CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname 92234**] is a 78 y/o man with PMH significant for ESRD on
dialysis secondary to type 2 DM and hypertension, CAD s/p
NSTEMI, and left internal cartotid artery stenosis who presented
to the ED this morning c/o worsening shortness of breath. Mr.
[**Known lastname 92234**] reports that he just "didn't feel right" after
dialysis yesterday. He had worsening shortness of breath as the
day went on, until it became so bad this morning that the family
called an ambulance. The shortness of breath is not affected by
position. The patient denies chest pain at any time.
In the ED, vital signs were: SBP 230s, HR 48-58, SpO2 90% on
room air. On exam, he had moderate respiratory distress, JVD,
pulm edema, and bipedal edema. EKG showed AV dissociation. The
patient was seen by renal in the ED, started on CPAP, and
started on nitro drip which was titrated up to control BP and
aspirin.
.
On review of symptoms, he denies fevers, nausea or vomiting .
Cardiac review of systems is notable for absence of chest pain,
syncope or presyncope

MEDICAL HISTORY: * Known RBBB and LAFB with prolonged PR interval: (saw Dr.
[**Last Name (STitle) **] in [**3-/2166**])
* Known CAD: Patient diagnosed with a non-Q wave MI in [**2150**]. EKG
had biphasic T-waves in V2 through V4 which evolved into T-wave
inversion in V1-V6. His CPK total was serially 221, 155 and 121
with O% MBs. But he was still thought to have an MI due to his
EKG. He was treated with nitroglycerin, heparin, Inderal,
aspirin, lasix (had pulm. edema.) During this hospitalization,
he underwent exercise treadmill test in which he went four
minutes, obtaining 80% of maximum heart rate and stopped due to
fatigue. His thallium scan was normal. A persantine MIBI in [**12-15**]
showed normal myocardial perfusion. ECHO in [**7-19**] showed mild LVH
with normal LV size and regional LV systolic function. LVEF>55%.
LA was mildly enlarged. RV chamber size and function was normal.
NO AS, AR, 1+ MR.

MEDICATION ON ADMISSION: Lipitor 20
Plavix 75
Trandolapril 2
Nifedipine 90
Glipizide

ALLERGIES: Aspirin

PHYSICAL EXAM: VS: T 98.6, BP 195/45, HR 55, RR 22, O2 96% on 5L NC
Gen: Pleasant WDWN elderly male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 9 cm. No [**Doctor Last Name **] a waves appreciated
CV: Distant heart sounds.Audible L neck ?radiated bruit from L
AV fistula, Decreased heart sounds (increased AP diameter) RR,
normal S1, S2. No S4, no S3.
Chest: Mild respiratory distress, no accessory muscle use.
Decreased BS R >L, especially at bases, with crackles on L.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: Mother- DM, CAD

SOCIAL HISTORY: Lives with wife and son. [**Name (NI) **] another son who lives in downstairs
apartment. He worked as a bricklayer for many years. Reports a
45 pk/yr h/o tobacco but quit over 20 yrs ago. Has glass of wine
with lunch and dinner. Occasional beer on a hot day.
Atrioventricular block, complete,Diastolic heart failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Acute respiratory failure,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other iatrogenic hypotension,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Accidents occurring in residential institution
Atriovent block complete,Diastolc hrt failure NOS,Hyp kid NOS w cr kid V,End stage renal disease,Ocl crtd art wo infrct,Acute respiratry failure,DMII wo cmp nt st uncntr,Iatrogenc hypotnsion NEC,Adv eff cardiovasc NEC,Accid in resident instit
Admission Date:  [**2167-7-3**]              Discharge Date:   [**2167-7-7**]

Date of Birth:  [**2088-10-27**]             Sex:   M

Service: MEDICINE

Allergies:
Aspirin

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
Pacemaker Placement
Foley Catheter
Hemodialysis


History of Present Illness:
Mr. [**Known lastname 92234**] is a 78 y/o man with PMH significant for ESRD on
dialysis secondary to type 2 DM and hypertension, CAD s/p
NSTEMI, and left internal cartotid artery stenosis who presented
to the ED this morning c/o worsening shortness of breath. Mr.
[**Known lastname 92234**] reports that he just "didn't feel right" after
dialysis yesterday. He had worsening shortness of breath as the
day went on, until it became so bad this morning that the family
called an ambulance. The shortness of breath is not affected by
position. The patient denies chest pain at any time.
In the ED, vital signs were: SBP 230s, HR 48-58, SpO2 90% on
room air. On exam, he had moderate respiratory distress, JVD,
pulm edema, and bipedal edema. EKG showed AV dissociation. The
patient was seen by renal in the ED, started on CPAP, and
started on nitro drip which was titrated up to control BP and
aspirin.
.
On review of symptoms, he denies fevers, nausea or vomiting .
Cardiac review of systems is notable for absence of chest pain,
syncope or presyncope


Past Medical History:
* Known RBBB and LAFB with prolonged PR interval: (saw Dr.
[**Last Name (STitle) **] in [**3-/2166**])
* Known CAD: Patient diagnosed with a non-Q wave MI in [**2150**]. EKG
had biphasic T-waves in V2 through V4 which evolved into T-wave
inversion in V1-V6. His CPK total was serially 221, 155 and 121
with O% MBs. But he was still thought to have an MI due to his
EKG. He was treated with nitroglycerin, heparin, Inderal,
aspirin, lasix (had pulm. edema.) During this hospitalization,
he underwent exercise treadmill test in which he went four
minutes, obtaining 80% of maximum heart rate and stopped due to
fatigue. His thallium scan was normal. A persantine MIBI in [**12-15**]
showed normal myocardial perfusion. ECHO in [**7-19**] showed mild LVH
with normal LV size and regional LV systolic function. LVEF>55%.
LA was mildly enlarged. RV chamber size and function was normal.
NO AS, AR, 1+ MR.

* Left internal carotid artery stenosis: (Carotid US in [**3-19**]
showed a L ICA 70-79% stenosis with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**]/LCCA index of 3.6, no
right ICA stenosis with a [**Country **]/RCCA index of 1. in [**2164**]) on
Plavix

* ESRD: Paitent started on hemodialysis in [**5-20**] for ESRD due to
hypertension and DMII. Patient receives hemodialysis on Tuesday,
Thrusday and Saturday via a left AV fistula.
* Type 2 DM: (last A1c 6.6% in [**11-19**])
* Hypertension
* Chronic anema: (baseline hct ~ 35)
* Hyperlipidemia: (total 180, TG 95, HDL 57, LDL 104 in [**11-19**])
* Secondary hyperparathyroidism
* Bilateral cataracts s/p surgical intervention
* s/p ERCP for bile duct stenosis
* Mild dementia


Social History:
Lives with wife and son. [**Name (NI) **] another son who lives in downstairs
apartment. He worked as a bricklayer for many years. Reports a
45 pk/yr h/o tobacco but quit over 20 yrs ago. Has glass of wine
with lunch and dinner. Occasional beer on a hot day.


Family History:
Mother- DM, CAD


Physical Exam:
VS: T 98.6, BP 195/45, HR 55, RR 22, O2 96% on 5L NC
Gen: Pleasant WDWN elderly male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 9 cm. No [**Doctor Last Name **] a waves appreciated
CV: Distant heart sounds.Audible L neck ?radiated bruit from L
AV fistula, Decreased heart sounds (increased AP diameter) RR,
normal S1, S2. No S4, no S3.
Chest: Mild respiratory distress, no accessory muscle use.
Decreased BS R >L, especially at bases, with crackles on L.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP



Pertinent Results:
EKG [**7-3**] demonstrated bradycardia with AV dissociation, complete
heart block.
.
TELEMETRY demonstrated: bradycardia 50s.
CXR ([**2167-7-3**]): Mildly enlarged heart. Right-sided pleural
effusion and right lower lobe opacification. Pulmonary vascular
congestion suggest heart failure.
.
CXR ([**7-3**]): New moderate right-sided pleural effusion and right
lower lobe opacification and pulmonary vascular congestion
suggests heart failure.
.
LABORATORY DATA:
WBC 8.8 (68% neutrophils, 21% lymphs), Hct 34, Plt 276
K 3.9, bicarb 37, creatinine 3.6
INR 1
CK 56 --> 40, MB not done, trop 0.10 --> 0.08
[**2167-7-3**]   HGB-11.8*

Brief Hospital Course:
78 yr old gentleman with remote hx MI '[**50**], ESRD on HD, HTN
admitted with acutely worsening shortness of breath, found in
the ED to be bradycardia and in complete heart block.

# Third degree AV block - Over fifteen year hx of long PR
interval, known history of RBBB and L ant. fascicular block,
seen by cardiology in [**3-20**]. He has been asymptomatic to date.
Escape rhythm in 50s, with rates as low as 38. The patient was
closely monitored for further decrease in heart rate, and then
went for permanent pacemaker placement on [**7-6**], which he
tolerated well.  CXR prior to discharge confirmed lead
placement.  Patient was treated with a 3 day course of IV
vancomycin dosed renally after hemodialysis.  Patient recieved
last dose on the day of discharge.  Patient is to follow up in
device clinic in one week to have his pacemaker checked.  An
initial appointment with cardiology was scheduled with Dr.
[**Last Name (STitle) **] at [**Hospital1 18**]-[**Location (un) 620**].

# Dyspnea - Likely volume overload, and may be secondary to
decreased CO in setting of complete heart block. Also, patient
hypertensive on arrival with SBPs in 200s which may have caused
pulmonary edema. History of renal failure. Pleural effusion on
CXR. Infection unlikely - patient afebrile with normal WBC
count.  Volume overload was addressed with hemodialysis.

# Hypertension - Hx of HTN with SBPs in 170s at home. Due to
complete heart block,  all nodal agents were held. Initially he
was restarted on his outpatient [**Last Name (un) **], but his SBPs continued to
be in the 190s. Po hydralazine and nifedipine were added to his
regimen with good response.  Patient experienced episode of
hypotension the am of dialysis and his regimen was adjusted to
nifedipine 30 every 8hours and valsartan 160mg twice daily.

# Hyperlipidemia - Home Lipitor was continued.

# ESRD - Received ultrafiltration and hemodialysis during this
admission with the removal of volume.  Last dialysis performed
on [**7-7**].  Ultra filtration was performed on [**7-6**] and [**7-7**] with
3.5 kg removed over those two days.  Renal followed during stay.
 Patient received erythropoetin during stay.  Patient to return
to his T/TH/S dialysis schedule on discharge.

# DMII - Uncontrolled with HbA1c of 11.8 on admission. Blood
glucose level was monitored and ISS given as needed.  On
discharge, home medications were resumed.  Patient advised to
follow up with primary physician for further blood glucose
control.

# h/o Left internal Carotid artery stenosi - Patient continued
on home plavix 75mg daily.

# PPx: Hep SC for DVT prophylaxis and bowel regimen of senna and
colace were administered during this admission.

# FEN: Cardiac/Renal diet, replete lytes as needed.

# Code: Full




Medications on Admission:
Lipitor 20
Plavix 75
Trandolapril 2
Nifedipine 90
Glipizide


Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nifedipine 10 mg Capsule Sig: Three (3) Capsule PO Q8H (every
8 hours).
Disp:*270 Capsule(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation. Capsule(s)
6. Glipizide 5 mg Tablet Sig: [**12-16**]  Tablet PO once a day.
7. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO once a
day.
8. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO three
times a day.


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Third Degree Heart Block status post pacemaker placement
Hypertension
End-stage renal dialysis on hemodialysis
Diabetes Mellitus type II

Secondary:
Hyperlipidemia


Discharge Condition:
Stable


Discharge Instructions:
You were evaluated for an arrhythmia and have been treated for
complete heart block with a permanent pacemaker.

Please continue all medications as directed on discharge.  You
have been scheduled for follow up with the electrophysiology
team and a cardiologist.

Please call you physician or return to the emergency department
if you experieince any chest pain, shortness of breath,
lightheadedness, palpitations, or fever.

Followup Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Thursday
[**7-16**] at 10:10 am. [**Telephone/Fax (1) 1579**]

Please follow-up with a cardiologist. We have scheduled you an
appointment with Dr. [**Last Name (STitle) **] at [**Hospital1 **] [**Location (un) 620**] on [**8-11**] at 2
pm. His office is located on the [**Location (un) 448**] of [**Hospital1 **] [**Location (un) 620**].
[**Telephone/Fax (1) 4105**]

Please follow-up at device clinic since [**Telephone/Fax (1) 59**]  you just
had your pacemaker placed and this will need to be checked out
next week. You have an appointment on Tuesday [**2167-7-14**] at 4 pm.
The office is on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Building.
{'Atrioventricular block, complete,Diastolic heart failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Acute respiratory failure,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other iatrogenic hypotension,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Accidents occurring in residential institution'}


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

PRESENT ILLNESS: Mr. [**Known lastname 92234**] is a 78 y/o man with PMH significant for ESRD on
dialysis secondary to type 2 DM and hypertension, CAD s/p
NSTEMI, and left internal cartotid artery stenosis who presented
to the ED this morning c/o worsening shortness of breath. Mr.
[**Known lastname 92234**] reports that he just "didn't feel right" after
dialysis yesterday. He had worsening shortness of breath as the
day went on, until it became so bad this morning that the family
called an ambulance. The shortness of breath is not affected by
position. The patient denies chest pain at any time.
In the ED, vital signs were: SBP 230s, HR 48-58, SpO2 90% on
room air. On exam, he had moderate respiratory distress, JVD,
pulm edema, and bipedal edema. EKG showed AV dissociation. The
patient was seen by renal in the ED, started on CPAP, and
started on nitro drip which was titrated up to control BP and
aspirin.
.
On review of symptoms, he denies fevers, nausea or vomiting .
Cardiac review of systems is notable for absence of chest pain,
syncope or presyncope

MEDICAL HISTORY: * Known RBBB and LAFB with prolonged PR interval: (saw Dr.
[**Last Name (STitle) **] in [**3-/2166**])
* Known CAD: Patient diagnosed with a non-Q wave MI in [**2150**]. EKG
had biphasic T-waves in V2 through V4 which evolved into T-wave
inversion in V1-V6. His CPK total was serially 221, 155 and 121
with O% MBs. But he was still thought to have an MI due to his
EKG. He was treated with nitroglycerin, heparin, Inderal,
aspirin, lasix (had pulm. edema.) During this hospitalization,
he underwent exercise treadmill test in which he went four
minutes, obtaining 80% of maximum heart rate and stopped due to
fatigue. His thallium scan was normal. A persantine MIBI in [**12-15**]
showed normal myocardial perfusion. ECHO in [**7-19**] showed mild LVH
with normal LV size and regional LV systolic function. LVEF>55%.
LA was mildly enlarged. RV chamber size and function was normal.
NO AS, AR, 1+ MR.

MEDICATION ON ADMISSION: Lipitor 20
Plavix 75
Trandolapril 2
Nifedipine 90
Glipizide

ALLERGIES: Aspirin

PHYSICAL EXAM: VS: T 98.6, BP 195/45, HR 55, RR 22, O2 96% on 5L NC
Gen: Pleasant WDWN elderly male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 9 cm. No [**Doctor Last Name **] a waves appreciated
CV: Distant heart sounds.Audible L neck ?radiated bruit from L
AV fistula, Decreased heart sounds (increased AP diameter) RR,
normal S1, S2. No S4, no S3.
Chest: Mild respiratory distress, no accessory muscle use.
Decreased BS R >L, especially at bases, with crackles on L.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: Mother- DM, CAD

SOCIAL HISTORY: Lives with wife and son. [**Name (NI) **] another son who lives in downstairs
apartment. He worked as a bricklayer for many years. Reports a
45 pk/yr h/o tobacco but quit over 20 yrs ago. Has glass of wine
with lunch and dinner. Occasional beer on a hot day. 

### Response:
{'Atrioventricular block, complete,Diastolic heart failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Acute respiratory failure,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other iatrogenic hypotension,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Accidents occurring in residential institution'}
