CHIEF COMPLAINT: Blurry vision

PRESENT ILLNESS: This is a 39 year old male with a history of hypertension (on
beta blockade, lasix, hydralazine, imdur, metolazone)
complicated by chronic kidney disease (stage IV), EF of 25-30%,
obesity, and
tobacco abuse.  He presented today to the emergency room after
[**Hospital 2081**] clinic noted severe bilateral papilledema; opthomology
suggested this was secondary to either elevated intracranial
pressure in the setting of malignant hypertension or pseudotumor
cerebri.  He has been symptomatic with blurry vision over the
past month in the absence of headaches or other central
symptoms.  He has noted some gait instability. In the ED, his
blood pressure was noted to be 180/118.  He took his usual dose
of one of his blood pressure meds (unknown) and his BP improved
to 160 systolic.  He was transferred to the MICU for management
of hypertensive emergency.

MEDICAL HISTORY: Hypertension, hypertensive chronic kidney disease stage IV,
systolic heart failure, last ejection fraction from [**Hospital 2082**] between 25 and 30%, obesity, and tobacco abuse.

MEDICATION ON ADMISSION: B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] -  (Prescribed by
Other Provider) - Dosage uncertain
CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day
FUROSEMIDE - 20 mg Tablet - 3 Tablet(s) by mouth twice a day
HYDRALAZINE - 100 mg Tablet - 1 Tablet(s) by mouth three times a
day
ISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr -
1
Tablet(s) by mouth Qday
METOLAZONE - 5 mg Tablet - 1 Tablet(s) by mouth Qday
METOPROLOL TARTRATE - 100 mg Tablet - 1 Tablet(s) by mouth twice
a day
POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 1
Tablet(s) by mouth Once a day
SEVELAMER HCL -  (Prescribed by Other Provider) - Dosage
uncertain

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
VS: HR 80 BP 170/100 RR 18 96% on RA
Gen: Obese. NAD.
HEENT:  Dilated fundoscopic exam revealed bilateral papilledema
without evidence of flame hemorrhages or distinct cotton whool
spots.  Mucous accumulation in canthal folds.  Mild proptosis
apprecaited. Otherwise MMM without any cervical LAD apprecatied.
 PERRLA.
CV: Faint heart sounds.  [**1-5**] pansystolic murmur best apprecaited
in mitral region.  No carotid bruits apprecaited. No rubs or
gallops.
Lungs: CTABL throughout all lung fields.
Abd: Obese.  Nontender throughout.  NBS.  No appreciable
organomegaly.
Ext: 1+ DPP with no appreciable edema.
NeurO: AOX3.  NO focal neurologic deficits appeciated on focused
cranial nerve exam or on brief gross motor exam.

FAMILY HISTORY: No history of hypertension, heart disease, or cancer.

SOCIAL HISTORY: The patient continues to smoke cigarettes about ten per day.  He
has cut down recently on the amount that he smokes, but still is
precontemplative about quitting at this time.
Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage IV (severe),Chronic systolic heart failure,Papilledema associated with increased intracranial pressure,Hypertensive encephalopathy,Cardiomyopathy in other diseases classified elsewhere,Hypopotassemia,Morbid obesity,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder,Personal history of noncompliance with medical treatment, presenting hazards to health
Mal hyp ht/kd I-IV w hf,Chr kidney dis stage IV,Chr systolic hrt failure,Papilledema w incr press,Hypertens encephalopathy,Cardiomyopath in oth dis,Hypopotassemia,Morbid obesity,Obstructive sleep apnea,Tobacco use disorder,Hx of past noncompliance
Admission Date:  [**2159-4-6**]              Discharge Date:   [**2159-4-10**]

Date of Birth:  [**2120-1-29**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Doctor First Name 2080**]
Chief Complaint:
Blurry vision

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 39 year old male with a history of hypertension (on
beta blockade, lasix, hydralazine, imdur, metolazone)
complicated by chronic kidney disease (stage IV), EF of 25-30%,
obesity, and
tobacco abuse.  He presented today to the emergency room after
[**Hospital 2081**] clinic noted severe bilateral papilledema; opthomology
suggested this was secondary to either elevated intracranial
pressure in the setting of malignant hypertension or pseudotumor
cerebri.  He has been symptomatic with blurry vision over the
past month in the absence of headaches or other central
symptoms.  He has noted some gait instability. In the ED, his
blood pressure was noted to be 180/118.  He took his usual dose
of one of his blood pressure meds (unknown) and his BP improved
to 160 systolic.  He was transferred to the MICU for management
of hypertensive emergency.


Past Medical History:
Hypertension, hypertensive chronic kidney disease stage IV,
systolic heart failure, last ejection fraction from [**Hospital 2082**] between 25 and 30%, obesity, and tobacco abuse.


Social History:
The patient continues to smoke cigarettes about ten per day.  He
has cut down recently on the amount that he smokes, but still is
precontemplative about quitting at this time.


Family History:
No history of hypertension, heart disease, or cancer.

Physical Exam:
ADMISSION EXAM:
VS: HR 80 BP 170/100 RR 18 96% on RA
Gen: Obese. NAD.
HEENT:  Dilated fundoscopic exam revealed bilateral papilledema
without evidence of flame hemorrhages or distinct cotton whool
spots.  Mucous accumulation in canthal folds.  Mild proptosis
apprecaited. Otherwise MMM without any cervical LAD apprecatied.
 PERRLA.
CV: Faint heart sounds.  [**1-5**] pansystolic murmur best apprecaited
in mitral region.  No carotid bruits apprecaited. No rubs or
gallops.
Lungs: CTABL throughout all lung fields.
Abd: Obese.  Nontender throughout.  NBS.  No appreciable
organomegaly.
Ext: 1+ DPP with no appreciable edema.
NeurO: AOX3.  NO focal neurologic deficits appeciated on focused
cranial nerve exam or on brief gross motor exam.

DISCHARGE EXAM:
VS: 98.0 BP 129-155/96-117 HR 75-96 RR 20 Satting 100% on RA.
GENERAL - well-appearing morbidly obese man in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD seen, no carotid bruits
LUNGS - CTA bilat
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-5**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait

Pertinent Results:
ADMISSION LABS:
[**2159-4-6**] 03:50PM BLOOD WBC-7.3 RBC-4.07* Hgb-12.5* Hct-37.0*
MCV-91 MCH-30.7 MCHC-33.7 RDW-13.6 Plt Ct-219
[**2159-4-6**] 03:50PM BLOOD Neuts-61.7 Lymphs-29.3 Monos-5.3 Eos-2.8
Baso-0.9
[**2159-4-6**] 03:50PM BLOOD PT-11.5 PTT-27.2 INR(PT)-1.1
[**2159-4-6**] 03:50PM BLOOD Glucose-84 UreaN-41* Creat-3.8* Na-142
K-3.4 Cl-100 HCO3-27 AnGap-18
[**2159-4-6**] 03:50PM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8

dischcarge labs:

[**2159-4-10**] 06:20AM BLOOD WBC-8.6 RBC-4.24* Hgb-13.4* Hct-38.8*
MCV-91 MCH-31.7 MCHC-34.6 RDW-13.3 Plt Ct-195
[**2159-4-10**] 06:20AM BLOOD Glucose-93 UreaN-53* Creat-4.1* Na-138
K-2.9* Cl-94* HCO3-26 AnGap-21*
[**2159-4-10**] 06:20AM BLOOD Calcium-9.5 Phos-5.9*# Mg-2.0
[**2159-4-10**] 06:20AM BLOOD ALDOSTERONE-PND
[**2159-4-10**] 06:20AM BLOOD RENIN-PND

OTHER LABS:
[**2159-4-7**] 01:46AM BLOOD ALT-14 AST-20 AlkPhos-42 TotBili-0.4
[**2159-4-7**] 01:46AM BLOOD TSH-1.1

IMAGING:

CT Head w/o contrast [**2159-4-6**]:
1. No acute intracranial pathology.
2. Bilateral proptosis.

renal u/s [**2159-4-9**]:
Both kidneys show increased echogenicity consistent with chronic

kidney disease. Two simple cysts in the right kidney, one at the
upper pole and one at the lower pole. Doppler evaluation of both
renal arteries and of the arcuate/segmental vessels in the renal
parenchyma was within normal limits. No ultrasound/Doppler
evidence for renal artery stenosis.

tte [**2159-4-10**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is at
least 15 mmHg. There is severe symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular free wall
is hypertrophied. Right ventricular chamber size is normal. with
depressed free wall contractility. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.


Brief Hospital Course:
#Hypertensive Emergency:  Pt presented with HTN systolics >200
and blurry vision, found to have papilledema. The patient's
blood pressure was markedly elevated with systolic blood
pressures ranging from 160-210 during ICU stay.  Review of prior
notes outlines a longstanding history of poorly controlled blood
pressures.  His home isosorbide and carvedilol were
discontinued. Labetalol was uptitrated to 200mg TID, Hydral
downtitrated to 50mg TID, clonidine 0.3mg weekly patch started,
and furosemide/metolazone continued as is. MAP >120 was goal. On
leaving the ICU SPB was in 130s. TSH was within normal limits.
It was felt that this patient needed a full workup for secondary
causes of hypertension. In the meantime renal artery ultrasound
done here showed no renal artery stenosis but did show chornic
bilateral changes consistent with CKDD. He should likely have a
workup for hyperaldosteronism (see hypokalemia below) and workup
including urine metanephrines and dexamethasone suppression
test, as he is quite young for this degree of hypertension and
seems to be compliant with his medications. He was initially
started on spironolactone given report of EF 25-30% and thought
that it may help with hypokalemia, however after 3 days (3
doses) this was discontinued so that pt could ideally have a
renin/aldosterone level drawn prior to discharge (which is now
pending), several days after discontinuation. Would recommend
restarting this medication after the appropriate studies have
been done. It is more than likely this patient has sleep apnea
as well; in the ICU he was noted to have desats during sleep
with very loud snoring. Desats resolved instantly on waking. Pt
is also smoking and quite obese both of which are likely
worsening his hypertension. Would recommend outpatient sleep
study as well.
.
#hypokalemia - pt was noted to be hypokalemic with potassium
2.9-3.2. Concern for hyperaldosterone state given concommittant
resistant hypertension. Pt required >160meq potassium repletion
per day while in the [**Hospital Unit Name 153**] and still remained with K below 4.0.
Outpatient records demonstrate history of low potassium. Pt also
had been started on spironolactone, and while it was low dose,
it did not appear to help with potassium retention. This was
also unusual in the setting of elevated creatinine/chronic renal
failure, which emphasized concerns for hyperaldosterone state.
Spironolactone was DCd temporarily so that he could have
renin/[**Male First Name (un) 2083**] levels drawn.

#Intracranial hypertension: Likely secondary to systmemic
hypertension.  Neurology evalauted patient in ED and suggested
potential LP if BP controlled to assess for pseudotumor
cerebrii, though this can be deferred to outpatient setting if
papilledema does not improve with improved BP control.
.
#Chronic kidney disease: The patient's creatinine was elevated
at 3.6-3.7, which is baseline. CKD likely secondary to
hypertensive nephropathy.  Continued sevalamer and nephrocaps.
.
#Chronic systolic CHF: No echo in the system, but OSH records
per Dr.[**Name (NI) 2084**] note states TTE showed increased wall
thickness, estimated LVEF 25-30% and global hypokinesis without
focal wall motion abnormality, as well as increased [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 1934**], with estimated PA systolic pressure 32mm.  The
patient appeared euvolemic on exam, without evidence of an acute
sCHF exacerbation.  His blood pressure control was adjusted as
above, including the addition of spironolactone to his regimen.
Despite his renal impairment, he may benefit from the addition
of an ACEi/[**Last Name (un) **] and should discuss this with his PCP,
[**Name10 (NameIs) 2085**], and nephrologist.  He was continued on a beta
blocker (though switched from metoprolol/carvedilol to
labetalol), lasix, and metolazone. His EF on the TTE here showed
an EF of 55%.

TRANSITIONAL ISSUES:
-Has PCP, [**Name10 (NameIs) 2086**], and nephrology follow-up scheduled
-Needs outpatient sleep study
-Would benefit from work-up for secondary hypertension if not
already done at another facility - follow up renin/[**Male First Name (un) 2083**] ratio,
may draw urine metaneprhines, dex suppression testing
-Patient was a Full Code during this admission
-Would benefit from nutrition consult
- Has Cr and K ordered as outpt on Thursday which needs f/up

Medications on Admission:
B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] -  (Prescribed by
Other Provider) - Dosage uncertain
CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day
FUROSEMIDE - 20 mg Tablet - 3 Tablet(s) by mouth twice a day
HYDRALAZINE - 100 mg Tablet - 1 Tablet(s) by mouth three times a
day
ISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr -
1
Tablet(s) by mouth Qday
METOLAZONE - 5 mg Tablet - 1 Tablet(s) by mouth Qday
METOPROLOL TARTRATE - 100 mg Tablet - 1 Tablet(s) by mouth twice
a day
POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 1
Tablet(s) by mouth Once a day
SEVELAMER HCL -  (Prescribed by Other Provider) - Dosage
uncertain


Discharge Medications:
1. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
2. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
3. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
6. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patches
Transdermal QSAT (every Saturday).
Disp:*4 Patch Weekly(s)* Refills:*2*
7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*0*
9. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Hypertensive emergency

Secondary Diagnoses:
Chronic kidney disease
Chronic systolic heart failure
Tobacco abuse
Obesity


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Mr. [**Known lastname 2087**],

You were admitted to the intensive care unit at [**Hospital1 771**] with very high blood pressures and
blurry vision.  Your blurry vision was likely caused by your
high blood pressure.  When your blood pressure is this high, you
are at risk for serious complications including further kidney
damage and possible stroke.  We monitored you closely and
changed some of your blood pressure medications to help better
control your blood pressures.

We made the following changes to your medications:
STOPPED:
-Carvedilol
-Metoprolol
-Isosorbide mononitrate

DECREASED:
-Hydralazine from 100 mg three times a day to 50 mg three times
a day

INCREASED:
-Potassium chloride 20 meq chrystals increased from one dose
once a day to two doses once a day

STARTED:
-Clonidine patch 0.3 mg once a week
-Labetalol 400 mg three times a day
-Lisinopril 2.5mg once a day

We did not make any other changes to your medications.  Please
continue to take them as you have been doing.

It is very important that you take your blood pressure
medications and monitor your blood pressure.  If your blood
pressure is persistently higher than 190/110, you should contact
your doctor.  Also, if you develop any worsening blurry vision,
headache, chest pain, shortness of breath, slurred speech, or
weakness on one side of the face or body, you should seek
medical attention immediately.

We are concerned you may have a condition called obstructive
sleep apnea, and we recommend you have a sleep study after you
leave the hospital.

We also recommend that you see a nutritionist and work on
continuing to lose weight.  Please eat a low salt diet.

We also strongly encourage you to stop smoking.

Please also note that you will need to get your creatinine and
potassium checked on Thursday, [**2159-4-12**].

Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2159-4-12**] at 2:15 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: MONDAY [**2159-4-23**] at 9:40 AM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2159-5-30**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage
{'Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage IV (severe),Chronic systolic heart failure,Papilledema associated with increased intracranial pressure,Hypertensive encephalopathy,Cardiomyopathy in other diseases classified elsewhere,Hypopotassemia,Morbid obesity,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder,Personal history of noncompliance with medical treatment, presenting hazards to health'}


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: Blurry vision

PRESENT ILLNESS: This is a 39 year old male with a history of hypertension (on
beta blockade, lasix, hydralazine, imdur, metolazone)
complicated by chronic kidney disease (stage IV), EF of 25-30%,
obesity, and
tobacco abuse.  He presented today to the emergency room after
[**Hospital 2081**] clinic noted severe bilateral papilledema; opthomology
suggested this was secondary to either elevated intracranial
pressure in the setting of malignant hypertension or pseudotumor
cerebri.  He has been symptomatic with blurry vision over the
past month in the absence of headaches or other central
symptoms.  He has noted some gait instability. In the ED, his
blood pressure was noted to be 180/118.  He took his usual dose
of one of his blood pressure meds (unknown) and his BP improved
to 160 systolic.  He was transferred to the MICU for management
of hypertensive emergency.

MEDICAL HISTORY: Hypertension, hypertensive chronic kidney disease stage IV,
systolic heart failure, last ejection fraction from [**Hospital 2082**] between 25 and 30%, obesity, and tobacco abuse.

MEDICATION ON ADMISSION: B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] -  (Prescribed by
Other Provider) - Dosage uncertain
CARVEDILOL - 25 mg Tablet - 1 Tablet(s) by mouth twice a day
FUROSEMIDE - 20 mg Tablet - 3 Tablet(s) by mouth twice a day
HYDRALAZINE - 100 mg Tablet - 1 Tablet(s) by mouth three times a
day
ISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr -
1
Tablet(s) by mouth Qday
METOLAZONE - 5 mg Tablet - 1 Tablet(s) by mouth Qday
METOPROLOL TARTRATE - 100 mg Tablet - 1 Tablet(s) by mouth twice
a day
POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 1
Tablet(s) by mouth Once a day
SEVELAMER HCL -  (Prescribed by Other Provider) - Dosage
uncertain

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
VS: HR 80 BP 170/100 RR 18 96% on RA
Gen: Obese. NAD.
HEENT:  Dilated fundoscopic exam revealed bilateral papilledema
without evidence of flame hemorrhages or distinct cotton whool
spots.  Mucous accumulation in canthal folds.  Mild proptosis
apprecaited. Otherwise MMM without any cervical LAD apprecatied.
 PERRLA.
CV: Faint heart sounds.  [**1-5**] pansystolic murmur best apprecaited
in mitral region.  No carotid bruits apprecaited. No rubs or
gallops.
Lungs: CTABL throughout all lung fields.
Abd: Obese.  Nontender throughout.  NBS.  No appreciable
organomegaly.
Ext: 1+ DPP with no appreciable edema.
NeurO: AOX3.  NO focal neurologic deficits appeciated on focused
cranial nerve exam or on brief gross motor exam.

FAMILY HISTORY: No history of hypertension, heart disease, or cancer.

SOCIAL HISTORY: The patient continues to smoke cigarettes about ten per day.  He
has cut down recently on the amount that he smokes, but still is
precontemplative about quitting at this time. 

### Response:
{'Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage IV (severe),Chronic systolic heart failure,Papilledema associated with increased intracranial pressure,Hypertensive encephalopathy,Cardiomyopathy in other diseases classified elsewhere,Hypopotassemia,Morbid obesity,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder,Personal history of noncompliance with medical treatment, presenting hazards to health'}
