CHIEF COMPLAINT: Dyspnea, LE edema

PRESENT ILLNESS: 74 yo M hx CAD s/p IMI, AF with CMP (EF 40%) p/w dyspnea for the
past few days, lower leg edema, and rapid AF to 180. The patient
denies CP, palpatations, LH. He has not been feeling well for
the past few days, and for that reason, has not taken any of his
medications since thursday. The SOB made him come in to the ED
yesterday. The SOB is on exertion, not at rest. He generally has
LE edema, but his legs have never as swollen as they are now.
.
In the ED, he responded to 30mg IV diltizem, and is now on gtt,
at 15mg/hr. Has old RBBB. On BB and CCB at home, and has been
non compliant with all his medications for the past 2 days
(including lovenox)
.
On admission to CCU, rate in 110-120's, VSS. no longer
complaining of SOB.
.
ROS:
- denies history of stroke, TIA, PE, bleeding during surgery,
myalgias, cough, hemoptysis, black stools or red stools.
- denies recent fevers, chills or rigors.
- ROS positive for hx of DVT (popliteal, while anticoagulated on
coumadin, now in lovenox), and occassional joint pain.
.
Cardiac ROS:
- positive for DOE, LE edema.
- denies chest pain, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.

MEDICAL HISTORY: HTN
Atrial fibrillation
Dyslipidemia
h/o L popliteal vein DVT
History of anxiety and depression.
Peptic ulcer disease.
Diaphragmatic hernia.
CKD
Prostate CA dx [**5-2**] T2a prostate cancer
R hernia repair [**2069**]
Cardoimyopathy, ? tachycardia induced
.

MEDICATION ON ADMISSION: -aspirin 325
-Lovenox 12/.8mL [**Hospital1 **]
-Toprol XL 200 mg daily
-verapamil 240
-Lasix 10
-atorvastatin 10
-ranitidine 150 twice a day
-pantoprazole 40
-triamterene & hydrochlorothiazide 37.5/25
-paroxetine 10
-benicar 40 daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VS: T 97.2, BP 161/105, HR 121, RR 22, O2 100% on 2l
Gen: pleasant black male in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. injected conjuctiva. PERRL, EOMI. non pallor or
cyanosis of the oral mucosa.
Neck: Supple with non elevated JVP.
CV: irregularly irregular, no murmurs appreciated. non displaced
PMI
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. bibasilar crackles, no
wheezes or rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: 4+ LE edema
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: No family history of prostate cancer.

SOCIAL HISTORY: married, lives with wife, retired walks reg for exercise. quit
cig 30yrs ago (~ 15 pack years). no etoh.  Walks without a
walker.
Acute on chronic diastolic heart failure,Other primary cardiomyopathies,Chronic kidney disease, unspecified,Hypopotassemia,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Personal history of noncompliance with medical treatment, presenting hazards to health,Esophageal reflux,Depressive disorder, not elsewhere classified
Ac on chr diast hrt fail,Prim cardiomyopathy NEC,Chronic kidney dis NOS,Hypopotassemia,Atrial fibrillation,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Hx of past noncompliance,Esophageal reflux,Depressive disorder NEC
Admission Date:  [**2114-9-16**]              Discharge Date:   [**2114-9-17**]

Date of Birth:  [**2039-9-24**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Dyspnea, LE edema

Major Surgical or Invasive Procedure:
Major Procedures:
None


History of Present Illness:
74 yo M hx CAD s/p IMI, AF with CMP (EF 40%) p/w dyspnea for the
past few days, lower leg edema, and rapid AF to 180. The patient
denies CP, palpatations, LH. He has not been feeling well for
the past few days, and for that reason, has not taken any of his
medications since thursday. The SOB made him come in to the ED
yesterday. The SOB is on exertion, not at rest. He generally has
LE edema, but his legs have never as swollen as they are now.
.
In the ED, he responded to 30mg IV diltizem, and is now on gtt,
at 15mg/hr. Has old RBBB. On BB and CCB at home, and has been
non compliant with all his medications for the past 2 days
(including lovenox)
.
On admission to CCU, rate in 110-120's, VSS. no longer
complaining of SOB.
.
ROS:
- denies history of stroke, TIA, PE, bleeding during surgery,
myalgias, cough, hemoptysis, black stools or red stools.
- denies recent fevers, chills or rigors.
- ROS positive for hx of DVT (popliteal, while anticoagulated on
coumadin, now in lovenox), and occassional joint pain.
.
Cardiac ROS:
- positive for DOE, LE edema.
- denies chest pain, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.


Past Medical History:
HTN
Atrial fibrillation
Dyslipidemia
h/o L popliteal vein DVT
History of anxiety and depression.
Peptic ulcer disease.
Diaphragmatic hernia.
CKD
Prostate CA dx [**5-2**] T2a prostate cancer
R hernia repair [**2069**]
Cardoimyopathy, ? tachycardia induced
.


Social History:
married, lives with wife, retired walks reg for exercise. quit
cig 30yrs ago (~ 15 pack years). no etoh.  Walks without a
walker.


Family History:
No family history of prostate cancer.

Physical Exam:
PHYSICAL EXAMINATION:
VS: T 97.2, BP 161/105, HR 121, RR 22, O2 100% on 2l
Gen: pleasant black male in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. injected conjuctiva. PERRL, EOMI. non pallor or
cyanosis of the oral mucosa.
Neck: Supple with non elevated JVP.
CV: irregularly irregular, no murmurs appreciated. non displaced
PMI
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. bibasilar crackles, no
wheezes or rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: 4+ LE edema
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

.
EKG demonstrated rate of 155, RBBB, atrial fibrillation.
.


Pertinent Results:
Chest Xray [**2114-9-15**]
No acute pulmonary process
.
LLE LENI [**2114-9-15**]
No evidence of left lower extremity DVT. Popliteal vein appears
to compress normally in comparison to prior examination but exam
was limited in this region.
.
CTA Chest [**2114-9-15**]
No central or segmental pe. distal branches obscured due to
breathing. ?mild chf.
.
2D-ECHOCARDIOGRAM performed on [**2114-5-1**] demonstrated:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. Overall left ventricular systolic function is
normal (LVEF 60%; this value represents the estimated ejection
fraction following a normal left ventricular filling period).
There is no ventricular septal defect. The right ventricular
cavity is dilated. Right ventricular systolic function appears
depressed. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
Compared with the findings of the prior study (images reviewed)
of [**2113-12-14**], the ventricular rate is now well-controlled
and the left ventricular ejection fraction is increased.
.
ETT performed on [**2112-10-4**] demonstrated:
4.5 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol (3.5METs) and stopped for
fatigue. The ST segments are uninterpretable in the setting of
RBBB with diffuse ST-T wave abnormalities at baseline. The
rhythm was sinus with frequent AEA (isolated APDs) and frequent
VEA (isolated multifocal VPDs, ventricular couplets and
ventricular bigeminy). The hemodynamic response to exercise was
appropriate.


Brief Hospital Course:
This patient is a 74 y/o M with history of a fib,
cardiomyopathy, HTN, gerd, DVT (on lovenox), p/w SOB, LE edema
and in Afib with RVR.
.
1. AFib RVR: Patient has been noncompliant with his medications
for the last few days, secondary to "not feeling well." on
lovenox, on rate control, working with Dr. [**Last Name (STitle) **] as
outpatient to control without starting amiodarone.
- Patient on Diltizem drip 20mg/hr. Start wean
- Load with PO dilt, 60 QID
- Metoprolol 100mg [**Hospital1 **] (on 200mg toprol as outpatient)
- monitor vital signs, consider cardioversion for instability
-> Pt admitted to CCU.  Rate control achieved with 200mg toprol
XL and verpamil 240mg and diltiazem weaned.  Patient discharged
on above regimen.  Lovenox continued at therapeutic doses for
anticoagulation for DVT and A. Fib.
.
2. CHF, diastolic acute on chronic: patient with significant LE
edema, has not taken diuretics for last 2 days, bibasilar
crackles, SOB, O2 requirement
- back on home dyazide
- 10mg Lasix IV
- goal out 1L today
-> Patient diuresed well with net ouf 750cc day 1 and net out on
day of discharge.  Symptomatically improved.  Home lasix dose
increased to 20mg PO.  Given 10meq PO Potassium as mildly
hypokalemic during hospital stay.
.
3. CAD: ? old infarct on EKG. No history of MI, stress
uninterpretable secondary to RBBB
- continue ASA, Statin, BBlocker, ACEI
- f/u with outpatient provider.
.
4. Dyspnea: likely secondary to a fib and CHF exacerbation. no
wheezes
- treat a fib with rate control
- diurese
-> Improved and 93% on RA on day of discharge.
-> CTA of chest showed no significant PE but ? RLL filling
defect.  Low suspicion for PE, patient anticoagulated in any
case and study not repeated.  LE USD negative for DVT with
compression of popliteal vein (also limited study).  CT Scan of
chest demonstrated lymphadenopathy noted on prior scans and
stable RUL nodule.  Recommend repeat CT in [**5-8**] months for
lymphadenopathy, and outpatient CT scan or PET scan for
lymphadenopathy.  Discussed with PCP who is aware and agrees
with plan.
.
5. depression - stable
- continue paxil
.
6. GERD, Hiatal Hernia - stable
- Ranitidine decreased for Cr 1.4 to daily dosing.
- continue pantoprazole
.
Code: presumed full
.
Dispo: Tranfer to home directly from CCU.  F/u as below.
.


Medications on Admission:
-aspirin 325
-Lovenox 12/.8mL [**Hospital1 **]
-Toprol XL 200 mg daily
-verapamil 240
-Lasix 10
-atorvastatin 10
-ranitidine 150 twice a day
-pantoprazole 40
-triamterene & hydrochlorothiazide 37.5/25
-paroxetine 10
-benicar 40 daily


Discharge Medications:
1. Outpatient Lab Work
Chem-7 on friday [**2114-9-21**]
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Enoxaparin 60 mg/0.6 mL Syringe Sig: Two (2) syringe
Subcutaneous [**Hospital1 **] (2 times a day): Please inject 120mg or 1.2ml
twice per day.  Disp:*120 syringe* Refills:*1*
5. Metoprolol Succinate 100 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*
6. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
11. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Olmesartan 20 mg Tablet Sig: Two (2) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*2*
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO DAILY (Daily) for 3 days.
Disp:*3 Capsule, Sustained Release(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
1. Atrial Fibrillation,
2. Acute on chronic systolic and diastolic heart failure.
3. Dilated cardiomyoapthy
3. Gastroesophageal reflux disease
4. Hypertension
5. Depression
6. Lung Nodule
7. Lymphadenopathy

Discharge Condition:
Stable


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: as per primary physician.

You were admitted to the hospital for evaluation of shortness of
breath, and lower extremity swelling.  These symptoms are likely
related to your heart failure and having missed doses of your
medications.  While in the hospital your doses of medication
were increased and fluid was removed.  Upon leaving the hospital
your dose of furosemide was increased to 20mg PO daily.  In
addition, please take a dialy potassium supplement of 10meq per
day for the next 3 days.  Please take this and all other
medications as directed.  Should you develop any new shortness
of breath, lower extremity swelling please call your primary
physician or present to the Emergency Room.  If you develop any
sudden severe chest pain or other symptoms concerning to you
please call your PCP or return to the ED.

Followup Instructions:
Please follow-up as follows:
1.  Laboratory Draw this Friday, [**2114-9-21**] - as instructed.
2.  Repeat CT scan in [**5-8**] months for interval change in lung
nodules.
3.  Discuss with your PCP regarding PET scan or CT scan for
lymphadenopathy in lung nodules.  PCP [**Name Initial (PRE) 12309**].
4.  Please call your PCP for an appointment for next week.
[**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 2205**].  She is awaiting your call and will
follow-up your lab results.
5.  Follow-up with your Cardiologist as directed.





Name:  [**Known lastname 5282**],[**Known firstname **]                     Unit No:   [**Numeric Identifier 16188**]

Admission Date:  [**2114-9-16**]              Discharge Date:   [**2114-9-17**]

Date of Birth:  [**2039-9-24**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4868**]
Addendum:
After discharge, LMWH level was returned showing that it was
slightly sub-therapeutic 0.4 (0.6 low end of therapeutic range).
 It was unclear whether the level had been drawn at the
appropriate interval s/p lovenox dosing (typically drawn [**3-2**]
hours after dosing).  As a result, it was determined that it
would be optimal to have the patient f/u with his PCP for [**Name Initial (PRE) **]
second check of his LMHW level prior to adjusting his dose.
This was discussed with PCP and patient who are in agreement
with the plan.  Patient advised to continue taking lovenox as
directed 120mg [**Hospital1 **].  On day of lab test, will take 120mg at 8am
(as per normal) and then present for blood draw at PCP's office
at 12pm.  No further changes to original discharge summary and
plan.

Discharge Disposition:
Home

                             [**Name6 (MD) **] [**Last Name (NamePattern4) 4869**] MD [**MD Number(2) 4870**]

Completed by:[**2114-9-19**]
{'Acute on chronic diastolic heart failure,Other primary cardiomyopathies,Chronic kidney disease, unspecified,Hypopotassemia,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Personal history of noncompliance with medical treatment, presenting hazards to health,Esophageal reflux,Depressive disorder, not elsewhere classified'}


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, LE edema

PRESENT ILLNESS: 74 yo M hx CAD s/p IMI, AF with CMP (EF 40%) p/w dyspnea for the
past few days, lower leg edema, and rapid AF to 180. The patient
denies CP, palpatations, LH. He has not been feeling well for
the past few days, and for that reason, has not taken any of his
medications since thursday. The SOB made him come in to the ED
yesterday. The SOB is on exertion, not at rest. He generally has
LE edema, but his legs have never as swollen as they are now.
.
In the ED, he responded to 30mg IV diltizem, and is now on gtt,
at 15mg/hr. Has old RBBB. On BB and CCB at home, and has been
non compliant with all his medications for the past 2 days
(including lovenox)
.
On admission to CCU, rate in 110-120's, VSS. no longer
complaining of SOB.
.
ROS:
- denies history of stroke, TIA, PE, bleeding during surgery,
myalgias, cough, hemoptysis, black stools or red stools.
- denies recent fevers, chills or rigors.
- ROS positive for hx of DVT (popliteal, while anticoagulated on
coumadin, now in lovenox), and occassional joint pain.
.
Cardiac ROS:
- positive for DOE, LE edema.
- denies chest pain, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.

MEDICAL HISTORY: HTN
Atrial fibrillation
Dyslipidemia
h/o L popliteal vein DVT
History of anxiety and depression.
Peptic ulcer disease.
Diaphragmatic hernia.
CKD
Prostate CA dx [**5-2**] T2a prostate cancer
R hernia repair [**2069**]
Cardoimyopathy, ? tachycardia induced
.

MEDICATION ON ADMISSION: -aspirin 325
-Lovenox 12/.8mL [**Hospital1 **]
-Toprol XL 200 mg daily
-verapamil 240
-Lasix 10
-atorvastatin 10
-ranitidine 150 twice a day
-pantoprazole 40
-triamterene & hydrochlorothiazide 37.5/25
-paroxetine 10
-benicar 40 daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VS: T 97.2, BP 161/105, HR 121, RR 22, O2 100% on 2l
Gen: pleasant black male in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. injected conjuctiva. PERRL, EOMI. non pallor or
cyanosis of the oral mucosa.
Neck: Supple with non elevated JVP.
CV: irregularly irregular, no murmurs appreciated. non displaced
PMI
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. bibasilar crackles, no
wheezes or rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: 4+ LE edema
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: No family history of prostate cancer.

SOCIAL HISTORY: married, lives with wife, retired walks reg for exercise. quit
cig 30yrs ago (~ 15 pack years). no etoh.  Walks without a
walker. 

### Response:
{'Acute on chronic diastolic heart failure,Other primary cardiomyopathies,Chronic kidney disease, unspecified,Hypopotassemia,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Personal history of noncompliance with medical treatment, presenting hazards to health,Esophageal reflux,Depressive disorder, not elsewhere classified'}
