CHIEF COMPLAINT: hypertensive urgency

PRESENT ILLNESS: 55 Y F with hx diastolic HF, [**First Name3 (LF) 2091**] with baseline Cr of 2.2, HTN,
CAD (50% stenosis of OM, no stents), DM, presenting with BP
242/124 in the setting of inability to take meds for 3 days [**3-7**]
N+V.
N+V started 4 days ago, last solid meal 3 days ago, and has not
been taking meds for past 3 days. Usually applies clonidine
patch on Sunday but reports that she didn't take a shower on
sunday [**3-7**] NFW and therefore never put on her patch. She doesn't
remember ever taking her old patch off but states that it must
have come off at some point. Mild abd pain, none now. No
diarrhea or constipation, last bm yesterday. Seen today at Heart
Failure clinic, sent here for SBP>200. She denies fever, chills,
URI symptoms, diarrhea, sick contacts.
.
In the ED she had mild chest pressure when she arrived, which
resolved now after treating BP. EKG was negative, trop 0.39 (but
not up from baseline) and CK-MB negative (10). They were unable
to get IV access so an EJ was placed. No HA, dizziness, visual
changes on presentation. Her BP was treated with labetalol 20 mg
IV x2, then a nitro gtt. Her SBP remained in the 190s. Head CT
was obtained due to the isolated nausea/vomiting, no ICH seen.
.
At time of transfer she continues to report nausea and slight
headache, worsened since getting NTG in ED. ROS negative for
fevers, chills, cough, URI ,dysuria, hematuria, melena, BRBPR,
rash.
.

MEDICAL HISTORY: CAD (stent in [**May 2131**])
CRI (baseline Cr ~2.0)
diastolic CHF
HTN
Anemia
DM
peripheral neuropathy
.

MEDICATION ON ADMISSION: diovan 160 mg [**Hospital1 **]
coreg 25 mg [**Hospital1 **]
clonidine 0.3mg/24h patch QSun
amlodipine 10 mg QDay
lasix 100/80 mg [**Hospital1 **]
neurontin 300 PO QDay
zetia 10 mg QDay
vitamin D 1000 U QDay
lantus 16 units QHS
ASA 81 mg QDay
FeSo4 325 mg QDay

ALLERGIES: Crestor

PHYSICAL EXAM: Vitals: T97.2 HR 74 BP 207/98 RR 8 100%RA .
GEN: Middle aged female, sleeping, awakens easily, appears
uncomfortable
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM, no LAD, No
JVD, REJ IV in place
CV: regular, nl s1, s2, +syst II/VI murmor at RUSB.
PULM: CTAB anteriorly, no r/r/w.
ABD: soft,obese, nontender, nondistended, BS+
EXT: warm, no pedal edema, DP's 2+ bilaterally
NEURO: alert & oriented x 3, CN II-XII grossly intact

FAMILY HISTORY: Mother with HTN and [**Name (NI) 2091**], denies fh of DM, CAd.

SOCIAL HISTORY: Denies tobbacco, denies alcohol, denies IVDU.
Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified,Acute kidney failure, unspecified,Chronic diastolic heart failure,Chronic kidney disease, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Gastroparesis,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery
Mal hy kid w cr kid I-IV,Acute kidney failure NOS,Chr diastolic hrt fail,Chronic kidney dis NOS,DMII neuro nt st uncntrl,Neuropathy in diabetes,Gastroparesis,Anemia in chr kidney dis,Crnry athrscl natve vssl
Admission Date:  [**2133-2-18**]              Discharge Date:   [**2133-2-23**]

Date of Birth:  [**2077-11-22**]             Sex:   F

Service: MEDICINE

Allergies:
Crestor

Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
hypertensive urgency

Major Surgical or Invasive Procedure:
none

History of Present Illness:
55 Y F with hx diastolic HF, [**First Name3 (LF) 2091**] with baseline Cr of 2.2, HTN,
CAD (50% stenosis of OM, no stents), DM, presenting with BP
242/124 in the setting of inability to take meds for 3 days [**3-7**]
N+V.
N+V started 4 days ago, last solid meal 3 days ago, and has not
been taking meds for past 3 days. Usually applies clonidine
patch on Sunday but reports that she didn't take a shower on
sunday [**3-7**] NFW and therefore never put on her patch. She doesn't
remember ever taking her old patch off but states that it must
have come off at some point. Mild abd pain, none now. No
diarrhea or constipation, last bm yesterday. Seen today at Heart
Failure clinic, sent here for SBP>200. She denies fever, chills,
URI symptoms, diarrhea, sick contacts.
.
In the ED she had mild chest pressure when she arrived, which
resolved now after treating BP. EKG was negative, trop 0.39 (but
not up from baseline) and CK-MB negative (10). They were unable
to get IV access so an EJ was placed. No HA, dizziness, visual
changes on presentation. Her BP was treated with labetalol 20 mg
IV x2, then a nitro gtt. Her SBP remained in the 190s. Head CT
was obtained due to the isolated nausea/vomiting, no ICH seen.
.
At time of transfer she continues to report nausea and slight
headache, worsened since getting NTG in ED. ROS negative for
fevers, chills, cough, URI ,dysuria, hematuria, melena, BRBPR,
rash.
.


Past Medical History:
CAD (stent in [**May 2131**])
CRI (baseline Cr ~2.0)
diastolic CHF
HTN
Anemia
DM
peripheral neuropathy
.


Social History:
Denies tobbacco, denies alcohol, denies IVDU.

Family History:
Mother with HTN and [**Name (NI) 2091**], denies fh of DM, CAd.

Physical Exam:
Vitals: T97.2 HR 74 BP 207/98 RR 8 100%RA .
GEN: Middle aged female, sleeping, awakens easily, appears
uncomfortable
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM, no LAD, No
JVD, REJ IV in place
CV: regular, nl s1, s2, +syst II/VI murmor at RUSB.
PULM: CTAB anteriorly, no r/r/w.
ABD: soft,obese, nontender, nondistended, BS+
EXT: warm, no pedal edema, DP's 2+ bilaterally
NEURO: alert & oriented x 3, CN II-XII grossly intact


Pertinent Results:
[**2133-2-18**] 12:00PM   GLUCOSE-236* UREA N-33* CREAT-2.2* SODIUM-143
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-26 ANION GAP-15
[**2133-2-18**] 12:00PM   CK-MB-10 cTropnT-0.39*
.
[**2133-2-18**] 12:00PM   WBC-10.9 RBC-4.05* HGB-11.0* HCT-34.1* MCV-84
MCH-27.3 MCHC-32.3 RDW-14.5
[**2133-2-18**] 12:00PM   NEUTS-85.0* LYMPHS-11.8* MONOS-2.8 EOS-0.4
BASOS-0.1
[**2133-2-18**] 12:00PM   PLT COUNT-197
[**2133-2-18**] 12:00PM   PT-12.0 PTT-24.6 INR(PT)-1.0
.
.
STUDIES:
R heart Cath [**8-10**]:
1. Resting hemodynamic measurements by right heart
catheterization demonstrated elevated left and right heart
pressures with a mean PCWP of 37mmHg, RVEDP of 24mmHg and RA of
21mmHg. The pulmonary artery systolic pressure was significantly
elevated with a mean of 50mmHg. The calculated Fick C.I. was
preserved at 3.33 L/min/m2.
FINAL DIAGNOSIS:
1. Severe biventricular diastolic dysfunction.
2. Severe primary pulmonary hypertension.
.
TTE [**8-10**]:
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler
and tissue velocity imaging are consistent with Grade II
(moderate) LV diastolic dysfunction. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension. There
is a small pericardial effusion. There are no echocardiographic
signs of tamponade.
.
Compared with the prior study (images reviewed) of [**2132-8-14**],
the degree of tricuspid regurgitation (underestimated on prior
study and pulmonary hypertension detected have decreased. These
constellation of diastolic heart failure, LVH, thickened valves,
large atria and pericardial effusion are suggestive (not
diagnostic) of cardiac amyloidosis.
.
CXR [**2-18**]: No radiographic evidence of pneumonia or CHF.
.
Head CT [**2-18**]: No acute intracranial hemorrhage.
.
[**2133-2-18**] EKG 19:56 - NSR at 68bpm, evidence of atrial
enlargement, L axis deviation, minimal criteria for LVH, normal
intervals. '
EKG 11:29 NSR at 88bpm, LAD, atrial enlargement, LVH, strain
pattern with ST elevation in V1 through V3.


Brief Hospital Course:
This is a 55 year old woman with h/o of diastolic CHF, [**Month/Day/Year 2091**], and
diabetes who presented with hypertensive emergency, and was
transferred to ICU on nitroprusside gtt.
.
# Hypertensive Emergency/Urgency: Thought most likely [**3-7**] to
stopping antihypyertensives, including clonidine patch and
inability to take oral pills due to nausea/vomiting. Patient has
severe HTN likely worsened by [**Month/Day (2) 2091**] and is on a 4 drug regimen as
an outpatient. Associated symptoms of headache and chest pain
with strain pattern on EKG were concerning for HTN emergency.
She was admitted to ICU, ruled out for MI, required nitro drip.
On transfer to the floor she was able to tolerate po's and was
restarted on her home regimen with good effect.   By discharge
day, the trend had shown that the one time of day when blood
pressure above goal was shortly after waking.  Pt was told to
take her carvedilol very soon after awakening rather than
waiting an hour and a half as she had been doing.  Pt states she
sleeps until 9am every morning.

# Nausea/Vomiting: Resolved with addition of reglan.  Pt was
warned of side effects and discharged on one week supply.  Told
to follow up with PCP as she may only require this for one week
if nausea and vomitting were due to virus.  If due to developing
gastroparesis, may need indefinitely.
.
# Chronic Diastolic Dysfunction: At dry weight currently (166
lbs) and without evidence of volume overload.
.
#Chronic Kidney disease: Creatinine at baseline by discharge.

.
# Anemia: at baseline of 35, attributed to [**Month/Day (2) 2091**], no evidence of
acute bleed at this time.


Medications on Admission:
diovan 160 mg [**Hospital1 **]
coreg 25 mg [**Hospital1 **]
clonidine 0.3mg/24h patch QSun
amlodipine 10 mg QDay
lasix 100/80 mg [**Hospital1 **]
neurontin 300 PO QDay
zetia 10 mg QDay
vitamin D 1000 U QDay
lantus 16 units QHS
ASA 81 mg QDay
FeSo4 325 mg QDay


Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID w/
meals for 1 weeks.
Disp:*20 Tablet(s)* Refills:*0*
7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
8. Lasix
100 mg in the morning and 80 mg in the eveming


Discharge Disposition:
Home

Discharge Diagnosis:
hypertensive emergency
nausea


Discharge Condition:
stable


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

Please be sure to take the same blood pressure medications you
were taking prior to admission, BUT make a point to take the
carvedilol as soon as you wake up in the morning.

Followup Instructions:
Please follow up with your primary care doctor within one week.
You will be given enough of the anti-nausea medication to last
one week.


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]

Completed by:[**2133-2-24**]
{'Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified,Acute kidney failure, unspecified,Chronic diastolic heart failure,Chronic kidney disease, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Gastroparesis,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery'}


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: hypertensive urgency

PRESENT ILLNESS: 55 Y F with hx diastolic HF, [**First Name3 (LF) 2091**] with baseline Cr of 2.2, HTN,
CAD (50% stenosis of OM, no stents), DM, presenting with BP
242/124 in the setting of inability to take meds for 3 days [**3-7**]
N+V.
N+V started 4 days ago, last solid meal 3 days ago, and has not
been taking meds for past 3 days. Usually applies clonidine
patch on Sunday but reports that she didn't take a shower on
sunday [**3-7**] NFW and therefore never put on her patch. She doesn't
remember ever taking her old patch off but states that it must
have come off at some point. Mild abd pain, none now. No
diarrhea or constipation, last bm yesterday. Seen today at Heart
Failure clinic, sent here for SBP>200. She denies fever, chills,
URI symptoms, diarrhea, sick contacts.
.
In the ED she had mild chest pressure when she arrived, which
resolved now after treating BP. EKG was negative, trop 0.39 (but
not up from baseline) and CK-MB negative (10). They were unable
to get IV access so an EJ was placed. No HA, dizziness, visual
changes on presentation. Her BP was treated with labetalol 20 mg
IV x2, then a nitro gtt. Her SBP remained in the 190s. Head CT
was obtained due to the isolated nausea/vomiting, no ICH seen.
.
At time of transfer she continues to report nausea and slight
headache, worsened since getting NTG in ED. ROS negative for
fevers, chills, cough, URI ,dysuria, hematuria, melena, BRBPR,
rash.
.

MEDICAL HISTORY: CAD (stent in [**May 2131**])
CRI (baseline Cr ~2.0)
diastolic CHF
HTN
Anemia
DM
peripheral neuropathy
.

MEDICATION ON ADMISSION: diovan 160 mg [**Hospital1 **]
coreg 25 mg [**Hospital1 **]
clonidine 0.3mg/24h patch QSun
amlodipine 10 mg QDay
lasix 100/80 mg [**Hospital1 **]
neurontin 300 PO QDay
zetia 10 mg QDay
vitamin D 1000 U QDay
lantus 16 units QHS
ASA 81 mg QDay
FeSo4 325 mg QDay

ALLERGIES: Crestor

PHYSICAL EXAM: Vitals: T97.2 HR 74 BP 207/98 RR 8 100%RA .
GEN: Middle aged female, sleeping, awakens easily, appears
uncomfortable
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM, no LAD, No
JVD, REJ IV in place
CV: regular, nl s1, s2, +syst II/VI murmor at RUSB.
PULM: CTAB anteriorly, no r/r/w.
ABD: soft,obese, nontender, nondistended, BS+
EXT: warm, no pedal edema, DP's 2+ bilaterally
NEURO: alert & oriented x 3, CN II-XII grossly intact

FAMILY HISTORY: Mother with HTN and [**Name (NI) 2091**], denies fh of DM, CAd.

SOCIAL HISTORY: Denies tobbacco, denies alcohol, denies IVDU. 

### Response:
{'Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified,Acute kidney failure, unspecified,Chronic diastolic heart failure,Chronic kidney disease, unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Gastroparesis,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery'}
