CHIEF COMPLAINT: fatigue

PRESENT ILLNESS: Mr [**Known lastname 7982**] is an 84 yo M with a history of biventricular heart
failure, atrial fibrillation, ICD and CAD s/p CABG who presented
today to Dr.[**Name (NI) 7914**] clinic for his usual follow up. On
evaluation the patient was found to be fluid overloaded and was
directly admitted to the CCU.
.
The patient reports that over the last 1.5 months he has had
progressive fatigue and weakness. During this time he has also
noted an increase in his weight from a baseline of 151 lb to a
peak weight of 171 lbs. Approximately a month ago the patient's
lasix was changed to torsamide which improved his weight by a
few pounds. However, the patient has continued to feel unwell.
He notes that prior to these changes, the patent had a decrease
in his digoxin from 1 tab daily to [**1-3**] tab every other day,
secondary to "toxicity". He notes not other acute issue
preceeding his decline including no chest pain, no acute
dyspnea, no change in his diet or other symptoms. He has had
persistent dyspnea on exertion for two months with 200 yards
walking, though he does not think that it has worsened.
.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, myalgias, joint pains,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.

MEDICAL HISTORY: CARDIAC HISTORY:
- MI X2
-CABG: 4 vessel [**2165**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
- Pacemaker placed [**2183**] for sick sinus syndrome
- Upgrade to [**Hospital1 **]-v ICD in [**3-/2189**]
- Generator change [**5-8**], pocket revision [**8-8**] (lead protruding
from skin)
- s/p VT ablation
- Atrial fibrillation
- Systolic, diastolic CHF last EF:
OTHER PAST MEDICAL HISTORY:
Ischemic Cardiomyopathy-LVEF 30%
Hypertension
Hyperlipidemia
Prior TIA??????s with aphasia (none in the past 4 years)
Orchiectomy due to a gunshot wound sustained in the service
Central retinal vein occlusion

MEDICATION ON ADMISSION: amiodarone 100 mg daily
aggrenox 25/200 mg daily
Torsemide 50 mg twice daily
Carvedilol 3.125mg [**Hospital1 **]
coumadin 2.5 mg daily except 5 mg on MWF
zocor 10 mg daily
Digoxin 0.0625 mg every other day (decreased from his last
visit).

ALLERGIES: Penicillins / Quinidine

PHYSICAL EXAM: Height: 66 Inch, 168 cm
Weight: 161.5 kg
T 97 BP 105/63
RR 19 02 96% RA

FAMILY HISTORY: No family history of early MI, otherwise non-contributory.

SOCIAL HISTORY: -Tobacco history: Quit smoking approx 25 years ago, did have
heavy pipe/cigar smoking for approx 8-10 years
-ETOH: rare glass of wine
-Illicit drugs: none
Served in the Army
Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Automatic implantable cardiac defibrillator in situ,Other specified forms of chronic ischemic heart disease,Aortocoronary bypass status,Old myocardial infarction,Other and unspecified hyperlipidemia,Tricuspid valve disorders, specified as nonrheumatic,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Hematuria, unspecified,Other specified retention of urine,Cardiac rhythm regulators causing adverse effects in therapeutic use,Pressure ulcer, buttock,Abnormal weight gain,Other specified acquired hypothyroidism,Personal history of tobacco use
Ac/chr syst/dia hrt fail,Acute kidney failure NOS,Atrial fibrillation,Long-term use anticoagul,Status autm crd dfbrltr,Chr ischemic hrt dis NEC,Aortocoronary bypass,Old myocardial infarct,Hyperlipidemia NEC/NOS,Nonrheum tricusp val dis,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Hematuria NOS,Oth spcf retention urine,Adv eff card rhyth regul,Pressure ulcer, buttock,Abnormal weight gain,Acquired hypothyroid NEC,History of tobacco use
Admission Date:  [**2194-1-8**]              Discharge Date:   [**2194-1-15**]


Service: MEDICINE

Allergies:
Penicillins / Quinidine

Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
fatigue

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr [**Known lastname 7982**] is an 84 yo M with a history of biventricular heart
failure, atrial fibrillation, ICD and CAD s/p CABG who presented
today to Dr.[**Name (NI) 7914**] clinic for his usual follow up. On
evaluation the patient was found to be fluid overloaded and was
directly admitted to the CCU.
.
The patient reports that over the last 1.5 months he has had
progressive fatigue and weakness. During this time he has also
noted an increase in his weight from a baseline of 151 lb to a
peak weight of 171 lbs. Approximately a month ago the patient's
lasix was changed to torsamide which improved his weight by a
few pounds. However, the patient has continued to feel unwell.
He notes that prior to these changes, the patent had a decrease
in his digoxin from 1 tab daily to [**1-3**] tab every other day,
secondary to "toxicity". He notes not other acute issue
preceeding his decline including no chest pain, no acute
dyspnea, no change in his diet or other symptoms. He has had
persistent dyspnea on exertion for two months with 200 yards
walking, though he does not think that it has worsened.
.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, myalgias, joint pains,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.


Past Medical History:
CARDIAC HISTORY:
- MI X2
-CABG: 4 vessel [**2165**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
- Pacemaker placed [**2183**] for sick sinus syndrome
- Upgrade to [**Hospital1 **]-v ICD in [**3-/2189**]
- Generator change [**5-8**], pocket revision [**8-8**] (lead protruding
from skin)
- s/p VT ablation
- Atrial fibrillation
- Systolic, diastolic CHF last EF:
OTHER PAST MEDICAL HISTORY:
Ischemic Cardiomyopathy-LVEF 30%
Hypertension
Hyperlipidemia
Prior TIA??????s with aphasia (none in the past 4 years)
Orchiectomy due to a gunshot wound sustained in the service
Central retinal vein occlusion


Social History:
-Tobacco history: Quit smoking approx 25 years ago, did have
heavy pipe/cigar smoking for approx 8-10 years
-ETOH: rare glass of wine
-Illicit drugs: none
Served in the Army


Family History:
No family history of early MI, otherwise non-contributory.

Physical Exam:
Height: 66 Inch, 168 cm
Weight: 161.5 kg
T 97 BP 105/63
RR 19 02 96% RA

Eyes: (Conjunctiva and lids: WNL)

Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums
and palette: WNL)

Neck: (Right carotid artery: Bruit present), (Left carotid
artery: No bruit), (Jugular veins: JVP, ~20 cm), (Thyroid: WNL)

Back / Musculoskeletal: (Chest wall structure: WNL)

Respiratory: (Effort: WNL), (Auscultation: Abnormal, crackles in
lower [**1-4**] of posterior lung fields)

Cardiac: (Rhythm: Regular), (Palpation / PMI: Abnormal,
laterally displaced PMI), (Auscultation: S1: WNL, systolic
murmur loudest at the LLSB )

Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),
(Pulsatile mass: No), (Hepatosplenomegaly: No)

Genitourinary: (WNL)

Extremities / Musculoskeletal: (Dorsalis pedis artery: Right:
1+, Left: 1+), (Edema: Right: 2+, Left: 2+), (Extremity details:
to kneew)

Skin: (Abnormal, multiple ecchymoses)





Pertinent Results:
Basic admission labs:
[**2194-1-8**] 08:17PM   WBC-4.7 RBC-3.71* HGB-12.0* HCT-34.5* MCV-93
MCH-32.3* MCHC-34.7 RDW-15.6*
[**2194-1-8**] 08:17PM   NEUTS-68.2 LYMPHS-22.3 MONOS-8.1 EOS-1.2
BASOS-0.2
[**2194-1-8**] 08:17PM   GLUCOSE-120* UREA N-93* CREAT-3.1*#
SODIUM-134 POTASSIUM-5.1 CHLORIDE-97 TOTAL CO2-23 ANION GAP-19

Cardiac labs:
[**2194-1-8**] 08:17PM BLOOD proBNP-[**Numeric Identifier 7983**]*
[**2194-1-10**] 04:58AM BLOOD Digoxin-0.9

TFTs
[**2194-1-8**] 08:17PM BLOOD TSH-6.9*
[**2194-1-9**] 03:39PM BLOOD T4-8.0 calcTBG-0.87 TUptake-1.15
T4Index-9.2

[**2194-1-9**] echo:

The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is low
normal (LVEF 50%) secondary to hypokinesis of the inferior and
posterior walls; the other walls are hyperdynamic. There is no
ventricular septal defect. The right ventricular cavity is
dilated with severe global free wall hypokinesis. There is
abnormal diastolic septal motion/position consistent with right
ventricular volume overload. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Mild to moderate ([**1-3**]+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. Severe
[4+] tricuspid regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.

Brief Hospital Course:
84 yo M with history of diastolic and systolic heart failure who
presents with significant volume overload.
.
# Acute on chronic systolic congestive heart failure:  There was
likely a large contribution from tricuspid regurgitation. On
admission, patient noted to have 15-20 lb weight gain and
significantly elevated JVP. The precipitating event was unclear,
but possibly related to recent medication changes.  He was
started on a dopamine gtt and lasix gtt with good response in
terms of blood pressure and urine output. He diuresed ~1 L daily
for 4 days, after which lasix drip was slowly weaned and
outpatient diuretic-torsemide-was restarted.  Dopamine drip was
also weaned, and blood pressure fell back to baseline SBP 80s.
He was stabilized on a regimen of torsemide 50 mg in the morning
and 25 mg in the evening.  He will need electrolyte and
creatinine follow-up by his PCP. [**Name10 (NameIs) **] addition, his digoxin dose
was increased to .0625 mg daily, and aminophylline
(theophylline) was started.  He will need levels checked on both
of these medications at his visit on [**2194-1-17**].
.
# Atrial fibrillation:  Patient was anticoagulated on admission
for a history of atrial fibrillation.  He remained in AV paced
rhythm and anticoagulated throughout his stay.  INR on discharge
was 2.3.  INR follow-up will be with visiting nurse.
.
# Acute on chronic renal failure:  Creatinine on admission was
elevated from baseline 1.5-2.0 to 3.1.  This was most likely
prerenal in the setting of poor forward flow from heart failure.
 Creatinine improved to baseline with diuresis. Creatinine on
discharge was 2.0.
.
# Hematuria:  Patient was noted to have clots in his foley
catheter that were unable to be manually irrigated.  A triple
lumen 22-french catheter was placed, and continuous bladder
irrigation was started, with resolution of clots.  Urology was
consulted and recommended work-up of hematuria to include
abdominal CT, urine cytology, and outpatient follow-up for
cystoscopy.  CT did not show any stone or other clear inciting
abnormality.  An appointment was made with urology for
outpatient follow-up of the cytology and possible cystoscopy.

# Hypothyroid:  The patient was found to be hypothyroid with TSH
6.9.  This was likely attributable to amiodarone treatment.  Low
dose levothyroxine (25 mcg daily) was started.  He will need TSH
checked again in 6 weeks by his PCP.
.
# Pyuria:  The patient had WBC on urinalysis the day prior to
discharge.  Culture was not growing.  He will need to have a
repeat urinalysis at his appointment with his PCP [**Last Name (NamePattern4) **] 2 days.


Medications on Admission:
amiodarone 100 mg daily
aggrenox 25/200 mg daily
Torsemide 50 mg twice daily
Carvedilol 3.125mg [**Hospital1 **]
coumadin 2.5 mg daily except 5 mg on MWF
zocor 10 mg daily
Digoxin 0.0625 mg every other day (decreased from his last
visit).


Discharge Medications:
1. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO DAILY (Daily).
2. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS (MO,WE,FR).

7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],TU,TH,SA).
8. Aminophylline 100 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
Disp:*90 Tablet(s)* Refills:*2*
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
10. Torsemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)). Tablet(s)
11. Torsemide 5 mg Tablet Sig: One (1) Tablet PO qpm.
Disp:*30 Tablet(s)* Refills:*2*
12. Torsemide 100 mg Tablet Sig: .5 Tablet PO QAM (once a day
(in the morning)).
Disp:*15 Tablet(s)* Refills:*2*
13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Digoxin 125 mcg Tablet Sig: .5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
primary:  Acute exacerbation of chronic diastolic congestive
heart failure
secondary:  atrical fibrillation, hypertension, hyperliidemia


Discharge Condition:
hemodynamically stable, euvolemic


Discharge Instructions:
You were admitted to [**Hospital1 18**] due to worsening heart failure. You
were treated with IV medications to remove extra fluid. You also
had some blood in your urine. This may have been from the
catheter palcement, but you should see a urologist after
discharge to see if other studies are needed.

Changes were made to your home medications:
digoxin was increased
torsemide was changed to 50 mg in the morning and 25 mg in the
evening
levothyroxine was added
aminophylline was added

Please keep your follow up appointments as below.  Please call
your doctor if your weight increases by more than 3 pounds.
Please return to the emergency department if you have chest
pain, shortness of breath, high fevers and chills, or other
symptoms that are concerning to you.  Adhere to a 2 gm sodium
diet.  Fluid Restriction: 1.5 liters of fluid intake per day.

Followup Instructions:
You have an appointment this [**Last Name (LF) 2974**], [**1-17**], at 10 a.m. to
see Pat [**Doctor Last Name 7984**] ([**Telephone/Fax (1) 7985**]) at your PCPs office. We spoke
with their office and they are aware of the tests that are
needed as well as medication changes that were made.  A summary
of your hospitalization will be faxed to that office prior to
the appointment.

You also have the following  appointments:

Urology:  [**Doctor Last Name **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3752**] Date/Time:[**2194-2-6**]
2:45

cardiologist: Dr. [**First Name (STitle) **] on [**1-24**] at 2 pm.

cardiologist:  [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**] [**4-2**] at
3:20 pm.



Completed by:[**2194-1-15**]
{'Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Automatic implantable cardiac defibrillator in situ,Other specified forms of chronic ischemic heart disease,Aortocoronary bypass status,Old myocardial infarction,Other and unspecified hyperlipidemia,Tricuspid valve disorders, specified as nonrheumatic,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Hematuria, unspecified,Other specified retention of urine,Cardiac rhythm regulators causing adverse effects in therapeutic use,Pressure ulcer, buttock,Abnormal weight gain,Other specified acquired hypothyroidism,Personal history of tobacco use'}


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: fatigue

PRESENT ILLNESS: Mr [**Known lastname 7982**] is an 84 yo M with a history of biventricular heart
failure, atrial fibrillation, ICD and CAD s/p CABG who presented
today to Dr.[**Name (NI) 7914**] clinic for his usual follow up. On
evaluation the patient was found to be fluid overloaded and was
directly admitted to the CCU.
.
The patient reports that over the last 1.5 months he has had
progressive fatigue and weakness. During this time he has also
noted an increase in his weight from a baseline of 151 lb to a
peak weight of 171 lbs. Approximately a month ago the patient's
lasix was changed to torsamide which improved his weight by a
few pounds. However, the patient has continued to feel unwell.
He notes that prior to these changes, the patent had a decrease
in his digoxin from 1 tab daily to [**1-3**] tab every other day,
secondary to "toxicity". He notes not other acute issue
preceeding his decline including no chest pain, no acute
dyspnea, no change in his diet or other symptoms. He has had
persistent dyspnea on exertion for two months with 200 yards
walking, though he does not think that it has worsened.
.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, myalgias, joint pains,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.

MEDICAL HISTORY: CARDIAC HISTORY:
- MI X2
-CABG: 4 vessel [**2165**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
- Pacemaker placed [**2183**] for sick sinus syndrome
- Upgrade to [**Hospital1 **]-v ICD in [**3-/2189**]
- Generator change [**5-8**], pocket revision [**8-8**] (lead protruding
from skin)
- s/p VT ablation
- Atrial fibrillation
- Systolic, diastolic CHF last EF:
OTHER PAST MEDICAL HISTORY:
Ischemic Cardiomyopathy-LVEF 30%
Hypertension
Hyperlipidemia
Prior TIA??????s with aphasia (none in the past 4 years)
Orchiectomy due to a gunshot wound sustained in the service
Central retinal vein occlusion

MEDICATION ON ADMISSION: amiodarone 100 mg daily
aggrenox 25/200 mg daily
Torsemide 50 mg twice daily
Carvedilol 3.125mg [**Hospital1 **]
coumadin 2.5 mg daily except 5 mg on MWF
zocor 10 mg daily
Digoxin 0.0625 mg every other day (decreased from his last
visit).

ALLERGIES: Penicillins / Quinidine

PHYSICAL EXAM: Height: 66 Inch, 168 cm
Weight: 161.5 kg
T 97 BP 105/63
RR 19 02 96% RA

FAMILY HISTORY: No family history of early MI, otherwise non-contributory.

SOCIAL HISTORY: -Tobacco history: Quit smoking approx 25 years ago, did have
heavy pipe/cigar smoking for approx 8-10 years
-ETOH: rare glass of wine
-Illicit drugs: none
Served in the Army 

### Response:
{'Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Atrial fibrillation,Long-term (current) use of anticoagulants,Automatic implantable cardiac defibrillator in situ,Other specified forms of chronic ischemic heart disease,Aortocoronary bypass status,Old myocardial infarction,Other and unspecified hyperlipidemia,Tricuspid valve disorders, specified as nonrheumatic,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Hematuria, unspecified,Other specified retention of urine,Cardiac rhythm regulators causing adverse effects in therapeutic use,Pressure ulcer, buttock,Abnormal weight gain,Other specified acquired hypothyroidism,Personal history of tobacco use'}
