CHIEF COMPLAINT: worsening lower extremity edema

PRESENT ILLNESS: HPI: 45yo female with HCV cirrhosis, R-sided CHF p/w increasing
bilateral [**Location (un) **], DOE. Recent admit [**Date range (1) 51555**] ([**Doctor Last Name 22583**] [**Location (un) **]). This
admission was for hypotension and lightheadedness. She had a
short stay in the MICU however etiology of hypotension was
unclear, however felt most likely secondary to right sided HF
and possible hypovolemia. However unfortuantely with hydration
she experienced worsening edema for which she got diuretics.
Also had episode of confusion during her stay which was
ultimately found to be caused by a UTI which was treated with
levofloxacin. She was discharged last Thursday with plans for
close follow up with [**Hospital **] clinic. Over the past week the patient
states she has been taking her meds as prescribed however her LE
edema continued to worsen. However she does state that her
weight has not changed from discharge at 264 pounds. Along with
worsening edema she noted onset of SOB this AM. She denies any
chest pain, N/V, diaphoresis, palpitations. No recent fevers,
chills. Denies any sick contacts. [**Name (NI) **] she has been following
low sodium diet and watching her fluid intake.

MEDICAL HISTORY: 1. Asthma
2. Pulmonary HTN - cathed [**8-/2161**], mean PA pressure 63 mmHg.
Right-
sided filling pressures severely elevated: RA mean 24 mmHg,
RVEDP
24 mmHg). Left sided filling pressures mildly elevated: PCW 20
mmHg.
3. Thrombocytopenia
4. IDDM - unknown duration, on Lispro and NPH at home.
5. RHF - Echo in 7/[**2161**]. EF>55%, Global right ventricular
hypokinesis.
6. Liver cirrhosis - HCV positive Ab, neg VL in [**8-/2161**], not a
transplant candidate due to cor pulmonale. LFTs have been stable

MEDICATION ON ADMISSION: 1.Albuterol MDI 1-2 Puffs q6 hr prn
2.Fluticasone-Salmeterol 250-50 mcg 1 inhalation [**Hospital1 **]
3.Pantoprazole 40 mg q12 hr
4.Lactulose 30 ml tid
5.Levofloxacin 500 mg
6.Furosemide 40 mg po qam
7.NPH insulin 25 units qam

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: Obese female, comfortable, NAD
HEENT: clear OP, mmm, PERRL, EOMI
Neck: supple, no LAD, no thyromegaly, JVD to the ear
Lungs: Poor inspiratory effort and difficult to hear [**3-17**]
obesity. Otherwise clear no crackles, wheezes
Heart: RRR + S1/S2 no m/r/g
Abd: Large edematous pannus that is tender to the touch, soft,
ND, +BS
Ext: 2+ pitting edema in LE foot to sacrum, 2+ DP's
Neuro: A&O times 3, pt appropriate, no signs of delerium, no
asterixis

FAMILY HISTORY: HTN
CAD
Breast CA

SOCIAL HISTORY: Smoke cigaretes on occasiona, last one 2 days ago. Denies any
etoh, IVDU. Lives alone with her cat.
Unspecified hypertensive heart disease with heart failure,Acute respiratory failure,Acquired coagulation factor deficiency,Alcoholic cirrhosis of liver,Unspecified viral hepatitis C with hepatic coma,Acute posthemorrhagic anemia,Other and unspecified alcohol dependence, unspecified,Urinary tract infection, site not specified,Internal hemorrhoids with other complication,Congestive heart failure, unspecified,Portal hypertension,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Long-term (current) use of insulin,Trichomonal vulvovaginitis,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus]
Hyp ht dis NOS w ht fail,Acute respiratry failure,Acq coagul factor defic,Alcohol cirrhosis liver,Hpt C w hepatic coma NOS,Ac posthemorrhag anemia,Alcoh dep NEC/NOS-unspec,Urin tract infection NOS,Int hemrrhoid w comp NEC,CHF NOS,Portal hypertension,Chr pulmon heart dis NEC,DMII wo cmp nt st uncntr,Asthma NOS,Long-term use of insulin,Trichomonal vaginitis,Enterococcus group d
Admission Date:  [**2162-3-10**]              Discharge Date:   [**2162-4-8**]

Date of Birth:  [**2116-6-18**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
worsening lower extremity edema

Major Surgical or Invasive Procedure:
none

History of Present Illness:
HPI: 45yo female with HCV cirrhosis, R-sided CHF p/w increasing
bilateral [**Location (un) **], DOE. Recent admit [**Date range (1) 51555**] ([**Doctor Last Name 22583**] [**Location (un) **]). This
admission was for hypotension and lightheadedness. She had a
short stay in the MICU however etiology of hypotension was
unclear, however felt most likely secondary to right sided HF
and possible hypovolemia. However unfortuantely with hydration
she experienced worsening edema for which she got diuretics.
Also had episode of confusion during her stay which was
ultimately found to be caused by a UTI which was treated with
levofloxacin. She was discharged last Thursday with plans for
close follow up with [**Hospital **] clinic. Over the past week the patient
states she has been taking her meds as prescribed however her LE
edema continued to worsen. However she does state that her
weight has not changed from discharge at 264 pounds. Along with
worsening edema she noted onset of SOB this AM. She denies any
chest pain, N/V, diaphoresis, palpitations. No recent fevers,
chills. Denies any sick contacts. [**Name (NI) **] she has been following
low sodium diet and watching her fluid intake.

Past Medical History:
1. Asthma
2. Pulmonary HTN - cathed [**8-/2161**], mean PA pressure 63 mmHg.
Right-
sided filling pressures severely elevated: RA mean 24 mmHg,
RVEDP
24 mmHg). Left sided filling pressures mildly elevated: PCW 20
mmHg.
3. Thrombocytopenia
4. IDDM - unknown duration, on Lispro and NPH at home.
5. RHF - Echo in 7/[**2161**]. EF>55%, Global right ventricular
hypokinesis.
6. Liver cirrhosis - HCV positive Ab, neg VL in [**8-/2161**], not a
transplant candidate due to cor pulmonale. LFTs have been stable

since previous admission in 12/[**2161**].

Social History:
Smoke cigaretes on occasiona, last one 2 days ago. Denies any
etoh, IVDU. Lives alone with her cat.


Family History:
HTN
CAD
Breast CA

Physical Exam:
Gen: Obese female, comfortable, NAD
HEENT: clear OP, mmm, PERRL, EOMI
Neck: supple, no LAD, no thyromegaly, JVD to the ear
Lungs: Poor inspiratory effort and difficult to hear [**3-17**]
obesity. Otherwise clear no crackles, wheezes
Heart: RRR + S1/S2 no m/r/g
Abd: Large edematous pannus that is tender to the touch, soft,
ND, +BS
Ext: 2+ pitting edema in LE foot to sacrum, 2+ DP's
Neuro: A&O times 3, pt appropriate, no signs of delerium, no
asterixis


Pertinent Results:
[**2162-3-10**] 09:55AM   WBC-4.3 RBC-2.34* HGB-7.8* HCT-25.4* MCV-109*
MCH-33.5* MCHC-30.9* RDW-16.9*
[**2162-3-10**] 09:55AM   PLT COUNT-84*
[**2162-3-10**] 09:55AM   NEUTS-50.6 LYMPHS-38.2 MONOS-7.8 EOS-2.6
BASOS-0.8

[**2162-3-10**] 09:55AM   GLUCOSE-113* UREA N-13 CREAT-1.4* SODIUM-133
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-24 ANION GAP-10

[**2162-3-10**] 09:55AM   ALT(SGPT)-55* AST(SGOT)-123* LD(LDH)-563* ALK
PHOS-80 TOT BILI-4.4*
[**2162-3-10**] 09:55AM   ALBUMIN-2.6*

Abdominal US:  The liver parenchyma is relatively unremarkable.
The portal vein is patent but has reversed (centrifugal flow).
No evidence of thrombus within the portal vein. The main hepatic
artery is visualized. Left branch of the portal vein is also
patent. The splenic vein and splenomesenteric confluence appears
patent.
   There is no evidence of significant ascites. Some
subcutaneous edema and induration is identified, but no clearly
identified fluid collection.


Brief Hospital Course:
45 yo woman w/ h/o HCV cirrhosis, right sided HF, recently d/c
after treatment of orthostatic hypotension, now a/w  worsening
LE edema and cough.

1. Cor pulmonale:  she has severe right sided heart failure [**3-17**]
pulm HTN, which is responsible for her complaints of peripheral
edema.  This has been difficult to control given her concurrent
cirrhosis w/ low albumin.  Aggressive diuresis depletes
intravascular volume and deprives RV of high filling volumes
that are needed to maintain cardiac output.  There is no
evidence of ACS by EKG and cardiac enzymes.  We transitioned her
to PO lasix with success. Her fluid status is very tenuous
therefore if her weight increases, he Lasix may need to be
increased.

2. Pulm HTN:  this is likely [**3-17**] portopulmonary HTN.  It was
unresponsive to NO2 during cath.  There are few remaining
options for treatment in this pt. Dr. [**Last Name (STitle) **] was consulted for
this patient and it was determined that there were no other
therapies with would change this patient's poor prognosis.

3. HCV cirrhosis:  She has cirrhosis from HCV and h/o etoh
abuse. She denies any recent ETOH.  LFTs have been stable for
months though her synthetic function is comprimised.  RUQ
doppler US shows no evidence of ascites or portal thrombosis.
The patient intermittenly becomes encheplpathic and this usually
correlates with her refusal of lactulose. She will continue the
lactulose TID for [**2-14**] BM q day.

4. Coagulopathy: [**3-17**] cirrhosis w/ thrombocytopenia.  No evidence
of bleeding though she has had a recent GIB. She should be
transfused for platelets less than 50.

5. Asthma: well controlled w/ advair and albuterol; Continue
current regimin.

6. DM: Her DM was controlled with NPH and regular insulin SS.

7. Anemia: She has h/o hemolytic anemia on last admission in
setting of mycoplasma IgM, now s/p course of levaquin.  HCT
remained low on admission.  No evidence of active bleeding.  She
was transfused 2 units PRBCs during this admission. Her HCT was
stable following this. Her hemolytic workup was negative. This
workup can be continued as an outpatient.

8. Mental Status: The patient has had changes in her mental
status before and during this admission, she had several days
where her mental status was altered. This was very difficult to
assess because even when she was felt to be cleared, she would
continually incoorperative with interviews and exams. When she
was altered, she would responed to questions with often correct
answers, but repeat her answers many times, even after the team
had left the room. These episodes corresponded to times when the
paitent would refuse her lactulose and she would improve with
more lactulose. It was felt to be caused by hepatic
encalholpaty. Though it is very difficult for the patient to
have multiple BM/day, she will need to continue lactulose daily.
Given her diagnoses, her mental status will likely deterioate.

9. Trichomonas infection: The pateitn was found to have
occasinnal trichonomas on a routine UA. She was asked about
sexual contacts but would not coorperate with interviews. She
refused a pelvic exam. She was treated with Flagyl 500 PO BID fo
2 days and will continue this fo 5 days as an outpatient. She
should have a pelvic exam as an outpatient for GC and chalmyidia
screens and preventative health care.

10. Care Plan: The team had multiple discussion with the patient
and her family about her poor prognosis. The patient was not
receptive to the conversations and often said she did not want
to think of these topics and directed us to talk with her
mother. The mother, brother, and sister-in-law are very involved
and understand the patient's prognosis. It was agreed that the
patietn could not take care of herself at home and discharged to
a rehab. The paitnet has not designated a health care proxy and
she does not want to discuss her code status on multiple
attments by the team.

Medications on Admission:
1.Albuterol MDI 1-2 Puffs q6 hr prn
2.Fluticasone-Salmeterol 250-50 mcg 1 inhalation [**Hospital1 **]
3.Pantoprazole 40 mg q12 hr
4.Lactulose 30 ml tid
5.Levofloxacin 500 mg
6.Furosemide 40 mg po qam
7.NPH insulin 25 units qam

Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: ** Do not exceed 2gm/day**.
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for sbp<100; do not give after 3PM.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day): hold if having 3 BMs per day  .
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
8. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: Twenty (20)
units Subcutaneous qAM: Hold if patient not eating.
9. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: Fifteen
(15) units Subcutaneous qPM: Hold if patient not eating.
10. Insulin Regular Human 300 unit/3 mL Syringe Sig: as per RISS
 Subcutaneous four times a day: administer per ISS.
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 5 days.
12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO Every
other Day.
13. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).


Discharge Disposition:
Extended Care

Facility:
Roscommon

Discharge Diagnosis:
ETOH and HCV cirrhosis
right sided heart failure
pulmonary hypertension
asthma
diabetes type II
cor pulmonale

Discharge Condition:
good, stable. Fluid status well controlled with PO lasix.

Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
You should be having [**3-18**] bowel movements per day.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5265**], M.D. Where: [**Hospital6 29**] REHAB
SERVICES (DYSPNEA) Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2162-3-23**] 10:30

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2162-3-23**] 2:30

Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2162-3-23**]
10:15

[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD (PCP) at [**Hospital6 **]. [**4-1**] at 1:30
PM




Name:  [**Known lastname 855**],[**Known firstname 9591**]                   Unit No:   [**Numeric Identifier 9592**]

Admission Date:  [**2162-3-10**]              Discharge Date:   [**2162-4-8**]

Date of Birth:  [**2116-6-18**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2339**]
Addendum:
# LGIB: The patient had been ready for discharge and was then
noted to have BRBPR. She underwent colonoscopy which revealed a
blood clot overlying a visible vessel which was thought to be a
bleeding artery. She underwent epinephrine injection and
cauterization. The bleeding was thought [**3-17**] a Dieulafoy's
Lesion. Her hematocrit, though stable when she had the bleeding,
began to decrease from 30 to 27 therefore she was transfused
with 1 PRBC unit with Lasix.  She was also tansfused FFP q6
hours and given Vit K, to no avail though, her coagulopathy
persisted and she continued to bleed. She was then taken to a
second colonoscopy which showed continued bleeding with areas of
ulceration, therefore the patient was taken to the OR by
colorectal surgery for ligation of the area under MAC. The
patient then ceased bleeding following this procedure. It was
unclear if she had a [**Name (NI) 9593**] lesion of a bleeding rectal
variocele. If she returns with bleeding, the team should preform
an MRI or endoscopic ultrasound to find out if this is arterial
or venous. She then may benefit from ligation under general
anesteisa.

# Coagulopathy: While the paitent had a GI bleed, she was given
a total of 4 units of FFP and 10mg of Vit K x3 days to correct
her elevated INR. Her coagulopathy is thought to be due to liver
disease, however, she does have a history of hemolysis but did
not appear to have hemolysis this admission. All anticoagulants
should be avoided.

# Mental status: The patient's baseline mental status is alert,
Ox3. She normally lives at home alone and can preform her ADLs,
however she has very little insight into her diseases. During
this admission, there were multiple times when she became
combative, agitated, and confused where she would refuse
medications, namely lactulose, and attempt to leave the
hospital. During one of these periods a code purple was called
as the patient attempted to leave and it was though that she dis
not have the capacity to make this decision since she was
actively having a brisk lower GI bleed. She was then placed in
leather restraints and given haldol.
   These epidoses of confusion and agitation were followed three
times by peroids of obtundation. Thourough workups were done
each time to find the etiolgy of these states, including an EEG
which showed severe encephlopathy. She was transferred to the
ICU during the most severe of these periods for airway
protection where she was intubated breifly. She was then
discharged to the floor. It was determined that these were due
to hepatic encephalopathy and could be avoided if she faithfully
took her lactulose. She was also placed on Flagyl to aid in
decreasing her ammonia level.

# Cirrhosis: The patient was started on Aldactone 2 days before
discharge. Her Lasix was decreased to 40mg a day becasue her
blood pressure was lower than her baseline (baseline being 100 -
110 systolic).

# Disposition: The staff stressed that the patient be discharged
to a nursing home or at least her mother's house since she lives
alone. The patient adamatly refused when she was lucid. Her
mental status improved greatly and with a great amount of
teaching by the nursing and medical team, she was felt capable
to go home with close follow-up. VNA will check her HCT QOD and
she has an appointment with her PCP in less than 1 week.

# UTI: After her ICU stay, the patient was found to have a VRE
UTI. She was discharge on 5 days of Linezolid with instructions
to have her CBC checked in 1 week by VNA to monitor her
leukopenia.

Discharge Disposition:
Home with Service

Facility:
Roscommon

                             [**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**] MD [**MD Number(1) 628**]

Completed by:[**2162-4-20**]
{'Unspecified hypertensive heart disease with heart failure,Acute respiratory failure,Acquired coagulation factor deficiency,Alcoholic cirrhosis of liver,Unspecified viral hepatitis C with hepatic coma,Acute posthemorrhagic anemia,Other and unspecified alcohol dependence, unspecified,Urinary tract infection, site not specified,Internal hemorrhoids with other complication,Congestive heart failure, unspecified,Portal hypertension,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Long-term (current) use of insulin,Trichomonal vulvovaginitis,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus]'}


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: worsening lower extremity edema

PRESENT ILLNESS: HPI: 45yo female with HCV cirrhosis, R-sided CHF p/w increasing
bilateral [**Location (un) **], DOE. Recent admit [**Date range (1) 51555**] ([**Doctor Last Name 22583**] [**Location (un) **]). This
admission was for hypotension and lightheadedness. She had a
short stay in the MICU however etiology of hypotension was
unclear, however felt most likely secondary to right sided HF
and possible hypovolemia. However unfortuantely with hydration
she experienced worsening edema for which she got diuretics.
Also had episode of confusion during her stay which was
ultimately found to be caused by a UTI which was treated with
levofloxacin. She was discharged last Thursday with plans for
close follow up with [**Hospital **] clinic. Over the past week the patient
states she has been taking her meds as prescribed however her LE
edema continued to worsen. However she does state that her
weight has not changed from discharge at 264 pounds. Along with
worsening edema she noted onset of SOB this AM. She denies any
chest pain, N/V, diaphoresis, palpitations. No recent fevers,
chills. Denies any sick contacts. [**Name (NI) **] she has been following
low sodium diet and watching her fluid intake.

MEDICAL HISTORY: 1. Asthma
2. Pulmonary HTN - cathed [**8-/2161**], mean PA pressure 63 mmHg.
Right-
sided filling pressures severely elevated: RA mean 24 mmHg,
RVEDP
24 mmHg). Left sided filling pressures mildly elevated: PCW 20
mmHg.
3. Thrombocytopenia
4. IDDM - unknown duration, on Lispro and NPH at home.
5. RHF - Echo in 7/[**2161**]. EF>55%, Global right ventricular
hypokinesis.
6. Liver cirrhosis - HCV positive Ab, neg VL in [**8-/2161**], not a
transplant candidate due to cor pulmonale. LFTs have been stable

MEDICATION ON ADMISSION: 1.Albuterol MDI 1-2 Puffs q6 hr prn
2.Fluticasone-Salmeterol 250-50 mcg 1 inhalation [**Hospital1 **]
3.Pantoprazole 40 mg q12 hr
4.Lactulose 30 ml tid
5.Levofloxacin 500 mg
6.Furosemide 40 mg po qam
7.NPH insulin 25 units qam

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: Obese female, comfortable, NAD
HEENT: clear OP, mmm, PERRL, EOMI
Neck: supple, no LAD, no thyromegaly, JVD to the ear
Lungs: Poor inspiratory effort and difficult to hear [**3-17**]
obesity. Otherwise clear no crackles, wheezes
Heart: RRR + S1/S2 no m/r/g
Abd: Large edematous pannus that is tender to the touch, soft,
ND, +BS
Ext: 2+ pitting edema in LE foot to sacrum, 2+ DP's
Neuro: A&O times 3, pt appropriate, no signs of delerium, no
asterixis

FAMILY HISTORY: HTN
CAD
Breast CA

SOCIAL HISTORY: Smoke cigaretes on occasiona, last one 2 days ago. Denies any
etoh, IVDU. Lives alone with her cat. 

### Response:
{'Unspecified hypertensive heart disease with heart failure,Acute respiratory failure,Acquired coagulation factor deficiency,Alcoholic cirrhosis of liver,Unspecified viral hepatitis C with hepatic coma,Acute posthemorrhagic anemia,Other and unspecified alcohol dependence, unspecified,Urinary tract infection, site not specified,Internal hemorrhoids with other complication,Congestive heart failure, unspecified,Portal hypertension,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Long-term (current) use of insulin,Trichomonal vulvovaginitis,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus]'}
