CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 78 yo male with CHF, severe TR, cardiac cirrhosis, multiple
episodes of GIB secondary to AVM's who presented to the ED on
[**6-29**] for routine paracentesis.  He complained of dyspnea and was
found to be have a hct of 18 and melenic stool on rectal exam.
He noticed increasing abdominal distension and tried to schedule
a paracentesis (he routinely gets at least 2 per month) but was
unable to, so he came to the ED instead for the procedure. He
noted there that he had been weak and fatigued for the past two
weeks and was found to have a hct of 18.
.
In the ED, rectal exam revealed dark, guaiac positive stool; he
refused NG-lavage or placement of central line or peripheral
IV's. He denied lightheadedness or dyspnea, his SBP's were
initially in the 110's but drifted down to the 90's, and his ECG
was unchanged. He also denies recent f/c, uri, chest pain,
dyspnea (though has had orthopnea for past few weeks), n/v/d,
melena (stool is always dark from iron), hematochezia, or
urinary sx.
.
He was admitted to the MICU for further management.  He was
transfused a total of 3 units PRBC's with increase in hematocrit
from 18 -> 25.  Paracentesis was peformed with removal of 4.8
liters of serous fluid.  He remained hemodynamically stable.  GI
was consulted and is planning for EGD and colonoscopy on Monday.

MEDICAL HISTORY: -HTN
-CAD: CABG [**2140**], cath [**2151**] with patent lima-lad, occluded
svg-om, near occluded svg-rca
-CHF: TTE [**9-/2151**] with EF 40-50%, mild LVH and LV-HK, 2+MR, 4+TR

MEDICATION ON ADMISSION: 1) Amiodarone 200 mg daily
2) Levothyroxine 150 mcg daily
3) FeSO4 325 mg daily
4) Pantoproazole 40 mg [**Hospital1 **]
5) Digoxin 125 mcg 3x/wk (MWF)
6) Furosemide 120 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: T 98, BP 100/60, HR 70, RR 18, SpO2 97% on RA
Gen: pleasant, chronically-ill male, fair function, non-toxic,
NAD
HEENT: anicteric, op clear with dry mucosa
Neck: distended ej's that fill from above, not below, no lad, no
thyromegaly
CV: rrr, soft s1s2, [**3-6**] llsb systol murmur
PULM: no resp distress or accessory muscle use, fair air
movement, decreased breath sounds at bases
ABD: firm, distended but not tense with positive fluid wave,
large  ventral hernia (pt states chronic), mild diffuse
tenderness
BACK: no cva/vert tendrn, no sacral edema
EXTREM: chronic venous stasis changes with scars from previous
grafts, no edema
NEURO: a&ox3, no focal cn/motor defect

FAMILY HISTORY: Mother- HTN, ?died of MI; Father-83 yo and died of "old age"; no
FH of cancer

SOCIAL HISTORY: Originally from [**Country 3397**]. Previously living with wife in [**Name (NI) 3146**],
but has been at rehab since recent hospitalization. Quit smoking
15 years ago. Smoked 1 ppd x 40 years. No EtOH. Retired, but
used to work as a machinist. Unable to walk.  Needs
wheelchair/walker to get around his house.
Angiodysplasia of intestine with hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Cirrhosis of liver without mention of alcohol,Chronic kidney disease, unspecified,Rheumatic heart failure (congestive),Diseases of tricuspid valve,Mitral stenosis,Hyposmolality and/or hyponatremia,Atrial fibrillation,Urinary tract infection, site not specified,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Postsurgical hypothyroidism,Coronary atherosclerosis of unspecified type of vessel, native or graft,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Aortocoronary bypass status,Personal history of colonic polyps
Angio intes w hmrhg,Chr blood loss anemia,Cirrhosis of liver NOS,Chronic kidney dis NOS,Rheumatic heart failure,Tricuspid valve disease,Mitral stenosis,Hyposmolality,Atrial fibrillation,Urin tract infection NOS,Hpt B acte wo cm wo dlta,Hy kid NOS w cr kid I-IV,Postsurgical hypothyroid,Cor ath unsp vsl ntv/gft,Osteoarthros NOS-unspec,Aortocoronary bypass,Prsnl hst colonic polyps
Admission Date:  [**2153-6-29**]              Discharge Date:   [**2153-7-3**]

Date of Birth:  [**2075-5-19**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
Paracentesis x 2
EGD
Blood transfusion x 4 units


History of Present Illness:
78 yo male with CHF, severe TR, cardiac cirrhosis, multiple
episodes of GIB secondary to AVM's who presented to the ED on
[**6-29**] for routine paracentesis.  He complained of dyspnea and was
found to be have a hct of 18 and melenic stool on rectal exam.
He noticed increasing abdominal distension and tried to schedule
a paracentesis (he routinely gets at least 2 per month) but was
unable to, so he came to the ED instead for the procedure. He
noted there that he had been weak and fatigued for the past two
weeks and was found to have a hct of 18.
.
In the ED, rectal exam revealed dark, guaiac positive stool; he
refused NG-lavage or placement of central line or peripheral
IV's. He denied lightheadedness or dyspnea, his SBP's were
initially in the 110's but drifted down to the 90's, and his ECG
was unchanged. He also denies recent f/c, uri, chest pain,
dyspnea (though has had orthopnea for past few weeks), n/v/d,
melena (stool is always dark from iron), hematochezia, or
urinary sx.
.
He was admitted to the MICU for further management.  He was
transfused a total of 3 units PRBC's with increase in hematocrit
from 18 -> 25.  Paracentesis was peformed with removal of 4.8
liters of serous fluid.  He remained hemodynamically stable.  GI
was consulted and is planning for EGD and colonoscopy on Monday.


Past Medical History:
-HTN
-CAD: CABG [**2140**], cath [**2151**] with patent lima-lad, occluded
svg-om, near occluded svg-rca
-CHF: TTE [**9-/2151**] with EF 40-50%, mild LVH and LV-HK, 2+MR, 4+TR

-Severe TR
-Moderate MR
[**Name13 (STitle) **]
-Cardiac cirrhosis: Requiring repeat sx paracenteses
-Recurrent GIB [**3-2**] AVMs
-Colon polyps
-HBV
-CRI: cr 1.5-1.8
-Hypothyroidism
-OA

Social History:
Originally from [**Country 3397**]. Previously living with wife in [**Name (NI) 3146**],
but has been at rehab since recent hospitalization. Quit smoking
15 years ago. Smoked 1 ppd x 40 years. No EtOH. Retired, but
used to work as a machinist. Unable to walk.  Needs
wheelchair/walker to get around his house.


Family History:
Mother- HTN, ?died of MI; Father-83 yo and died of "old age"; no
FH of cancer

Physical Exam:
PE: T 98, BP 100/60, HR 70, RR 18, SpO2 97% on RA
Gen: pleasant, chronically-ill male, fair function, non-toxic,
NAD
HEENT: anicteric, op clear with dry mucosa
Neck: distended ej's that fill from above, not below, no lad, no
thyromegaly
CV: rrr, soft s1s2, [**3-6**] llsb systol murmur
PULM: no resp distress or accessory muscle use, fair air
movement, decreased breath sounds at bases
ABD: firm, distended but not tense with positive fluid wave,
large  ventral hernia (pt states chronic), mild diffuse
tenderness
BACK: no cva/vert tendrn, no sacral edema
EXTREM: chronic venous stasis changes with scars from previous
grafts, no edema
NEURO: a&ox3, no focal cn/motor defect

Pertinent Results:
[**2153-6-29**] 04:40PM BLOOD WBC-8.2 RBC-1.84*# Hgb-5.8*# Hct-18.2*#
MCV-99* MCH-31.7 MCHC-32.0 RDW-22.9* Plt Ct-272
.
[**2153-7-3**] 06:09AM BLOOD Hct-28.1*
.
ECG: difffuse low voltage, sinus, sl rightward axis, rbbb, no
st-t changes; no major change from prior
.
PA AND LATERAL CHEST [**2153-6-29**]:  Patient is status post sternotomy
and CABG, and the heart again appears enlarged.  Compared to the
prior study, there is persistent pulmonary congestion with
blunting in the the left costophrenic angle again noted and
persistent fluid within the right horizontal fissure. A right
subclavian central venous catheter is unchanged in position.
IMPRESSION:  Persistent mild to moderate CHF.
.
TTE [**2153-6-30**]: The left atrium is mildly dilated. The right atrium
is moderately dilated. The  estimated right atrial pressure is
>20 mmHg. Left ventricular wall thicknesses and cavity size are
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. There is moderate global
left ventricular hypokinesis. [Intrinsic left ventricular
systolic function is
likely more depressed given the severity of valvular
regurgitation.] The right
ventricular cavity is markedly dilated with prominent free wall
hypokinesis.
[Intrinsic right ventricular systolic function is likely more
depressed given
the severity of tricuspid regurgitation.] There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly
thickened. There is no mitral valve prolapse. An eccentric,
anteriorly
directed jet of moderate (2+) mitral regurgitation is seen. The
tricuspid
valve leaflets are mildly thickened and fail to fully coapt.
Severe [4+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic
hypertension. There is no pericardial effusion.  Compared with
the prior study (images reviewed) of [**2151-9-30**], the estimated
pulmonary artery systolic pressure and right ventricular cavity
size have increased and global left ventricular systolic
function is slightly worse. The severity of tricuspid
regurgitation is similar.
.
EGD [**2153-7-2**]:
*Esophagus: Normal esophagus.
*Stomach: Normal. Duodenum: A few small non-bleeding
angioectasias were seen in the 3rd and 4th portions of the
duodenum.  [**Hospital1 **]-CAP Electrocautery was applied for hemostasis with
success.
*Jejunum: Flat Lesions Several small angioectasias that were not
bleeding were seen in the proximal jejunum, mid jejunum and
3rd/4th portion of
*Duodenum. [**Hospital1 **]-CAP Electrocautery was applied for hemostasis
successfully.
*Ileum: Not examined.
Impression: Angioectasias in the proximal jejunum and mid
jejunum and 3rd portion of duodenum (thermal therapy).
Otherwise normal EGD to mid jejunum.


Brief Hospital Course:
78m with cad, chf, tr, cardiac cirrhosis, reccurent avm-related
gi bleeds, cri here with increasing abominal distension,
fatigue, and a hct of 18.
.
1) Anemia:  Patient is chronically transfusion-dependent
secondary to multiple AVM's.  Bleed is known to be slow and
chronic, and patient maintains symptomatic and hemodynamic
tolerance of low hematocrit.  Patient was initially admitted to
the medical ICU for close hemodynamic monitoring.  There, he
refused multiple interventions, including foley to monitor u/o,
NG-lavage, and peripheral IV's, stating he's aware that he may
become very ill or die without these interventions.  In the
MICU, he received 3 units PRBC's with increase in hematocrit
from 18.2 to 25.7.  He was subsequently transferred to the
medicine unit and under went enteroscopy which revealed multiple
non-bleeding AVM's; cautery was performed.  Mr. [**Known lastname **] was
transfused an additional unit of PRBC's prior to discharge
(total of 4 units this admission).  His hematocrit was 28.1 on
the morning of discharge.
.
2) Cirrhosis with ascites:  Patient routinely requires
paracenteses bimonthly due to rapid reaccumulation of fluid in
the setting of right heart failure.  INR 1.1, indicating
preserved synthetic liver function. Of note, patient is on
regimen of furosemide 120 mg [**Hospital1 **] as outpatient.  Spironolactone
was recently discontinued due to hyperkalemia during previous
hospitalization.  A therapeutic paracentesis was performed on
[**6-30**] with removal of 4.8 liters of serous fluid and no
complications.   Given residual ascites and persistent abdominal
discomfort, a second paracentesis was performed on [**7-2**] with
removal of an additional 3 liters of serous fluids.
.
3) Cardiac:
(a) Pump: Patient with known right side CHF, and as a result,
much of his total body fluid likely contained within the
abdomen. TTE was repeated during this hospitalization, revealing
an ejection fraction of 35% with unchanged severe (4+) tricuspid
regurgitation.  This reflects increased pulmonary artery
systolic pressure and right ventricular cavity size with slight
worsening of global left ventricular systolic function.  He was
continued on digoxin and furosemide.
(b) Vessels:  Patient with known CAD and slight troponin leak of
0.26 in the setting of severe anemia.  This leak was consistent
with known baseline.  ASA has been held indefinitely in the
setting of chronic bleed.
(c) Rhythm: Continue amiodarone for rate control.
Anti-coagulation contraindicated in the setting of high bleeding
risk.
.
4) Chronic renal insufficiency:  Creatinine ~1.2 was at baseline
during this hospitalization, improved from previous
hospitalization.
.
5) UTI: UA on [**6-29**] with 11-20 WBC's, 0 epi's.  He was started on
Bactrim for UTI, but this was disconinued after urine culture
returned with no growth.
.
6) Hypothyroidism: h/o thyroid goiter s/p thyroidectomy.
Continued levothyroxine.
.
7) Code status: DNR/DNI.


Medications on Admission:
1) Amiodarone 200 mg daily
2) Levothyroxine 150 mcg daily
3) FeSO4 325 mg daily
4) Pantoproazole 40 mg [**Hospital1 **]
5) Digoxin 125 mcg 3x/wk (MWF)
6) Furosemide 120 mg [**Hospital1 **]

Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Nursing Home

Discharge Diagnosis:
Anemia
Chronic GI bleed secondary to arteriovenous malformations
Recurrent ascites
Right heart failure
Severe tricuspid regurgitation


Discharge Condition:
Stable


Discharge Instructions:
You were admitted with ascites (collection of fluid in your
abdomen) and lower extremity swelling.  A paracentesis was done
to take some of the fluid off of your abdomen.

In addition, you were transfused a total of 4 units of blood for
your anemia.  You underwent an EGD with cautery of several blood
vessels.
.
You should be sure to continue taking all your medications, as
prescribed.  Also please be sure to follow-up with Dr. [**Last Name (STitle) **]
(see appointments below).

Given your history of heart failure and swelling, you should
weigh yourself every morning and call Dr. [**Last Name (STitle) **] if you weight
increases by 3 pounds or more.  In addition, adhere to a 2
gram/day sodium diet.


Followup Instructions:
You are scheduled to undergo an outpatient paracentesis on [**7-17**] at 10:30  a.m.  Please come to the Radiology Department on
the [**Location (un) 470**] of the [**Hospital Unit Name 1825**] on the [**Hospital1 18**] [**Hospital Ward Name 516**].
Please call [**Telephone/Fax (1) 327**] with questions.
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] HEALTH CARE [**Location (un) 2352**]
Address: 1000 [**Last Name (LF) **], [**First Name3 (LF) 2352**],[**Numeric Identifier 9121**]
Phone: [**Telephone/Fax (1) 1144**]
Appt time/date:  [**7-27**] at 9:30 a.m.
.
{'Angiodysplasia of intestine with hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Cirrhosis of liver without mention of alcohol,Chronic kidney disease, unspecified,Rheumatic heart failure (congestive),Diseases of tricuspid valve,Mitral stenosis,Hyposmolality and/or hyponatremia,Atrial fibrillation,Urinary tract infection, site not specified,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Postsurgical hypothyroidism,Coronary atherosclerosis of unspecified type of vessel, native or graft,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Aortocoronary bypass status,Personal history of colonic polyps'}


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: 78 yo male with CHF, severe TR, cardiac cirrhosis, multiple
episodes of GIB secondary to AVM's who presented to the ED on
[**6-29**] for routine paracentesis.  He complained of dyspnea and was
found to be have a hct of 18 and melenic stool on rectal exam.
He noticed increasing abdominal distension and tried to schedule
a paracentesis (he routinely gets at least 2 per month) but was
unable to, so he came to the ED instead for the procedure. He
noted there that he had been weak and fatigued for the past two
weeks and was found to have a hct of 18.
.
In the ED, rectal exam revealed dark, guaiac positive stool; he
refused NG-lavage or placement of central line or peripheral
IV's. He denied lightheadedness or dyspnea, his SBP's were
initially in the 110's but drifted down to the 90's, and his ECG
was unchanged. He also denies recent f/c, uri, chest pain,
dyspnea (though has had orthopnea for past few weeks), n/v/d,
melena (stool is always dark from iron), hematochezia, or
urinary sx.
.
He was admitted to the MICU for further management.  He was
transfused a total of 3 units PRBC's with increase in hematocrit
from 18 -> 25.  Paracentesis was peformed with removal of 4.8
liters of serous fluid.  He remained hemodynamically stable.  GI
was consulted and is planning for EGD and colonoscopy on Monday.

MEDICAL HISTORY: -HTN
-CAD: CABG [**2140**], cath [**2151**] with patent lima-lad, occluded
svg-om, near occluded svg-rca
-CHF: TTE [**9-/2151**] with EF 40-50%, mild LVH and LV-HK, 2+MR, 4+TR

MEDICATION ON ADMISSION: 1) Amiodarone 200 mg daily
2) Levothyroxine 150 mcg daily
3) FeSO4 325 mg daily
4) Pantoproazole 40 mg [**Hospital1 **]
5) Digoxin 125 mcg 3x/wk (MWF)
6) Furosemide 120 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: T 98, BP 100/60, HR 70, RR 18, SpO2 97% on RA
Gen: pleasant, chronically-ill male, fair function, non-toxic,
NAD
HEENT: anicteric, op clear with dry mucosa
Neck: distended ej's that fill from above, not below, no lad, no
thyromegaly
CV: rrr, soft s1s2, [**3-6**] llsb systol murmur
PULM: no resp distress or accessory muscle use, fair air
movement, decreased breath sounds at bases
ABD: firm, distended but not tense with positive fluid wave,
large  ventral hernia (pt states chronic), mild diffuse
tenderness
BACK: no cva/vert tendrn, no sacral edema
EXTREM: chronic venous stasis changes with scars from previous
grafts, no edema
NEURO: a&ox3, no focal cn/motor defect

FAMILY HISTORY: Mother- HTN, ?died of MI; Father-83 yo and died of "old age"; no
FH of cancer

SOCIAL HISTORY: Originally from [**Country 3397**]. Previously living with wife in [**Name (NI) 3146**],
but has been at rehab since recent hospitalization. Quit smoking
15 years ago. Smoked 1 ppd x 40 years. No EtOH. Retired, but
used to work as a machinist. Unable to walk.  Needs
wheelchair/walker to get around his house. 

### Response:
{'Angiodysplasia of intestine with hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Cirrhosis of liver without mention of alcohol,Chronic kidney disease, unspecified,Rheumatic heart failure (congestive),Diseases of tricuspid valve,Mitral stenosis,Hyposmolality and/or hyponatremia,Atrial fibrillation,Urinary tract infection, site not specified,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Postsurgical hypothyroidism,Coronary atherosclerosis of unspecified type of vessel, native or graft,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Aortocoronary bypass status,Personal history of colonic polyps'}
