CHIEF COMPLAINT: Facial swelling

PRESENT ILLNESS: 46 y/o M w/ OSA on CPAP and HTN (on ACE-I) who presents with
generalized body and facial swelling.  The patient was in his
usual state of health until this AM when he woke up coughing and
with a hoarse voice.  Patient noted that he had generalized
swelling along his body, but noted swelling of the lips and
tongue swelling.  Patient went to the ED.  Per OMR records the
patient has been on Quinipril since [**2115**], but there is a
question of whether he was changed to lisinopril in mid-[**Month (only) 958**].
The wife is unsure.  There was no history of insect sting or new
food/drug ingestion.
.
In the ED, initial vs were: 97.3 74 161/103 18 95%RA. Patient
was given Benadryl 50mg IV x 1, Solumedrol 125mg IV x 1,
Famotidine 40mg and 2L IVF.  Patient has a laryngoscopy and was
noted to have supraglottic swelling, but no cord swelling.  The
patient started to have increased tongue swelling and lip
swelling in the ED and was intubated by anesthesia.  Patient was
started on Propofol.  ENT was called and recommended Decadron
10mg IV q8hrs x 3 and allergy c/s.  On transfer VS are Afeb, 86,
132/86, 15, 100% AC 100Fio2
.
Review of systems:
(+) Per HPI. Additionally, the wife reports he did have chest
pain and SOB prior yesterday.
.
(-) Wife denied the patient had any fever, chills, night sweats,
recent weight loss or gain. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough, or wheezing. Denies
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain.

MEDICAL HISTORY: obstructive sleep apnea
hypertension
obesity
hyperlipidemia
low back pain
right rotator cuff tear

MEDICATION ON ADMISSION: Lisinopril (unclear exact dose) x a few months, previously on
Quinipril 20mg daily previously
Lipitor 80mg daily
Diltiazem SR 180mg daily
Gabapentin 600mg qam and 1200mg qhs
HCTZ 25mg daily
Percocet 5mg-325mg 2tabs 3x per day
ASA 81mg daily

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: Vitals: T:97.5 BP:152/84 P:80 R:14  O2: 99%
AC Vt 550, Rate: 16 PEEP 5, FiO2 50
General: intubated and sedated, withraws to pain
HEENT: facial swelling including lips and tongue, Sclera
anicteric, MMM, ET and OG tube in place
Neck: supple, JVP difficult to assess, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
lower ext edema. Pt with b/l hand swelling

FAMILY HISTORY: mother alive at 71 with COPD, T2DM, and cancer; Father deceased
at young age from a construction accident

SOCIAL HISTORY: Works as laborer.  Lives at home with his wife.  no tobacco,
etoh, drugs.  Has h/o illicit drug use.
Angioneurotic edema, not elsewhere classified,Acute respiratory failure,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Morbid obesity,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension
Angioneurotic edema,Acute respiratry failure,Adv eff cardiovasc NEC,Hyperlipidemia NEC/NOS,Morbid obesity,Obstructive sleep apnea,Hypertension NOS
Admission Date:  [**2119-3-25**]              Discharge Date:   [**2119-3-28**]

Date of Birth:  [**2072-8-24**]             Sex:   M

Service: MEDICINE

Allergies:
Ace Inhibitors

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Facial swelling

Major Surgical or Invasive Procedure:
None

History of Present Illness:
46 y/o M w/ OSA on CPAP and HTN (on ACE-I) who presents with
generalized body and facial swelling.  The patient was in his
usual state of health until this AM when he woke up coughing and
with a hoarse voice.  Patient noted that he had generalized
swelling along his body, but noted swelling of the lips and
tongue swelling.  Patient went to the ED.  Per OMR records the
patient has been on Quinipril since [**2115**], but there is a
question of whether he was changed to lisinopril in mid-[**Month (only) 958**].
The wife is unsure.  There was no history of insect sting or new
food/drug ingestion.
.
In the ED, initial vs were: 97.3 74 161/103 18 95%RA. Patient
was given Benadryl 50mg IV x 1, Solumedrol 125mg IV x 1,
Famotidine 40mg and 2L IVF.  Patient has a laryngoscopy and was
noted to have supraglottic swelling, but no cord swelling.  The
patient started to have increased tongue swelling and lip
swelling in the ED and was intubated by anesthesia.  Patient was
started on Propofol.  ENT was called and recommended Decadron
10mg IV q8hrs x 3 and allergy c/s.  On transfer VS are Afeb, 86,
132/86, 15, 100% AC 100Fio2
.
Review of systems:
(+) Per HPI. Additionally, the wife reports he did have chest
pain and SOB prior yesterday.
.
(-) Wife denied the patient had any fever, chills, night sweats,
recent weight loss or gain. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough, or wheezing. Denies
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain.


Past Medical History:
obstructive sleep apnea
hypertension
obesity
hyperlipidemia
low back pain
right rotator cuff tear

Social History:
Works as laborer.  Lives at home with his wife.  no tobacco,
etoh, drugs.  Has h/o illicit drug use.


Family History:
mother alive at 71 with COPD, T2DM, and cancer; Father deceased
at young age from a construction accident


Physical Exam:
Vitals: T:97.5 BP:152/84 P:80 R:14  O2: 99%
AC Vt 550, Rate: 16 PEEP 5, FiO2 50
General: intubated and sedated, withraws to pain
HEENT: facial swelling including lips and tongue, Sclera
anicteric, MMM, ET and OG tube in place
Neck: supple, JVP difficult to assess, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
lower ext edema. Pt with b/l hand swelling


Pertinent Results:
LABS ON ADMISSION:
[**2119-3-25**] 06:20AM BLOOD WBC-7.7 RBC-4.79 Hgb-14.2 Hct-42.6 MCV-89
MCH-29.5 MCHC-33.2 RDW-14.0 Plt Ct-257
[**2119-3-25**] 06:20AM BLOOD Neuts-61.3 Lymphs-30.6 Monos-6.3 Eos-1.4
Baso-0.4
[**2119-3-25**] 06:20AM BLOOD Plt Ct-257
[**2119-3-25**] 06:20AM BLOOD Glucose-122* UreaN-13 Creat-0.8 Na-143
K-4.5 Cl-104 HCO3-28 AnGap-16
[**2119-3-25**] 06:20AM BLOOD CK(CPK)-509*
[**2119-3-25**] 02:14PM BLOOD ALT-36 AST-20 CK(CPK)-368* AlkPhos-34*
TotBili-0.4
[**2119-3-25**] 02:14PM BLOOD Albumin-4.3

Cardiac Enzymes:
[**2119-3-26**] 03:56AM BLOOD CK-MB-3 cTropnT-<0.01
[**2119-3-25**] 02:14PM BLOOD CK-MB-5 cTropnT-<0.01
[**2119-3-25**] 06:20AM BLOOD cTropnT-<0.01
[**2119-3-25**] 06:20AM BLOOD CK-MB-5

Blood Gases:
[**2119-3-25**] 11:49PM BLOOD Type-ART Tidal V-650 FiO2-50 pO2-84*
pCO2-44 pH-7.42 calTCO2-30 Base XS-3 -ASSIST/CON
Intubat-INTUBATED
[**2119-3-25**] 09:51AM BLOOD Type-ART pO2-87 pCO2-52* pH-7.34*
calTCO2-29 Base XS-0
[**2119-3-25**] 06:38AM BLOOD Type-ART pO2-91 pCO2-52* pH-7.39
calTCO2-33* Base XS-4 Intubat-NOT INTUBA Comment-O2 DELIVER

LABS ON DISCHARGE:
[**2119-3-28**] 06:44AM BLOOD WBC-14.2* RBC-4.43* Hgb-12.9* Hct-39.0*
MCV-88 MCH-29.1 MCHC-33.0 RDW-13.5 Plt Ct-284
[**2119-3-28**] 06:44AM BLOOD Plt Ct-284
[**2119-3-28**] 06:44AM BLOOD Glucose-124* UreaN-15 Creat-0.8 Na-139
K-3.6 Cl-99 HCO3-32 AnGap-12
[**2119-3-28**] 06:44AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.2

EKG:
Baseline artifact. Sinus rhythm. Left axis deviation. Late R
wave progression. Since the previous tracing of [**2103-8-30**] axis is
more leftward.
Probably no significant change.

IMAGING:
CXR, single portable upright: The enlarged cardiomediastinal
silhouette is stable. The pulmonary vasculature is within normal
limits. There is no pleural effusion or pneumothorax. No focal
consolidation is noted. Degenerative changes are moderate.
IMPRESSION: No pneumonia or CHF.


Brief Hospital Course:
46M with obstructive sleep apnea on CPAP and hypertension on
ACE-I presenting with angioedema and respiratory distress.

1. Angioedema with Respiratory Distress: Intubated as below.
Allergy consulted and felt most likely secondary to the
ACE-inhibitor. Additional causes that were considered were
infection, complement consumption, or C1 inhibitor deficiency.
C4 and C1 levels were sent and were pending at discharge.
Treated with decadron, diphenhydramine, and famotidine. His
ACE-inhibitor was discontinued and an ADR added to his medical
record. His aspirin was also held during the course of his
hospitalization. Discharged on prednisone taper as well as one
week of ranitidine. Complement levels pending at time of
discharge. Per discussion with allergy will f/u C1, C1 inh, C4
levels at primary care follow up and only have patient return to
allergy if abnormal results or symptoms return.

2. Respiratory Failure: Intubated in the ED for respiratory
distress in the setting of angioedema. ENT eval that showed
supraglottic swelling. No evidence of consolidation or other
acute process on CXR or history. Treated with steroids and
antihistamines. Successfully extubated on [**2119-3-26**] without
complication. Breathing comfortably on room air at the time of
discharge.

3. Hypertension: Lisinopril stopped as above. Diltiazem and HCTZ
continued but with suboptimal control with SBPs into the 170s.
Started clonidine 0.1 [**Hospital1 **] prior to discharge with primary care
follow up the day after discharge. Per discussion with allergy
we should avoid ARBs as well as ACE-Is, as there is a small but
significant incidence (~5%) of angioedema with ARBs in patient
with ACE-I- induced angioedema.

4. Obesity: Patient is morbidly obese. He appears highly
motivated to address this and spontaneously states that most of
his medical issues would be significantly helped by losing
weight, including his hypertension, OSA, and borderline
diabetes. Given his motivation, weight loss strategies were
discussed at length, and will be followed up by myself and Dr.
[**Last Name (STitle) **] in the primary care setting. In particular we discussed
setting very moderate but realistic goals and emphasized the
likely benefit to his health of even moderate sustained weight
loss. Suggested trying to lose no more than 0.5 to 1 pound per
week, with the goal of losing 25-30 pounds across the next year.
Exercise possibilities were discussed with an emphasis placed on
finding something he enjoyed and would stick with rather than
setting a likely unrealistic/unsustainable goal of spending an
hour a day on a treadmill. Of note, he and his son both stated
that he enjoys swimming, which might be an excellent option for
him, especially given his current body habitus. We also
discussed dieting at length and shared in the difficulty
involved. Rather than suggest that he immediately start any
particular low-calorie diet, which he has failed in the past, I
suggested that he spend the next week simply recording
everything he eats in a food journal, and then plan to review
the food journal with us at his next follow up appointment in 1
week, with the goal of gradually making small changes in his
diet that will enable him to sustain a slow but steady weight
loss. The possibility of bariatric surgery was not discussed,
but might be considered given his BMI and increasing
obesity-related morbidity. The services of a nutritionist were
also not specifically discussed, and will be discussed in follow
up.

5. Obstructive sleep apnea: continued on CPAP after extubation.
Per OMR it appears that the patient missed or had to reschedule
his most recent sleep study. The likely impact of weight loss on
his OSA was discussed.

6. Hyperlipidemia: continued on his home dose of lipitor.

7. Lower back pain: chronic, stable. Managed with patient's home
regimen of gabapentin and percocet after extubation.

Medications on Admission:
Lisinopril (unclear exact dose) x a few months, previously on
Quinipril 20mg daily previously
Lipitor 80mg daily
Diltiazem SR 180mg daily
Gabapentin 600mg qam and 1200mg qhs
HCTZ 25mg daily
Percocet 5mg-325mg 2tabs 3x per day
ASA 81mg daily


Discharge Medications:
1. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
6. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day:
Take 6 tablets on day #1, 4 tablets on day #2, 2 tablets on day
#3, and 1 tablet on day #4, or as otherwise directed.
Disp:*30 Tablet(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
9. Diltzac ER 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
10. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice
a day for 7 days: Please take 1 tablet twice per day for the
next week.
Disp:*14 Capsule(s)* Refills:*0*
11. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO ASDIR: 1
tablet by mouth every morning and 2 tablets by mouth at bedtime.

12. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for pain.


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY:
1. Angioedema
2. Respiratory Failure
3. Hypertension

SECONDARY:
1. Obesity
2. OSA


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


Discharge Instructions:
You were admitted to the hospital for facial swelling and
shortness of breath. While you were here you were intubated to
help you breath. We think that the cause of your swelling and
difficulty breathing was a reaction called angioedema which is
similar to an allergic reaction. It is likely that you had this
from the lisinopril you were taking, as this drug is known to
occasionally cause angioedema.

We have accordingly stopped this medication and added it to your
list of drug allergies. You should never take lisinopril, or any
other medication in this category of drugs (called ACE
inhibitors) again. Please make sure to tell all of your doctors
that [**Name5 (PTitle) **] have a significant life-threatening allergy to ACE
inhibitors.

You had originally been prescribed this medication to help
control your blood pressure. Since we are stopping it, we have
started you on a new medication to help control your blood
pressure. This medication is called clonidine, and you should
take it twice every day. With this medication it is important
not to skip doses or stop taking it abruptly; doing so can cause
your blood pressure to get much higher very quickly.

We have also started you on a few other medications which you
should take for the next few weeks. The first medication is
called prednisone, which you will take decreasing doses of over
the next week. The second medication is famotidine, which is a
drug used for allergies. You should take this twice a day for
the next week. Please take both of these medications exactly as
directed.

We have scheduled you to have a brief follow up visit with Dr.
[**First Name (STitle) 1726**] at [**Hospital1 **] tomorrow, Wednesday, [**3-29**], at 1:30PM. You
will also then follow up with Dr. [**Last Name (STitle) **] the week after as
previously scheduled.


Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**]
[**Hospital3 26956**]
Wednesday, [**3-29**], at 1:30PM

Dr. [**Last Name (STitle) **] as previously scheduled

In addition, we may decide to have you follow-up with allergy.
You should discuss this with Dr. [**First Name (STitle) 1726**] or Dr. [**Last Name (STitle) **] at your
follow up appointments.
{'Angioneurotic edema, not elsewhere classified,Acute respiratory failure,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Morbid obesity,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension'}


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: Facial swelling

PRESENT ILLNESS: 46 y/o M w/ OSA on CPAP and HTN (on ACE-I) who presents with
generalized body and facial swelling.  The patient was in his
usual state of health until this AM when he woke up coughing and
with a hoarse voice.  Patient noted that he had generalized
swelling along his body, but noted swelling of the lips and
tongue swelling.  Patient went to the ED.  Per OMR records the
patient has been on Quinipril since [**2115**], but there is a
question of whether he was changed to lisinopril in mid-[**Month (only) 958**].
The wife is unsure.  There was no history of insect sting or new
food/drug ingestion.
.
In the ED, initial vs were: 97.3 74 161/103 18 95%RA. Patient
was given Benadryl 50mg IV x 1, Solumedrol 125mg IV x 1,
Famotidine 40mg and 2L IVF.  Patient has a laryngoscopy and was
noted to have supraglottic swelling, but no cord swelling.  The
patient started to have increased tongue swelling and lip
swelling in the ED and was intubated by anesthesia.  Patient was
started on Propofol.  ENT was called and recommended Decadron
10mg IV q8hrs x 3 and allergy c/s.  On transfer VS are Afeb, 86,
132/86, 15, 100% AC 100Fio2
.
Review of systems:
(+) Per HPI. Additionally, the wife reports he did have chest
pain and SOB prior yesterday.
.
(-) Wife denied the patient had any fever, chills, night sweats,
recent weight loss or gain. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denies cough, or wheezing. Denies
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain.

MEDICAL HISTORY: obstructive sleep apnea
hypertension
obesity
hyperlipidemia
low back pain
right rotator cuff tear

MEDICATION ON ADMISSION: Lisinopril (unclear exact dose) x a few months, previously on
Quinipril 20mg daily previously
Lipitor 80mg daily
Diltiazem SR 180mg daily
Gabapentin 600mg qam and 1200mg qhs
HCTZ 25mg daily
Percocet 5mg-325mg 2tabs 3x per day
ASA 81mg daily

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: Vitals: T:97.5 BP:152/84 P:80 R:14  O2: 99%
AC Vt 550, Rate: 16 PEEP 5, FiO2 50
General: intubated and sedated, withraws to pain
HEENT: facial swelling including lips and tongue, Sclera
anicteric, MMM, ET and OG tube in place
Neck: supple, JVP difficult to assess, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
lower ext edema. Pt with b/l hand swelling

FAMILY HISTORY: mother alive at 71 with COPD, T2DM, and cancer; Father deceased
at young age from a construction accident

SOCIAL HISTORY: Works as laborer.  Lives at home with his wife.  no tobacco,
etoh, drugs.  Has h/o illicit drug use. 

### Response:
{'Angioneurotic edema, not elsewhere classified,Acute respiratory failure,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Morbid obesity,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension'}
