CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 73 year old F with h/o CHF, critical AS, s/p MVR on
anticoagulation, severe COPD, and cryptogenic cirrhosis who
presented from OSH with hyponatremia and change in mental status
transferred to CCU for SOB.
.
On review of discharge summary from OSH, she presented on
[**2110-7-16**] with increasing dyspnea, orthopnea, and chest tightness.
 CXR showed  small left pleural effusion, bibasilar scarring,
and atelectasis  (per patient, pleural effusion is old and [**State 2690**]
MDs did not pursue thoracentesis given anticoagulation).  Labs
showed BNP 710, mildly elevated alk phos, LDH, and AST.  It was
felt she was volume overloaded and she was diuresed.  EKG showed
AFib with LBBB (also old).  She reportedly improved with initial
management and was ruled out for MI.  Echocardiogram was done
that reportedly showed borderline LVH, dyskinesis of mid to
distal intraventricular septum and adjacent anterior wall with
preserved contractile function of other segments.  Peak gradient
of aortic valve was 55-60.  Mild to moderate aortic
insufficiency, RV hypertrophy, severe TR, PA pressure 45mm.
Aortic valve area 0.6.  She was also seen by pulmonary, who felt
that her pleural effusions were chronic and the her dyspnea was
secondary to her aortic stenosis.
.
An acute change in mental status was noted on the morning of
[**7-24**].  Labs revealed a sodium of 110, urine osmolarity 521,
serum osms 247, amonium 55.  Normal saline was given.  There are
no records of her Na level between from [**7-20**] to [**7-24**].  Patient
was transfered to [**Hospital1 18**] for further management.
.
On arrival she was noted to be dyspneic on 3L NC, ABG
7.32/68/76.  Her mental status declined and repeat ABG 2 hours
later was 7.36/65/70.  Her BNP was 4237 and CXR looked congested
so she was diuresed with lasix.  Her Na returned at 111, repeat
was 109, and renal was consulted.  They recommended 3% NaCl
solution, but due to poor IV access she only received 2 hours
this.  This am she again looked distressed and ABG was
7.36/58/187; after lasix IV and MSO4 2 mg IV ABG was
7.25/82/318.  She was transferred to the CCU for elective
intubation.
.
After intubation the patient's ABG was 7.40/49/103.  During
attempt at A-line placement she received 12.5 mcg fentanyl and
became hypotensive with SBP in the 60s and HR 60s.  She received
atropine 1mg and dopamine gtt was started.  Her pressure
responded well and this was quickly weaned off.
.
Of note, after speaking with her PCP in [**State 2690**], she was
hospitalized in [**Month (only) **] for b/t LE cellulitis.  She was
hyponatremic to 114 at that time and was advised to stop taking
chlorthalidone on discharge (with Na of 127).  She was also
noted to have delirium during her hospital stay.  Upon traveling
to [**Location (un) 86**], she was worked up in primary care clinic at [**Hospital1 2025**] for
mental status changes.  She had a normal brain MRI and work-up
revealed only elev NH4, alk phos, and GGT, and positive [**Last Name (un) 15412**]
1:20.

MEDICAL HISTORY: -CHF: preserved EF
-critical aortic stenosis - valve area 0.6
-s/p Mitral valve replacement, INR 2.5-3.5 [**2100**].  on coumadin.
-cryptogenic cirrhosis - followed in TX.  no liver bx done.
with hepatomegaly.  neg HBV Ag, neg HCVAb.  ? of
amiodarone-induced
-idiopathic hyponatremia - baseline 120s
-Atrial fibrillation
-Severe obstructive lung disease: PFTs in [**2106**] with FEV1 0.61
(28% predicted). non-smoker
-Radiation pneumonitis
-Breast cancer @ age 24.  s/p left mastectomy, Cobalt radiation.

MEDICATION ON ADMISSION: Digoxin 0.125  (0.25 in OSH records)
Lasix 40 Qday
Clarinex 5 mg day
potasium chloride 10 meq day
Spiriva one inhalation daily
Advair 250/50
valsartan 80 [**Hospital1 **]
Vitamin b6 50 mg/day
Neurontin 200 mg am, 100 at noon 300 bed time
Coumadin, 2.5, 5- 5- 5, 2.5,
MVI
Calcium 600 mg each evening
Albuterol
Clonidine 0.1 mg PRN

ALLERGIES: Biaxin / Ciprofloxacin / Procainamide / Ceftin / Lipitor / Latex

PHYSICAL EXAM: Vitals: T: 97.4    P: 88   BP: 154/37    AC: 450/14/0.40/5
General: intubated, occ agitated.
HEENT: EOMI/PERRL, sclera anicteric.  dry oral mucosa
Neck: JVD to level of jaw.  2+ carotid pulses
Pulm: Decrease breath sounds to left base, coarse otherwise.
Cardiac: irregularly irregular, nl S1/S2, systolic ejection
murmur at RUSB with radiation to neck
Thorax: status post mastectomy
Abdomen: soft, non tender, + liver edge 2 cm below costal margen

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives in [**State 2690**] with her husband. She spends every summer here
visiting her daughter.  [**Name (NI) **] smoking or alcohol.  second-hand
exposure with husband.
Rheumatic heart failure (congestive),Acute respiratory failure,Intermediate coronary syndrome,Cirrhosis of liver without mention of alcohol,Atrial fibrillation,Cardiogenic shock,Hyposmolality and/or hyponatremia,Unspecified pleural effusion,Chronic airway obstruction, not elsewhere classified,Acute kidney failure with lesion of tubular necrosis,Mitral valve insufficiency and aortic valve stenosis,Pressure ulcer, lower back,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Heart valve replaced by other means,Personal history of malignant neoplasm of breast,Personal history of irradiation, presenting hazards to health,Other disorders of plasma protein metabolism
Rheumatic heart failure,Acute respiratry failure,Intermed coronary synd,Cirrhosis of liver NOS,Atrial fibrillation,Cardiogenic shock,Hyposmolality,Pleural effusion NOS,Chr airway obstruct NEC,Ac kidny fail, tubr necr,Mitral insuf/aort stenos,Pressure ulcer, low back,Crnry athrscl natve vssl,Chr pulmon heart dis NEC,Heart valve replac NEC,Hx of breast malignancy,Hx of irradiation,Dis plas protein met NEC
Admission Date:  [**2110-7-24**]              Discharge Date:   [**2110-8-12**]

Date of Birth:  [**2037-3-6**]             Sex:   F

Service: MEDICINE

Allergies:
Biaxin / Ciprofloxacin / Procainamide / Ceftin / Lipitor / Latex

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
intubation, pleurodesis


History of Present Illness:
73 year old F with h/o CHF, critical AS, s/p MVR on
anticoagulation, severe COPD, and cryptogenic cirrhosis who
presented from OSH with hyponatremia and change in mental status
transferred to CCU for SOB.
.
On review of discharge summary from OSH, she presented on
[**2110-7-16**] with increasing dyspnea, orthopnea, and chest tightness.
 CXR showed  small left pleural effusion, bibasilar scarring,
and atelectasis  (per patient, pleural effusion is old and [**State 2690**]
MDs did not pursue thoracentesis given anticoagulation).  Labs
showed BNP 710, mildly elevated alk phos, LDH, and AST.  It was
felt she was volume overloaded and she was diuresed.  EKG showed
AFib with LBBB (also old).  She reportedly improved with initial
management and was ruled out for MI.  Echocardiogram was done
that reportedly showed borderline LVH, dyskinesis of mid to
distal intraventricular septum and adjacent anterior wall with
preserved contractile function of other segments.  Peak gradient
of aortic valve was 55-60.  Mild to moderate aortic
insufficiency, RV hypertrophy, severe TR, PA pressure 45mm.
Aortic valve area 0.6.  She was also seen by pulmonary, who felt
that her pleural effusions were chronic and the her dyspnea was
secondary to her aortic stenosis.
.
An acute change in mental status was noted on the morning of
[**7-24**].  Labs revealed a sodium of 110, urine osmolarity 521,
serum osms 247, amonium 55.  Normal saline was given.  There are
no records of her Na level between from [**7-20**] to [**7-24**].  Patient
was transfered to [**Hospital1 18**] for further management.
.
On arrival she was noted to be dyspneic on 3L NC, ABG
7.32/68/76.  Her mental status declined and repeat ABG 2 hours
later was 7.36/65/70.  Her BNP was 4237 and CXR looked congested
so she was diuresed with lasix.  Her Na returned at 111, repeat
was 109, and renal was consulted.  They recommended 3% NaCl
solution, but due to poor IV access she only received 2 hours
this.  This am she again looked distressed and ABG was
7.36/58/187; after lasix IV and MSO4 2 mg IV ABG was
7.25/82/318.  She was transferred to the CCU for elective
intubation.
.
After intubation the patient's ABG was 7.40/49/103.  During
attempt at A-line placement she received 12.5 mcg fentanyl and
became hypotensive with SBP in the 60s and HR 60s.  She received
atropine 1mg and dopamine gtt was started.  Her pressure
responded well and this was quickly weaned off.
.
Of note, after speaking with her PCP in [**State 2690**], she was
hospitalized in [**Month (only) **] for b/t LE cellulitis.  She was
hyponatremic to 114 at that time and was advised to stop taking
chlorthalidone on discharge (with Na of 127).  She was also
noted to have delirium during her hospital stay.  Upon traveling
to [**Location (un) 86**], she was worked up in primary care clinic at [**Hospital1 2025**] for
mental status changes.  She had a normal brain MRI and work-up
revealed only elev NH4, alk phos, and GGT, and positive [**Last Name (un) 15412**]
1:20.


Past Medical History:
-CHF: preserved EF
-critical aortic stenosis - valve area 0.6
-s/p Mitral valve replacement, INR 2.5-3.5 [**2100**].  on coumadin.
-cryptogenic cirrhosis - followed in TX.  no liver bx done.
with hepatomegaly.  neg HBV Ag, neg HCVAb.  ? of
amiodarone-induced
-idiopathic hyponatremia - baseline 120s
-Atrial fibrillation
-Severe obstructive lung disease: PFTs in [**2106**] with FEV1 0.61
(28% predicted). non-smoker
-Radiation pneumonitis
-Breast cancer @ age 24.  s/p left mastectomy, Cobalt radiation.

-Reactive Airway Disease
-Diverticulitis - [**2108**]; last Cscope 6 yrs prior
-Neuropathy
-chronic left pleural effusion
-pulmonary HTN


Social History:
Lives in [**State 2690**] with her husband. She spends every summer here
visiting her daughter.  [**Name (NI) **] smoking or alcohol.  second-hand
exposure with husband.


Family History:
non-contributory

Physical Exam:
Vitals: T: 97.4    P: 88   BP: 154/37    AC: 450/14/0.40/5
General: intubated, occ agitated.
HEENT: EOMI/PERRL, sclera anicteric.  dry oral mucosa
Neck: JVD to level of jaw.  2+ carotid pulses
Pulm: Decrease breath sounds to left base, coarse otherwise.
Cardiac: irregularly irregular, nl S1/S2, systolic ejection
murmur at RUSB with radiation to neck
Thorax: status post mastectomy
Abdomen: soft, non tender, + liver edge 2 cm below costal margen

Extremities: No edema
Neurologic: intubated, sedated.  MAE.


Pertinent Results:
CXR: [**7-22**] apical pleural capping, bilateral pleural effusion,
interstitial prominence probably due to vascular congestion.
.
OSH MRI brain: small lacunar infarcts, microangiopathic disease
.
OSH Echo [**2-/2110**]:
Aortic valve area 1.2.  nl LVEF. mild AI, mod AS.  LAE and
severe [**Last Name (un) **].  RVE.  mod/severe TR with mod pulm HTN.
.
CXR [**7-24**]: Mild pulmonary edema.  Moderate bilateral pleural
effusions. Question abnormal right hilum.
.
CXR 9/1a: Moderate pulmonary edema has worsened, accompanied by
increasing moderate left and stable small right pleural
effusion.  Lobulation of the right hilus and infrahilar
consolidation need to be evaluated to exclude mass.
.
CXR 9/1b: ET tube tip is 45 mm above the carina.  NG tube tip is
not included in the film, below the diaphragm.  There is no
pneumothorax.  The lungs are more expanded.  Unchanged biapical
pleural parenchymal scarring.  Moderate pulmonary edema is less
conspicuous. Unchanged prominence of the right hilus.  Cardiac
contour is obscured by the stable bilateral moderate pleural
effusions.
.
TTE [**7-25**]: LA is mildly dilated.  No ASD is seen by 2D or color
Doppler. The IVC is dilated (>2.5 cm).  LV wall thicknesses are
normal. The LV cavity size is normal.  Overall LV systolic
function is mildly-to-moderately depressed (EF 40%); the apex
appears dyskinetic; left BBB with abnormal septal activation is
also contributing to reduced EF. The RV cavity is dilated. RV
systolic function is borderline normal. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (0.4). Mild (1+) aortic regurgitation is seen. A
bileaflet mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen (TR
gradient 51). There is moderate pulmonary artery systolic
hypertension. The main pulmonary artery is dilated. The branch
pulmonary arteries are dilated. There is no pericardial
effusion.

Brief Hospital Course:
73 yo F with h/o CHF, critical AS, s/p MVR on anticoagulation,
severe COPD, and cryptogenic cirrhosis who presented from OSH
with hyponatremia and change in mental status transferred to CCU
for SOB and intubated. S/P extubation, patient went into
cardiogenic shock and was found to have an occlusion of the left
main coronary which was stented. IABP was placed for a few days,
then successfully removed.  During her hospitalization, the
following issues were addressed:
.
Cardiovascular: Ischemia: Pt was found to have L main disease by
cath, with ostial 80% lesion with heavy calcification. First
cath, LCA unable to be stented [**12-26**] anatomical variation (too
short) that would not accommodate a stent. 2nd cath, L Cx/LAD
stented.  Her CAD was treated medically, she was anticoagulated
on heparin. .
*Valves: Severe AS (area 0.8 confirmed on cath). MVR in '[**00**], on
anticoagulation.
* Pump: Echo with EF 40%. Pt was thought to be intravascularly
depleted given persistent pleural drainage and low BP, likely
due to intravascular depletion; she was given several PRBC
transfusions, IVF, and albumin x2. .
*Rhythm: A. fib, continued on digoxin for rate control and
anticoagulaiton as above.
.
# Respiratory Failure: Patient was intubated at start of
hospitalization for hypercapnic respiratory failure.  She was
successfully extubated, but continued to have respiratory
difficulty given her pulmonary hypertension, obstructive
disease, pleural effusions, CHF, R hilar consolidation and
fullness.  CT surgery placed bilateral chest tubes which drained
large amounts of transudative fluid daily.  Pleurodesis was
performed on the R lung on [**8-10**] and on hte L lung on [**8-11**].
.
#ARF: The patient developed ARF on [**8-10**], and became oliguric on
[**8-11**].  Renal U/S was normal.  Likely due to prerenal etiology
due to intravascular hypovolemia as well as hypotension causing
decreased renal artery perfusion, despite NS boluses,
maintenance IVF, albumin, PRBC as above to maintain
intravascular volume and pressors to attempt to maintain BP.
.
#ID: the patient was treated with empiric zosyn and vancomycin
for leukocytosis and abnormal chest xray. Cultures were
persistantly negative.
.
# Hyponatremia: Acute on chronic history of hyponatremia, likely
due to intravascular volume depletion.  Na of 109 on admission
improved to baseline of 130's with hydration.
.
# H/O Cryptogenic Cirrhosis: Elevated LFTs and +[**Last Name (un) 15412**], biopsy was
never done due to anticoagulation.
.
On [**2110-8-11**] the patient went into bradycardic/asystolic arrest.
ACLS was performed, and the patient was resuscitated after [**4-2**]
minutes of CPR.  She was intubated and started on 2 pressors.
Despite this, she remained hypotensive.  A family meeting was
held and the family (husband and daughter) decided to make the
patient [**Name (NI) 3225**] given her obvious discomfort and poor prognosis.  A
morphine drip was started and other modalities of care,
including pressors and the ventilator were withdrawn.  The
patient died at 12:50AM on [**8-12**] with her husband and daughter at
her side.  An autopsy was refused.

Medications on Admission:
Digoxin 0.125  (0.25 in OSH records)
Lasix 40 Qday
Clarinex 5 mg day
potasium chloride 10 meq day
Spiriva one inhalation daily
Advair 250/50
valsartan 80 [**Hospital1 **]
Vitamin b6 50 mg/day
Neurontin 200 mg am, 100 at noon 300 bed time
Coumadin, 2.5, 5- 5- 5, 2.5,
MVI
Calcium 600 mg each evening
Albuterol
Clonidine 0.1 mg PRN


Discharge Medications:
NA

Discharge Disposition:
Expired

Discharge Diagnosis:
Expired.

Discharge Condition:
Expired.

Discharge Instructions:
Expired.

Followup Instructions:
Expired.
{'Rheumatic heart failure (congestive),Acute respiratory failure,Intermediate coronary syndrome,Cirrhosis of liver without mention of alcohol,Atrial fibrillation,Cardiogenic shock,Hyposmolality and/or hyponatremia,Unspecified pleural effusion,Chronic airway obstruction, not elsewhere classified,Acute kidney failure with lesion of tubular necrosis,Mitral valve insufficiency and aortic valve stenosis,Pressure ulcer, lower back,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Heart valve replaced by other means,Personal history of malignant neoplasm of breast,Personal history of irradiation, presenting hazards to health,Other disorders of plasma protein metabolism'}


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

PRESENT ILLNESS: 73 year old F with h/o CHF, critical AS, s/p MVR on
anticoagulation, severe COPD, and cryptogenic cirrhosis who
presented from OSH with hyponatremia and change in mental status
transferred to CCU for SOB.
.
On review of discharge summary from OSH, she presented on
[**2110-7-16**] with increasing dyspnea, orthopnea, and chest tightness.
 CXR showed  small left pleural effusion, bibasilar scarring,
and atelectasis  (per patient, pleural effusion is old and [**State 2690**]
MDs did not pursue thoracentesis given anticoagulation).  Labs
showed BNP 710, mildly elevated alk phos, LDH, and AST.  It was
felt she was volume overloaded and she was diuresed.  EKG showed
AFib with LBBB (also old).  She reportedly improved with initial
management and was ruled out for MI.  Echocardiogram was done
that reportedly showed borderline LVH, dyskinesis of mid to
distal intraventricular septum and adjacent anterior wall with
preserved contractile function of other segments.  Peak gradient
of aortic valve was 55-60.  Mild to moderate aortic
insufficiency, RV hypertrophy, severe TR, PA pressure 45mm.
Aortic valve area 0.6.  She was also seen by pulmonary, who felt
that her pleural effusions were chronic and the her dyspnea was
secondary to her aortic stenosis.
.
An acute change in mental status was noted on the morning of
[**7-24**].  Labs revealed a sodium of 110, urine osmolarity 521,
serum osms 247, amonium 55.  Normal saline was given.  There are
no records of her Na level between from [**7-20**] to [**7-24**].  Patient
was transfered to [**Hospital1 18**] for further management.
.
On arrival she was noted to be dyspneic on 3L NC, ABG
7.32/68/76.  Her mental status declined and repeat ABG 2 hours
later was 7.36/65/70.  Her BNP was 4237 and CXR looked congested
so she was diuresed with lasix.  Her Na returned at 111, repeat
was 109, and renal was consulted.  They recommended 3% NaCl
solution, but due to poor IV access she only received 2 hours
this.  This am she again looked distressed and ABG was
7.36/58/187; after lasix IV and MSO4 2 mg IV ABG was
7.25/82/318.  She was transferred to the CCU for elective
intubation.
.
After intubation the patient's ABG was 7.40/49/103.  During
attempt at A-line placement she received 12.5 mcg fentanyl and
became hypotensive with SBP in the 60s and HR 60s.  She received
atropine 1mg and dopamine gtt was started.  Her pressure
responded well and this was quickly weaned off.
.
Of note, after speaking with her PCP in [**State 2690**], she was
hospitalized in [**Month (only) **] for b/t LE cellulitis.  She was
hyponatremic to 114 at that time and was advised to stop taking
chlorthalidone on discharge (with Na of 127).  She was also
noted to have delirium during her hospital stay.  Upon traveling
to [**Location (un) 86**], she was worked up in primary care clinic at [**Hospital1 2025**] for
mental status changes.  She had a normal brain MRI and work-up
revealed only elev NH4, alk phos, and GGT, and positive [**Last Name (un) 15412**]
1:20.

MEDICAL HISTORY: -CHF: preserved EF
-critical aortic stenosis - valve area 0.6
-s/p Mitral valve replacement, INR 2.5-3.5 [**2100**].  on coumadin.
-cryptogenic cirrhosis - followed in TX.  no liver bx done.
with hepatomegaly.  neg HBV Ag, neg HCVAb.  ? of
amiodarone-induced
-idiopathic hyponatremia - baseline 120s
-Atrial fibrillation
-Severe obstructive lung disease: PFTs in [**2106**] with FEV1 0.61
(28% predicted). non-smoker
-Radiation pneumonitis
-Breast cancer @ age 24.  s/p left mastectomy, Cobalt radiation.

MEDICATION ON ADMISSION: Digoxin 0.125  (0.25 in OSH records)
Lasix 40 Qday
Clarinex 5 mg day
potasium chloride 10 meq day
Spiriva one inhalation daily
Advair 250/50
valsartan 80 [**Hospital1 **]
Vitamin b6 50 mg/day
Neurontin 200 mg am, 100 at noon 300 bed time
Coumadin, 2.5, 5- 5- 5, 2.5,
MVI
Calcium 600 mg each evening
Albuterol
Clonidine 0.1 mg PRN

ALLERGIES: Biaxin / Ciprofloxacin / Procainamide / Ceftin / Lipitor / Latex

PHYSICAL EXAM: Vitals: T: 97.4    P: 88   BP: 154/37    AC: 450/14/0.40/5
General: intubated, occ agitated.
HEENT: EOMI/PERRL, sclera anicteric.  dry oral mucosa
Neck: JVD to level of jaw.  2+ carotid pulses
Pulm: Decrease breath sounds to left base, coarse otherwise.
Cardiac: irregularly irregular, nl S1/S2, systolic ejection
murmur at RUSB with radiation to neck
Thorax: status post mastectomy
Abdomen: soft, non tender, + liver edge 2 cm below costal margen

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives in [**State 2690**] with her husband. She spends every summer here
visiting her daughter.  [**Name (NI) **] smoking or alcohol.  second-hand
exposure with husband. 

### Response:
{'Rheumatic heart failure (congestive),Acute respiratory failure,Intermediate coronary syndrome,Cirrhosis of liver without mention of alcohol,Atrial fibrillation,Cardiogenic shock,Hyposmolality and/or hyponatremia,Unspecified pleural effusion,Chronic airway obstruction, not elsewhere classified,Acute kidney failure with lesion of tubular necrosis,Mitral valve insufficiency and aortic valve stenosis,Pressure ulcer, lower back,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Heart valve replaced by other means,Personal history of malignant neoplasm of breast,Personal history of irradiation, presenting hazards to health,Other disorders of plasma protein metabolism'}
