CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: [**Age over 90 **]yo [**Age over 90 595**]-speaking female with CHF, presents with increasing
dyspnea, pedal edema x1wk.  According to the patient's Grandson,
she has had issues with medication and dietary compliance.  VNA
at home note the patient's dyspnea and edema, was concerned
about a CHF exacerbation yesterday.  However, the patient
refused to come in until today, when her symptoms continued to
worsen.  Per the patient, at that time her O2 sat was 88% on 5L
oxygen via NC at home.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY:
-dCHF last echo on [**7-/2168**] EF of 65%
-aFIB not anticoagulated due to fall risk
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Microvascular disease
-Extensive basal ganglia disease
-Gait disorder
-HTN
-Dyslipidemia
-Advanced DJD
-Meniere's disease
-hard of hearing

MEDICATION ON ADMISSION: Medications:
Phenytoin sodium extended 300 mg 6 DAYS/WEEK (Every day except
Sunday)
Phenytoin sodium extended 400 mg qSUN
Ursodiol 300 mg [**Hospital1 **]
Aspirin 325 mg Daily
Metoprolol succinate 100 mg [**Hospital1 **]
Senna 8.6 mg qHS prn
Docusate sodium 100 mg [**Hospital1 **]
Furosemide 120mg [**Hospital1 **]

ALLERGIES: Iodine; Iodine Containing / Ampicillin / Phenergan / Zaroxolyn

PHYSICAL EXAM: Admission Exam
Vitals: 96.2 140/101 92 20 93%3L, Wt 64Kg
Gen:  Elderly female, frail, NAD.
HEENT:  PERRL, EOMI.  No scleral icterus.  No conjunctival
injection.
Neck:  Supple, JVP to ear lobe.
Lungs: diffuse wheezes throughout w rales, no ronchi. Normal
respiratory effort
CV: Irregularly irregular, no murmurs, rubs, gallops.
Abdomen:  soft, NT, ND, NABS, no HSM.
Extremities:  WWP, no cyanosis.  2 + edema to knee
Neurological:  AOx3, CN II-XII intact.
Skin:  Paper-thin skin, no rashes or ulcers.
GU:  foley in place

FAMILY HISTORY: No clear history of CAD.

SOCIAL HISTORY: Patient lives at home by herself at subsidized senior housing
with assistance from family.  Her Grandson [**Name (NI) 382**] is an
interpreter at [**Hospital1 18**] and is very active in her care.
Acute on chronic diastolic heart failure,Atrial fibrillation,Unspecified essential hypertension,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,History of fall,Hypoxemia,Other iatrogenic hypotension,Other antihypertensive agents causing adverse effects in therapeutic use
Ac on chr diast hrt fail,Atrial fibrillation,Hypertension NOS,Cholelithiasis NOS,Personal history of fall,Hypoxemia,Iatrogenc hypotnsion NEC,Adv eff antihyperten agt
Admission Date:  [**2168-12-3**]              Discharge Date:   [**2168-12-14**]


Service: MEDICINE

Allergies:
Iodine; Iodine Containing / Ampicillin / Phenergan / Zaroxolyn

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
none

History of Present Illness:
[**Age over 90 **]yo [**Age over 90 595**]-speaking female with CHF, presents with increasing
dyspnea, pedal edema x1wk.  According to the patient's Grandson,
she has had issues with medication and dietary compliance.  VNA
at home note the patient's dyspnea and edema, was concerned
about a CHF exacerbation yesterday.  However, the patient
refused to come in until today, when her symptoms continued to
worsen.  Per the patient, at that time her O2 sat was 88% on 5L
oxygen via NC at home.

In the ED, patient's vitals were 98.2 100 130/93 22 88% 5L NC.
Patient reported feeling "lowsy", with shortness of breath and
edema.  She denied fevers, cough.  On 5L nasal cannula, she was
comfortable, with a mid-high 90s O2 sat.  On physical exam she
was noted to have crackles and tachypnea.  A CXR showed
bilateral pulmonary congestion.  A UA was negative for signs of
a UTI.  Her HCT was at baseline 35.  EKG demonstrated afib with
around 80.  Pt denied CP, but did report some occassional "heart
pauses" that were believed to be palpitations, however no
changes were observed on telemtry.
.
Patient is now being admitted to medicine for treatment of a CHF
exacerbation.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias. All
other review of systems are negative.

Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY:
-dCHF last echo on [**7-/2168**] EF of 65%
-aFIB not anticoagulated due to fall risk
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Microvascular disease
-Extensive basal ganglia disease
-Gait disorder
-HTN
-Dyslipidemia
-Advanced DJD
-Meniere's disease
-hard of hearing

Social History:
Patient lives at home by herself at subsidized senior housing
with assistance from family.  Her Grandson [**Name (NI) 382**] is an
interpreter at [**Hospital1 18**] and is very active in her care.


Family History:
No clear history of CAD.

Physical Exam:
Admission Exam
Vitals: 96.2 140/101 92 20 93%3L, Wt 64Kg
Gen:  Elderly female, frail, NAD.
HEENT:  PERRL, EOMI.  No scleral icterus.  No conjunctival
injection.
Neck:  Supple, JVP to ear lobe.
Lungs: diffuse wheezes throughout w rales, no ronchi. Normal
respiratory effort
CV: Irregularly irregular, no murmurs, rubs, gallops.
Abdomen:  soft, NT, ND, NABS, no HSM.
Extremities:  WWP, no cyanosis.  2 + edema to knee
Neurological:  AOx3, CN II-XII intact.
Skin:  Paper-thin skin, no rashes or ulcers.
GU:  foley in place

Discharge Exam:
Temp Max: 97.5 Temp current: 97.5 HR: 64-92 RR: 24-26 BP:
102-122/56-88 O2 Sat: 95% on 5L   Weight 61.5 Kg
24 hour I= 1000 O= 1060++
8 hour I= 90 O= 300
Physical Exam:
Gen: alert, tachypnic
HEENT: supple
CV: irreg, irreg. no M/R/G
RESP: Poor effort, no crackles or wheezes
ABD: soft, NT, ND
EXTR: trace peripheral edema to knee bilat
NEURO: alert, answering questions appropriately, good appetite.

Extremeties:
Pulses:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Skin: intact


Pertinent Results:
Blood Counts:
[**2168-12-3**] 03:00PM BLOOD WBC-8.1 RBC-3.87* Hgb-12.3 Hct-35.7*
MCV-92 MCH-31.8 MCHC-34.6 RDW-16.1* Plt Ct-224
[**2168-12-6**] 05:30AM BLOOD WBC-9.4 RBC-3.91* Hgb-12.1 Hct-37.2
MCV-95 MCH-31.0 MCHC-32.6 RDW-16.1* Plt Ct-245
[**2168-12-8**] 06:00AM BLOOD WBC-6.4 RBC-3.46* Hgb-11.0* Hct-32.0*
MCV-92 MCH-31.9 MCHC-34.5 RDW-15.8* Plt Ct-180

Coags:
[**2168-12-3**] 03:00PM BLOOD PT-13.4 PTT-26.0 INR(PT)-1.1

Chemistry
[**2168-12-3**] 03:00PM BLOOD Glucose-115* UreaN-27* Creat-0.9 Na-139
K-3.4 Cl-97 HCO3-32 AnGap-13
[**2168-12-5**] 06:49AM BLOOD Glucose-104* UreaN-25* Creat-0.9 Na-144
K-3.0* Cl-96 HCO3-36* AnGap-15
[**2168-12-6**] 05:30AM BLOOD Glucose-128* UreaN-26* Creat-0.9 Na-141
K-4.9 Cl-97 HCO3-35* AnGap-14
[**2168-12-8**] 06:00AM BLOOD Glucose-99 UreaN-25* Creat-0.7 Na-140
K-3.8 Cl-98 HCO3-35* AnGap-11

Cardiac:
[**2168-12-3**] 03:00PM BLOOD cTropnT-<0.01 proBNP-4693*
[**2168-12-4**] 08:10AM BLOOD CK-MB-2 cTropnT-<0.01

Blood Gas:
[**2168-12-6**] 09:10PM BLOOD Type-ART pO2-76* pCO2-59* pH-7.41
calTCO2-39* Base XS-9
[**2168-12-6**] 11:32PM BLOOD Type-ART Temp-37.0 O2 Flow-4 pO2-67*
pCO2-60* pH-7.43 calTCO2-41* Base XS-12 Intubat-NOT INTUBA

[**2168-12-3**]
EKG: Atrial fibrillation. Non-specific ST-T wave changes are
diffuse. Compared to the previous tracing of [**2168-11-1**] the ST-T
wave changes are similar.

[**2168-12-3**]
CXR: Prominent bronchovascular markings, with bilateral small
pleural
effusions and bibasilar atelectases, concerning for congestive
failure and
pulmonary edema.

[**2168-12-5**]
CXR: Increase in bilateral moderate-sized pleural effusions with

associated pulmonary vascular congestion and mild-to-moderate
pulmonary edema. On this background assessment for pneumonia is
limited and if concern exists, repeat examination should be
performed after diuresis.

11.13 CXR:
FRONTAL CHEST RADIOGRAPH: Cardiomediastinal silhouette is
stable. Pulmonary
vasculature indistinctness is improving consistent with
resolving pulmonary
edema. There are small bilateral pleural effusions as well as
retrocardiac
and bibasilar atelectasis.


Brief Hospital Course:
[**Age over 90 **]yo [**Age over 90 595**]-speaking female admitted to general medicine
service for likely CHF exacerbation in the setting of poor
medication compliance transferred to the CCU secondary to
persistent tachypnea.
.
# Tachpnea/CHF: Pt was admitted for CHF exacerbation likely
secondary to med non-compliance and poor rate control of A. fib.
CXR revealed pulm edema. Initially cared for on the medical
floor, where she was diuresed to 64kg (previous d/c weight was
62kg) with IV Lasix [**Hospital1 **] 120mg. She was trasferred to the CCU for
close monitoring after an episode of tachypnea and desaturation.
 While in the ICU, challenging to balance her blood pressure and
fluid status. Pt was given gentle Lasix for diuresis and then
transitionted to torsemide PO 100mg [**Hospital1 **]. Went home with
torsemide 100mg [**Hospital1 **] and potassium supplementation. Discharge
weight was 61.5 kg. Pt with stage IV heart failure. Prognosis
discussed with family. Family and patient decided to be DNR/DNI.
Strongly encouraged pt to go to rehab but family and pt declined
and preferred to go home. Pt has 24 hour support at home.
.
#Afib: hx afib, CHADS score 3, and only on ASA, since fall risk.
Rate controlled with metoprolol 75mg once a day (decreased home
dose of 100mg [**Hospital1 **]) and diltiazem was added on this admission.
Metoprolol dose was decreased since pt became more hypotensive
with  higher dose of metoprolol. Pt went home on Diltiazem 240mg
daily and metoprolol 75 mg daily.
.
#Chronic Falls: Continued Phenytoin
.
#Gallstones: Continued home Ursodiol

Medications on Admission:
Medications:
Phenytoin sodium extended 300 mg 6 DAYS/WEEK (Every day except
Sunday)
Phenytoin sodium extended 400 mg qSUN
Ursodiol 300 mg [**Hospital1 **]
Aspirin 325 mg Daily
Metoprolol succinate 100 mg [**Hospital1 **]
Senna 8.6 mg qHS prn
Docusate sodium 100 mg [**Hospital1 **]
Furosemide 120mg [**Hospital1 **]

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
3. food supplement, lactose-free     Liquid Sig: One (1) bottle
PO once a day.
4. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. phenytoin sodium extended 100 mg Capsule Sig: Four (4)
Capsule PO QSUN (every Sunday).
8. phenytoin sodium extended 100 mg Capsule Sig: Three (3)
Capsule PO DAYS (MO,TU,WE,TH,FR,SA) ().
9. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
10. diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
11. torsemide 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
12. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
13. Outpatient Lab Work
Please check Chem-7 on [**2168-12-16**] with results to [**Last Name (LF) **],[**First Name3 (LF) **]
R. [**Telephone/Fax (1) 142**]


Discharge Disposition:
Home With Service

Facility:
surburban

Discharge Diagnosis:
Acute on Chronic Diastolic Congestive Heart Failure
Atrial fibrillation with rapid ventricular response


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted to the hospital for heart failure. We gave you
diuretics to help you urinate some of the extra fluid. This
helped your symptoms. It is very important to maintain a low
sodium diet, use oxygen at home, and take your medications every
day.
Please weight yourself every day in the morning and call Dr.
[**Last Name (STitle) **] if your weight increases more than 3 pounds in 1 day
or 6 pounds in 3 days.
It is very important that you do not eat foods high in sodium or
it is very likely that you will need to come back to the
hospital.

We made the following changes to your medications:
1. Start taking potassium every day
2. Decrease Metoprolol to 1.5 tablets of 100mg daily in the am,
do not take in the pm.
3. Start Diltiazem 240 mg daily to control your heart rate
4. Stop taking Furosemide, take Torsemide instead twice daily to
take off extra fluid.


Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2168-12-19**] at 1:20 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: INTERNAL MEDICINE
When: TUESDAY [**2168-12-20**] at 9:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Acute on chronic diastolic heart failure,Atrial fibrillation,Unspecified essential hypertension,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,History of fall,Hypoxemia,Other iatrogenic hypotension,Other antihypertensive agents causing adverse effects in therapeutic use'}


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: [**Age over 90 **]yo [**Age over 90 595**]-speaking female with CHF, presents with increasing
dyspnea, pedal edema x1wk.  According to the patient's Grandson,
she has had issues with medication and dietary compliance.  VNA
at home note the patient's dyspnea and edema, was concerned
about a CHF exacerbation yesterday.  However, the patient
refused to come in until today, when her symptoms continued to
worsen.  Per the patient, at that time her O2 sat was 88% on 5L
oxygen via NC at home.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Dyslipidemia
2. CARDIAC HISTORY:
-dCHF last echo on [**7-/2168**] EF of 65%
-aFIB not anticoagulated due to fall risk
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Microvascular disease
-Extensive basal ganglia disease
-Gait disorder
-HTN
-Dyslipidemia
-Advanced DJD
-Meniere's disease
-hard of hearing

MEDICATION ON ADMISSION: Medications:
Phenytoin sodium extended 300 mg 6 DAYS/WEEK (Every day except
Sunday)
Phenytoin sodium extended 400 mg qSUN
Ursodiol 300 mg [**Hospital1 **]
Aspirin 325 mg Daily
Metoprolol succinate 100 mg [**Hospital1 **]
Senna 8.6 mg qHS prn
Docusate sodium 100 mg [**Hospital1 **]
Furosemide 120mg [**Hospital1 **]

ALLERGIES: Iodine; Iodine Containing / Ampicillin / Phenergan / Zaroxolyn

PHYSICAL EXAM: Admission Exam
Vitals: 96.2 140/101 92 20 93%3L, Wt 64Kg
Gen:  Elderly female, frail, NAD.
HEENT:  PERRL, EOMI.  No scleral icterus.  No conjunctival
injection.
Neck:  Supple, JVP to ear lobe.
Lungs: diffuse wheezes throughout w rales, no ronchi. Normal
respiratory effort
CV: Irregularly irregular, no murmurs, rubs, gallops.
Abdomen:  soft, NT, ND, NABS, no HSM.
Extremities:  WWP, no cyanosis.  2 + edema to knee
Neurological:  AOx3, CN II-XII intact.
Skin:  Paper-thin skin, no rashes or ulcers.
GU:  foley in place

FAMILY HISTORY: No clear history of CAD.

SOCIAL HISTORY: Patient lives at home by herself at subsidized senior housing
with assistance from family.  Her Grandson [**Name (NI) 382**] is an
interpreter at [**Hospital1 18**] and is very active in her care. 

### Response:
{'Acute on chronic diastolic heart failure,Atrial fibrillation,Unspecified essential hypertension,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,History of fall,Hypoxemia,Other iatrogenic hypotension,Other antihypertensive agents causing adverse effects in therapeutic use'}
