CHIEF COMPLAINT: falls and hypotension

PRESENT ILLNESS: [**Age over 90 **]F with CHF, CAD, DM2, AS, PAFib presents after 2 falls in 24
hours. Does not remember circumstances of fall this AM. Alert,
neuro intact.
.
According to her family--she lives in a duplex above her eldest
daughter--she has become progressively weaker over the past 6
months or so and recently can only walk ~10 feet with walker,
limited by SOB. The night before admission, her daughter found
her slumped out of a chair, and the morning of admission, she
fell while trying to get out of bed and used her lifeline. She
has ho history of falls. Pt does not recall events leading up to
either fall, saying only "I guess I'm showing my age." Daughter
says pt was normal when she found her, no incontinence, spasms,
or altered sensorium. Of note, pt reportedly says she hopes
she'll die almost daily.
.
Last week, she gained almost 5 lbs in 5 days; on Tuesday, her
PCP told her to increase her dose of lasix from 60mg daily to
80mg daily.
.
In ED, SBP 80s with pulse 50s, got 2L IVF and 1 unit PRBCs, SBP
still marginal, so placed RIJ. SBP up to 110s by the time
placement CXR was read, so did not start pressors. No infectious
source apparent; hypotension thought [**2-11**] volume status and
severe AS. Sats 96% on 3L NC after receiving volume.

MEDICAL HISTORY: 1. HTN
2. CHF: (Ef= 30% by [**12-14**] TTE)
3. Severe AS, aortic valve area 0.6cm2
4. 3+MR, 2+ TR
5. CAD- single vessel disease, s/p drug eluting stent to LAD
[**2-15**].
6. Type 2 DM
7. Hyperlipidemia
8. S/P TAH/BSO
9. S/P appendectomy
10. Multinodular goiter- diagnosed [**9-11**]
11. Paroxysmal atrial fib
12.Chronic lower extremity edema
13.Chronic Renal insufficiency: basline Cr 1.5-1.7

MEDICATION ON ADMISSION: 1. HTN
2. CHF- (Ef= 30% by [**12-14**] TTE)
3. Severe AS, AoVA 0.6cm2/peak gradient 58mmHg
4. 3+MR, 2+ TR
5. CAD- single vessel disease, s/p drug eluting stent to LAD
[**2-15**].
6. Type 2 DM
7. Hyperlipidemia
8. S/P TAH/BSO
9. S/P appendectomy
10. Multinodular goiter- diagnosed [**9-11**]
11. Paroxysmal atrial fib
12. Chronic lower extremity edema
13. Chronic Renal insufficiency: baseline Cr 1.7

ALLERGIES: Penicillins / Tylenol / Lipitor

PHYSICAL EXAM: 95.0 130/96 63 23 99% 4L NC
GEN: frail elderly woman sitting upright, AAOx2
HEENT: NC/AT but TTP over L parietal bone, PERRL, EOMI
NECK: JVP 12-14cm but difficult to asses [**2-11**] RIJ
CHEST: fine crackles L base > R
CV: IV/VI high-pitched late systolic m, absent s2
ABD: firm, nontender. NABS. Guaiac negative.
EXT: massive ankle edema/3+ but with only mod pitting
SKIN: ecchymoses on R wrist and L arm
NEURO: CN II-XII intact

FAMILY HISTORY: NA

SOCIAL HISTORY: Lives alone in a [**Location (un) 1773**] apartment (daughter lives
downstairs).  No etoh or tobacco.
Mitral valve insufficiency and aortic valve stenosis,Rheumatic heart failure (congestive),Hypovolemia,Atrial fibrillation,Diseases of tricuspid valve,Cardiogenic shock,Chronic kidney disease, unspecified,Accidental fall from bed,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Other and unspecified hyperlipidemia
Mitral insuf/aort stenos,Rheumatic heart failure,Hypovolemia,Atrial fibrillation,Tricuspid valve disease,Cardiogenic shock,Chronic kidney dis NOS,Fall from bed,DMII wo cmp nt st uncntr,Hypothyroidism NOS,Hy kid NOS w cr kid I-IV,Crnry athrscl natve vssl,Status-post ptca,Hyperlipidemia NEC/NOS
Admission Date:  [**2152-8-5**]              Discharge Date:   [**2152-8-6**]


Service: MEDICINE

Allergies:
Penicillins / Tylenol / Lipitor

Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
falls and hypotension

Major Surgical or Invasive Procedure:
Right internal jugular central venous catheter placement

History of Present Illness:
[**Age over 90 **]F with CHF, CAD, DM2, AS, PAFib presents after 2 falls in 24
hours. Does not remember circumstances of fall this AM. Alert,
neuro intact.
.
According to her family--she lives in a duplex above her eldest
daughter--she has become progressively weaker over the past 6
months or so and recently can only walk ~10 feet with walker,
limited by SOB. The night before admission, her daughter found
her slumped out of a chair, and the morning of admission, she
fell while trying to get out of bed and used her lifeline. She
has ho history of falls. Pt does not recall events leading up to
either fall, saying only "I guess I'm showing my age." Daughter
says pt was normal when she found her, no incontinence, spasms,
or altered sensorium. Of note, pt reportedly says she hopes
she'll die almost daily.
.
Last week, she gained almost 5 lbs in 5 days; on Tuesday, her
PCP told her to increase her dose of lasix from 60mg daily to
80mg daily.
.
In ED, SBP 80s with pulse 50s, got 2L IVF and 1 unit PRBCs, SBP
still marginal, so placed RIJ. SBP up to 110s by the time
placement CXR was read, so did not start pressors. No infectious
source apparent; hypotension thought [**2-11**] volume status and
severe AS. Sats 96% on 3L NC after receiving volume.


Past Medical History:
1. HTN
2. CHF: (Ef= 30% by [**12-14**] TTE)
3. Severe AS, aortic valve area 0.6cm2
4. 3+MR, 2+ TR
5. CAD- single vessel disease, s/p drug eluting stent to LAD
[**2-15**].
6. Type 2 DM
7. Hyperlipidemia
8. S/P TAH/BSO
9. S/P appendectomy
10. Multinodular goiter- diagnosed [**9-11**]
11. Paroxysmal atrial fib
12.Chronic lower extremity edema
13.Chronic Renal insufficiency: basline Cr 1.5-1.7


Social History:
Lives alone in a [**Location (un) 1773**] apartment (daughter lives
downstairs).  No etoh or tobacco.


Family History:
NA

Physical Exam:
95.0 130/96 63 23 99% 4L NC
GEN: frail elderly woman sitting upright, AAOx2
HEENT: NC/AT but TTP over L parietal bone, PERRL, EOMI
NECK: JVP 12-14cm but difficult to asses [**2-11**] RIJ
CHEST: fine crackles L base > R
CV: IV/VI high-pitched late systolic m, absent s2
ABD: firm, nontender. NABS. Guaiac negative.
EXT: massive ankle edema/3+ but with only mod pitting
SKIN: ecchymoses on R wrist and L arm
NEURO: CN II-XII intact


Pertinent Results:
[**2152-8-5**] 09:26AM   WBC-4.3 RBC-2.77*# HGB-9.0*# HCT-25.4* MCV-92
MCH-32.5* MCHC-35.4* RDW-15.4
[**2152-8-5**] 09:26AM   NEUTS-65 BANDS-0 LYMPHS-22 MONOS-10 EOS-3
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2152-8-5**] 09:26AM   PLT COUNT-209
[**2152-8-5**] 09:26AM   CK(CPK)-85
[**2152-8-5**] 09:26AM   CK-MB-NotDone cTropnT-0.07*
[**2152-8-5**] 09:26AM   GLUCOSE-119* UREA N-73* CREAT-2.0*
SODIUM-127* POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-26 ANION GAP-15
[**2152-8-5**] 10:34AM   LACTATE-0.6
[**2152-8-5**] 12:19PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2152-8-5**] 12:19PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2152-8-5**] 09:46PM   DIGOXIN-1.3

CXR: Single portable upright chest radiograph is reviewed and
compared to [**2152-5-18**]. Cardiomediastinal silhouette is unchanged,
with continued evidence of mild pulmonary vascular engorgement
and perihilar haziness, as well as unchanged small bilateral
pleural effusions. There is worsening atelectasis at the right
base. Left basilar atelectasis is unchanged.

IMPRESSION: Unchanged mild congestive heart failure, and small
bilateral pleural effusions, with slightly worse atelectasis at
the right base.

EKG: Sinus bradycardia. Occasional atrial premature beats. Left
axis deviation. Intraventricular conduction defect. Compared to
tracing of [**2152-5-18**] there is no significant diagnostic change.

RENAL ULTRASOUND: There are bilateral pleural effusions. The
right kidney measures 10.5 cm in length. The left kidney
measures 8.6 cm in length. There is no hydronephrosis or
nephrolithiasis. No renal mass or apparent renal fluid
collections are seen.


Brief Hospital Course:
[**Age over 90 **]F w/ CHF EF 30%, CAD, DM2, AS, paroxysmal Afib, CRI, presented
with 2 falls in 24hrs, found to be hypotensive to 80s in ED
.
# s/p falls - increasing weakness/deconditioning finally leading
to apparently mechanical falls, based on family report, but must
also consider syncope given severe AS.
.
# hypotension - based on reported exam in ED and response to
volume resuscitation, was likely hypovolemic and severe AS is
very pre-load dependent, causing hypotension. Normotensive on
arrival to unit, after 1 unit PRBCs and 2 liter NS in ED, but
became hypotensive to SBP 80s, requiring dopamine for
maintenance of blood pressure.
.
# CHF: ischemic cardiomyopathy/global LV HK with EF 30%, severe
AS and 3+ MR contributing as well. Close monitoring of fluid
status; appeared euvolemic on arrival to unit, but
decompensation morning of [**8-6**] have been due to fact that
she was initially over-resuscitated. Digoxin level 1.3, so no
additional doses digoxin administered. Patient was started on
dopamine to augment LV function. Held beta blocker given low
SBP. Attempted BiPAP for pulmonary edema and hypoxia, with some
effect.
.
# CAD - s/p DES in [**2151**], maintained on [**Last Name (LF) **], [**First Name3 (LF) **], statin
.
# PAF - amio/beta blocker/dig for rate control, not
anticoagulated per old notes
.
# CKD: recent baseline Cr 1.8. Held ACE inh since Cr elevated.
.
# anemia: baseline Hct 28-30, received 1 unit PRBCs because
anemic to 25 and hypotensive in ED. Guaiac neg/no source of
bleeding.
.
# hypothyroid: home dose levothyroxine
.
# DM2: not on any therapy currently; will monitor with AM lab
draw
.
# Ppx: heparin subcut. home ppi.
.
# Access - RIJ, PIV
.
# CODE: DNR/DNI, confirmed with son and daughter [**Name (NI) **] [**Name (NI) 9802**],
[**Telephone/Fax (1) 9803**]; after family meeting on [**2152-8-6**], patient was made
comfort measures only. Pressors were stopped and BiPAP
withdrawn, and the patient subsequently expired.

Medications on Admission:
1. HTN
2. CHF- (Ef= 30% by [**12-14**] TTE)
3. Severe AS, AoVA 0.6cm2/peak gradient 58mmHg
4. 3+MR, 2+ TR
5. CAD- single vessel disease, s/p drug eluting stent to LAD
[**2-15**].
6. Type 2 DM
7. Hyperlipidemia
8. S/P TAH/BSO
9. S/P appendectomy
10. Multinodular goiter- diagnosed [**9-11**]
11. Paroxysmal atrial fib
12. Chronic lower extremity edema
13. Chronic Renal insufficiency: baseline Cr 1.7


Discharge Medications:
N/a

Discharge Disposition:
Expired

Discharge Diagnosis:
1. congestive heart failure
2. aortic stenosis
3. coronary artery disease
4. hypertension
5. hyperlipidemia
6. paroxysmal atrial fibrillation

Discharge Condition:
expired

Discharge Instructions:
n/a

Followup Instructions:
n/a
{'Mitral valve insufficiency and aortic valve stenosis,Rheumatic heart failure (congestive),Hypovolemia,Atrial fibrillation,Diseases of tricuspid valve,Cardiogenic shock,Chronic kidney disease, unspecified,Accidental fall from bed,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Other and unspecified hyperlipidemia'}


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: falls and hypotension

PRESENT ILLNESS: [**Age over 90 **]F with CHF, CAD, DM2, AS, PAFib presents after 2 falls in 24
hours. Does not remember circumstances of fall this AM. Alert,
neuro intact.
.
According to her family--she lives in a duplex above her eldest
daughter--she has become progressively weaker over the past 6
months or so and recently can only walk ~10 feet with walker,
limited by SOB. The night before admission, her daughter found
her slumped out of a chair, and the morning of admission, she
fell while trying to get out of bed and used her lifeline. She
has ho history of falls. Pt does not recall events leading up to
either fall, saying only "I guess I'm showing my age." Daughter
says pt was normal when she found her, no incontinence, spasms,
or altered sensorium. Of note, pt reportedly says she hopes
she'll die almost daily.
.
Last week, she gained almost 5 lbs in 5 days; on Tuesday, her
PCP told her to increase her dose of lasix from 60mg daily to
80mg daily.
.
In ED, SBP 80s with pulse 50s, got 2L IVF and 1 unit PRBCs, SBP
still marginal, so placed RIJ. SBP up to 110s by the time
placement CXR was read, so did not start pressors. No infectious
source apparent; hypotension thought [**2-11**] volume status and
severe AS. Sats 96% on 3L NC after receiving volume.

MEDICAL HISTORY: 1. HTN
2. CHF: (Ef= 30% by [**12-14**] TTE)
3. Severe AS, aortic valve area 0.6cm2
4. 3+MR, 2+ TR
5. CAD- single vessel disease, s/p drug eluting stent to LAD
[**2-15**].
6. Type 2 DM
7. Hyperlipidemia
8. S/P TAH/BSO
9. S/P appendectomy
10. Multinodular goiter- diagnosed [**9-11**]
11. Paroxysmal atrial fib
12.Chronic lower extremity edema
13.Chronic Renal insufficiency: basline Cr 1.5-1.7

MEDICATION ON ADMISSION: 1. HTN
2. CHF- (Ef= 30% by [**12-14**] TTE)
3. Severe AS, AoVA 0.6cm2/peak gradient 58mmHg
4. 3+MR, 2+ TR
5. CAD- single vessel disease, s/p drug eluting stent to LAD
[**2-15**].
6. Type 2 DM
7. Hyperlipidemia
8. S/P TAH/BSO
9. S/P appendectomy
10. Multinodular goiter- diagnosed [**9-11**]
11. Paroxysmal atrial fib
12. Chronic lower extremity edema
13. Chronic Renal insufficiency: baseline Cr 1.7

ALLERGIES: Penicillins / Tylenol / Lipitor

PHYSICAL EXAM: 95.0 130/96 63 23 99% 4L NC
GEN: frail elderly woman sitting upright, AAOx2
HEENT: NC/AT but TTP over L parietal bone, PERRL, EOMI
NECK: JVP 12-14cm but difficult to asses [**2-11**] RIJ
CHEST: fine crackles L base > R
CV: IV/VI high-pitched late systolic m, absent s2
ABD: firm, nontender. NABS. Guaiac negative.
EXT: massive ankle edema/3+ but with only mod pitting
SKIN: ecchymoses on R wrist and L arm
NEURO: CN II-XII intact

FAMILY HISTORY: NA

SOCIAL HISTORY: Lives alone in a [**Location (un) 1773**] apartment (daughter lives
downstairs).  No etoh or tobacco. 

### Response:
{'Mitral valve insufficiency and aortic valve stenosis,Rheumatic heart failure (congestive),Hypovolemia,Atrial fibrillation,Diseases of tricuspid valve,Cardiogenic shock,Chronic kidney disease, unspecified,Accidental fall from bed,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Other and unspecified hyperlipidemia'}
