CHIEF COMPLAINT: Shortness of breath, cough

PRESENT ILLNESS: 73 yo F with h/o poorly-controlled HTN, ESRD, and DM p/w SOB x1
day, started 1 day after regular HD session. SOB associated with
cough, white sputum for about a week. Pt attributes this to a
cold, although denies rhinorrhea, nasal congestion, sore throat.
+ sick contacts at dialysis center. Notes increased abdominal
girth for several days. Loose BM 3 days ago, passing flatus. +
subjective fever, low grade temp to 100.0 this morning. Slight
bleeding from fistula.
.
ED course: CXR with pulmonary edema, ? pneumonia - given ctx,
azithro. Recieved HD in preparation for CTA which was negative
for PE, + for pulmonary edema.
.
ROS: + low grade fever, no n/v/abd pain, + loose stools several
days ago, make urine, no dysuria or urinary frequency. +20 pound
weight loss over last 6 months

MEDICAL HISTORY: ) Type 2 diabetes mellitus: Started insulin in [**2157**].
2) Hypertension: Poorly controlled with many admissions to
MICU/CCU for hypertensive urgency.
3) Renal artery stenosis: Last MRA [**1-6**] revealed 3 left renal
arteries, superior with question of stenosis and middle with
stenosis.
4) Hypercholesterolemia
5) ESRD on HD M/W/F. Followed by Dr. [**First Name (STitle) **]
6) Diastolic CHF
7) Osteoarthritis
8) Depression
9) Anxiety
10) Sickle cell trait
11) Hiatal hernia
12) Gastroesophageal reflux disease
13) Chronic constipation
14) History of mechanical falls.
15) Chronic anemia: Presumed secondary to renal failure.
16) Status post hysterectomy in [**2132**].

MEDICATION ON ADMISSION: Labetalol 300 mg PO TID
Lisinopril 40 mg PO QD
Nifedipine 180 mg QD
Hydralazine 50 mg PO BID
Clonidine 0.3 mg PO BID
Isosorbide Mononitrate 90 mg Sustained Release PO DAILY
Atorvastatin 10 mg PO DAILY
Pantoprazole 40 mg PO once a day.
Ferrous Sulfate 325 PO DAILY
Clonazepam 1 mg PO BID
Folic acid 1 mg daily
Insulin Lantus 45 units QAM, 15 units Qpm
glyburide 2 mg [**Hospital1 **]
MVI 1 tablet daily
B12 50 mcg po daily
Tylenol prn arthritis
Sevelemer 400 mg TID
ASA 325 mg daily
Rhinocort Acqua

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98.8, BP 163/76, HR 110-120, RR 16, O2 sat 98% on RA
GEN: A&O x 3, pleasant, thin F sitting up in bed in NAD. No
accessory muscle use, talking in full sentences.
HEENT: EOMI, OP clear with MMM.
Neck: JVD to jaw
CV: irregular, tachycardic, nl S1/S2, II/VI SEM at LUSB
LUNGS: crackles at bases bilaterally, good air entry
ABD: soft, moderately distended, palpable hepatomegaly, 10cm
below costal margin, NT, +BS
EXT: tr pitting edema b/l, warm. L AVF with palpable thrill.

FAMILY HISTORY: Mother alive at 89, with DM2, HTN. Father died of Alzheimer's
Disease. Brother with hypertension.

SOCIAL HISTORY: Lives at home with her husband. Moved to the US in [**2124**].
Originally from Barbados, but lived in [**Location **] for 20 years as
well. She used to work as a medic in the PACU at [**Hospital1 18**], then
later as a recreational assistant at another facility. Denies
any alcohol use, no history of smoking, no IVDU. Has mother who
is sick in a hospital in Barbados.
Atrial fibrillation,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Hemorrhage complicating a procedure,Diaphragmatic hernia without mention of obstruction or gangrene,Anemia in chronic kidney disease,Esophageal reflux,Dysthymic disorder,Pure hypercholesterolemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Constipation, unspecified,Epistaxis,Long-term (current) use of insulin
Atrial fibrillation,Chr diastolic hrt fail,Hyp kid NOS w cr kid V,DMII wo cmp uncntrld,Hemorrhage complic proc,Diaphragmatic hernia,Anemia in chr kidney dis,Esophageal reflux,Dysthymic disorder,Pure hypercholesterolem,Osteoarthros NOS-unspec,Constipation NOS,Epistaxis,Long-term use of insulin
Admission Date:  [**2159-4-4**]              Discharge Date:   [**2159-4-11**]

Date of Birth:  [**2085-6-27**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 19193**]
Chief Complaint:
Shortness of breath, cough

Major Surgical or Invasive Procedure:
Transesophageal echo

History of Present Illness:
73 yo F with h/o poorly-controlled HTN, ESRD, and DM p/w SOB x1
day, started 1 day after regular HD session. SOB associated with
cough, white sputum for about a week. Pt attributes this to a
cold, although denies rhinorrhea, nasal congestion, sore throat.
+ sick contacts at dialysis center. Notes increased abdominal
girth for several days. Loose BM 3 days ago, passing flatus. +
subjective fever, low grade temp to 100.0 this morning. Slight
bleeding from fistula.
.
ED course: CXR with pulmonary edema, ? pneumonia - given ctx,
azithro. Recieved HD in preparation for CTA which was negative
for PE, + for pulmonary edema.
.
ROS: + low grade fever, no n/v/abd pain, + loose stools several
days ago, make urine, no dysuria or urinary frequency. +20 pound
weight loss over last 6 months

Past Medical History:
) Type 2 diabetes mellitus: Started insulin in [**2157**].
2) Hypertension: Poorly controlled with many admissions to
MICU/CCU for hypertensive urgency.
3) Renal artery stenosis: Last MRA [**1-6**] revealed 3 left renal
arteries, superior with question of stenosis and middle with
stenosis.
4) Hypercholesterolemia
5) ESRD on HD M/W/F. Followed by Dr. [**First Name (STitle) **]
6) Diastolic CHF
7) Osteoarthritis
8) Depression
9) Anxiety
10) Sickle cell trait
11) Hiatal hernia
12) Gastroesophageal reflux disease
13) Chronic constipation
14) History of mechanical falls.
15) Chronic anemia: Presumed secondary to renal failure.
16) Status post hysterectomy in [**2132**].


Social History:
Lives at home with her husband. Moved to the US in [**2124**].
Originally from Barbados, but lived in [**Location **] for 20 years as
well. She used to work as a medic in the PACU at [**Hospital1 18**], then
later as a recreational assistant at another facility. Denies
any alcohol use, no history of smoking, no IVDU. Has mother who
is sick in a hospital in Barbados.

Family History:
Mother alive at 89, with DM2, HTN. Father died of Alzheimer's
Disease. Brother with hypertension.

Physical Exam:
Vitals: T 98.8, BP 163/76, HR 110-120, RR 16, O2 sat 98% on RA
GEN: A&O x 3, pleasant, thin F sitting up in bed in NAD. No
accessory muscle use, talking in full sentences.
HEENT: EOMI, OP clear with MMM.
Neck: JVD to jaw
CV: irregular, tachycardic, nl S1/S2, II/VI SEM at LUSB
LUNGS: crackles at bases bilaterally, good air entry
ABD: soft, moderately distended, palpable hepatomegaly, 10cm
below costal margin, NT, +BS
EXT: tr pitting edema b/l, warm. L AVF with palpable thrill.


Pertinent Results:
[**2159-4-4**] 06:15PM   HCT-28.8*
[**2159-4-4**] 01:30PM ASCITES  TOT PROT-4.5 GLUCOSE-211 CREAT-4.2
LD(LDH)-119 AMYLASE-41 ALBUMIN-2.7
[**2159-4-4**] 01:30PM ASCITES  WBC-261* RBC-[**Numeric Identifier 22475**]* POLYS-1*
LYMPHS-32* MONOS-54* MESOTHELI-3* MACROPHAG-10*
[**2159-4-4**] 06:35AM   GLUCOSE-154* UREA N-33* CREAT-4.2* SODIUM-135
POTASSIUM-3.6 CHLORIDE-90* TOTAL CO2-33* ANION GAP-16
[**2159-4-4**] 06:35AM   ALT(SGPT)-22 AST(SGOT)-30 LD(LDH)-215
CK(CPK)-55 ALK PHOS-123* AMYLASE-112* TOT BILI-0.5
[**2159-4-4**] 06:35AM   LIPASE-141*
[**2159-4-4**] 06:35AM   CK-MB-NotDone cTropnT-0.15*
[**2159-4-4**] 06:35AM   TOT PROT-7.9 ALBUMIN-4.3 GLOBULIN-3.6
CALCIUM-9.7 PHOSPHATE-3.5 MAGNESIUM-2.1 IRON-67
[**2159-4-4**] 06:35AM   calTIBC-231* FERRITIN-GREATER TH TRF-178*
[**2159-4-4**] 06:35AM   WBC-10.3 RBC-4.41 HGB-10.4* HCT-33.0* MCV-75*
MCH-23.6* MCHC-31.5 RDW-21.8*
[**2159-4-4**] 06:35AM   PLT COUNT-201
[**2159-4-4**] 06:35AM   PT-17.1* PTT-30.4 INR(PT)-1.6*
[**2159-4-4**] 02:20AM   CK(CPK)-57
[**2159-4-4**] 02:20AM   CK-MB-NotDone cTropnT-0.14*
[**2159-4-3**] 04:15PM   LACTATE-1.9
[**2159-4-3**] 04:00PM   GLUCOSE-282* UREA N-29* CREAT-3.8* SODIUM-139
POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-33* ANION GAP-17
[**2159-4-3**] 04:00PM   estGFR-Using this
[**2159-4-3**] 04:00PM   CK(CPK)-56
[**2159-4-3**] 04:00PM   cTropnT-0.13*
[**2159-4-3**] 04:00PM   CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2159-4-3**] 04:00PM   CALCIUM-10.0 PHOSPHATE-3.6 MAGNESIUM-1.9
[**2159-4-3**] 04:00PM   WBC-9.0 RBC-4.32 HGB-10.5* HCT-32.5* MCV-75*
MCH-24.2* MCHC-32.2 RDW-21.8*
[**2159-4-3**] 04:00PM   NEUTS-76.4* LYMPHS-14.2* MONOS-7.9 EOS-0.9
BASOS-0.6
[**2159-4-3**] 04:00PM   HYPOCHROM-1+ ANISOCYT-2+ MICROCYT-3+
[**2159-4-3**] 04:00PM   PLT COUNT-219 LPLT-1+
[**2159-4-3**] 04:00PM   D-DIMER-1224*
.
Imaging:
.
[**4-3**] CXR: CHF, no PNA
.
[**4-3**] ABD XR: MPRESSION: Dilated loops of small bowel with
multiple "step-ladder" fluid levels, and paucity of large bowel
gas, highly concerning for small bowel obstruction; adynamic
ileus is less likely.
.
[**4-3**] CT Chest, ABD, Pelvis: IMPRESSION:
1) No pulmonary embolism or evidence of bowel obstruction.
2) Moderate amount of ascites.
3) Cardiomegaly with evidence of mild congestive heart failure
and passive hepatic congestion. Small right pleural effusion.
4) Coronary artery calcification.
5) Mild enlargement of the pulmonary arteries, suggestive of
pulmonary arterial hypertension.
6) At least one small cystic lesion in the head of the pancreas,
which appears likely to connect to the main pancreatic duct but
is not well evaluated on CT; this could be followed up in 6
months.
7) Adrenal lesions not well characterized on this study appear
consistent with adenomas on prior studies.
.
[**4-4**] RUQ U/S:
1. Liver Doppler findings consistent with right heart
failure/triscuspid regurgitation. Patent hepatic vasculature.
2. Hepatomegaly. No evidence of splenomegaly.
3. Limited evaluation of the gallbladder which may contain
stones.
.
[**4-4**] ECHO:
Conclusions:
Moderate to severe spontaneous echo contrast is seen in the body
of the left atrium. No mass/thrombus is seen in the left atrium
or left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular ejection
fraction appears somewhat reduced. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are mildly thickened. No masses or vegetations are seen
on the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. No mass or vegetation is
seen on the mitral valve. Mild (1+) mitral regurgitation is
seen.
IMPRESSION: No left atrial or left atrial appendage clot, but
severe left atrial appendage spontaneous echo contrast
.
[**4-7**] CXR
IMPRESSION: Improvement in the congestive heart failure seen on
the prior examination.
.
Other Data:
.
HBcAb negative ([**1-6**])
HCV Ab negative ([**1-6**])
HEPATITIS BE ANTIBODY NON-REACTIVE ([**1-6**])
.
Ascitic Fluid [**2159-4-4**]
Cultures pending
WBC RBC Polys Lymphs Monos Mesothe Macroph
261* [**Numeric Identifier 22475**]* 1* 32* 54* 3* 10*
TotPro Glucose Creat LD(LDH) Amylase Albumin
4.5 211 4.2 119 41 2.7
.
SAAG greater than 1.1
Ascitic fluid total protein is 4.5 (greater than 2.5) indicating
a cardiac etiology for the ascites.


Brief Hospital Course:
This is a 73 yo F with DM II, HTN, ESRD on HD, who presented
with shortness of breath, found to have new onset atrial
fibrillation, cardiac ascites, course complicated by persistent
bleeding in the setting of attempted [**Numeric Identifier **] in
preparation for cardioversion, requiring transfer to the MICU.
.
On the floor patient underwent an abdominal CT scan which showed
moderate ascites as well as hepatomegaly. She also underwent
abdominal ultrasound as well as paracentesis with 800cc of fluid
removed, and ultimately it was thought that her ascites was c/w
cardiac ascites. Hepatology was consulted and agreed. Hepatitis
serologies have been negative.
.
She also had new onset atrial fibrillation, and patient was
started on a heparin gtt with the plan for TEE and subsequent
cardioversion. However, after TEE was performed, she had not yet
been dialyzed and it was thought that cardioversion would not be
successful in the setting of volume overload. Cardioversion was
postponed, and course was then complicated by continuous oozing
and bleeding, both from her nares as well as paracentesis site.
Topical thrombin was applied to paracentesis site which
eventually stabilized bleeding. The patient also had a
significant amount of epistaxis, which was eventually tamponaded
by ENT with packing and afrin. Paracentesis site again started
to ooze, and it was difficult to control bleeding on the floor.
Her hematocrit trended downwards over this course from 28 -->
23. She had been scheduled to receive blood transfusion with
dialysis, but HD would not accept her because she was bleeding.
Because nursing was not comfortable administering dDAVP on the
floor, the patient was transferred to the MICU. She received 1
unit of pRBCs prior to transfer to the unit.
.
Trauma surgery was consulted for persistent bleed, and it was
determined that she should no longer continue on a heparin gtt.
Heparin had not been supratherapeutic during this time, however,
she had been bleeding almost persistently despite this. She was
transfused one more unit of pRBCs with an appropriate
stabilization of her hematocrit.
.
# Bleeding: Initially patient was started on a heparin gtt and
Coumadin, was on ASA 325mg. In addition, she is a dialysis
patient and has platelet dysfunction at baseline. Heparin gtt
has been discontinued as well as Coumadin, and ASA was reduced
to 81mg given bleeding. Paracentesis site bleeding was initially
tamponaded and controlled with topical thrombin, but in the
setting of being on heparin gtt, bleeding has persisted,
requiring compression for >30minutes and dDAVP to control
bleeding. Epistaxis required ENT consult with nasal packing to
control. The patient received 2 u of pRBC with an appropriate
increase in her HCT and vital signs stable.
.
# Atrial fibrillation: No prior hx of AFib, prior EKG
interpreted as ? wandering atrial pacemaker. Pt is at risk for
developing AF in setting of stretched R atrium and ECG is
consistent with that. Unable to perform cardioversion as unable
to anticoagulate.  Moderate to severe contrast echo seen in
atrium, representing likely very poor flow state, high risk for
thrombus formation. There are also complex (>4mm) atheroma in
the descending thoracic aorta.  However, unable to anticoagulate
given high risk of bleeding.  The patient will be treated with
aspirin 325mg po daily now that HCT is stable.  For rate control
she is on metoprolol XL and verapamil SR.  She had an episode of
tachycardia to the 140s during dialysis, likely due to the fact
that she was due for rate controlling medications.  She has
outpatient follow up appointment with cardiology.
.
# Ascites: Patient is s/p paracentesis, ascitic fluid consistent
with portal hypertension from cardiac etiology. Abdominal
ultrasound also c/w liver enlargement from RHF, normal flow on
dopplers. Fluid cytology negative for malignancy. Appreciate
hepatology recommendations who also agree that ascites is most
likely from cardiac etiology.
.
# Diabetes Mellitus, type 2, well controlled: Glyburide
discontinued on admission, given renal failure. Likely should
not be continued as an outpatient. On admission was on lantus
45U qam and 15 units of lantus qhs. She had multiple episodes of
hypoglycemia during her admission and required a D10 gtt. Likely
hepatic impairment of gluconeogenesis as well as impaired renal
clearance are likely playing a role. [**Last Name (un) **] involved.  Lantus
now decreased, made daily instead of [**Hospital1 **] dosing.  The patient
was informed of insulin regimen changes for outpatient and to
continue to monitor blood glucose with fingersticks, primary
physician's direction.
.
# ESRD on HD: Renal failure likely secondary to DM and HTN. She
received hemodialysis while inpatient and also nephrocaps,
sevelamer, fluid restriction.  Dr. [**First Name (STitle) 805**] is outpatient
nephrologist.
.
# Hypertension: Previously on regimen of labetalol, lisinopril,
nifedipine, hydralazine, clonidine, and isosorbide. We have
discontinued hydralazine, changed nifedipine to verapamil, and
decreased metoprolol, titrated down clonidine.
.
# Dyspnea: Likely a combination of fluid overload, atrial
fibrillation, mechanical stress of ascites. CTA negative on
admission for PE. No evidence of pneumonia on CXR. No evidence
of new coronary event, troponin at baseline.  DFA for influenza
was negative.  Continue dialysis for volume overload.
.
# Pancreatic lesion: ?cyst, consider MRI eval as outpatient.

Medications on Admission:
Labetalol 300 mg PO TID
Lisinopril 40 mg PO QD
Nifedipine 180 mg QD
Hydralazine 50 mg PO BID
Clonidine 0.3 mg PO BID
Isosorbide Mononitrate 90 mg Sustained Release PO DAILY
Atorvastatin 10 mg PO DAILY
Pantoprazole 40 mg PO once a day.
Ferrous Sulfate 325 PO DAILY
Clonazepam 1 mg PO BID
Folic acid 1 mg daily
Insulin Lantus 45 units QAM, 15 units Qpm
glyburide 2 mg [**Hospital1 **]
MVI 1 tablet daily
B12 50 mcg po daily
Tylenol prn arthritis
Sevelemer 400 mg TID
ASA 325 mg daily
Rhinocort Acqua


Discharge Medications:
1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Four (4) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed for anxiety.
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous qam: Take as directed by your doctor.  .
10. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
12. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

14. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*150 Tablet Sustained Release 24 hr(s)* Refills:*2*
15. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary diagnosis:
- Atrial fibrillation
- Diastolic congestive heart failure
.
Secondary diagnosis:
- Diabetes mellitus type 2
- Hypertension
- Hypercholesterolemia
- End stage renal disease on hemodialysis
- Osteoarthritis
- Gastroesophageal reflux disease
- Chronic anemia


Discharge Condition:
Atrial fibrillation on aspirin, respiratory status stable


Discharge Instructions:
You presented to the hospital with shortness of breath and were
found to have atrial fibrillation.  You were originally treated
with [**Hospital **] (blood thinner) but due to increased
bleeding, the [**Hospital **] was held.  You will need to go to
a follow up appointment with your cardiologist to reassess
[**Hospital **].

Please take all medications as directed.  Some of your
medications have been changed:
a. Stop taking labetalol, nifedipine, hydralazine, glyburide.
b. New medications include metoprolol XL 150mg by mouth once
daily, verapamil SR 240mg by mouth once daily.
c. The doses have been changed on some of your medications.
- decrease clonidine to 0.2mg by mouth twice daily
- increase isosorbide mononitrate to 120mg by mouth once daily
- insulin glargine has been decreased to 20 units once each
morning.  Do not take any insulin glargine (lantus) in the
evening.

Continue to check your blood sugar regularly and call your
doctor if your blood sugar is less than 60 or greater than 400.

Please attend all follow up appointments.

Continue to go to your regularly scheudle dialysis appointments.


Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500ml per day.

If you develop fever, chills, shortness of breath, chest pain or
any other symptom that concerns you, call your primary doctor,
or if unavailable go to the emergency room.

Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 911**], MD  Phone: [**Telephone/Fax (1) 22476**]  Date/Time: [**2159-4-19**]
12:30

Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2159-4-24**] 9:50

PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 11595**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 19196**]  Date/Time: [**2159-4-24**] 2:15pm
Follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] (you
will have already seen your cardiologist prior to this
appointment), your blood sugar, and discuss a pancreatic cyst
seen on imaging and MRI may be indicated for further evaluation.
{'Atrial fibrillation,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Hemorrhage complicating a procedure,Diaphragmatic hernia without mention of obstruction or gangrene,Anemia in chronic kidney disease,Esophageal reflux,Dysthymic disorder,Pure hypercholesterolemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Constipation, unspecified,Epistaxis,Long-term (current) use of insulin'}


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, cough

PRESENT ILLNESS: 73 yo F with h/o poorly-controlled HTN, ESRD, and DM p/w SOB x1
day, started 1 day after regular HD session. SOB associated with
cough, white sputum for about a week. Pt attributes this to a
cold, although denies rhinorrhea, nasal congestion, sore throat.
+ sick contacts at dialysis center. Notes increased abdominal
girth for several days. Loose BM 3 days ago, passing flatus. +
subjective fever, low grade temp to 100.0 this morning. Slight
bleeding from fistula.
.
ED course: CXR with pulmonary edema, ? pneumonia - given ctx,
azithro. Recieved HD in preparation for CTA which was negative
for PE, + for pulmonary edema.
.
ROS: + low grade fever, no n/v/abd pain, + loose stools several
days ago, make urine, no dysuria or urinary frequency. +20 pound
weight loss over last 6 months

MEDICAL HISTORY: ) Type 2 diabetes mellitus: Started insulin in [**2157**].
2) Hypertension: Poorly controlled with many admissions to
MICU/CCU for hypertensive urgency.
3) Renal artery stenosis: Last MRA [**1-6**] revealed 3 left renal
arteries, superior with question of stenosis and middle with
stenosis.
4) Hypercholesterolemia
5) ESRD on HD M/W/F. Followed by Dr. [**First Name (STitle) **]
6) Diastolic CHF
7) Osteoarthritis
8) Depression
9) Anxiety
10) Sickle cell trait
11) Hiatal hernia
12) Gastroesophageal reflux disease
13) Chronic constipation
14) History of mechanical falls.
15) Chronic anemia: Presumed secondary to renal failure.
16) Status post hysterectomy in [**2132**].

MEDICATION ON ADMISSION: Labetalol 300 mg PO TID
Lisinopril 40 mg PO QD
Nifedipine 180 mg QD
Hydralazine 50 mg PO BID
Clonidine 0.3 mg PO BID
Isosorbide Mononitrate 90 mg Sustained Release PO DAILY
Atorvastatin 10 mg PO DAILY
Pantoprazole 40 mg PO once a day.
Ferrous Sulfate 325 PO DAILY
Clonazepam 1 mg PO BID
Folic acid 1 mg daily
Insulin Lantus 45 units QAM, 15 units Qpm
glyburide 2 mg [**Hospital1 **]
MVI 1 tablet daily
B12 50 mcg po daily
Tylenol prn arthritis
Sevelemer 400 mg TID
ASA 325 mg daily
Rhinocort Acqua

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98.8, BP 163/76, HR 110-120, RR 16, O2 sat 98% on RA
GEN: A&O x 3, pleasant, thin F sitting up in bed in NAD. No
accessory muscle use, talking in full sentences.
HEENT: EOMI, OP clear with MMM.
Neck: JVD to jaw
CV: irregular, tachycardic, nl S1/S2, II/VI SEM at LUSB
LUNGS: crackles at bases bilaterally, good air entry
ABD: soft, moderately distended, palpable hepatomegaly, 10cm
below costal margin, NT, +BS
EXT: tr pitting edema b/l, warm. L AVF with palpable thrill.

FAMILY HISTORY: Mother alive at 89, with DM2, HTN. Father died of Alzheimer's
Disease. Brother with hypertension.

SOCIAL HISTORY: Lives at home with her husband. Moved to the US in [**2124**].
Originally from Barbados, but lived in [**Location **] for 20 years as
well. She used to work as a medic in the PACU at [**Hospital1 18**], then
later as a recreational assistant at another facility. Denies
any alcohol use, no history of smoking, no IVDU. Has mother who
is sick in a hospital in Barbados. 

### Response:
{'Atrial fibrillation,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Hemorrhage complicating a procedure,Diaphragmatic hernia without mention of obstruction or gangrene,Anemia in chronic kidney disease,Esophageal reflux,Dysthymic disorder,Pure hypercholesterolemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Constipation, unspecified,Epistaxis,Long-term (current) use of insulin'}
