CHIEF COMPLAINT: Chest discomfort, shortness of breath

PRESENT ILLNESS: 84-year-old female with CAD s/p CABG in [**9-18**] (LIMA-LAD,
SVG-OM1), CHF, ESRD on HD, DMII, PAF who is transferred from
outside hospital for cardiac catheterization.
.
The patient recently presented to [**Hospital3 **] with a CHF
exacerbation and developed worsening renal failure requiring
initiation of hemodialysis. She was discharged to rehab and
developed chest discomfort, epigastric discomfort and
progressive shortness of breath. She represented to [**Hospital1 **] where she admitted to the ICU. She had evidence of
moderate CHF on CXR and was also in atrial fibrillation. She was
started on a diltiazem drip which was discontinued with
metoprolol tartrate PO for rate control. Her oxygen saturation
was 94-97% on 5 liters of O2. Dr. [**Last Name (STitle) 4469**] was worried that the
CHF could be related to ongoing ischemia and transferred the
patient to [**Hospital1 18**] for cardiac catheterization.
.
Vital signs on transfer were afebrile, BP 149/46, HR 65 SR, RR
21, SaO2 94-97% on 5 liters.
.
On review of systems, 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 current absence of
chest pain. Reports dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema.

MEDICAL HISTORY: 1. coronary artery disease: s/p CABG x2v, LIMA-LAD, SVG-OM1, ETT
- per Dr. [**Last Name (STitle) 4469**] fall of [**2189**] with infero-apical ischemia and
normal LVEF
2. diastolic congestive heart failure - EF 65%
3. Pulmonary hypertension - PA pressure 56mmHg
4. hypertension:
5. diabetes mellitus type II:
6. end-stage renal disease: on hemodialysis, s/p recent tunneled
catheter
7. hyperlipidemia:
8. h/o breast cancer: s/p R mastectomy
9. h/o rheumatic fever:
10. hypothyroidism s/p thyroidectomy:
11. peptic ulcer disease:
12. s/p hysterectomy:
13. chronic anemia
14. degenerative joint disease
15. paroxysmal atrial fibrillation - with RVR
16. chronic low back pain
17. GERD

MEDICATION ON ADMISSION: Ativan 0.5mg PO qhs
Zocor 40mg PO daily
Protonix 40mg PO daily
Allopurinol 200mg PO daily
Hydralazine 25mg PO daily
Tylenol PRN
Ferrous sulfate 325mg PO daily
Aspirin 81mg PO daily
Amiodarone 100mg PO daily
Synthroid 25mcg PO daily
Toprol XL 25mg PO daily
Imdur 90mg PO daily
Maalox PRN
Levaquin 250mg daily for 5 days (to be continued until [**2190-3-28**])
.
MEDICATIONS: at transfer
Levoxyl 25mcg PO daily
Ferrous sulfate 325mg daily
Lorazepam 0.5mg qHS PRN
Amiodarone 100mg PO daily
Aspirin 81mg PO daily
Allopurinol 100mg PO daily
Protonix 40mg PO daily
Diltiazem gtt - 15mg per hour
Metoprolol tartrate 25mg PO BID
Simvastatin 40mg PO daily
Levalbuterol hydrochloride 1.25mg QID PRN inhaled
Heparin SQ TID
Nitroglycerin SL PRN
Bumex 4mg PO or IV - as directed

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission exam:

FAMILY HISTORY: Positive for CKD. Daughter has DM, CAD. Mother and sister have
CAD. Although negative for premature coronary artery disease.

SOCIAL HISTORY: The patient lives in a nursing home, prior to [**Month (only) 404**] lived in
[**Location 5110**]. Sister [**Name (NI) 2048**] [**Telephone/Fax (1) 98209**].
-[**Name2 (NI) 1139**] history: Prior history, quit
-ETOH: None
-Illicit drugs: None
Acute on chronic diastolic heart failure,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Primary pulmonary hypertension,Renal dialysis status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Anemia, unspecified,Unspecified acquired hypothyroidism,Esophageal reflux,Dyspepsia and other specified disorders of function of stomach,Personal history of malignant neoplasm of breast
Ac on chr diast hrt fail,End stage renal disease,Hyp kid NOS w cr kid V,Prim pulm hypertension,Renal dialysis status,DMII wo cmp nt st uncntr,Atrial fibrillation,Anemia NOS,Hypothyroidism NOS,Esophageal reflux,Stomach function dis NEC,Hx of breast malignancy
Name:  [**Known lastname 15670**],[**Known firstname 15671**]                  Unit No:   [**Numeric Identifier 15672**]

Admission Date:  [**2190-3-26**]              Discharge Date:   [**2190-3-31**]

Date of Birth:  [**2105-9-13**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3780**]
Addendum:
Pt has acute on chronic diastolic congestive heart failure. An
ACE or [**Last Name (un) **] was not prescribed at discharge because of her ESRD.

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 49**] - [**Location (un) 50**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3782**] MD [**MD Number(2) 3783**]

Completed by:[**2190-3-31**]

Admission Date:  [**2190-3-26**]              Discharge Date:   [**2190-3-31**]

Date of Birth:  [**2105-9-13**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest discomfort, shortness of breath

Major Surgical or Invasive Procedure:
None

History of Present Illness:
84-year-old female with CAD s/p CABG in [**9-18**] (LIMA-LAD,
SVG-OM1), CHF, ESRD on HD, DMII, PAF who is transferred from
outside hospital for cardiac catheterization.
.
The patient recently presented to [**Hospital3 **] with a CHF
exacerbation and developed worsening renal failure requiring
initiation of hemodialysis. She was discharged to rehab and
developed chest discomfort, epigastric discomfort and
progressive shortness of breath. She represented to [**Hospital1 **] where she admitted to the ICU. She had evidence of
moderate CHF on CXR and was also in atrial fibrillation. She was
started on a diltiazem drip which was discontinued with
metoprolol tartrate PO for rate control. Her oxygen saturation
was 94-97% on 5 liters of O2. Dr. [**Last Name (STitle) 4469**] was worried that the
CHF could be related to ongoing ischemia and transferred the
patient to [**Hospital1 18**] for cardiac catheterization.
.
Vital signs on transfer were afebrile, BP 149/46, HR 65 SR, RR
21, SaO2 94-97% on 5 liters.
.
On review of systems, 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 current absence of
chest pain. Reports dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema.


Past Medical History:
1. coronary artery disease: s/p CABG x2v, LIMA-LAD, SVG-OM1, ETT
- per Dr. [**Last Name (STitle) 4469**] fall of [**2189**] with infero-apical ischemia and
normal LVEF
2. diastolic congestive heart failure - EF 65%
3. Pulmonary hypertension - PA pressure 56mmHg
4. hypertension:
5. diabetes mellitus type II:
6. end-stage renal disease: on hemodialysis, s/p recent tunneled
catheter
7. hyperlipidemia:
8. h/o breast cancer: s/p R mastectomy
9. h/o rheumatic fever:
10. hypothyroidism s/p thyroidectomy:
11. peptic ulcer disease:
12. s/p hysterectomy:
13. chronic anemia
14. degenerative joint disease
15. paroxysmal atrial fibrillation - with RVR
16. chronic low back pain
17. GERD


Social History:
The patient lives in a nursing home, prior to [**Month (only) 404**] lived in
[**Location 5110**]. Sister [**Name (NI) 2048**] [**Telephone/Fax (1) 98209**].
-[**Name2 (NI) 1139**] history: Prior history, quit
-ETOH: None
-Illicit drugs: None


Family History:
Positive for CKD. Daughter has DM, CAD. Mother and sister have
CAD. Although negative for premature coronary artery disease.

Physical Exam:
Admission exam:

GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: JVP of 10cm.
CARDIAC: Promenant PMI located in 5th intercostal space,
midclavicular line. RR, normal S1, loud S2. II/VI SM at LLSB
increased with inspiration. No lifts. No S3 or S4.
LUNGS: Diffuse rales in bilateral lung fields. R tunnel cath in
place.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.

EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+


Pertinent Results:
Transthoracic Echo [**2190-3-27**]: The left atrium is mildly dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Doppler parameters are most consistent with Grade II (moderate)
left ventricular diastolic dysfunction. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function.
Moderate diastolic LV dysfunction. Mild mitral regurgitation.
Mild pulmonary hypertension.

CXR [**2190-3-26**]: There are median sternotomy wires. Right-sided
dual-lumen central venous catheter with distal tip at the
cavoatrial junction. Cardiac silhouette is within normal limits.
There is increased opacity at the right lung base with
obscuration of the right hemidiaphragm and costophrenic angle,
most likely in keeping with a moderate-sized pleural effusion.
There is blunting of the left costophrenic angle, in keeping
with a mild subpleural effusion. There are increased linear
opacities, vascular distention and parahilar opacities in
keeping with moderate CHF. No evidence of pneumothorax.

[**2190-3-29**] 07:15AM BLOOD WBC-8.8 RBC-2.98* Hgb-8.1* Hct-27.1*
MCV-91 MCH-27.3 MCHC-30.0* RDW-17.5* Plt Ct-461*
[**2190-3-29**] 07:15AM BLOOD Plt Ct-461*
[**2190-3-29**] 07:15AM BLOOD Glucose-71 UreaN-32* Creat-2.7* Na-135
K-3.8 Cl-96 HCO3-28 AnGap-15
[**2190-3-29**] 07:15AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.0
[**2190-3-27**] 06:05AM BLOOD calTIBC-229* Ferritn-335* TRF-176*
[**2190-3-27**] 06:05AM BLOOD PTH-116*
[**2190-3-26**] 10:47PM BLOOD Glucose-89 UreaN-36* Creat-2.8* Na-133
K-4.4 Cl-96 HCO3-33* AnGap-8
[**2190-3-26**] 10:47PM BLOOD WBC-9.6 RBC-3.31* Hgb-8.8* Hct-29.5*
MCV-89 MCH-26.5* MCHC-29.8* RDW-16.5* Plt Ct-348

Brief Hospital Course:
Ms. [**Known lastname **] is an 84 year old woman with past medical history of
DM, HTN, CKD, hyperlipidemia and CAD s/p CABG x2
LIMA->LAD,SVG->OM1 who initially presented to an outside
hospital with chest discomfort and shortness of breath.  She was
transferred here for possible cardiac catherization as her
symptoms were thought to be ischemic in nature.

#.Acute on Chronic Diastolic Congestive Heart Failure:
Ms. [**Known lastname **] was admitted to the hospital with an acute
exacerbation of her congestive heart failure. She was noted to
have diffuse crackles in both lungs and 1+ pitting lower
extremity edema on admission.  A transthroacic echo was done on
[**2190-3-27**] which revealed Diastolic dysfunction with EF of >55%.
She underwent multiple hemodialysis treatments with removal of
fluid and subsequent improvement of her symptoms.

# Coronary Artery Disease:
Patient is s/p CABG x 2 - SVG-OM and LIMA-LAD.  Her chest
discomfort was thought to be anginal in nature, however it was
believed that this was likely due to her atrial fibrillation and
RVR and more related to demand ischemia rather than acute plaque
rupture.  The decision was made to medically manage her coronary
artery disease, and she was discharged on metoprolol for rate
control, hydralazine for afterload reduction and isosorbide
mononitrate for anginal symptom control.

# ESRD currently on Hemodialysis
She was started on Hemodialysis at [**Hospital3 **] and was
transferred with a right sided tunneled IJ Quinton catheter in
place.  She was followed by the Nephrology team and received
regular Hemodialysis during hospitalization.  There is still
potential for recovery of her renal function in the future,
though she will need dialysis for the near future.  She has had
a Chest Xray and a PPD was placed on [**2190-3-30**] in preparation for
outpatient hemodialysis.  She will need an outpatient
nephrologist.  PPD will need to be read on [**4-1**] or [**4-2**].

# Paroxsymal atrial fibrillation:
The patient initially presented in atrial fibrillation with RVR
at an outside hospital, where she was placed on diltiazem drip.
On transfer she was still in atrial fibrillation and rate
controlled with metoprolol, also on amiodarone for rhythm
control.  She converted to normal sinus rhythm during
hospitalization.  She was also started on warfarin because her
CHADS score was 4.  Her metoprolol dose was decreased in the
setting of low heart rate.

# Hypertension:
Patient's BP has been elevated throughout her stay here
150/50-160/60.  She was re-started on her home dose hydralazine
which was further increased to 50mg TID for better blood
pressure control prior to discharge. Her chronic kidney disease
is likely secondary to longstanding hypertension.

# Right sided flank pain:
Patient complained of intermittent band like pain, localized
mostly under her Right breast. This pain was reproducible, and
the patient was noted to have bruising in that area.  Rib films
showed no displaced fracture.

# Diabetes Mellitus.
She was on Insulin sliding scale regimen in the hospital and she
had good glycemic control.  She will be placed back onto her
diet-controlled regimen upon discharge.

# Anemia
Patient has chronic anemia in the setting of End Stage Renal
Disease. She was continued on her home iron suppements.

# Hyperlipidemia:  Simvastatin was changed to pravastatin due to
potential interaction of simvastatin with amiodarone.

# Peptic Ulcer Disease.
She was continued on famotidine 20mg PO daily.

# Hypothyroidism s/p Thyroidectomy
Patient was continued on home dose Levothyroxine.

Medications on Admission:
Ativan 0.5mg PO qhs
Zocor 40mg PO daily
Protonix 40mg PO daily
Allopurinol 200mg PO daily
Hydralazine 25mg PO daily
Tylenol PRN
Ferrous sulfate 325mg PO daily
Aspirin 81mg PO daily
Amiodarone 100mg PO daily
Synthroid 25mcg PO daily
Toprol XL 25mg PO daily
Imdur 90mg PO daily
Maalox PRN
Levaquin 250mg daily for 5 days (to be continued until [**2190-3-28**])
.
MEDICATIONS: at transfer
Levoxyl 25mcg PO daily
Ferrous sulfate 325mg daily
Lorazepam 0.5mg qHS PRN
Amiodarone 100mg PO daily
Aspirin 81mg PO daily
Allopurinol 100mg PO daily
Protonix 40mg PO daily
Diltiazem gtt - 15mg per hour
Metoprolol tartrate 25mg PO BID
Simvastatin 40mg PO daily
Levalbuterol hydrochloride 1.25mg QID PRN inhaled
Heparin SQ TID
Nitroglycerin SL PRN
Bumex 4mg PO or IV - as directed


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Acute on Chronic Diastolic Congestive Failure
End stage renal disease on Hemodialysis
Coronary Artery Disease
diabetes Mellitus Type 2
Paroxysmal Atrial Fibrillation
Anemia of chronic Disease


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent


Discharge Instructions:
You had an episode of congestive heart failure that responded to
hemodialysis treatment that was able to remove excess fluid. We
adjusted your medicine to keep your blood pressure under better
control. We decided that we would not do a cardiac
catheterization because we [**Male First Name (un) **] not want to make your kidneys
worse with IV contrast (dye). You may be able to get a cardiac
catheterization when your kidneys improve.
.
Medication changes:
1. Zocor was changed to Pravastatin
2. Protonix was changed to famotidine
3. Amiodarone was increased to 200 mg daily
4. Hydralazine was increased to 50 mg three times a day
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] S. Phone: [**Telephone/Fax (1) 8506**] Date/Time: please make an
appt to see Dr. [**First Name (STitle) 1557**] when you get out of rehabilitation
.
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) **] W. Phone: [**Telephone/Fax (1) 4475**] Date/time: Friday [**4-16**] at
1:30pm.
{'Acute on chronic diastolic heart failure,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Primary pulmonary hypertension,Renal dialysis status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Anemia, unspecified,Unspecified acquired hypothyroidism,Esophageal reflux,Dyspepsia and other specified disorders of function of stomach,Personal history of malignant neoplasm of breast'}


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: Chest discomfort, shortness of breath

PRESENT ILLNESS: 84-year-old female with CAD s/p CABG in [**9-18**] (LIMA-LAD,
SVG-OM1), CHF, ESRD on HD, DMII, PAF who is transferred from
outside hospital for cardiac catheterization.
.
The patient recently presented to [**Hospital3 **] with a CHF
exacerbation and developed worsening renal failure requiring
initiation of hemodialysis. She was discharged to rehab and
developed chest discomfort, epigastric discomfort and
progressive shortness of breath. She represented to [**Hospital1 **] where she admitted to the ICU. She had evidence of
moderate CHF on CXR and was also in atrial fibrillation. She was
started on a diltiazem drip which was discontinued with
metoprolol tartrate PO for rate control. Her oxygen saturation
was 94-97% on 5 liters of O2. Dr. [**Last Name (STitle) 4469**] was worried that the
CHF could be related to ongoing ischemia and transferred the
patient to [**Hospital1 18**] for cardiac catheterization.
.
Vital signs on transfer were afebrile, BP 149/46, HR 65 SR, RR
21, SaO2 94-97% on 5 liters.
.
On review of systems, 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 current absence of
chest pain. Reports dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema.

MEDICAL HISTORY: 1. coronary artery disease: s/p CABG x2v, LIMA-LAD, SVG-OM1, ETT
- per Dr. [**Last Name (STitle) 4469**] fall of [**2189**] with infero-apical ischemia and
normal LVEF
2. diastolic congestive heart failure - EF 65%
3. Pulmonary hypertension - PA pressure 56mmHg
4. hypertension:
5. diabetes mellitus type II:
6. end-stage renal disease: on hemodialysis, s/p recent tunneled
catheter
7. hyperlipidemia:
8. h/o breast cancer: s/p R mastectomy
9. h/o rheumatic fever:
10. hypothyroidism s/p thyroidectomy:
11. peptic ulcer disease:
12. s/p hysterectomy:
13. chronic anemia
14. degenerative joint disease
15. paroxysmal atrial fibrillation - with RVR
16. chronic low back pain
17. GERD

MEDICATION ON ADMISSION: Ativan 0.5mg PO qhs
Zocor 40mg PO daily
Protonix 40mg PO daily
Allopurinol 200mg PO daily
Hydralazine 25mg PO daily
Tylenol PRN
Ferrous sulfate 325mg PO daily
Aspirin 81mg PO daily
Amiodarone 100mg PO daily
Synthroid 25mcg PO daily
Toprol XL 25mg PO daily
Imdur 90mg PO daily
Maalox PRN
Levaquin 250mg daily for 5 days (to be continued until [**2190-3-28**])
.
MEDICATIONS: at transfer
Levoxyl 25mcg PO daily
Ferrous sulfate 325mg daily
Lorazepam 0.5mg qHS PRN
Amiodarone 100mg PO daily
Aspirin 81mg PO daily
Allopurinol 100mg PO daily
Protonix 40mg PO daily
Diltiazem gtt - 15mg per hour
Metoprolol tartrate 25mg PO BID
Simvastatin 40mg PO daily
Levalbuterol hydrochloride 1.25mg QID PRN inhaled
Heparin SQ TID
Nitroglycerin SL PRN
Bumex 4mg PO or IV - as directed

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission exam:

FAMILY HISTORY: Positive for CKD. Daughter has DM, CAD. Mother and sister have
CAD. Although negative for premature coronary artery disease.

SOCIAL HISTORY: The patient lives in a nursing home, prior to [**Month (only) 404**] lived in
[**Location 5110**]. Sister [**Name (NI) 2048**] [**Telephone/Fax (1) 98209**].
-[**Name2 (NI) 1139**] history: Prior history, quit
-ETOH: None
-Illicit drugs: None 

### Response:
{'Acute on chronic diastolic heart failure,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Primary pulmonary hypertension,Renal dialysis status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Anemia, unspecified,Unspecified acquired hypothyroidism,Esophageal reflux,Dyspepsia and other specified disorders of function of stomach,Personal history of malignant neoplasm of breast'}
