CHIEF COMPLAINT: Pericardial effusion

PRESENT ILLNESS: 79 yo female with h/o COPD on home O2, HTN, HLP, DM,
osteoporosis, morbid obesity who presented to an OSH with
worsening SOB.  She had been treated with Z-pack without
benefit.  She continued to have worsening SOB throughout her
admission there.  She had an echocardiogram initially which
showed a pericardial effusion, which was fairly small without
any evidence of tamponade physiology, but she then had a repeat
echo cardiogram on [**11-5**] with which showed a large anterior and
posterior pericardial effusion which measured 17 mm in diastole
and 21 mm in systole.  She was then transferred for further
evaluation and potential pericardiocentesis.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
COPD on home O2
Diverticulitis
Morbid Obesity
Hypothyroidism
Chronic LBP
Chronic Headaches
Glaucoma

MEDICATION ON ADMISSION: MEDICATIONS AT HOME:
Lasix 40 mg daily
Antivert 25 mg TID
Lipitor 10 mg daily
Prilosec 20 mg daily
Synthroid 125 mcg daily
Xalatan 0.005% each eye qhs
Advair diskus 500/50 mcg [**Hospital1 **]
Nasonex 1 squirt in each nose [**Hospital1 **]
Avandamet 25/250 mg [**Hospital1 **]
Albuterol 2.5 mg q2H nebulized PRN
Claritin 10 mg QHS
Fosamax 70 mg daily
Hydroxyzine

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: VS: T=97.9  BP=132/94 HR=70 RR=16  O2 sat=100% on 2L
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No family history of early MI, otherwise non-contributory.

SOCIAL HISTORY: The patient is retired; used to work in a stitching factory;
lives alone.
-Tobacco history: [**11-23**] ppd x 10 yrs  Quit smoking:  quit 30 yrs
ago
-ETOH:  none
-Illicit drugs:  none
Unspecified disease of pericardium,Acute systolic heart failure,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Morbid obesity,Unspecified acquired hypothyroidism
Pericardial disease NOS,Ac systolic hrt failure,Chr airway obstruct NEC,Hypertension NOS,DMII wo cmp nt st uncntr,Hyperlipidemia NEC/NOS,Morbid obesity,Hypothyroidism NOS
Admission Date:  [**2136-11-7**]              Discharge Date:   [**2136-11-10**]

Date of Birth:  [**2057-1-28**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
Pericardial effusion

Major Surgical or Invasive Procedure:
Drainage of a pericardial effusion


History of Present Illness:
79 yo female with h/o COPD on home O2, HTN, HLP, DM,
osteoporosis, morbid obesity who presented to an OSH with
worsening SOB.  She had been treated with Z-pack without
benefit.  She continued to have worsening SOB throughout her
admission there.  She had an echocardiogram initially which
showed a pericardial effusion, which was fairly small without
any evidence of tamponade physiology, but she then had a repeat
echo cardiogram on [**11-5**] with which showed a large anterior and
posterior pericardial effusion which measured 17 mm in diastole
and 21 mm in systole.  She was then transferred for further
evaluation and potential pericardiocentesis.

On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.

Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.

Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
COPD on home O2
Diverticulitis
Morbid Obesity
Hypothyroidism
Chronic LBP
Chronic Headaches
Glaucoma

Social History:
The patient is retired; used to work in a stitching factory;
lives alone.
-Tobacco history: [**11-23**] ppd x 10 yrs  Quit smoking:  quit 30 yrs
ago
-ETOH:  none
-Illicit drugs:  none


Family History:
No family history of early MI, otherwise non-contributory.

Physical Exam:
VS: T=97.9  BP=132/94 HR=70 RR=16  O2 sat=100% on 2L
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. few bibasilar crackles
with a scattered expiratory wheezes throughout lung fields.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c. 2+ BLE edema [**11-23**] to knees. No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 2+


Pertinent Results:
Admission labs:
[**2136-11-8**] 03:43AM BLOOD WBC-17.3* RBC-4.11* Hgb-11.4* Hct-33.7*
MCV-82 MCH-27.6 MCHC-33.7 RDW-14.4 Plt Ct-300
[**2136-11-8**] 03:43AM BLOOD Neuts-79.5* Lymphs-11.2* Monos-8.9
Eos-0.4 Baso-0
[**2136-11-8**] 03:43AM BLOOD PT-12.2 PTT-23.9 INR(PT)-1.0
[**2136-11-8**] 03:43AM BLOOD Glucose-86 UreaN-31* Creat-0.8 Na-137
K-4.3 Cl-98 HCO3-32 AnGap-11
[**2136-11-8**] 03:43AM BLOOD ALT-42* AST-14 LD(LDH)-224 CK(CPK)-27
AlkPhos-67 TotBili-0.7
[**2136-11-8**] 03:43AM BLOOD Albumin-4.0 Calcium-9.2 Phos-4.6* Mg-2.5
[**2136-11-8**] 03:43AM BLOOD TSH-5.2*
[**2136-11-9**] 05:30AM BLOOD Free T4-1.5

Discharge labs:
[**2136-11-10**] 07:35AM BLOOD WBC-11.5* RBC-4.05* Hgb-11.6* Hct-33.8*
MCV-83 MCH-28.6 MCHC-34.3 RDW-14.3 Plt Ct-237
[**2136-11-10**] 07:35AM BLOOD PT-12.5 PTT-23.7 INR(PT)-1.1
[**2136-11-10**] 07:35AM BLOOD Glucose-115* UreaN-18 Creat-0.7 Na-138
K-5.3* Cl-100 HCO3-33* AnGap-10
[**2136-11-10**] 07:35AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.3

[**11-8**] Pericardial fluid:
   GRAM STAIN (Final [**2136-11-8**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Preliminary):    NO GROWTH.

   ANAEROBIC CULTURE (Preliminary):    NO GROWTH.

   ACID FAST SMEAR (Final [**2136-11-9**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

   ACID FAST CULTURE (Preliminary):

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

[**11-8**] pericardial fluid cytology: Pending

[**11-8**] pericardial fluid
OTHER BODY FLUID ANALYSIS WBC   Hct,Fl Polys Lymphs Monos
[**2136-11-8**] 02:30PM      889*1   21*2   48*3   44*   8*
PERICARDIAL FLUID

BLOODY, SUPERNATANT MODERATELY XANTHOCHROMIC
SPUN HCT
SPUN HEMATOCRIT PERFORMED
50 CELL DIFFERENTIAL

OTHER BODY FLUID CHEMISTRY TotProt Glucose Amylase Albumin
[**2136-11-8**] 02:30PM         4.4      127      26     3.1

STUDIES
EKG: NSR HR approx 70, left shift axis; slightly decreased
voltage on precordial leads, and possibly alternans in
precordial leads

2D-ECHOCARDIOGRAM: [**2136-11-5**]
1) RV systolic function is decreased
2) A large anterior and posterior pericardial effusion is
present, posteriorly measuring 17 mm in diastole and 21 mm in
systole.

TTE [**11-8**]: The left atrium is mildly dilated. The estimated
right atrial pressure is 10-20mmHg. Overall left ventricular
systolic function is 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. The estimated pulmonary artery systolic pressure is
normal. There is a large circumferential pericardial effusion
with a small layer (0.9 cm) echo dense material on the right
ventricle consistent with blood, inflammation or other cellular
elements. No right ventricular diastolic collapse is seen. There
is brief right atrial diastolic collapse. The heart swings with
each cardiac cycle and the anterior echolucent pericardial
effusion varied between 2 cm and 0 cm. Apically, the effusion
varied between 2.1 cm and 0.8 cm.
IMPRESSION: Large circumferencial pericardial effusion with no
clear evidence of tamponade. There is significant cardiac motion
with variable local pericardial effusion size between cardiac
cycles.

Cath [**11-8**]: COMMENTS:
1. Resting hemodynamics revealed elevated right sided pressures
and
equalization of of RA, PCW and pericardial pressures consistent
with
tamponade.
2. Subxiphoid pericardiocentesis removed 820 cc of bloody fluid.

Pericardial pressure fell to 2 mmHg with RA pressure of 8 mmHg.
Fluid
was sent for cytology, culture, and chemistries. Echo confirmed
pericardial effusion was now only small post-pericardiocentesis.


FINAL DIAGNOSIS:
1. Large pericardial effsusion with tamponade physiology.
2. Successful pericardiocentesis with removal of 820 cc of
fluid.

Repeat TTE [**11-8**]:There is a small pericardial effusion (mostly
posterior to the LV).
Compared with the prior study (images reviewed) of [**2136-11-8**],
the amount of pericardial effusion has significantly decreased.


TTE [**11-9**]: Overall left ventricular systolic function is normal
(LVEF>55%). with normal free wall contractility. There is a
small pericardial effusion. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
IMPRESSION: Very small residual echodense pericardial effusion.
Compared with the prior study (images reviewed) of [**2136-11-8**],
pericardial effusion size has further decreased.

TTE [**11-10**]: Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). There is
abnormal septal motion/position. The mitral valve leaflets are
mildly thickened. There is a small pericardial effusion. There
are no echocardiographic signs of tamponade.
IMPRESSION: Small pericardial effusion, located posterior to the
right atrium without evidence of tamponade. There is a septal
bounce seen which could be consistent with effusive-constrictive
pericardial disease.
Compared with the prior study (images reviewed) of [**2136-11-9**],
the size of the effusion is similar. The septal bounce may be
slightly more prominent.


Brief Hospital Course:
79 yo F with COPD, DM, HTN, hyperlipidemia, who was transferred
from an OSH for worsening SOB found to have a large pericardial
effusion with tamponade physiology on ECHO no s/p drainage.

# PERICARDIAL EFFUSION: The patient was admitted to the outside
hospital with increasing shortness of breath over weeks and was
found to have an increasing pericardial effusion with tamponade
physiology.  She underwent pericardiocentesis during which 800
cc of bloody fluid was removed.  The main differential for her
effusion includes malignancy, TB, post viral, autoimmune,
infectious.  A TSH was checked and was slightly elevated at 5.2,
however her free T4 was normal at 1.5.  Her fluid cultures have
been no growth to date and fluid cytology is pending.
Malignancy is highly possible given her age and size of
effusion.  She remained hemodynamically stable during her
admission.  She had several echos after drainage which showed no
reaccumulation of fluid.  She will continue to undergo workup
for this as an outpatient with her cardiologist.

# CORONARIES: The patient has no known history of coronary
artery disease.  She was transferred on a B-blocker from the
OSH, however she was not on one at home.  This was stopped given
the concern for tamponade physiology and was not restarted.  She
was started on 81 mg of ASA daily for primary prevention given
her history of DM and hypertension.  She was continued on her
home statin.

# Acute systolic heart faliure: The patient had slight edema on
exam on admission and was thought to be in acute systolic heart
failure secondary to the pericardial effusion/tamponade
physiology.  She was treated initally with 40 mg IV lasix and
then changed back to her home dose of lasix 40 mg po daily.  Her
EF normalized on TTE after drainage of the effusion.

# RHYTHM:  The patient remain in normal sinus rhythm during her
hospitalization.

# COPD: The patient had been treated for a COPD exacerbation at
the OSH, however her SOB was likely due to the pericardial
effusion and resolved once it was drained.  She was continued on
her home medications including advair [**Hospital1 **], flonase, and
albuterol prn.  She was also treated with atrovent while she was
hospitalized, but was not discharge on this.  She had been
treated with prednisone at the OSH, so this was quickly tapered
and she will complete the taper the day after discharge.

# DM: The patient takes avandamet as an outpatient, however this
was held during her hospitalization.  She was initally covered
with sliding scale insulin, however her sugars were elevated so
she was given a small dose of lantus in addition to the sliding
scale.  She was discharged back on her home regimen of
avandamet.

# HTN: She was generally normotensive while hospitalized and was
intially given IV lasix for diuresis, but then was continued on
her home dose of 40 mg po lasix daily.

# Hyperlipidemia: The patient was continued on her home statin.

# Hypothyroidism: The patient was continued on her home
levothyroxine.

Medications on Admission:
MEDICATIONS AT HOME:
Lasix 40 mg daily
Antivert 25 mg TID
Lipitor 10 mg daily
Prilosec 20 mg daily
Synthroid 125 mcg daily
Xalatan 0.005% each eye qhs
Advair diskus 500/50 mcg [**Hospital1 **]
Nasonex 1 squirt in each nose [**Hospital1 **]
Avandamet 25/250 mg [**Hospital1 **]
Albuterol 2.5 mg q2H nebulized PRN
Claritin 10 mg QHS
Fosamax 70 mg daily
Hydroxyzine

MEDICATIONS AT TRANSFER:
Prednisone 50 mg daily - taper
Metoprolol tartrate 12.5 mg [**Hospital1 **]
Synthroid 125 mcg daily
Prevacid 30 mg [**Hospital1 **]
Nystatin powder daily
Lasix 40 mg daily
Lipitor 10 mg daily
Xalatan 0.005% QHS each eye
Nasonex [**Hospital1 **]
Claritin 10 mg daily
Heparin sc
Tylenol PRN
Lorazepam 0.5 mg Q6H PRN
Antivert 25 mg PO Q6H PRN dizziness

Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Meclizine 25 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for dizziness.
3. Psyllium     Packet Sig: One (1) Packet PO DAILY (Daily).
4. Claritin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Synthroid 125 mcg Tablet Sig: One (1) Tablet PO once a day.
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
11. AVANDAMET  Oral
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
13. Fosamax 70 mg Tablet Oral
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for
1 days.
Disp:*1 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
All Care VNA of Greater [**Location (un) **]

Discharge Diagnosis:
Primary -
Pericardial effusion

Secondary -
Hypertension
Diabetes
Hypothyroidism
Chronic obstructive pulmonary disease
Hyperlipidemia


Discharge Condition:
Hemodynamically stable, without shortness of breath.


Discharge Instructions:
You were transferred to this hospital becuase you had a large
pericardial effusion.  You underwent a pericardiocentesis
(drainage of the fluid around your heart).  It is unclear what
caused the pericardial effusion, however tests on the fluid are
pending.  You may need to undergo further tests and imaging
studies as an outpatient to figure out the cause of the
effusion.  You were also treated for an exacerbation of your
chronic obstructive pulmonary disease prior to transfer to this
hospital.  You will need to take one more day of prednisone to
complete treatment for this exacerbation.

You were started on aspirin 81 mg daily.  You will need to take
10 mg of prednisone the day after discharge.  Otherwise continue
your outpatient medications as prescribed.

Go to the emergency room or call your primary docotor if you
experience fevers, chills, chest pain, shortness of breath,
dizziness, blood in your stool, or black stool.

Followup Instructions:
You will need to follow up with Dr. [**Last Name (STitle) **] in [**11-23**] weeks.  His
office number is [**0-0-**].  Please call and make an
appointment on Monday.  It is very improtant that you follow up
with him in this time frame.

You should also follow up with your primary doctor within in the
next month.



Completed by:[**2136-11-10**]
{'Unspecified disease of pericardium,Acute systolic heart failure,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Morbid obesity,Unspecified acquired hypothyroidism'}


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: Pericardial effusion

PRESENT ILLNESS: 79 yo female with h/o COPD on home O2, HTN, HLP, DM,
osteoporosis, morbid obesity who presented to an OSH with
worsening SOB.  She had been treated with Z-pack without
benefit.  She continued to have worsening SOB throughout her
admission there.  She had an echocardiogram initially which
showed a pericardial effusion, which was fairly small without
any evidence of tamponade physiology, but she then had a repeat
echo cardiogram on [**11-5**] with which showed a large anterior and
posterior pericardial effusion which measured 17 mm in diastole
and 21 mm in systole.  She was then transferred for further
evaluation and potential pericardiocentesis.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
COPD on home O2
Diverticulitis
Morbid Obesity
Hypothyroidism
Chronic LBP
Chronic Headaches
Glaucoma

MEDICATION ON ADMISSION: MEDICATIONS AT HOME:
Lasix 40 mg daily
Antivert 25 mg TID
Lipitor 10 mg daily
Prilosec 20 mg daily
Synthroid 125 mcg daily
Xalatan 0.005% each eye qhs
Advair diskus 500/50 mcg [**Hospital1 **]
Nasonex 1 squirt in each nose [**Hospital1 **]
Avandamet 25/250 mg [**Hospital1 **]
Albuterol 2.5 mg q2H nebulized PRN
Claritin 10 mg QHS
Fosamax 70 mg daily
Hydroxyzine

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: VS: T=97.9  BP=132/94 HR=70 RR=16  O2 sat=100% on 2L
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No family history of early MI, otherwise non-contributory.

SOCIAL HISTORY: The patient is retired; used to work in a stitching factory;
lives alone.
-Tobacco history: [**11-23**] ppd x 10 yrs  Quit smoking:  quit 30 yrs
ago
-ETOH:  none
-Illicit drugs:  none 

### Response:
{'Unspecified disease of pericardium,Acute systolic heart failure,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Morbid obesity,Unspecified acquired hypothyroidism'}
