICU; on transfer to
the medicine service he emphasized the history of dyspnea on
exertion. He denied sinus congestion, headache, rhinorrhea or
sore throat. His dyspnea on exertion continued; he says that
today he came to the emergency department because "my wife made
me" come. He had chest wall pain bilaterally by his history with
me (described as left-sided when he first came in), which he
says was worsened by deep breathing and coughing.
.
In the ED, his initial vital signs were 100.7 132 230/80 42 99%
NRB. He was initially placed on nitroglycerin gtt for blood
pressure control. A CXR was inconclusive for edema vs.
infiltrate. His BNP returned low so the nitroglycerin gtt was
discontinued in favor of labetalol. He received ceftriaxone and
levofloxacin; he grew out GPCs so was started on vancomycin;
these returned as pan-sensitive pneumococcus, so vanco was
d/c'ed and IV penicillin G was started while the patient was in
the MICU. He was called out to the floor as his clinical
condition improved.
.
ROS: no HA, abd pain, no dysuria, no rash, no leg swelling. no
weight gain. no increasing abd girth. + snores, no known apneic
spells during sleep.


Past Medical History:
hypertension
past hypothyroidism
?newly detected ascites


Social History:
Lives with wife and 18 year old grandson. distant smoking
history >40 years ago. On admission: Says he drinks alcohol
(shots Bourbon or vodka) 2-3x/week unless celebrating; last
drink 2 weeks ago. Later: history suggested a much heavier
consumption pattern prior to one year ago, and possibly heavier
at present.

Family History:
Father - deceased hx of stroke. Mother - deceased hx of
alzheimers. No cancers. no MI, no DM2

Physical Exam:
On arrival at [**Hospital1 18**]/MICU
VS: 99.6 96 120/72 28 100% (15L mask)
GEN: tachypneic. speaking in full sentences, obese male
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, dry MM, Neck supple, no LAD, no carotid
bruits, JVP not seen due to body habitus
CV: distant heart sounds RRR, nl s1, s2, no m/r/g. chest pain
reproduced with palpation.
PULM: late crackles at the bases with faint wheeze bilat.
ABD: soft, NT, mod distension, + BS, no HSM, + fluid
EXT: warm, dry, +2 distal pulses BL, no femoral bruits
NEURO: alert & oriented x3, no right/left neglect, CN II-XII
grossly intact, 5/5 strength throughout upper and lower
extremities. No sensory deficits to light touch appreciated. No
asterixis
PSYCH: appropriate affect
.
Additional findings on transfer from the MICU:
PULM: Egophony at the left lower half of lung field; bronchial
breath sounds from right middle to bottom of lung field. Fair
air movement above these findings.
GENITAL: macerated, depigmented area on underpart of foreskin,
appears to be some constriction of foreskin around distal
portion of penis shaft; no isolated lesions


Pertinent Results:
[**2175-6-4**] 08:50PM BLOOD
WBC-17.4*# RBC-4.03* Hgb-11.7* Hct-35.1* MCV-87 MCH-28.9
MCHC-33.2 RDW-13.4 Plt Ct-557*# Neuts-73* Bands-3 Lymphs-16*
Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2175-6-5**] 03:46AM BLOOD
WBC-19.2* RBC-3.16* Hgb-9.2* Hct-28.1* MCV-89 MCH-29.1 MCHC-32.7
RDW-13.8 Plt Ct-454*
[**2175-6-9**] 06:50AM BLOOD
WBC-11.7* RBC-3.20* Hgb-9.9* Hct-28.7* MCV-90 MCH-30.8 MCHC-34.3
RDW-13.7 Plt Ct-508*
.
[**2175-6-5**] 01:30PM BLOOD PT-16.9* PTT-30.6 INR(PT)-1.5*
.
[**2175-6-4**] 08:50PM BLOOD
Glucose-159* UreaN-20 Creat-1.6* Na-136 K-4.3 Cl-98 HCO3-21*
AnGap-21*
[**2175-6-9**] 06:50AM BLOOD
Glucose-102 UreaN-16 Creat-1.3* Na-137 K-4.9 Cl-99 HCO3-27
AnGap-16
.
[**2175-6-4**] 08:50PM BLOOD
ALT-52* AST-38 LD(LDH)-265* CK(CPK)-223* AlkPhos-162*
TotBili-1.3
[**2175-6-8**] 06:40AM BLOOD ALT-87* AST-88* AlkPhos-223* TotBili-0.8
.
[**2175-6-5**] 05:43AM BLOOD calTIBC-161* VitB12-526 Folate-9.6
Ferritn-1309* TRF-124*
[**2175-6-5**] 12:05PM BLOOD %HbA1c-6.6*
[**2175-6-4**] 08:50PM BLOOD TSH-37*
[**2175-6-5**] 05:43AM BLOOD Free T4-0.45*

Brief Hospital Course:
A/P: 65M with hx of hypertension, hypothyroidism who presented
with fever, cough and respiratory distress.
.
# Respiratory Distress: Exam and imaging were very consistent w
pneumococcal pneumonia, and most conclusively, [**3-31**] blood
cultures from [**6-4**] were positive for strep pneumo. Urine
legionella was negative. There was a small left sided effusion
visualized on CT chest but this was too small for thoracentesis;
ultimately since Mr [**Known lastname **] was improving clinically, the team
felt there was no urgent need to pursue this further unless he
were to worsen. His cultures were no growth starting on [**6-5**]; he
had started on effective treatment in the emergency department
on [**6-4**]. He was continued on penicillin G while on the floor, and
ultimately after consulting the infectious disease service we
decided he would finish out his course on amoxicillin, with
eight more days of antibiosis after the six days he had received
in the hospital.
.
# Hearing loss: Mr. [**Known lastname **] complained of a sensation of
discomfort in his ear just prior to coming into the hospital,
and while here he noted decreased hearing in the left ear. On
examination, there were very small bullae in the upper portion
of the tympanic membrane, suggestive of early/mild bullous
myringitis which can be seen with strep pneumoniae. We set him
up with audiologic evaluation, and will refer him to ENT if
indicated based on the audiologic evaluation.

# Penile lesion: Mr [**Known lastname **] had a slightly bulbous and
circumferential depigmented lesion around the foreskin of his
penis. Originally we thought this might have been an unfortunate
effect of the condom catheter but it remained after
discontinuing the catheter. We referred him for [**Known lastname **]
follow-up with concern that this might represent a malignancy.
.
# Hypothyroidism: He had not been on medicines since he had lost
his health care insurance about 5 years prior; he reported
weight gain and poor energy and recalled a past diagnosis of low
thyroid. His TSH was elevated to 37 with FT4 low at 0.45. We
started levothyroxine at previous home dose of 75mcg; given that
his values were checked in the inpatient setting of critical
illness these should be followed up when he is more stable.
.
# Hypertension: He was hypertensive coming in to ED, was mostly
normotensive in the days after that, and then towards the end of
his admission was hypertensive again; he was sent out on a
starting dose of HCTZ. This should be followed up in subsequent
outpatient visits.
.
# Anemia: There was no evidence of blood loss. His labs were
consistent with an anemia of chronic inflammation. This might be
from the pneumonia or some more chronic cause and should be
followed.
.
# Acute renal failure: He was originally in acute renal failure,
likely from pre-renal state exacerbated by NSAIDs. His
creatinine had normalized by the time of discharge.
.
# Abdominal distension: Abdominal U/S showed no ascites or other
acute issues; it did show a possibly fibrotic/cirrhotic liver
but no ascites nor splenomegaly to suggest portal hypertension.
His LFTs were normal as was synthetic function and normal
platelets. His physical exam was benign and as he improved
clinically we saw no evidence of abdominal process, and his
abdominal appearance may simply be from disproportionate
abdominal obesity.
.
# FEN: He was given a heart-healthy diet and lytes were repleted
PRN.
.
#ACCESS: PIV
.
#PPx
- Heparin sub-q for DVT prophylaxis
.
#CODE: FULL
.
#COMMUNICATION: patient
.
#DISPO: to home with close follow-up.
.


Medications on Admission:
benadryl prn
advil 400 mg [**Hospital1 **] (for past 2 weeks)
.
previously prescribed: metoprolol, synthroid


Discharge Medications:
1. Amoxicillin 875 mg Tablet Sig: One (1) Tablet PO twice a day
for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Pneumococcal pneumonia


Discharge Condition:
Good


Discharge Instructions:
You were diagnosed with pneumonia. You need to keep taking your
antibiotics for the prescribed time. It is extremely important
that you take ALL your antibiotics even if you are feeling
better.
.
You have had some high blood pressure. We've prescribed you some
blood pressure pills. You also had low thyroid levels, which
means you need to keep taking your thyroid medication. It's very
important that you take all the medicines that have been
prescribed to you.
.
You had some hearing loss. It's most likely that this was a
complication of the pneumonia you had, and we hope it will get
better, but it's important that this be followed up. Go to the
audiology appointment (hearing test) to check if your hearing
has got better.
.
You should go to the doctor's office next week to make sure that
everything is going OK. Call [**Telephone/Fax (1) 30910**] on Wednesday to make
an appointment for Thursday or Friday.
.
You'll then have another check up on [**7-5**], which will also
be where you have a complete history and physical to start your
primary care.
.
Come back to the emergency department if you have new fevers, if
you are having more difficulty breathing, if you are coughing up
blood, or if you are having other concerning symptoms.
.
We are concerned about the skin discoloration on your penis and
are concerned that it might be a sign of a problem that may need
treatment. We have set up a [**Month (only) **] appointment for you (a
doctor [**First Name (Titles) **] [**Last Name (Titles) 14903**] in this type of problem); please go to
this appointment as it will be important to follow up.
.
Follow up with your new primary care physician on [**7-5**]
(appointment shown below).
.


Followup Instructions:
.
Call on Wednesday or Thursday: [**Telephone/Fax (1) 30910**]--for visit at
[**Hospital3 **] for hospital visit follow-up.
.
AUDIOLOGY APPOINTMENT (hearing test) [**6-19**] 11:15 Dr [**First Name (STitle) 3175**]
.
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2175-6-21**]
9:00
.
Go to a follow-up appointment with your new primary care
provider:
[**Known firstname **] [**Last Name (NamePattern4) 15398**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2175-7-5**] 3:30
.
Provider: [**Name10 (NameIs) 6410**] [**Name Initial (NameIs) **] [**Last Name (NamePattern4) **], AU.D. Phone:[**Telephone/Fax (1) 6411**]
Date/Time:[**2175-6-19**] 11:15
.
{'Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute kidney failure, unspecified,Other pulmonary insufficiency, not elsewhere classified,Bacteremia,Unspecified pleural effusion,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Bullous myringitis,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Anemia of other chronic disease,Alcoholic cirrhosis of liver'}


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: shortness of breath

PRESENT ILLNESS: 65M with hx of hypertension, hypothyroidism presenting with
shortness of breath and fever. He was in his usual state of
health until ~2 weeks ago at which time he developed mild
shortness of breath and cough. He described cough as the
dominant symptom when he first came to the MICU; on transfer to
the medicine service he emphasized the history of dyspnea on
exertion. He denied sinus congestion, headache, rhinorrhea or
sore throat. His dyspnea on exertion continued; he says that
today he came to the emergency department because "my wife made
me" come. He had chest wall pain bilaterally by his history with
me (described as left-sided when he first came in), which he
says was worsened by deep breathing and coughing.
.
In the ED, his initial vital signs were 100.7 132 230/80 42 99%
NRB. He was initially placed on nitroglycerin gtt for blood
pressure control. A CXR was inconclusive for edema vs.
infiltrate. His BNP returned low so the nitroglycerin gtt was
discontinued in favor of labetalol. He received ceftriaxone and
levofloxacin; he grew out GPCs so was started on vancomycin;
these returned as pan-sensitive pneumococcus, so vanco was
d/c'ed and IV penicillin G was started while the patient was in
the MICU. He was called out to the floor as his clinical
condition improved.
.
ROS: no HA, abd pain, no dysuria, no rash, no leg swelling. no
weight gain. no increasing abd girth. + snores, no known apneic
spells during sleep.

MEDICAL HISTORY: hypertension
past hypothyroidism
?newly detected ascites

MEDICATION ON ADMISSION: benadryl prn
advil 400 mg [**Hospital1 **] (for past 2 weeks)
.
previously prescribed: metoprolol, synthroid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On arrival at [**Hospital1 18**]/MICU
VS: 99.6 96 120/72 28 100% (15L mask)
GEN: tachypneic. speaking in full sentences, obese male
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, dry MM, Neck supple, no LAD, no carotid
bruits, JVP not seen due to body habitus
CV: distant heart sounds RRR, nl s1, s2, no m/r/g. chest pain
reproduced with palpation.
PULM: late crackles at the bases with faint wheeze bilat.
ABD: soft, NT, mod distension, + BS, no HSM, + fluid
EXT: warm, dry, +2 distal pulses BL, no femoral bruits
NEURO: alert & oriented x3, no right/left neglect, CN II-XII
grossly intact, 5/5 strength throughout upper and lower
extremities. No sensory deficits to light touch appreciated. No
asterixis
PSYCH: appropriate affect
.
Additional findings on transfer from the MICU:
PULM: Egophony at the left lower half of lung field; bronchial
breath sounds from right middle to bottom of lung field. Fair
air movement above these findings.
GENITAL: macerated, depigmented area on underpart of foreskin,
appears to be some constriction of foreskin around distal
portion of penis shaft; no isolated lesions

FAMILY HISTORY: Father - deceased hx of stroke. Mother - deceased hx of
alzheimers. No cancers. no MI, no DM2

SOCIAL HISTORY: Lives with wife and 18 year old grandson. distant smoking
history >40 years ago. On admission: Says he drinks alcohol
(shots Bourbon or vodka) 2-3x/week unless celebrating; last
drink 2 weeks ago. Later: history suggested a much heavier
consumption pattern prior to one year ago, and possibly heavier
at present. 

### Response:
{'Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute kidney failure, unspecified,Other pulmonary insufficiency, not elsewhere classified,Bacteremia,Unspecified pleural effusion,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Bullous myringitis,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Anemia of other chronic disease,Alcoholic cirrhosis of liver'}
