CHIEF COMPLAINT: tongue swelling

PRESENT ILLNESS: Mr. [**Known lastname **] is a 64 YOM with a PMH of hypertension who presented
to the ED with tongue swelling and muffled voice which began 45
minutes after he woke up.  He is not having difficulty manageing
his secretions though he has increased saliva.  This similar
presentation happened once before and no cause was ever found
for the angioedema (went to [**Doctor Last Name **] in [**Location (un) 3844**]).  The
patientis not on an ace inhibitor and he denies taking any new
medications.  His only medications are terazosin (been on this
for 6 months), baby aspirin (years), and fish oil.  He has eaten
no new foods and has no family history of swelling.  Denies
insect bites. Has no pets. Works in construction.

MEDICAL HISTORY: Hypertension
fractured right ankle and ribs during construction accident (no
surgeries)

MEDICATION ON ADMISSION: terazosin for HTN
81 mg Aspirin
fish oil

ALLERGIES: Codeine

PHYSICAL EXAM: Admission Exam:
General: Alert, oriented, no acute distress, appears
comfortable, muffled voice
HEENT: Sclera anicteric, MMM, tongue enlarged more on the left
side than right, submandibular swelling, mild parotid fullness,
no drooling, no lip swelling, no stridor
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi,
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema
.
Discharge Exam:
General: Alert, oriented, no acute distress, appears
comfortable, muffled voice
HEENT: Sclera anicteric, MMM, no appreciable tongue swelling
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi,
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema

FAMILY HISTORY: No history of angioedema

SOCIAL HISTORY: Married to [**First Name4 (NamePattern1) **] [**Known lastname **], has 3 children.  Lives in [**Location **].
Works in construction.  Drinks 2 glasses wine a night, denies
tobacco or other drug use.
Angioneurotic edema, not elsewhere classified,Hyperpotassemia,Unspecified accident,Unspecified essential hypertension,Home accidents
Angioneurotic edema,Hyperpotassemia,Accident NOS,Hypertension NOS,Accident in home
Admission Date:  [**2187-9-19**]              Discharge Date:   [**2187-9-20**]

Date of Birth:  [**2123-6-13**]             Sex:   M

Service: MEDICINE

Allergies:
Codeine

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
tongue swelling


Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname **] is a 64 YOM with a PMH of hypertension who presented
to the ED with tongue swelling and muffled voice which began 45
minutes after he woke up.  He is not having difficulty manageing
his secretions though he has increased saliva.  This similar
presentation happened once before and no cause was ever found
for the angioedema (went to [**Doctor Last Name **] in [**Location (un) 3844**]).  The
patientis not on an ace inhibitor and he denies taking any new
medications.  His only medications are terazosin (been on this
for 6 months), baby aspirin (years), and fish oil.  He has eaten
no new foods and has no family history of swelling.  Denies
insect bites. Has no pets. Works in construction.

In the ED, VS were:  97.6 102 196/135 18 96%.  Exam was notable
for an "impressively swollen" tongue.  Labs showed WBC 5.1 (4.2%
Eos), otherwise chem 7 WNL.  He was given 125 mg solumedrol, 20
mg famotidine,  50 mg benadryl, and Zofran for nausea.  He was
admitted to the ICU for observation for possible intubation.
Vital signs prior to transfer were: HR 80 151/95 97% on RA.

On the floor, pt appeared comfortable and was breathing
normally.  Voice was muffled, but no stridor.  He denied
complaint and ROS was negative for fever, chills, headache,
sinus tenderness, rhinorrhea or congestion, cough, shortness of
breath, wheezing, chest pain, chest pressure, palpitations,
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits, dysuria, frequency, or urgency. Denies
rashes or skin changes.


Past Medical History:
Hypertension
fractured right ankle and ribs during construction accident (no
surgeries)


Social History:
Married to [**First Name4 (NamePattern1) **] [**Known lastname **], has 3 children.  Lives in [**Location **].
Works in construction.  Drinks 2 glasses wine a night, denies
tobacco or other drug use.


Family History:
No history of angioedema


Physical Exam:
Admission Exam:
General: Alert, oriented, no acute distress, appears
comfortable, muffled voice
HEENT: Sclera anicteric, MMM, tongue enlarged more on the left
side than right, submandibular swelling, mild parotid fullness,
no drooling, no lip swelling, no stridor
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi,
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema
.
Discharge Exam:
General: Alert, oriented, no acute distress, appears
comfortable, muffled voice
HEENT: Sclera anicteric, MMM, no appreciable tongue swelling
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi,
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema


Pertinent Results:
Admission Labs:
[**2187-9-19**] 06:40AM BLOOD WBC-5.1 RBC-4.74 Hgb-15.5 Hct-43.6 MCV-92
MCH-32.6* MCHC-35.4* RDW-14.3 Plt Ct-146*
[**2187-9-19**] 06:40AM BLOOD Neuts-64.9 Lymphs-24.2 Monos-6.1 Eos-4.2*
Baso-0.6
[**2187-9-19**] 06:40AM BLOOD Glucose-133* UreaN-18 Creat-0.9 Na-138
K-5.6* Cl-102 HCO3-26 AnGap-16
.
Markers:
[**2187-9-19**] 08:58AM BLOOD C1 ESTERASE INHIBITOR, FUNCTIONAL
ASSAY-PND
.
CHEST (PA & LAT) Study Date of [**2187-9-19**]
IMPRESSION:
1. Nonvisualization of the subglottic airways. In a patient with
the clinical history of angioedema, this may represent
subglottic edema, but upper airway is better assessed by soft
tissue neck radiographs, cross-sectional imaging or direct
visualization.
2. Apparent widening of the mediastinum. In the absence of prior
radiographs for comparison, consider chest CT to differentiate
prominent mediastinal fat and vessels from lymph node
enlargement or mass.
3. Focal right lower lobe opacity which may represent aspiration
or early pneumonia.
4. Multiple healed and some subacute rib fractures involving the
lateral aspect of the mid thoracic right ribs.
.
CT chest [**2187-9-19**]:
1.Central airway till subsegmental level is patent. There is no
focal lung
lesion/consolidation.
2.Bilateral minimal dependent lung atelectasis.
3.Cholelithiasis without cholecystitis.
4.Multiple old rib fractures on right side.
.
CT neck [**2187-9-19**]
1. No obstructing lesion compressing the airway.
2. Abundant mediastinal lipomatosis likely accounts for the
radiographic
finding of "mediastinal widening."
3. No mass, lymphadenopathy, or other soft tissue abnormality.
.
Echo [**2187-9-20**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is borderline
pulmonary artery systolic hypertension. The pulmonic valve
leaflets are thickened. There is stenosis of the main pulmonary
artery. There is no pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
The right ventricular wall may be hypertrophied. There is
turbulent flow with an increased gradient of approximately 16mm
Hg seen through the pulmonary outflow tract - this is probably
because of a mild narrowing of the main pulmonary artery just
distal to the pulmonic valve.
.
Discharge labs:
[**2187-9-20**] 04:22AM BLOOD WBC-7.7# RBC-4.35* Hgb-14.4 Hct-41.2
MCV-95 MCH-33.0* MCHC-34.9 RDW-14.0 Plt Ct-152
[**2187-9-20**] 04:22AM BLOOD PT-12.4 PTT-21.4* INR(PT)-1.0
[**2187-9-20**] 04:22AM BLOOD Glucose-135* UreaN-18 Creat-0.9 Na-142
K-4.1 Cl-105 HCO3-31 AnGap-10
[**2187-9-20**] 04:22AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.4

Brief Hospital Course:
Mr. [**Known lastname **] is a 64 YOM with a history of hypertension, on
terazosin, who presented to the ED with his second episode of
tongue swelling.  He was admitted to the ICU for observation in
case he needed intubation.
.
# Tongue swelling:  Unclear etiology as pt not on ACEI or any
new medications.  Differential diagnosis includes allergic
reaction to unknown environmental exposure (insects, food,
animal saliva- shellfish ingestion day prior to admission),
acquired C1 esterase deficiency (which usually occurs in this
age group), medications, or idiopathic angioedema.  He has not
taken any medications usually implicated with this presentation
(NSAIDS, ACEI, CCB, estrogens), however terazosin is listed as a
<1% incidence of facial swelling.  He does not have a peripheral
eosinophilia.  C1 esterase level was sent, but pending at the
time of discharge. His terazosin was stopped and when taking PO
he was changed to a different PO BP medication (as below). He
was treated with a pulse of 40mg of steroids x5 days as well as
famotidine and benadryl. Upon discharge, he will need further
work-up with an allergist close to home investigate the cause of
his angioedema. He has been advised to avoid shellfish until
formal allergy testing is done.
.
# Mediastinal fullness: Concern for mass or other lesion of left
hilum on admission CXR. CT was done and did not should any mass
or enlarged lymph nodes, but a narrowing of the PA was noted.
This finding was confirmed with echo, but not found to be
hemodynamically significant.
.
# Hypertension: He was normotensive in the hospital with
occasional hypertensive readings. He was on terazosin, which was
held in setting of angioedema (see above). Started on HCTZ
12.5mg daily for hypertension. Pressures were in the 130s on the
day of discharge.
.
Full Code


Medications on Admission:
terazosin for HTN
81 mg Aspirin
fish oil


Discharge Medications:
1. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
4. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day.



Discharge Disposition:
Home

Discharge Diagnosis:
Primary: Angioedema
.
Secondary: Hypertension


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Mr. [**Known lastname **],
.
It was a pleasure taking part in your care. You were admitted to
[**Hospital1 18**] because of tongue swelling. You were admitted to the ICU
for close monitoring in case you developed difficulty breathing.

.
Over the course of the day, the swelling improved, and you were
able to tolerate eating and drinking. We did not find a clear
reason for the swelling of your tongue. We strongly recommend
seeing an allergy specialist at home after your discharge. Until
you have allergy testing you should NOT eat clams, lobster, or
other shellfish. We changed your blood pressure medicine.
.
You had a small abnormaility on your chest xray, so we did a CT
scan and echocardiogram to evaluate. You have a narrowing of the
pulmonary artery which brings blood from the heart to the lungs.
This is not causing any issues, and there is nothing to do for
this problem. Please call you doctor if you develop leg
swelling, distention of your belly, or shortness of breath.
.
We made the following changes to your medications:
- STOP terazosin
- START Hydrochlorothiazide 12.5mg by mouth daily
- START prednisone 40mg for 3 more days.
.
Please follow-up with your PCP and an allergy specialist.

Followup Instructions:
Please follow-up with your primary care physician (Dr. [**Last Name (STitle) 410**],
[**Telephone/Fax (1) 91416**]) within 1 week and establish care with an allergy
specialist.
.
There is a test (called the C1-esterase inhibitor) pending at
the time of your discharge. Your PCP should follow up on this
result.
{'Angioneurotic edema, not elsewhere classified,Hyperpotassemia,Unspecified accident,Unspecified essential hypertension,Home accidents'}


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: tongue swelling

PRESENT ILLNESS: Mr. [**Known lastname **] is a 64 YOM with a PMH of hypertension who presented
to the ED with tongue swelling and muffled voice which began 45
minutes after he woke up.  He is not having difficulty manageing
his secretions though he has increased saliva.  This similar
presentation happened once before and no cause was ever found
for the angioedema (went to [**Doctor Last Name **] in [**Location (un) 3844**]).  The
patientis not on an ace inhibitor and he denies taking any new
medications.  His only medications are terazosin (been on this
for 6 months), baby aspirin (years), and fish oil.  He has eaten
no new foods and has no family history of swelling.  Denies
insect bites. Has no pets. Works in construction.

MEDICAL HISTORY: Hypertension
fractured right ankle and ribs during construction accident (no
surgeries)

MEDICATION ON ADMISSION: terazosin for HTN
81 mg Aspirin
fish oil

ALLERGIES: Codeine

PHYSICAL EXAM: Admission Exam:
General: Alert, oriented, no acute distress, appears
comfortable, muffled voice
HEENT: Sclera anicteric, MMM, tongue enlarged more on the left
side than right, submandibular swelling, mild parotid fullness,
no drooling, no lip swelling, no stridor
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi,
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema
.
Discharge Exam:
General: Alert, oriented, no acute distress, appears
comfortable, muffled voice
HEENT: Sclera anicteric, MMM, no appreciable tongue swelling
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi,
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema

FAMILY HISTORY: No history of angioedema

SOCIAL HISTORY: Married to [**First Name4 (NamePattern1) **] [**Known lastname **], has 3 children.  Lives in [**Location **].
Works in construction.  Drinks 2 glasses wine a night, denies
tobacco or other drug use. 

### Response:
{'Angioneurotic edema, not elsewhere classified,Hyperpotassemia,Unspecified accident,Unspecified essential hypertension,Home accidents'}
