CHIEF COMPLAINT: weakness, fever
.

PRESENT ILLNESS: This is a 78 year old man with a history of multiple CVAs with
right side weakness who presented to the ED on [**2181-6-8**]
complaining of weakness x 3 days.  He also complained of
abdominal pain which he has had in the past with a negative
workup.  He denied N/V/D.
.
In the ED, abdominal CT scan revealed some diverticulosis but
otherwise no explanation for his abdominal pain.  He had a fever
to 101.1 in the ED and was admitted to Medicine for workup of
his weakness/fever/abdominal pain.
In the ED, he was started on empirical levo and flagyl and blood
cultures were drawn.  a U/A, and CT abdomen/pelvis were
negative.  CXR showed mild fluid overload and enlarged heart,
and CT of his head was neg for new pathology.  He had a neuro
consult that demonstrated no neurological changes from baseline.
 The patient had a ground level fall in the ED, and a repeat CT
scan of the head showed no bleeding.

MEDICAL HISTORY: hypertension
s/p CVA (mulitple, large R ischemic CVA, multiple small CVAs in
white matter)
h/o HOCM by last echo
seizures
hyperlipidemia
s/p hip fracture
anemia
? hx of hyperglycemia
Chronic low back pain s/p laminectomy
migraines
depression

MEDICATION ON ADMISSION: Ativan 1mg daily
depacote 500mg [**Hospital1 **]
gemfibrozil 600mg [**Hospital1 **]
atorvastatin 40mg daily
lisinopril 2.5mg daily
neurontin 300mg TID
oxycontin 10mg [**Hospital1 **]
zoloft 50mg daily
aggrenox 1 cap daily

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: VS:T:99.0   BP:130/82   HR:80   RR:16  O2sat:95%RA
gen: mildly confused elderly man in NAD.  difficulty sitteing up
on own
HEENT: EOMI, PERRLA, some L facial droop.  Oropharynx: mild
erythema
Ears:  TMs clear bilaterally.  Some erythema in canal in R ear.
Neck: no JVD
Chest: Lungs CTA
Heart: distant heart sounds, RRR, no murmur
Abd:  soft, non-distended, +BS, mildly tender to palpation
periumbilical.  No rebound, no guarding, no hepatosplenomegaly.
Ext:  [**4-13**] motor strength in all extremities.
Decreased DTRs L side.  Mild facial drop L side.

FAMILY HISTORY: -both parents with CAD

SOCIAL HISTORY: -lives with wife
-smokes one cigar per day
-no alcohol use
-worked in sales
Angioneurotic edema, not elsewhere classified,Acute respiratory failure,Congestive heart failure, unspecified,Other convulsions,Adult failure to thrive,Abdominal pain, left lower quadrant,Chest pain, unspecified,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Diverticulosis of colon (without mention of hemorrhage),Hypotension, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia of other chronic disease,Other late effects of cerebrovascular disease,Other musculoskeletal symptoms referable to limbs
Angioneurotic edema,Acute respiratry failure,CHF NOS,Convulsions NEC,Failure to thrive-adult,Abdmnal pain lt lwr quad,Chest pain NOS,Adv eff cardiovasc NEC,Dvrtclo colon w/o hmrhg,Hypotension NOS,DMII wo cmp nt st uncntr,Anemia-other chronic dis,Late effect CV dis NEC,Muscskel sympt limb NEC
Admission Date:  [**2181-6-7**]              Discharge Date:   [**2181-6-19**]

Date of Birth:  [**2102-11-4**]             Sex:   M

Service: MEDICINE

Allergies:
Ace Inhibitors

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
weakness, fever
.


Major Surgical or Invasive Procedure:
Central line
s/p fiberoptic intubation


History of Present Illness:
This is a 78 year old man with a history of multiple CVAs with
right side weakness who presented to the ED on [**2181-6-8**]
complaining of weakness x 3 days.  He also complained of
abdominal pain which he has had in the past with a negative
workup.  He denied N/V/D.
.
In the ED, abdominal CT scan revealed some diverticulosis but
otherwise no explanation for his abdominal pain.  He had a fever
to 101.1 in the ED and was admitted to Medicine for workup of
his weakness/fever/abdominal pain.
In the ED, he was started on empirical levo and flagyl and blood
cultures were drawn.  a U/A, and CT abdomen/pelvis were
negative.  CXR showed mild fluid overload and enlarged heart,
and CT of his head was neg for new pathology.  He had a neuro
consult that demonstrated no neurological changes from baseline.
 The patient had a ground level fall in the ED, and a repeat CT
scan of the head showed no bleeding.


Past Medical History:
hypertension
s/p CVA (mulitple, large R ischemic CVA, multiple small CVAs in
white matter)
h/o HOCM by last echo
seizures
hyperlipidemia
s/p hip fracture
anemia
? hx of hyperglycemia
Chronic low back pain s/p laminectomy
migraines
depression

Social History:
-lives with wife
-smokes one cigar per day
-no alcohol use
-worked in sales


Family History:
-both parents with CAD

Physical Exam:
VS:T:99.0   BP:130/82   HR:80   RR:16  O2sat:95%RA
gen: mildly confused elderly man in NAD.  difficulty sitteing up
on own
HEENT: EOMI, PERRLA, some L facial droop.  Oropharynx: mild
erythema
Ears:  TMs clear bilaterally.  Some erythema in canal in R ear.
Neck: no JVD
Chest: Lungs CTA
Heart: distant heart sounds, RRR, no murmur
Abd:  soft, non-distended, +BS, mildly tender to palpation
periumbilical.  No rebound, no guarding, no hepatosplenomegaly.
Ext:  [**4-13**] motor strength in all extremities.
Decreased DTRs L side.  Mild facial drop L side.

Pertinent Results:
CT head:No evidence of intracranial hemorrhage or mass effect.
Chronic changes.  Stable appearance compared to [**2181-5-14**].
CT A/P:Diverticulosis without evidence of diverticulitis.  No
explanation seen for the patient's acute abdominal pain
KUB: Normal bowel gas pattern without evidence of obstruction.
CXR:Mild CHF/volume overload.  No evidence of pneumonia
CT chest:
1.  No evidence of pulmonary embolism or aortic dissection.
2.  Small bilateral pleural effusions and associated bibasilar
atelectasis. The effusions are new since the prior chest CT in
[**2179**].
3.  Coronary arterial calcification.  The study was not
performed using gated technique.
ECHO:
The left atrium is moderately dilated. There is moderate
symmetric left  ventricular hypertrophy with normal cavity size
and hyperdynamic systolic  function (EF>75%). Due to suboptimal
technical quality, a focal wall motion  abnormality cannot be
fully excluded. Tissue velocity imaging E/e' is elevated  (>15)
suggesting increased left ventricular filling pressure
(PCWP>18mmHg).  There is systolic anterior motion of the mitral
valve leaflets with a moderate  resting left ventricular outflow
tract obstruction (peak 54mmhg). Right  ventricular chamber size
and free wall motion are normal. The aortic valve  leaflets are
moderately thickened. Severe aortic stenosis is not suggested,
but mild aortic stenosis cannot be excluded/possible. No aortic
regurgitation  is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral  regurgitation is seen.
There is mild pulmonary artery systolic hypertension.  There is
a a very small anterior pericardial effusion with a prominent
epicardial fat pad. No hemodynamic compromise is suggested.
CT neck: Suboptimal study due to the artifacts from the teeth.
No evidence of parotid abscess/stones. Evidence of inflammation
in the soft tissues of the neck.
.
[**2181-6-6**] 03:35PM   PT-11.3 PTT-23.3 INR(PT)-1.0
[**2181-6-6**] 03:35PM   PLT COUNT-131*
[**2181-6-6**] 03:35PM   WBC-6.7 RBC-4.10* HGB-13.9* HCT-40.3 MCV-98
MCH-33.9* MCHC-34.5 RDW-13.1
[**2181-6-6**] 03:35PM   cTropnT-<0.01
[**2181-6-6**] 03:35PM   ALT(SGPT)-20 AST(SGOT)-33 ALK PHOS-85
AMYLASE-41
[**2181-6-6**] 03:35PM   GLUCOSE-103 UREA N-18 CREAT-1.0 SODIUM-139
POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-27 ANION GAP-15
[**2181-6-6**] 09:40PM   cTropnT-<0.01
[**2181-6-7**] 05:00PM   CK(CPK)-74

Brief Hospital Course:
# Angioedema/ airway compromise: While on the floor, the pt's
throat and cheeks and neck began to swell.  Two days later, on
[**2181-6-10**], his blood pressure dropped to 50/palp.  He was given 3L
NS and his BP rebounded to the 80's.  However, his O2 sats
dropped to 90% on 4L and he was transferred to the ICU for
further management of his hypotension/ hypoxia/ angioedema. A CT
of the neck was negative for abscess, however soft tissue
inflammation was seen. Pt's O2 requirement was felt to likely
related to airway compromise from severe facial/neck swelling.
He underwent fiber optic intubation for airway protection. He
was initially on AC which was weaned to PSV 5/5 and he was
successfully extubated on [**2181-6-14**] and comfortable on room air
prior to discharge to floor. In terms of his fever/facial
swelling, the differential included mumps, adeno, paraflu,
parotid duct obstruction, bacterial parotitis, or facial
cellulitis. Angioedema also possible given hx of lisinopril
(most likely cause), aspirin, and ibuprofen use, combined with
eosinophilia.  His neck CT findings were not consistent with
enlarged parotid glands or severe facial cellulits; hence
angioedema seemed most likely. His lisinopril and ASA were
stopped because of their penchant (especially lisinopril) for
causing angioedema. ENT was also consulted and did not find any
obvious sources for his neck swelling. Steroids were held
because of concern for infectious etiology (though 1 dose was
given; ENT had felt that holding the steroids for use until
prior to extubation would be a better strategy).
Viral throat cx negative, strep throat cx negative. After his
initial neck CT, he had a repeat neck CT on [**6-12**] which showed new
stranding in the subcutaneous soft tissues of the posterior neck
and occiput consistent with edema. THere was also stranding of
soft tissues of the chest, slight stranding near the parotid
glands is stable, irregularity of opacification of the left
internal jugular vein (probably due to filling artefact as this
appears to occur near the entry point of an anterior venous
structure), and iterval opacification of the paranasal sinuses
with increasing mucosal thickening. Unclear [**Name2 (NI) 100410**] of these
findings, as diagnosis still remained uncertain. The filling
defect was not a thrombus as confirmed by US.
He was initially on steroids, but stopped per ENT as it was felt
that the effects of the steroids would be most useful to
decrease airway edema prior to extubation.
Allergy was consulted who felt that patient should not be
continued on lisinopril, but K to restart ASA and dipyridamole.
Per dental consult, tooth pathology likely not cause of pt's
neck swelling. With Diphenhydramine alone, the patient's edema
had started to resolve and his oxygenation and ventilation were
appropriate four days after intubate; hence he was extubated
without difficulty. On discharge C1 esterase inhibitor, Mumps
antibody and C2 was still pending.
.
# Hypotension: no clear etiology of the pt's hypotension during
the initial episode of neck swelling was found. The pt was
thought to be hypovolemic and he was thought to have increased
intrathoracic pressures due to airway obstruction from the
swelling. These two factors were thought to decrease the pt's
diastolic filling on which he was largly dependent given his
outflow obstruction in the context of HCOM. The pt was treated
with Nafcillin, Levo and Flagyl for five days, but antibtiotics
were subsequently discontinued as the pt was afebrile and all
cultures were negative and no clear source of infection was
found. THe pt remained afebrile for four days after
discontinuation of the antibiotics.
.
# Hypoxia: Pt's O2 requirement was felt to likely related to
airway compromise from severe facial/neck swelling. He underwent
fiber optic intubation for airway protection. He was initially
on AC which was weaned to PSV 5/5 and he was successfully
extubated on [**2181-6-14**] and comfortable on room air prior to
discharge to floor. On CXR, he was found to have a slightly
widened mediastinum; a chest CT ruled out dissection. Of note,
his CXR was also consistent with pulm edema, likely secondary to
aggressive IVF, but did not impair his oxygenation.
.
# Abdominal pain: no evidence of intrabdominal pathology on CT.
POssible in the context of angioedema. Resolved.
.
# Anemia: Pt hematocrit was trending down in the setting of
acute disease. Guaiac negative. No other source of bleeding.
Folate and Vit B12 normal. Iron studies consistent with anemia
of chronic disease. The pt's hct stabilized with improvement of
clinical status, although his reticulocyte count was not
adequate. The pt was not on any medications other then Depakote
that could explain his anemia, especially no marrow suppressive
medications. Further work up should be performed as an
outpatient if the pt persists to be anemic. F/u hct recommended
within one week.
.
# Seizures: Continued depakote.  THe pt missed a few doses while
he was intubated which explains his transiently low valproic
acid level. Levels were rising as Depakote was restarted at home
dose. F/u level in one week is recommended to ensure adequate
levels.
.
# Rash: The pt developed a mild diffuse rash thought to be
secondary to antibiotics which was given when he was hypotensive
to treat for sepsis emperically.  His rash improved after
withdrawing the antibiotics.
.
# Low back pain-chronic s/p laminectomy. Pt on oxycontin at
home, held in the context of hypotension. Not restarted upon
discharge as the pt was pain free.
.
# Code: full




Medications on Admission:
Ativan 1mg daily
depacote 500mg [**Hospital1 **]
gemfibrozil 600mg [**Hospital1 **]
atorvastatin 40mg daily
lisinopril 2.5mg daily
neurontin 300mg TID
oxycontin 10mg [**Hospital1 **]
zoloft 50mg daily
aggrenox 1 cap daily


Discharge Medications:
1. Depakote 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Aggrenox 200-25 mg Cap, Multiphasic Release 12 HR Sig: One
(1) Cap, Multiphasic Release 12 HR PO twice a day.
Disp:*60 Cap, Multiphasic Release 12 HR(s)* Refills:*2*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.

7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Diphenhydramine HCl 25 mg Tablet Sig: One (1) Tablet PO twice
a day for 7 days.
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain.
10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]

Discharge Diagnosis:
PRIMARY DX:
Angioedema of the throat, tongue and lip
Abdominal pain secondary to ?angioedema
Hypotension
Respiratory failure due to airway obstruction from angioedema
Anemia of chronic disease
.
SECONDARY DX:
Chronic low back pain
HCOM

Discharge Condition:
Hemodynamically stable, afebrile, out of bed with assistance.

Discharge Instructions:
Please take all medication as prescribe.  Follow up with all
appointments.  If you experience any more swelling or difficulty
breathing, please call your doctor.  Also call your doctor if
you have chest pain or shortness of breath.
Please make sure you remove all Lisinopril from you medication
boxes. You should never again in your live take Lisinopril or
any medication from the same class.

Followup Instructions:
Follow up with your doctor in the week after discharge from
rehab: [**Last Name (LF) 10531**],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 9347**].
.
Other appointments:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2181-8-20**] 12:30





Name:  [**Known lastname 16132**],[**Known firstname 133**]                 Unit No:   [**Numeric Identifier 16133**]

Admission Date:  [**2181-6-7**]              Discharge Date:   [**2181-6-19**]

Date of Birth:  [**2102-11-4**]             Sex:   M

Service: MEDICINE

Allergies:
Ace Inhibitors

Attending:[**First Name3 (LF) 161**]
Addendum:
78 year old man with h/o stroke admitted for weakness, course
complicated by angioedema s/p intubation.
.
# Fever + Leukocytosis:
Patient devoloped low grade fever (100.4) the day before
discharge.  He has no localizing symptoms.  UA and CXR is
negative.  Blood cultures are pending.  However he has been
having diarrhea during this time.  Stool cultures and Cdiff
panel were sent.  He has been afebrile overnight and this
morning and afternoon.  Please follow up on stool and cdiff
cultures.  Cdiff has only been sent once so it will have to be
sent twice more to rule out infection.
.
# Anemia:
Normocytic anemia.  B12 and Folate normal.  Haptoglobin
Likely anemia of chronic disease: Iron: 49, calTIBC: 211,
Ferritn: 1169, TRF: 162
.
# Insulin resistance:
His blood sugars has been elevated: fingersticks 115-170.  He
should follow up as an outpatient.  He may benefit from
Metformin.
.
# Aspiration:
Per speech and swallow eval by video: he continues to aspirate
thin liquids which may be his baseline from his history of
strokes.  He is currently on a pureed, nectar prethickened
liquids diet.  He may resume a thin liquid diet on discharge if
he chooses to knowning that he will aspirate small amounts.  Of
note, speech and swallow recommends that all his meds be crushed
and given in apple sauce.  However, Mr. [**Known lastname **] does not like
to have his medications crushed.  He understands that he has
risks of aspiration that might result in pneumonia and other
complications.  He should have another swallow video done in two
weeks.

Discharge Disposition:
Extended Care

Facility:
[**Doctor Last Name 321**] Nursing & Rehabilitation Center - [**Location (un) 322**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**]

Completed by:[**2181-6-19**]
{'Angioneurotic edema, not elsewhere classified,Acute respiratory failure,Congestive heart failure, unspecified,Other convulsions,Adult failure to thrive,Abdominal pain, left lower quadrant,Chest pain, unspecified,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Diverticulosis of colon (without mention of hemorrhage),Hypotension, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia of other chronic disease,Other late effects of cerebrovascular disease,Other musculoskeletal symptoms referable to limbs'}


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: weakness, fever
.

PRESENT ILLNESS: This is a 78 year old man with a history of multiple CVAs with
right side weakness who presented to the ED on [**2181-6-8**]
complaining of weakness x 3 days.  He also complained of
abdominal pain which he has had in the past with a negative
workup.  He denied N/V/D.
.
In the ED, abdominal CT scan revealed some diverticulosis but
otherwise no explanation for his abdominal pain.  He had a fever
to 101.1 in the ED and was admitted to Medicine for workup of
his weakness/fever/abdominal pain.
In the ED, he was started on empirical levo and flagyl and blood
cultures were drawn.  a U/A, and CT abdomen/pelvis were
negative.  CXR showed mild fluid overload and enlarged heart,
and CT of his head was neg for new pathology.  He had a neuro
consult that demonstrated no neurological changes from baseline.
 The patient had a ground level fall in the ED, and a repeat CT
scan of the head showed no bleeding.

MEDICAL HISTORY: hypertension
s/p CVA (mulitple, large R ischemic CVA, multiple small CVAs in
white matter)
h/o HOCM by last echo
seizures
hyperlipidemia
s/p hip fracture
anemia
? hx of hyperglycemia
Chronic low back pain s/p laminectomy
migraines
depression

MEDICATION ON ADMISSION: Ativan 1mg daily
depacote 500mg [**Hospital1 **]
gemfibrozil 600mg [**Hospital1 **]
atorvastatin 40mg daily
lisinopril 2.5mg daily
neurontin 300mg TID
oxycontin 10mg [**Hospital1 **]
zoloft 50mg daily
aggrenox 1 cap daily

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: VS:T:99.0   BP:130/82   HR:80   RR:16  O2sat:95%RA
gen: mildly confused elderly man in NAD.  difficulty sitteing up
on own
HEENT: EOMI, PERRLA, some L facial droop.  Oropharynx: mild
erythema
Ears:  TMs clear bilaterally.  Some erythema in canal in R ear.
Neck: no JVD
Chest: Lungs CTA
Heart: distant heart sounds, RRR, no murmur
Abd:  soft, non-distended, +BS, mildly tender to palpation
periumbilical.  No rebound, no guarding, no hepatosplenomegaly.
Ext:  [**4-13**] motor strength in all extremities.
Decreased DTRs L side.  Mild facial drop L side.

FAMILY HISTORY: -both parents with CAD

SOCIAL HISTORY: -lives with wife
-smokes one cigar per day
-no alcohol use
-worked in sales 

### Response:
{'Angioneurotic edema, not elsewhere classified,Acute respiratory failure,Congestive heart failure, unspecified,Other convulsions,Adult failure to thrive,Abdominal pain, left lower quadrant,Chest pain, unspecified,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Diverticulosis of colon (without mention of hemorrhage),Hypotension, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia of other chronic disease,Other late effects of cerebrovascular disease,Other musculoskeletal symptoms referable to limbs'}
