CHIEF COMPLAINT: Fatigue

PRESENT ILLNESS: 84 yo male with a history of biventricular heart failure, atrial
fibrillation, ICD and CAD s/p CABG who was directly admitted to
the CCU today from Dr.[**Name (NI) 7914**] clinic for medical treatment
of volume overload.  According to the patient's daughter, his
primary complaint is fatigue.  He feels "whole body" fatigue
with minimal exertion.  He was able to walk approximately 5
minutes without fatigue in the past, however recently has
required resting for minimal movement including going from
sitting to standing position.  The patient reports improvement
of BL LE edema, however increased amount of ascites.  The
daughter also reports decreased appetite.

MEDICAL HISTORY: CARDIAC HISTORY:
- MI X2
- CABG: 4 vessel [**2165**]
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
- Pacemaker placed [**2183**] for sick sinus syndrome
- Upgrade to [**Hospital1 **]-v ICD in [**3-/2189**]
- Generator change [**5-8**], pocket revision [**8-8**] (lead protruding
from skin)
- s/p VT ablation
- Atrial fibrillation
- Systolic, diastolic CHF last EF: 50% with LV hypertrophy and
severe global RV free wall hypokinesis and 4+ TR
OTHER PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
Prior TIA??????s with aphasia (none in the past 4 years)
Orchiectomy due to a gunshot wound sustained in the service
Central retinal vein occlusion

MEDICATION ON ADMISSION: Midodrine 5mg 1 PO QAM, then 6 hours later
Colchicine 0.6mg [**Hospital1 **]
Torsemide 50mg [**Hospital1 **]
Metolazone 5mg (1 or [**1-3**] tablet) prior to torsemide dosing
Flomax 0.4mg QD
Aminophylline 50mg QD
KCL 10 mEq QD
Amiodarone 100mg QD
Carvedilol 3.125mg [**Hospital1 **]
Digoxin 125mcg [**1-3**] tab QD
Aggrenox 1 cap QD
Simvastatin 10mg QD
Coumadin 5mg QD
Predfort opthalmic
Cosopt opthalmic
Zymar opthalmic
Acular opthalmic

ALLERGIES: Penicillins / Quinidine

PHYSICAL EXAM: VS:  HR 77 BP 120/75 RR 15 O2 99%
GENERAL: elderly man in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink.  Hematoma on left anterior forehead with surrounding
ecchymoses.
NECK: Supple with JVP of anterior ear
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**2-7**] holosystolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, ascites present, NTND. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ pitting edema to the thigh BL LE. No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1 PT 1
Left: Carotid 2+ Femoral 2+ DP 1 PT 1

FAMILY HISTORY: No family history of early MI, otherwise non-contributory

SOCIAL HISTORY: -Tobacco history: Quit smoking approx 25 years ago, did have
heavy pipe/cigar smoking for approx 8-10 years
-ETOH: rare glass of wine
-Illicit drugs: none
Served in the Army
Acute on chronic combined systolic and diastolic heart failure,Atrial flutter,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ,Unspecified essential hypertension,Gout, unspecified,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Other specified forms of chronic ischemic heart disease
Ac/chr syst/dia hrt fail,Atrial flutter,Aortocoronary bypass,Status autm crd dfbrltr,Hypertension NOS,Gout NOS,Hypothyroidism NOS,Hyperlipidemia NEC/NOS,BPH w/o urinary obs/LUTS,Chr ischemic hrt dis NEC
Admission Date:  [**2194-4-2**]              Discharge Date:   [**2194-4-8**]


Service: MEDICINE

Allergies:
Penicillins / Quinidine

Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Fatigue

Major Surgical or Invasive Procedure:
DCCV

History of Present Illness:
84 yo male with a history of biventricular heart failure, atrial
fibrillation, ICD and CAD s/p CABG who was directly admitted to
the CCU today from Dr.[**Name (NI) 7914**] clinic for medical treatment
of volume overload.  According to the patient's daughter, his
primary complaint is fatigue.  He feels "whole body" fatigue
with minimal exertion.  He was able to walk approximately 5
minutes without fatigue in the past, however recently has
required resting for minimal movement including going from
sitting to standing position.  The patient reports improvement
of BL LE edema, however increased amount of ascites.  The
daughter also reports decreased appetite.

On review of systems, he denies any prior history of deep venous

thrombosis, pulmonary embolism, myalgias, joint pains,
hemoptysis, black stools or red stools. He denies recent
fevers, chills or rigors. He denies exertional buttock or calf
pain. All of the other review of systems were negative.

Cardiac review of systems is notable for absence of chest pain,
shortness of breath, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.


Past Medical History:
CARDIAC HISTORY:
- MI X2
- CABG: 4 vessel [**2165**]
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
- Pacemaker placed [**2183**] for sick sinus syndrome
- Upgrade to [**Hospital1 **]-v ICD in [**3-/2189**]
- Generator change [**5-8**], pocket revision [**8-8**] (lead protruding
from skin)
- s/p VT ablation
- Atrial fibrillation
- Systolic, diastolic CHF last EF: 50% with LV hypertrophy and
severe global RV free wall hypokinesis and 4+ TR
OTHER PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
Prior TIA??????s with aphasia (none in the past 4 years)
Orchiectomy due to a gunshot wound sustained in the service
Central retinal vein occlusion

CARDIAC RISK FACTORS: HTN, hyperlipidemia, former smoker


Social History:
-Tobacco history: Quit smoking approx 25 years ago, did have
heavy pipe/cigar smoking for approx 8-10 years
-ETOH: rare glass of wine
-Illicit drugs: none
Served in the Army


Family History:
No family history of early MI, otherwise non-contributory

Physical Exam:
VS:  HR 77 BP 120/75 RR 15 O2 99%
GENERAL: elderly man in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink.  Hematoma on left anterior forehead with surrounding
ecchymoses.
NECK: Supple with JVP of anterior ear
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**2-7**] holosystolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, ascites present, NTND. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ pitting edema to the thigh BL LE. No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1 PT 1
Left: Carotid 2+ Femoral 2+ DP 1 PT 1


Pertinent Results:
ECG:  V paced rhythm at 75, with possible atrial flutter at a
rate of 150bpm.

TELEMETRY:  V paced rhythm at 75 bpm

Admission Labs:
[**2194-4-2**] 07:52PM   GLUCOSE-113* UREA N-63* CREAT-2.0* SODIUM-137
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
[**2194-4-2**] 07:52PM   proBNP-6409*
[**2194-4-2**] 07:52PM   CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-2.0
[**2194-4-2**] 07:52PM   TSH-7.2*
[**2194-4-2**] 07:52PM   DIGOXIN-0.4*
[**2194-4-2**] 07:52PM   WBC-4.5 RBC-3.17* HGB-10.0* HCT-29.4* MCV-93
MCH-31.4 MCHC-33.9 RDW-17.5*
[**2194-4-2**] 07:52PM   PLT COUNT-153
[**2194-4-2**] 07:52PM   PT-36.6* PTT-38.9* INR(PT)-3.9*

Brief Hospital Course:
1.  CHF exacerbation:  Biventricular failure secondary to
ischemic cardiomyopathy, right sided failure secondary to left
sided failure. The patient has severe tricuspid regurgitation,
moderate mitral and aortic regurgitation on recent TTE.  The
patient does not have typical CHF symptoms considering his
severe TR.  His symptomatic equivalent is fatigue and whole body
weakness.  It seems that he has progressed over the past few
months from Stage 3 NYHA classification to Stage 4, with
symptoms with minimal exertion/rest.  On admission, the patient
was very volume overloaded.  He was treated with IV lasix drip
with good diuresis.  Diuresis with lasix drip was initiated,
with weaning and placement on torsemide 80mg PO daily he did not
have adequate urine output and was thus placed back on the lasix
gtt until discharge. As his BPs were low with the lasix gtt a
PICC line was placed and dopamine was initiated to maintain
adequate blood pressures while aggressive diuresis. He was
continued on digoxin. Held carvedilol initially given attempt at
diuresis and risk of hypotension, however then this medication
were reinitiated to help control AF.  Held midodrine and
aminophylline given dopamine treatment and risk of
tachyarrhytmias initially, then once weaned off dopamine, these
medications were restarted.  Aminophylline was increased to
100mg [**Hospital1 **].  His torsemide was increased to 100mg [**Hospital1 **] for
discharge.  He also was instructed to take metolazone daily
prior to his AM dose of torsemide. Lasix drip was continued
untill discharge when he was sent home on metolazone and
torsemide.

2. Atrial Flutter:  The patient has been in atrial fibrillation
regardless of attempts at chemical cardioversion with amiodarone
in the past.  It appeared on 12 lead from admission that the
patient is in atrial flutter at a rate of 150bpm.   Continued
amiodarone.  Continued carvedilol.  Continued coumadin,
monitored INR daily.

3. CAD s/p CABG:  Continued simvastatin, aggrenox. Coreg was
held given hypotension initially and then re-started.

4. History of TIAs: Continued aggrenox.

5. BPH: Continued flomax, with holding parameters.

6. Cataracts: Continued opthalmic treatments including predfort,
acular, zymar, and cosopt.

7. Gout:  Continued colchicine

8. Hypothyroidism:  The patient's daughter reports that they did
not initiate levothyroxine therapy given unclear [**Name2 (NI) **] results.
TSH elevated but T4 and free T3 within normal limits. Did not
make any changes to medications.

9. Long term goal: Palliative care was involved and discussion
with patient and family took place re: long term goals of care.
The decision to eventually go home with home care, and think
about hospice care in the future.

Medications on Admission:
Midodrine 5mg 1 PO QAM, then 6 hours later
Colchicine 0.6mg [**Hospital1 **]
Torsemide 50mg [**Hospital1 **]
Metolazone 5mg (1 or [**1-3**] tablet) prior to torsemide dosing
Flomax 0.4mg QD
Aminophylline 50mg QD
KCL 10 mEq QD
Amiodarone 100mg QD
Carvedilol 3.125mg [**Hospital1 **]
Digoxin 125mcg [**1-3**] tab QD
Aggrenox 1 cap QD
Simvastatin 10mg QD
Coumadin 5mg QD
Predfort opthalmic
Cosopt opthalmic
Zymar opthalmic
Acular opthalmic


Discharge Medications:
1. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO BID (2 times a day).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
7. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
8. Ketorolac Tromethamine 0.5 % Drops Sig: One (1)  Ophthalmic
QID (4 times a day).
9. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic Q6H
(every 6 hours).
10. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Aminophylline 100 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
12. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.
Disp:*60 Tablet(s)* Refills:*2*
13. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
14. Torsemide 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
15. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please take 1 hour prior to torsemide dosing, if weight is
increased by 2lbs.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary Diagnoses:
Biventricular Congestive Heart failure
Atrial Fibrillation/Atrial Flutter
.
Secondary Diagnoses:
Hypertension
Hyperlipidemia
Prior TIA??????s with aphasia (none in the past 4 years)
Orchiectomy due to a gunshot wound sustained in the service
Central retinal vein occlusion


Discharge Condition:
The patient was hemodynamically stable at discharge.


Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation and treatment of your
heart failure.  You were treated with IV medications to help
remove excess fluid.  You were changed back to most of your home
medications prior to discharge, the changes are below.
.
These medications were changed:
- Aminophylline increased to 100mg [**Hospital1 **]
- Torsemide increased to 100mg [**Hospital1 **]
- Metolazone to be taken one hour prior to dose of Torsemide in
the event that your weight is 2lbs higher than the previous day
- Coumadin decreased to 3mg QD, please check your INR in 2 days
and adjust the coumadin dose accordingly
.
These medications were discontinued:
- Midodrine
.
You should continue to weigh yourself every morning, [**Name6 (MD) 138**] your
MD if your weight increases by 2 lbs.  If your weight is
elevated, please take 5mg of metolazone 1 hour prior to your
torsemide dose.  Please attempt to restrict your fluid intake to
1L per day.  Please decrease the amount of salt intake to 2gm
per day.
.
If you experience worsening fatigue, whole body weakness,
shortness of breath, chest pain, fever, chills or any other
worrisome symptoms please seek medical attention.

Followup Instructions:
Please follow up with your primary cardiologist, Dr. [**Last Name (STitle) **],
in 2 weeks regarding your treatment.
.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7986**], in
[**1-3**] weeks.
.
Please have your labs drawn, specifically your INR in 2 days
following discharge.



Completed by:[**2194-4-9**]
{'Acute on chronic combined systolic and diastolic heart failure,Atrial flutter,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ,Unspecified essential hypertension,Gout, unspecified,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Other specified forms of chronic ischemic heart disease'}


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: Fatigue

PRESENT ILLNESS: 84 yo male with a history of biventricular heart failure, atrial
fibrillation, ICD and CAD s/p CABG who was directly admitted to
the CCU today from Dr.[**Name (NI) 7914**] clinic for medical treatment
of volume overload.  According to the patient's daughter, his
primary complaint is fatigue.  He feels "whole body" fatigue
with minimal exertion.  He was able to walk approximately 5
minutes without fatigue in the past, however recently has
required resting for minimal movement including going from
sitting to standing position.  The patient reports improvement
of BL LE edema, however increased amount of ascites.  The
daughter also reports decreased appetite.

MEDICAL HISTORY: CARDIAC HISTORY:
- MI X2
- CABG: 4 vessel [**2165**]
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
- Pacemaker placed [**2183**] for sick sinus syndrome
- Upgrade to [**Hospital1 **]-v ICD in [**3-/2189**]
- Generator change [**5-8**], pocket revision [**8-8**] (lead protruding
from skin)
- s/p VT ablation
- Atrial fibrillation
- Systolic, diastolic CHF last EF: 50% with LV hypertrophy and
severe global RV free wall hypokinesis and 4+ TR
OTHER PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
Prior TIA??????s with aphasia (none in the past 4 years)
Orchiectomy due to a gunshot wound sustained in the service
Central retinal vein occlusion

MEDICATION ON ADMISSION: Midodrine 5mg 1 PO QAM, then 6 hours later
Colchicine 0.6mg [**Hospital1 **]
Torsemide 50mg [**Hospital1 **]
Metolazone 5mg (1 or [**1-3**] tablet) prior to torsemide dosing
Flomax 0.4mg QD
Aminophylline 50mg QD
KCL 10 mEq QD
Amiodarone 100mg QD
Carvedilol 3.125mg [**Hospital1 **]
Digoxin 125mcg [**1-3**] tab QD
Aggrenox 1 cap QD
Simvastatin 10mg QD
Coumadin 5mg QD
Predfort opthalmic
Cosopt opthalmic
Zymar opthalmic
Acular opthalmic

ALLERGIES: Penicillins / Quinidine

PHYSICAL EXAM: VS:  HR 77 BP 120/75 RR 15 O2 99%
GENERAL: elderly man in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink.  Hematoma on left anterior forehead with surrounding
ecchymoses.
NECK: Supple with JVP of anterior ear
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**2-7**] holosystolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, ascites present, NTND. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ pitting edema to the thigh BL LE. No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1 PT 1
Left: Carotid 2+ Femoral 2+ DP 1 PT 1

FAMILY HISTORY: No family history of early MI, otherwise non-contributory

SOCIAL HISTORY: -Tobacco history: Quit smoking approx 25 years ago, did have
heavy pipe/cigar smoking for approx 8-10 years
-ETOH: rare glass of wine
-Illicit drugs: none
Served in the Army 

### Response:
{'Acute on chronic combined systolic and diastolic heart failure,Atrial flutter,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ,Unspecified essential hypertension,Gout, unspecified,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Other specified forms of chronic ischemic heart disease'}
