CHIEF COMPLAINT: Shortness of breath and palpitations

PRESENT ILLNESS: [**Age over 90 **] year old female with hypertension, dementia, presenting to ED
with acute onset of palpitations and dyspnea.  Started at 4:30pm
after drinking a cup of coffee, which caused her to cough, and
continued afterwards.  Thought perhaps was aspiration or
irritation related.  Denies chest pain, back pain, nausea,
diaphoresis.

MEDICAL HISTORY: - Hyperlipidemia
- Hypertension
- Hypothyroidism
- History of cellulitis of leg [**8-/2120**]
- Dementia
- Bipolar illness
- History of hernia repair
- Constipation
- Osteoporosis
- compression fx seen on xrays
- AAA s/p repair

MEDICATION ON ADMISSION: Aspirin 81 mg daily
Levothyroxine 75 mcg daily
Simvastatin 10 mg daily
Risperdal 0.5 mg QAM, 1.5 mg QPM
Mirtazepine 22.5 mg daily
Ranitidine 150 mg daily
Calcium plus D [**Hospital1 **]
Multivitamin daily
B12 1000 mcg daily
B6 100 mg daily
Folate 0.4 mg daily
mag citrate prn
lactulose prn
eucerin cream

ALLERGIES: Neomycin/Bacitrac Zn/Polymyxin

PHYSICAL EXAM: T 98.4 BP: 121/54 P: 75 R: 18 O2: 95% on 3L
General: Sleepy though easily arousable, cachectic elderly
female.
HEENT: Sclera anicteric, PERRL. MM slightly dry, oropharynx
clear
Neck: supple, JVD to 2 cm ASA, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused UEs, slightly cool LEs, 2+ pulses, no
clubbing, cyanosis. Trace to 1+ bilateral LE edema.

FAMILY HISTORY: Son was [**Name2 (NI) 82909**], committed suicide. Daughter deceased from
pancreatic cancer. One other daughter currently alive and well.

SOCIAL HISTORY: Lives in dementia unit at [**Last Name (un) 35689**] House, daughter actively
involved in her care. Formerly worked as a dental assistant
No current smoking or EtOH.
Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Other pulmonary embolism and infarction,Urinary tract infection, site not specified,Diseases of tricuspid valve,Other chronic pulmonary heart diseases,Dysphagia, unspecified,Leukocytosis, unspecified,Bipolar disorder, unspecified,Diaphragmatic hernia without mention of obstruction or gangrene,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Osteoporosis, unspecified,Anemia, unspecified,Congestive heart failure, unspecified
Ac DVT/emb prox low ext,Pulm embol/infarct NEC,Urin tract infection NOS,Tricuspid valve disease,Chr pulmon heart dis NEC,Dysphagia NOS,Leukocytosis NOS,Bipolar disorder NOS,Diaphragmatic hernia,Hypertension NOS,Mental disor NEC oth dis,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,Osteoporosis NOS,Anemia NOS,CHF NOS
Admission Date:  [**2121-10-2**]              Discharge Date:   [**2121-10-7**]


Service: MEDICINE

Allergies:
Neomycin/Bacitrac Zn/Polymyxin

Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
Shortness of breath and palpitations

Major Surgical or Invasive Procedure:
Placement of IVC filter.

History of Present Illness:
[**Age over 90 **] year old female with hypertension, dementia, presenting to ED
with acute onset of palpitations and dyspnea.  Started at 4:30pm
after drinking a cup of coffee, which caused her to cough, and
continued afterwards.  Thought perhaps was aspiration or
irritation related.  Denies chest pain, back pain, nausea,
diaphoresis.

In the ED, initial vs were: T98.2, HR130, BP 95/67, R24, 96% on
NRB. Still requiring NRB (though 99% on this, appears to desat
with lower amounts of O2).  Lowest SBP 93.  CXR with large
hiatal hernia.  CTA with multi-focal PEs.  NGT was placed to
decompress hernia.  Guaiac negative.  BNP 4700 and troponin
0.09.  Patient was started on IV heparin.

In the MICU, patient notes feeling tired without other
complaints.  States her breathing is still difficult, though
better than before.  No palpitations currently. Unsure if she
has had any recent weight loss.  Does not recall recent
mammography or other cancer screenings.

Review of systems:
(+) Per HPI
(-) Denies fever, headache, cough, chest pain or tightness,
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.


Past Medical History:
- Hyperlipidemia
- Hypertension
- Hypothyroidism
- History of cellulitis of leg [**8-/2120**]
- Dementia
- Bipolar illness
- History of hernia repair
- Constipation
- Osteoporosis
- compression fx seen on xrays
- AAA s/p repair


Social History:
Lives in dementia unit at [**Last Name (un) 35689**] House, daughter actively
involved in her care. Formerly worked as a dental assistant
No current smoking or EtOH.

Family History:
Son was [**Name2 (NI) 82909**], committed suicide. Daughter deceased from
pancreatic cancer. One other daughter currently alive and well.

Physical Exam:
T 98.4 BP: 121/54 P: 75 R: 18 O2: 95% on 3L
General: Sleepy though easily arousable, cachectic elderly
female.
HEENT: Sclera anicteric, PERRL. MM slightly dry, oropharynx
clear
Neck: supple, JVD to 2 cm ASA, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused UEs, slightly cool LEs, 2+ pulses, no
clubbing, cyanosis. Trace to 1+ bilateral LE edema.


Pertinent Results:
Images:
CT chest: extensive bilateral filling defects in main and lobar
arterial branches.  CT evidence of possible R heart strain.
Large hiatal hernia.  LLL compressive atelectasis.

CXR: Hiatal hernia with compressive atelectasis.  Lungs clear.

EKG: Sinus tach at 124, NANI, 1mm ST depression in I and aVL, no
prior.

Hematology:
[**2121-10-1**] 07:25PM BLOOD WBC-14.0* RBC-4.50 Hgb-13.1 Hct-41.7
MCV-93 MCH-29.2 MCHC-31.5 RDW-14.5 Plt Ct-253
[**2121-10-1**] 07:25PM BLOOD Neuts-87.0* Lymphs-9.4* Monos-3.2 Eos-0.3
Baso-0.2
[**2121-10-2**] 04:35AM BLOOD PT-12.8 PTT-124.9* INR(PT)-1.1

Chemistries:
[**2121-10-1**] 07:25PM BLOOD Glucose-227* UreaN-20 Creat-0.9 Na-139
K-5.4* Cl-104 HCO3-21* AnGap-19
[**2121-10-1**] 07:25PM BLOOD CK(CPK)-76
[**2121-10-1**] 07:25PM BLOOD cTropnT-0.09*
[**2121-10-1**] 07:25PM BLOOD CK-MB-NotDone proBNP-4736*
[**2121-10-2**] 04:35AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.1

ABG:
[**2121-10-2**] 08:22AM BLOOD Type-ART pO2-226* pCO2-37 pH-7.44
calTCO2-26 Base XS-1

Brief Hospital Course:
[**Age over 90 **] year old female with hypertension, hyperlipidemia,
hypothyroidism; presenting with extensive bilateral PE and high
O2 requirement.

#Pulmonary embolism. CTA showed massive bilateral filling
defects and R heart strain. Trigger unknown, but given cachexia
and age would be concerned for malignancy.  Ambulatory at
facility at baseline.  Unlikely to be primary hypercoaguable
state at her age.  No identified meds that would put her at
risk. She was hemodynamically stable with high O2 requirements.
She was started on IV heparin drip.  LENI's showed nonocclusive
thrombus involving the left superficial femoral
vein. TTE showed LEF 55% and most significant for markedly
dilated and hypokinetic RV, mod-severe TR, and mod pulm HTN. An
IVC filter was placed to prevent further clot burden.  IV
heparin was transitioned to lovenox for faciliation of
outpatient therapy.

#UTI - Patient was note dto have a positive urine culture for
pansensitive Ecoli.  She denied urinary symptoms, but due to her
incontinence and inability to assess dementia from baseline was
treated with at 3 day course of clinidamycin.

#Dysphagia - Patient was noted to have coughing with po intake
of nectar thick liquids.  It is unclear if her dysphagia is a
consequence of deconditioning from her acute illness and/or a
chronic change due to her dementia.  Speech and swallow was
consulted and recommended a video study.  Prior to the study,
patient and daughter discussed what they would want if patient
was aspirating on food and/or liquids, and pt wanted to be
allowed to eat anyway.  She was discharged to rehab with
instruction to include swallow therapy during her stay with
supervision during meals.

#Weakness - Pt was noted to be deconditioned due to her PE
during her hospitalization.

#Tachycardia/palpitations. In setting of acute PE.  Her heart
rate and her symptoms inproved with gentle hydration and
initiation of anticoagulation.

#Leukocytosis.  Initial WBCs 14K which improved to 8 without
intervention.  Likely stress response to PE and hypoxia.

#Dementia/bipolar. She was continued on home risperdal and
mirtazepine.

#Hiatal hernia.  NGT placed in ED for decompression out of
concern that this was leading to symptoms.  This was
discontinued on arrival to the MICU.

#Code:  Pt and daughter both confirm DNR/DNI status
Communication: Patient and daughter [**Name (NI) **] [**Name (NI) 14164**] [**Telephone/Fax (1) 82910**]

Medications on Admission:
Aspirin 81 mg daily
Levothyroxine 75 mcg daily
Simvastatin 10 mg daily
Risperdal 0.5 mg QAM, 1.5 mg QPM
Mirtazepine 22.5 mg daily
Ranitidine 150 mg daily
Calcium plus D [**Hospital1 **]
Multivitamin daily
B12 1000 mcg daily
B6 100 mg daily
Folate 0.4 mg daily
mag citrate prn
lactulose prn
eucerin cream


Discharge Medications:
1. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Risperidone 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).

10. Risperidone 1 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
11. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) teaspoon PO
BID (2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
17. Mirtazapine 45 mg Tablet Sig: half Tablet PO at bedtime.
18. Magnesium Citrate 1.745 g/30mL Solution Sig: Three (3)
teaspooon PO once a day as needed for constipation.
19. Lactulose 10 gram/15 mL Solution Sig: One (1) tablespoon PO
once a day as needed for constipation.
20. Eucerin     Cream Sig: apply liberally  Topical three times
a day as needed for dry or itchy skin.
21. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM.
22. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days: through [**10-7**] evening. Tablet(s)


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]

Discharge Diagnosis:
Primary: Pulmonary embolism
Secondary: Deep vein thrombosis


Discharge Condition:
Stable, afebrile, 96% on 2L oxygen


Discharge Instructions:
You were seen at the [**Hospital1 18**] ED for heart palpitations and
shortness of breath.

CT imaging in the ED revealed large blood clots in your
pulmonary arteries, and you were started on blood thinners to
prevent worsening of the blood clots.  An ultrasound examination
of your legs showed a clot in your left leg, and a IVC filter
was placed to prevent further clots from travelling to your
lungs.  Due to deconditioning you were sent to rehab for
continued physical therapy.

During your hospitalization it was noted that you cough with
nectar thick liquids.  You should receive swallow therapy during
your rehab stay.

Medications changed on this admission:
-->You are being sent home on lovenox and coumadin.  Lovenox
acts as a blood thinner that you should continue to use until
your coumadin levels are therapeutic. Your goal INR is [**12-24**].  It
should be rechecked in one week.
--> Please take ciprofloxacin for a urinary tract infection,
please complete course as directed

Please call your doctor or go the nearest emergency room if:
-You have new shortness of breath
-You have chest pain
-You become lightheaded or faint
-You develop blood in the stool
-Any other concerning symptom


Followup Instructions:
Please follow up with your primary care physician after you are
discharged from rehab.  Dr. [**First Name8 (NamePattern2) 4320**] [**Last Name (NamePattern1) 4321**] [**Telephone/Fax (1) 82911**]


                             [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]

Completed by:[**2121-10-7**]
{'Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Other pulmonary embolism and infarction,Urinary tract infection, site not specified,Diseases of tricuspid valve,Other chronic pulmonary heart diseases,Dysphagia, unspecified,Leukocytosis, unspecified,Bipolar disorder, unspecified,Diaphragmatic hernia without mention of obstruction or gangrene,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Osteoporosis, unspecified,Anemia, unspecified,Congestive heart failure, unspecified'}


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: Shortness of breath and palpitations

PRESENT ILLNESS: [**Age over 90 **] year old female with hypertension, dementia, presenting to ED
with acute onset of palpitations and dyspnea.  Started at 4:30pm
after drinking a cup of coffee, which caused her to cough, and
continued afterwards.  Thought perhaps was aspiration or
irritation related.  Denies chest pain, back pain, nausea,
diaphoresis.

MEDICAL HISTORY: - Hyperlipidemia
- Hypertension
- Hypothyroidism
- History of cellulitis of leg [**8-/2120**]
- Dementia
- Bipolar illness
- History of hernia repair
- Constipation
- Osteoporosis
- compression fx seen on xrays
- AAA s/p repair

MEDICATION ON ADMISSION: Aspirin 81 mg daily
Levothyroxine 75 mcg daily
Simvastatin 10 mg daily
Risperdal 0.5 mg QAM, 1.5 mg QPM
Mirtazepine 22.5 mg daily
Ranitidine 150 mg daily
Calcium plus D [**Hospital1 **]
Multivitamin daily
B12 1000 mcg daily
B6 100 mg daily
Folate 0.4 mg daily
mag citrate prn
lactulose prn
eucerin cream

ALLERGIES: Neomycin/Bacitrac Zn/Polymyxin

PHYSICAL EXAM: T 98.4 BP: 121/54 P: 75 R: 18 O2: 95% on 3L
General: Sleepy though easily arousable, cachectic elderly
female.
HEENT: Sclera anicteric, PERRL. MM slightly dry, oropharynx
clear
Neck: supple, JVD to 2 cm ASA, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused UEs, slightly cool LEs, 2+ pulses, no
clubbing, cyanosis. Trace to 1+ bilateral LE edema.

FAMILY HISTORY: Son was [**Name2 (NI) 82909**], committed suicide. Daughter deceased from
pancreatic cancer. One other daughter currently alive and well.

SOCIAL HISTORY: Lives in dementia unit at [**Last Name (un) 35689**] House, daughter actively
involved in her care. Formerly worked as a dental assistant
No current smoking or EtOH. 

### Response:
{'Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Other pulmonary embolism and infarction,Urinary tract infection, site not specified,Diseases of tricuspid valve,Other chronic pulmonary heart diseases,Dysphagia, unspecified,Leukocytosis, unspecified,Bipolar disorder, unspecified,Diaphragmatic hernia without mention of obstruction or gangrene,Unspecified essential hypertension,Other persistent mental disorders due to conditions classified elsewhere,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Osteoporosis, unspecified,Anemia, unspecified,Congestive heart failure, unspecified'}
