CHIEF COMPLAINT: DOE/Submassive PE

PRESENT ILLNESS: This is a 54 yo M with no significant past medical history who
presented to an OSH with 3 days of progressive dyspnea on
exertion. The patient noticed intermittent R calf swelling for
2-3 months prior to presentation. The patient thought that this
was due to trauma from exercise and did not undergo further
workup. Over the past three days, the patient noted increasing
dyspnea on exertion. One day prior to admission, he noted that
he was breathing harder at rest and he presented to OSH for
further workup. At the OSH, the patient had a LE US that showed
a RLE clot and a CTA that showed a sub-massive PE (unable to
view reports yet). He was started on a heparin gtt and
transfered to the [**Hospital1 18**] ED for further workup. For the last 2
weeks, the patient has noted chills, subjective fevers,
myalgias, drneching night sweats, and fatigue. He has taken
intermittent ibuprofen without much relief. He denies cough,
rashes, sore throat, rhinorrhea, abd pain, N/V, diarrhea. The
patient denies sick contacts.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission exam
Vitals: T: 101.5 BP: 116/71 P: 96 R: 18 O2: 96% 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear without exudates,
EOMI, PERRL
Neck: obese, supple, JVP not elevated to level of mandible, no
discrete LAD but exquisitely tender below left mandible to
palpation
CV: Sinus tachycardia, RV heave, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: RLE larger than left, no Homigs sign or palpable cords
although slight increased erythema and warmth, TTP of posterior
R calf
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: Family History:  No cancers, blood clots, hematological
disorders noted

SOCIAL HISTORY: Social History:
- Tobacco:  None
- Alcohol:  Socially
- Illicits:  None
Saddle embolus of pulmonary artery,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Obesity, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Heart disease, unspecified,Other chronic pulmonary heart diseases,Edema,Myalgia and myositis, unspecified,Fever, unspecified,Leukocytosis, unspecified,Headache
Saddle embol pulmon art,Ac DVT/emb distl low ext,Obesity NOS,Elev transaminase/ldh,Heart disease NOS,Chr pulmon heart dis NEC,Edema,Myalgia and myositis NOS,Fever NOS,Leukocytosis NOS,Headache
Admission Date:  [**2103-12-12**]              Discharge Date:   [**2103-12-22**]

Date of Birth:  [**2049-8-10**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 602**]
Chief Complaint:
DOE/Submassive PE

Major Surgical or Invasive Procedure:
Intensive Care Unit stay


History of Present Illness:
This is a 54 yo M with no significant past medical history who
presented to an OSH with 3 days of progressive dyspnea on
exertion. The patient noticed intermittent R calf swelling for
2-3 months prior to presentation. The patient thought that this
was due to trauma from exercise and did not undergo further
workup. Over the past three days, the patient noted increasing
dyspnea on exertion. One day prior to admission, he noted that
he was breathing harder at rest and he presented to OSH for
further workup. At the OSH, the patient had a LE US that showed
a RLE clot and a CTA that showed a sub-massive PE (unable to
view reports yet). He was started on a heparin gtt and
transfered to the [**Hospital1 18**] ED for further workup. For the last 2
weeks, the patient has noted chills, subjective fevers,
myalgias, drneching night sweats, and fatigue. He has taken
intermittent ibuprofen without much relief. He denies cough,
rashes, sore throat, rhinorrhea, abd pain, N/V, diarrhea. The
patient denies sick contacts.

In the ED, initial VS were: 100 112 165/110 22 99% 3L. He was
kept on heparin gtt. He had a bedside, portable US that showed ?
septal bowing and R heart strain. His EKG did not have evidence
of R strain, however. Vitals on transfer were 100, 102, 18,
106/63, 100% 3L.
.
On arrival to the MICU, the patient does not have increased work
of breathing. He is not hypoxic on 3 L. He is comfortable.


Past Medical History:
None

Social History:
Social History:
- Tobacco:  None
- Alcohol:  Socially
- Illicits:  None


Family History:
Family History:  No cancers, blood clots, hematological
disorders noted


Physical Exam:
Admission exam
Vitals: T: 101.5 BP: 116/71 P: 96 R: 18 O2: 96% 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear without exudates,
EOMI, PERRL
Neck: obese, supple, JVP not elevated to level of mandible, no
discrete LAD but exquisitely tender below left mandible to
palpation
CV: Sinus tachycardia, RV heave, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: RLE larger than left, no Homigs sign or palpable cords
although slight increased erythema and warmth, TTP of posterior
R calf
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

Discharge exam
Vitals: Tm: 97.7 BP: 124/80 P: 79 R: 18 O2: 97 RA
General: Alert, oriented, NAD, speaking in full sentences
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, no accessory muscle use
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, no right heart heave.
Abdomen: obese, soft, non-tender, non-distended,
Ext: no right lower extremity edema, no left lower extremity
edema, 2+ DP/PT pulses.


Pertinent Results:
Admission labs
[**2103-12-12**] 09:30PM BLOOD WBC-11.2* RBC-4.76 Hgb-14.0 Hct-40.8
MCV-86 MCH-29.4 MCHC-34.3 RDW-12.0 Plt Ct-229
[**2103-12-12**] 09:30PM BLOOD Neuts-68.7 Lymphs-20.6 Monos-7.4 Eos-2.8
Baso-0.6
[**2103-12-13**] 03:44AM BLOOD PT-12.7* PTT-78.1* INR(PT)-1.2*
[**2103-12-12**] 09:30PM BLOOD Glucose-100 UreaN-15 Creat-1.1 Na-139
K-4.7 Cl-102 HCO3-28 AnGap-14
[**2103-12-12**] 09:30PM BLOOD cTropnT-<0.01
[**2103-12-12**] 09:59PM BLOOD Lactate-1.3

Discharge labs:
[**2103-12-21**] 06:16AM BLOOD WBC-9.6 RBC-4.74 Hgb-13.9* Hct-41.4
MCV-87 MCH-29.4 MCHC-33.6 RDW-12.1 Plt Ct-410
[**2103-12-22**] 06:40AM BLOOD PT-24.5* PTT-68.9* INR(PT)-2.3*
[**2103-12-13**] 06:23AM BLOOD Glucose-121* UreaN-14 Creat-1.1 Na-141
K-4.4 Cl-106 HCO3-25 AnGap-14

Studies
CXR [**2103-12-12**]
Assessment of the lungs is more thoroughly performed on the
outside
hospital CT, though there is no focal consolidation, effusion,
or pneumothorax seen. Cardiomediastinal silhouette appears
normal. Bony structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION: No pneumonia.

TTE [**2103-12-13**]
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is moderately dilated with
borderline normal free wall function. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. No aortic regurgitation is seen. No
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is an anterior space
which most likely represents a prominent fat pad. IMPRESSION:
Moderately dilated right ventricle with borderline normal
function and evidence of pressure/volume overload. Unable to
determine pulmonary artery pressure on this exam. Normal left
ventricular size and function.


Brief Hospital Course:
54 yo M with no prior medical history who presents with RLE
swelling and SOB, found to have deep venous thrombosis and
submassive pulmonary embolism.  Patient was placed on heparin
drip and transitioned to coumadin.

.
# Pulmonary Embolism/DVT: Patient presented with several months
of shortness of breath and worsening dyspnea on exertion.  He
also noted a 6 month history of swelling and pain in his right
leg.  He reported several 14 hour car trips to the midwest in
the months leading up to his leg swelling.  He was sent to an
OSH by his PCP where [**Name Initial (PRE) **] saddle pulmonary embolism was seen on
CTA.  The patient was transferred to [**Hospital1 18**] and placed on a
heparin drip.  He was unable to bridge to coumadin with lovenox
given his weight (>150 kg) outside of guidelines.  He had a slow
to respond INR and was discharged on 10 mg coumadin daily with
INR of 2.3 at discharge after being therapeutic for >48 hours.
He was discharged to follow up with his PCP regarding future INR
checks and coumadin dosing over then 6 months.
.
Transitional issues
# Should have age appropriate cancer screening (colonoscopy) if
not already planned
# Would recommend sleep study to assess for OSA
# Would recommend fasting lipids if not reccently checked
# Will need frequent INR checks until stable INR is achieved.

Medications on Admission:
None

Discharge Medications:
1. Outpatient Lab Work
INR with PT and PTT
fax results to [**Telephone/Fax (1) 29683**]
Care of: [**Last Name (LF) **],[**First Name3 (LF) **] B.
[**Hospital3 **] INTERNAL MEDICINE ASSOCIATES


2. Coumadin 2.5 mg Tablet Sig: Four (4) Tablet PO once a day:
daily at 4 pm.
Disp:*120 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY:
-Pulmonary Embolism
-Deep vein thrombosis

SECONDARY:
-obesity


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital.  You were admitted for evaluation of your leg swelling
and shortness of breath.  You were found to have both a large
blood clot in your right leg as well as a large blood clot in
your lungs.  You were started on blood thinners and transitioned
to an oral medicine called coumadin.  On this drug you will
bleed much more easily and will need be careful when shaving and
using sharp objects.  Your primary care doctor will help manage
your blood levels.  You will need to have regular blood checks
done at [**Hospital3 4107**] and these results will be faxed to his
office.

The following changes were made to your medications:
START
-coumadin 10 mg daily at 4 pm (4 2.5 mg tablets)

Followup Instructions:
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appt:  [**12-24**] at 1:45pm
{'Saddle embolus of pulmonary artery,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Obesity, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Heart disease, unspecified,Other chronic pulmonary heart diseases,Edema,Myalgia and myositis, unspecified,Fever, unspecified,Leukocytosis, unspecified,Headache'}


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: DOE/Submassive PE

PRESENT ILLNESS: This is a 54 yo M with no significant past medical history who
presented to an OSH with 3 days of progressive dyspnea on
exertion. The patient noticed intermittent R calf swelling for
2-3 months prior to presentation. The patient thought that this
was due to trauma from exercise and did not undergo further
workup. Over the past three days, the patient noted increasing
dyspnea on exertion. One day prior to admission, he noted that
he was breathing harder at rest and he presented to OSH for
further workup. At the OSH, the patient had a LE US that showed
a RLE clot and a CTA that showed a sub-massive PE (unable to
view reports yet). He was started on a heparin gtt and
transfered to the [**Hospital1 18**] ED for further workup. For the last 2
weeks, the patient has noted chills, subjective fevers,
myalgias, drneching night sweats, and fatigue. He has taken
intermittent ibuprofen without much relief. He denies cough,
rashes, sore throat, rhinorrhea, abd pain, N/V, diarrhea. The
patient denies sick contacts.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission exam
Vitals: T: 101.5 BP: 116/71 P: 96 R: 18 O2: 96% 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear without exudates,
EOMI, PERRL
Neck: obese, supple, JVP not elevated to level of mandible, no
discrete LAD but exquisitely tender below left mandible to
palpation
CV: Sinus tachycardia, RV heave, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft obese, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: no foley
Ext: RLE larger than left, no Homigs sign or palpable cords
although slight increased erythema and warmth, TTP of posterior
R calf
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: Family History:  No cancers, blood clots, hematological
disorders noted

SOCIAL HISTORY: Social History:
- Tobacco:  None
- Alcohol:  Socially
- Illicits:  None 

### Response:
{'Saddle embolus of pulmonary artery,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Obesity, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Heart disease, unspecified,Other chronic pulmonary heart diseases,Edema,Myalgia and myositis, unspecified,Fever, unspecified,Leukocytosis, unspecified,Headache'}
