CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: Ms. [**Known lastname **] is a 69 year old female with history of DM2, HTN,
hypercholesterolemia, who is transfered from [**Hospital **] Hospital
after a CTA demonstrated a large pulmonary embolus.  The patient
presented to [**Hospital1 **] on the morning of transfer complaining of
progressive shortness of breath over the last 1.5 weeks.  She
flew here from [**Country 6257**] about 3.5 weeks ago, however it wasn't
until about 1.5 weeks ago that she noted increased shortness of
breath with minor activity, accompanied by a substernal feeling
of tightness without radiation.  Per her son, she has been
relatively immobile as a general rule, and did complain of
increased LLE calf pain over the same time frame.  She denies
any dyspnea at rest, orthopnea, chest pain, or hemoptysis.  No
lightheadedness or syncope.  A CTA at the OSH demonstrated
extensive pulmonary embolus with thrombus in the R main
pulmonary artery and arteries to RUL, RLL, LUL, LLL.  She was
placed on a heparin drip and transfered to [**Hospital1 18**] ED for further
management.
.
On arrival to the ED her vitals were 97.6, HR 65, BP 145/75, RR
20, 93% on 5L.  An EKG showed NSR at 66 bpm, TWI in III, AVF,
V2-V6, as well as a Q in III.  An ABG on 5L via NC was
7.42/35/59.
.

MEDICAL HISTORY: DM2
HTN
Hypercholesterolemia

MEDICATION ON ADMISSION: Metoprolol XL 200 PO QAM
Telmisartan 80/12.5 QAM
Lipanor 100 mg QHS
Allopurinol 150 mg QDay
Metformin Q day

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: HR 63, 150/88, 20, 94% on 2L via NC.
Gen:  Obese portugese female lying in a stretcher with HOB at 30
degrees, appearing comfortable.
HEENT:  Anicteric, JVP difficult to evaluate.
Cor: RR, normal rate, 2/6 systolic murmur heard across the
precordium.
Lungs:  Rales at L base.
Abd: NABS, soft, NT/ND.
Extr:  Trace bilateral lower extremity edema, firmness of L calf
relative to R.
Neuro:  Alert, responds to questions from her son.

FAMILY HISTORY: No family hx of clots.  Her father had an MI at 65.  No family
history of cancer.

SOCIAL HISTORY: Denies etoh, drug, or cigarette use.
Other pulmonary embolism and infarction,Mitral valve insufficiency and aortic valve stenosis,Acidosis,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Gout, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Pulm embol/infarct NEC,Mitral insuf/aort stenos,Acidosis,Long-term use anticoagul,Hypertension NOS,Gout NOS,DMII wo cmp nt st uncntr
Admission Date:  [**2160-9-17**]              Discharge Date:   [**2160-9-24**]

Date of Birth:  [**2091-3-6**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath


Major Surgical or Invasive Procedure:
None

History of Present Illness:
Ms. [**Known lastname **] is a 69 year old female with history of DM2, HTN,
hypercholesterolemia, who is transfered from [**Hospital **] Hospital
after a CTA demonstrated a large pulmonary embolus.  The patient
presented to [**Hospital1 **] on the morning of transfer complaining of
progressive shortness of breath over the last 1.5 weeks.  She
flew here from [**Country 6257**] about 3.5 weeks ago, however it wasn't
until about 1.5 weeks ago that she noted increased shortness of
breath with minor activity, accompanied by a substernal feeling
of tightness without radiation.  Per her son, she has been
relatively immobile as a general rule, and did complain of
increased LLE calf pain over the same time frame.  She denies
any dyspnea at rest, orthopnea, chest pain, or hemoptysis.  No
lightheadedness or syncope.  A CTA at the OSH demonstrated
extensive pulmonary embolus with thrombus in the R main
pulmonary artery and arteries to RUL, RLL, LUL, LLL.  She was
placed on a heparin drip and transfered to [**Hospital1 18**] ED for further
management.
.
On arrival to the ED her vitals were 97.6, HR 65, BP 145/75, RR
20, 93% on 5L.  An EKG showed NSR at 66 bpm, TWI in III, AVF,
V2-V6, as well as a Q in III.  An ABG on 5L via NC was
7.42/35/59.
.


Past Medical History:
DM2
HTN
Hypercholesterolemia

Social History:
Denies etoh, drug, or cigarette use.

Family History:
No family hx of clots.  Her father had an MI at 65.  No family
history of cancer.


Physical Exam:
HR 63, 150/88, 20, 94% on 2L via NC.
Gen:  Obese portugese female lying in a stretcher with HOB at 30
degrees, appearing comfortable.
HEENT:  Anicteric, JVP difficult to evaluate.
Cor: RR, normal rate, 2/6 systolic murmur heard across the
precordium.
Lungs:  Rales at L base.
Abd: NABS, soft, NT/ND.
Extr:  Trace bilateral lower extremity edema, firmness of L calf
relative to R.
Neuro:  Alert, responds to questions from her son.


Brief Hospital Course:
69 year old female with HTN, DM2, presenting with new large PE
and evidence of RH strain on EKG, though hemodynamically stable,
being admitted to MICU for respiratory monitoring and
consideration of thrombolysis.
.
1) PE:  Precipitating factor likely immobility.  She was
admitted to the MICU because of evidence of RH strain on EKG,
although she was hemodynamically stable.  An echocardiagram was
performed showing that the left atrium is moderately dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). Right ventricular chamber
size appears normal (limited assessment, poor subcostal views).
Right ventricular systolic function appears normal. There is
abnormal septal motion/septal bounce. The aortic valve leaflets
are moderately thickened. There is moderate aortic valve
stenosis. Mild to moderate ([**12-30**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
left ventricular inflow pattern suggests impaired relaxation.
There is moderate pulmonary artery systolic hypertension. The
main pulmonary artery is dilated. There is no pericardial
effusion.  No thrombolytics were required and her A-a gradient
was at 90. She was transferred to the floors stable, and was
continued on heparin weight based protocol, after
anticoagulation she was started on coumadin and her INR was
followed for therapeutic range on discharge it was 2.7.  She was
weaned off oxygen eventually with oxygen saturation at 97% on
room air, with good saturation while ambulating.

.
2) HTN:  Patient was hypertensive on admission, but currently
antihypertensives were held off given possibility of hemodynamic
worsening. Her pressures normalized to the 130s/70s without
antihypertensives.  Her outpatient lopressor and [**Last Name (un) **] were
restarted on discharge.

3) DM:  Her metformin given condition predisposing to lactic
acidosis, and possibility of further contrast loads.  Her sugars
were well controlled with an insulin sliding scale. She was
restarted on metformin on discharge

4) Hypercholesterolemia:  She was continued on her outpatient
lipitor
.
5) PPx:  On heparin.  No need for protonix, tolerating POs
.
6) Communication:  Son, [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 62690**], Work ([**Telephone/Fax (1) 62691**].
.
7) Code:  Presumed full, will discuss further.
.
8) Access:  PIVs.  No need for central access currently.
.
9) Disp: Discharged home with physical therapy. For coumadin
therapy for 6 months, a follow up was arranged to manage her
anticoagulation.
.

Medications on Admission:
Metoprolol XL 200 PO QAM
Telmisartan 80/12.5 QAM
Lipanor 100 mg QHS
Allopurinol 150 mg QDay
Metformin Q day


Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 6 months.
Disp:*30 Tablet(s)* Refills:*1*
4. Telmisartan-Hydrochlorothiazid 80-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Metformin 750 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Lopressor 100 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
VNA of Greater [**Location (un) 5871**]/[**Location (un) 6159**]

Discharge Diagnosis:
Pulmonary Embolism
Diabetes
Hypertension


Discharge Condition:
Good, Stable, Afebrile


Discharge Instructions:
You were admitted for shortness of breath and found to have a
pulmonary embolism. You were started on heparin for
anticoagulation and converted to coumadin.  You should follow up
with your PCP for further management of your coumadin.  You
should stay on coumadin for 6 months.

Please take your medications as directed.

Please call your PCP or go to the Emergency room if you develop
shortness of breath, chest pain, fevers or chills

Below is information regarding coumadin (warfarin)

What is warfarin?
Warfarin is an anticoagulant. Anti means against, and coagulant
refers to blood clotting. Warfarin counteracts the effect of
vitamin K and helps prevent harmful blood clots. Blood clots can
cause harm by preventing blood flow. Coumadin is a brand name
for warfarin.

Why is it taken?
Some common reasons for needing anticoagulation are:
&#[**Numeric Identifier 62692**]; atrial fibrillation
&#[**Numeric Identifier 62692**]; heart attack
&#[**Numeric Identifier 62692**]; heart valve replacement
&#[**Numeric Identifier 62692**]; pulmonary embolism ( blood clot in the lung)
&#[**Numeric Identifier 62692**]; stroke
&#[**Numeric Identifier 62692**]; deep vein thrombosis (blood clot in the upper or lower
leg or arm)
&#[**Numeric Identifier 62692**]; after certain surgeries

How do I take it?
Warfarin is taken in pill form. For warfarin to work properly,
it must be taken exactly as prescribed. In addition, follow
these important instructions when taking your warfarin:

&#[**Numeric Identifier 62692**]; Try to take it about the same time every day.
&#[**Numeric Identifier 62692**]; Taking too much or too little warfarin can be harmful.
Find a system so you make sure you take the right dose each day
and do not forget your dose. Some people find using a
pill-keeper or dosing calendar makes it easier to make sure the
right dose is taken every day.
&#[**Numeric Identifier 62692**]; If you forget a dose of warfarin, take the dose as soon
as possible on the same day.
&#[**Numeric Identifier 62692**]; If you miss a dose completely, do not take the missed
dose the next day to ??????catch up.?????? Instead, contact your provider
for instructions.

Why do I need blood tests?
Everyone who is on warfarin must have an important blood test
done on a regular basis. The blood test frequency will depend on
many factors. If your situation is stable, the blood test is
usually done every 4 weeks. This test is called a prothrombin
time, or PT, and the result is called and ??????international
normalized ratio?????? or INR. This test shows how fast your blood is
clotting and tells the provider whether your warfarin dose needs
adjustment.

Your provider will want your INR to fall within a certain range.
This ??????goal range?????? is different for everyone. Ask your provider
what your goal range is. Your provider will adjust your dose of
warfarin from time to time in order to keep your INR in the goal
range. Make sure you take the right dose of warfarin on the
right day, and that you get all your blood tests as scheduled.

What should I be watching for?
Sometimes, taking warfarin can cause problems that your provider
needs to know about. Please watch for the following:
&#[**Numeric Identifier 62692**]; Bleeding When you are anticoagulated, your blood takes
longer to form a clot. This means you are at an increased risk
for bleeding. Contact your provider right away or go to an
emergency room if you experience signs or symptoms of bleeding.
Some examples of bleeding could be:
&#[**Numeric Identifier 62693**]; headache, dizziness, or weakness
&#[**Numeric Identifier 62693**]; bleeding from a cut that does not stop
&#[**Numeric Identifier 62693**]; nosebleeds
&#[**Numeric Identifier 62693**]; bleeding from gums when brushing your teeth (if this is
a new symptom)
&#[**Numeric Identifier 62693**]; bruising for unknown reasons
&#[**Numeric Identifier 62693**]; pain, discomfort, or swelling in any area, especially
after an injury
&#[**Numeric Identifier 62693**]; dark brown or red urine
&#[**Numeric Identifier 62693**]; throwing up blood, or throwing up material that looks
like ??????coffee grounds??????
&#[**Numeric Identifier 62693**]; blood in the bowel movements, or very dark bowel
movements
&#[**Numeric Identifier 62693**]; more bleeding than usual with your menstrual cycle or
unexpected vaginal bleeding
&#[**Numeric Identifier 62692**]; Circulation problems If the warfarin is not working as
it should, you could develop a blood clot (thrombosis). Contact
your provider right away, or go to an emergency room, if you
have any signs of circulation problems. Watch for the following
problems:
&#[**Numeric Identifier 62693**]; [**Name2 (NI) **]is or a blood clot. Signs might include
swelling, pain or redness in the arm or leg; shortness of
breath; irregular heart beat; numbness or tingling, especially
on one side of your body; changes in your speech, vision or
level of alertness.
&#[**Numeric Identifier 62693**]; Purple Toe Syndrome, which causes purple discoloration
of your fingers or toes, or sudden leg or foot pain. This is a
rare complication caused by interruption of blood flow.
&#[**Numeric Identifier 62693**]; Necrosis characterized by blackening of the skin which
indicates a death of tissue due to lack of circulation. This is
a serious, but rare side effect in people who have an inherited
blood clotting disorder.

&#[**Numeric Identifier 62692**]; Allergic reaction In some cases, warfarin causes an
allergic reaction. If you have any of the following signs of an
allergic reaction, stop taking warfarin and go to the nearest
emergency room:
&#[**Numeric Identifier 62693**]; difficulty breathing
&#[**Numeric Identifier 62693**]; swelling of your throat, tongue or face
&#[**Numeric Identifier 62693**]; hives or a rash

What else do I need to know?
&#[**Numeric Identifier 62692**]; Diet - [**Male First Name (un) **]??????t make major changes in your daily eating
habits without checking with your doctor. Also, [**Male First Name (un) **]??????t eat large
portions at once of a food that has a lot of Vitamin K. The
Vitamin K can interact with the warfarin and prevent it from
working the way it should. It??????s OK to continue to eat Vitamin
K-[**Doctor First Name **] foods; just make sure the portions are not large. Have
the Vitamin K-[**Doctor First Name **] foods in consistent portions from week to
week. Examples of Vitamin K-[**Doctor First Name **] foods are:
&#[**Numeric Identifier 62693**]; broccoli	&#[**Numeric Identifier 62693**]; soybean
&#[**Numeric Identifier 62693**]; canola oil	&#[**Numeric Identifier 62693**]; kale
&#[**Numeric Identifier 62693**]; turnip greens	&#[**Numeric Identifier 62693**]; beef liver
&#[**Numeric Identifier 62693**]; spinach	&#[**Numeric Identifier 62693**]; green tea
&#[**Numeric Identifier 62693**]; Swiss chard	&#[**Numeric Identifier 62693**]; [**Location (un) 2831**] sprouts

&#[**Numeric Identifier 62692**]; Medicine interactions -  Warfarin interacts with many
different types of medicines. This includes medicine your doctor
prescribes and products you buy over the counter, including
vitamins, herbs, and supplements. It may also interfere with
foods that have been enriched with vitamins or herbs. Some
medicines may put you at risk for forming a blood clot, others
may cause you to bleed.

In particular, you must not take aspirin or anti-inflammatory
medicines such as ibuprofen, Motrin, Advil, Nuprin, or Aleve
unless your doctor says it is OK. These medicines and others
like them can increase the risk of bleeding. Many
over-the-counter medicines contain these ingredients. An example
is Alka Seltzer, which contains aspirin. Make sure any medicine
you take, including medicines with multiple ingredients, do not
contain these substances.

Most doctors recommend that [**Name5 (PTitle) **] (Tylenol) be taken for
short periods if needed to manage pain or fever.  Like any drug,
it too may affect your therapy. Let your provider know if you
will be taking [**Name5 (PTitle) **] or any other new medicine.

Talk with your provider before starting, stopping or changing
doses of any medicine, vitamin, herb, or supplement. If your
provider approves the change, you may need an adjustment in your
warfarin dose or your schedule for blood tests.

Talk with your pharmacist when having prescriptions filled or
refilled.  Tell your pharmacist that you are taking warfarin and
ask if any new medications will interact with warfarin.

&#[**Numeric Identifier 62692**]; Illness - Changes in your health may influence your
response to anticoagulation. You may need your blood tests
checked more frequently during times of illness. You may need
your medication dose changed. Contact your provider if you
experience:
&#[**Numeric Identifier 62693**]; nausea, vomiting, diarrhea
&#[**Numeric Identifier 62693**]; fever
&#[**Numeric Identifier 62693**]; infection
&#[**Numeric Identifier 62693**]; decreased appetite or change in diet
&#[**Numeric Identifier 62693**]; any other change in health

Alcohol - Alcohol should be avoided while taking warfarin.
Alcohol changes the way your body processes warfarin and puts
you at increased risk for bleeding or clotting.

Exercise  - Regular exercise can be beneficial to your health.
However, while taking warfarin, it is important to avoid contact
sports or activities that may result in a fall or serious
injury. Contact your provider before you start or change your
activity.

Travel -  Tell your provider when you will be traveling. You may
need a PT/INR prior to or during your trip. Be sure to keep your
routine and diet consistent while you are away form home.  Make
sure to take enough warfarin with you.

Alerts -  Always carry a card in your wallet or purse with your
anticoagulation information. Notify anyone who provides care to
you that you are anticoagulated (doctor, nurse, dentist,
chiropractor, physical therapist, pharmacist). You may want to
consider wearing a medical alert bracelet or necklace while you
are taking warfarin.

The goal of anticoagulation therapy is to decrease your body??????s
ability to form harmful blood clots while keeping you safe from
the risk of bleeding. Treatment of each patient taking warfarin
is a highly individualized. Please ask your provider for more
information about a detailed plan that is right for you.


Followup Instructions:
PCP [**Last Name (NamePattern4) **] [**2160-9-26**] for management of coumadin.
{'Other pulmonary embolism and infarction,Mitral valve insufficiency and aortic valve stenosis,Acidosis,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Gout, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: Ms. [**Known lastname **] is a 69 year old female with history of DM2, HTN,
hypercholesterolemia, who is transfered from [**Hospital **] Hospital
after a CTA demonstrated a large pulmonary embolus.  The patient
presented to [**Hospital1 **] on the morning of transfer complaining of
progressive shortness of breath over the last 1.5 weeks.  She
flew here from [**Country 6257**] about 3.5 weeks ago, however it wasn't
until about 1.5 weeks ago that she noted increased shortness of
breath with minor activity, accompanied by a substernal feeling
of tightness without radiation.  Per her son, she has been
relatively immobile as a general rule, and did complain of
increased LLE calf pain over the same time frame.  She denies
any dyspnea at rest, orthopnea, chest pain, or hemoptysis.  No
lightheadedness or syncope.  A CTA at the OSH demonstrated
extensive pulmonary embolus with thrombus in the R main
pulmonary artery and arteries to RUL, RLL, LUL, LLL.  She was
placed on a heparin drip and transfered to [**Hospital1 18**] ED for further
management.
.
On arrival to the ED her vitals were 97.6, HR 65, BP 145/75, RR
20, 93% on 5L.  An EKG showed NSR at 66 bpm, TWI in III, AVF,
V2-V6, as well as a Q in III.  An ABG on 5L via NC was
7.42/35/59.
.

MEDICAL HISTORY: DM2
HTN
Hypercholesterolemia

MEDICATION ON ADMISSION: Metoprolol XL 200 PO QAM
Telmisartan 80/12.5 QAM
Lipanor 100 mg QHS
Allopurinol 150 mg QDay
Metformin Q day

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: HR 63, 150/88, 20, 94% on 2L via NC.
Gen:  Obese portugese female lying in a stretcher with HOB at 30
degrees, appearing comfortable.
HEENT:  Anicteric, JVP difficult to evaluate.
Cor: RR, normal rate, 2/6 systolic murmur heard across the
precordium.
Lungs:  Rales at L base.
Abd: NABS, soft, NT/ND.
Extr:  Trace bilateral lower extremity edema, firmness of L calf
relative to R.
Neuro:  Alert, responds to questions from her son.

FAMILY HISTORY: No family hx of clots.  Her father had an MI at 65.  No family
history of cancer.

SOCIAL HISTORY: Denies etoh, drug, or cigarette use. 

### Response:
{'Other pulmonary embolism and infarction,Mitral valve insufficiency and aortic valve stenosis,Acidosis,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Gout, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
