CHIEF COMPLAINT: Lower extremity edema.

PRESENT ILLNESS: Pt is a 73yo F w/ PMH of HTN, ESRD on HD, diastolic dysfunction,
who presented to the ED with increased BLE edema. Her LE have
been getting more and more edematous, to the point where she is
unable to wear her shoes. She is now on rehab with the purpose
of getting her functional enough to undergo a R TKR (per the
patient). At rehab, she has been limited due to her LE edema.
Her R knee has been more painful and more swollen over last
month. No h/o trauma or falls. She denies any recent fevers or
chills and has not had swelling this bad in her knees in the
past. They have been trying to run her dry at HD, but the
swelling persists. Denies any recent CP, SOB. + palpitations.
Sleeps on 3 pillows behind her head and 2 underneath her feet,
which is stable. Mild DOE - has 15 stairs to climb at her house,
sometimes has to sit between flights. No n/v recently. Still w/
profuse diarrhea. Swelling in LE as noted above.
.
Pt was recently admitted [**4-13**] - [**4-24**] with diagnosis of AF with
RVR, abd pain and distention, as well as an elevated INR.
Briefly, she was rate controlled with IV and PO medicines, had a
paracentesis for ascites felt to be due to CHF induced hepatic
congestion, and then ultimately found to have C diff for which
she was treated with PO vanco/flagyl. There was a question of
mesenteric ischemia vs. IBD as well, given that she frequently
had bloody stools. It was recommended to undergo a colonoscopy
as an outpatient for further evaluation. She continues on PO
vanco, to finish her course on [**5-8**].
.
In the ED, VS showed T 98.4, BP 120/60, HR 75, RR 20, sats 99%
on RA. Arthrocentesis was performed on her R knee. She was given
morphine for pain relief. CXR was performed. Labs revealed a BNP
of 54K. She was admitted to medicine for management of her CHF.

MEDICAL HISTORY: 1) 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) 805**]
6) Diastolic CHF, last echo [**2159-4-5**] with mildly reduced systolic
function (TEE)
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: Acetaminophen 325-650 mg PO Q4-6H:PRN
Heparin 5000 UNIT SC TID
Senna 1 TAB PO BID:PRN
Docusate Sodium 100 mg PO BID
Diltiazem 90 mg PO QID
Isosorbide Dinitrate 10 mg PO TID
Metoprolol 100 mg PO TID
Insulin SC
Losartan Potassium 50 mg PO DAILY
Clonazepam 0.5 mg PO BID
Aspirin EC 81 mg PO DAILY
Sevelamer 400 mg PO TID
Cyanocobalamin 50 mcg PO DAILY
FoLIC Acid 1 mg PO DAILY
Ferrous Sulfate 325 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Atorvastatin 10 mg PO DAILY
CloniDINE 0.1 mg PO BID
Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS - T 97.8, BP 156/84, HR 107, RR 22, sats 100% on 2L (on RA on
exam)
Gen: Thin, AfAm female in NAD.
HEENT: Sclera anicteric, EOMI, OP clear, MMM. No JVD.
CV: Irreg irreg, normal S1, S2. II/VI SEM best heard at LUSB, no
r/g. Dynamic precordium.
Lungs: Crackles at L base, otherwise clear.
Abd: Soft, protuberant abdomen. + BS throughout. No appreciable
fluid wave, but with some lower abdominal dullness to
percussion. + hepatomegaly w/ liver edge percussed to [**3-4**]
fingerbreadths below RCM.
Ext: 2+ pitting edema to knees bilaterally, RLE slightly worse
than LLE. R knee is swollen, with effusion. No warmth or
erythema. Bandaid in place over arthrocentesis site. AVF in LUE
+ thrill.
Neuro: AAOx3. CN II-XII grossly intact. Strength grossly intact
- pt able to move around in bed on her own.

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, but since d/c on [**4-24**] has been
at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. 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.
Congestive heart failure, unspecified,Other closed transcervical fracture of neck of femur,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Unspecified septicemia,Severe sepsis,Intestinal infection due to Clostridium difficile,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Hemorrhage complicating a procedure,Acquired coagulation factor deficiency,Effusion of joint, lower leg,Atrial fibrillation,Long-term (current) use of insulin,Accidental fall from bed,Unspecified disorder of liver
CHF NOS,Fx femur intrcaps NEC-cl,Hyp kid NOS w cr kid V,End stage renal disease,Septicemia NOS,Severe sepsis,Int inf clstrdium dfcile,DMII oth nt st uncntrld,Hemorrhage complic proc,Acq coagul factor defic,Joint effusion-l/leg,Atrial fibrillation,Long-term use of insulin,Fall from bed,Liver disorder NOS
Admission Date:  [**2159-5-8**]              Discharge Date:   [**2159-5-14**]

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

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Lower extremity edema.

Major Surgical or Invasive Procedure:
1. Joint aspiration, right knee ([**2159-5-8**]).
2. Hydrocortisone injection, right knee ([**2159-5-9**]).
3. s/p ORIF
4. Intubation


History of Present Illness:
Pt is a 73yo F w/ PMH of HTN, ESRD on HD, diastolic dysfunction,
who presented to the ED with increased BLE edema. Her LE have
been getting more and more edematous, to the point where she is
unable to wear her shoes. She is now on rehab with the purpose
of getting her functional enough to undergo a R TKR (per the
patient). At rehab, she has been limited due to her LE edema.
Her R knee has been more painful and more swollen over last
month. No h/o trauma or falls. She denies any recent fevers or
chills and has not had swelling this bad in her knees in the
past. They have been trying to run her dry at HD, but the
swelling persists. Denies any recent CP, SOB. + palpitations.
Sleeps on 3 pillows behind her head and 2 underneath her feet,
which is stable. Mild DOE - has 15 stairs to climb at her house,
sometimes has to sit between flights. No n/v recently. Still w/
profuse diarrhea. Swelling in LE as noted above.
.
Pt was recently admitted [**4-13**] - [**4-24**] with diagnosis of AF with
RVR, abd pain and distention, as well as an elevated INR.
Briefly, she was rate controlled with IV and PO medicines, had a
paracentesis for ascites felt to be due to CHF induced hepatic
congestion, and then ultimately found to have C diff for which
she was treated with PO vanco/flagyl. There was a question of
mesenteric ischemia vs. IBD as well, given that she frequently
had bloody stools. It was recommended to undergo a colonoscopy
as an outpatient for further evaluation. She continues on PO
vanco, to finish her course on [**5-8**].
.
In the ED, VS showed T 98.4, BP 120/60, HR 75, RR 20, sats 99%
on RA. Arthrocentesis was performed on her R knee. She was given
morphine for pain relief. CXR was performed. Labs revealed a BNP
of 54K. She was admitted to medicine for management of her CHF.



Past Medical History:
1) 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) 805**]
6) Diastolic CHF, last echo [**2159-4-5**] with mildly reduced systolic
function (TEE)
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, but since d/c on [**4-24**] has been
at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. 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.

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

Physical Exam:
VS - T 97.8, BP 156/84, HR 107, RR 22, sats 100% on 2L (on RA on
exam)
Gen: Thin, AfAm female in NAD.
HEENT: Sclera anicteric, EOMI, OP clear, MMM. No JVD.
CV: Irreg irreg, normal S1, S2. II/VI SEM best heard at LUSB, no
r/g. Dynamic precordium.
Lungs: Crackles at L base, otherwise clear.
Abd: Soft, protuberant abdomen. + BS throughout. No appreciable
fluid wave, but with some lower abdominal dullness to
percussion. + hepatomegaly w/ liver edge percussed to [**3-4**]
fingerbreadths below RCM.
Ext: 2+ pitting edema to knees bilaterally, RLE slightly worse
than LLE. R knee is swollen, with effusion. No warmth or
erythema. Bandaid in place over arthrocentesis site. AVF in LUE
+ thrill.
Neuro: AAOx3. CN II-XII grossly intact. Strength grossly intact
- pt able to move around in bed on her own.

Pertinent Results:
CBC:  [**2159-5-7**]
WBC-8.2 RBC-4.45 Hgb-11.9* Hct-37.9 MCV-85 MCH-26.9* MCHC-31.5
RDW-20.8* Plt Ct-301  Neuts-77* Bands-0 Lymphs-17* Monos-5 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0

COAGS:  [**2159-5-8**]
PT-17.8* PTT-34.4 INR(PT)-1.7*

CHEMISTRIES:  [**2159-5-7**]
Glucose-71 UreaN-14 Creat-2.7* Na-141 K-3.2* Cl-95* HCO3-37*
AnGap-12
Calcium-8.4 Phos-5.2*# Mg-1.9 UricAcd-3.8

LFTS:   [**2159-5-8**]
ALT-HEMOLYSIS  AST-37 LD(LDH)-391* CK(CPK)-40 AlkPhos-102
TotBili-0.5

CARDIAC STUDIES:   [**2159-5-7**]
CK-MB-2 cTropnT-0.23* proBNP-[**Numeric Identifier 22636**]*

CXR ([**2159-5-8**]):
Long-standing severe cardiomegaly, particularly left atrial and
right ventricular enlargement is unchanged. Pulmonary
vasculature is unremarkable and there is no edema or pleural
effusion. Enlargement of the pulmonary arteries suggests
pulmonary hypertension perhaps related to mitral valve disease.
Lungs are clear of any focal abnormality. Stomach is moderately
distended with gas.

RIGHT KNEE PLAIN FILM ([**2159-5-8**]):
1. There are severe osteoarthritic changes comparable in
appearance to [**1-5**].
2. The degree of lateral subluxation of the tibia is less than
on that study.
3. No acute fracture is identified, although there is
considerable preexisting deformity of the subarticular bone.
.
ct pelvis [**5-10**]:
IMPRESSION: Minimally impacted fracture through the
intertrochanteric region of the proximal right femur
.
[**5-13**] head ct:
FINDINGS: There is no evidence of hemorrhage, mass effect, or
shift of normally midline structures. There is no evidence of
infarction. Mild low attenuation in the periventricular white
matter is consistent with chronic microvascular infarction. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. The surrounding
soft tissue and osseous structures are unremarkable. The
visualized paranasal sinuses and mastoid air cells are clear.
.
IMPRESSION: No evidence of hemorrhage or mass effect. No
significant change from prior study

Brief Hospital Course:
Floor course:
1. Femeral neck fracture:  The patient fell morning of [**5-10**].
Plain film shows fracture.  On [**5-11**]: ORIF with ortho, and on
[**5-12**]: Hct drop post-op with clear hematoma in right leg.  The
patient was given blood with no issues
.
2. Congestive heart failure:  Presented with elevated BNP of
~54K, LE edema, and crackles on exam, but pt had stable O2 sats
on RA. Unclear that this was true CHF exacerbation because she
appeared dry on exam. Per HD notes, pt has been getting dialyzed
to below her dry weight (59.5 kg -> 55.5 kg on [**5-4**]).  She
remained stable with HD M/W/F and renal meds
.
3. Gout:  WBC in tap elevated with 96% polys, but gram stain w/o
PMNs or orgs. Afebrile, no peripheral leukocytosis. Crystals are
c/w gout and/or pseudogout. Was injected by rheum on [**5-9**], and
did well with tylenol prn.  Was not given colchicine given ESRD

.
4. Hypertension: The patient was continue on outpatient
antihypertensives, with no issues
.
5. ESRD: The patient had no issues on the floor and had HD on
MWF.
.
6. CDIFF: Completed course of PO vancomycin for now.
.
Micu transfer and course:
Code blue called late [**5-12**] for unresponsiveness, pt's blood
sugar was found to be 8. Bradycardia down to thirties, sbp
dropped as low as 80s. Given atropine one mg x1 and [**1-2**] amp D50.
HR recovered to 90s-110s, irreg rhythm. Repeat sugar 47 and a
full amp D50 was given. During the code a central line was
placed in L femoral. Her mental status returned to baseline and
pt transferred to MICU for further management.
.
The patient was initially stable in the unit, but during her
course she developed several hypotensive episodes and received
boluses of IVF. The patient was on diltiazem and metoprolol for
afib, but her pressure dropped so these were stopped.  During
this episode of hypotension, the patient was not moving her left
leg, but her head ct was negative so stroke was unlikely. She
was intubated for confusion, at that time.  Originally her
hypotension was attributed to her nodal agents, but then given
her white count and clinical picture she was likely septic so
vanc and levo were started. With IVF, and antibiotics she
remained hypotensive so she was requiring 3 pressors
vasopressin, levophed and neosynephrine. Her pressure continued
to drop despite pressors, and she had cardiac arrest. Once her
DNR/DNI status was confirmed life saving measures were stopped
and the patient expired.

Medications on Admission:
Acetaminophen 325-650 mg PO Q4-6H:PRN
Heparin 5000 UNIT SC TID
Senna 1 TAB PO BID:PRN
Docusate Sodium 100 mg PO BID
Diltiazem 90 mg PO QID
Isosorbide Dinitrate 10 mg PO TID
Metoprolol 100 mg PO TID
Insulin SC
Losartan Potassium 50 mg PO DAILY
Clonazepam 0.5 mg PO BID
Aspirin EC 81 mg PO DAILY
Sevelamer 400 mg PO TID
Cyanocobalamin 50 mcg PO DAILY
FoLIC Acid 1 mg PO DAILY
Ferrous Sulfate 325 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Atorvastatin 10 mg PO DAILY
CloniDINE 0.1 mg PO BID
Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift


Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired
{'Congestive heart failure, unspecified,Other closed transcervical fracture of neck of femur,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Unspecified septicemia,Severe sepsis,Intestinal infection due to Clostridium difficile,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Hemorrhage complicating a procedure,Acquired coagulation factor deficiency,Effusion of joint, lower leg,Atrial fibrillation,Long-term (current) use of insulin,Accidental fall from bed,Unspecified disorder of liver'}


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: Lower extremity edema.

PRESENT ILLNESS: Pt is a 73yo F w/ PMH of HTN, ESRD on HD, diastolic dysfunction,
who presented to the ED with increased BLE edema. Her LE have
been getting more and more edematous, to the point where she is
unable to wear her shoes. She is now on rehab with the purpose
of getting her functional enough to undergo a R TKR (per the
patient). At rehab, she has been limited due to her LE edema.
Her R knee has been more painful and more swollen over last
month. No h/o trauma or falls. She denies any recent fevers or
chills and has not had swelling this bad in her knees in the
past. They have been trying to run her dry at HD, but the
swelling persists. Denies any recent CP, SOB. + palpitations.
Sleeps on 3 pillows behind her head and 2 underneath her feet,
which is stable. Mild DOE - has 15 stairs to climb at her house,
sometimes has to sit between flights. No n/v recently. Still w/
profuse diarrhea. Swelling in LE as noted above.
.
Pt was recently admitted [**4-13**] - [**4-24**] with diagnosis of AF with
RVR, abd pain and distention, as well as an elevated INR.
Briefly, she was rate controlled with IV and PO medicines, had a
paracentesis for ascites felt to be due to CHF induced hepatic
congestion, and then ultimately found to have C diff for which
she was treated with PO vanco/flagyl. There was a question of
mesenteric ischemia vs. IBD as well, given that she frequently
had bloody stools. It was recommended to undergo a colonoscopy
as an outpatient for further evaluation. She continues on PO
vanco, to finish her course on [**5-8**].
.
In the ED, VS showed T 98.4, BP 120/60, HR 75, RR 20, sats 99%
on RA. Arthrocentesis was performed on her R knee. She was given
morphine for pain relief. CXR was performed. Labs revealed a BNP
of 54K. She was admitted to medicine for management of her CHF.

MEDICAL HISTORY: 1) 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) 805**]
6) Diastolic CHF, last echo [**2159-4-5**] with mildly reduced systolic
function (TEE)
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: Acetaminophen 325-650 mg PO Q4-6H:PRN
Heparin 5000 UNIT SC TID
Senna 1 TAB PO BID:PRN
Docusate Sodium 100 mg PO BID
Diltiazem 90 mg PO QID
Isosorbide Dinitrate 10 mg PO TID
Metoprolol 100 mg PO TID
Insulin SC
Losartan Potassium 50 mg PO DAILY
Clonazepam 0.5 mg PO BID
Aspirin EC 81 mg PO DAILY
Sevelamer 400 mg PO TID
Cyanocobalamin 50 mcg PO DAILY
FoLIC Acid 1 mg PO DAILY
Ferrous Sulfate 325 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Atorvastatin 10 mg PO DAILY
CloniDINE 0.1 mg PO BID
Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS - T 97.8, BP 156/84, HR 107, RR 22, sats 100% on 2L (on RA on
exam)
Gen: Thin, AfAm female in NAD.
HEENT: Sclera anicteric, EOMI, OP clear, MMM. No JVD.
CV: Irreg irreg, normal S1, S2. II/VI SEM best heard at LUSB, no
r/g. Dynamic precordium.
Lungs: Crackles at L base, otherwise clear.
Abd: Soft, protuberant abdomen. + BS throughout. No appreciable
fluid wave, but with some lower abdominal dullness to
percussion. + hepatomegaly w/ liver edge percussed to [**3-4**]
fingerbreadths below RCM.
Ext: 2+ pitting edema to knees bilaterally, RLE slightly worse
than LLE. R knee is swollen, with effusion. No warmth or
erythema. Bandaid in place over arthrocentesis site. AVF in LUE
+ thrill.
Neuro: AAOx3. CN II-XII grossly intact. Strength grossly intact
- pt able to move around in bed on her own.

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, but since d/c on [**4-24**] has been
at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. 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. 

### Response:
{'Congestive heart failure, unspecified,Other closed transcervical fracture of neck of femur,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Unspecified septicemia,Severe sepsis,Intestinal infection due to Clostridium difficile,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Hemorrhage complicating a procedure,Acquired coagulation factor deficiency,Effusion of joint, lower leg,Atrial fibrillation,Long-term (current) use of insulin,Accidental fall from bed,Unspecified disorder of liver'}
