CHIEF COMPLAINT: pulmonary htn

PRESENT ILLNESS: see previous summary

MEDICAL HISTORY: -Right heart failure
-Obstructive sleep apnea
-Type II Diabetes Mellitus
-Chronic obstructive pulmonary disease
-Hypertension
-BPPV
-h/o leiomyomata
-chronic venous insufficiency
-depression.

MEDICATION ON ADMISSION: -lasix 80mg po bid
-zolpidem 5mg po qhs prn
-albuterol nebs
-lipitor 10mg po once daily
-pantoprazole 40mg po once daily
-atrovent nebs
-meclizine 25mg po bid
-amitryptiline 25mg po qhs
-humalog 75/25 units once daily

ALLERGIES: Penicillins

PHYSICAL EXAM: see previous dc summary

FAMILY HISTORY: Remarkable for diabetes mellitus in a number of family members.

SOCIAL HISTORY: Pt lives on a [**Location (un) **] apartment. She denied tobacco use or
illicit drug use.  She drinks one glass of alcohol (usually
wine) once per month.
Congestive heart failure, unspecified,Cardiogenic shock,Cardiac arrest,Chronic airway obstruction, not elsewhere classified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Other chronic pulmonary heart diseases,Unspecified sleep apnea,Morbid obesity,Unspecified hemorrhoids with other complication,Other diseases of pharynx, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Closed fracture of other bone of wrist,Unspecified accident
CHF NOS,Cardiogenic shock,Cardiac arrest,Chr airway obstruct NEC,Acute kidney failure NOS,Hyp kid NOS w cr kid V,Urin tract infection NOS,Hyposmolality,Chr pulmon heart dis NEC,Sleep apnea NOS,Morbid obesity,Hemrrhoid NOS w comp NEC,Disease of pharynx NEC,DMII renl nt st uncntrld,Fx carpal bone NEC-close,Accident NOS
Name:  [**Known lastname **],[**Known firstname **]                    Unit No:   [**Numeric Identifier 15642**]

Admission Date:  [**2176-10-16**]              Discharge Date:   [**2176-11-4**]

Date of Birth:  [**2115-11-19**]             Sex:   F

Service: [**Hospital Unit Name 319**]

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2129**]
Chief Complaint:
pulmonary htn

Major Surgical or Invasive Procedure:
Cardiac catheterization


History of Present Illness:
see previous summary

Past Medical History:
-Right heart failure
-Obstructive sleep apnea
-Type II Diabetes Mellitus
-Chronic obstructive pulmonary disease
-Hypertension
-BPPV
-h/o leiomyomata
-chronic venous insufficiency
-depression.

Social History:
Pt lives on a [**Location (un) **] apartment. She denied tobacco use or
illicit drug use.  She drinks one glass of alcohol (usually
wine) once per month.

Family History:
Remarkable for diabetes mellitus in a number of family members.

Sister with breast and ovarian cancer.

Physical Exam:
see previous dc summary

Pertinent Results:
see previous dc summary

Brief Hospital Course:
Patient is HIT antibody posititive, this has been noted on her
discharge worksheet


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 15504**]

Discharge Diagnosis:
Congestive Heart Failure
Pulmonary Hypertesion, severe
Chronic Obstructive Pulmonary disease
Chronic renal failure
Obstructive sleep apnea
Hypertension


Discharge Condition:
Stable

Discharge Instructions:
Please follow the instructions given to you by your Hospice
nurse.
Please continue to take all of your prescribed medications.

Followup Instructions:
Please follow the recommendations of hospice care


                             [**First Name11 (Name Pattern1) 448**] [**Last Name (NamePattern4) 2130**] MD [**MD Number(1) 2131**]

Completed by:[**2176-11-4**]

Admission Date:  [**2176-10-16**]              Discharge Date:   [**2176-11-4**]

Date of Birth:  [**2115-11-19**]             Sex:   F

Service: [**Hospital Unit Name 196**]

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest pain, shortness of breath and increased lower extremity
edema.

Major Surgical or Invasive Procedure:
Cardiac catheterization.

History of Present Illness:
The pt. is a 60 year-old female with multiple medical problems
including right heart failure, obstructive sleep apnea and COPD
who presented with a one day history of progressive shortness of
breath, chest "tightness" and increased lower extremity edema.
As per the pt., the VNA nurses were at her home yesterday and
commented on how her legs appeared more swollen.  In addition,
she stated that she did become somewhat more short of breath
over her baseline yesterday.  She added that she was eventually
unable to take more than 2 or 3 steps without becoming dyspneic.
 This morning, the pt. stated that she also developed a "tight"
feeling in the center of her chest which radiated to her back.
The pain is made worse with deep breathing. She stated that the
pain was a [**5-11**] at its worst.  She also noted [**Month/Year (2) 9140**] dyspnea
and diaphoresis associated with this chest tightness and
occasional episodes of lightheadedness and palpitations.  She
denied nausea or vomiting.  She did admit to increasing lower
extremity edema, PND and orthopnea.
On arrival to the ED, she was noted to be tachycardic with a
heart rate in the 120s.  It was felt that she was in MAT.  She
was given 50mg of IV diltiazem, followed by 30mg po diltiazem
with effect and the pt's. heart rate decreased to the 90's and
was noted to be in sinus rhythm.  Her chest pain resolved with a
nitroglycerin IV drip and 2mg morphine sulfate IV times two.
Her first set of cardiac enzymes were negative.  She had a CXR
performed which showed cardiomegaly and mild CHF.  She received
40mg of IV lasix with a good response, as the pt. became less
dyspneic. She was ordered for a V/Q scan to rule out PE in light
of dyspnea and an elevated Ddimer.
Currently, the pt. complains of minor persistent shortness of
breath.  She added that her chest pain has resolved.

Past Medical History:
-Right heart failure
-Obstructive sleep apnea
-Type II Diabetes Mellitus
-Chronic obstructive pulmonary disease
-Hypertension
-BPPV
-h/o leiomyomata
-chronic venous insufficiency
-depression.

Social History:
Pt lives on a [**Location (un) 10043**] apartment. She denied tobacco use or
illicit drug use.  She drinks one glass of alcohol (usually
wine) once per month.

Family History:
Remarkable for diabetes mellitus in a number of family members.

Sister with breast and ovarian cancer.

Physical Exam:
Vitals: T:97.3F  P: 110 R: 20  BP: 91/58 SaO2: 97% on 3L via NC
General: awake, alert, NAD
HEENT: PERRL, EOMI, MMM, no lesions noted in oropharynx
Neck: supple, JVD to approximately 14-15 cm
Pulmonary: bibasilar rales noted
Cardiac: tachycardic, regular rate, S1S2, II/VI HSM at LUSB
radiating to apex
Abdomen: obese, soft, NT/ND, active BS, no masses appreciated
Extremities: no c/c, chronic venous stasis changes over BLE,
[**3-5**]+ BLE edema.
Neurologic: pt. alert and oriented in all 3 spheres, no focal
deficits noted.
Skin: venous stasis changes over BLE

Pertinent Results:
CXR: remarkable for cardiomegaly, mild CHF

EKG: sinus tachycardia, rate 124, q waves in inferior leads, no
change from previous EKG

[**2176-10-16**] 10:02PM URINE  COLOR-LtAmb APPEAR-SlCldy SP [**Last Name (un) 155**]-1.020
[**2176-10-16**] 10:02PM URINE  BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-MOD
[**2176-10-16**] 10:02PM URINE  RBC-262* WBC-157* BACTERIA-MANY
YEAST-NONE EPI-<1
[**2176-10-16**] 10:02PM URINE  CA OXAL-OCC
[**2176-10-16**] 10:01PM   CK(CPK)-80
[**2176-10-16**] 10:01PM   CK-MB-NotDone cTropnT-0.02*
[**2176-10-16**] 04:40PM   CK(CPK)-71
[**2176-10-16**] 04:40PM   CK-MB-NotDone cTropnT-0.02*
[**2176-10-16**] 10:20AM   GLUCOSE-146* UREA N-26* CREAT-1.6* SODIUM-138
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18
[**2176-10-16**] 10:20AM   CK(CPK)-94
[**2176-10-16**] 10:20AM   cTropnT-<0.01
[**2176-10-16**] 10:20AM   CK-MB-NotDone
[**2176-10-16**] 10:20AM   WBC-7.8 RBC-4.08* HGB-12.5 HCT-38.1 MCV-94
MCH-30.6 MCHC-32.7 RDW-16.2*
[**2176-10-16**] 10:20AM   NEUTS-84.7* LYMPHS-9.4* MONOS-4.8 EOS-0.8
BASOS-0.3
[**2176-10-16**] 10:20AM   HYPOCHROM-1+ ANISOCYT-1+ MACROCYT-1+
[**2176-10-16**] 10:20AM   PLT COUNT-278
[**2176-10-16**] 10:20AM   PT-15.3* PTT-34.4 INR(PT)-1.5
[**2176-10-16**] 10:20AM   D-DIMER-1736*

PATIENT/TEST INFORMATION:
Indication: Congestive heart failure. Pulmonary hypertension.
Height: (in) 61
Weight (lb): 380
BSA (m2): 2.48 m2
BP (mm Hg): 107/69
HR (bpm): 106
Status: Inpatient
Date/Time: [**2176-10-28**] at 13:43
Test: Portable TTE (Complete)
Doppler: Full doppler and color doppler
Contrast: None
Tape Number: 2004W401-0:00
Test Location: West CCU
Technical Quality: Suboptimal




REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
  DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]

MEASUREMENTS:
TR Gradient (+ RA = PASP): *73 mm Hg (nl <= 25 mm Hg)

INTERPRETATION:

Findings:

RIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is dilated.

LEFT VENTRICLE: The left ventricular cavity is unusually small.
Overall left
ventricular systolic function is normal (LVEF>55%).

RIGHT VENTRICLE: The right ventricular cavity is markedly
dilated. Right
ventricular systolic function appears depressed. There is
abnormal septal
motion/position consistent with right ventricular
pressure/volume overload.

AORTIC VALVE: There is no aortic valve stenosis. No aortic
regurgitation is
seen.

MITRAL VALVE: The mitral valve leaflets are moderately
thickened. No mitral
regurgitation is seen.

TRICUSPID VALVE: Moderate to severe [3+] tricuspid regurgitation
is seen.
There is severe pulmonary artery systolic hypertension.

GENERAL COMMENTS: Suboptimal image quality due to poor echo
windows.
Suboptimal image quality due to body habitus.

Conclusions:
The right atrium is dilated. The left ventricular cavity is
unusually small
due to compression from the dilated right ventricle. Overall
left ventricular
systolic function appears normal but focal/regional wall motion
abnormality
cannot be excluded due to suboptimal image quality. The right
ventricular
cavity is markedly dilated. Right ventricular systolic function
appears
depressed. There is abnormal septal motion/position consistent
with right
ventricular pressure/volume overload. There is no aortic valve
stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
moderately
thickened. No mitral regurgitation is seen. Moderate to severe
[3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension.

Compared with the findings of the prior report (tape unavailable
for review)
of [**2176-10-26**] no significant change.





Brief Hospital Course:
1. Atypical chest pain: The pt. had cardiac enzymes which were
negative times three, ruling out an acute myocardial infarction
as cause for her chest pain.  Her nitroglycerin drip was
titrated off by the morning of the second hospital day and she
remained chest-pain free for the remainder of the hospital stay.
 Telemetry showed only sinus tachycardia.

2. CHF:  The pt. appeared to be suffering from an exacerbation
of CHF on admission.  She was aggressively diuresed with IV
lasix with improvement in her shortness of breath and mild
improvement in her lower extremity edema over the first four
hospital days.

A TTE was performed on the third hospital day which revealed the
following:

The left atrium is markedly dilated. The right atrium is
dilated. The left ventricular cavity is unusually small. Overall
left ventricular systolic function is probably preserved. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The right ventricular cavity is
markedly dilated. Right ventricular systolic function appears
depressed. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic
valve leaflets are mildly thickened. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
moderate thickening of the mitral valve chordae. Trivial mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion.

On hospital day number five, the pt. was noted to be very
lethargic and had minimal urine output over the previous night
despite treatment with lasix.  Her blood pressure was noted to
be 80-85 systolic which was a signficant decrease from her
baseline.  On examination, she had very cold extremities.  It
was felt that she was experiencing cardiogenic shock.  She was
transferred to the CCU.  While in the CCU, she was aggressively
diuresed with nesiritide and was noted to have improved
breathing and less peripheral edema over the four day course in
the CCU.  While in the CCU, a cardiac catheterization was
performed.  This showed the following:

Severely elevated right sided filling pressures (mean RA
pressure was 34 mm Hg and RVEDP was 38 mmHg). Severe pulmonary
hypertension was noted (PA pressure was 90/48 mm
Hg). Mildly elevated left sided filling pressures were present
(mean PCW pressure was 20 mm Hg). Severe tricuspid regurgitation
was suggested by prominant ventricular waves on the RA tracing
and catheter fling from the right ventricle throughout the whole
procedure. Cardiac index was low (at 1.7 L.min/m2).

After a four day stay in the CCU, she was transferred back to
the floor on a nesiritide drip.  As the pt. had minimal urine
output on a nesiritide drip alone, a dopamine drip was begun. on
[**10-26**], patient was found to be unresponsive with a rhythym that
was originally thought to be vfib, and the patient was shocked
(EP evaluation of the tele strips at a later time indicated that
the patient seemed to be in afib arrest). She was shocked with
200J x 1--> PEA arrest--> epi x 2--> NSR with BP 120's on
dopamine and natrecor shut off.  Patient was then transferred
back to the CCU. A work up for PEA at the time indicated no
evidence of a tamponade(assessed by using echo) and  started in
heparin drip prohylactically for ?PE, however V?Q scan with low
probability for PE,  Doppler imaging showed no evidence of a
DVT.

On [**10-27**], patient then had a swan ganz catheter under ultrasound
placed. First set of numbers indicated CVP of 34, RV 95/30, PA
95/45 PCWP mean 40, CO/CI 5.3/1.82 with SVR 775.  Patient
continued to be oliguric with a positive fluid status despite
bring placed in nesiritide and lasix.

Patient also had a lower GI bleed (most likely hemoorhoids) and
heparin was dc'ed.

Repeat echo on [**10-28**] showed no significant change from [**10-26**] (see
reports section). Patient continued to have positive fluid
status, therefore, the decision to perform ultrafiltration to
remove excess fluid. on day 2 of UF patient had negative fluid
balance. Patient was also maintained on nestiride. Patient was
continued on amiodarone and digoxin for her afib.  Eventually
patient had decreased platelets and HITs was of a concern,
heparin (used to keep CVVHD from clotting off) was dc'ed and the
CVVHD machine clotted off. UF was not restated.

3. Pulmonary Hypertension: Please refer to the cardiac
catheterization results cited under #2.  It was felt that the
cause of the pulmonary hypertension was likely related to the
combination of obstructive sleep apnea for which the pt. only
intermittently uses her CPAP machine, morbid obesity and
long-standing COPD.  Nevertheless, a workup for causes of
secondary pulmonary hypertension was performed and included
lower extremity duplex doppler ultrasonography which was
negative for DVT, a lung scan which was not suggestive of
pulmonary emboli. The pt. was scheduled for an outpatient sleep
study on [**2176-11-11**]. Severe pulm HTN not reversible with
100% O2.  Non-compliant with CPAP and not candidate for Flolan.
Therefore, nasal CPAP was continued at night, supplemental O2
PRN and MDIs. Throughout the hospital stay pulmonary htn
remained high, and patient was dc'ed home with hospice with a
diagnosis of pulm HTN and CHF

3. COPD:
The pt. was maintained on albuterol and ipratropium nebulizers
for the duration of the hospitalization.

4. DM2:
The pt. was maintained on a sliding scale of regular insulin.
Her fingersticks were noted to be within acceptable ranges.

5. CRF: The pt. was noted to have a baseline creatinine of 1.3
to 1.4.
The etiology is uncertain, but may be related to long-standing
HTN and diabetes mellitus.  Her creatinine was noted to be 1.6
on admission, but slowly rose to a peak of 3.0.  It was felt
that she was suffering from acute on chronic renal failure with
a prerenal etiology secondary to renal hypoperfusion resulting
from severe CHF.  Her serum creatinine responded well once
aggressive diuresis was undertaken beginning in the CCU, however
patient became less responsive to diuresis and BUn and CR  rose
to 77/3.7 on [**10-28**]. CR decreased with UF and rose to 3.7 after UF
was stopped. Patient also developed hyponatremia while on UF and
dialyste was adjusted appropriately

6: ID- patient was also treated for a UTI (urine grew out
Klebsiella sensitive to bactrim) - patient txed with bactrim,
but on fourth day of bactrim ([**10-28**])- noted to have white count
of 17.6, patient pan cultured (blood cultured, sputum cultures),
chest x-ray showed no evidence of pneumonia. Patient received
three days of vanc while final blood cultures were pending- the
final culture indicated 1/2 bottles of coag negative staph, most
likely a contaminant so vanco was stopped.

7: Psych: Patient has an extensive history of physical and
sexual abuse from husband, SW addressed these issues with
patient

8: MSK: on [**10-31**] patient developed wrist pain and was found to
have a wrist fracture with cortical interruption of fifth
metatarsal- wrist was splinted

9: Dispo: once patient had maximal medical therapy with minimal
results, condition was discussed with patient and family. In
according with her wishes, she was made DNR/DNI and CMO and sent
home with hospice care.

Medications on Admission:
-lasix 80mg po bid
-zolpidem 5mg po qhs prn
-albuterol nebs
-lipitor 10mg po once daily
-pantoprazole 40mg po once daily
-atrovent nebs
-meclizine 25mg po bid
-amitryptiline 25mg po qhs
-humalog 75/25 units once daily

Discharge Medications:
1. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day) for 3 months.
Disp:*qS mdi* Refills:*2*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for 3 months.
Disp:*qS mdi* Refills:*2*
4. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QOD (every
other day) for 3 months.
Disp:*45 Tablet(s)* Refills:*0*
6. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 2 months.
Disp:*240 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 2 months.
Disp:*120 Capsule(s)* Refills:*0*
Scripts given for MSIR, Ativan, Scopolamine, and Levsin


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **]

Discharge Diagnosis:
Congestive Heart Failure
Pulmonary Hypertesion, severe
Chronic Obstructive Pulmonary disease
Chronic renal failure
Obstructive sleep apnea
Hypertension

Congestive Heart Failure
Pulmonary Hypertesion, severe
Chronic Obstructive Pulmonary disease
Chronic renal failure
Obstructive sleep apnea
Hypertension


Discharge Condition:
Stable.

Discharge Instructions:
Please follow the instructions given to you by your Hospice
nurse.
Please continue to take all of your prescribed medications.

Followup Instructions:
Please follow the recommendations of hospice care



Completed by:[**2176-11-4**]
{'Congestive heart failure, unspecified,Cardiogenic shock,Cardiac arrest,Chronic airway obstruction, not elsewhere classified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Other chronic pulmonary heart diseases,Unspecified sleep apnea,Morbid obesity,Unspecified hemorrhoids with other complication,Other diseases of pharynx, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Closed fracture of other bone of wrist,Unspecified accident'}


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: pulmonary htn

PRESENT ILLNESS: see previous summary

MEDICAL HISTORY: -Right heart failure
-Obstructive sleep apnea
-Type II Diabetes Mellitus
-Chronic obstructive pulmonary disease
-Hypertension
-BPPV
-h/o leiomyomata
-chronic venous insufficiency
-depression.

MEDICATION ON ADMISSION: -lasix 80mg po bid
-zolpidem 5mg po qhs prn
-albuterol nebs
-lipitor 10mg po once daily
-pantoprazole 40mg po once daily
-atrovent nebs
-meclizine 25mg po bid
-amitryptiline 25mg po qhs
-humalog 75/25 units once daily

ALLERGIES: Penicillins

PHYSICAL EXAM: see previous dc summary

FAMILY HISTORY: Remarkable for diabetes mellitus in a number of family members.

SOCIAL HISTORY: Pt lives on a [**Location (un) **] apartment. She denied tobacco use or
illicit drug use.  She drinks one glass of alcohol (usually
wine) once per month. 

### Response:
{'Congestive heart failure, unspecified,Cardiogenic shock,Cardiac arrest,Chronic airway obstruction, not elsewhere classified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Other chronic pulmonary heart diseases,Unspecified sleep apnea,Morbid obesity,Unspecified hemorrhoids with other complication,Other diseases of pharynx, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Closed fracture of other bone of wrist,Unspecified accident'}
