CHIEF COMPLAINT: sob

PRESENT ILLNESS: 75F with metastatic breast cancer, s/p recent chemo (last on
[**8-19**]), CHF who gradually started to develop SOB 1d after chemo.
Her SOB increased gradually, until the morning of her admission,
when she was SOB @ rest and therefore presented to [**Hospital3 **]
Hospital.
.
At OSH, VS=97.6 97/38  115  22  99%4L NC.  Per report she was
bradycardic and with ?heart block, and received atropine x1.
CXR showed ?new LLL opacity.  Labs revealed ARF (k= 6.0 -> given
calcium, insulin, glucose, kayexalate, no acute EKG changes).  A
R femoral TLC was placed.  She was transferred to [**Hospital1 18**] for
evaluation for HD.  En route SBP dropped (no documentation of
SBPs), and pt was started on dopa gtt.
.
Pt presented to [**Hospital1 18**] ED with VS: 97.8  70  106/56 18 96% NRB on
dopamine gtt.  SBP down to 78/38 in ED.  In the ED, given 1U
PRBC, 1L IVF NS. Her O2 requirement was weaned down to 6L, she
was mentating appropriately per report.  She was admitted to
MICU [**1-9**] hypotension.

MEDICAL HISTORY: - breast cancer (mets to bone) dx [**2119**], s/p 2nd dose of chemo
([**8-19**], taxol, gemcitabine, seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Location (un) **]
Muger [**Hospital3 **]), previously treated with XRT, Zometa, Arimidex.

MEDICATION ON ADMISSION: atenolol 25mg po qdaily
dilaudid prn bone pain
compazine prn
immodium prn
procrit qwk
zometa qmo (next [**9-9**])

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 97.0  104  126/43   26 98% 6LNC (on dopa 7mcg/hr)
GEN: NAD
HEENT: PERRLA, EOMI, sclera anicteric, +conjunctival hemorhage,
OP clear, MMM, no LAD, no carotid bruits.  No JVD.
CV: regular, nl s1, s2, no m/r/g.
PULM: few crackles at basees bilaterally, no r/w.
ABD: soft, ND, + BS, no HSM.  mild epigastric tenderness to
palpation, no rebound, no gaurding.
EXT: warm, 2+ dp/radial pulses BL.  trace B LE edema.
NEURO: alert & oriented x 2, CN II-XII grossly intact.  +flap.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: 2ppd x 20y tobbacco quit 20y ago, denies alcohol, IVDU.
Acute kidney failure, unspecified,Acute respiratory failure,Acute and subacute necrosis of liver,Congestive heart failure, unspecified,Atrial fibrillation,Hyperpotassemia,Secondary malignant neoplasm of brain and spinal cord,Poisoning by other and unspecified agents primarily affecting the cardiovascular system,Accidental poisoning by agents primarily affecting cardiovascular system,Neutropenia, unspecified,Personal history of malignant neoplasm of breast
Acute kidney failure NOS,Acute respiratry failure,Acute necrosis of liver,CHF NOS,Atrial fibrillation,Hyperpotassemia,Sec mal neo brain/spine,Pois-cardiovasc agt NEC,Acc poisn-cardiovasc agt,Neutropenia NOS,Hx of breast malignancy
Admission Date:  [**2122-8-23**]              Discharge Date:   [**2122-9-5**]

Date of Birth:  [**2047-6-26**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 330**]
Chief Complaint:
sob

Major Surgical or Invasive Procedure:
none

History of Present Illness:
75F with metastatic breast cancer, s/p recent chemo (last on
[**8-19**]), CHF who gradually started to develop SOB 1d after chemo.
Her SOB increased gradually, until the morning of her admission,
when she was SOB @ rest and therefore presented to [**Hospital3 **]
Hospital.
.
At OSH, VS=97.6 97/38  115  22  99%4L NC.  Per report she was
bradycardic and with ?heart block, and received atropine x1.
CXR showed ?new LLL opacity.  Labs revealed ARF (k= 6.0 -> given
calcium, insulin, glucose, kayexalate, no acute EKG changes).  A
R femoral TLC was placed.  She was transferred to [**Hospital1 18**] for
evaluation for HD.  En route SBP dropped (no documentation of
SBPs), and pt was started on dopa gtt.
.
Pt presented to [**Hospital1 18**] ED with VS: 97.8  70  106/56 18 96% NRB on
dopamine gtt.  SBP down to 78/38 in ED.  In the ED, given 1U
PRBC, 1L IVF NS. Her O2 requirement was weaned down to 6L, she
was mentating appropriately per report.  She was admitted to
MICU [**1-9**] hypotension.

Past Medical History:
- breast cancer (mets to bone) dx [**2119**], s/p 2nd dose of chemo
([**8-19**], taxol, gemcitabine, seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Location (un) **]
Muger [**Hospital3 **]), previously treated with XRT, Zometa, Arimidex.

- baseline HCT [**8-11**] WBC=4500, HCT 30, PLT 327, HgB 9.9.
- baseline creatinine 1.1 [**7-13**], 1.1 [**8-13**], [**7-27**] 1.38.
- HTN
-h/o recluse spider bite.
-post-herpetic neuralgia
- denies cad/dm/pe/dvt.

Social History:
2ppd x 20y tobbacco quit 20y ago, denies alcohol, IVDU.

Family History:
non-contributory

Physical Exam:
VS: 97.0  104  126/43   26 98% 6LNC (on dopa 7mcg/hr)
GEN: NAD
HEENT: PERRLA, EOMI, sclera anicteric, +conjunctival hemorhage,
OP clear, MMM, no LAD, no carotid bruits.  No JVD.
CV: regular, nl s1, s2, no m/r/g.
PULM: few crackles at basees bilaterally, no r/w.
ABD: soft, ND, + BS, no HSM.  mild epigastric tenderness to
palpation, no rebound, no gaurding.
EXT: warm, 2+ dp/radial pulses BL.  trace B LE edema.
NEURO: alert & oriented x 2, CN II-XII grossly intact.  +flap.

Pertinent Results:
[**2122-8-23**] CXR: bibasilar opacities, which may represent
atelectasis or
pneumonia.  Small bilateral pleural effusions.
.
[**2122-8-23**] EKG: sinus bradycardia.
.
CT head:
FINDINGS: There is no evidence of hemorrhage, infarction, shift
of normally midline structures or hydrocephalus. There are small
subinsular white matter lucencies suggesting chronic ischemia.
[**Doctor Last Name **]- white matter differentiation appears grossly preserved.
Visualized paranasal sinuses appear normally aerated.
IMPRESSION: Subinsular lacunes. Otherwise normal study. MRI with
gadolinium is more sensitive in the evaluation for metastases.
.
Ultrasound:
FINDINGS: Portable bedside evaluation was performed with
limitations secondary to patient respirations.
An approximately 1.6 x 1.4 x 1.5 cm iso- to hypoechoic lesion is
present within segment VIII of the liver. No other focal hepatic
lesion is identified and a previously noted cyst within segment
[**Doctor First Name 690**] is not adequately seen. There is no intrahepatic biliary
ductal dilatation, the patient is status post cholecystectomy.
The right kidney measures 9.7 cm. The left kidney measures 9.8
cm. No hydronephrosis, stone, or renal mass is identified. The
pancreas is poorly evaluated. The abdominal aorta is normal
caliber throughout and demonstrates scattered mural
atherosclerotic calcification. Spleen appears unremarkable. A
left-sided pleural effusion is partially imaged.
Doppler interrogation of the liver demonstrates patent hepatic
and portal vessels. Flow within the main portal vein is
hepatopetal. The main hepatic artery demonstrates a waveform
within normal limits.
IMPRESSION:
1. Solid-appearing segment VIII hepatic lesion is a nonspecific
finding but may represent a metastasis.
2. Patent portal and hepatic veins.
3. Left pleural effusion.
.
CT abd/pelvis:
IMPRESSION:
1. No evidence of retroperitoneal hematoma, hydronephrosis or
pathologic lymph node enlargement.
2. Two hypodense hepatic lesions, one of which is compatible
with a cyst and the other of which cannot be definitively
characterized but could represent a hepatic metastatic focus.
3. Bilateral pleural effusions, the left of which is loculated
and incompletely imaged.
4. Peripancreatic fat stranding which may be related to anasarca
given the patient's recent normal lipase value.
5. Multiple osseous metastases, as detailed above.
.
Echo:The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right
ventricular cavity is dilated. Right ventricular systolic
function is normal. The mitral valve leaflets are structurally
normal. There is no pericardial effusion.
.
CT chest: 1. Bilateral small-to-moderate sized partially
loculated pleural effusions. Given the history the suspicion for
malignant pleural invasion is high, especially given thick
nodular soft tissue enhancement within the pleural effusions on
the prior abdomen CT (not evaluated today due to absence of
contrast).
2. Innumerable skeletal metastases.
3. Peripheral ground-glass opacities in the upper lobes
bilaterally; considerations include infectious of inflammatory
process; less likely would be metastases.
4. Two hypodense liver lesions, incompletely characterized,
concerning for metastatic foci.
.
CXR [**8-28**]:
New bilateral perihilar opacities extending towards the lower
lobes representing new pulmonary edema. The previously seen
right lower lobe opacity related to pleural effusion is changed
in appearance most likely due to currently supine position of
the patient. The cardiac silhouette has been markedly enlarged
in the meantime interval, which may be corresponding to both
changing of the patient's position and its hemodynamic status.
The left internal jugular line tip terminates at the junction of
the brachiocephalic vein and SVC.
IMPRESSION:
1. New pulmonary edema.
2. Increased heart size.
3. Bilateral pleural effusions.
.


Brief Hospital Course:
75 F with metastatic breast ca, paroxysmal AFIB with RVR, with
resolved neutropenia after chemo, resolved heart block while in
ARF on atenolol.
.
# Hypotension and sinus bradycardia:
She arrived at [**Hospital1 18**] on dopamine gtt, started en route in life
flight (no documentation). Initial concern was for sepsis vs
volume vs volume loss (hct=23, baseline unclear, was 28 at OSH),
concerning for GIB given guaic+ in ED vs RP bleed given femoral
access at OSH vs tamponade (uremic, coagulopathic, and h/o
breast malignancy) vs atenolol toxicity in setting of ARF [**1-9**]
chemotherapy. CT abd/PELVIS was negative for retroperitoneal
bleed.  Pt was transfused with PRBC with slowly responding HCT.
Cardiology consult was obtained given concern for tamponade,
pulsus was initially [**7-17**], +pericardial knock. TTE was negative
for tamponade, grossly normal EF, ?RV dilation. Given concern
for GI bleeding, thrombocytopenia, and ARF, as well as rapidly
improving O2 status, PE was felt less likely, and heparin gtt
was not started. She was weaned from dopamine gtt gradually over
~2d, though was found to be acutely sensitive to weaning with
periods of bradycardia to 20s (including 1.5-4 second pauses)
while weaning, these episodes were asymptomatic. Bradycardia
resolved over several days.
.
# Hypoxemia:
On presentation, etiology was felt likely [**1-9**] pulmonary edema
from ARF, however given neutropenia, concerning for PNA.
PaO2/FiO2 gradient = 90 / 0.40 = 360.  no effusion seen on
bedside TTE.  given hypotension, diuresis was deferred. Since
she was afebrile but neutropenic, she was treated empirically
with cefepime/vanco.  pt was seen by the renal service, and felt
not to require acute dialysis on the basis of volume removal.
on HD2 pt began to auto-diurese aggresively (felt [**1-9**] ATN), and
was weaned down to RA by HD#3.  repeat CXR on HD#3 showed
?increasing pulmonary edema (felt unlikley given clinical
improvement), however was concerning for new consolidations.  A
CT CHEST was ordered to further evaluate, as given neutropenia
she was felt susceptible for atypical infections (ie fungal).
Her volume status quickly improved with auto-diuresis, and she
was weaned from NRB to 4L NC quickly overnight on admission.
Given her rapid imrovement, pt was empirically placed on a 7d
course of cefepime/vanco with resolution of hypoxemia to room
air. All culture data was negative.
.
# Afebrile neutropenia:
For neutropenia, pt empirically started on cefepime and
vancomycin on [**8-23**] for 7 day course, and blood, urine, sputum
cultures were negative.
.
# Cardiac ischemia:
She does not have known coronary disease. Given unclear etiology
of hypotension, cardiac enzymes were checked but were negative
x3.
.
# Paroxysmal AFIB with RVR:
EKGs at OSH were concerning for intermittent afib vs mat vs
atrial tachycardia with intermittent block.  per report, pt had
an episode of "my heart stopping" at OSH requiring atropine (no
documentation).  on arrival, pt was in nsr, on doparmine,
however, she was acutely sensitive to weaning of dopamine with
sinus bradycardia (asymptomatic) when dopamine was weaned from
5mcg/hr to 3mcg/hr.  This was felt [**1-9**] atenolol toxicity, though
she was intermittently hypertensive while bradycardic (CT HEAD
negative for intracranial process).
.
Pt seen by cardiology, who felt that given that escape rythym
was narrow complex, and pt was asymptomatic. Neither pacer pads
nor atropine were needed. Pt seen by EP who felt pacemaker was
not indicated.  Further, pt elected to not pursue further
chemotherapy, and she was not felt to be a good candidate for
pacemaker implant in setting of poor prognosis and
neutropenia/thrombocytopenia. Atenolol should be avoided if pt
intendes to continue with chemotherapy given risk of atenolol
toxicity [**1-9**] ARF.
.
# Cardiac pump:
No known CHF, on admission had ?pericardial knock, with pulsus
8-10mmgHg, though TTE showed no pericardial effusion, ?RV
dilation, grossly normal EF (limited study).
.
# ARF:
Reportedly normal kidney function at baseline, presented with Cr
4.0. Initial insult felt most likely to be recent chemotherapy
[**8-19**], though other causes include recent NSAID use vs [**1-9**]
hypotension at OSH. Double acid base disorder of AG and non-GAP
acidosis was present. Respiratory compensation was appropriate
for metabolic acidosis felt [**1-9**] ARF. For hyperkalemia and mild
asterixis, renal recommended kayexalate (which pt vomited) for
K=5.7, pt was given insulin, d50, calcium, and HCO3 in d5w
overnight with normal K and no concerning EKG changes.  emergent
HD was declined given absence of pericardial effusion, as
hyperK, acidemia, and uremia felt stable.  K improved with
autodiuresis in AM and pt eventually able to tolerate
kayexalate.
.
# Thrombocytopenia:
Given thrombocytopenia, and concern for active bleeding, pt was
given DDAVP x 2 on HD1-2. She required multiple platelet
transfusions in setting of GI bleeding and conjunctival
hemorrhage.
.
# mental status changes -  pt midly confused on admission
(A&Ox2), sluggish, and flapping.  most likely felt [**1-9**] uremia vs
infection, however CT HEAD obtained to r/o intracranial bleed
given thrombocytopenia, and conjunctival hemhorages concerning
for bleeding.  heme-onc consult obtained to evalute smear to r/o
schistocytes and TTP given anemia, thrombocytopenia, uremia/ARF,
though INR only 1.2.  no schistocytes seen.  pt's mental status
resolved with improvement in uremia and with antibiotic course
as above.
.
# Metastatic breast ca s/p chemo x2:
Recently s/p chemo (gemecitibine/taxol) [**8-19**] (only her second
dose), neutropenic on admission, no reports of fever, though
hypotension concerning for sepsis. Heme/onc consult assessed
peripheral smear as negative for DIC or TTP. DIC labs were
followed q8h and felt unremarkable in setting of onc diagnosis.
Per heme-onc she was started on g-csf for neutropenia with
recovery of WBC. Platelets were maintained initially at goal >50
for concern for bleeding, however given that her hct was found
to be at her baseline, transfusion threshold was changed to 20.
She received ddavp as above for concern for uremic platelets in
setting of bleeding. On HD#3, pt expressed wishes not to pursue
further chemotherapy, and plans were made for discussion to
address overall goals of care. Patient also noted mucositis and
thrush, treated with magic mouthwash, peridex, nystatin swish
and swallow, with returning ability to take small POs.
.
# Elevated LFTs - tbil mildly elevated 2.6, pt s/p
cholecystectomy however, though felt she could still have CBD
stone, CT ABD/PELVIS [**Location (un) 1131**] negative for significant hydro, CBD
dilation.  initial elevation of LFTs/TBIL thus felt more likely
[**1-9**] chemo and shock liver, and started trending down slowly by
HD#3.  INR was stable 1.2-1.3, suggesting intact liver function.
 on HD#3 amylase/lipase started trending up. pt with ongoing n/v
likely [**1-9**] chemo, however CT abd/pelvis did show ?peripancreatic
stranding.  plan made to follow pt clinically, and obtain repeat
imaging if she developed abdominal pain.
.
#FEN - pt npo initially, then advanced to renal diet, which was
d/c'd once renal function improved.  she had n/v treated with
zofran.  abdominal xray ruled out obstruction, and n/v
attributed most likely to chemo.  also with diarrhea, stool sent
for cdiff (though has h/o pelvic radiation).  on HD#3 renal
recommended modest maintenance fluids to keep up with aggresive
autodiuresis.
.
During the evening of [**2122-9-5**] the patient developed respiratory
distress. Per discussion with the family, the patient was made
CMO and given low dose IV Morphine to reduce dyspnea. She died
on [**2122-9-5**] of cardiopulmonary arrest.

Medications on Admission:
atenolol 25mg po qdaily
dilaudid prn bone pain
compazine prn
immodium prn
procrit qwk
zometa qmo (next [**9-9**])

Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
N/A

Discharge Condition:
expired

Discharge Instructions:
N/A

Followup Instructions:
N/A
{'Acute kidney failure, unspecified,Acute respiratory failure,Acute and subacute necrosis of liver,Congestive heart failure, unspecified,Atrial fibrillation,Hyperpotassemia,Secondary malignant neoplasm of brain and spinal cord,Poisoning by other and unspecified agents primarily affecting the cardiovascular system,Accidental poisoning by agents primarily affecting cardiovascular system,Neutropenia, unspecified,Personal history of malignant neoplasm of breast'}


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: sob

PRESENT ILLNESS: 75F with metastatic breast cancer, s/p recent chemo (last on
[**8-19**]), CHF who gradually started to develop SOB 1d after chemo.
Her SOB increased gradually, until the morning of her admission,
when she was SOB @ rest and therefore presented to [**Hospital3 **]
Hospital.
.
At OSH, VS=97.6 97/38  115  22  99%4L NC.  Per report she was
bradycardic and with ?heart block, and received atropine x1.
CXR showed ?new LLL opacity.  Labs revealed ARF (k= 6.0 -> given
calcium, insulin, glucose, kayexalate, no acute EKG changes).  A
R femoral TLC was placed.  She was transferred to [**Hospital1 18**] for
evaluation for HD.  En route SBP dropped (no documentation of
SBPs), and pt was started on dopa gtt.
.
Pt presented to [**Hospital1 18**] ED with VS: 97.8  70  106/56 18 96% NRB on
dopamine gtt.  SBP down to 78/38 in ED.  In the ED, given 1U
PRBC, 1L IVF NS. Her O2 requirement was weaned down to 6L, she
was mentating appropriately per report.  She was admitted to
MICU [**1-9**] hypotension.

MEDICAL HISTORY: - breast cancer (mets to bone) dx [**2119**], s/p 2nd dose of chemo
([**8-19**], taxol, gemcitabine, seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Location (un) **]
Muger [**Hospital3 **]), previously treated with XRT, Zometa, Arimidex.

MEDICATION ON ADMISSION: atenolol 25mg po qdaily
dilaudid prn bone pain
compazine prn
immodium prn
procrit qwk
zometa qmo (next [**9-9**])

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 97.0  104  126/43   26 98% 6LNC (on dopa 7mcg/hr)
GEN: NAD
HEENT: PERRLA, EOMI, sclera anicteric, +conjunctival hemorhage,
OP clear, MMM, no LAD, no carotid bruits.  No JVD.
CV: regular, nl s1, s2, no m/r/g.
PULM: few crackles at basees bilaterally, no r/w.
ABD: soft, ND, + BS, no HSM.  mild epigastric tenderness to
palpation, no rebound, no gaurding.
EXT: warm, 2+ dp/radial pulses BL.  trace B LE edema.
NEURO: alert & oriented x 2, CN II-XII grossly intact.  +flap.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: 2ppd x 20y tobbacco quit 20y ago, denies alcohol, IVDU. 

### Response:
{'Acute kidney failure, unspecified,Acute respiratory failure,Acute and subacute necrosis of liver,Congestive heart failure, unspecified,Atrial fibrillation,Hyperpotassemia,Secondary malignant neoplasm of brain and spinal cord,Poisoning by other and unspecified agents primarily affecting the cardiovascular system,Accidental poisoning by agents primarily affecting cardiovascular system,Neutropenia, unspecified,Personal history of malignant neoplasm of breast'}
