CHIEF COMPLAINT: Shortness of breath.

PRESENT ILLNESS: 73F h/o DM, PVD s/p bilateral BKA, ESRD Afib and diastolic CHF
with multiple admissions for acute pulmonary edema (most recent
[**2164-1-4**]) who presents with acute SOB, 1 hour prior to admission.

MEDICAL HISTORY: # CKD V on hemodialysis; qMWF schedule at [**Location (un) **] [**Location (un) **]
# DM2 on insulin
# HTN
# Chronic diastolic CHF (LVEF >75%) with a history of
tachycardia-induced acute LVOT obstruction
# Hyperlipidemia
# PVD s/p bilateral BKAs (left in [**2156**]; right in [**2157**])
# Paroxysmal a-flutter s/p failed ablation with subsequent
atrial fibrillation; on warfarin
# Chronic nighttime hypoxemia on 3 L/min nc
# Secondary hyperparathyroidism
# No occlusive coronary disease on cardiac cath [**12/2162**]
# Left eye blindness
# Mild functional mitral stenosis
# GERD
# Tobacco abuse-- still smokes [**12-23**] PPD as of [**12-30**]
# h/o VRE UTI's
# H/o Tibial fracture

MEDICATION ON ADMISSION: 1. Valsartan 160 mg QD
2. Lisinopril 10 mg QD
3. Metoprolol Succinate 150 mg QD
4. Simvastatin 40 mg QD
5. Amiodarone 200 mg PO QD
6. Warfarin 2 mg MO,WE,FR
7. Warfarin 1 mg [**Doctor First Name **],TU,TH,SA
8. Pantoprazole 40 mg QD
9. Albuterol MDI 2 puffs Q4 hours PRN
10. Brimonidine 0.15 % Drops 1 drop [**Hospital1 **]
11. Dorzolamide-Timolol 2-0.5 % Drops 2 drops [**Hospital1 **]
12. Folic Acid 1 mg QD
13. Latanoprost 0.005 % Drops 1 drop QHS
14. Sevelamer Carbonate 800 mg TID
15. Calcium Acetate 667 TID with meals
16. Aspirin 81 mg QD
17. Insulin NPH 4 U [**Hospital1 **] + Humalog SSI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98.4, 134/48, 68, 18 98% on room air.
Tm 98.8, 114-134/48, 68-74, 18, 93-98% on RA
General: Alert, oriented, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no JVD
Lungs: Clear in bilateral upper fields with crackles in
bilateral lower fields.
CV: Regular, II/VI SEM at R/LUSB w/o radiation to the neck; no
rubs or gallops; left arm AV fistula with strong palpable thrill
and continuous machine-like murmur.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: b/l BKA; no evidnee of cellulitis; WWP; no edema
Neuro: AA, OX3; CN II-XII; moving all limbs

FAMILY HISTORY: Her father died in his 90s of complications of DM2 and mother at
the age of 102 of a stroke. Patient had a sister who died in her
70s of cancer (unknown type and site) and 2 brothers that died
stroke and brain cancer. She has 7 children who are healthy. Her
family history is significant for coronary artery disease,
cancer, and diabetes.

SOCIAL HISTORY: The patient denies alcohol and IV drug use.  She states that she
smokes approximately 3 cigarettes daily and has history of ~30
pack-year.  She lives in a senior citizen center; her daughter
lives with her.
Acute on chronic diastolic heart failure,End stage renal disease,Urinary tract infection, site not specified,Secondary hyperparathyroidism (of renal origin),Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease,Tobacco use disorder,Below knee amputation status,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin
Ac on chr diast hrt fail,End stage renal disease,Urin tract infection NOS,Sec hyperparathyrd-renal,Ben hyp kid w cr kid V,Tobacco use disorder,Status amput below knee,Chr airway obstruct NEC,Atrial fibrillation,DMII wo cmp nt st uncntr,Long-term use of insulin
Admission Date:  [**2164-1-8**]              Discharge Date:   [**2164-1-10**]

Date of Birth:  [**2090-1-9**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 30201**]
Chief Complaint:
Shortness of breath.

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
73F h/o DM, PVD s/p bilateral BKA, ESRD Afib and diastolic CHF
with multiple admissions for acute pulmonary edema (most recent
[**2164-1-4**]) who presents with acute SOB, 1 hour prior to admission.


She was sitting at home watching a football game when the SOB
came on suddenly; she denied CP, palpitations, cough, F/C, N/V,
abd pain. EMS found that she was unable to speak in full
sentences and BP was 220; they put her on CPAP (10) and gave NG
x 3 with improvement in sx.

By arrival to the ED, SBP was 130's; she was kept on CPAP for
high RR (36) and started on a nitro drip and ASA 325 mg. TWI
were noted on EKG in V5-V6 (though these were old compared to
[**2164-1-4**] EKG). She was afebrile. (In addition, she was given
ceftriaxone 1 g IV x 1 for a UTI; UCx from [**1-4**] grew Klebsiella,
though returned after discharge so she has not received tx yet.)


By arrival to the MICU, she was weaned to a NRB and quickly to
3LNC (home night O2 requirements). VS were T 96.0, HR 65, BP
115/46, RR 12, 100% on 3LNC. She was no longer ont he nitro
drip. She said her sx were considerably improved. She denied
missing her medications this morning; she lives alone at home,
but a visting nurse normally arranges her medications for her.

Of note, she has frequent hospitalizations for similar symtoms,
the most recent of which was this last week [**1-4**] - [**1-5**].

Past Medical History:
# CKD V on hemodialysis; qMWF schedule at [**Location (un) **] [**Location (un) **]
# DM2 on insulin
# HTN
# Chronic diastolic CHF (LVEF >75%) with a history of
tachycardia-induced acute LVOT obstruction
# Hyperlipidemia
# PVD s/p bilateral BKAs (left in [**2156**]; right in [**2157**])
# Paroxysmal a-flutter s/p failed ablation with subsequent
atrial fibrillation; on warfarin
# Chronic nighttime hypoxemia on 3 L/min nc
# Secondary hyperparathyroidism
# No occlusive coronary disease on cardiac cath [**12/2162**]
# Left eye blindness
# Mild functional mitral stenosis
# GERD
# Tobacco abuse-- still smokes [**12-23**] PPD as of [**12-30**]
# h/o VRE UTI's
# H/o Tibial fracture

Social History:
The patient denies alcohol and IV drug use.  She states that she
smokes approximately 3 cigarettes daily and has history of ~30
pack-year.  She lives in a senior citizen center; her daughter
lives with her.


Family History:
Her father died in his 90s of complications of DM2 and mother at
the age of 102 of a stroke. Patient had a sister who died in her
70s of cancer (unknown type and site) and 2 brothers that died
stroke and brain cancer. She has 7 children who are healthy. Her
family history is significant for coronary artery disease,
cancer, and diabetes.

Physical Exam:
Vitals: T 98.4, 134/48, 68, 18 98% on room air.
Tm 98.8, 114-134/48, 68-74, 18, 93-98% on RA
General: Alert, oriented, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no JVD
Lungs: Clear in bilateral upper fields with crackles in
bilateral lower fields.
CV: Regular, II/VI SEM at R/LUSB w/o radiation to the neck; no
rubs or gallops; left arm AV fistula with strong palpable thrill
and continuous machine-like murmur.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: b/l BKA; no evidnee of cellulitis; WWP; no edema
Neuro: AA, OX3; CN II-XII; moving all limbs

Pertinent Results:
Labs on admission:
[**2164-1-8**] 07:20PM BLOOD WBC-11.4* RBC-3.76* Hgb-10.7* Hct-34.9*
MCV-93 MCH-28.4 MCHC-30.6* RDW-19.3* Plt Ct-276
[**2164-1-8**] 07:20PM BLOOD Neuts-86.9* Lymphs-8.6* Monos-2.9 Eos-1.4
Baso-0.2
[**2164-1-8**] 07:20PM BLOOD PT-27.5* PTT-35.8* INR(PT)-2.8*
[**2164-1-8**] 07:20PM BLOOD Glucose-168* UreaN-44* Creat-6.8*# Na-138
K-3.9 Cl-97 HCO3-28 AnGap-17
[**2164-1-8**] 07:20PM BLOOD CK(CPK)-47
[**2164-1-8**] 07:20PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 5405**]*
[**2164-1-8**] 07:20PM BLOOD cTropnT-0.06*
[**2164-1-9**] 05:46AM BLOOD Albumin-3.3* Calcium-8.1* Phos-4.7*
Mg-2.0
[**2164-1-9**] 05:46AM BLOOD TSH-0.43
[**2164-1-9**] 05:46AM BLOOD Free T4-1.3

Labs on discharge:
[**2164-1-10**] 06:35AM BLOOD WBC-7.8 RBC-3.89* Hgb-11.5* Hct-36.0
MCV-92 MCH-29.6 MCHC-32.0 RDW-20.0* Plt Ct-266
[**2164-1-10**] 06:35AM BLOOD PT-26.8* PTT-34.1 INR(PT)-2.7*
[**2164-1-10**] 06:35AM BLOOD Glucose-69* UreaN-29* Creat-5.2*# Na-141
K-3.9 Cl-101 HCO3-30 AnGap-14
[**2164-1-10**] 06:35AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.8

Chest x-ray [**2164-1-8**]:
1. Slight interval improvement in pulmonary edema which is now
mild-to-moderate in extent, with small bilateral pleural
effusions.
2. More focal nodular opacities within the right upper lobe and
right lower lobe which raise suspicion for superimposed
infectious process.


Brief Hospital Course:
This is a 73 year old female with a history of DM, PVD s/p
bilateral BKA, ESRD Afib and diastolic CHF with multiple
admissions for acute pulmonary edema (most recent [**2164-1-4**]) who
presented with acute SOB. EMS found that she was unable to speak
in full sentences and BP was 220; they put her on CPAP (10) and
gave NG x 3 with improvement in SBP to 130's. In the MICU, she
was maintained on CPAP overnight; in the morning, she became
subjectively dyspneic though her oxygen sats were 100%. She
asked for BIPAP until HD, and she was able to be taken off BIPAP
support when she initiated her HD run. During her period of
dyspnea, she was also hypertensive with systolics in the high
100s where she was briefly given nitropaste until HD.

# SOB: There is likely some degree of flash pulmonary edema in
the setting of high BP. She had a significant improvement in
symptoms with NG/afterload reduction. She denied medical
non-compliance, however she seems to come in for similar
symptoms often. She was easily weaned back to [**Month/Day/Year 5348**] O2
requirements (3LNC) with better BP control without lasix. Renal
team followed the patient and she received HD on her regular
schedule. Of note, she often experiences these symptoms on
Sunday due to the extra day before dialysis (she normally has HD
MWF). The extra day between Fri and Mon dialysis was addressed
by providing the patient a low dose calcium channel blocker to
take on Sundays. In addition, changing her Friday dialysis to
the afternoons may be helpful in helping her make it through the
extra time to Monday dialysis.

#. HTN: She was continued on her home valsartan, lisinopril,
metoprolol (tartrate 75 mg [**Hospital1 **] rather than home succinate 150 mg
QD while in-patient).

#. UTI: The patient has a positive urine culture from [**1-4**]
admission, though the patient left before the culture returned.
She was given one dose ceftriaxone in the ED, and was treated
with a 3 day course of ceftriaxone.

Medications on Admission:
1. Valsartan 160 mg QD
2. Lisinopril 10 mg QD
3. Metoprolol Succinate 150 mg QD
4. Simvastatin 40 mg QD
5. Amiodarone 200 mg PO QD
6. Warfarin 2 mg MO,WE,FR
7. Warfarin 1 mg [**Doctor First Name **],TU,TH,SA
8. Pantoprazole 40 mg QD
9. Albuterol MDI 2 puffs Q4 hours PRN
10. Brimonidine 0.15 % Drops 1 drop [**Hospital1 **]
11. Dorzolamide-Timolol 2-0.5 % Drops 2 drops [**Hospital1 **]
12. Folic Acid 1 mg QD
13. Latanoprost 0.005 % Drops 1 drop QHS
14. Sevelamer Carbonate 800 mg TID
15. Calcium Acetate 667 TID with meals
16. Aspirin 81 mg QD
17. Insulin NPH 4 U [**Hospital1 **] + Humalog SSI

Discharge Medications:
1. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO once a day.
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
7. Warfarin 1 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H
(Every 12 Hours).
10. Dorzolamide-Timolol 2-0.5 % Drops Sig: Two (2) Drop
Ophthalmic Q12 HOURS.
11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Insulin NPH 4U [**Hospital1 **] + Humalog SSI
17. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO every Sunday morning.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
18. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Take after dialysis for the next two days.
Disp:*2 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] [**Location (un) 269**]

Discharge Diagnosis:
- Acute on chronic diastolic congestive heart failure (CHF),
LVEF >80%
- Chronic Kidney Disease (CKD) on hemodialysis.
- Diabetes Mellitus II on insulin.
- Hypertension.


Discharge Condition:
Stable, afebrile.

Discharge Instructions:
You were admitted for shortness of breath. This improved greatly
with hemodialysis. You have a very difficult balance of fluids
to maintain. It is important to adhere to your sodium (salt) and
fluid restriction in order to prevent fluid from building up in
your body. Please be careful to take all of your medications and
maintain your dialysis schedule.

You have an additional two days of CEFPODOXIME to take for
treating your urinary tract infection. Please take this
medication after your dialysis on Wednesday.

You are being given an additional medication called Imdur. You
should take this medication (30mg by mouth) on Sunday morning.
This medication is to help prevent hig blood pressure and fluid
build-up on Sundays, prior to your hemodialysis on Monday. Your
other medications were not changed. Please resume taking them as
before.

Please adhere to your follow-up appointments. They are important
for managing your long-term health.

Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.

Followup Instructions:
You have the following follow-up appointments:

Cardiology:
-Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2164-1-16**]
3:40

Primary care:
-Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2164-1-19**] 12:40


Completed by:[**2164-1-23**]
{'Acute on chronic diastolic heart failure,End stage renal disease,Urinary tract infection, site not specified,Secondary hyperparathyroidism (of renal origin),Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease,Tobacco use disorder,Below knee amputation status,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin'}


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: 73F h/o DM, PVD s/p bilateral BKA, ESRD Afib and diastolic CHF
with multiple admissions for acute pulmonary edema (most recent
[**2164-1-4**]) who presents with acute SOB, 1 hour prior to admission.

MEDICAL HISTORY: # CKD V on hemodialysis; qMWF schedule at [**Location (un) **] [**Location (un) **]
# DM2 on insulin
# HTN
# Chronic diastolic CHF (LVEF >75%) with a history of
tachycardia-induced acute LVOT obstruction
# Hyperlipidemia
# PVD s/p bilateral BKAs (left in [**2156**]; right in [**2157**])
# Paroxysmal a-flutter s/p failed ablation with subsequent
atrial fibrillation; on warfarin
# Chronic nighttime hypoxemia on 3 L/min nc
# Secondary hyperparathyroidism
# No occlusive coronary disease on cardiac cath [**12/2162**]
# Left eye blindness
# Mild functional mitral stenosis
# GERD
# Tobacco abuse-- still smokes [**12-23**] PPD as of [**12-30**]
# h/o VRE UTI's
# H/o Tibial fracture

MEDICATION ON ADMISSION: 1. Valsartan 160 mg QD
2. Lisinopril 10 mg QD
3. Metoprolol Succinate 150 mg QD
4. Simvastatin 40 mg QD
5. Amiodarone 200 mg PO QD
6. Warfarin 2 mg MO,WE,FR
7. Warfarin 1 mg [**Doctor First Name **],TU,TH,SA
8. Pantoprazole 40 mg QD
9. Albuterol MDI 2 puffs Q4 hours PRN
10. Brimonidine 0.15 % Drops 1 drop [**Hospital1 **]
11. Dorzolamide-Timolol 2-0.5 % Drops 2 drops [**Hospital1 **]
12. Folic Acid 1 mg QD
13. Latanoprost 0.005 % Drops 1 drop QHS
14. Sevelamer Carbonate 800 mg TID
15. Calcium Acetate 667 TID with meals
16. Aspirin 81 mg QD
17. Insulin NPH 4 U [**Hospital1 **] + Humalog SSI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98.4, 134/48, 68, 18 98% on room air.
Tm 98.8, 114-134/48, 68-74, 18, 93-98% on RA
General: Alert, oriented, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no JVD
Lungs: Clear in bilateral upper fields with crackles in
bilateral lower fields.
CV: Regular, II/VI SEM at R/LUSB w/o radiation to the neck; no
rubs or gallops; left arm AV fistula with strong palpable thrill
and continuous machine-like murmur.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: b/l BKA; no evidnee of cellulitis; WWP; no edema
Neuro: AA, OX3; CN II-XII; moving all limbs

FAMILY HISTORY: Her father died in his 90s of complications of DM2 and mother at
the age of 102 of a stroke. Patient had a sister who died in her
70s of cancer (unknown type and site) and 2 brothers that died
stroke and brain cancer. She has 7 children who are healthy. Her
family history is significant for coronary artery disease,
cancer, and diabetes.

SOCIAL HISTORY: The patient denies alcohol and IV drug use.  She states that she
smokes approximately 3 cigarettes daily and has history of ~30
pack-year.  She lives in a senior citizen center; her daughter
lives with her. 

### Response:
{'Acute on chronic diastolic heart failure,End stage renal disease,Urinary tract infection, site not specified,Secondary hyperparathyroidism (of renal origin),Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease,Tobacco use disorder,Below knee amputation status,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin'}
