CHIEF COMPLAINT: Shortness of Breath

PRESENT ILLNESS: Pt is a 49 yo M with PMH of HTN, ETOH abuse, asthma who
presented to OSH with 1 month history of DOE and palpitations.
Formerly active person but reports recently exercise limited to
SOB. Noted last night unable to walk upstairs due to SOB.
Patient was seen by PCP who noted him to be in rapid a-fib. He
was sent to OSH ED.

MEDICAL HISTORY: HTN
Asthma
OSA on CPAP
ETOH abuse

MEDICATION ON ADMISSION: ASA 81mg daily
Lisinopril 10mg daily
Singulair 10mg daily
Albuterol PRN
Nicorette

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: VS: T= BP=97/78 HR= 104-115 in atrial fibrillation RR= 16 O2
sat= 96 4L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

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

SOCIAL HISTORY: -Tobacco history: Former smoker, quit 20 yrs ago
-ETOH: 6-12 beers 3-4x per week, no history of withdrawal
seizures
-Illicit drugs: No marijuana, cocaine, IVDU (prior history of
amphetamines)
Acute systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Atrial fibrillation,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Other and unspecified alcohol dependence, continuous,Anxiety state, unspecified
Ac systolic hrt failure,Acute kidney failure NOS,Prim cardiomyopathy NEC,Atrial fibrillation,Hypertension NOS,Asthma NOS,Obstructive sleep apnea,Alcoh dep NEC/NOS-contin,Anxiety state NOS
Admission Date:  [**2141-10-26**]              Discharge Date:   [**2141-10-30**]

Date of Birth:  [**2092-6-19**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Shortness of Breath

Major Surgical or Invasive Procedure:
Trans esophageal echocardiogram
Cardioversion


History of Present Illness:
Pt is a 49 yo M with PMH of HTN, ETOH abuse, asthma who
presented to OSH with 1 month history of DOE and palpitations.
Formerly active person but reports recently exercise limited to
SOB. Noted last night unable to walk upstairs due to SOB.
Patient was seen by PCP who noted him to be in rapid a-fib. He
was sent to OSH ED.

At the OSH, initial vitals were T97.4 hR 120-130s BP 120/79 RR
18-20 99% RA. There, patient had CTA that was negative for PE
but did reveal an enlarged heart. He received ceftriaxone and
azithromycin for concern of PNA. Pt was in afib with RVR (HR
120-130s). He received lopressor IV 5mg x 2, Digoxin 0.25mg x 1,
ASA 325mg, 1L NS. Given persistent rapid A fib, he was started
on diltiazem gtt which brought heart rate down to 110's prior to
transfer. His first set of cardiac enzymes was negative. He then
received lasix 40mg IV x 1 for presumed volume overload. Patient
admits to excessive drinking, approximately [**11-30**] drinks per day
with recent increase secondary to job stress.

Taken from admission note


Past Medical History:
HTN
Asthma
OSA on CPAP
ETOH abuse

Social History:
-Tobacco history: Former smoker, quit 20 yrs ago
-ETOH: 6-12 beers 3-4x per week, no history of withdrawal
seizures
-Illicit drugs: No marijuana, cocaine, IVDU (prior history of
amphetamines)

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

Physical Exam:
VS: T= BP=97/78 HR= 104-115 in atrial fibrillation RR= 16 O2
sat= 96 4L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. atrial fibrillation, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at bases
bilaterally ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

Pertinent Results:
[**2141-10-30**] 07:30AM BLOOD WBC-8.5 RBC-4.89 Hgb-16.4 Hct-45.1 MCV-92
MCH-33.6* MCHC-36.5* RDW-13.4 Plt Ct-265
[**2141-10-30**] 07:30AM BLOOD PT-15.2* PTT-97.5* INR(PT)-1.3*
[**2141-10-30**] 07:30AM BLOOD Glucose-95 UreaN-24* Creat-1.1 Na-137
K-4.3 Cl-104 HCO3-23 AnGap-14
[**2141-10-28**] 04:15AM BLOOD ALT-94* AST-73* AlkPhos-46 TotBili-0.3
[**2141-10-30**] 07:30AM BLOOD Calcium-9.5 Phos-4.1 Mg-1.7
[**2141-10-28**] 04:15AM BLOOD calTIBC-296 Ferritn-1298* TRF-228
[**2141-10-26**] 11:46PM BLOOD TSH-1.8
[**2141-10-26**] 11:46PM BLOOD T4-7.0
[**2141-10-27**] 12:32PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2141-10-27**] 12:32PM BLOOD HIV Ab-NEGATIVE
[**2141-10-27**] 12:32PM BLOOD HCV Ab-NEGATIVE

[**10-27**] TEE: No intracardiac thrombus seen. Moderate mitral
regurgitation.

[**10-27**] TTE: Dilated left ventricle with severe global systolic
dysfunction. Mild right ventricular systolic dysfunction.
Moderate secondary mitral regurgitation. Pleural effusion.

[**10-27**] CXR: Borderline cardiomegaly. Bilateral pleural effusions,
left
greater than right. Retrocardiac opacity.


Brief Hospital Course:
49 yo M with PMH of HTN presents with DOE and new onset atrial
fibrillation

# CAD: Pt had a normal ECHO in [**2139**]. EKG showed T wave inversion
and pt ruled out for MI with negative cardiac enzymes.

# PUMP: Per OSH report and confirmed on [**Hospital1 18**] CXR, pt had
cardiomegaly. This was though to be due to either tachycardia
induced cardiomyopathy, idiopathic cardiomyopathy, viral
cardiomyopathy or alcohol induced cardiomyopathy. Other etiology
were ruled out including hemochromatosis (normal Iron and TIBC,
although Ferritin elevated), thyroid disease (normal TSH), HIV
and viral hepatitis. Pt responded well to IV lasix with improved
shortness of breath and oxygen requirement.

# RHYTHM: Atrial fibrillation with RVR. Unclear if dilated
cardiomyopathy was the primary etiology with secondary afib, or
if chronic paroxysmal afib is the cause of the dilation. ECHO
did not reveal any structural abnormalities other than a reduced
ejection fraction, there was no evidence of pulmonary causes and
thyroid disease was ruled out.

Pt was initially rate controlled with a diltiazem drip, later
transitioned to rate control with beta blocker. Pt was initially
anticoagulated with heparin.

After TTE and TEE to rule out thrombus, pt underwent
cardioversion which was only transiently successful before the
rhythm reverted to atrial fibrillation. He was then started on
Amiodarone load and anticoagulation with Coumadin and Lovenox
drip.

# HTN: Pt was titrated up on lisinopril and metoprolol.

# Elevated LFTs: Unclear etiology as pattern is neither
obstructive nor consistent with etoh, viral or ischemia. Pt
denied abdominal/RUQ tenderness. Hepatotoxic meds were avoided
and LFTs remained stably elevated.

# OSA: Pt evaluated by respiratory but did not tolerate CPAP. He
was counseled to follow up evaluation for OSA and CPAP as an
outpt.  He was noted to have confirmed periods of apnea and
desats to 80s on monitor with following episodes of tachypnea
and resolving sats.

# ETOH ABUSE: Pt did not show signs of withdrawl but was
maintained on a CIWA scale and prn Diazepam or Ativan.

# ANXIETY: Pt had multiple episodes of anxiety, intially thought
to be alcohol withdrawl but timeframe not consistent. He was
treated with low dose ativan with good effect.


Medications on Admission:
ASA 81mg daily
Lisinopril 10mg daily
Singulair 10mg daily
Albuterol PRN
Nicorette

Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Warfarin 2 mg Tablet Sig: 3.5 Tablets PO once a day.
Disp:*150 Tablet(s)* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 days: Take until [**2141-11-1**].
Disp:*8 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
Please check INR on [**2141-10-31**] when you see Dr. [**Last Name (STitle) **].
8. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day).
Disp:*4 syringe* Refills:*2*
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start taking on [**2141-11-2**].
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO once a day.
Disp:*180 Tablet Sustained Release 24 hr(s)* Refills:*3*
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*3*


Discharge Disposition:
Home

Discharge Diagnosis:
Dilated Cardiomyopathy
Acute Systolic Congestive Heart Failure: EF 28%
Atrial Fibrillation


Discharge Condition:
stable.
INR 1.3
BUN 24
Creat: 1.1
K 4.3
HIV and Hepatitis neg


Discharge Instructions:
You had trouble breathing before you were admitted and was found
to have a a weak heart. Your ejection fraction (a measure of
heart strength) is 28%. A normal ejection fraction is 55%. This
means that you have been diagnosed with Acute Systolic
Congestive Heart Failure. We started you on Toprol XL to slow
your heart rate and continued you on Lisinopril to decrease the
workload of the heart.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days. Please also call Dr. [**Last Name (STitle) **] if you have
trouble breating, lying flat or notice any swelling.
Adhere to 2 gm sodium diet
.
Please refrain from drinking caffeinated coffee and using
nicorette gum. There can interfere with your medicines.
.
You also have atrial fibrillation, a common heart arrhythmia.
This rhythm, along with the weak heart, puts you at risk for a
stroke. You have been started on a blood thinner, coumadin
(warfarin) to prevent blood clots that can lead to a stroke. The
goal INR (coumadin level) is [**1-15**]. Today your INR is 1.3. Until
your INR is therapeutic, you will need to inject Lovonox, a long
acting blood thinner. You will be seen by Dr. [**Last Name (STitle) **] tomorrow.
He will tell you what dose of coumadin to take from now on.
You have been started on amiodarone for control of the atrial
fibrillation. This medicine can sometimes affect your lungs and
your thyroid. Your thyroid function is normal now, you will need
to check this again in a few months. You will also need pulmonay
function tests soon, this will be set up by Dr. [**Last Name (STitle) **].
.
Please call Dr. [**Last Name (STitle) **] if you have any nosebleeds, dark or
bloody stools, increasing bruising, dizziness, swelling in your
hands or feet, chest pain, trouble breathing at night, or any
other unusual symptoms.

Followup Instructions:
Primary Care:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 3858**] Date/Time: Tuesday
[**10-31**] at 1:15pm.

Cardiology:
[**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: Tuesday
[**11-14**] at 9am



Completed by:[**2141-10-31**]
{'Acute systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Atrial fibrillation,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Other and unspecified alcohol dependence, continuous,Anxiety state, unspecified'}


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: Pt is a 49 yo M with PMH of HTN, ETOH abuse, asthma who
presented to OSH with 1 month history of DOE and palpitations.
Formerly active person but reports recently exercise limited to
SOB. Noted last night unable to walk upstairs due to SOB.
Patient was seen by PCP who noted him to be in rapid a-fib. He
was sent to OSH ED.

MEDICAL HISTORY: HTN
Asthma
OSA on CPAP
ETOH abuse

MEDICATION ON ADMISSION: ASA 81mg daily
Lisinopril 10mg daily
Singulair 10mg daily
Albuterol PRN
Nicorette

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: VS: T= BP=97/78 HR= 104-115 in atrial fibrillation RR= 16 O2
sat= 96 4L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

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

SOCIAL HISTORY: -Tobacco history: Former smoker, quit 20 yrs ago
-ETOH: 6-12 beers 3-4x per week, no history of withdrawal
seizures
-Illicit drugs: No marijuana, cocaine, IVDU (prior history of
amphetamines) 

### Response:
{'Acute systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Atrial fibrillation,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Other and unspecified alcohol dependence, continuous,Anxiety state, unspecified'}
