CHIEF COMPLAINT: Shortness of breath, Left leg swelling

PRESENT ILLNESS: 62yo woman with history of hypertension presented to [**Hospital 191**] clinic
on day of admission with multiple complaints including chest
pain radiating to her left shoulder, shortness of breath on
exertion, cough, and worsening LLE swelling and pain x 2 days.
On initial exam, her vitals were stable: T 97.7, BP 126/84, P65,
RR10 98%RA. Her exam was notable for LLE swelling and warmth.
She was sent to the ED for further evaluation. In the ED, her
evaluation was notable for the following: clear chest film; CTA
demonstrating bilateral PE's; LLE LENI with extensive DVT in
left common femoral, superficial femoral, and popliteal veins,
also extending into greater saphenous; also found to have acute
coagulopathy, anemia, and thrombocytopenia.
She was also found to have BRBPR. GI was consulted, and
recommended to perform bowel prep in anticipation of colonoscopy
in AM. Surgery was consulted as well, and agreed with plan for
anticoagulation for PE's and further investigation for GI
bleeding by GI.
.
On interview on the floor she is alert, oriented, very pleasant,
and in no distress. She confirms that over the past several days
she has had exertional dyspnea, chest pain (described as dull
pressure, [**5-29**], mid-sternal with radiation to bilateral
shoulders, not clearly pleuritic) and worsening LLE swelling and
pain. She also reports several recent bouts of upper respiratory
symptoms after exposure to her grandson who is an infant in
daycare (reportedly had RSV bronchiolitis recently). Otherwise,
she denies any fever, chills, n/v, lymphadenopathy, night
sweats, unintentional weight loss, abdominal pain/increased
girth, or pruritus. She does report one episode of BRBPR on day
prior to admission after having bowel movement. ROS otherwise
negative. She also reports a worsening dry cough since she has
been in the hospital. She did not have a flu shot. She does not
report any long plane/car trips, no prolonged bed-rest. She
notes that the swelling in her L leg has improved since being in
the hospital.

MEDICAL HISTORY: Hypertension
Osteopenia
h/o pneumonia
liver hemangioma
psoriasis
rosacea
Diverticulosis

MEDICATION ON ADMISSION: ASPIRIN 81 mg
BETAMETHASONE VALERATE 0.1 % to skin
METROGEL 1 % to skin
MULTIVITAMIN qD
VERAPAMIL HCL CR 240 MG qD
VIACTIV 500-100-40 mg-unit-mcg [**Hospital1 **]

ALLERGIES: Bactrim Ds / Sulfa (Sulfonamides)

PHYSICAL EXAM: 99.6, 92, 124/61, 18, 99% 2L nc
.
gen a/o, no distress, speaking in full sentences, no accessory
resp muscle use
heent moist mm, anicteric
neck supple, from, no meningeal signs, no JVD, no
lymphadenopathy
cv rrr, no m/r/g
resp CTA with decreased breath sounds in bilateral bases L>R
abd obese, soft, nabs, nt, no hepatosplenomegaly
extr asymmetric 2+ edema and erythema in LLE
neuro grossly non-focal

FAMILY HISTORY: Father and mother with heart disease. Father had a triple A.
HTN. No blood clots. Father nieces with stomach cancer. Aunt
with lung cancer but was a smoker.

SOCIAL HISTORY: Lives in [**Location 2624**], MA and summers on [**Location (un) 945**]. Married, two adult
children. Retired. No etoh/drugs/tobacco. Very active involved
in re-modelling her house. Babysits her grandson once per week.
Prior to onset of multiple viral illnesses last fall she did the
treadmill for 25 mins at speed 3.3 3-4 times per week.
Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Diverticulosis of colon with hemorrhage,Acute posthemorrhagic anemia,Thrombocytopenia, unspecified,Pneumonia, organism unspecified,Unspecified essential hypertension
Pulm embol/infarct NEC,Ac DVT/emb prox low ext,Dvrtclo colon w hmrhg,Ac posthemorrhag anemia,Thrombocytopenia NOS,Pneumonia, organism NOS,Hypertension NOS
Admission Date:  [**2127-3-7**]              Discharge Date:   [**2127-3-14**]

Date of Birth:  [**2064-4-1**]             Sex:   F

Service: MEDICINE

Allergies:
Bactrim Ds / Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Shortness of breath, Left leg swelling

Major Surgical or Invasive Procedure:
None.


History of Present Illness:
62yo woman with history of hypertension presented to [**Hospital 191**] clinic
on day of admission with multiple complaints including chest
pain radiating to her left shoulder, shortness of breath on
exertion, cough, and worsening LLE swelling and pain x 2 days.
On initial exam, her vitals were stable: T 97.7, BP 126/84, P65,
RR10 98%RA. Her exam was notable for LLE swelling and warmth.
She was sent to the ED for further evaluation. In the ED, her
evaluation was notable for the following: clear chest film; CTA
demonstrating bilateral PE's; LLE LENI with extensive DVT in
left common femoral, superficial femoral, and popliteal veins,
also extending into greater saphenous; also found to have acute
coagulopathy, anemia, and thrombocytopenia.
She was also found to have BRBPR. GI was consulted, and
recommended to perform bowel prep in anticipation of colonoscopy
in AM. Surgery was consulted as well, and agreed with plan for
anticoagulation for PE's and further investigation for GI
bleeding by GI.
.
On interview on the floor she is alert, oriented, very pleasant,
and in no distress. She confirms that over the past several days
she has had exertional dyspnea, chest pain (described as dull
pressure, [**5-29**], mid-sternal with radiation to bilateral
shoulders, not clearly pleuritic) and worsening LLE swelling and
pain. She also reports several recent bouts of upper respiratory
symptoms after exposure to her grandson who is an infant in
daycare (reportedly had RSV bronchiolitis recently). Otherwise,
she denies any fever, chills, n/v, lymphadenopathy, night
sweats, unintentional weight loss, abdominal pain/increased
girth, or pruritus. She does report one episode of BRBPR on day
prior to admission after having bowel movement. ROS otherwise
negative. She also reports a worsening dry cough since she has
been in the hospital. She did not have a flu shot. She does not
report any long plane/car trips, no prolonged bed-rest. She
notes that the swelling in her L leg has improved since being in
the hospital.


Past Medical History:
Hypertension
Osteopenia
h/o pneumonia
liver hemangioma
psoriasis
rosacea
Diverticulosis


Social History:
Lives in [**Location 2624**], MA and summers on [**Location (un) 945**]. Married, two adult
children. Retired. No etoh/drugs/tobacco. Very active involved
in re-modelling her house. Babysits her grandson once per week.
Prior to onset of multiple viral illnesses last fall she did the
treadmill for 25 mins at speed 3.3 3-4 times per week.

Family History:
Father and mother with heart disease. Father had a triple A.
HTN. No blood clots. Father nieces with stomach cancer. Aunt
with lung cancer but was a smoker.

Physical Exam:
99.6, 92, 124/61, 18, 99% 2L nc
.
gen a/o, no distress, speaking in full sentences, no accessory
resp muscle use
heent moist mm, anicteric
neck supple, from, no meningeal signs, no JVD, no
lymphadenopathy
cv rrr, no m/r/g
resp CTA with decreased breath sounds in bilateral bases L>R
abd obese, soft, nabs, nt, no hepatosplenomegaly
extr asymmetric 2+ edema and erythema in LLE
neuro grossly non-focal


Pertinent Results:
[**2127-3-6**] 06:50PM   WBC-11.7*# RBC-3.75* HGB-11.4* HCT-31.8*
MCV-85 MCH-30.2 MCHC-35.7* RDW-13.7
[**2127-3-6**] 06:50PM   NEUTS-81.0* LYMPHS-13.3* MONOS-3.7 EOS-1.6
BASOS-0.3
[**2127-3-6**] 06:50PM   PLT SMR-VERY LOW PLT COUNT-61*# LPLT-2+
[**2127-3-6**] 06:50PM   PT-15.9* PTT-44.8* INR(PT)-1.4*
[**2127-3-6**] 06:50PM   FIBRINOGE-65*

[**2127-3-6**] 06:50PM   calTIBC-281 HAPTOGLOB-248* FERRITIN-192*
TRF-216
[**2127-3-6**] 06:50PM   HOMOCYSTN-12.4

[**2127-3-6**] 06:50PM   GLUCOSE-119* UREA N-27* CREAT-1.1 SODIUM-136
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16
[**2127-3-6**] 06:50PM   ALT(SGPT)-30 AST(SGOT)-24 LD(LDH)-333*
CK(CPK)-276* ALK PHOS-82 AMYLASE-38 TOT BILI-0.5
[**2127-3-6**] 06:50PM   CK-MB-3
[**2127-3-6**] 06:50PM   cTropnT-<0.01

[**2127-3-7**] 05:30AM   D-DIMER-8945*

CTA CHEST:
1. Extensive bilateral pulmonary emboli, with probable
developing infarction in the left lingula.
2. Left pelvic vein clot from imaged portion of common femoral
to the confluence of the common iliac veins, likely the source
of pulmonary emboli. No definite extension to the right common
iliac vein or IVC.
3. Large hemangioma in liver.
4. Colonic diverticulosis without diverticulitis.
5. Left adnexal cyst, unusual in a postmenopausal patient. This
should be further evaluated with pelvic ultrasound on a
nonemergent basis.

LENI:  Extensive acute DVT within the entire left lower
extremity deep venous systems. No right DVT.

ECG:  Sinus rhythm. Non-specific junctional ST segment
depressions. Compared to the previous tracing this finding is
new.

TTE:
The left atrium is elongated. Left ventricular wall thicknesses
are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic
function is normal (LVEF>55%). Tissue Doppler imaging suggests a
normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and
free wall motion are normal. The aortic arch is mildly dilated.
The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The left
ventricular inflow pattern suggests impaired relaxation. There
is borderline
pulmonary artery systolic hypertension. There is a
trivial/physiologic
pericardial effusion.

PELVIC US: Fibroids, follicular activity left ovary, right ovary
not seen, thrombus in the left iliac vein


Brief Hospital Course:
1) DVT/PE:
Patient was started on anticoagulation with heparin for
extensive PE/DVT (LLE).  This was continued despite bleeding.
Once the bleeding has stabilized, she was started on coumadin.
She was discharged on a lovenox bridge to coumadin.

In terms of workup for cause of this thrombosis, pt had a pelvic
US to further evaluate mass since on CT as potential malignancy.
 But there was no evidence of ovarian malignancy.  She was up to
date on other cancer screening.  Factor V leiden and prothrombin
gene mutation were pending at time of discharge.  The rest of
the hypercoagulable workup will have to be done once acute
thrombosis resolves.

The left leg swelling improved throughout the admission.  Pt was
instructed to keep the leg wrapped most of the day.  And to keep
it elevated when lying in bed or sitting.

..

2) GI BLEED:  Flex sig showed diverticulosis so this bleeding
was secondary to that.  Pt did have blood loss anemia requiring
transfusions.  During the last 5days of the admission, there was
no clinical bleeding and her Hct was stable to slightly
improving.  Aspirin was held.  Verapamil was also held and not
restarted as pt's BP was well controlled in house.

..

3)  HTN:  As above, verapamil was held.

..

4) COAGULOPATHY:  On admission, pt had thromboctyopenia, low
fibrinogen.  This was felt to be due to consumption and factors
improved once anticoagulation was started.  There was no
evidence of frank DIC.

..

5) PNEUMONIA:  Several days into the admission, pt developed a
low grade temperature and cough.  Though this was most likely
due to pulmonary infarction, levaquin was started for pneumonia.
 Pt's cough improved with this and she completed a 5d course of
levaquin before discharge.

Medications on Admission:
ASPIRIN 81 mg
BETAMETHASONE VALERATE 0.1 % to skin
METROGEL 1 % to skin
MULTIVITAMIN qD
VERAPAMIL HCL CR 240 MG qD
VIACTIV 500-100-40 mg-unit-mcg [**Hospital1 **]


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day.
Disp:*150 Tablet(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 1 weeks.
Disp:*14 syringe* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Deep Venous Thrombosis
Pulmonary embolism
Diverticular hemorrhage
Pneumonia


Discharge Condition:
Good.


Discharge Instructions:
Take medications as prescribed.  You should not take aspirin or
verapamil until you are reassessed by Dr. [**First Name (STitle) 216**].  Do not take a
multivitamin or anything else with vitamin k as that will
counteract the coumadin.

For the next week, you can do basic daily activities but avoid
anything that requires prolonged standing, sitting (with legs
not elevated) ie driving, or walking.  You can continue to use
the leg wrap during the night and part of the day.  As your
swelling improves, you should not continue to need that.

Followup Instructions:
You will have your INR checked on monday with results sent to
Dr. [**First Name (STitle) 216**].  He will instruct you on whether you need to
continue lovenox and how to adjust your coumadin dose.  Please
ask the VNA which lab the blood will be sent to.

Please follow up with Dr. [**First Name (STitle) 216**] late next week or early the
following week.
{'Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Diverticulosis of colon with hemorrhage,Acute posthemorrhagic anemia,Thrombocytopenia, unspecified,Pneumonia, organism unspecified,Unspecified essential hypertension'}


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, Left leg swelling

PRESENT ILLNESS: 62yo woman with history of hypertension presented to [**Hospital 191**] clinic
on day of admission with multiple complaints including chest
pain radiating to her left shoulder, shortness of breath on
exertion, cough, and worsening LLE swelling and pain x 2 days.
On initial exam, her vitals were stable: T 97.7, BP 126/84, P65,
RR10 98%RA. Her exam was notable for LLE swelling and warmth.
She was sent to the ED for further evaluation. In the ED, her
evaluation was notable for the following: clear chest film; CTA
demonstrating bilateral PE's; LLE LENI with extensive DVT in
left common femoral, superficial femoral, and popliteal veins,
also extending into greater saphenous; also found to have acute
coagulopathy, anemia, and thrombocytopenia.
She was also found to have BRBPR. GI was consulted, and
recommended to perform bowel prep in anticipation of colonoscopy
in AM. Surgery was consulted as well, and agreed with plan for
anticoagulation for PE's and further investigation for GI
bleeding by GI.
.
On interview on the floor she is alert, oriented, very pleasant,
and in no distress. She confirms that over the past several days
she has had exertional dyspnea, chest pain (described as dull
pressure, [**5-29**], mid-sternal with radiation to bilateral
shoulders, not clearly pleuritic) and worsening LLE swelling and
pain. She also reports several recent bouts of upper respiratory
symptoms after exposure to her grandson who is an infant in
daycare (reportedly had RSV bronchiolitis recently). Otherwise,
she denies any fever, chills, n/v, lymphadenopathy, night
sweats, unintentional weight loss, abdominal pain/increased
girth, or pruritus. She does report one episode of BRBPR on day
prior to admission after having bowel movement. ROS otherwise
negative. She also reports a worsening dry cough since she has
been in the hospital. She did not have a flu shot. She does not
report any long plane/car trips, no prolonged bed-rest. She
notes that the swelling in her L leg has improved since being in
the hospital.

MEDICAL HISTORY: Hypertension
Osteopenia
h/o pneumonia
liver hemangioma
psoriasis
rosacea
Diverticulosis

MEDICATION ON ADMISSION: ASPIRIN 81 mg
BETAMETHASONE VALERATE 0.1 % to skin
METROGEL 1 % to skin
MULTIVITAMIN qD
VERAPAMIL HCL CR 240 MG qD
VIACTIV 500-100-40 mg-unit-mcg [**Hospital1 **]

ALLERGIES: Bactrim Ds / Sulfa (Sulfonamides)

PHYSICAL EXAM: 99.6, 92, 124/61, 18, 99% 2L nc
.
gen a/o, no distress, speaking in full sentences, no accessory
resp muscle use
heent moist mm, anicteric
neck supple, from, no meningeal signs, no JVD, no
lymphadenopathy
cv rrr, no m/r/g
resp CTA with decreased breath sounds in bilateral bases L>R
abd obese, soft, nabs, nt, no hepatosplenomegaly
extr asymmetric 2+ edema and erythema in LLE
neuro grossly non-focal

FAMILY HISTORY: Father and mother with heart disease. Father had a triple A.
HTN. No blood clots. Father nieces with stomach cancer. Aunt
with lung cancer but was a smoker.

SOCIAL HISTORY: Lives in [**Location 2624**], MA and summers on [**Location (un) 945**]. Married, two adult
children. Retired. No etoh/drugs/tobacco. Very active involved
in re-modelling her house. Babysits her grandson once per week.
Prior to onset of multiple viral illnesses last fall she did the
treadmill for 25 mins at speed 3.3 3-4 times per week. 

### Response:
{'Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Diverticulosis of colon with hemorrhage,Acute posthemorrhagic anemia,Thrombocytopenia, unspecified,Pneumonia, organism unspecified,Unspecified essential hypertension'}
