CHIEF COMPLAINT: Refractory Hypertension

PRESENT ILLNESS: This is a 73 year-old female with a history of hypertension,
coronary artery disease, migraine headaches, who was transferred
from [**Hospital3 10377**] hospital for neurosurgical
evaluation after a right parietal intracranial hemorrhage was
noted on CT scan performed for evaluation of headache. Patient
presented initially due to persistent headache for 3 weeks. She
denied any focal weakness, gait instability, visual disturbance,
dysarthria, nausea, vomitting, or any other symptoms. She
initially felt the headache was secondary to migraine and took
Fioricet with minimal relief. Eventually, she let her primary
care physician know, and he referred her to the emergency room.
At [**Hospital3 417**] ED, right parietal hemorrhage was noted and
patient was referred for neurosurgical evaluation. She was also
treated with labetalol 5mg IV x 4. At [**Hospital1 18**], Preliminary [**Location (un) 1131**]
of repeat head CT demonstrated right parietal calcifications,
with no cerebral oedema, mass effect, or midline shift. Patient
continued to have marked hypertension (190/50) in the emergency
room and was started on labetalol continuous infusion. She was
admitted to MICU for further management of refractory
hypertension. She reports she has been adherent to all her
anti-hypertensive medications.
.
In the ED, initial blood pressure was 205/85. She received total
labetalol IV total of 20mg, then started on continuous infusion.
She was also given potassium chloride 50mEq for hypokalemia and
was admitted for further management. Neurosurgery was consulted
and recommended conservative management, blood pressure control,
and no need for seizure prophylaxis.
.
On review of systems, patient denies any fevers, chills, chest
discomfort, shortness of breath, abdominal pain, diarrhea,
conspipation, lower exremity oedema, dysuria, or rashes.

MEDICAL HISTORY: #. Hypertension
#. Coronary artery disease, S/P MI in [**2130**]
#. Migraine headaches
#. Hyperlipidemia
#. Hypothyroidism secondary to partial thyroidectomy for nodule

MEDICATION ON ADMISSION: Metoprolol 50mg [**Hospital1 **]
Levothyroxine 100mcg daily
HCTZ 50mg daily
Atorvastatin 10mg daily
Potassium Chloride
Fioricet PRN for Migraine hx

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission to the ICU , PE was as follows:

FAMILY HISTORY: Father - died age 58 MI
Brother - died age 58 MI
Mother - died age 39 ??

SOCIAL HISTORY: The patient lives at home alone in [**Hospital1 1474**]. She is divorced,
with 5 children whom live locally. She previously worked for
[**Company 78921**] but is now retired.
Tobacco: [**1-13**] pack daily x 50 years, still smoking
ETOH: No use
Illicts: No use
Malignant neoplasm of other parts of bronchus or lung,Iatrogenic pulmonary embolism and infarction,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Secondary malignant neoplasm of brain and spinal cord,Acute posthemorrhagic anemia,Hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Tobacco use disorder,Coronary atherosclerosis of native coronary artery,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Postsurgical hypothyroidism,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Aortic valve disorders,Atherosclerosis of renal artery,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Chronic kidney disease, Stage III (moderate),Stricture of artery
Mal neo bronch/lung NEC,Iatrogen pulm emb/infarc,Mal neo lymph-intrathor,Sec mal neo brain/spine,Ac posthemorrhag anemia,Mal hy ht/kd I-IV w/o hf,Tobacco use disorder,Crnry athrscl natve vssl,Migrne unsp wo ntrc mgrn,Postsurgical hypothyroid,Ocl crtd art wo infrct,Aortic valve disorder,Renal artery atheroscler,Abn react-procedure NEC,Accid in resident instit,Chr kidney dis stage III,Stricture of artery
Admission Date:  [**2134-8-16**]              Discharge Date:   [**2134-8-31**]

Date of Birth:  [**2061-6-2**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Refractory Hypertension

Major Surgical or Invasive Procedure:
bronchoscopy with biopsy


History of Present Illness:
This is a 73 year-old female with a history of hypertension,
coronary artery disease, migraine headaches, who was transferred
from [**Hospital3 10377**] hospital for neurosurgical
evaluation after a right parietal intracranial hemorrhage was
noted on CT scan performed for evaluation of headache. Patient
presented initially due to persistent headache for 3 weeks. She
denied any focal weakness, gait instability, visual disturbance,
dysarthria, nausea, vomitting, or any other symptoms. She
initially felt the headache was secondary to migraine and took
Fioricet with minimal relief. Eventually, she let her primary
care physician know, and he referred her to the emergency room.
At [**Hospital3 417**] ED, right parietal hemorrhage was noted and
patient was referred for neurosurgical evaluation. She was also
treated with labetalol 5mg IV x 4. At [**Hospital1 18**], Preliminary [**Location (un) 1131**]
of repeat head CT demonstrated right parietal calcifications,
with no cerebral oedema, mass effect, or midline shift. Patient
continued to have marked hypertension (190/50) in the emergency
room and was started on labetalol continuous infusion. She was
admitted to MICU for further management of refractory
hypertension. She reports she has been adherent to all her
anti-hypertensive medications.
.
In the ED, initial blood pressure was 205/85. She received total
labetalol IV total of 20mg, then started on continuous infusion.
She was also given potassium chloride 50mEq for hypokalemia and
was admitted for further management. Neurosurgery was consulted
and recommended conservative management, blood pressure control,
and no need for seizure prophylaxis.
.
On review of systems, patient denies any fevers, chills, chest
discomfort, shortness of breath, abdominal pain, diarrhea,
conspipation, lower exremity oedema, dysuria, or rashes.


Past Medical History:
#. Hypertension
#. Coronary artery disease, S/P MI in [**2130**]
#. Migraine headaches
#. Hyperlipidemia
#. Hypothyroidism secondary to partial thyroidectomy for nodule

#. Low-back surgery



Social History:
The patient lives at home alone in [**Hospital1 1474**]. She is divorced,
with 5 children whom live locally. She previously worked for
[**Company 78921**] but is now retired.
Tobacco: [**1-13**] pack daily x 50 years, still smoking
ETOH: No use
Illicts: No use

Family History:
Father - died age 58 MI
Brother - died age 58 MI
Mother - died age 39 ??

Physical Exam:
On admission to the ICU , PE was as follows:

GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.



Pertinent Results:
Admission Laboratories [**8-17**]: Notable for potassium of 2.5 and
creatinine of 1.5. ECG: Sinus rhythm at 70 bpm, normal axis,
normal PR, QRS intervals. QT is 452mm intervals, normal R-wave
progress, LVH, no ST or T-wave changes, Q-waves in inferior
leads.

Imaging:
Head CT [**8-17**]:
IMPRESSION: Three rounded foci, 1-2 mm in size within the right

frontoparietal region and a second focus in the left temporal
lobe most likely represent calcium, possibly sequelae from prior
infection or inflammation. These calcifications could also be
associated with an underlying vascular abnormality. If
clinically indicated, an MRI could be performed to further
characterize this finding.
Air-fluid level within the left maxillary sinus may represent
acute sinusitis. Clinical correlation recommended.
_____
[**2134-8-18**]   Radiology MRA CHEST W&W/O CONTRAS
IMPRESSION:
1. Right lung mass with subcarinal and right paratracheal
lymphadenopathy,
highly suspicious for metastatic lung cancer. Dedicated
evaluation with chest CT is recommended.
2. Severe narrowing of the origin and 3.5 cm distal to the
origin of the left subclavian artery. A small filling defect at
the origin of the left
subclavian may represent thrombus superimposed on athersclerotic
plaque.
3. Moderate-to-severe stenosis of the left common carotid
origin.
4. Probable aortic stenosis and regurgitation. Further
evaluation with
echocardiography is recommended.
5. Atrophic left kidney.
6. Small vertebral lesion, which may represent a hemangioma but
not fully
characterized on this exam.
_____
[**2134-8-19**] ECHO: normal biventricular systolic function
_____
[**2134-8-19**]   Radiology CT CHEST W/CONTRAST
IMPRESSION:
1. Large heterogeneous mass in the right upper and middle lobes
with
associated hilar and mediastinal lymphadenopathy, highly
concerning for
bronchogenic carcinoma. No pleural effusion or chest wall
invasion.
2. Additional pulmonary nodules in the right middle and lower
lobes,
measuring up to 8 mm each.
3. Small segmental pulmonary embolus within the anterior segment
of the right lower lobe pulmonary artery.
4. Extensive atherosclerotic disease within the aorta and
moderate
calcification in the LAD.
5. Moderately severe centrilobular emphysema.
6. Left adrenal hyperplasia without focal nodule.
_____
[**2134-8-20**]   Radiology MRA ABDOMEN W&W/O CONTR
IMPRESSION:
Bilateral high-grade stenoses of the proximal renal arteries,
left greater
than right, with bilateral renal atrophy, also left greater than
right. The function of the left kidney is likely quite imparied
and could be quantified with nuclear medicine, if needed.
_____
FNA, right paratracheal lymph node:
Positive for malignant cells, consistent with metastatic
adenocarcinoma.
_____


Brief Hospital Course:
She is a 73 year-old female with a history of hypertension,
hyperlipidemia, coronary artery disease and previous stroke who
presents with 3 week course of headache and intracranial
densities concerning for ICH vs. previous insult.

1. NON SMALL CELL LUNG CANCER -patient originally transferred
for evalutation of hypertensive urgency, headache, and
?intracranail bleed. Due to marked blood pressure differential,
MRI/A was obtained to rule out dissection, which ultimately
diagnosed a RML lung mass. Patient underwent bronchoscopy with
biopsy confirming adenocarcinoma. Oncology was consulted. MRI
head was obtained for staging purposes and to follow up
?calcifications noted on head ct, now with new diagnosis of lung
cancer. MRI showed possible leptomeningeal metastases.
Outpatient follow up in Thoracic [**Hospital **] clinic was arranged,
and she will be called with an appointment time. She was seen by
the palliative care service while she was inpatient to address
goals of care. She was DNR/DNI throughout her stay. She will not
need a PET/CT given her brain metastases, and presumed Stage IV
diagnosis.

2. RENAL ARTERY STENOSIS -Patient initially admitted with
difficult to control blood pressure and evidence of atrophic
kidney. MRI abdomen confirmed high grade renal artery stenosis,
Left greater than Right. Her blood pressure was eventually
controlled on 3 agents, however, due to impending nephrotoxic
chemotherapy agents, and plan for long term anticoagulation,
consideration was given to intervention on arterial stenosis
this admit, while she was on a heparin drip. Cardiology was
consulted and evaluation and intervention was recommended, on
both her stenosed/occluded subclavian arteries and bilateral
renal arteries, to 1. provide better information of her true
central pressures, since hypertensive urgency was her presenting
complaint and 2. to attempt to maximize her renal preservation
in the setting of probable nephrotoxic chemotherapy. Patient and
family were agreeable to proceding with procedure, which patient
underwent [**2134-8-26**], and had stent placed in her subclavian and
renal arteries. She had a small hematoma after the procedure
without bruit.

3. PULMONARY EMBOLISM - small segmental pulmonary embolism was
identified on chest ct. Patient remained hemodynamically stable
and had no respiratory symptoms. Heparin drip was initiated
without complication, and continued until possible inpatient
procedures were completed. Renal function was borderline for
consideration of lmwh for discharge, however Ms. [**Known lastname 15532**] [**Last Name (Titles) 3139**] attempts at home management and administration,
therefore, she remained hospitalized on heparin drip until
coumadin, INR therapeutic. At time of discharge, she had an INR
of 3.3, and was instructed to hold one dose, and restart at a
lower dose of 3 mg daily. She had hematuria while on heparin and
coumadin, which resolved with the discontinuation of the
heparin.

4. CKD (III) -kidney function remained stable during admission,
patient found to have renal artery stenosis as discussed above.
patient underwent cath/stenting.

5.CAD(NATIVE VESSEL) -asymptomatic during hospitalization, no
chest pain in setting of hypertensive urgency, asa/bb/statin
continued.


Medications on Admission:
Metoprolol 50mg [**Hospital1 **]
Levothyroxine 100mcg daily
HCTZ 50mg daily
Atorvastatin 10mg daily
Potassium Chloride
Fioricet PRN for Migraine hx


Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day for 2 weeks: take
aspirin 81 mg a day while you are taking plavix. .
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: start taking this
dose once you are no longer taking plavix.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day:
Start taking this dose tomorrow night. Please have your INR
checked on Thursday or Friday.
Disp:*90 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
NON SMALL CELL LUNG CANCER
HTN, MALIGNANT/REVOVASCULAR
PULMONARY EMBOLISM
CAD (NATIVE VESSEL)
CKD III
RENAL ARTERY STENOSIS
HEMATURIA
ACUTE BLOOD LOSS ANEMIA


Discharge Condition:
Stable


Discharge Instructions:
You had initially gone to [**Hospital3 10377**] Hospital for a
persistent headache.  Due to concern for a possible bleed in
your brain, you were transferred to [**Hospital1 827**].  After a repeat CT showed that you did not have
an acute bleed in your brain, you were transferred to our
intensive care unit for the treatment of high blood pressure,
which was discovered in the emergency department.  During the
course of your evaluation, a lung mass and a blood clot in the
lung were discovered as well as severe narrowing of your renal
arteries, subclavian arteries, and carotid artery.  Further
evaluation by CT, MRI, and biopsy of the lung mass led to the
diagnosis of non-small cell lung cancer that showed evidence of
spread to other parts of your body.  You were being followed by
the Oncology service and Pulmonary service for this during your
stay.
.
You were then transferred to the Cardiology service for stenting
of your narrowed right renal artery and left subclavian artery.
This was completed without complications, and your blood
pressure improved following the stenting of your arteries.
.
You were given medication for your pulmonary embolus. Please
watch for signs of increased bleeding, shortness of breath,
nausea, chest pain, or increased confusion.

Followup Instructions:
Please follow up with your primary care doctor, Dr. [**Last Name (STitle) **] on
[**Last Name (LF) 766**], [**9-6**] at 12:45 pm.
You should go to clinic on Thursday or Friday to have your INR
checked. Dr.[**Name (NI) 65062**] office will call you and set this up.
Today you should hold your coumadin dose, and tomorrow start
taking 3 mg daily.

You will need to follow up with oncology and with
radiation-oncology to discuss treatment of your cancer. The
number for thoracic oncology clinic is [**0-0-**]. They will
call you to make the appointment.

You will need to follow up with Dr. [**First Name (STitle) **] in cardiology in [**3-16**]
for the stent that was placed in your artery. The number to call
to make this appointment is [**Telephone/Fax (1) 42006**].
{'Malignant neoplasm of other parts of bronchus or lung,Iatrogenic pulmonary embolism and infarction,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Secondary malignant neoplasm of brain and spinal cord,Acute posthemorrhagic anemia,Hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Tobacco use disorder,Coronary atherosclerosis of native coronary artery,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Postsurgical hypothyroidism,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Aortic valve disorders,Atherosclerosis of renal artery,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Chronic kidney disease, Stage III (moderate),Stricture of artery'}


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: Refractory Hypertension

PRESENT ILLNESS: This is a 73 year-old female with a history of hypertension,
coronary artery disease, migraine headaches, who was transferred
from [**Hospital3 10377**] hospital for neurosurgical
evaluation after a right parietal intracranial hemorrhage was
noted on CT scan performed for evaluation of headache. Patient
presented initially due to persistent headache for 3 weeks. She
denied any focal weakness, gait instability, visual disturbance,
dysarthria, nausea, vomitting, or any other symptoms. She
initially felt the headache was secondary to migraine and took
Fioricet with minimal relief. Eventually, she let her primary
care physician know, and he referred her to the emergency room.
At [**Hospital3 417**] ED, right parietal hemorrhage was noted and
patient was referred for neurosurgical evaluation. She was also
treated with labetalol 5mg IV x 4. At [**Hospital1 18**], Preliminary [**Location (un) 1131**]
of repeat head CT demonstrated right parietal calcifications,
with no cerebral oedema, mass effect, or midline shift. Patient
continued to have marked hypertension (190/50) in the emergency
room and was started on labetalol continuous infusion. She was
admitted to MICU for further management of refractory
hypertension. She reports she has been adherent to all her
anti-hypertensive medications.
.
In the ED, initial blood pressure was 205/85. She received total
labetalol IV total of 20mg, then started on continuous infusion.
She was also given potassium chloride 50mEq for hypokalemia and
was admitted for further management. Neurosurgery was consulted
and recommended conservative management, blood pressure control,
and no need for seizure prophylaxis.
.
On review of systems, patient denies any fevers, chills, chest
discomfort, shortness of breath, abdominal pain, diarrhea,
conspipation, lower exremity oedema, dysuria, or rashes.

MEDICAL HISTORY: #. Hypertension
#. Coronary artery disease, S/P MI in [**2130**]
#. Migraine headaches
#. Hyperlipidemia
#. Hypothyroidism secondary to partial thyroidectomy for nodule

MEDICATION ON ADMISSION: Metoprolol 50mg [**Hospital1 **]
Levothyroxine 100mcg daily
HCTZ 50mg daily
Atorvastatin 10mg daily
Potassium Chloride
Fioricet PRN for Migraine hx

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission to the ICU , PE was as follows:

FAMILY HISTORY: Father - died age 58 MI
Brother - died age 58 MI
Mother - died age 39 ??

SOCIAL HISTORY: The patient lives at home alone in [**Hospital1 1474**]. She is divorced,
with 5 children whom live locally. She previously worked for
[**Company 78921**] but is now retired.
Tobacco: [**1-13**] pack daily x 50 years, still smoking
ETOH: No use
Illicts: No use 

### Response:
{'Malignant neoplasm of other parts of bronchus or lung,Iatrogenic pulmonary embolism and infarction,Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes,Secondary malignant neoplasm of brain and spinal cord,Acute posthemorrhagic anemia,Hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Tobacco use disorder,Coronary atherosclerosis of native coronary artery,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Postsurgical hypothyroidism,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Aortic valve disorders,Atherosclerosis of renal artery,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Chronic kidney disease, Stage III (moderate),Stricture of artery'}
