CHIEF COMPLAINT: SOB

PRESENT ILLNESS: The pt is a 72M w/ Type 2 DM, ESRD on HD, referred by
nephrologist for shortness of breath, likely from fluid
overload.  For the last 4 days he has been feeling more short of
breath that has improved with dialysis.  He also had one day of
dysuria.  Otherwise he has had no other symptomatic complaints
including no nausea, vomiting, or diarrhea, no chest pain, no
fever or chills. Reports chronic cough productive of a teaspoon
of sputum, whitish-green tinged color which has been stable.
.
In the ED Vitals were t 98.8 Hr 126 (went to 70-80s) BP 104/54,
then went to SBPs in 80s, 91 % RA.  While in the ED, he was
given a dose of vancomycin 1g x 1, levofloxacin 500 mg x1 and 1
g tylenol, lasix 40 IV.

MEDICAL HISTORY: 1)CAD s/p CABG [**2102**]
2)PVD: s/p fem-[**Doctor Last Name **] bypass in [**12-29**] for cluadication, non-healing

MEDICATION ON ADMISSION: (Per last d/c, per patient he is not taking all of these but
can't remember what he isn't taking )
-- atorvastatin 10mg po qd
-- ASA 81mg po qd
-- levothyroxine 100mcg po qd
-- vitamin E 400U po qd
-- B complex-Vitamin C-Folic acid 1mg po qd
-- folic acid 1mg po qd
-- sevelamer 800mg po tid
-- amiodarone 200mg po qd
-- digoxin 125mcg po qod
-- NPH 16U qam, 8U qpm
-- mirtazapine 15mg po qodhs
-- tamsulosin 0.4mg p qhs
-- warfarin 1mg po qhs
-- hydromorphone 4mg po q8h prn
-- metoprolol 150mg po qd
-- lisinopril 1.25mg po qd

ALLERGIES: Sulfonamides / Amlodipine / Percocet

PHYSICAL EXAM: BP 134/72 HR 88 RR 18 T98.7 O2Sat 94% on RA
Gen: AAO X 3, elderly gentleman
HEENT: EOMI, PERRL, sclera anicteric, MMM
Neck: supple, JVP of 5 cm.
Pulm: coarse rhonchi b/l with crackles at R base, increased
expiratory phase
Cor:  RRR, normal S1S2, no rubs, murmurs, clicks or gallops.
Abd: soft, NT, ND, normoactive BS
Ext: no pallor, cyanosis, clubbing, trace edema with
erythematous and warm LE b/l up to mid lower leg.
Skin: stasis dermatitis of LE
Pulses: 2+ r DP, 1+ l DP

FAMILY HISTORY: Father with DM type 2
Two sisters and one brother--all well

SOCIAL HISTORY: Significant for the absence of current tobacco use although he
is a former smoker. Reports smoking 2PPD X 40 yrs, quit 30 yrs
ago. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death.
Congestive heart failure, unspecified,Atrial fibrillation,Cellulitis and abscess of leg, except foot,End stage renal disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism
CHF NOS,Atrial fibrillation,Cellulitis of leg,End stage renal disease,DMII wo cmp nt st uncntr,Hypothyroidism NOS
Admission Date:  [**2108-10-16**]              Discharge Date:   [**2108-10-21**]

Date of Birth:  [**2036-8-7**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfonamides / Amlodipine / Percocet

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
HD

History of Present Illness:
The pt is a 72M w/ Type 2 DM, ESRD on HD, referred by
nephrologist for shortness of breath, likely from fluid
overload.  For the last 4 days he has been feeling more short of
breath that has improved with dialysis.  He also had one day of
dysuria.  Otherwise he has had no other symptomatic complaints
including no nausea, vomiting, or diarrhea, no chest pain, no
fever or chills. Reports chronic cough productive of a teaspoon
of sputum, whitish-green tinged color which has been stable.
.
In the ED Vitals were t 98.8 Hr 126 (went to 70-80s) BP 104/54,
then went to SBPs in 80s, 91 % RA.  While in the ED, he was
given a dose of vancomycin 1g x 1, levofloxacin 500 mg x1 and 1
g tylenol, lasix 40 IV.

Past Medical History:
1)CAD s/p CABG [**2102**]
2)PVD: s/p fem-[**Doctor Last Name **] bypass in [**12-29**] for cluadication, non-healing

ulcer on [**2-26**] s/p atherectomy of L SFA popliteal tbioperoneal
trunk with angioplasty x 2. Pt had recent right first toe
amputation and left TMA on [**2107-3-24**].
3)Paroxysmal atrial fibrillation
4)Type II DM: followed by [**Last Name (un) **]
5)Hyperlipidemia
6)Chronic bronchiectasis
7)EF 35%
p-MIBI [**2108-2-27**]: Mild-moderate anterior-lateral and apical
reversible defect. 2. Mild global hypokinesis and septal
akinesis. 3. Ejection fraction is 35%.
8)BPH
9)Anemia of chronic illness
10)CRI on daily peritoneal dialysis
.
PAST SURGICAL HISTORY:
1) s/p angioplasties of the left common femoral, superficial
femoral, tibioperoneal trunk in ([**2106-11-24**])
2) left CEA ([**2102**] at [**Hospital1 2025**])
3) CABG (LIMA to the LAD and saphenous vein graft to the
obtuse marginal 1 and the ramus intermedius - [**2103-9-24**])
4) s/p cholecystectomy with exploratory lap with repair of
liver lacerations ([**2105-11-23**])
5) PD catheter placement in ([**2106-9-24**])
6) right eye cataract with intraocular lens, right
eye vitrectomy
7) right common femoral artery to posterior
tibial bypass graft with in situ saphenous vein in [**Month (only) 404**] of
[**2106**].


Social History:
Significant for the absence of current tobacco use although he
is a former smoker. Reports smoking 2PPD X 40 yrs, quit 30 yrs
ago. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death.

Family History:
Father with DM type 2
Two sisters and one brother--all well


Physical Exam:
BP 134/72 HR 88 RR 18 T98.7 O2Sat 94% on RA
Gen: AAO X 3, elderly gentleman
HEENT: EOMI, PERRL, sclera anicteric, MMM
Neck: supple, JVP of 5 cm.
Pulm: coarse rhonchi b/l with crackles at R base, increased
expiratory phase
Cor:  RRR, normal S1S2, no rubs, murmurs, clicks or gallops.
Abd: soft, NT, ND, normoactive BS
Ext: no pallor, cyanosis, clubbing, trace edema with
erythematous and warm LE b/l up to mid lower leg.
Skin: stasis dermatitis of LE
Pulses: 2+ r DP, 1+ l DP

Pertinent Results:
[**2108-10-16**] 05:28PM   WBC-9.3 RBC-3.36* HGB-11.4* HCT-35.1*
MCV-104* MCH-34.0* MCHC-32.5 RDW-15.8*
[**2108-10-16**] 05:28PM   PLT COUNT-474*
[**2108-10-16**] 05:28PM   PT-15.7* PTT-43.9* INR(PT)-1.4*
[**2108-10-16**] 05:28PM   CALCIUM-7.9*
[**2108-10-16**] 05:28PM   CK-MB-NotDone cTropnT-2.33*
[**2108-10-16**] 05:28PM   UREA N-16 CREAT-1.7* SODIUM-138 POTASSIUM-4.3
CHLORIDE-100 TOTAL CO2-33* ANION GAP-9
[**2108-10-16**] 05:30PM   GLUCOSE-98 LACTATE-1.8 K+-3.9

EKG:  NSR with mild elevation of ST segments onf V2, V3.
Otherwise unchanged from prior.
.
CXR: Again seen is evidence of CHF and bilateral pleural
effusions. New opacity in the left upper lung, possibly
represents early pneumonia versus asymmetric edema.
.
Chest CT [**10-17**] - Multifocal consolidation and peribronchial
infiltration is present in all lobes.  The largest region of
abnormality is the apical and posterior portions of the left
upper lobe, but smaller abnormalities are present in the
superior
segment of the left lower lobe and at the base of the right
lower lobe is also mild septal thickening throughout the lungs.
The lingula is largely collapsed distal to what appears to be
impacted bronchi.  Small-to-moderate bilateral pleural effusion
is nonhemorrhagic, layering posteriorly having developed
between [**9-25**] and 15.  There is extensive central lymph node
enlargement ranging up to 20 mm in the right lower paratracheal
and 18 mm in diameter in the pretracheal stations of the
mediastinum with many smaller lymph nodes distributed and there
is no bronchial obstruction by lymph node or compromise
of any other vital structures.  Atherosclerotic calcification in
the aorta and native coronary arteries is severe.  There is no
pericardial effusion.  This examination is not designed for
subdiaphragmatic evaluation except to note the absence of
ascites.
.
CT scan corroborates the well-documented pattern in this patient

of current episodes of pulmonary edema and pleural effusions
also accompanied by mass-like consolidation.  Findings of
extensive central lymph node enlargement are difficult correlate
with those of plain radiographs, but are not necessarily new.
Differential diagnosis of the multifocal pulmonary abnormality
includes current pneumonia, drug reaction, or pulmonary
hemorrhage.
.
Past cardiology studies:
.
[**2108-2-27**] Persantine MIBI: IMPRESSION: 1. Mild-moderate
anterior-lateral and apical reversible defect. 2. Mild global
hypokinesis and septal akinesis. 3. Ejection fraction is 35%.
.
Cath [**2106-12-22**]:
R dominant system
LMCA: 60% occluded
LAD: widely patent LIMA to LAD. SVG to RI 80% ostial
LCX: patent SVG to OM. LCX 80% prox.
RCA: proximally occluded, filled by collaterals from LIMA/SVG
.
Cath [**2108-3-28**]
1. Selective coronary angiography in this right dominant
circulation demonstrated severe native vessel coronary artery
disease. The LMCA was diffusely diseased with 60% distal
stenosis. The LAD was totally occluded in the proximal segement.
The distal LAD had mild disease and was supplied by the LIMA
graft. The LCx had severe diffuse disease. The OM and Ramus were
totally occluded at their origins, but filled via an SVG.
2. Saphenous vein angiography demonstrated widely patent SVG to
OM and SVG to Ramus. The Ramus was totally occluded after the
touchdown point and filled via collaterals from the grafted OM.

3. Arterial conduit arteriography demonstrated a widely patent
LIMA to LAD.
4. Opening pressure in the central aorta was moderately
elevated.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA to LAD.
3. Patent SVG to OM.
4. Patent SVG to Ramus, but total occlusion after touchdown
point.
.
TTE [**10-17**] -  1. The left atrium is moderately dilated. The left
atrium is elongated.
2. Left ventricular wall thicknesses are normal. There is
asymmetric left  ventricular hypertrophy. There is no asymmetric
left ventricular hypertrophy.  The left ventricular cavity size
is normal. Overall left ventricular systolic  function is normal
(LVEF>55%). Tissue velocity imaging E/e' is elevated (>15)
suggesting increased left ventricular filling pressure
(PCWP>18mmHg).
3. Right ventricular chamber size is normal. Right ventricular
systolic  function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is  seen.
5.The mitral valve leaflets are structurally normal. Mild (1+)
mitral  regurgitation is seen.
6.There is a trivial/physiologic pericardial effusion.
7. There is a large pleural effusion present.


Brief Hospital Course:
1) Shortness of breath: Likely due to fluid overload [**1-26**]
paroxysmal a-fib c RVR given prior history of paroxysmal a-fib
with RVR. Unfortunately, pt is not aware when he is in a-fib.
Differential also included fluid overload [**1-26**] ESRD; however pt
did not miss HD session prior to admission. CXR findings with
possible element of PNA, however pt did not have leukocytosis,
fever, and productive cough. Given dose of levaquin while in ED
which was not continued on the floor. Sputum culture was
significant only for sparse OP flora. Evaluated by renal and
given daily HD during hospital course with subsequent improval
in pt's shortness of breath. CT chest performed given question
of diagnosis of chronic bronchietasis. CT significant for
multifocal consolidation and infiltrates with lingula largely
collaspsed distal to what appears to be impacted bronchi which
supports diagnosis of chronic bronchiectasis.
.
2) ESRD - Followed by renal consult and had HD qd during
hospital course with subsequent resolution in pt's shortness of
breath. On Nephrocaps.
.
3) Troponin elevation: Recent troponin elevation during last
admission felt to be from demand ischemia while in rapid afib in
the setting of ESRD. During hospital course had troponin peak to
2.33.  Likely still demand ischemia as patient did not have any
signs of CP or cardiac dysfunction. EKG without new ischemic
changes. Given that the patient has recent troponin leak,
elevated troponins may be persistent due to poor renal function.
Cardiology made aware of troponin leak and agreed that it was
[**1-26**] rate related demand ischemia. Continued on aspirin,
metoprolol, lisinopril, and statin.
.
4) CHF- TTE on [**10-17**] significant for nl LVEF but with elevated
LV filling pressures. Fluid removed via HD. Stressed importance
of fluid and salt restriction to pt. Continued beta-blocker,
ACE-I.
.
5) Paroxysmal afib - Continued on amiodarone, metoprolol, and
digoxin. Dig level checked and was therapeutic. Pt remained in
NSR during hospital course with HR in 70-80s. Warfarin was also
continued.
.
6) Hypotension - Was transiently hypotensive with SBPs in 80s
while in ED, and was admitted to MICU where low BPs resolved
without intervention. Remained normotensive during remaining
hospital course.
.
7) DM2  - Continued outpt regimen of NPH 16 U qam and 8 U qhs,
RISS with good effect.
.
8) LE cellulitis- Was treated as outpatient with augmentin [**1-27**]
weeks ago per pt.  On admission, PE significant for continued
b/l LE cellulitis. Was treated with Augmentin post-HD during
hospital course X 5. By discharge, exam was underwhelming for
active LE cellulitis and pt was not discharged on further
antibiotics.
.
9) Hypothyroidism - Synthroid continued.
.
10) Code - DNR, DNI per patient


Medications on Admission:
(Per last d/c, per patient he is not taking all of these but
can't remember what he isn't taking )
-- atorvastatin 10mg po qd
-- ASA 81mg po qd
-- levothyroxine 100mcg po qd
-- vitamin E 400U po qd
-- B complex-Vitamin C-Folic acid 1mg po qd
-- folic acid 1mg po qd
-- sevelamer 800mg po tid
-- amiodarone 200mg po qd
-- digoxin 125mcg po qod
-- NPH 16U qam, 8U qpm
-- mirtazapine 15mg po qodhs
-- tamsulosin 0.4mg p qhs
-- warfarin 1mg po qhs
-- hydromorphone 4mg po q8h prn
-- metoprolol 150mg po qd
-- lisinopril 1.25mg po qd

Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
7. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
9. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO bid as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
14. Lisinopril 5 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily).
Disp:*10 Tablet(s)* Refills:*2*
15. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: 1.5
Tablet Sustained Release 24HRs PO once a day.
Disp:*45 Tablet Sustained Release 24HR(s)* Refills:*2*
16. Atrovent 18 mcg/Actuation Aerosol Sig: 2-3 puffs Inhalation
every 6-8 hours as needed for shortness of breath or wheezing.
Disp:*qs inhalers* Refills:*3*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnoses:
Fluid Overload [**1-26**] CHF, paroxysmal a-fib c RVR
Lower Extremity Cellulitis

Secondary Diagnoses:


Discharge Condition:
stable


Discharge Instructions:
Please call your physician or return to the emergency room if
you experience any of the following: chest pain, increased
shortness of breath, fevers, chills, night sweats, increased
lower extremity pain and warmth.

It is very important that you continue to keep all of your
outpatient dialysis sessions. It is also very important that you
continue fluid restriction and adhere to a low sodium diet when
you are at home.

Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week
of discharge.

You have an appointment to see Dr. [**Last Name (STitle) **], a cardiologist, on
118 at 3:40 pm. Please report to [**Hospital Ward Name 23**] Building, [**Location (un) 436**].
[**Telephone/Fax (1) 4022**].

Please follow up with Dr. [**First Name (STitle) 805**] at hemodialysis.



Completed by:[**2108-10-21**]
{'Congestive heart failure, unspecified,Atrial fibrillation,Cellulitis and abscess of leg, except foot,End stage renal disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism'}


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: SOB

PRESENT ILLNESS: The pt is a 72M w/ Type 2 DM, ESRD on HD, referred by
nephrologist for shortness of breath, likely from fluid
overload.  For the last 4 days he has been feeling more short of
breath that has improved with dialysis.  He also had one day of
dysuria.  Otherwise he has had no other symptomatic complaints
including no nausea, vomiting, or diarrhea, no chest pain, no
fever or chills. Reports chronic cough productive of a teaspoon
of sputum, whitish-green tinged color which has been stable.
.
In the ED Vitals were t 98.8 Hr 126 (went to 70-80s) BP 104/54,
then went to SBPs in 80s, 91 % RA.  While in the ED, he was
given a dose of vancomycin 1g x 1, levofloxacin 500 mg x1 and 1
g tylenol, lasix 40 IV.

MEDICAL HISTORY: 1)CAD s/p CABG [**2102**]
2)PVD: s/p fem-[**Doctor Last Name **] bypass in [**12-29**] for cluadication, non-healing

MEDICATION ON ADMISSION: (Per last d/c, per patient he is not taking all of these but
can't remember what he isn't taking )
-- atorvastatin 10mg po qd
-- ASA 81mg po qd
-- levothyroxine 100mcg po qd
-- vitamin E 400U po qd
-- B complex-Vitamin C-Folic acid 1mg po qd
-- folic acid 1mg po qd
-- sevelamer 800mg po tid
-- amiodarone 200mg po qd
-- digoxin 125mcg po qod
-- NPH 16U qam, 8U qpm
-- mirtazapine 15mg po qodhs
-- tamsulosin 0.4mg p qhs
-- warfarin 1mg po qhs
-- hydromorphone 4mg po q8h prn
-- metoprolol 150mg po qd
-- lisinopril 1.25mg po qd

ALLERGIES: Sulfonamides / Amlodipine / Percocet

PHYSICAL EXAM: BP 134/72 HR 88 RR 18 T98.7 O2Sat 94% on RA
Gen: AAO X 3, elderly gentleman
HEENT: EOMI, PERRL, sclera anicteric, MMM
Neck: supple, JVP of 5 cm.
Pulm: coarse rhonchi b/l with crackles at R base, increased
expiratory phase
Cor:  RRR, normal S1S2, no rubs, murmurs, clicks or gallops.
Abd: soft, NT, ND, normoactive BS
Ext: no pallor, cyanosis, clubbing, trace edema with
erythematous and warm LE b/l up to mid lower leg.
Skin: stasis dermatitis of LE
Pulses: 2+ r DP, 1+ l DP

FAMILY HISTORY: Father with DM type 2
Two sisters and one brother--all well

SOCIAL HISTORY: Significant for the absence of current tobacco use although he
is a former smoker. Reports smoking 2PPD X 40 yrs, quit 30 yrs
ago. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death. 

### Response:
{'Congestive heart failure, unspecified,Atrial fibrillation,Cellulitis and abscess of leg, except foot,End stage renal disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism'}
