CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: 81 year-old male with history of CHF, atrial fibrillation,
ascending aortic aneurysm and mitral regurgitation who is
admitted with dyspnea and failure to thrive.
.
The patient's daughter reports that the patient has been sick
for "a while", particularly since he was admitted in [**2119-2-22**].
Since his discharge, he was improving and doing better at home
until three days ago when he started declining rather rapidly.
She reports that he has had shortness of breath, slurred speech
and difficulty walking over the last three days. He has also
been confused and falling asleep in his chair and falling out of
the chair and from his bed. He has been refusing help, but
unable to get up. She also reports that her father has had
decreased grip strength and things have been falling out of his
hands. As a result of his confusion, he has been eating less,
though he has been very thirsty and is drinking a lot of fluids.
There have been no fevers, chills, night sweats, cough, emesis,
diarrhea. She also reports "difficulty with motor planning", as
if he had trouble "putting one foot in front of the other".
Interestingly, his mental status has been waxing and [**Doctor Last Name 688**].
Although he has been confused, he was able to have a completely
coherent conversation with his sister yesterday. [**Name2 (NI) **] was recently
on Coumadin but this was held secondary to fall risk.
.
In the ED, he was given 100mg of IV Lasix and ASA 325mg x 1.
.
Today, the patient states that his main concern is his shortness
of breath. He has been feeling dyspneic over the last several
days. Has a mild cough, non-productive. No chest pain or
palpitations. Denies edema. Reports orthopnea but no PND.

MEDICAL HISTORY: 1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2.  3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine.  No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia

MEDICATION ON ADMISSION: levothyroxine 25mcg daily
allopurinol 150mg qOD
Toprol XL 25mg daily
tylenol 325mg q4-6h prn
lasix 40mg daily
ferrous gluconate 300mg [**Hospital1 **]
combivent inh [**Hospital1 **]
celexa 10mg daily
glipizide 2.5mg daily
lipitor ? dose

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98.7 BP 116/69 (104-136/49-69) HR 91 (87-101) RR 25
(25-38) 100% 4L
General: restless in bed, no spontaneous eye opening, answers
questions, follows some commands (aside from eye opening)
HEENT: pupils small but reactive, dry mucous membranes
Neck: no evidence of JVD
Lung: rales at bilateral bases
Cor: irregularly irregular, 3/6 systolic murmur loudest at apex
Abd: NABS, soft, non-distended, reports some tenderness in RUQ
Ext: warm, no edema, pneumoboots in place
Neuro: oriented x 2 (hospital, name), follows some commands,
somewhat restless

FAMILY HISTORY: no Alzhemer's or Parkinson's

SOCIAL HISTORY: Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards).
Subdural hemorrhage,Acute diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Acquired coagulation factor deficiency,Acute and subacute necrosis of liver,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hyperosmolality and/or hypernatremia,Atrial fibrillation,Mitral valve disorders,Delirium due to conditions classified elsewhere,Hydantoin derivatives causing adverse effects in therapeutic use,History of fall,Adult failure to thrive,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism
Subdural hemorrhage,Ac diastolic hrt failure,Ac kidny fail, tubr necr,Pneumonia, organism NOS,Urin tract infection NOS,Acq coagul factor defic,Acute necrosis of liver,Hyp kid NOS w cr kid V,Hyperosmolality,Atrial fibrillation,Mitral valve disorder,Delirium d/t other cond,Adv eff hydantoin deriv,Personal history of fall,Failure to thrive-adult,DMII wo cmp nt st uncntr,Hypothyroidism NOS
Name:  [**Known lastname **],[**Known firstname 2415**]                   Unit No:   [**Numeric Identifier 2416**]

Admission Date:  [**2119-3-31**]              Discharge Date:   [**2119-4-19**]

Date of Birth:  [**2037-6-17**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 391**]
Addendum:
Pt developed some mild chest pain on day of discharged over his
right nipple. Pain occurred while lifting himself in bed. The
chest pain spontaneously resolved without intervention. Vitals
signs remained stable and chest X-ray and ECG were unchanged. It
was concluded that this was most likely musculoskeletal in
nature and the patient was discharged without incident.

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]

                             [**Name6 (MD) 116**] [**Name8 (MD) 117**] MD [**MD Number(1) 392**]

Completed by:[**2119-4-19**]

Admission Date:  [**2119-3-31**]              Discharge Date:   [**2119-4-19**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
[**4-12**] Right-sided crani for evac of subdural hematoma


History of Present Illness:
81 year-old male with history of CHF, atrial fibrillation,
ascending aortic aneurysm and mitral regurgitation who is
admitted with dyspnea and failure to thrive.
.
The patient's daughter reports that the patient has been sick
for "a while", particularly since he was admitted in [**2119-2-22**].
Since his discharge, he was improving and doing better at home
until three days ago when he started declining rather rapidly.
She reports that he has had shortness of breath, slurred speech
and difficulty walking over the last three days. He has also
been confused and falling asleep in his chair and falling out of
the chair and from his bed. He has been refusing help, but
unable to get up. She also reports that her father has had
decreased grip strength and things have been falling out of his
hands. As a result of his confusion, he has been eating less,
though he has been very thirsty and is drinking a lot of fluids.
There have been no fevers, chills, night sweats, cough, emesis,
diarrhea. She also reports "difficulty with motor planning", as
if he had trouble "putting one foot in front of the other".
Interestingly, his mental status has been waxing and [**Doctor Last Name 688**].
Although he has been confused, he was able to have a completely
coherent conversation with his sister yesterday. [**Name2 (NI) **] was recently
on Coumadin but this was held secondary to fall risk.
.
In the ED, he was given 100mg of IV Lasix and ASA 325mg x 1.
.
Today, the patient states that his main concern is his shortness
of breath. He has been feeling dyspneic over the last several
days. Has a mild cough, non-productive. No chest pain or
palpitations. Denies edema. Reports orthopnea but no PND.

Past Medical History:
1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2.  3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine.  No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia

Social History:
Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards).


Family History:
no Alzhemer's or Parkinson's

Physical Exam:
Vitals: T 98.7 BP 116/69 (104-136/49-69) HR 91 (87-101) RR 25
(25-38) 100% 4L
General: restless in bed, no spontaneous eye opening, answers
questions, follows some commands (aside from eye opening)
HEENT: pupils small but reactive, dry mucous membranes
Neck: no evidence of JVD
Lung: rales at bilateral bases
Cor: irregularly irregular, 3/6 systolic murmur loudest at apex
Abd: NABS, soft, non-distended, reports some tenderness in RUQ
Ext: warm, no edema, pneumoboots in place
Neuro: oriented x 2 (hospital, name), follows some commands,
somewhat restless

Pertinent Results:
Head CT ([**4-1**]): Moderate right subdural hemorrhage with
associated subfalcine herniation.
.
CTA ([**4-1**]): New CHF with enlarging moderate/large bilateral
pleural effusions with concomitant atelectasis.  No evidence for
pulmonary embolus
.
Head CT ([**4-2**]):  No significant change from prior study with
right-sided pleural hematoma and subfalcine herniation again
seen.
.
EKG ([**4-2**]): very wavy baseline, largely uninterpretable secondary
to motion, afib with HR 100s, no ST changes (but diff to
interpret)
.
Renal US ([**4-2**]): No evidence of hydronephrosis or stones.
.
Echo ([**4-3**]): LVEF>55%. Significant aortic regurgitation is
present, but cannot be quantified. The mitral valve leaflets are
mildly thickened. At least, moderate (2+) mitral regurgitation
is seen.
.
Head CT ([**4-3**]): Stable appearance of the right-sided subdural
hematoma and stable to mildly improved subfalcine herniation
.
Abd US ([**4-4**]): No focal or textural hepatic abnormality is
identified. Patent portal vein with hepatopetal flow. Mild
splenomegaly. Small amount of ascites.
.
Head CT ([**4-4**]): Stable appearance of a large right subdural
hematoma
.
CXR ([**4-5**]): Cardiomegaly, bilateral effusions, and borderline
vascular congestion with little interval change
.
Head CT [**4-14**] evacuation of hematoma stable.
.
Head CT [**4-17**] hematoma stable.

Brief Hospital Course:
1. altered mental status -
He was admitted with subacute course of non-specific mental
status changes and was found to have a chronic appearing with
superimposed acute features subdural hemorrhage. He was followed
by neurosurgery, who deferred evacuation on account of the
stability of the SDH as well as his concomitant medical issues
(liver failure,
renal failure, UTI, CHF).
.
His mental status was poor with marked delirium, but remained
stable. Serial head CTs demonstrated stable subdural hemorrhage.
Pt was taken to the operating room on [**4-12**] for a right crani for
evacuation of Subdural hematoma.  [**Name (NI) **] pt was extubated and
reintubated within 1 hr.  Pt had aggressive pulm toilet and self
extubated overnoc on [**5-2**].  Drain removed [**4-13**].  Pt
currently doing well extubated.  Staples to be dc'd [**4-21**].  .
   Patient transferred to Neurosurgery service on [**2119-4-12**] for
subdural hematoma evacuation after become medically stable. His
INR has been stable under 1.3. His mental status improved over
the course of time, as his electrolytes, and coags improved. His
initial INR went up as high as 1.8 which stayed around the same
level until given factor VIIa  on [**4-5**] then stayed around
1.2-1.3 range per recommendation of Hematology service. His
creatinine improved greatly, his creatinine jumped up to 2.5,
but now dropped down to 1.5 renal service has been following
along.  He is cleared by medicine team to be operated on his
subdural hematoma. He had a left lower lobe pneumonia which is
treated with Levo. He had a hypernatremia Na up to 157 on [**4-11**],
eventually corrected with fluid.
.
He underwent right craniotomy on [**2119-4-12**]  for evacuation of
subdural hematoma and placement of subdural JP drain placement
under general anesthesia without complications, he was able to
extubated in [**Hospital **] transferred to PACU, however 2 hour later he
required re-intubation secondary to hypoventilation. He is
neurologically moving all extremities, opens his eyes to voice
intermittently, squeezes to command. He placed on a beta-blocker
[**Hospital **] for heart rate control, [**Hospital **] ECG remained unchanged,
underlying rhythm being atrial fibrillation. His postoperative
head CT([**4-12**]) is revealed residual small amount of hemorrhage
mixed with fluid, pneumocephalus and postoperative changes. No
further shift of normally midline structures. Repeat head CT on
[**4-13**] remained stable, therefore his right subdural JP removed,
patient tolerated procedure well.
.
Patient will need drain stitch and staples removed on [**4-21**].  If
cant be done at nursing home will need to see Dr. [**Last Name (STitle) 739**].
 Switched from dilantin to keppra.
.
2. congestive heart failure -
He was worked up for dyspnea and hypoxemia. Final etiology
was clearly congestive heart failure. He had a repeat Echo
which demonstrated preserved EF and some MR. [**Name13 (STitle) **] was
maintained on a regimen of hydral/nitro, beta blocker,
and cautious diuresis. He was maintained on oxygen by
nasal canula.  Patient sent out on lasix.
.
3. Liver failure/coagulopathy -
He had a self limited course of liver failure with associated
coagulopathy. This was felt to be secondary to dilantin
toxicity.
Dilantin was stopped and his liver enzymes ultimately trended
down
toward normal. Alternative explanation could have been acute
hepatic congestion from heart failure.
.
Re: coagulopathy, he was treated with vitamin K, FFP, and
also proplex in acute setting. Thereafter, his INR trended
down and he was given po vitamin K. Heme/onc involved
in his care; agreed with hepatic synthetic dysfunction
as etiology of coagulopathy.
.
4. Acute on chronic renal failure -
Likely pre-renal exacerbation of chronic kidney disease.
Resolving toward baseline.
.
5. Atrial fibrillation
Continued rate control with bblocker. Held warfarin on account
of
coagulopathy and SDH.
.
6. DM
Held oral hypoglycemics; kept RISS.  Patient has been having low
blood sugars so sliding scale reduced.  Patient will need
frequent blood sugar.

Medications on Admission:
levothyroxine 25mcg daily
allopurinol 150mg qOD
Toprol XL 25mg daily
tylenol 325mg q4-6h prn
lasix 40mg daily
ferrous gluconate 300mg [**Hospital1 **]
combivent inh [**Hospital1 **]
celexa 10mg daily
glipizide 2.5mg daily
lipitor ? dose

Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-26**]
Puffs Inhalation Q6H (every 6 hours) as needed.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED): see insulin sliding scale.
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day): hold for SBP < 100.
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]

Discharge Diagnosis:
Primary diagnoses:
1. Subdural hematoma s/p evacuation
2. Congestive heart failure
3. Pneumonia
4. Urinary Tract infection
.
Secondary diagnoses:
1. Mitral regurgitation
2. Atrial fibrillation
3. Diabetes Mellitus


Discharge Condition:
Stable


Discharge Instructions:
You are discharged to a Rehabilitation facility where you should
continue all medications as prescribed.

Please alert the physicians at the facility or contact your
physician if you experience headache, visual changes, shortness
of breath, chest pain, palpitations, or other concerns.

You should be weighed every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.

Followup Instructions:
You will need a follow-up appointment with your primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3649**] in [**1-27**] weeks.  Please call [**Telephone/Fax (1) 3070**] to
make that appointment.

You will need an appointment with Dr. [**Last Name (STitle) 739**] 4 weeks
after your surgery with a head CT.  Please call ([**Telephone/Fax (1) 11314**] to
make that appointment.

Right craniotmy drain stitch to be dc'd [**4-21**]; Craniotomy staples
to be dc'd [**4-21**].  If pt in house this will be done by
neurosurgery team; if in rehab they can be dc'd there, otherwise
pt to return to Dr.[**Name (NI) 4674**] office to be dc'd.


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
{'Subdural hemorrhage,Acute diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Acquired coagulation factor deficiency,Acute and subacute necrosis of liver,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hyperosmolality and/or hypernatremia,Atrial fibrillation,Mitral valve disorders,Delirium due to conditions classified elsewhere,Hydantoin derivatives causing adverse effects in therapeutic use,History of fall,Adult failure to thrive,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: dyspnea

PRESENT ILLNESS: 81 year-old male with history of CHF, atrial fibrillation,
ascending aortic aneurysm and mitral regurgitation who is
admitted with dyspnea and failure to thrive.
.
The patient's daughter reports that the patient has been sick
for "a while", particularly since he was admitted in [**2119-2-22**].
Since his discharge, he was improving and doing better at home
until three days ago when he started declining rather rapidly.
She reports that he has had shortness of breath, slurred speech
and difficulty walking over the last three days. He has also
been confused and falling asleep in his chair and falling out of
the chair and from his bed. He has been refusing help, but
unable to get up. She also reports that her father has had
decreased grip strength and things have been falling out of his
hands. As a result of his confusion, he has been eating less,
though he has been very thirsty and is drinking a lot of fluids.
There have been no fevers, chills, night sweats, cough, emesis,
diarrhea. She also reports "difficulty with motor planning", as
if he had trouble "putting one foot in front of the other".
Interestingly, his mental status has been waxing and [**Doctor Last Name 688**].
Although he has been confused, he was able to have a completely
coherent conversation with his sister yesterday. [**Name2 (NI) **] was recently
on Coumadin but this was held secondary to fall risk.
.
In the ED, he was given 100mg of IV Lasix and ASA 325mg x 1.
.
Today, the patient states that his main concern is his shortness
of breath. He has been feeling dyspneic over the last several
days. Has a mild cough, non-productive. No chest pain or
palpitations. Denies edema. Reports orthopnea but no PND.

MEDICAL HISTORY: 1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2.  3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine.  No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia

MEDICATION ON ADMISSION: levothyroxine 25mcg daily
allopurinol 150mg qOD
Toprol XL 25mg daily
tylenol 325mg q4-6h prn
lasix 40mg daily
ferrous gluconate 300mg [**Hospital1 **]
combivent inh [**Hospital1 **]
celexa 10mg daily
glipizide 2.5mg daily
lipitor ? dose

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98.7 BP 116/69 (104-136/49-69) HR 91 (87-101) RR 25
(25-38) 100% 4L
General: restless in bed, no spontaneous eye opening, answers
questions, follows some commands (aside from eye opening)
HEENT: pupils small but reactive, dry mucous membranes
Neck: no evidence of JVD
Lung: rales at bilateral bases
Cor: irregularly irregular, 3/6 systolic murmur loudest at apex
Abd: NABS, soft, non-distended, reports some tenderness in RUQ
Ext: warm, no edema, pneumoboots in place
Neuro: oriented x 2 (hospital, name), follows some commands,
somewhat restless

FAMILY HISTORY: no Alzhemer's or Parkinson's

SOCIAL HISTORY: Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards). 

### Response:
{'Subdural hemorrhage,Acute diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Acquired coagulation factor deficiency,Acute and subacute necrosis of liver,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hyperosmolality and/or hypernatremia,Atrial fibrillation,Mitral valve disorders,Delirium due to conditions classified elsewhere,Hydantoin derivatives causing adverse effects in therapeutic use,History of fall,Adult failure to thrive,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism'}
