CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: The patient is a 73 year old woman with history of ESRD on HD,
hypertension, severe PVD s/p bilateral BKA, and LVH with LVOT
who is presenting with acute shortness of breath. She was in her
usual state of health until earlier this evening when she
noticed that she "just didn't feel right." When she went to lay
down, she noted the onset of shortness of breath.  She denied
chest pain or palpitations. She had her last HD session on
Friday. She denies eating salty food or missing medications
.
In the ED her initial vital signs were 220/110 120 RR 40 and
100% on BIPAP.  She continued on BIPAP with improvement in her
oxygenation.  An EKG was interpreted as unchanged from prior.
Nitro-paste was administered for blood pressure control.  A left
femoral central line was placed for IV access.  Both cardiology
and nephrology were consulted who recommended urgent dialysis
for volume control.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She 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,  palpitations, syncope or presyncope.

MEDICAL HISTORY: - Diastolic CHF with LVOT obstruction at rest
- Chronic 2L NC at night
- Hypertension
- Diabetes
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
- GERD
- Hypercholesterolemia
- ESRD on hemodialysis M,W,F. Receives dialysis at [**Location (un) **]
hemodialysis center in [**Location (un) **].
- Paroxysmal atrial flutter, s/p failed ablation with subsequent
a. fib
- Peptic ulcer disease
- Hypertrophic obstructive cardiomyopathy
- Mild mitral stenosis (MVA 1.5-2.0 cm2)
- Secondary Hyperparathyroidism
- Diastolic Congestive Heart Failure

MEDICATION ON ADMISSION: Nephro-cap 1 capsule daily
Warfarin 2 mg Daily
Brimonidine 0.15 % Drops DAILY
Latanoprost 0.005 % Drops HS
Tiotropium 18 mcg DAILY
Ranitidine HCl 150 mg DAILY
Lisinopril 30 mg DAILY
Insulin NPH 4 [**Hospital1 **]
Albuterol 90 mcg 1 puff:q6hours
Aspirin 325 mg daily
Simvastatin 80 mg daily
Diltiazem HCl SR 120 mg DAILY
Irbesartan 150 mg daily
Metoprolol Tartrate 100 mg [**Hospital1 **]
Sevelamer HCl 800 mg TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.3, BP 121/69, HR 78, RR 18, O2 99% on 4L
Gen: thin elderly, African American female. Oriented x3. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. right pupil 2mm->1, left surgical
pupil, EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa.
Neck: Supple with JVP to angle of jaw. gauze in place from LIJ
line placement w/o hematoma
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. II/VI holosystolic murmur at
LLSB/apex
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles and rhonchi to
[**12-22**] way up back.
Abd: flat, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No c/c/e. No femoral bruits. b/l BKA. left femoral TLC
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit
Left: Carotid 2+ without bruit; Femoral 2+ without bruit

FAMILY HISTORY: Her father died in his 90s and mother at the age of 102. Patient
unable to specify cause of death. She has one living sister and
6 sisters and one brother who passed away. Her family history is
significant for coronary artery disease, cancer, and diabetes.

SOCIAL HISTORY: Social history is significant for the presence of current
tobacco use (1 pack per week), and [**12-22**] PPD x 50 years. There is
no history of alcohol abuse. Lives in [**Hospital3 **] facility
and uses a mobile wheelchair or a walker.
Acute on chronic diastolic heart failure,End stage renal disease,Other pulmonary insufficiency, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Secondary hyperparathyroidism (of renal origin),Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Long-term (current) use of insulin,Atherosclerosis of native arteries of the extremities, unspecified,Below knee amputation status,Atrial fibrillation,Polycythemia, secondary,Esophageal reflux,Pure hypercholesterolemia,Personal history of tobacco use
Ac on chr diast hrt fail,End stage renal disease,Other pulmonary insuff,Hyp kid NOS w cr kid V,Sec hyperparathyrd-renal,DMII renl nt st uncntrld,Nephritis NOS in oth dis,Long-term use of insulin,Athscl extrm ntv art NOS,Status amput below knee,Atrial fibrillation,Secondary polycythemia,Esophageal reflux,Pure hypercholesterolem,History of tobacco use
Admission Date:  [**2163-6-20**]              Discharge Date:   [**2163-6-22**]

Date of Birth:  [**2090-1-9**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 134**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
none

History of Present Illness:
The patient is a 73 year old woman with history of ESRD on HD,
hypertension, severe PVD s/p bilateral BKA, and LVH with LVOT
who is presenting with acute shortness of breath. She was in her
usual state of health until earlier this evening when she
noticed that she "just didn't feel right." When she went to lay
down, she noted the onset of shortness of breath.  She denied
chest pain or palpitations. She had her last HD session on
Friday. She denies eating salty food or missing medications
.
In the ED her initial vital signs were 220/110 120 RR 40 and
100% on BIPAP.  She continued on BIPAP with improvement in her
oxygenation.  An EKG was interpreted as unchanged from prior.
Nitro-paste was administered for blood pressure control.  A left
femoral central line was placed for IV access.  Both cardiology
and nephrology were consulted who recommended urgent dialysis
for volume control.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She 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,  palpitations, syncope or presyncope.

Past Medical History:
- Diastolic CHF with LVOT obstruction at rest
- Chronic 2L NC at night
- Hypertension
- Diabetes
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
- GERD
- Hypercholesterolemia
- ESRD on hemodialysis M,W,F. Receives dialysis at [**Location (un) **]
hemodialysis center in [**Location (un) **].
- Paroxysmal atrial flutter, s/p failed ablation with subsequent
a. fib
- Peptic ulcer disease
- Hypertrophic obstructive cardiomyopathy
- Mild mitral stenosis (MVA 1.5-2.0 cm2)
- Secondary Hyperparathyroidism
- Diastolic Congestive Heart Failure

Social History:
Social history is significant for the presence of current
tobacco use (1 pack per week), and [**12-22**] PPD x 50 years. There is
no history of alcohol abuse. Lives in [**Hospital3 **] facility
and uses a mobile wheelchair or a walker.


Family History:
Her father died in his 90s and mother at the age of 102. Patient
unable to specify cause of death. She has one living sister and
6 sisters and one brother who passed away. Her family history is
significant for coronary artery disease, cancer, and diabetes.


Physical Exam:
VS: T 97.3, BP 121/69, HR 78, RR 18, O2 99% on 4L
Gen: thin elderly, African American female. Oriented x3. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. right pupil 2mm->1, left surgical
pupil, EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa.
Neck: Supple with JVP to angle of jaw. gauze in place from LIJ
line placement w/o hematoma
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. II/VI holosystolic murmur at
LLSB/apex
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles and rhonchi to
[**12-22**] way up back.
Abd: flat, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No c/c/e. No femoral bruits. b/l BKA. left femoral TLC
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit
Left: Carotid 2+ without bruit; Femoral 2+ without bruit

Pertinent Results:
[**2163-6-20**] 12:00AM BLOOD WBC-16.1*# RBC-4.34 Hgb-12.5 Hct-41.2
MCV-95 MCH-28.9 MCHC-30.4* RDW-18.8* Plt Ct-350
[**2163-6-22**] 04:54AM BLOOD WBC-7.8 RBC-4.16* Hgb-12.0 Hct-38.9
MCV-93 MCH-29.0 MCHC-31.0 RDW-17.8* Plt Ct-324

[**2163-6-20**] 12:00AM BLOOD PT-17.6* PTT-94.2* INR(PT)-1.6*
[**2163-6-22**] 04:54AM BLOOD PT-27.2* PTT-38.1* INR(PT)-2.7*

[**2163-6-20**] 12:00AM BLOOD Glucose-182* UreaN-74* Creat-8.1*# Na-140
K-5.6* Cl-100 HCO3-26 AnGap-20
[**2163-6-20**] 11:30AM BLOOD K-6.4*
[**2163-6-22**] 04:54AM BLOOD Glucose-100 UreaN-65* Creat-6.9*# Na-135
K-5.0 Cl-98 HCO3-27 AnGap-15

[**2163-6-20**] 12:00AM BLOOD CK(CPK)-49
[**2163-6-20**] 06:24AM BLOOD CK(CPK)-53
[**2163-6-20**] 12:00AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2163-6-20**] 06:24AM BLOOD CK-MB-NotDone cTropnT-0.05*

[**2163-6-20**] 06:24AM BLOOD Calcium-8.7 Phos-6.4* Mg-2.7*
[**2163-6-20**] 08:00PM BLOOD Calcium-8.6 Phos-2.8# Mg-2.0
[**2163-6-22**] 04:54AM BLOOD Calcium-8.7 Phos-5.6*# Mg-2.5


Brief Hospital Course:
The patient is a 73 year old woman with history of ESRD on HD,
severe PVD, LVH with LVOT obstruction presenting with shortness
of breath and pulmonary edema.
.
# CAD:
Although patient has with multiple CAD risk factors, prior
non-invasive and invasive testing showed no significant
obstructive coronary disease.  A troponin of 0.04 in the context
of normal CK and EKG with no ST-T changes was likely demand
ischemia secondary to hypertensive heart disease. Admission EKG
did not show signs of active ischemia and the patient was
monitored on telemetry and continued on aspirin and statin.
.
# CHF:
The pt's hypoxia was attributed to CHF and not pneumonia as she
denied any cough, and was afebrile and lacking a consolidate on
chest xray. Pulmonary embolism was also unlikely as the patient
is on chronic anticoagulation.  Due to chronic diastolic
congestive heart failure and a physiologic HOCM that leads to
hypotension during dialysis sessions, it is most likely that the
patient developed pulmonary edema  in the setting of volume
status change while receiving dialysis.  Her oxygenation status
improved significantly following blood pressure and rate control
and a dialysis session. There are no PFT's to support the
diagnosis of COPD, but marked hyperinflation on CXR and notable
smoking history indicated strong possibility of COPD
contributing to patient's symptoms so patient was treated with
home dose of spiriva and albuterol as needed. The patient was
weaned on BiPap and began to breathe comfortably on room air
following dialysis.
.
# Atrial fibrillation:
The pt was anticoagulated with coumadin and rate controlled with
metoprolol and diltiazem for her history of atrial fibrillation.

.
# Hypertension:
The patient's hypertension was also controlled with diltiazem
and metoprolol and following a successful dialysis session her
lisinopril and irbesartan were restarted.
.
# Diabetes:
For her diabetes the patient was continued on her home dose of
NPH with an insulin sliding scale.
.
# Hyperkalemia:
The patient has end stage renal disease and receiving HD.  The
patient was orginally volume overloaded and on day two of
admission developed hyperkalemia to a K of 6.7.  She had no
peaked T waves or QT prolongation on EKG and received calcium
carbonate and D5/insulin as well as dialysis.  Her electrolytes
were monitored closely with subsequent K between 4.1 and 5.0.

# Heme:
On admission labs the patient was erythrocytotic. Prior
evaluations had not shown renal mass that could contribute to
over production of erythropoietin and on [**2163-5-30**] the epo
level was low normal which would suggest a MPD such as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].
Patient would benefit from heme follow up as an outpatient.


Medications on Admission:
Nephro-cap 1 capsule daily
Warfarin 2 mg Daily
Brimonidine 0.15 % Drops DAILY
Latanoprost 0.005 % Drops HS
Tiotropium 18 mcg DAILY
Ranitidine HCl 150 mg DAILY
Lisinopril 30 mg DAILY
Insulin NPH 4 [**Hospital1 **]
Albuterol 90 mcg 1 puff:q6hours
Aspirin 325 mg daily
Simvastatin 80 mg daily
Diltiazem HCl SR 120 mg DAILY
Irbesartan 150 mg daily
Metoprolol Tartrate 100 mg [**Hospital1 **]
Sevelamer HCl 800 mg TID

Discharge Medications:
1. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.

2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
11. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
12. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
13. Diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Four
(4) units Subcutaneous twice a day.
15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] [**Location (un) 269**]

Discharge Diagnosis:
Primary:
Acute diastolic Heart Failure
End stage renal disease on hemodialysis
.
Secondary:
Peripheral Vascular disease
Atrial Fibrillation on Coumadin
Hypertension


Discharge Condition:
stable


Discharge Instructions:
You were admitted with shortness of breath and acute diastolic
heart failure.  This has been treated with dialysis & aggressive
blood pressure control.
.
We have not made any changes to your medications, please make
sure to adhere to a low salt diet and keep all your follow up
appointments as shown below.
.
If you develop any worsening shortness of breath, chest pain,
weakness or any other general worsening of condition, please
call your PCP or come directly to the ED.
.
It is very important that you adhere to a low sodium diet.

Followup Instructions:
1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2163-7-14**] 12:40
.
2. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2163-8-29**] 11:40am
.
3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2163-12-7**] 1:40pm
{'Acute on chronic diastolic heart failure,End stage renal disease,Other pulmonary insufficiency, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Secondary hyperparathyroidism (of renal origin),Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Long-term (current) use of insulin,Atherosclerosis of native arteries of the extremities, unspecified,Below knee amputation status,Atrial fibrillation,Polycythemia, secondary,Esophageal reflux,Pure hypercholesterolemia,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: shortness of breath

PRESENT ILLNESS: The patient is a 73 year old woman with history of ESRD on HD,
hypertension, severe PVD s/p bilateral BKA, and LVH with LVOT
who is presenting with acute shortness of breath. She was in her
usual state of health until earlier this evening when she
noticed that she "just didn't feel right." When she went to lay
down, she noted the onset of shortness of breath.  She denied
chest pain or palpitations. She had her last HD session on
Friday. She denies eating salty food or missing medications
.
In the ED her initial vital signs were 220/110 120 RR 40 and
100% on BIPAP.  She continued on BIPAP with improvement in her
oxygenation.  An EKG was interpreted as unchanged from prior.
Nitro-paste was administered for blood pressure control.  A left
femoral central line was placed for IV access.  Both cardiology
and nephrology were consulted who recommended urgent dialysis
for volume control.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She 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,  palpitations, syncope or presyncope.

MEDICAL HISTORY: - Diastolic CHF with LVOT obstruction at rest
- Chronic 2L NC at night
- Hypertension
- Diabetes
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
- GERD
- Hypercholesterolemia
- ESRD on hemodialysis M,W,F. Receives dialysis at [**Location (un) **]
hemodialysis center in [**Location (un) **].
- Paroxysmal atrial flutter, s/p failed ablation with subsequent
a. fib
- Peptic ulcer disease
- Hypertrophic obstructive cardiomyopathy
- Mild mitral stenosis (MVA 1.5-2.0 cm2)
- Secondary Hyperparathyroidism
- Diastolic Congestive Heart Failure

MEDICATION ON ADMISSION: Nephro-cap 1 capsule daily
Warfarin 2 mg Daily
Brimonidine 0.15 % Drops DAILY
Latanoprost 0.005 % Drops HS
Tiotropium 18 mcg DAILY
Ranitidine HCl 150 mg DAILY
Lisinopril 30 mg DAILY
Insulin NPH 4 [**Hospital1 **]
Albuterol 90 mcg 1 puff:q6hours
Aspirin 325 mg daily
Simvastatin 80 mg daily
Diltiazem HCl SR 120 mg DAILY
Irbesartan 150 mg daily
Metoprolol Tartrate 100 mg [**Hospital1 **]
Sevelamer HCl 800 mg TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.3, BP 121/69, HR 78, RR 18, O2 99% on 4L
Gen: thin elderly, African American female. Oriented x3. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. right pupil 2mm->1, left surgical
pupil, EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa.
Neck: Supple with JVP to angle of jaw. gauze in place from LIJ
line placement w/o hematoma
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. II/VI holosystolic murmur at
LLSB/apex
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles and rhonchi to
[**12-22**] way up back.
Abd: flat, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No c/c/e. No femoral bruits. b/l BKA. left femoral TLC
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit
Left: Carotid 2+ without bruit; Femoral 2+ without bruit

FAMILY HISTORY: Her father died in his 90s and mother at the age of 102. Patient
unable to specify cause of death. She has one living sister and
6 sisters and one brother who passed away. Her family history is
significant for coronary artery disease, cancer, and diabetes.

SOCIAL HISTORY: Social history is significant for the presence of current
tobacco use (1 pack per week), and [**12-22**] PPD x 50 years. There is
no history of alcohol abuse. Lives in [**Hospital3 **] facility
and uses a mobile wheelchair or a walker. 

### Response:
{'Acute on chronic diastolic heart failure,End stage renal disease,Other pulmonary insufficiency, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Secondary hyperparathyroidism (of renal origin),Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Long-term (current) use of insulin,Atherosclerosis of native arteries of the extremities, unspecified,Below knee amputation status,Atrial fibrillation,Polycythemia, secondary,Esophageal reflux,Pure hypercholesterolemia,Personal history of tobacco use'}
