CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: The patient is a 36F with a past medical history of mental
retardation with Angelmann syndrome, Antiphospholipid antibody
syndrome, CAD s/p STEMI, systolic heart failure with EF of 20%
who presents from her group home with shortness of breath. Per
health aide for the past month has been having progressively
worsening dyspnea, noted to be grunting, leaning forward when
walks and in bed, tachypnea. Has been eating mostly pizza all
week but today refusing to eat. Had episode of non-bilious
vomitting x1. ROS unable to obtain but denies recent fever. Sent
to PCP (has seen several times in past month), who referred to
ED. Unclear how many pillows sleeps on. Believes that weight
stable. No recent change in meds, compliant with meds.
.
In the ED, initial vs were: T98.5 101 103/61 30 100. BNP of 2800
(up from 1000 in [**2148**]), supratherapeutic INR of 8.0. CXR showed
bilateral pleural effusions. EKG unchanged, initial troponin
negative. She was given lasix 40IV and ativan 2mg x2. Trying to
obtain CT head but unable to lie flat [**3-11**] orthopnea. Maintaining
sats, tachynpic and looked tired so put on CPAP. Vitals on
transfer: 106  101/61 22 100% on CPAP 40%
.
On the floor, patient's caregiver reports that looks much better
with less grunting and more comfortable.

MEDICAL HISTORY: 1. Mental retardation with Angelmann syndrome.
2. Systolic heart failure with ejection fracture of 20 to 25%.
3. Status post MI with 100% LAD occlusion in [**2147-3-10**].
4. Antiphospholipid antibody syndrome.
5. History of seizure disorder.
6. G-tube in place for medication administration.
7. H/o Recurrent UTIs.

MEDICATION ON ADMISSION: - warfarin 8mg and 10mg alternating QHS
- aspirin 325mg daily
- colase 100mg daily
- metoprolol 25mg daily and 12.5mg QHS
- omeprazole 20mg daily
- lasix 20mg daily
- lisinopril 2.5mg daily
- MVI
- klonopin 1mg [**Hospital1 **]
- senna [**Hospital1 **]
- tegretol 350mg [**Hospital1 **]
- Lipitor 80mg QHS
- Milk of magnesia
- tylenol PRN
- advil PRN

ALLERGIES: Cefepime

PHYSICAL EXAM: Vitals: 99.7  109/52  103  22 99%2L
General: Caucasian female in NAD, pleasant, childish affect
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JPV difficult to assess [**3-11**] body habitus, supple
Lungs:  tachypnic to mid-twenties, no accessory muscle use,
faint bibasilar rales bibasilarly, poor air movement, no whezes
CV: S1, S2 regular rhythm, borderline fast rate, I/VI systolic
murmur
Abdomen: soft, NTND, no guarding, G-tube in place C/D/I
GU: foley to gravity
Ext: warm, trace LE edema, no clubbing
Neuro: not oriented, fluent speach, CNII-XII intact, MAE
antigravity

FAMILY HISTORY: NC

SOCIAL HISTORY: She lives in [**Location 686**], Bay Cove Group Home.
She does not smoke. Father lives in [**Location (un) 74962**] and visits her
Acute on chronic systolic heart failure,Other specified congenital anomalies,Other and unspecified coagulation defects,Unspecified intellectual disabilities,Other and unspecified nonspecific immunological findings,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Epilepsy, unspecified, without mention of intractable epilepsy,Gastrostomy status,Anemia of other chronic disease
Ac on chr syst hrt fail,Specfied cong anomal NEC,Coagulat defect NEC/NOS,Intellect disability NOS,Oth unspcf nspf imun fnd,Crnry athrscl natve vssl,Old myocardial infarct,Epilep NOS w/o intr epil,Gastrostomy status,Anemia-other chronic dis
Admission Date:  [**2149-9-2**]              Discharge Date:   [**2149-9-5**]

Date of Birth:  [**2112-10-29**]             Sex:   F

Service: MEDICINE

Allergies:
Cefepime

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a 36F with a past medical history of mental
retardation with Angelmann syndrome, Antiphospholipid antibody
syndrome, CAD s/p STEMI, systolic heart failure with EF of 20%
who presents from her group home with shortness of breath. Per
health aide for the past month has been having progressively
worsening dyspnea, noted to be grunting, leaning forward when
walks and in bed, tachypnea. Has been eating mostly pizza all
week but today refusing to eat. Had episode of non-bilious
vomitting x1. ROS unable to obtain but denies recent fever. Sent
to PCP (has seen several times in past month), who referred to
ED. Unclear how many pillows sleeps on. Believes that weight
stable. No recent change in meds, compliant with meds.
.
In the ED, initial vs were: T98.5 101 103/61 30 100. BNP of 2800
(up from 1000 in [**2148**]), supratherapeutic INR of 8.0. CXR showed
bilateral pleural effusions. EKG unchanged, initial troponin
negative. She was given lasix 40IV and ativan 2mg x2. Trying to
obtain CT head but unable to lie flat [**3-11**] orthopnea. Maintaining
sats, tachynpic and looked tired so put on CPAP. Vitals on
transfer: 106  101/61 22 100% on CPAP 40%
.
On the floor, patient's caregiver reports that looks much better
with less grunting and more comfortable.


Past Medical History:
1. Mental retardation with Angelmann syndrome.
2. Systolic heart failure with ejection fracture of 20 to 25%.
3. Status post MI with 100% LAD occlusion in [**2147-3-10**].
4. Antiphospholipid antibody syndrome.
5. History of seizure disorder.
6. G-tube in place for medication administration.
7. H/o Recurrent UTIs.


Social History:
She lives in [**Location 686**], Bay Cove Group Home.
She does not smoke. Father lives in [**Location (un) 74962**] and visits her

infrequently.


Family History:
NC

Physical Exam:
Vitals: 99.7  109/52  103  22 99%2L
General: Caucasian female in NAD, pleasant, childish affect
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JPV difficult to assess [**3-11**] body habitus, supple
Lungs:  tachypnic to mid-twenties, no accessory muscle use,
faint bibasilar rales bibasilarly, poor air movement, no whezes
CV: S1, S2 regular rhythm, borderline fast rate, I/VI systolic
murmur
Abdomen: soft, NTND, no guarding, G-tube in place C/D/I
GU: foley to gravity
Ext: warm, trace LE edema, no clubbing
Neuro: not oriented, fluent speach, CNII-XII intact, MAE
antigravity


Pertinent Results:
Labs on Admission:
[**2149-9-2**] 11:18AM BLOOD WBC-6.0 RBC-3.28* Hgb-8.5* Hct-26.1*
MCV-79* MCH-25.8* MCHC-32.5 RDW-18.2* Plt Ct-508*
[**2149-9-2**] 11:18AM BLOOD Glucose-87 UreaN-9 Creat-0.7 Na-136 K-3.9
Cl-99 HCO3-27 AnGap-14
[**2149-9-2**] 11:18AM BLOOD ALT-14 AST-29 CK(CPK)-62 AlkPhos-112*
TotBili-0.5
[**2149-9-2**] 11:28AM BLOOD Lactate-1.3
[**2149-9-3**] 03:19AM BLOOD calTIBC-169* VitB12-449 Ferritn-163*
TRF-130*

Labs on Discharge:
[**2149-9-5**] 06:10AM BLOOD WBC-3.9* RBC-3.37* Hgb-8.7* Hct-27.0*
MCV-80* MCH-25.7* MCHC-32.1 RDW-17.4* Plt Ct-475*
[**2149-9-5**] 06:10AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-139 K-3.9
Cl-100 HCO3-33* AnGap-10
[**2149-9-5**] 06:10AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.1

Imaging:
CXR ([**8-29**]): IMPRESSION: Findings compatible with severe
congestive heart failure,
bilateral pleural effusions also present.

KUB ([**8-29**]): IMPRESSION: Nonspecific bowel gas pattern, with no
evidence of obstruction or
ileus.

ECHO ([**9-4**]): The estimated right atrial pressure is 0-10mmHg.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is severe regional
left ventricular systolic dysfunction with thinning and akinesis
of the anterior, anteroseptal and apical segments. The remaining
segments contract normally (LVEF = 20%). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. Mild to
moderate ([**2-8**]+) mitral regurgitation is seen. There is no
pericardial effusion.

IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w remote proximal LAD infarction. Mild to
moderate mitral regurgitation.

Compared with the prior study (images reviewed) of [**2149-7-25**],
pulmonary hypertension is not seen (likely secondary to
technically-suboptimal images). The other findings are similar.


Brief Hospital Course:
36yo F with a past medical history of mental retardation with
Angelmann syndrome, Antiphospholipid antibody syndrome, CAD s/p
STEMI, systolic heart failure with EF of 20% who presents from
her group home with shortness of breath most likely due to
decompensated heart failure.

#Shortness of breath: Patient has a history of CHF with an EF
20%. Upon presentation, she demonstated evidence of fluid
retention on exam, elevated BNP, and effusions c/w severe CHF on
CXR. Precipitant for CHF exacerbation remains unclear, but there
was a report from group home that patient had consumed excessive
pizza in days PTA. No evidence of ischemia, as there were no
changes on EKG and no bump in troponins. No evidence of
infection, as all cultures were negative. The patient improved
clinically over the course of her hospital stay with IV lasix.
An ECHO from [**9-4**] showed severe regional left ventricular
systolic dysfunction, c/w remote proximal LAD infarction and
mild to moderate mitral regurgitation.
.
#Anemia: Likely [**3-11**] AOCD, given low iron, elevated ferritin and
decreated TIBC. HCT remained stable at 27-29. Baseline appears
to range from 25-30 based on past admission data. No evidence
acute blood loss.
.
#Supratherapeutic INR: The patient presented with an INR of 8.0.
She was given 2mg of vitamin k in the ICU. Her coumadin was
held, and the INR trended down to 1.3. After discussions with
hematology, it was decided that she would be bridged with
lovenox given her history of antiphospholipid syndrome. The goal
is INR [**3-12**]. The reason for the supratherapeutic INR at
presentation is unclear, as she is given the prescribed dose of
coumadin by the staff at her group home. She will need to be
monitored as an outpatient.
.
#Antiphospholipid Syndrome: The patient was supratherapeutic at
presentation. When her INR dropped to 1.3, she was bridged with
lovenox to reach goal of [**3-12**].
.
#Hx of Seizures: No evidence of any current seizure activity.
Carbamazepine level was 5.8 during admission.
.

Medications on Admission:
- warfarin 8mg and 10mg alternating QHS
- aspirin 325mg daily
- colase 100mg daily
- metoprolol 25mg daily and 12.5mg QHS
- omeprazole 20mg daily
- lasix 20mg daily
- lisinopril 2.5mg daily
- MVI
- klonopin 1mg [**Hospital1 **]
- senna [**Hospital1 **]
- tegretol 350mg [**Hospital1 **]
- Lipitor 80mg QHS
- Milk of magnesia
- tylenol PRN
- advil PRN

Discharge Medications:
1. Lovenox 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous
twice a day: Continue until therapeutic INR [**3-12**]. Bridging with
coumadin. .
Disp:*10 syringe* Refills:*2*
2. Warfarin 2 mg Tablet Sig: Four (4) Tablet PO EVERY OTHER DAY
(Every Other Day).
3. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY
(Every Other Day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO once
a day.
7. Metoprolol Tartrate 25 mg Tablet Sig: [**2-8**] Tablet PO at
bedtime.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Carbamazepine 200 mg/10 mL Suspension Sig: Three Hundred
Fifty (350) mg PO BID (2 times a day).
14. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Outpatient Lab Work
Please check INR and fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 4647**]


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Pulmonary edema


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted to the hospital with shortness of breath. You
were found to have fluid on your lungs which responded to
diuretic medicine and non-invasive ventilation. Your INR (or
coumadin level) was found to be high, so you were given some
medicine to reverse this level and it went too low. For this
reason you are being discharged on lovenox to thin the blood
while your coumadin level becomes therapeutic.
.
The only change to your medication regimen was the addition of
lovenox, which you will need while you await a therapeutic
coumadin level.
.
You are being discharged back to your group home.

Followup Instructions:
Please follow up with your primary care provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in the next 1-2 weeks. You can call [**Telephone/Fax (1) 608**] for an
appointment.

Department: CARDIAC SERVICES
When: MONDAY [**2150-7-13**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
{'Acute on chronic systolic heart failure,Other specified congenital anomalies,Other and unspecified coagulation defects,Unspecified intellectual disabilities,Other and unspecified nonspecific immunological findings,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Epilepsy, unspecified, without mention of intractable epilepsy,Gastrostomy status,Anemia of other chronic 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: shortness of breath

PRESENT ILLNESS: The patient is a 36F with a past medical history of mental
retardation with Angelmann syndrome, Antiphospholipid antibody
syndrome, CAD s/p STEMI, systolic heart failure with EF of 20%
who presents from her group home with shortness of breath. Per
health aide for the past month has been having progressively
worsening dyspnea, noted to be grunting, leaning forward when
walks and in bed, tachypnea. Has been eating mostly pizza all
week but today refusing to eat. Had episode of non-bilious
vomitting x1. ROS unable to obtain but denies recent fever. Sent
to PCP (has seen several times in past month), who referred to
ED. Unclear how many pillows sleeps on. Believes that weight
stable. No recent change in meds, compliant with meds.
.
In the ED, initial vs were: T98.5 101 103/61 30 100. BNP of 2800
(up from 1000 in [**2148**]), supratherapeutic INR of 8.0. CXR showed
bilateral pleural effusions. EKG unchanged, initial troponin
negative. She was given lasix 40IV and ativan 2mg x2. Trying to
obtain CT head but unable to lie flat [**3-11**] orthopnea. Maintaining
sats, tachynpic and looked tired so put on CPAP. Vitals on
transfer: 106  101/61 22 100% on CPAP 40%
.
On the floor, patient's caregiver reports that looks much better
with less grunting and more comfortable.

MEDICAL HISTORY: 1. Mental retardation with Angelmann syndrome.
2. Systolic heart failure with ejection fracture of 20 to 25%.
3. Status post MI with 100% LAD occlusion in [**2147-3-10**].
4. Antiphospholipid antibody syndrome.
5. History of seizure disorder.
6. G-tube in place for medication administration.
7. H/o Recurrent UTIs.

MEDICATION ON ADMISSION: - warfarin 8mg and 10mg alternating QHS
- aspirin 325mg daily
- colase 100mg daily
- metoprolol 25mg daily and 12.5mg QHS
- omeprazole 20mg daily
- lasix 20mg daily
- lisinopril 2.5mg daily
- MVI
- klonopin 1mg [**Hospital1 **]
- senna [**Hospital1 **]
- tegretol 350mg [**Hospital1 **]
- Lipitor 80mg QHS
- Milk of magnesia
- tylenol PRN
- advil PRN

ALLERGIES: Cefepime

PHYSICAL EXAM: Vitals: 99.7  109/52  103  22 99%2L
General: Caucasian female in NAD, pleasant, childish affect
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JPV difficult to assess [**3-11**] body habitus, supple
Lungs:  tachypnic to mid-twenties, no accessory muscle use,
faint bibasilar rales bibasilarly, poor air movement, no whezes
CV: S1, S2 regular rhythm, borderline fast rate, I/VI systolic
murmur
Abdomen: soft, NTND, no guarding, G-tube in place C/D/I
GU: foley to gravity
Ext: warm, trace LE edema, no clubbing
Neuro: not oriented, fluent speach, CNII-XII intact, MAE
antigravity

FAMILY HISTORY: NC

SOCIAL HISTORY: She lives in [**Location 686**], Bay Cove Group Home.
She does not smoke. Father lives in [**Location (un) 74962**] and visits her 

### Response:
{'Acute on chronic systolic heart failure,Other specified congenital anomalies,Other and unspecified coagulation defects,Unspecified intellectual disabilities,Other and unspecified nonspecific immunological findings,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Epilepsy, unspecified, without mention of intractable epilepsy,Gastrostomy status,Anemia of other chronic disease'}
