CHIEF COMPLAINT: SOB, dizziness, weakness

PRESENT ILLNESS: Briefly, Mr. [**Known lastname 32126**] is a 64 y/o M with CAD, MI [**2-26**] to cocaine
use, DM, ESRD on HD, polysubstance abuse, and cirrhosis who
presented to the ED with severe electrolyte abnormalities in the
setting of missing HD x 3 weeks.

MEDICAL HISTORY: Diabetes- neuropathy, microalbuinuria
Alcohol abuse
Cocaine abuse- drug free since [**2194-1-25**]
Anemia
Back pain- central and right paracentral disc herniation
compressing the thecal sac with moderate central canal stenosis
and compression right L4.
CKD- on dialysis
CAD
Hyperlipidemia
Hypertension

MEDICATION ON ADMISSION: The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Valsartan 320 mg PO DAILY
2. Labetalol 400 mg PO BID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
GEN: NAD, awake, alert
VS: T 99.7 BP 162/101 HR 110 RR 18 Sat 96% RA
NECK: no JVD
CV: RRR, no murmurs, no rub.
PULM: crackles at b/l bases
ABD: soft, distended, mildly tender to palpation
EXT: WWP, no edema BLE

FAMILY HISTORY: One brother with MI at age 54, multiple siblings with DMII.
Father died of lung CA in his 60's.
Diabetes in his mother, brother, and sisters along with
hypertension. No history of renal disease.

SOCIAL HISTORY: Per psych) recent homelessness leading to living at the [**Hospital1 **]
homeless shelter, multiple chronic medical problems, living away
from his wife and kids, and unemployment. The patient has a
remote history of cocaine dependence and alcohol dependence
which he refused to elaborate on. The patient was born and
raised in [**State 5111**] by both of his parents. He has 5 brothers,
4 sisters, and 2 children with his wife. Currently, his wife and
children reside in [**Name (NI) 29530**]. Mr. [**Known lastname 32126**] states that he is
religious and that god was the main reason that "I am still here
today". He completed the 9th grade and would not reveal any
other information about his social history.
Hyperpotassemia,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atrial flutter,Acute venous embolism and thrombosis of superficial veins of upper extremity,Acute kidney failure, unspecified,Unspecified disease of pericardium,Other ascites,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Noncompliance with renal dialysis,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Personal history of tobacco use,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, in remission,Other specified disorders resulting from impaired renal function,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Disorders of phosphorus metabolism,Lack of housing
Hyperpotassemia,End stage renal disease,Hyp kid NOS w cr kid V,Atrial flutter,Ac embl suprfcl up ext,Acute kidney failure NOS,Pericardial disease NOS,Ascites NEC,DMII renl nt st uncntrld,Noncmplnt w renal dialys,Crnry athrscl natve vssl,Old myocardial infarct,History of tobacco use,Alcohol cirrhosis liver,Alcoh dep NEC/NOS-remiss,Impair ren funct dis NEC,Hyperlipidemia NEC/NOS,Depressive disorder NEC,Dis phosphorus metabol,Lack of housing
Admission Date:  [**2201-11-10**]              Discharge Date:   [**2201-11-14**]

Date of Birth:  [**2137-7-10**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
SOB, dizziness, weakness

Major Surgical or Invasive Procedure:
Large volume paracentesis
Hemodialysis


History of Present Illness:
Briefly, Mr. [**Known lastname 32126**] is a 64 y/o M with CAD, MI [**2-26**] to cocaine
use, DM, ESRD on HD, polysubstance abuse, and cirrhosis who
presented to the ED with severe electrolyte abnormalities in the
setting of missing HD x 3 weeks.

The patient presented to the ED where he c/o SOB, dizziness,
weakness. Had hyperkalemia to 7.4, hyponatremia to 126, BUN 203
and Cr 23.8. Went into wide complex tach and went to ICU where
he was emergently dialyzed. Patient also found to have aflutter
in the MICU and seen by cards who are planning for ablation.
Cardiology and EP was consulted and planned for ablation on
Friday. On labetalol and nifedipine for rate control.  TTE
pending.  Myo/pericarditis MB 15

Friday should go for early dialysis and then ablation. ?SBP in
ED but no overt signs of infection, abdominal exam benign.

Past Medical History:
Diabetes- neuropathy, microalbuinuria
Alcohol abuse
Cocaine abuse- drug free since [**2194-1-25**]
Anemia
Back pain- central and right paracentral disc herniation
compressing the thecal sac with moderate central canal stenosis
and compression right L4.
CKD- on dialysis
CAD
Hyperlipidemia
Hypertension


Social History:
Per psych) recent homelessness leading to living at the [**Hospital1 **]
homeless shelter, multiple chronic medical problems, living away
from his wife and kids, and unemployment. The patient has a
remote history of cocaine dependence and alcohol dependence
which he refused to elaborate on. The patient was born and
raised in [**State 5111**] by both of his parents. He has 5 brothers,
4 sisters, and 2 children with his wife. Currently, his wife and
children reside in [**Name (NI) 29530**]. Mr. [**Known lastname 32126**] states that he is
religious and that god was the main reason that "I am still here
today". He completed the 9th grade and would not reveal any
other information about his social history.


Family History:
One brother with MI at age 54, multiple siblings with DMII.
Father died of lung CA in his 60's.
Diabetes in his mother, brother, and sisters along with
hypertension. No history of renal disease.


Physical Exam:
ADMISSION EXAM:
GEN: NAD, awake, alert
VS: T 99.7 BP 162/101 HR 110 RR 18 Sat 96% RA
NECK: no JVD
CV: RRR, no murmurs, no rub.
PULM: crackles at b/l bases
ABD: soft, distended, mildly tender to palpation
EXT: WWP, no edema BLE

DISCHARGE EXAM:
98.3  143/85  95-112  18  97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, Regular rate, normal S1 + S2, II/VI SEM, rubs,
gallops
Lungs: Bilateral inspiratory rhonchi improved, no wheezes,
rales.
Abdomen: soft, minimally tender to deep palpation, distended,
BS+, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

Pertinent Results:
ADMISSION LABS:

[**2201-11-10**] 12:40PM   WBC-8.8 RBC-3.65* HGB-11.2* HCT-33.9* MCV-93
MCH-30.6 MCHC-32.9 RDW-14.8
[**2201-11-10**] 12:40PM   NEUTS-87.7* LYMPHS-7.1* MONOS-4.3 EOS-0.8
BASOS-0.2
[**2201-11-10**] 12:40PM   PLT COUNT-316
[**2201-11-10**] 12:40PM   CK-MB-20* MB INDX-6.3* proBNP-GREATER TH
[**2201-11-10**] 12:40PM   cTropnT-0.59*

WBC RBC Polys Lymphs Monos Eos Mesothe Macroph Other
[**2201-11-13**] 16:44    186* 36* 10* 3* 0   13* 74*

BLOOD CX X 2 FROM [**2201-11-11**]: NGTD

IMAGING:
EKG [**2201-11-12**]:
Atrial flutter with 3:1 and 4:1 conduction with a single, likely
aberrantly  conducted beat versus a ventricular premature beat.
Borderline low limb lead QRS amplitude. There are likely diffuse
repolarization abnormalities which are distorted and accentuated
by the underlying flutter waves. Compared to the previous
tracing of [**2201-11-10**], computed frontal plane axis is no longer
rightward. Criteria for left ventricular hypertrophy are no
longer fulfilled. T wave inversions in the left precordial leads
are unchanged, accounting for differences in electrode
placement. An ongoing lateral ischemic process cannot be
excluded. Clinical correlation is suggested. Presence of
inferior
flutter waves makes excluding inferior ischemia difficult.

ECHO (TTE) [**2201-11-11**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 0-5 mmHg.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is akinesi and
thinning of the basal inferior septum. The remaining segments
contract normally. Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is mildly
dilated with borderline normal free wall function. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. The main pulmonary artery is dilated.
There is a trivial/physiologic pericardial effusion.

Compared with the prior study (images reviewed) of [**2201-6-18**],
pulmonary pressures are higher. Other findings are similar.
There is no significant pericardial effusion.

DISCHARGE LABS:

[**2201-11-14**] 08:45AM BLOOD WBC-8.2 RBC-2.80* Hgb-8.6* Hct-25.9*
MCV-92 MCH-30.5 MCHC-33.1 RDW-14.4 Plt Ct-250
[**2201-11-14**] 08:45AM BLOOD Plt Ct-250
[**2201-11-14**] 08:45AM BLOOD Glucose-142* UreaN-38* Creat-5.7*# Na-137
K-3.9 Cl-100 HCO3-25 AnGap-16
[**2201-11-13**] 01:20PM BLOOD PT-12.1 PTT-35.4 INR(PT)-1.1
[**2201-11-14**] 08:45AM BLOOD Calcium-8.5 Phos-2.7# Mg-1.9

Brief Hospital Course:
Mr. [**Known lastname 32126**] is a 64 year old man with a history of CAD, MI
secondary to cocaine use, HTN, hyperlipidemia, DM, ESRD,
polysubstance abuse, and cirrhosis who presented to the ED with
progressive weakness, dyspnea, and dizziness in the setting of
not going to hemodialysis for the past 3 weeks.

#Electrolyte abnormalities: On admission, patient with metabolic
acidosis with anion gap of 40 in setting of missing dialysis for
past 2-3 weeks. Labs notable for hyponatremia (126),
hyperkalemia (7.4), BUN of 203, and Cr 23.8. He did have ECG
notable for widening QRS on interval studies. He was given 3
amps of calcium gluconate, insulin/dextrose and ECG normalized.
He was emergently dialyzed with normalization of electrolytes.
He was restarted on his home sevelamer and calcium acetate.  He
continued to undergo HD daily and his electrolytes slowly
improved prior to d/c.  He will resume HD at [**Hospital1 **] on his
normal dialysis schedule upon discharge.

#Atrial Flutter: Following first dialysis session, pt was found
to be in a-flutter with a HR of 150. He was rate contolled on
labetalol. Cardiology consult saw patient and believed he would
benefit from ablation. However, because the patient admitted
that he may not be able to adhere to AC.  If can show compliance
by coming to cardiology f/u as outpatient, then Ablation and AC
will be considered.  His rate control was switched to metoprolol
and nifedipine as the patient was hypotensive with the
combination of labetalol and nifedipine on the regular floor.

#Pericarditis: Pt promotes CP and SOB prior to admission but
states it has resolved. Per cardiology consult, he had a
pericardial rub in ED and ECG was consistent with pericarditis
with ST-segment elevations in V2-V4 and diffuse pr depressions.
Given patients elevated BUN of 206, most likely uremic
pericarditis. Vital not concerning for tamponade or constrictive
physiology. His uremia resolved with dialysis and he did not
require NSAIDS for pain. A TTE showed trivial pericardial
effusion.

# Anemia - Patient had HCT drop overnight from 32.8 -->24.5.  No
signs of active bleeding on exam today, abdominal exam unchanged
from prior. Patient endorses abdominal pain in setting of being
hungry but no continued pain after eating.  Anemia likely [**2-26**] to
poor nutritional status and and chronic kidney disease with poor
epo production.  [**Month (only) 116**] also be [**2-26**] bone marrow suppression if
patient is continuing to consume alcohol although he denies it.
He received iron IV and epoietin infusion during dialysis.  His
HCTs were trended and continued to be stable.

#CAD: Pt notes some chest pain and SOB in days prior to
admission but pt not complaining of any CP on arrival. Pt does
have elevated troponin on admission but believed to be secondary
to renal failure. ST elevations in leads V2-5 thought to be
secondary to pericarditis. PR depressions and rub on PE
coorbarated this diagnosis. He was started on home ASA,
valsartan, nifedipine, labatalol. Serial ECGs showed a-flutter
with resolution of ST elevations. Cardiac enzymes downtrended
from admission. A TTE showed moderately dilated LA/RA, moderate
symmetric LVH with EF >55%.  There is akinesis and thinning of
the basal inferior septum. Mildly dilated RV with borderline
normal free wall function. Trivial MR, Moderate AR, moderate
pulmonary artery systolic hypertension with dilation of main
pulmonary artery, and trivial/physiologic pericardial effusion

#Cirrhosis: Pt has cirrhosis most likely [**2-26**] EtOH. Last
theraputic paracentesis in 6/[**2201**]. RUQ US in [**5-/2201**] notable of
cirrhosis with no potal vein abnormality. Physical exam
consistent was consistent with ascities this admission. No fever
or elevated WBC to indicate SBP.  He underwent therapeutic
thoracentesis of 5L with no evidence of SBP on peritoneal fluid
analysis.

#DM: On admission to MICU, held home NPH and started on humolog
sliding scale.

#Social Work: Pt has missed several HD sessions in the past and
was seen by social work. SW receives return call from  [**Doctor First Name **], SW
on [**Hospital1 **] dialysis unit.  [**Doctor First Name 717**] explains that it  would be
very difficult to change pt. to another shift since that could
only happen if he traded slots with another pt.   Pt. has a
history of non-compliance with dialysis, both at [**Hospital1 **] and at
prior facility, Da Vita.  [**Doctor First Name **] is reluctant to work out a trade
with another pt. as this will be an inconvenience for this other
pt. and may be done in vain if pt. continues to be
non-compliant.

SW receives return call from D&G Towing ([**Telephone/Fax (1) 37137**]).  They
agree to waive some of pt's car's storage fees.  They request
that pt. come to retrieve his car at discharge which is
anticipated for tomorrow.

-SW FAX'es a letter to towing company confirming pt's presence
in
hospital.


Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Valsartan 320 mg PO DAILY
2. Labetalol 400 mg PO BID


Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Calcium Acetate 1334 mg PO TID W/MEALS
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 50 mg 3 tablet(s) by mouth
daily Disp #*90 Tablet Refills:*0
6. Lorazepam 0.5 mg PO HS:PRN Insomnia
7. NIFEdipine CR 90 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL PRN Chest Pain
9. Omeprazole 40 mg PO DAILY
10. Oxycodone-Acetaminophen (5mg-325mg) [**1-26**] TAB PO Q6H:PRN Pain
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. NPH 15 Units Breakfast
13. Nephrocaps 1 CAP PO DAILY


Discharge Disposition:
Home

Discharge Diagnosis:
Electrolyte abnormalities
ESRD on Dialysis
Atrial Flutter
Cirrhosis


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:
It was a pleasure taking care of you at [**Hospital1 18**]!

You were admitted due to electrolyte abnormalities that happened
because of missing your dialysis. You were in the intensive care
unit for a number of days being treated for an abnormal heart
rhythym. You improved and were transferred to the general
medicine floor to continue dialysis. You also had fluid in your
abdomen drained.

MEDICATION CHANGES:
- Please STOP Valsartan. You can discuss re-starting this with
your primary care doctor if your blood pressure improves.
- Please STOP Labetolol and replace it with Metoprolol

You continue to have an abnormal heart rhythym called atrial
flutter. We do not believe this is dangerous right now but you
need to follow-up with doctors as [**Name5 (PTitle) **] outpatient.

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

Your car is in a lot:
DNG Towing
[**Male First Name (un) 37138**]
[**Location (un) 577**] [**Numeric Identifier **]
([**Telephone/Fax (1) 37139**]

Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: THURSDAY [**2201-11-19**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site

Department: LIVER CENTER
When: TUESDAY [**2201-12-1**] at 1:20 PM
With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: CARDIAC SERVICES
When: THURSDAY [**2201-12-3**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37140**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Hyperpotassemia,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atrial flutter,Acute venous embolism and thrombosis of superficial veins of upper extremity,Acute kidney failure, unspecified,Unspecified disease of pericardium,Other ascites,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Noncompliance with renal dialysis,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Personal history of tobacco use,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, in remission,Other specified disorders resulting from impaired renal function,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Disorders of phosphorus metabolism,Lack of housing'}


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: SOB, dizziness, weakness

PRESENT ILLNESS: Briefly, Mr. [**Known lastname 32126**] is a 64 y/o M with CAD, MI [**2-26**] to cocaine
use, DM, ESRD on HD, polysubstance abuse, and cirrhosis who
presented to the ED with severe electrolyte abnormalities in the
setting of missing HD x 3 weeks.

MEDICAL HISTORY: Diabetes- neuropathy, microalbuinuria
Alcohol abuse
Cocaine abuse- drug free since [**2194-1-25**]
Anemia
Back pain- central and right paracentral disc herniation
compressing the thecal sac with moderate central canal stenosis
and compression right L4.
CKD- on dialysis
CAD
Hyperlipidemia
Hypertension

MEDICATION ON ADMISSION: The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Valsartan 320 mg PO DAILY
2. Labetalol 400 mg PO BID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
GEN: NAD, awake, alert
VS: T 99.7 BP 162/101 HR 110 RR 18 Sat 96% RA
NECK: no JVD
CV: RRR, no murmurs, no rub.
PULM: crackles at b/l bases
ABD: soft, distended, mildly tender to palpation
EXT: WWP, no edema BLE

FAMILY HISTORY: One brother with MI at age 54, multiple siblings with DMII.
Father died of lung CA in his 60's.
Diabetes in his mother, brother, and sisters along with
hypertension. No history of renal disease.

SOCIAL HISTORY: Per psych) recent homelessness leading to living at the [**Hospital1 **]
homeless shelter, multiple chronic medical problems, living away
from his wife and kids, and unemployment. The patient has a
remote history of cocaine dependence and alcohol dependence
which he refused to elaborate on. The patient was born and
raised in [**State 5111**] by both of his parents. He has 5 brothers,
4 sisters, and 2 children with his wife. Currently, his wife and
children reside in [**Name (NI) 29530**]. Mr. [**Known lastname 32126**] states that he is
religious and that god was the main reason that "I am still here
today". He completed the 9th grade and would not reveal any
other information about his social history. 

### Response:
{'Hyperpotassemia,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atrial flutter,Acute venous embolism and thrombosis of superficial veins of upper extremity,Acute kidney failure, unspecified,Unspecified disease of pericardium,Other ascites,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Noncompliance with renal dialysis,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Personal history of tobacco use,Alcoholic cirrhosis of liver,Other and unspecified alcohol dependence, in remission,Other specified disorders resulting from impaired renal function,Other and unspecified hyperlipidemia,Depressive disorder, not elsewhere classified,Disorders of phosphorus metabolism,Lack of housing'}
