CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: 66 year old male with history of bicuspid aortic valve s/p AVR
in [**2187**], complicated by prosthetic valve endocarditis requiring
redo AVR, presented initially to floor with dyspnea.  Upon
arrival to floor, patient experienced acute worsening dyspnea,
without associated symptoms.  BP was noted to be in 180s-190s
systolic range.  Patient triggered and was transferred to
cardiac care unit.  Upon arrival to unit, patient was anxious,
tachypneic, no chest discomfort, and hypertensive to 210s
systolic.  A nitro drip and lasix IV were given immediately,
with good effect.  See hospital course for further details.

MEDICAL HISTORY: HTN
bicuspid aortic valve s/p AVR
prosthetic valve endocarditis s/p redo AVR
chronic renal insufficiency

MEDICATION ON ADMISSION: Benicar and Lisinopril
Furosemide and Metolazone PRN
Bisystolic
Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for insomnia.
Folgard 0.8-10-115 mg-mg-mcg Tablet Sig: One (1) Tablet PO once
a day.
Clonidine 0.3 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal QSUN (every Sunday).
Lantus 100 unit/mL Solution Sig: 20-26 units Subcutaneous at
bedtime: Please titrate to blood sugars.
Novolog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous four times a day
Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Doxazosin 1 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours.
Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily). Disp:*60 Tablet Sustained
Release(s)* Refills:*2*
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.

ALLERGIES: Ativan / Morphine / Iodine-Iodine Containing

PHYSICAL EXAM: initial vital signs notable for oxygen saturation in the mid 90s
on [**3-9**] liters nasal cannulu, with BP, as noted before, as high
as 210s/90s
GENERAL:  well nourished, anxious, tachypneic
HEENT:  PERRLa, NCAT, clear oropharynx, MMM, no thyromegaly
CV:  RRR, S1, S2, no S3 or S4, II/VI SEM at left upper sternal
border, JVD not elevated, 2+ pulses throughout
PULM:  bibasilar rales
ABD:  soft, NT, ND, active BS, no HSM
EXT:  no rash, [**1-8**]+ pretibial pitting edema
NEURO:  CNs II-XII intact, strength and sensation grossly
intact, no cerebellar deficits
SKIN - no rash or evidence of chronic venous stasis

FAMILY HISTORY: Father died of a heart attack at 76 years
old and had prostate cancer.  Mother died of lung cancer in
her 70s.  There is a positive family history of diabetes
mellitus.

SOCIAL HISTORY: no tobacco or alcohol use
Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Acute on chronic diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Hypoxemia,Coronary atherosclerosis of native coronary artery,Chronic kidney disease, unspecified,Anemia of other chronic disease,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Heart valve replaced by other means,Dysthymic disorder,Gout, unspecified,Other and unspecified hyperlipidemia,Long-term (current) use of insulin
Hyp ht/kd NOS I-IV w hf,Ac on chr diast hrt fail,Ac kidny fail, tubr necr,Pneumonia, organism NOS,Hypoxemia,Crnry athrscl natve vssl,Chronic kidney dis NOS,Anemia-other chronic dis,Chr pulmon heart dis NEC,DMII wo cmp nt st uncntr,Heart valve replac NEC,Dysthymic disorder,Gout NOS,Hyperlipidemia NEC/NOS,Long-term use of insulin
Admission Date:  [**2196-9-21**]              Discharge Date:   [**2196-10-1**]

Date of Birth:  [**2130-5-14**]             Sex:   M

Service: MEDICINE

Allergies:
Ativan / Morphine / Iodine-Iodine Containing

Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
Cardiac Catheterization


History of Present Illness:
66 year old male with history of bicuspid aortic valve s/p AVR
in [**2187**], complicated by prosthetic valve endocarditis requiring
redo AVR, presented initially to floor with dyspnea.  Upon
arrival to floor, patient experienced acute worsening dyspnea,
without associated symptoms.  BP was noted to be in 180s-190s
systolic range.  Patient triggered and was transferred to
cardiac care unit.  Upon arrival to unit, patient was anxious,
tachypneic, no chest discomfort, and hypertensive to 210s
systolic.  A nitro drip and lasix IV were given immediately,
with good effect.  See hospital course for further details.

ROS notable for increasing lower extremity edema over past few
weeks while self-limiting diuretic use.

Past Medical History:
HTN
bicuspid aortic valve s/p AVR
prosthetic valve endocarditis s/p redo AVR
chronic renal insufficiency

Social History:
no tobacco or alcohol use

Family History:
Father died of a heart attack at 76 years
old and had prostate cancer.  Mother died of lung cancer in
her 70s.  There is a positive family history of diabetes
mellitus.


Physical Exam:
initial vital signs notable for oxygen saturation in the mid 90s
on [**3-9**] liters nasal cannulu, with BP, as noted before, as high
as 210s/90s
GENERAL:  well nourished, anxious, tachypneic
HEENT:  PERRLa, NCAT, clear oropharynx, MMM, no thyromegaly
CV:  RRR, S1, S2, no S3 or S4, II/VI SEM at left upper sternal
border, JVD not elevated, 2+ pulses throughout
PULM:  bibasilar rales
ABD:  soft, NT, ND, active BS, no HSM
EXT:  no rash, [**1-8**]+ pretibial pitting edema
NEURO:  CNs II-XII intact, strength and sensation grossly
intact, no cerebellar deficits
SKIN - no rash or evidence of chronic venous stasis

exam at discharge:
BP 130s-140s/70s
lungs were clear to auscultation
edema had resolved


Pertinent Results:
Labs at discharge:

WBC  RBC  Hgb   Hct  MCV MCH   MCHC  RDW  Plt Ct
9.7 3.20* 8.5* 26.8* 84  26.5* 31.7  15.9* 411

PT 15.3*   PTT 31.1   INR 1.3

Glucose UreaN Creat              Na  K   Cl  HCO3 AnGap
  175*   104   3.3* (peak 4.7)  137 3.6  100  23   18

Calcium Phos  Mg
  8.6    5.5  2.2

TTE:  Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. Mild to
moderate mitral regurgitation. Mild pulmonary hypertension.

ECG:  Sinus rhythm. A-V conduction delay. Prior anteroseptal
myocardial infarction. Compared to the previous tracing of
[**2190-10-9**] sinus rhythm is now recorded. The anterolateral ischemic
appearing ST-T wave changes have improved. Sinus rhythm with A-V
conduction delay is now present. The rate has slowed.

Admission CXR:
1. Patchy focal consolidation within the left mid-lung. Followup
to resolution is recommended.

2. Small-to-moderate size right pleural effusion, with
associated
opacification of the lung base, may reflect atelectasis.
Underlying
consolidation not excluded.

3. Stable mild cardiomegaly

Renal ultrasound:
1. Normal acceleration time in the right main renal artery with
no evidence of right renal artery stenosis.
2. Nondiagnostic left renal artery waveforms.
3. Normal appearance and size of both kidneys.
4. Morphological appearance of mild benign prostatic
hyperplasia.

Cardiac cath:
1. Elevated right and left sided filling pressures.
2. Moderate to severe pulmonary hypertension.
3. Moderate systemic hypertension.
4. High cardiac output state.

Resting hemodynamics revealed elevated right sided and left
sided filling pressure with an RVEDP of 17 mmHg and a PCWP mean
of 27 mmHg. There was severe pulmonary hypertension with a pasp
of 65/27 mmHg. There was a high output cardiac index of 4.37
L/min/m2. The femoral arterial pressure was moderately elevated
with a pressure of 163/55 mmHg which correlated with the
noninvasive cuff pressure.

CT Chest, Abdomen, Pelvis:
1. Diffuse bilateral central pulmonary opacities with associated
fissural
fluid and pleural effusions, large on the right and moderate on
the left
side, favoring pulmonary edema with superimposed infection.
Pulmonary
hemorrhage cannot be ruled out.

2. No additional source of infection or acute process identified
in the
abdomen or pelvis.














Brief Hospital Course:
66 year old male with history of bicuspid aortic valve s/p AVR
in [**2187**], complicated by prosthetic valve endocarditis requiring
redo AVR, presented initially to floor with dyspnea.  Upon
arrival to floor, patient experienced acute worsening dyspnea,
without associated symptoms.  BP was noted to be in 180s-190s
systolic range.  Patient triggered and was transferred to
cardiac care unit.  Upon arrival to unit, patient was anxious,
tachypneic, no chest discomfort, and hypertensive to 210s
systolic.  A nitro drip and lasix IV were given immediately,
with good effect.  The patient continued to receive aggressive
IV diuresis, and was maintained on a nitro drip until blood
pressure was better controlled with long-acting nitrates and,
arterial vasodilators, and non-specific beta blockers, in
addition to his home regimen.  It was thought that the patient
presented in flash pulmonary edema secondary to severe
hypertension, and an underlying pulmonary infection could not be
ruled out.  Bronchoscopy was entertained but ultimately not
pursued given likelihood of pulmonary edema as etiology of
radiographic lung findings.  There was no evidence of myocardial
ischemia as the etiology.  No diastolic murmur was noted on
exam, there was a low suspicion for recurrent endocarditis, and
TTE did not show any vegetation, see above.  A cardiac
catheterization was done to evaluate the patient's refractory
hypertension, and both the BP cuff pressure and central pressure
correlated well.  Initial antibiotic therapy covering
community-acquired pneumonia was soon discontinued after patient
did not develop additional signs/symptoms of infections.  It was
thought that poor renal perfusion in the setting of likely
chronic hypertensive/diabetic nephropathy contributed to the
patient's acute renal failure.  Renal ultrasound did not show
any evidence of obstruction.  Following improved blood pressure
control, the patient's renal function slowly recovered.
Hemodialysis was never indicated.  The patient also received two
units of packed red blood cells with an appropriate response.
The patient was maintained on a basal/bolus insulin regimen.  He
was discharged on [**2196-10-1**] with improved BP control and clear
lungs.  See below for medication changes.



Medications on Admission:
Benicar and Lisinopril
Furosemide and Metolazone PRN
Bisystolic
Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for insomnia.
Folgard 0.8-10-115 mg-mg-mcg Tablet Sig: One (1) Tablet PO once
a day.
Clonidine 0.3 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal QSUN (every Sunday).
Lantus 100 unit/mL Solution Sig: 20-26 units Subcutaneous at
bedtime: Please titrate to blood sugars.
Novolog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous four times a day
Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Doxazosin 1 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours.
Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily). Disp:*60 Tablet Sustained
Release(s)* Refills:*2*
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Medications:
1. Outpatient Lab Work
Please check Chem-7, Ca, Mag, Phosphate on [**2196-10-4**] at Dr. [**Name (NI) 100470**] office. Results to Dr. [**Last Name (STitle) 1407**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 721**]
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.

3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.

5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three
times a day: take before meals.
Disp:*90 Tablet(s)* Refills:*2*
7. Folgard 0.8-10-115 mg-mg-mcg Tablet Sig: One (1) Tablet PO
once a day.
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal QSUN (every Sunday).
9. Lantus 100 unit/mL Solution Sig: 20-26 units Subcutaneous at
bedtime: Please titrate to blood sugars.
10. Novolog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous four times a day.
11. Hydralazine 100 mg Tablet Sig: 1.5 Tablets PO three times a
day.
Disp:*135 Tablet(s)* Refills:*2*
12. Carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
13. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
15. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO DAILY (Daily).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
16. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
Disp:*150 Tablet(s)* Refills:*2*
17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
18. Metolazone 5 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.



Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Acute Kidney Injury
Acute on Chronic Diastolic Congestive Heart Failure
SEcondary Diagnosis:
Hypertension
Hyperlipidemia
Diabetes Mellitus type 2
Anemia


Discharge Condition:
hemodynamically stable, creat 3.3. Afebrile.


Discharge Instructions:
You had high blood pressure that led to fluid overload and
kidney failure. Your kidney function is slowly improving and
your fluid status is better after medication adjustment. You
will need to follow up with your nephrologist and Dr. [**Last Name (STitle) **]
after you go home. You should see a dietician for counseling on
a renal diet if your creatinine is still high. Your goal blood
sugar is 80-120 but it is important that the number stays below
150, goal A1C is < 7.0. Your goal systolic BP is 120-130.
For now, avoid High Phosphorus foods:
-dairy products such as milk, cheese,
yogurt, ice cream and pudding
-nuts and peanut butter
-dried beans and peas such as kidney
beans, split peas and lentils
-beverages such as cocoa, beer and
dark cola drinks
.
Medication changes:
1. STOP taking Benicar and Lisinopril
2. START taking Hydralazine to lower your blood pressure
3. Take 100 mg of Furosemide twice a day and Metolazone 2.5 mg
once a day
4. START Sevelamer, one tablet before meals to lower your
phosphate level.
5. START Imdur to lower your blood pressure
6. Take Nifedipine CR instead of Amlodipine to lower your blood
pressure
6. Use Carvedilol instead of Bisystolic to lower your blood
pressure.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 1407**] if weight > 3 lbs
in 1 day or 6 pounds in 3 days.
Adhere to 2 gm sodium diet, a diabetic diet and the phosphorus
restrictions noted above.
Call Dr. [**Last Name (STitle) 1407**] if you notice increased swelling in your legs,
trouble lying flat, decreased appetite or shortness of breath.
.
If you experience worsening shortness of breath, fever, chills,
chest pain, palpitations, dizziness, or increased swelling of
your extremities, please call 911 or your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1407**].

Followup Instructions:
Dermatology:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 4961**], MD Phone:[**Telephone/Fax (1) 2309**]
Date/Time:[**2196-10-3**] 3:45
Nephrology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 721**]  Date/Time: Office will
call you at home with an appt.
.
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) 20**] R. Phone: [**Telephone/Fax (1) 1408**] Date/Time: Tuesday [**10-4**]
at 3:30pm.
.
Cardiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: Please call
to schedule an appt in 1 month
{'Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Acute on chronic diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Hypoxemia,Coronary atherosclerosis of native coronary artery,Chronic kidney disease, unspecified,Anemia of other chronic disease,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Heart valve replaced by other means,Dysthymic disorder,Gout, unspecified,Other and unspecified hyperlipidemia,Long-term (current) use of insulin'}


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: dyspnea

PRESENT ILLNESS: 66 year old male with history of bicuspid aortic valve s/p AVR
in [**2187**], complicated by prosthetic valve endocarditis requiring
redo AVR, presented initially to floor with dyspnea.  Upon
arrival to floor, patient experienced acute worsening dyspnea,
without associated symptoms.  BP was noted to be in 180s-190s
systolic range.  Patient triggered and was transferred to
cardiac care unit.  Upon arrival to unit, patient was anxious,
tachypneic, no chest discomfort, and hypertensive to 210s
systolic.  A nitro drip and lasix IV were given immediately,
with good effect.  See hospital course for further details.

MEDICAL HISTORY: HTN
bicuspid aortic valve s/p AVR
prosthetic valve endocarditis s/p redo AVR
chronic renal insufficiency

MEDICATION ON ADMISSION: Benicar and Lisinopril
Furosemide and Metolazone PRN
Bisystolic
Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.
Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for insomnia.
Folgard 0.8-10-115 mg-mg-mcg Tablet Sig: One (1) Tablet PO once
a day.
Clonidine 0.3 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal QSUN (every Sunday).
Lantus 100 unit/mL Solution Sig: 20-26 units Subcutaneous at
bedtime: Please titrate to blood sugars.
Novolog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous four times a day
Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Doxazosin 1 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours.
Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily). Disp:*60 Tablet Sustained
Release(s)* Refills:*2*
Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.

ALLERGIES: Ativan / Morphine / Iodine-Iodine Containing

PHYSICAL EXAM: initial vital signs notable for oxygen saturation in the mid 90s
on [**3-9**] liters nasal cannulu, with BP, as noted before, as high
as 210s/90s
GENERAL:  well nourished, anxious, tachypneic
HEENT:  PERRLa, NCAT, clear oropharynx, MMM, no thyromegaly
CV:  RRR, S1, S2, no S3 or S4, II/VI SEM at left upper sternal
border, JVD not elevated, 2+ pulses throughout
PULM:  bibasilar rales
ABD:  soft, NT, ND, active BS, no HSM
EXT:  no rash, [**1-8**]+ pretibial pitting edema
NEURO:  CNs II-XII intact, strength and sensation grossly
intact, no cerebellar deficits
SKIN - no rash or evidence of chronic venous stasis

FAMILY HISTORY: Father died of a heart attack at 76 years
old and had prostate cancer.  Mother died of lung cancer in
her 70s.  There is a positive family history of diabetes
mellitus.

SOCIAL HISTORY: no tobacco or alcohol use 

### Response:
{'Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Acute on chronic diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Hypoxemia,Coronary atherosclerosis of native coronary artery,Chronic kidney disease, unspecified,Anemia of other chronic disease,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Heart valve replaced by other means,Dysthymic disorder,Gout, unspecified,Other and unspecified hyperlipidemia,Long-term (current) use of insulin'}
