CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 73-year-old
woman with pulmonary sarcoidosis, type 2 diabetes, severe
pulmonary hypertension who presents with dyspnea.

MEDICAL HISTORY: 1.  Sarcoidosis with pulmonary and ocular involvement.
2.  Type 2 diabetes.
3.  Diastolic congestive heart failure.
4.  Pulmonary hypertension.
5.  Iron-deficiency anemia as well as multifactorial anemia
from hemoglobin C trait.
6.  Gastroesophageal reflux disease.

MEDICATION ON ADMISSION: 1.  Prednisone 13 mg q. day.
2.  Accupril 20 mg q. day.
3.  Lasix 140 mg q. day.
4.  Avandia 4 mg q. day.
5.  Albuterol q. 4 to 6 hours p.r.n.
6.  Xanax p.r.n.
7.  Iron sulfate 325 mg q. day.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Lives with her daughter who has cerebral
palsy.  She has multiple family supports.  She lives in a
house.  She has no tobacco or alcohol use.  She is actively
working as a secretary.
Other chronic pulmonary heart diseases,Acute on chronic diastolic heart failure,Sarcoidosis,Lung involvement in other diseases classified elsewhere,Hyperpotassemia,Other emphysema,Diseases of tricuspid valve
Chr pulmon heart dis NEC,Ac on chr diast hrt fail,Sarcoidosis,Lung involv in oth dis,Hyperpotassemia,Emphysema NEC,Tricuspid valve disease
Admission Date:  [**2134-5-24**]     Discharge Date:  [**2134-6-5**]

Date of Birth:   [**2060-8-8**]     Sex:  F

Service:  [**Doctor Last Name 1181**]

HISTORY OF PRESENT ILLNESS:  The patient is a 73-year-old
woman with pulmonary sarcoidosis, type 2 diabetes, severe
pulmonary hypertension who presents with dyspnea.

The patient reports that her shortness of breath has been
steadily worsening since [**Holiday **] and she has required more
oxygen up from her baseline of 6 liters to as much as 10
liters.  She denies chest pain.  Her dyspnea has progressed
to the point that even moving around in bed increases it.

She occasionally goes up to as high as 10 liters at home.
She otherwise ambulatory and has also had an increase in
lower extremity edema since she did not take her Lasix
yesterday, but there has been no asymmetry in her legs.
Of note, the patient drinks iron supplementation and drinks
[**Location (un) 2452**] juice with this.  Otherwise, there are no nephrotoxins
or potassium-containing foods.

PAST MEDICAL HISTORY:
1.  Sarcoidosis with pulmonary and ocular involvement.
2.  Type 2 diabetes.
3.  Diastolic congestive heart failure.
4.  Pulmonary hypertension.
5.  Iron-deficiency anemia as well as multifactorial anemia
from hemoglobin C trait.
6.  Gastroesophageal reflux disease.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON ADMISSION:
1.  Prednisone 13 mg q. day.
2.  Accupril 20 mg q. day.
3.  Lasix 140 mg q. day.
4.  Avandia 4 mg q. day.
5.  Albuterol q. 4 to 6 hours p.r.n.
6.  Xanax p.r.n.
7.  Iron sulfate 325 mg q. day.

SOCIAL HISTORY:  Lives with her daughter who has cerebral
palsy.  She has multiple family supports.  She lives in a
house.  She has no tobacco or alcohol use.  She is actively
working as a secretary.

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAMINATION:  Temperature is 97.8, pulse 74, blood
pressure 128/79, respiratory rate 24, O2 sat 100% on 6
liters.  In general, she is a pleasant woman who is dyspneic.
Her mucous membranes are moist.  Her neck exam:  She has
jugular venous distention to the angle of her mandible.
Lungs have crackles in the upper lung zones.  Her heart is
regular with no murmurs, rubs, or gallops.  It is difficult
to discern due to breathing.  Subsequently, she has a II/VI
systolic ejection murmur at the left sternal border that is
discernible.  Her abdomen is soft, nontender, nondistended;
normoactive bowel sounds.  She has 2+ pitting edema of her
lower extremities.

LABORATORY DATA:  She had a white count of 5.5, hematocrit
25.7 slightly lower than baseline, platelets 151.  Her sodium
was 142, potassium 6.4, chloride 107, bicarbonate 30, BUN 39,
creatinine 1.4, glucose 42.

Her EKG was normal sinus rhythm.  There was a Q in V1.  There
were T-wave inversions in III and bifid T-waves V2 and V3.

She had a chest x-ray on admission that showed no acute
cardiopulmonary pathology, however, a left upper lobe opacity
consistent with sarcoidosis.

SUMMARY OF HOSPITAL COURSE:
1.  Pulmonary and sarcoid:  The patient's physical exam and
chest film did not suggest left heart failure despite her
symptoms of lower extremity edema.  These were more likely
secondary to progressive right heart congestive heart failure
which could explain the lower extremity edema as well as her
known intrinsic pulmonary disease.

The differential diagnosis of her chronic right heart failure
and pulmonary hypertension was brought.  The patient was not
tachycardiac, which lowers the differential of PE and chronic
thromboembolia, although this could not be ruled out.  She
does have a history of sarcoidosis, although pulmonary
function tests have not worsened over the past several years.
At the time of admission it was felt that she had progressive
right heart strain from sarcoidosis.

On the second day of admission she had an echocardiogram
which was notable for a normal ejection fraction, however, a
right ventricular wall that was hypertrophied and a markedly
dilated right ventricular cavity as well as moderate global
right ventricular free wall hypokinesis.  There was also
abnormal septal motion in position consistent with right
ventricular pressure and volume overload.  In addition, she
had an estimated PASP of 142 to 164.  She had, as well, 3+
tricuspid regurgitation.  These findings were as compared to
an echo four years ago.

A pulmonary consult was obtained to further tease out why she
has worsening right heart failure.  She had a CT angiogram of
her chest which was notable for no pulmonary emboli but
mildly dilated pulmonary vessels consistent with pulmonary
hypertension.  There were emphysematous changes seen
throughout the lungs as well as nonspecific pleural
thickening in the right lung apex and a 7 mm vague nodular
density in the right lower lobe.

Given the concerns for progressive right heart failure, a
Cardiology consult was obtained to consider a right heart
catheterization.  Prior to this, however, the patient
underwent pulmonary function tests which were notable for an
FVC and FEV1 of 50 and 46%, respectively, in a ratio of 91%.
There was no change with bronchodilators.  This is felt to be
consistent with some obstructive disease as well as a
restrictive component.  This was further suggested by her
lung volumes, which were total lung capacity 97% of
predicted, FRC of 121%, and RV of 162%.  These are more
consistent with obstructive lung disease.  More impressively,
the DLCO was 11% of predicted.

At this point a Cardiology consult was obtained to consider
her for right and left heart catheterization.  Initially they
recommended conservative treatment with calcium channel
blocker.  However, given the concerns for potentially
worsening and throwing the patient into severe right heart
failure, ultimately it was decided to take the patient to the
Catheterization Lab.  While initially there were concerns
about the risks of a right heart catheter, the potential
benefits of pulmonary histodilation were thought to outweigh
these.

She subsequently went to the Catheterization Lab and had both
a right and left heart catheterization.  These results were
quite interesting.  Her right heart catheterization revealed
a pulmonary artery pressure of 118/43 with a pulmonary
vascular resistance of 878.  With 100% oxygen her pulmonary
pressures went down slightly to 111/38 with her pulmonary
vascular resistance dropping to 546.  Even further, with
nitrous oxide administration her pressures dropped to 92/28
with a pulmonary vascular resistance of 275.  These results
were impressive, and at this point it was decided to take the
patient with a Swan to the Medical Intensive Care Unit for
further titration of calcium channel blockers and potential
vasodilators.

While she was in the MICU the patient was started on
Nifedipine with her pulmonary pressures closely monitored.
She was rapidly titrated up to Nifedipine 80 mg p.o. q. 6
hours with a small improvement in her pulmonary vascular
resistance.  Symptomatically, however, the patient felt
significantly better.

At this point, though, given the modest improvement, it was
decided to start the patient on sildenafil to improve her
pulmonary vascular resistance.  She was started on escalating
doses of sildenafil with significant improvement in her
pulmonary vascular resistance as well as in her symptoms.
Her PVR fell to as low as 412 on the Viagra therapy.  After
her brief stay in the Medical Intensive Care Unit the patient
was transferred back out to the floor for further management.

At this time the patient did have mild hypervolemia and mild
congestive heart failure perhaps due to the increased venous
pressure into left side of her heart.  She was given one dose
of intravenous Lasix and was restarted back on oral Lasix for
home use.  The concern was that patient is preload dependent
and overdiuresing her could potentially worsen both left and
right heart function.

In addition to all of the above, the patient was anemic, and
given her strong need to have increased oxygen content, the
patient was transfused to a hematocrit greater than 30.  Of
any one particular intervention, this was probably the most
successful.  After just two units of packed red blood cells
with her hematocrit above 30, the patient reported
significantly improved symptoms.  She was kept above 30 for
the remainder of her admission, and this in the future should
be considered a prime goal of care.  She was continued on her
iron supplementation for iron-deficiency anemia.

2.  Hyperkalemia:  The patient presented with a potassium of
6.2.  This is likely due to mildly reducing her function as
well as increased [**Location (un) 2452**] juice consumption at home.  There
were no peak T waves.  The patient was given Kayexalate with
improvement, and there were no further complications of
hyperkalemia.

3.  Anemia:  The patient has a multifactorial anemia that has
been followed as an outpatient by Dr. [**Last Name (STitle) 410**], who is a
hematologist.  The patient has, in the past, deferred a bone
marrow biopsy to evaluate whether sarcoidosis could be
contributing to her anemia.  This may be considered in the
future, but currently keeping her hematocrit above 30 seems
to be a reasonable goal with blood transfusions.

4.  Hypertension:  The patient was admitted on Accupril.
However, though this is beneficial for her systolic
hypertension and renal protection and diabetes, it was felt
that the more impressing goal would be to improve her
pulmonary vascular resistance, and so her blood pressure
medications were changed from Accupril to Nifedipine with
stable blood pressure.

5.  Code:  The patient is currently a Full Code.  That being
said, she is aware of her medical problems and is considering
her code status, but at the time of this dictation the
patient is a Full Code.

DISPOSITION:  To home with services.

DISCHARGE CONDITION:  Stable.

DISCHARGE DIAGNOSES:
1.  Sarcoidosis.
2.  Pulmonary hypertension.
3.  Right-sided heart failure.
4.  Chronic obstructive pulmonary disease.
5.  Diabetes.
6.  Anemia.

DISCHARGE INSTRUCTIONS:
1.  The patient will contact Dr. [**Last Name (STitle) 575**], her pulmonologist, to
make an appointment in the next two weeks.
2.  She will also contact Dr. [**First Name (STitle) 4702**] to make an appointment
for the next week.
3.  A referral was made by this intern to the Sleep Apnea
Study Center, and they are willing to take her once she
schedules an appointment.
4.  The patient will be contact[**Name (NI) **] by Interventional
Pulmonology to consider and discuss the option of
transtracheal oxygen therapy.
5.  Finally, she will contact Pulmonary Rehabilitation to
begin pulmonary rehab.  A prescription was left for the
patient.

DISCHARGE MEDICATIONS:
1.  Prednisone 13 mg q. day.
2.  Sildenafil citrate 50 mg t.i.d.
3.  Lasix 60 mg q. day.
4.  Rosiglitazone 4 mg q. day.
5.  Iron sulfate 325 mg q. day.
6.  Atrovent nebulizer, one nebulizer q. 6 hours p.r.n.
7.  Nifedipine 90 mg q. day.



                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4704**], M.D.  [**MD Number(1) 4705**]

Dictated By:[**Last Name (NamePattern1) 7693**]

MEDQUIST36

D:  [**2134-6-6**]  15:19
T:  [**2134-6-6**]  19:21
JOB#:  [**Job Number 103646**]
{'Other chronic pulmonary heart diseases,Acute on chronic diastolic heart failure,Sarcoidosis,Lung involvement in other diseases classified elsewhere,Hyperpotassemia,Other emphysema,Diseases of tricuspid valve'}


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: 

PRESENT ILLNESS: The patient is a 73-year-old
woman with pulmonary sarcoidosis, type 2 diabetes, severe
pulmonary hypertension who presents with dyspnea.

MEDICAL HISTORY: 1.  Sarcoidosis with pulmonary and ocular involvement.
2.  Type 2 diabetes.
3.  Diastolic congestive heart failure.
4.  Pulmonary hypertension.
5.  Iron-deficiency anemia as well as multifactorial anemia
from hemoglobin C trait.
6.  Gastroesophageal reflux disease.

MEDICATION ON ADMISSION: 1.  Prednisone 13 mg q. day.
2.  Accupril 20 mg q. day.
3.  Lasix 140 mg q. day.
4.  Avandia 4 mg q. day.
5.  Albuterol q. 4 to 6 hours p.r.n.
6.  Xanax p.r.n.
7.  Iron sulfate 325 mg q. day.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Lives with her daughter who has cerebral
palsy.  She has multiple family supports.  She lives in a
house.  She has no tobacco or alcohol use.  She is actively
working as a secretary. 

### Response:
{'Other chronic pulmonary heart diseases,Acute on chronic diastolic heart failure,Sarcoidosis,Lung involvement in other diseases classified elsewhere,Hyperpotassemia,Other emphysema,Diseases of tricuspid valve'}
