CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 57M  with HTN, DM Type II, CAD s/p MI in [**2175**], ESRD (baseline Cr
of 6.6) not on HD currently being screened for transplant, who
presented to the ED [**2180-8-4**] complaining of SOB over a few hours,
followed by chest discomfort, nausea, and vomiting. He denied
fevers or chills. He had taken two sublingual NTG tabs at home,
and reported some substernal 8/10 chest pain in the ED.  An
initial CXR in the ED showed clear lung fields, however a repeat
demonstrated flash pulmonary edema.  BiPAP was tried, however he
did not tolerate it and ended up vomiting. As he didn't tolerate
BiPAP, he was intubated. His BP, 180s SBP in the ED, was
initially controlled with NTG and propofol drips. At the time of
transfer to the CCU, he was changed to fentanyl and midazolam
drips, which made the pt normotensive and comfortable. While in
the ED, he was also treated with morphine 2mg IV, lasix 40 IV x1
and put out 370mL urine over 3 hours.  An ASA was given with
EMS. The patient was home alone the night he presented, so it is
possible he did not take his evening BP meds without his
girlfriend around to remind him. Tox screen was negative.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, + Hypertension
2. CARDIAC HISTORY:
- MI by report in [**2175**]
3. OTHER PAST MEDICAL HISTORY:
- Diabetes Type 2, diagnosed age 40, now on insulin
- CKD with AV fistula placed for potential HD in [**4-18**] but not
yet on HD, creatinine 6.6 mg/dL in [**4-/2180**]
- HTN

MEDICATION ON ADMISSION: toprol XL 300 mg QD, hydralazine 100 mg TID, clonidine 0.2 mg
TID, ASA 81, calcitriol 0.25 mg QG, phoslo 667 TID with meals,
nephrocaps, aranesp monthly, lasix 40 mg QD, hydroxizine 25 mg
TID PRN, chantix, vit D [**Numeric Identifier 1871**] weekly, viagra PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Initial ED vitals: T 98.1, HR 83, BP 185/95, RR 25, 99% on 3L by
NC

FAMILY HISTORY: Sister: breast cancer age 51
Brother: obesity, [**Name (NI) 21418**]
Father: [**Name (NI) 21418**], died of cancer

SOCIAL HISTORY: current smoker
Acute respiratory failure,End stage renal disease,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atrial flutter,Renal dialysis status,Tobacco use disorder,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Unspecified viral hepatitis C without hepatic coma,Anemia in chronic kidney disease,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Long-term (current) use of insulin
Acute respiratry failure,End stage renal disease,Ac on chr diast hrt fail,Acute kidney failure NOS,Hyp kid NOS w cr kid V,Atrial flutter,Renal dialysis status,Tobacco use disorder,Old myocardial infarct,Crnry athrscl natve vssl,Hpt C w/o hepat coma NOS,Anemia in chr kidney dis,DMII ophth nt st uncntrl,Diabetic retinopathy NOS,Nephritis NOS in oth dis,Long-term use of insulin
Admission Date:  [**2180-8-5**]              Discharge Date:   [**2180-8-14**]

Date of Birth:  [**2123-3-25**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
none

History of Present Illness:
57M  with HTN, DM Type II, CAD s/p MI in [**2175**], ESRD (baseline Cr
of 6.6) not on HD currently being screened for transplant, who
presented to the ED [**2180-8-4**] complaining of SOB over a few hours,
followed by chest discomfort, nausea, and vomiting. He denied
fevers or chills. He had taken two sublingual NTG tabs at home,
and reported some substernal 8/10 chest pain in the ED.  An
initial CXR in the ED showed clear lung fields, however a repeat
demonstrated flash pulmonary edema.  BiPAP was tried, however he
did not tolerate it and ended up vomiting. As he didn't tolerate
BiPAP, he was intubated. His BP, 180s SBP in the ED, was
initially controlled with NTG and propofol drips. At the time of
transfer to the CCU, he was changed to fentanyl and midazolam
drips, which made the pt normotensive and comfortable. While in
the ED, he was also treated with morphine 2mg IV, lasix 40 IV x1
and put out 370mL urine over 3 hours.  An ASA was given with
EMS. The patient was home alone the night he presented, so it is
possible he did not take his evening BP meds without his
girlfriend around to remind him. Tox screen was negative.






Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Hypertension
2. CARDIAC HISTORY:
- MI by report in [**2175**]
3. OTHER PAST MEDICAL HISTORY:
- Diabetes Type 2, diagnosed age 40, now on insulin
- CKD with AV fistula placed for potential HD in [**4-18**] but not
yet on HD, creatinine 6.6 mg/dL in [**4-/2180**]
- HTN

Social History:
current smoker

Family History:
Sister: breast cancer age 51
Brother: obesity, [**Name (NI) 21418**]
Father: [**Name (NI) 21418**], died of cancer

Physical Exam:
Initial ED vitals: T 98.1, HR 83, BP 185/95, RR 25, 99% on 3L by
NC

Gen: sedated, comfortable

HEENT: NCAT

Pulm: Coarse breath sounds noted bilaterally

CV: RR, nl S1, S2, +S4, no M/R appreciated

Abd: Soft, hypoactive BS

Ext: 2 + pulses, no cyanosis or edema, +clubbing


Pertinent Results:
[**2180-8-5**] 01:55AM   CK-MB-3 cTropnT-0.06* proBNP-[**Numeric Identifier **]*
[**2180-8-5**] 01:55AM   CK(CPK)-52

[**2180-8-5**] 01:55AM   WBC-13.2* RBC-3.58* HGB-10.0* HCT-28.5*
MCV-80* MCH-28.1 MCHC-35.2* RDW-14.4
[**2180-8-5**] 01:55AM   PLT COUNT-197

[**2180-8-5**] 02:10AM   GLUCOSE-186* LACTATE-1.1 NA+-141 K+-4.1
CL--100 TCO2-23
[**2180-8-5**] 01:55AM   UREA N-63* CREAT-4.8*#

[**2180-8-5**] 01:55AM   LIPASE-135*

[**2180-8-5**] 08:32AM   TRIGLYCER-166* HDL CHOL-25 CHOL/HDL-3.6
LDL(CALC)-31

[**2180-8-5**] 01:55AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG

CXR 2AM [**8-5**] Findings consistent with mild CHF
CXR 4AM [**8-5**] Interval development of pulmonary edema with fluid
overload with upper lobe venous congestion, and fluid in the
minor fissure.

Echo [**8-5**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is mild regional left ventricular systolic
dysfunction with focal hypokinesis of the basal inferior septum
and basal inferior wall. The remaining segments contract
normally (LVEF = 45-50 %). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.

IMPRESSION: Mild concentric left ventricular hypertrophy.
Regional systolic dysfunction c/w CAD. Mild mitral
regurgitation. Moderate pulmonary hypertension.

ECG [**8-4**] 2AM: normal sinus rhythm with prolonged QT at 422msec.
No ST segment abnormalities noted. Repeat study at 3:30AM showed
a normal QT.

Brief Hospital Course:
57M with DM-II, HTN, CAD s/p MI in [**2175**], and ESRD not on HD who
presented with SOB and CP and had flash pulmonary edema in the
setting of hypertensive urgency in the ED.
.
# CORONARIES: Known CAD s/p MI in [**2175**]. As the pat is new to our
system, his anatomy is unknown to us. During this
hospitalization, pt recieved ASA 325mg PO daily instead of his
usual home 81mg. No acute ECG changes were found during
hospitalization. Cardiac enzymes were followed and ruled out MI.
Lipid panel showed an LDL of 31 and a slightly elevated total
cholesterol of 166, so no statin was started.
.
# PUMP: Pt clinically presented with flash pulmonary edema. Echo
showed EF 45-55%, mild concentric left ventricular hypertrophy,
regional systolic dysfunction c/w CAD, mild mitral
regurgitation, and moderate pulmonary hypertension.  Patient was
able to be weaned off the ventilator and successfully extuibated
day 2 of hospitalization. Pt has vigorous response to IV Lasix
initially and was euvolemic for the rest of the admission.
.
# RHYTHM: Patient was in NSR until day 2 of admission when rates
of 140s-150s were seen on tele. ECG showed A Fib. Patient had no
known diagnosis of A Fib. Given his HTN and cardiac disease, it
was felt that the patient likely had undiagnosed paroxysmal A
Fib. He was already on a BBlocker for rate control, and coumadin
was started. INRs were follwed by CCU team and pharmacy. Pt's
PCP made aware of new Dx of A Fib and anti-coagulation. Pt given
a prescription to have INR checked in dialysys the day after
discharge with results to be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital 2082**].
.
# HTN / Hypertensive urgency: Blood pressures were difficult to
control. Clonidine was switched to a patch to prevent rebound
from missing a dose, but ultimately d/c as made pt sommulent.
Able to decrease home dose of hydralazine from 100mg [**Hospital1 **] to 50mg
TID by adding amlodipine 10mg daily. Patient had been titrated
up to max BBlocker dose prior to the initiation of HD, but with
HD the dose was lowered to metoprolol 75mg [**Hospital1 **]. Pt got his home
dose of Lasix as requested by renal, 40mg daily. Renal US showed
no revidence of renal vascular disease as a cause of refractory
HTN.
.
# ESRD: Renal follow the patient throughout admission. Cr rose
from 4.8 to 5.7 ultimately before the initiation of dialysis. Pt
began HD [**8-8**]. Nephrocaps were continues throught admission, and
calcium acetate was started per renal recs. He had three days of
a row of uneventful diaysis, but did experience hypertension
follwing the third HD treatment. During his 4th HD treatment on
[**8-12**], he had an episode of tacycardia into the 120s that resolved
with his usual AM dose of metoprolol. pt is on an afternoon
outpatient dialysys schedule, so will have morning meds on board
prior to dialysis to prevent HTN and tachycardia during HD.
Patient is scheduled for regular Tuesday, Thursday, and Saturday
dialysis at [**Location (un) **] - [**Location (un) 86**] Dialysis Center.
.
# Nausea: Intermittent complaint throughout admission. Normal
ECG and cardiac enzymes during episodes of nausea, so unlikely
an anginal equivalent. Episodes oftern required anti-emetics and
anxiolytics to resolve. The afternoon after the third course of
HD, the patient began to feel nauseated and have shaking chills.
SBP was 190s as he had not recieved his BP meds prior to
dialysis. Pan cultures were negative. Symptoms were managed with
hydralazine, NTG, and Ativan. CT was done to rule out an
intraabdominal infection or process; it showed 2 enlarged
mesenteric lymph nodes, likely reactive. No evidence of
mesenteric ischemia or infection. Patient should have f/u CT in
3 months to re-evalute lymph nodes. No nausea was reported on
day of discharge.
.
# Diabetes: The patient's home dose of Lantus was given during
admission. Elevated blood sugars were covered with sliding scale
humolog. His glucoses were well-controlled throughout admission.

.
# Hepatitis: Hepatitis panels were sent as part of routine
pre-dialysis labs. Hepatitis C antibody was positive.  Hep C
viral load was 8,670,000 IU/mL. patietn was instucted to call
[**Hospital1 18**] Liver Clinic to make an appointment for follow up.

Medications on Admission:
toprol XL 300 mg QD, hydralazine 100 mg TID, clonidine 0.2 mg
TID, ASA 81, calcitriol 0.25 mg QG, phoslo 667 TID with meals,
nephrocaps, aranesp monthly, lasix 40 mg QD, hydroxizine 25 mg
TID PRN, chantix, vit D [**Numeric Identifier 1871**] weekly, viagra PRN


Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please take half ([**2-12**]) a pill on Monday [**8-14**], and then take a
whole pill daily after that.
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Physical Therapy
Please evaluate and treat patient for any difficultly in
ambulating independently.
Medical Dx: ESRD on dialysis, hypertension


Discharge Disposition:
Home

Discharge Diagnosis:
Hypertension
Hepatitis C
ESRD on dialysis

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).

Discharge Instructions:
Thank you for coming to [**Hospital1 69**]. We
diagnosed a new condition this admission, Hepatitis C. Please
make an appointment to see a liver doctor. You started dialysis
this admission. We discontinued your clonidine; please stop
taking it. We changed your doses of metoprolol (Toprol) and
hydralazine. Please fill the new prescriptions and discard the
old ones. We started 3 new medicines. Amlodipine is for your
blood pressure. Calcium acetate helps your kidney balance the
salts in your body. Coumadin (warfarin) was started because of
an abnormal heart rhythm. It helps prevent blood clots from
forming. It is very important to keep your appointments with
your doctor while on this medicine.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Dialysis tomorrow (Tuesday)

Department: Internal Medicine
Name: Dr. [**First Name (STitle) **] [**Doctor Last Name **]
When: Wednesday [**2180-8-17**] at 1: 15 PM
Address: [**Apartment Address(1) 96275**], [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**Telephone/Fax (1) 54873**]

Department: Cardiology
Name: Dr. [**First Name8 (NamePattern2) **] [**Doctor Last Name 313**]
When: Wednesday [**2180-8-30**] at 11:00
Location: [**Hospital6 **]
Address: [**Location (un) **] 4TH FL, [**Location (un) **],[**Numeric Identifier 13108**]
Phone: [**Telephone/Fax (1) 47675**]
(Reminder that patient has an appointment with Neurology on the
same day at 2:30 PM)

Physical therapy has recommended you go to an outpatient
physical therapist near you. Please call to make an apointment.
You will need to bring the prescription we give you to that
appointment.

It is important that you call the liver clinic to make an
apointment at ([**Telephone/Fax (1) 451**].


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
{'Acute respiratory failure,End stage renal disease,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atrial flutter,Renal dialysis status,Tobacco use disorder,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Unspecified viral hepatitis C without hepatic coma,Anemia in chronic kidney disease,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Long-term (current) use of insulin'}


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: 57M  with HTN, DM Type II, CAD s/p MI in [**2175**], ESRD (baseline Cr
of 6.6) not on HD currently being screened for transplant, who
presented to the ED [**2180-8-4**] complaining of SOB over a few hours,
followed by chest discomfort, nausea, and vomiting. He denied
fevers or chills. He had taken two sublingual NTG tabs at home,
and reported some substernal 8/10 chest pain in the ED.  An
initial CXR in the ED showed clear lung fields, however a repeat
demonstrated flash pulmonary edema.  BiPAP was tried, however he
did not tolerate it and ended up vomiting. As he didn't tolerate
BiPAP, he was intubated. His BP, 180s SBP in the ED, was
initially controlled with NTG and propofol drips. At the time of
transfer to the CCU, he was changed to fentanyl and midazolam
drips, which made the pt normotensive and comfortable. While in
the ED, he was also treated with morphine 2mg IV, lasix 40 IV x1
and put out 370mL urine over 3 hours.  An ASA was given with
EMS. The patient was home alone the night he presented, so it is
possible he did not take his evening BP meds without his
girlfriend around to remind him. Tox screen was negative.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, + Hypertension
2. CARDIAC HISTORY:
- MI by report in [**2175**]
3. OTHER PAST MEDICAL HISTORY:
- Diabetes Type 2, diagnosed age 40, now on insulin
- CKD with AV fistula placed for potential HD in [**4-18**] but not
yet on HD, creatinine 6.6 mg/dL in [**4-/2180**]
- HTN

MEDICATION ON ADMISSION: toprol XL 300 mg QD, hydralazine 100 mg TID, clonidine 0.2 mg
TID, ASA 81, calcitriol 0.25 mg QG, phoslo 667 TID with meals,
nephrocaps, aranesp monthly, lasix 40 mg QD, hydroxizine 25 mg
TID PRN, chantix, vit D [**Numeric Identifier 1871**] weekly, viagra PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Initial ED vitals: T 98.1, HR 83, BP 185/95, RR 25, 99% on 3L by
NC

FAMILY HISTORY: Sister: breast cancer age 51
Brother: obesity, [**Name (NI) 21418**]
Father: [**Name (NI) 21418**], died of cancer

SOCIAL HISTORY: current smoker 

### Response:
{'Acute respiratory failure,End stage renal disease,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atrial flutter,Renal dialysis status,Tobacco use disorder,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Unspecified viral hepatitis C without hepatic coma,Anemia in chronic kidney disease,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Long-term (current) use of insulin'}
