CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 89 yo F with DM, HTN p/w chest pain and shortness of breath.
Patient is poor historian, so history was obtained from patient
and patient's family.
.
At around 4 p.m. yesterday, the patient had just returned home
from a meal of chinese food when she walked up one flight of
stairs and experienced the acute onset of severe dyspnea. She
went to sleep for a couple of hours and awoke with mild chest
pain. The patient cannot characterize the chest pain further.
The patient's family reports that she also experienced nausea,
coldness, severe fatigue, and difficulty sleeping during the
night. The shortness of breath became worse in the morning,
leading the patient to present to the emergency room. The
patient vomited once in the car.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, abnormal
bleeding myalgias, joint pains, cough, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for baseline dyspnea with 1
flight of stairs. The patient sleeps her side. Denies PND. She
has had swelling in her feet/ankles, but not currently. No
palpitations or syncope.
.
In the ED, initial vitals were HR 124 BP 210/93 RR 38 Sat
97%/NRB. Placed on Bipap, started on nitro gtt at 6 mcg/min and
given lasix 40 mg IV. Given ASA. ECG showed inf lat st dep, STE
AVR and I. Trop elevated to 2.5. TTE showed apical hypokinesis.
Cards evaluated. Plavix 600 mg and heparin given. Breathing
improved and more comfortable. Vitals at time of sign-out were
HR 89, BP 138/80, RR 23, Sat 98% on Bipap 8/5. Just prior to
transfer, the patient was weaned down to 4L nasal canula with O2
sats in the mid 90s.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: glyburide 1.25 mg PO daily
lisinopril 5 mg PO daily
ASA 81 mg PO intermittently
multivitamin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T=97.6 BP=147/75 HR=91 RR=25 O2 sat=93%/4L
GENERAL: WDWN female in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No xanthalesma.
NECK: Supple. No carotid bruits.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Normal respiratory effort. Bibasilar rales.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+

FAMILY HISTORY: Multiple children with CAD. Son died of leukemia.

SOCIAL HISTORY: Has 6 children (one died). Lives with son.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Acute diastolic heart failure,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Atrial fibrillation
Subendo infarct, initial,Acute kidney failure NOS,Ac diastolic hrt failure,Chronic kidney dis NOS,Hyperlipidemia NEC/NOS,Hy kid NOS w cr kid I-IV,DMII wo cmp nt st uncntr,Crnry athrscl natve vssl,Atrial fibrillation
Admission Date:  [**2141-2-9**]              Discharge Date:   [**2141-2-12**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
none


History of Present Illness:
89 yo F with DM, HTN p/w chest pain and shortness of breath.
Patient is poor historian, so history was obtained from patient
and patient's family.
.
At around 4 p.m. yesterday, the patient had just returned home
from a meal of chinese food when she walked up one flight of
stairs and experienced the acute onset of severe dyspnea. She
went to sleep for a couple of hours and awoke with mild chest
pain. The patient cannot characterize the chest pain further.
The patient's family reports that she also experienced nausea,
coldness, severe fatigue, and difficulty sleeping during the
night. The shortness of breath became worse in the morning,
leading the patient to present to the emergency room. The
patient vomited once in the car.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, abnormal
bleeding myalgias, joint pains, cough, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for baseline dyspnea with 1
flight of stairs. The patient sleeps her side. Denies PND. She
has had swelling in her feet/ankles, but not currently. No
palpitations or syncope.
.
In the ED, initial vitals were HR 124 BP 210/93 RR 38 Sat
97%/NRB. Placed on Bipap, started on nitro gtt at 6 mcg/min and
given lasix 40 mg IV. Given ASA. ECG showed inf lat st dep, STE
AVR and I. Trop elevated to 2.5. TTE showed apical hypokinesis.
Cards evaluated. Plavix 600 mg and heparin given. Breathing
improved and more comfortable. Vitals at time of sign-out were
HR 89, BP 138/80, RR 23, Sat 98% on Bipap 8/5. Just prior to
transfer, the patient was weaned down to 4L nasal canula with O2
sats in the mid 90s.

Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

2. CARDIAC HISTORY:
-CABG: n/a
-PERCUTANEOUS CORONARY INTERVENTIONS: n/a
-PACING/ICD: n/a
3. OTHER PAST MEDICAL HISTORY:
-memory loss
-osteoarthritis knees, hands, finger
-microalbuminuria, chronic kidney disease

Social History:
Has 6 children (one died). Lives with son.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none

Family History:
Multiple children with CAD. Son died of leukemia.

Physical Exam:
VS: T=97.6 BP=147/75 HR=91 RR=25 O2 sat=93%/4L
GENERAL: WDWN female in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No xanthalesma.
NECK: Supple. No carotid bruits.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Normal respiratory effort. Bibasilar rales.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+

Pertinent Results:
Admission labs:
[**2141-2-9**] WBC-13.2*# RBC-4.45 Hgb-12.5 Hct-39.6 MCV-89 MCH-28.1
MCHC-31.6 RDW-13.3 Plt Ct-267
[**2141-2-9**] Neuts-72.6* Lymphs-24.0 Monos-2.8 Eos-0.4 Baso-0.1
[**2141-2-9**] PT-11.0 PTT-23.9 INR(PT)-0.9
[**2141-2-9**] Glucose-406* UreaN-41* Creat-1.9* Na-133 K-4.6 Cl-100
HCO3-16* AnGap-22*
[**2141-2-10**] Calcium-9.6 Phos-4.0 Mg-2.0 Cholest-187
[**2141-2-10**] %HbA1c-7.1* eAG-157*
[**2141-2-10**] Triglyc-111 HDL-58 CHOL/HD-3.2 LDLcalc-107
.
Discharge labs:
[**2141-2-12**] 06:35AM BLOOD WBC-8.5 RBC-3.53* Hgb-9.9* Hct-30.3*
MCV-86 MCH-28.1 MCHC-32.6 RDW-13.3 Plt Ct-208
[**2141-2-12**] 06:35AM BLOOD Glucose-140* UreaN-74* Creat-2.2* Na-138
K-4.4 Cl-104 HCO3-23 AnGap-15
[**2141-2-12**] 06:35AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.2
.
Cardiac enzymes:
[**2141-2-10**] 04:55AM CK(CPK)-838* CK-MB-80* MB Indx-9.5*
cTropnT-5.95*
[**2141-2-9**] 09:13PM CK(CPK)-1133* CK-MB-154* MB Indx-13.6*
cTropnT-6.65*
[**2141-2-9**] 03:10PM CK(CPK)-954* CK-MB-150* MB Indx-15.7*
cTropnT-2.56* proBNP-9711*
.
Urine:
[**2141-2-9**] URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2141-2-9**] URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2141-2-9**] URINE RBC-7* WBC-2 Bacteri-FEW Yeast-NONE Epi-<1
TransE-<1
[**2141-2-9**] URINE CastHy-13*
[**2141-2-9**] URINE Hours-RANDOM UreaN-267 Creat-38 Na-98
.
Microbiology:
MRSA screen negative
.
EKG [**2141-2-9**]: Sinus tachycardia. Marked lateral ST segment
depression consistent with an acute ischemic process. No
previous tracing available for comparison.
.
Echocardiogram, transthoracic [**2141-2-10**]: The left atrium is normal
in size. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. There is mild
regional left ventricular systolic dysfunction with septal
hypokinesis. 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 aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. Tricuspid
regurgitation is present but cannot be quantified. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Regional LV systolic dysfunction c/w CAD.
.
CXR (portable AP) [**2141-2-9**]: Mild congestive heart failure.
.
CXR (PA and lateral) [**2141-2-10**]:
1. Improving pulmonary edema.
2. Basilar atelectasis versus pneumonia with right greater than
left pleural effusions.
3. Hilar prominence may represent vascular engorgement, although
attention should be paid to this area on followup.

Brief Hospital Course:
89 yo F with HTN and DM presents with acute shortness of breath
in setting of NSTEMI.
.
# NSTEMI: The patient presented with acute on chronic dyspnea
and lateral ST segment depressions that were suggestive of
ischemia. Her cardiac biomarkers were positive, with CK peaking
at 1133 and troponin peaking at 6.65 on the evening of [**2141-2-9**].
Echocardiogram showed regional wall motion abnormality in
anterior septum. The patient was treated with aspirin, Plavix,
nitroglycerin gtt, heparin gtt, Lipitor, and metoprolol. Cardiac
catheterization was deferred because of patient preference.
Heparin gtt was stopped after 48 hours. The patient was
discharged on aspirin, Plavix, Lipitor, and metoprolol. She was
also given a prescription for nitroglycerin. Lisinopril was
stopped due to acute renal failure. The patient's coronary
artery disease risk factors, which include hypertension,
hyperlipidemia, and diabetes, are discussed below. Primary care
and cardiology follow-up were arranged.
.
# Acute diastolic heart failure/shortness of breath: The patient
presented with shortness of breath, for which she was treated
with nitroglycerin, Lasix, and Bipap. The patient's respiratory
status improved rapidly, and she was able to be weaned off of
Bipap just prior to transfer from the emergency department to
the CCU. Echocardiogram showed septal hypokinesis, likely of
ischemic etiology. EF 45-50%. The patient's acute diastolic
heart failure was thought to be due to chronic hypertension and
acute MI, which was treated as above. The patient was discharged
on metoprolol succinate. No ACE inhibitor was prescribed due to
renal failure. The patient was advised to weigh herself daily
and adhere to a low-sodium diet.
.
# Acute on chronic kidney injury: The patient presented with
creatinine 1.9, increased from baseline 1.3. Creatinine peaked
at 2.4 and was 2.2 at the time of discharge. The acute component
of the patient's renal failure was thought to be pre-renal,
related to acute systolic heart failure. Consistent with this
idea, FeUrea was 33. The chronic component of the patient's
renal failure was thought to be related to her longstanding
diabetes and hypertension. Lisinopril and glyburide were both
discontinued due to the patient's renal failure.
.
# Diabetes mellitis: HbA1c was checked and was 7.1, improved
from 8.8 when last checked in [**2140-11-8**]. The patient was
treated with insulin sliding scale while in the hospital. She
was discharge on glipizide (with her glyburide discontinued due
to impaired kidney function). The patient was warned of the
signs and symptoms of hypertension and how to manage this.
.
# Hypertension: Lisinopril was distinued, and the patient was
started on metoprolol. She will follow up with her primary care
doctor and with cardiology for further management of her
hypertension.

Medications on Admission:
glyburide 1.25 mg PO daily
lisinopril 5 mg PO daily
ASA 81 mg PO intermittently
multivitamin

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Glipizide 5 mg Tablet Sig: one half Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed: Place one tablet under your tongue for
chest pain. [**Month (only) 116**] repeat up to two times at 5 minutes intervals.
Go to the emergency room if you still have pain after 2 tablets.
Disp:*10 tablets* Refills:*1*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2255**] [**Name (NI) 2256**]

Discharge Diagnosis:
Primary:
1. non-ST elevation myocardial infarction
2. Acute diastolic heart failure
.
Secondary:
1. Diabetes
2. Hypertension


Discharge Condition:
Alert and oriented. Hemodynamically stable. Chest-pain free.
Breathing comfortably. Satting well on room air.


Discharge Instructions:
You came to the hospital with difficulty breathing. You were
found to have a heart attack and congestive heart failure. You
were treated with medications, with improvement in your
breathing.
.
You had a decrease in your kidney function which was felt to be
related to your heart failure. You will need to follow up with
Dr. [**Last Name (STitle) **]/[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5749**] for close monitoring of your kidney
function.
.
Due to your decrease in kidney function, it is no longer safe
for you to take glyburide. You have been prescribed a different
medication call glipizide to take instead. Also, due to your
decreased kidney function, your lisinopril had been stopped.
Discuss these medication changes with Dr. [**Last Name (STitle) **]/[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5749**].
.
You should monitor your blood sugar at home. Monitor yourself
for symptoms of dizziness, confusion, or sweatiness, these can
be signs of a low blood sugar. Please call your primary care
phyisican if your blood sugar is <50 or >400.
.
There are some changes to your medications:
-START aspirin 325 mg daily
-START Plavix 75 mg daily
-START metoprolol XL 75 mg daily
-START Lipitor 80 mg daily
-START glipizide 2.5 mg daily
-STOP glyburide
-STOP lisinopril
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. Eat a diet that is low in sodium.
.
You have appointments for cardiology, primary care, and podiatry
follow-up, as indicated below.

Followup Instructions:
Primary Care:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], RN, [**Name8 (MD) 16569**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1579**]
Date/Time:[**2141-2-15**] 1:30
.
Podiatry:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**]
Date/Time:[**2141-2-15**] 3:00
.
Cardiology:
Dr. [**First Name (STitle) 37342**] [**Name (STitle) 37343**]/Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] Phone: [**Telephone/Fax (1) 62**]
Date/time: [**2-27**] at 1:20pm.
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Acute diastolic heart failure,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Atrial fibrillation'}


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: 89 yo F with DM, HTN p/w chest pain and shortness of breath.
Patient is poor historian, so history was obtained from patient
and patient's family.
.
At around 4 p.m. yesterday, the patient had just returned home
from a meal of chinese food when she walked up one flight of
stairs and experienced the acute onset of severe dyspnea. She
went to sleep for a couple of hours and awoke with mild chest
pain. The patient cannot characterize the chest pain further.
The patient's family reports that she also experienced nausea,
coldness, severe fatigue, and difficulty sleeping during the
night. The shortness of breath became worse in the morning,
leading the patient to present to the emergency room. The
patient vomited once in the car.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, abnormal
bleeding myalgias, joint pains, cough, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for baseline dyspnea with 1
flight of stairs. The patient sleeps her side. Denies PND. She
has had swelling in her feet/ankles, but not currently. No
palpitations or syncope.
.
In the ED, initial vitals were HR 124 BP 210/93 RR 38 Sat
97%/NRB. Placed on Bipap, started on nitro gtt at 6 mcg/min and
given lasix 40 mg IV. Given ASA. ECG showed inf lat st dep, STE
AVR and I. Trop elevated to 2.5. TTE showed apical hypokinesis.
Cards evaluated. Plavix 600 mg and heparin given. Breathing
improved and more comfortable. Vitals at time of sign-out were
HR 89, BP 138/80, RR 23, Sat 98% on Bipap 8/5. Just prior to
transfer, the patient was weaned down to 4L nasal canula with O2
sats in the mid 90s.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: glyburide 1.25 mg PO daily
lisinopril 5 mg PO daily
ASA 81 mg PO intermittently
multivitamin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T=97.6 BP=147/75 HR=91 RR=25 O2 sat=93%/4L
GENERAL: WDWN female in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No xanthalesma.
NECK: Supple. No carotid bruits.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Normal respiratory effort. Bibasilar rales.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+

FAMILY HISTORY: Multiple children with CAD. Son died of leukemia.

SOCIAL HISTORY: Has 6 children (one died). Lives with son.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none 

### Response:
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Acute diastolic heart failure,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Atrial fibrillation'}
