CHIEF COMPLAINT: hypotension and RLE edema

PRESENT ILLNESS: Pt is a 72 y.o man w/ NIDDM, CAD s/p MI x 2, class IV CHF (EF
20-25%), PVD, CRI who presented from his PCP's office on [**1-20**]
w/ asymptomatic BP 70's/40's and LE edema/pain in the setting of
cessation of lasix secondary to elevation in creatinine. He was
initially admitted to the MICU service for concern of sepsis
(given hypotension, hypothermia to 95, tachycardia 90's, wbc
3.6). Broad spectrum antibiotics were started (vancomycin and
levofloxacin), a dopamine infusion was started, and urine/blood
cultures were drawn.

MEDICAL HISTORY: 1) CAD, 3vd on last cath in [**2131**]- MI x 2 [**2131**], [**2143**]. MI in [**2143**]
was "silent" per pt's wife. [**Name (NI) 4084**] revascularized. In [**2131**], chose
medical mngt instead as pt was told his procedure was "high
risk"
2) CHF: echo [**2145-1-21**] w/ EF 20-35%,
3) DM 2
4) HTN
5) CRI: baseline cr 1.4-2.0 in past but has been 2-5.7 since
[**6-26**]
6) hyperlipidemia
7) PVD, s/p L BKA, and R femoral-tarsal bypass graft
8) hard of hearing, wears hearing aid

MEDICATION ON ADMISSION: MEDICATIONS UPON TRANSFER FROM MICU:
1. NESIRITIDE O.01 MCG/KG/MIN
2. SEVELAMER 800 MG TID
3. LEVOFLOXACIN 250 MG PO Q48
4. VANCO X 1 DOSE
5. ASCORBIC ACID
6. ZINC SULFATE
7. B12 50 MCG DAILY
8. ATORVASTATIN 10 MG DAILY
9. INSULIN SCALE
10. LEVOTHRYOXINE 75 MCG DAILY
11. PLAVIX 75 MG DAILY
12. DOPAMINE AT 3 MCG/KG/MIN
13. ASA 325 MG DAILY
14. PANTOPRAZOLE
15. HEPARIN 5000 SC TID
16. COLACE
17. BISACODLYL PRN
18. LORAZEPAM PRN

ALLERGIES: Betadine / Ibuprofen

PHYSICAL EXAM: PE:  T 97.7  BP 87/56  P 85  R 14 sats 99% CVP 10
696/830 = -160 today LOS +1674 (incl ICU admission)
GEN: comfortable man, in chair, no distress
HEENT: PERRL, EOMI, OP clear, hearing aid in place
NECK: JVP to angle of jaw, no JVD, supple, no LAD
CHEST: bibasilar crackles, upper fields clear, good air movement
CV: RRR w/ some irreg beats, +S3, 1/6 systolic blowing murmur
ABD: soft, non tender, no hepatosplenomegaly, small amount of
ascites w/ fluid wave, NABS
EXTRM: left extrm w/ stump (s/p BKA) with 3 ulcerations (all
bandaged in fresh bandage), no tenderness or ooze. Right LE with
scant, nonpitting edema, 1+ DP pulse, only 3 toes present, small
1x1 cm dry ulcer in between 2 and 3 digits.
NEURO: cranial nerves intact, 5/5 strength in upper extremity.
4/5 strength in LE bilaterally. Good historian. Normal (2+)
biceps and patellar reflexes bilaterally. Alert and oriented x
3.

FAMILY HISTORY: Mom w/ CAD, DM, but unclear details.
Rest of history is unknown to patient.

SOCIAL HISTORY: Pt. lives his wife. [**Name (NI) **] six children and many grandchildren. He
used to work in for the gas company in [**Location (un) 1411**] but is now
retired. He is a nonsmoker. Drinks 3-5 beers once a week, but
not recently. He is DNR/DNI.
Congestive heart failure, unspecified,Acute respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hypotension, unspecified,Unspecified acquired hypothyroidism,Other specified forms of chronic ischemic heart disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Other amputation stump complication,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
CHF NOS,Acute respiratry failure,Hyp kid NOS w cr kid V,Hypotension NOS,Hypothyroidism NOS,Chr ischemic hrt dis NEC,DMII wo cmp nt st uncntr,Anemia NOS,Amputat stump compl NEC,Abn react-procedure NEC
Admission Date:  [**2145-1-20**]              Discharge Date:   [**2145-1-30**]

Date of Birth:  [**2072-3-31**]             Sex:   M

Service: MEDICINE

Allergies:
Betadine / Ibuprofen

Attending:[**First Name3 (LF) 9569**]
Chief Complaint:
hypotension and RLE edema

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Pt is a 72 y.o man w/ NIDDM, CAD s/p MI x 2, class IV CHF (EF
20-25%), PVD, CRI who presented from his PCP's office on [**1-20**]
w/ asymptomatic BP 70's/40's and LE edema/pain in the setting of
cessation of lasix secondary to elevation in creatinine. He was
initially admitted to the MICU service for concern of sepsis
(given hypotension, hypothermia to 95, tachycardia 90's, wbc
3.6). Broad spectrum antibiotics were started (vancomycin and
levofloxacin), a dopamine infusion was started, and urine/blood
cultures were drawn.

At baseline, pt reports dyspnea w/ minimal to no exertion. He
denies chest pain. He is extremely compliant with his low sodium
diet, his medications. His lasix was stopped approx 10 days ago
for elevation in creatitine and concern for overdiuresis. His
weight has been stable in the 160's until he gained 10 lbs in
the last 6 weeks.

Past Medical History:
1) CAD, 3vd on last cath in [**2131**]- MI x 2 [**2131**], [**2143**]. MI in [**2143**]
was "silent" per pt's wife. [**Name (NI) 4084**] revascularized. In [**2131**], chose
medical mngt instead as pt was told his procedure was "high
risk"
2) CHF: echo [**2145-1-21**] w/ EF 20-35%,
3) DM 2
4) HTN
5) CRI: baseline cr 1.4-2.0 in past but has been 2-5.7 since
[**6-26**]
6) hyperlipidemia
7) PVD, s/p L BKA, and R femoral-tarsal bypass graft
8) hard of hearing, wears hearing aid

Social History:
Pt. lives his wife. [**Name (NI) **] six children and many grandchildren. He
used to work in for the gas company in [**Location (un) 1411**] but is now
retired. He is a nonsmoker. Drinks 3-5 beers once a week, but
not recently. He is DNR/DNI.

Family History:
Mom w/ CAD, DM, but unclear details.
Rest of history is unknown to patient.

Physical Exam:
PE:  T 97.7  BP 87/56  P 85  R 14 sats 99% CVP 10
696/830 = -160 today LOS +1674 (incl ICU admission)
GEN: comfortable man, in chair, no distress
HEENT: PERRL, EOMI, OP clear, hearing aid in place
NECK: JVP to angle of jaw, no JVD, supple, no LAD
CHEST: bibasilar crackles, upper fields clear, good air movement
CV: RRR w/ some irreg beats, +S3, 1/6 systolic blowing murmur
ABD: soft, non tender, no hepatosplenomegaly, small amount of
ascites w/ fluid wave, NABS
EXTRM: left extrm w/ stump (s/p BKA) with 3 ulcerations (all
bandaged in fresh bandage), no tenderness or ooze. Right LE with
scant, nonpitting edema, 1+ DP pulse, only 3 toes present, small
1x1 cm dry ulcer in between 2 and 3 digits.
NEURO: cranial nerves intact, 5/5 strength in upper extremity.
4/5 strength in LE bilaterally. Good historian. Normal (2+)
biceps and patellar reflexes bilaterally. Alert and oriented x
3.


Pertinent Results:
INITIAL LABS:

[**2145-1-20**] 06:38PM   PT-14.4* PTT-33.3 INR(PT)-1.3
[**2145-1-20**] 06:15PM   LACTATE-2.1*
[**2145-1-20**] 06:00PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2145-1-20**] 06:00PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2145-1-20**] 06:00PM URINE  RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-[**7-2**]
[**2145-1-20**] 05:55PM   GLUCOSE-90 UREA N-129* CREAT-4.8* SODIUM-130*
POTASSIUM-5.2* CHLORIDE-96 TOTAL CO2-19* ANION GAP-20
[**2145-1-20**] 05:55PM   ALT(SGPT)-36 AST(SGOT)-56* LD(LDH)-223
CK(CPK)-160 ALK PHOS-174* AMYLASE-82 TOT BILI-0.7
[**2145-1-20**] 05:55PM   CK-MB-16* MB INDX-10.0* cTropnT-0.11*
[**2145-1-20**] 05:55PM   CALCIUM-9.5 PHOSPHATE-5.2* MAGNESIUM-1.8
[**2145-1-20**] 05:55PM   WBC-3.6* RBC-3.06* HGB-11.0* HCT-32.3*
MCV-105* MCH-35.8* MCHC-34.0 RDW-13.6
[**2145-1-20**] 05:55PM   NEUTS-72.1* LYMPHS-15.7* MONOS-7.1 EOS-4.3*
BASOS-0.8
[**2145-1-20**] 05:55PM   MACROCYT-3+
[**2145-1-20**] 05:55PM   PLT SMR-LOW PLT COUNT-85* LPLT-2+

TODAY [**1-22**]:
WBC 4.5, HCT 30.7, MCV 107, PLATELETS 96 (FROM 102)
INR 1.4
RETIC 1.3
NA 130, K 4.9, CL 98, BICARBONATE 19, BUN 110, CR 3.9 (FROM 4.2,
4.5)
CA 9.9, MG 1.6, PHOS 4.4
B12 1321
FOLATE 15.8
URIC ACID 13.3

CK 92 (114, 122)
MB 0 (12)
TROP 0.17 (0.20, 0.12)

[**Last Name (un) **] STIM  27 ---> 48.8

MICRO DATA:
INFLUENZA DFA NEGATIVE
BLD CULTURE X 2: [**1-20**] NGTD
URINE CULTURE: NGTD ([**1-20**])

CXR: PULM EDEMA ([**1-22**]) STABLE, WIDENED MEDIASTINUM

EKG: NSR, RATE 100, IVCD, NL AXIS, PR 300 MS (1st degree block),
low voltage, ?apc's

Brief Hospital Course:
72 y.o man w/ h/o 3V CAD, MI X 2, CRI, IDDM, presents w/
asymptomatic hypotension, right lower extremity edema. During
his two days on the ICU service, he was afebrile with
normalization in his wbc's. He had no other focal signs of
infection and his cultures are negative to date. A cardiology
consultation was obtained upon admission given patient's
advanced heart failure and it was thought that the patient's
hypotension could also be due decompensated heart failure. Given
all of the above, he was transferred to the CCU service on [**1-22**]
for diuresis/heart failure management.
.
During the hospital stay the patient and family requested to
begin plans for hospice, palliative care team was involved and
pt was discharge to home with hospice care.
.
1. Hypotension: Etiology originally thought to be sepsis, but no
clear evidence: cultures negative, afebrile, no wbc. Patient not
adrenally insufficient as passed his [**Last Name (un) 104**]-stim test. His
hypotension likely due to decompenated CHF and lack of forward
flow. In the CCU he was continued on dopamine and started on
Natrecor with good effect of diuresis leading to normalizing of
blood pressure. Once the Natrecor was discontinued, a dopamine
wean was begun.  The blood pressure dropped off dopamine and so
it was restarted and eventually continued until two days before
discharge.  His levaquin and vancomycin were discontinued, given
the lack of evidence for infectious process.

2. Heart failure: Pt has EF 25% but w/ multiple valvlular
regurges (TR, MR, AR). His toprol, lasix were held, given low BP
and rising Cr. Started Natrecor infusion and continued low dose
dopa for BP support, renal perfusion. Natrecor worked with good
effect of diuresis leading to normalizing of blood pressure.  Pt
started on carvedilol with precipitous drop in blood pressure
and associated pulmonary edema, requiring restarting infusion of
dopamine until two days before discharge. Pt was also treated
with digoxin and lasix, continued upon discharge.

3. CAD: Had small trop leak but no evidence of acute ischemia.
Continued ASA/statin/plavix. BB held given hypotension.

4. CRI: Has had recent worsening of renal function over last 6
months. Likely progressing towards dialysis, but cr has been
improved slightly in CCU. Recent renal u/s showed echogenic 1.2
cm lesion on lower pole of left kidney. Pt was recommended to
have f/u MRI to further evaluate this but will likely not have
this in light of decision to commence hospice care.

5. Anemia: Macrocytic (new since [**9-26**]). Hct was 34 on [**1-8**].
Likely multifactorial, given acute on chronic renal disease. B12
and folate are normal, pt on B12.

6. DM: Well controlled.

7. Hypothyroid: TSH 13 on [**1-8**], but free t4 normal. He is on
levothyroxine.

8. PVD: s/p bipass on left LE and BKA on right. Has bilateral
ulcers that appear clean and non-infected. Continued aggressive
wound care.

9. FEN: Diabetic, low sodium diet


Medications on Admission:
MEDICATIONS UPON TRANSFER FROM MICU:
1. NESIRITIDE O.01 MCG/KG/MIN
2. SEVELAMER 800 MG TID
3. LEVOFLOXACIN 250 MG PO Q48
4. VANCO X 1 DOSE
5. ASCORBIC ACID
6. ZINC SULFATE
7. B12 50 MCG DAILY
8. ATORVASTATIN 10 MG DAILY
9. INSULIN SCALE
10. LEVOTHRYOXINE 75 MCG DAILY
11. PLAVIX 75 MG DAILY
12. DOPAMINE AT 3 MCG/KG/MIN
13. ASA 325 MG DAILY
14. PANTOPRAZOLE
15. HEPARIN 5000 SC TID
16. COLACE
17. BISACODLYL PRN
18. LORAZEPAM PRN

Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q 15
minutes as needed for shortness of breath or wheezing.
Disp:*60 cc* Refills:*2*
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for anxiety.
Disp:*60 Tablet(s)* Refills:*2*
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for shortness of breath or wheezing.
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*16 Tablet(s)* Refills:*2*
11. Docusate Sodium 50 mg/15 mL Syrup Sig: One Hundred (100) mg
PO twice a day.


Discharge Disposition:
Home with Service

Discharge Diagnosis:
Congestive Heart Failure

Discharge Condition:
Pt is discharged to hospice care.  O2 saturation 94% on room
air.

Discharge Instructions:
Continue care with Hospice nurses.

Followup Instructions:
Continue care with Hospice nurses.


Completed by:[**2145-2-24**]
{'Congestive heart failure, unspecified,Acute respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hypotension, unspecified,Unspecified acquired hypothyroidism,Other specified forms of chronic ischemic heart disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Other amputation stump complication,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: hypotension and RLE edema

PRESENT ILLNESS: Pt is a 72 y.o man w/ NIDDM, CAD s/p MI x 2, class IV CHF (EF
20-25%), PVD, CRI who presented from his PCP's office on [**1-20**]
w/ asymptomatic BP 70's/40's and LE edema/pain in the setting of
cessation of lasix secondary to elevation in creatinine. He was
initially admitted to the MICU service for concern of sepsis
(given hypotension, hypothermia to 95, tachycardia 90's, wbc
3.6). Broad spectrum antibiotics were started (vancomycin and
levofloxacin), a dopamine infusion was started, and urine/blood
cultures were drawn.

MEDICAL HISTORY: 1) CAD, 3vd on last cath in [**2131**]- MI x 2 [**2131**], [**2143**]. MI in [**2143**]
was "silent" per pt's wife. [**Name (NI) 4084**] revascularized. In [**2131**], chose
medical mngt instead as pt was told his procedure was "high
risk"
2) CHF: echo [**2145-1-21**] w/ EF 20-35%,
3) DM 2
4) HTN
5) CRI: baseline cr 1.4-2.0 in past but has been 2-5.7 since
[**6-26**]
6) hyperlipidemia
7) PVD, s/p L BKA, and R femoral-tarsal bypass graft
8) hard of hearing, wears hearing aid

MEDICATION ON ADMISSION: MEDICATIONS UPON TRANSFER FROM MICU:
1. NESIRITIDE O.01 MCG/KG/MIN
2. SEVELAMER 800 MG TID
3. LEVOFLOXACIN 250 MG PO Q48
4. VANCO X 1 DOSE
5. ASCORBIC ACID
6. ZINC SULFATE
7. B12 50 MCG DAILY
8. ATORVASTATIN 10 MG DAILY
9. INSULIN SCALE
10. LEVOTHRYOXINE 75 MCG DAILY
11. PLAVIX 75 MG DAILY
12. DOPAMINE AT 3 MCG/KG/MIN
13. ASA 325 MG DAILY
14. PANTOPRAZOLE
15. HEPARIN 5000 SC TID
16. COLACE
17. BISACODLYL PRN
18. LORAZEPAM PRN

ALLERGIES: Betadine / Ibuprofen

PHYSICAL EXAM: PE:  T 97.7  BP 87/56  P 85  R 14 sats 99% CVP 10
696/830 = -160 today LOS +1674 (incl ICU admission)
GEN: comfortable man, in chair, no distress
HEENT: PERRL, EOMI, OP clear, hearing aid in place
NECK: JVP to angle of jaw, no JVD, supple, no LAD
CHEST: bibasilar crackles, upper fields clear, good air movement
CV: RRR w/ some irreg beats, +S3, 1/6 systolic blowing murmur
ABD: soft, non tender, no hepatosplenomegaly, small amount of
ascites w/ fluid wave, NABS
EXTRM: left extrm w/ stump (s/p BKA) with 3 ulcerations (all
bandaged in fresh bandage), no tenderness or ooze. Right LE with
scant, nonpitting edema, 1+ DP pulse, only 3 toes present, small
1x1 cm dry ulcer in between 2 and 3 digits.
NEURO: cranial nerves intact, 5/5 strength in upper extremity.
4/5 strength in LE bilaterally. Good historian. Normal (2+)
biceps and patellar reflexes bilaterally. Alert and oriented x
3.

FAMILY HISTORY: Mom w/ CAD, DM, but unclear details.
Rest of history is unknown to patient.

SOCIAL HISTORY: Pt. lives his wife. [**Name (NI) **] six children and many grandchildren. He
used to work in for the gas company in [**Location (un) 1411**] but is now
retired. He is a nonsmoker. Drinks 3-5 beers once a week, but
not recently. He is DNR/DNI. 

### Response:
{'Congestive heart failure, unspecified,Acute respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hypotension, unspecified,Unspecified acquired hypothyroidism,Other specified forms of chronic ischemic heart disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Other amputation stump complication,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
