CHIEF COMPLAINT: Lower extremity swelling

PRESENT ILLNESS: [**Age over 90 **] year old female with asthma, atrial fibrillation on
Dabigatran and s/p dual-chamber (RA-RV) PPM in [**5-31**],
hypertension, and heart failure with preserved EF (EF 55% on
[**2119-6-28**] TTE but normal E wave, low deceleration time 133 msec)
and moderate pulmonary hypertension by TTE (TR Gradient + RA =
PASP: 44 mm Hg) who presented to the ED with lower extremity
edema. She reported considerable problems with lower extremity
edema over the weeks preceding admission with an approximately
12-lb weight gain and [**2-23**] pillow orthopnea. She further reported
dyspnea on exertion but not at rest. She has also had two
admissions within the last six weeks for AF with RVR. She had
been doing reasonably well despite persistent lower extremity
edema until the day prior to admision when she tripped and was
unable to get herself off the floor for a few hours due to
weakness.

MEDICAL HISTORY: -Coronary artery disease
-Paroxysmal atrial fibrillation on dabigatran with dual-chamber
PPM (RA/RV)
-Hypertension
-Hyperlipidemia
-Mild Aortic insufficiency
-Chronic kidney disease (stage III)
-Asthma
-Osteopenia
-Diverticulosis
-Gallstones
-Cataracts
-Internal hemorrhoids
-Allergic rhinitis
-Impaired glucose tolerance
-Breast cancer s/p RIND '[**94**]
-sp TABHSO for dysfunctional bleeding

MEDICATION ON ADMISSION: 1. Dabigatran etexilate 75 mg PO twice a day.
2. Simvastatin 20 mg PO DAILY
3. Vitamin D 50,000 unit PO once a month.
4. Travoprost Z 0.004 % Drops : One ophthalmic at bedtime.
5. Psyllium powder once a day.
6. Furosemide 80 mg QAM, 40 mg QPM DAILY
7. Amiodarone 200 mg TID
8. Metoprolol succinate 100 mg PO daily
9. Acetaminophen 650 mg PO every six hours as needed for pain

ALLERGIES: Amoxicillin / Verapamil / Univasc

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T 98, P 76, BP 90/51, RR 18
General: Mildly uncomfortable appearing female in NAD
HEENT: atraumatic, normocephalic, MMM, OP clear
Neck: supple, JVP not able to be assessed due to right sided CVL
with some surrounding blood
Lungs: Bilateral expiratory wheezes, mild respiratory distress
on speaking
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound, tenderness or guarding, no organomegaly
GU: Foley
Ext: warm, well perfused, 3+ edema in lower extremities to knee
bilaterally, left lower extremity with 4*4 area of ecchymoses
followed by nontender, slightly indurated red area that is
nontender

FAMILY HISTORY: Mother died from a myocardial infarction at 65 y/o but had T2DM,
PVD, and CHF. Father had Hodgkin's disease and laryngeal
carcinoma. Brother died from pancreatic cancer. Sister has CAD
c/b by MI x2 s/p PCI.

SOCIAL HISTORY: Retired book-keeper at a diamond merchant. She lives with her
sister, who is 14 years younger. Mobilizes with cane, exercise
tolerance 25 meters. Smoking/Tobacco: Never smoked. EtOH: none.
Illicits: none.
Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Acidosis,Paroxysmal supraventricular tachycardia,Hypotension, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Asthma, unspecified type, unspecified,Other chronic pulmonary heart diseases,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Leukocytosis, unspecified,Personal history of malignant neoplasm of breast,Cardiac pacemaker in situ
Ac on chr diast hrt fail,Pneumonia, organism NOS,Acute kidney failure NOS,Acidosis,Parox atrial tachycardia,Hypotension NOS,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Asthma NOS,Chr pulmon heart dis NEC,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Leukocytosis NOS,Hx of breast malignancy,Status cardiac pacemaker
Admission Date:  [**2119-6-26**]              Discharge Date:   [**2119-7-17**]


Service: MEDICINE

Allergies:
Amoxicillin / Verapamil / Univasc

Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Lower extremity swelling


Major Surgical or Invasive Procedure:
Right internal jugular line placement with replacment over a
guidewire
PICC line placement

History of Present Illness:
[**Age over 90 **] year old female with asthma, atrial fibrillation on
Dabigatran and s/p dual-chamber (RA-RV) PPM in [**5-31**],
hypertension, and heart failure with preserved EF (EF 55% on
[**2119-6-28**] TTE but normal E wave, low deceleration time 133 msec)
and moderate pulmonary hypertension by TTE (TR Gradient + RA =
PASP: 44 mm Hg) who presented to the ED with lower extremity
edema. She reported considerable problems with lower extremity
edema over the weeks preceding admission with an approximately
12-lb weight gain and [**2-23**] pillow orthopnea. She further reported
dyspnea on exertion but not at rest. She has also had two
admissions within the last six weeks for AF with RVR. She had
been doing reasonably well despite persistent lower extremity
edema until the day prior to admision when she tripped and was
unable to get herself off the floor for a few hours due to
weakness.

She denies having any shortness of breath, chest pain, dyspnea
on exertion or palpitations in association with this.  She
denies striking her head. Her grandson eventually was able to
help her to her feet and she seemed well without confusion so no
additional assistance was pursued at that time. She did report
three days of persistent cough, intermittently productive of
whitish sputum but denied any fevers. The morning after her fall
(the morning of admission), her family decided to bring her in
for further evaluation given her persistent cough and leg
swelling.

Past Medical History:
-Coronary artery disease
-Paroxysmal atrial fibrillation on dabigatran with dual-chamber
PPM (RA/RV)
-Hypertension
-Hyperlipidemia
-Mild Aortic insufficiency
-Chronic kidney disease (stage III)
-Asthma
-Osteopenia
-Diverticulosis
-Gallstones
-Cataracts
-Internal hemorrhoids
-Allergic rhinitis
-Impaired glucose tolerance
-Breast cancer s/p RIND '[**94**]
-sp TABHSO for dysfunctional bleeding

Social History:
Retired book-keeper at a diamond merchant. She lives with her
sister, who is 14 years younger. Mobilizes with cane, exercise
tolerance 25 meters. Smoking/Tobacco: Never smoked. EtOH: none.
Illicits: none.


Family History:
Mother died from a myocardial infarction at 65 y/o but had T2DM,
PVD, and CHF. Father had Hodgkin's disease and laryngeal
carcinoma. Brother died from pancreatic cancer. Sister has CAD
c/b by MI x2 s/p PCI.

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98, P 76, BP 90/51, RR 18
General: Mildly uncomfortable appearing female in NAD
HEENT: atraumatic, normocephalic, MMM, OP clear
Neck: supple, JVP not able to be assessed due to right sided CVL
with some surrounding blood
Lungs: Bilateral expiratory wheezes, mild respiratory distress
on speaking
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound, tenderness or guarding, no organomegaly
GU: Foley
Ext: warm, well perfused, 3+ edema in lower extremities to knee
bilaterally, left lower extremity with 4*4 area of ecchymoses
followed by nontender, slightly indurated red area that is
nontender

DISCHARGE PHYSICAL EXAM:
Gen: alert and resting in bed, pleasant, oriented x 4, NAD
CV: RRR (AV paced) with audible S1/S2, no murmurs or S3
Pulm: poor ae bilaterally due to kyphosis but clear without
rales or wheezes
Abd: soft, NT, ND
GU: no dysuria, no foley
Ext: 2+ radial pulses, 1+ DP pulses bilateral.  1+ bilateral
pitting edema in legs with L stasis dermatitis on the shin
Skin: dry skin throughout, worse on trunck and face with
flaking.  Left lower back with 7x4 cm erythematous patch--non
raised, no tenderness or pruritis

Pertinent Results:
Admission Labs:
[**2119-6-26**] 12:30PM BLOOD WBC-13.4* RBC-4.10* Hgb-11.5* Hct-34.0*
MCV-83 MCH-28.1 MCHC-33.9 RDW-16.0* Plt Ct-265
[**2119-6-26**] 12:30PM BLOOD Neuts-83.8* Lymphs-10.9* Monos-4.5
Eos-0.6 Baso-0.2
[**2119-6-26**] 07:13PM BLOOD PT-32.9* PTT-83.2* INR(PT)-3.3*
[**2119-6-26**] 12:30PM BLOOD Glucose-107* UreaN-59* Creat-2.1* Na-130*
K-4.3 Cl-86* HCO3-28 AnGap-20
[**2119-6-26**] 08:15PM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1
.
Cardiac Labs:
[**2119-6-26**] 12:30PM BLOOD CK-MB-7 cTropnT-0.02* proBNP-8710*
[**2119-6-27**] 01:53AM BLOOD CK-MB-5 cTropnT-0.02*
[**2119-7-3**] 03:21AM BLOOD proBNP-[**Numeric Identifier 106093**]*
[**2119-7-9**] 06:30AM BLOOD proBNP-5233*
.
Thyroid Studies:
[**2119-7-10**] 07:00AM BLOOD TSH-6.9*
[**2119-7-11**] 04:15AM BLOOD T3-56* Free T4-1.3
.
EKGs:
1. [**2119-6-26**]: Ventricular paced rhythm with a seven-beat run of an
irregular intrinsic wide complex rhythm of uncertain mechanism
but may be atrial fibrillation. Intermittent atrial pacer
activity also appears to be present. Clinical correlation is
suggested. Since the previous tracing of [**2119-5-27**] uniform atrial
pacing has been replaced by rhythm as outlined.
2. [**2119-7-11**]: Atrial paced rhythm. Left ventricular hypertrophy.
Diffuse ST-T wave abnormalities are non-specific but cannot
exclude myocardial ischemia. Clinical correlation is suggested.
Since the previous tracing of [**2119-6-26**] atrial pacing is now
present throughout and ventricular pacing is not seen.
.
Tib/Fib XRay ([**2119-6-26**]):  No acute fracture or dislocation in
either tibia or fibula.
.
Right Shoulder XRay ([**2119-6-26**]): No acute fracture or dislocation.
Findings suggestive of underlying rotator cuff disease.
.
Relevant CXR:
1. [**2119-6-26**]: Mild congestive heart failure with small bilateral
pleural effusions. Opacities within the lung bases may represent
atelectasis but infection or aspiration cannot be excluded.
2. [**2119-6-27**]: Bilateral pleural effusions blunt the pleural sinuses
and obliterate the diaphragmatic contours. They also conceal
major portions of the cardiac silhouette which undoubtedly
represents marked cardiac enlargement. The pulmonary vasculature
is congested with perivascular haze and hazy peripheral
densities in the mid lung field which have now increased in
comparison with the last study and suggest development of
pulmonary edema. No pneumothorax has developed. There is no
evidence of central airway occlusion and occlusion atelectasis
related to mucus airway plugging. Comparison is made with
multiple chest examinations obtained during the last week and
they disclose findings consistent with CHF, continues
progression of pulmonary congestion.
3. [**2119-7-5**]: There is no pulmonary edema or appreciable pulmonary
vascular engorgement.  Bilateral pleural effusions,
moderate-to-large on the right and moderate on the left are
stable, obscuring cardiac silhouette, which is probably enlarged
but not changed in the interim. Right PIC line can be traced to
the upper right atrium. No pneumothorax.
.
TTE ([**2119-6-28**]):
Suboptimal image quality. The left atrium is moderately dilated.
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). There is
no ventricular septal defect. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-22**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2119-5-9**], the estimated PA systolic
pressure is lower.
.
TTE ([**2119-7-11**]):
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal.  IMPRESSION: Mild symmetric left ventricular hypertrophy
with normal global and regional biventricular systolic function.
Mild aortic and mitral regurgitation. Compared with the prior
study (images reviewed) of [**2119-6-28**], severity of tricuspid
regurgitation and degree of pulmonary hypertension have both
decreased.
.
Discharge Labs:
Creatinine 1.9
Potassium 4.7
Sodium 140

Brief Hospital Course:
[**Age over 90 **] y/o female with CAD, atrial fibrillation c/b tachy-brady
syndrome s/p PPM placement, CKD, asthma and heart failure with
preserved EF, who presented with cough, lower extremity edema
and hypotension. Patient was initially treated with
Norepinephrine for hypotension and diuresed on a Lasix drip,
with a loss of approximately 12 pounds. Chest radiography
revealed a possible infiltrate and the patient received 8 days
of antibiotics for a health-care associated pneumonia
(Vancomycin plus Zosyn, which was switched to Cefepime, and,
finally, Levofloxacin to complete the course). No definitive
cause of her initial hypotension was identified, though
interrogation of pacemaker early in her hospitalization revealed
several prolonged episodes of atrial tachycardia (one lasting
approximately 50 hours).  Such episodes may have lead to a loss
of atrial kick with subsequent drop in cardiac output. Though
she was treated for an infection, the ICU team did not feel that
septic physiology was to blame for her presentation. Serum AM
cortisol of 26.4 argued against adrenal insufficiency. TSH was
elevated but did not indicate significant hypothyroidism (see
discussion below).

The patient was subsequently transfered to the inpatient
cardiology service to continue care for her hypotension and
acute on chronic kidney disease. Diuresis had been held for 48
hours prior to transfer. Diuresis was intermittently continued
on the cardiology service with little improvement in her
peripheral edema. Patient developed a persistent metabolic
alkalosis and her serum creatinine remained elevated at
approximately 2, up from a baseline of 1.5, which was concerning
for overdiuresis. Urine lytes were not helpful in assessing for
intravascular volume depletion (FEUrea ~ 43%, UNa 33). A TTE did
not reveal evidence of worsening cardiac function or valvular
disease but did reveal a near-normalization of pulmonary artery
pressures as well as loss of a TR gradient, which fit with a
clinical picture of overdiuresis. A diuretic regimen of
torsemide 20 mg PO daily was eventually restarted and patient
was discharged on this regimen.

Other Issues by Problem:

1. Atrial Fibrillation c/b Tachy-Brady Syndrome: Patient had
dual-chamber (RA/RV) [**Company 1543**] pacemaker placed on [**2119-5-26**] for
Tachy-Brady Syndrome. Pacemaker interrogation on admission
revealed frequent and prolonged episodes of atrial fibrillation.
Patient was continued on her Dabigatran throughout admission.
Her Amiodarone was dose reduced from 200 mg PO TID to 200 mg PO
daily as review of records indicated that she may have received
a load as high as 25 grams. She will need to take 200 mg
amiodarone daily for 10 days, then dose reduce to 100 mg daily
for maintenance.  Metoprolol required dose reduction due to
hypotension and at discharge was prescribed as metoprolol
succinate (Toprol XL) 25 mg PO daily.  Patient was continued on
dabigatran at the time of discharge.

2. Acute on Chronic Kidney Disease: Baseline creatinine in
recent months was ~ 1.5. Her serum creatinine peaked at
approximately 2. Urine lytes did not help in differentiating the
etiology (FEUrea ~ 43%, UNa 33) but other data suggested
overdiuresis.  On discharge her Cr stabilzed in the range of
1.8-1.9 after several days of regular diet with oral fluids and
torsemide 20 mg PO daily to maintain treatment of lower
extremity edema.

3. Left Lower Extremity Erythema: Patient was treated for
cellulitis during a recent admission in [**5-1**]. At that time a
LLE US was without evidence of DVT to explain the asymmetry
between the LLE and RLE. She was evaluated for fracture in the
ED but imaging was negative. Her erythema gradually improved
throughout the hospitalization and at the time of discharge
looked like the chronic changes of stasis dermatitis.

4. Leukocytosis: Patient presented with WBC count of 13.4 with
neutrophil predominance though no bands or atypicals. WBCs
intermittently as high as 19.2. Blood cultures negative on
admission. UA negative on admission (no urine culture
performed). Cough and CXR suggestive of consoliation concerning
for HCAP, for which she received 8 days of appropriate
antibiotics.  C. difficile toxin negative by EIA once. Patient
remained afebrile following transfer to the cardiology service.
Her leukocytosis resolved prior to discharge. Ultimately, it was
likely due to possible infection or stress response.

5. Metabolic Alkalosis: Patient developed elevated serum
bicarbonate (peak of 45) in setting of diuresis. She received
three days of Acetazolamide while diuresis was pursued. Her
serum bicarbonate at discharge was normalized.  This was likely
due to volume contraction/overdiuresis.

6. Abnormal Thyroid Function Tests: Baseline TSH 1.5 prior to
initiation of Amiodarone. TSH on [**2119-7-10**] is 6.9. Elevated TSH
may reflect a consequence of significant iodine load from
Amiodarone though it is difficult to interpret in the setting of
an acute illness. T4 is within normal limits and T3 is reduced
which is more consistent with a sick euthyroid state in the
setting of an ICU stay. No treatment was initiated in the acute
setting, especially as TSH < 10, but TFTs should be closely
monitored following discharge.

7. Asthma: Patient initially managed with Levalbuterol however
was transitioned to salmeterol given concern for worsening
tachycardia and compromising hemodynamics.

8. Normocytic Anemia: Hematocrit 34 on admission and remained
stable in the low 30s.

9. Hyperglycemia/Impaired Glucose Tolerance: Patient was
maintained on a Humalog insulin sliding scale for hyperglycemic
correction though only required this very infrequently and did
not need to be continued at discharge.

10. Right Shoulder Pain: In ED patient complained of right
shoulder pain in the setting of a recent fall. Shoulder xray
revealed no fracture but did indicate chronic rotator cuff
disease.

Transition Issues:
1. Close monitoring of thyroid function tests as above
2. Close monitoring of creatinine and BUN as above.  D/C Cr 1.9
3. Close monitoring of symptoms of diastolic heart failure.  See
D/C physical exam.
4. Daily standing weight, if greater than 3lbs change, call Dr.
[**Last Name (STitle) **].

Ppx: The patient was maintained on SQ heparin throughout the
hospital course
Code status: Full code
Contact: [**Name (NI) **] (sister), H:[**Telephone/Fax (1) 106094**], C:[**Telephone/Fax (1) 106095**]
Lines: none
Access issues: difficult but possible with peripheral sticks
Dispo: extended stay rehab facility


Medications on Admission:
1. Dabigatran etexilate 75 mg PO twice a day.
2. Simvastatin 20 mg PO DAILY
3. Vitamin D 50,000 unit PO once a month.
4. Travoprost Z 0.004 % Drops : One ophthalmic at bedtime.
5. Psyllium powder once a day.
6. Furosemide 80 mg QAM, 40 mg QPM DAILY
7. Amiodarone 200 mg TID
8. Metoprolol succinate 100 mg PO daily
9. Acetaminophen 650 mg PO every six hours as needed for pain

Discharge Medications:
1. dabigatran etexilate 75 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*30 Capsule(s)* Refills:*2*
2. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
month.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for CHF: Hold for SBP < 95.
Disp:*30 Tablet(s)* Refills:*1*
8. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*50 ML(s)* Refills:*2*
9. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours): Inhale once in the
morning and once at night.
Disp:*60 Disk with Device(s)* Refills:*2*
10. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day:
For ten days, take 2 tablets each day in the morning.  After ten
days decrease to one tablet each morning.  Hold for SBP < 95 or
HR < 50.
Disp:*30 Tablet(s)* Refills:*2*
11. miconazole nitrate 2 % Powder Sig: One (1)  Topical once a
day as needed: Apply once a day to area under breasts if moist
or painful.
Disp:*2 tubes* Refills:*2*
12. docusate sodium 50 mg Capsule Sig: [**1-22**] Capsules PO twice a
day as needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 39857**] - [**Location 9583**]

Discharge Diagnosis:
Primary
1. Congestive Heart Failure
2. Hypotension (Low Blood Pressure)
3. Acute on Chronic Kidney Disease
4. Healthcare Associated Pneumonia
5.  Atrial tachycardia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
1. You were admitted to [**Hospital1 18**] with low blood pressure and leg
swelling, likely due to heart failure. Fluid was removed with a
diuretic called Lasix but the amount of fluid that could be
taken off was limited by your blood pressure.  You will need to
continue diuretics as an outpatient.

2. The following changes were made to your medications:
CHANGE Amiodarone 200 mg by mouth daily x 10 days. Patient is
scheduled to follow-up with Dr. [**Last Name (STitle) **] (PCP) in 10 days, and
amiodarone dose will be adjusted as necessary then.
START Torsemdie 20 mg daily
CHANGE Metoprolol succinate (Toprol XL) 25 mg daily
START Salmeterol disukus twice daily

STOP Furosemide (lasix)

3. It is very important that you keep the appointments with your
doctors including Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **].

Followup Instructions:
You will be discharged to a rehab facility.

1. Please keep your appointment with your primary car doctor,
Dr. [**Last Name (STitle) **] on [**2119-7-27**] at 1:30 pm. His phone number is [**Telephone/Fax (1) 7728**].
His address is: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**]
{'Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Acidosis,Paroxysmal supraventricular tachycardia,Hypotension, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Asthma, unspecified type, unspecified,Other chronic pulmonary heart diseases,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Leukocytosis, unspecified,Personal history of malignant neoplasm of breast,Cardiac pacemaker in situ'}


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: Lower extremity swelling

PRESENT ILLNESS: [**Age over 90 **] year old female with asthma, atrial fibrillation on
Dabigatran and s/p dual-chamber (RA-RV) PPM in [**5-31**],
hypertension, and heart failure with preserved EF (EF 55% on
[**2119-6-28**] TTE but normal E wave, low deceleration time 133 msec)
and moderate pulmonary hypertension by TTE (TR Gradient + RA =
PASP: 44 mm Hg) who presented to the ED with lower extremity
edema. She reported considerable problems with lower extremity
edema over the weeks preceding admission with an approximately
12-lb weight gain and [**2-23**] pillow orthopnea. She further reported
dyspnea on exertion but not at rest. She has also had two
admissions within the last six weeks for AF with RVR. She had
been doing reasonably well despite persistent lower extremity
edema until the day prior to admision when she tripped and was
unable to get herself off the floor for a few hours due to
weakness.

MEDICAL HISTORY: -Coronary artery disease
-Paroxysmal atrial fibrillation on dabigatran with dual-chamber
PPM (RA/RV)
-Hypertension
-Hyperlipidemia
-Mild Aortic insufficiency
-Chronic kidney disease (stage III)
-Asthma
-Osteopenia
-Diverticulosis
-Gallstones
-Cataracts
-Internal hemorrhoids
-Allergic rhinitis
-Impaired glucose tolerance
-Breast cancer s/p RIND '[**94**]
-sp TABHSO for dysfunctional bleeding

MEDICATION ON ADMISSION: 1. Dabigatran etexilate 75 mg PO twice a day.
2. Simvastatin 20 mg PO DAILY
3. Vitamin D 50,000 unit PO once a month.
4. Travoprost Z 0.004 % Drops : One ophthalmic at bedtime.
5. Psyllium powder once a day.
6. Furosemide 80 mg QAM, 40 mg QPM DAILY
7. Amiodarone 200 mg TID
8. Metoprolol succinate 100 mg PO daily
9. Acetaminophen 650 mg PO every six hours as needed for pain

ALLERGIES: Amoxicillin / Verapamil / Univasc

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T 98, P 76, BP 90/51, RR 18
General: Mildly uncomfortable appearing female in NAD
HEENT: atraumatic, normocephalic, MMM, OP clear
Neck: supple, JVP not able to be assessed due to right sided CVL
with some surrounding blood
Lungs: Bilateral expiratory wheezes, mild respiratory distress
on speaking
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound, tenderness or guarding, no organomegaly
GU: Foley
Ext: warm, well perfused, 3+ edema in lower extremities to knee
bilaterally, left lower extremity with 4*4 area of ecchymoses
followed by nontender, slightly indurated red area that is
nontender

FAMILY HISTORY: Mother died from a myocardial infarction at 65 y/o but had T2DM,
PVD, and CHF. Father had Hodgkin's disease and laryngeal
carcinoma. Brother died from pancreatic cancer. Sister has CAD
c/b by MI x2 s/p PCI.

SOCIAL HISTORY: Retired book-keeper at a diamond merchant. She lives with her
sister, who is 14 years younger. Mobilizes with cane, exercise
tolerance 25 meters. Smoking/Tobacco: Never smoked. EtOH: none.
Illicits: none. 

### Response:
{'Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Acute kidney failure, unspecified,Acidosis,Paroxysmal supraventricular tachycardia,Hypotension, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Asthma, unspecified type, unspecified,Other chronic pulmonary heart diseases,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Leukocytosis, unspecified,Personal history of malignant neoplasm of breast,Cardiac pacemaker in situ'}
