CHIEF COMPLAINT: fatigue

PRESENT ILLNESS: Mr. [**Known lastname **] is a [**Age over 90 **] yoM with a history of HTN, HL, s/p
bioprosthetic AVR who presented to the ED today after several
weeks of progressive fatigue and moderate malaise. The patient
reports that beginning several months ago he began to note
shortness of breath. Whereas he was previously able to do any
physical activity he desired, he began to have trouble breathing
with activities such as climbing a flight of stairs. His PCP has
been evaluating this with reportedly unremarkable echo, PFTs,
stress test and ECG (reportedly showing sinus brady at 54); he
has recently been started on supplemental oxygen. Two to three
weeks ago the pt noted a fairly acute worsening in his dyspnea,
such he was now SOB with even minimal activities such as
brushing his teeth. Climbing a half a flight of stairs would
greatly fatigue him. He also began to note a sense of
intermittent nausea (no vomiting) and feeling unwell. He denies
any sense of dizziness, weakness or CP, but has noted an
intermittent sense of palpitations as if his heart was racing.
.
In the ED, initial vitals were 97.3, 36, 16, 175/68, 96% 2L. A
basic work-up was performed and the patient was admitted to the
CCU for further care.
.
On arrival to the CCU the pt is comfortable. On complete review
of systems, he denies fevers, chills, cough, black stools or red
stools. No weight change. He does endorse occasional PND
although this has not changed recently; he sleeps on two pillows
at home for general comfort. All of the other review of systems
were negative.
.
Intriguingly, the patient reports an episode one year ago when
he "blacked out" while driving and crashed his car. A trauma
work-up at that time was negative; no explaination for the
apparent syncope was identified per the patient, although he
does report having a carotid duplex performed which showed no
significant abnormalities.
.
Given the patient's significant bradycardia, non-emergent
placement of a temporary pacing wire was attempted by the EP
service on arrival the the CCU. Right IJ access was difficult to
obtain and the wire was unable to be placed.

MEDICAL HISTORY: 1. s/p bovine prosthetic AVR
2. HTN
3. hyperlipidemia
4. OSA, not on CPAP
5. delerium on prior hospitalizations
6. s/p inguinal hernia repaor
7. known gain instability; etiology unclear
8. prior renal calculus
9. BPH

MEDICATION ON ADMISSION: tamsulosin 0.4 mg once daily
simvastatin 20 mg daily
ASA 325 mg daily
oxygen 2L NC

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GENERAL: Well appearing adult male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: The patient's father had several strokes and passed away at a 72
from his first known MI. The patient's mother died in her 90s
from CHF. The patient has three decesed sisters: one died from
food poisoning, on from lung cancer and one from a probable
stroke. The patient his three children; all are healthy.

SOCIAL HISTORY: The patient lives at home with his daughter. [**Name (NI) **] is generally
independent with his ADLs although has been somewhat less so
with his recent fatige. He is a retired English teacher.
-Tobacco history: 70 year history of pipe smoking
-ETOH: [**2-14**] hard drinks per week
Atrioventricular block, complete,Acute diastolic heart failure,Unspecified transient mental disorder in conditions classified elsewhere,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Obstructive sleep apnea (adult)(pediatric),Abnormality of gait,Surgical or other procedure not carried out because of contraindication,Heart valve replaced by transplant,Personal history of urinary calculi
Atriovent block complete,Ac diastolic hrt failure,Transient mental dis NOS,Atrial fibrillation,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Hyperlipidemia NEC/NOS,BPH w/o urinary obs/LUTS,Obstructive sleep apnea,Abnormality of gait,No proc/contraindication,Heart valve transplant,Prsnl hst urnr dsrd calc
Admission Date:  [**2108-6-13**]              Discharge Date:   [**2108-6-16**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
fatigue

Major Surgical or Invasive Procedure:
pacemaker placement


History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] yoM with a history of HTN, HL, s/p
bioprosthetic AVR who presented to the ED today after several
weeks of progressive fatigue and moderate malaise. The patient
reports that beginning several months ago he began to note
shortness of breath. Whereas he was previously able to do any
physical activity he desired, he began to have trouble breathing
with activities such as climbing a flight of stairs. His PCP has
been evaluating this with reportedly unremarkable echo, PFTs,
stress test and ECG (reportedly showing sinus brady at 54); he
has recently been started on supplemental oxygen. Two to three
weeks ago the pt noted a fairly acute worsening in his dyspnea,
such he was now SOB with even minimal activities such as
brushing his teeth. Climbing a half a flight of stairs would
greatly fatigue him. He also began to note a sense of
intermittent nausea (no vomiting) and feeling unwell. He denies
any sense of dizziness, weakness or CP, but has noted an
intermittent sense of palpitations as if his heart was racing.
.
In the ED, initial vitals were 97.3, 36, 16, 175/68, 96% 2L. A
basic work-up was performed and the patient was admitted to the
CCU for further care.
.
On arrival to the CCU the pt is comfortable. On complete review
of systems, he denies fevers, chills, cough, black stools or red
stools. No weight change. He does endorse occasional PND
although this has not changed recently; he sleeps on two pillows
at home for general comfort. All of the other review of systems
were negative.
.
Intriguingly, the patient reports an episode one year ago when
he "blacked out" while driving and crashed his car. A trauma
work-up at that time was negative; no explaination for the
apparent syncope was identified per the patient, although he
does report having a carotid duplex performed which showed no
significant abnormalities.
.
Given the patient's significant bradycardia, non-emergent
placement of a temporary pacing wire was attempted by the EP
service on arrival the the CCU. Right IJ access was difficult to
obtain and the wire was unable to be placed.


Past Medical History:
1. s/p bovine prosthetic AVR
2. HTN
3. hyperlipidemia
4. OSA, not on CPAP
5. delerium on prior hospitalizations
6. s/p inguinal hernia repaor
7. known gain instability; etiology unclear
8. prior renal calculus
9. BPH


Social History:
The patient lives at home with his daughter. [**Name (NI) **] is generally
independent with his ADLs although has been somewhat less so
with his recent fatige. He is a retired English teacher.
-Tobacco history: 70 year history of pipe smoking
-ETOH: [**2-14**] hard drinks per week


Family History:
The patient's father had several strokes and passed away at a 72
from his first known MI. The patient's mother died in her 90s
from CHF. The patient has three decesed sisters: one died from
food poisoning, on from lung cancer and one from a probable
stroke. The patient his three children; all are healthy.

Physical Exam:
GENERAL: Well appearing adult male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple, short neck with flat veins.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Few crackles at bases
bilaterally, clearing with cough. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Trace LE edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+
Left: Carotid 2+ Femoral 2+ DP 1+


Pertinent Results:
[**2108-6-13**] 12:54PM BLOOD WBC-10.1 RBC-4.45* Hgb-13.7* Hct-40.9
MCV-92 MCH-30.8 MCHC-33.4 RDW-14.5 Plt Ct-188
[**2108-6-13**] 12:54PM BLOOD Plt Ct-188
[**2108-6-13**] 01:15PM BLOOD PT-15.3* PTT-27.5 INR(PT)-1.3*
[**2108-6-13**] 12:54PM BLOOD Glucose-170* UreaN-29* Creat-1.5* Na-145
K-4.2 Cl-110* HCO3-23 AnGap-16
[**2108-6-13**] 12:54PM BLOOD CK-MB-NotDone proBNP-7576*
[**2108-6-13**] 12:54PM BLOOD cTropnT-0.02*
[**2108-6-13**] 12:54PM BLOOD CK(CPK)-84
[**2108-6-13**] 12:54PM BLOOD Calcium-9.0 Phos-3.9 Mg-2.4
[**2108-6-14**] 05:16AM BLOOD HDL-49 CHOL/HD-2.8 LDLmeas-70
[**2108-6-13**] 12:54PM BLOOD TSH-2.1
[**2108-6-13**] 01:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.027
[**2108-6-13**] 01:45PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2108-6-13**] 01:45PM URINE RBC-[**6-20**]* WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2

URINE CULTURE (Final [**2108-6-14**]):    NO GROWTH.

[**2108-6-16**] 07:40AM BLOOD WBC-10.9 RBC-3.88* Hgb-11.6* Hct-35.2*
MCV-91 MCH-29.9 MCHC-32.9 RDW-14.4 Plt Ct-206
[**2108-6-16**] 07:40AM BLOOD PT-15.1* PTT-28.5 INR(PT)-1.3*
[**2108-6-16**] 07:40AM BLOOD Glucose-124* UreaN-17 Creat-1.2 Na-144
K-4.1 Cl-104 HCO3-28 AnGap-16
[**2108-6-16**] 07:40AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.4

ECG:
Atrial fibrillation with a mean ventricular rate of 45. Left
bundle-branch
block with secondary repolarization abnormalities. Compared to
the previous
tracing of [**2091-8-6**] cardiac rhythm is now atrial fibrillation
with a slow
ventricular response.

ECHO:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF 70-80%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. A bioprosthetic aortic valve prosthesis is present. The
prosthetic aortic valve leaflets are thickened. The transaortic
gradient is higher than expected for this type of prosthesis.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. There is severe mitral annular
calcification. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.

CXR:
Left transvenous pacemaker leads terminate in the standard
position in the
right atrium and right ventricle. There is marked cardiomegaly.
There is no
pneumothorax. Bilateral pleural effusions are small to moderate.
Mild
interstitial edema has improved.


Brief Hospital Course:
[**Age over 90 **] yoM presents with two weeks of shortness of breath and
weakness, found to be in AF with severe bradycardia.
.
RHYTHM: Pt appears to be in AF, of which he does not have a
prior history, as well as bradycardia. Suspect that this
dysrhythmia is likely causing his symptoms. No clear precipitant
for either dysrhythmia (i.e. thyroid dysfunction, medication
effect), thus suspect the bradycardia is secondary to
age-related fibrosis of the conduction system, occuring now in
the setting of idiopathic AF. He was evaluated by EP and
recommended pacemaker placement.  There was an attempt at temp
pacing, but patient was difficult access. Pacer pads were
placed, but patient did not have any episodes requiring pacing.
The pacemaker was placed on [**2108-6-14**] and post-procedure Hct
remained stable.  The patient received vancomycin 1 dose prior
to the procedure and post-procedure.  He was continued on 3 days
of levofloxacin after placement.  The patient had a CXR that did
not show PTX and pacemaker in proper position. An ECHO was
performed on [**2108-6-15**] and did not show effusion, his EF was
70-80%.  The patient remained stable and was discharged with
device clinic follow-up in 1 weel.
.
CORONARIES: The patient's history and ECG were not suggestive of
coronary ischemia. Cradiac enzymres showed normal CK with mildly
elevated troponin (0.02) in setting of renal failure. The
patient remained on ASA and without complaints of chest pain.
.

PUMP: The patient had evidence of mild to moderate volume
overload (some CHF on CXR, elevated BNP, peripheral edema). The
patient's failure may well be secondary to his bradycardia.  His
respiratory status remained stable and diuresis was held prior
to the procedure.  and could improve with pacing. As respiratory
status is stable for now, will hold on diuresis pending pacer
placement.  During the procedure he was found to have elevated
filling pressures and received lasix IV 10mg x3 during his
admission.

HTN: Pt denies being on any antihypertsives at home. His blood
pressures were elevated during his admission with SBP 170's.  He
was initiated on catopril that was titrated up 12.5mg TID.  He
was transitioned to lisinopril and discharged on 10mg daily.  It
is recommended he follow-up as an outpatient for BP med
titration.

RENAL FAILURE: The patient's recent labs from his PCP office
show SCr of 1.4, suggesting chronic

HYPERLIPIDEMIA: Continued home simvastatin.

BPH: Continued home tamsulosin.

FEN: Patient with several episodes of coughing and choking after
drinking liquids.  He was seen by speech and swallow who
recommended PO diet of nectar thick liquids and soft solids.  It
is recommended that the patient have an outpatient video swallow
study upon discharge.

Medications on Admission:
tamsulosin 0.4 mg once daily
simvastatin 20 mg daily
ASA 325 mg daily
oxygen 2L NC


Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Primary: Bradycardia, Atrial Fibrillation, status post pacemaker
placement
Secondary:
status post bovine prosthetic aortic valve repair
hypertension
hyperlipidemia
obstructive sleep apnea
delerium on prior hospitalizations
status post inguinal hernia repair
benign prostatic hypertrophy


Discharge Condition:
stable


Discharge Instructions:
You were found to have a slow and irregular heart rhythm that
required the cardiologists to place a pacemaker. You tolerated
this procedure well and your heart rate remains stable.

You were placed on a nectar thick liquids and soft solids.  You
should have supervision with meals.  It is also recommended you
have a video swallow eval as an outpatient for further eval.

You were started on an antibiotic called levofloxacin that you
will need to take daily for one more day (last dose on [**2108-6-17**]).
You were also started on a medication for blood pressure called
captopril.

Take the rest of your home medications as directed.

If you experience chest pain, shortness of breath,
lightheadedness, passing out, fevers or chills please contact
your cardiologist or go to the emergency department for
evaluation.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:

Followup Instructions:
The following procedure has been scheduled:
Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2108-6-22**]
9:00

Please call Speech and Swallow at [**Telephone/Fax (1) 3731**], to setup a video
swallow eval to advance your diet.



Completed by:[**2108-6-18**]
{'Atrioventricular block, complete,Acute diastolic heart failure,Unspecified transient mental disorder in conditions classified elsewhere,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Obstructive sleep apnea (adult)(pediatric),Abnormality of gait,Surgical or other procedure not carried out because of contraindication,Heart valve replaced by transplant,Personal history of urinary calculi'}


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 **] is a [**Age over 90 **] yoM with a history of HTN, HL, s/p
bioprosthetic AVR who presented to the ED today after several
weeks of progressive fatigue and moderate malaise. The patient
reports that beginning several months ago he began to note
shortness of breath. Whereas he was previously able to do any
physical activity he desired, he began to have trouble breathing
with activities such as climbing a flight of stairs. His PCP has
been evaluating this with reportedly unremarkable echo, PFTs,
stress test and ECG (reportedly showing sinus brady at 54); he
has recently been started on supplemental oxygen. Two to three
weeks ago the pt noted a fairly acute worsening in his dyspnea,
such he was now SOB with even minimal activities such as
brushing his teeth. Climbing a half a flight of stairs would
greatly fatigue him. He also began to note a sense of
intermittent nausea (no vomiting) and feeling unwell. He denies
any sense of dizziness, weakness or CP, but has noted an
intermittent sense of palpitations as if his heart was racing.
.
In the ED, initial vitals were 97.3, 36, 16, 175/68, 96% 2L. A
basic work-up was performed and the patient was admitted to the
CCU for further care.
.
On arrival to the CCU the pt is comfortable. On complete review
of systems, he denies fevers, chills, cough, black stools or red
stools. No weight change. He does endorse occasional PND
although this has not changed recently; he sleeps on two pillows
at home for general comfort. All of the other review of systems
were negative.
.
Intriguingly, the patient reports an episode one year ago when
he "blacked out" while driving and crashed his car. A trauma
work-up at that time was negative; no explaination for the
apparent syncope was identified per the patient, although he
does report having a carotid duplex performed which showed no
significant abnormalities.
.
Given the patient's significant bradycardia, non-emergent
placement of a temporary pacing wire was attempted by the EP
service on arrival the the CCU. Right IJ access was difficult to
obtain and the wire was unable to be placed.

MEDICAL HISTORY: 1. s/p bovine prosthetic AVR
2. HTN
3. hyperlipidemia
4. OSA, not on CPAP
5. delerium on prior hospitalizations
6. s/p inguinal hernia repaor
7. known gain instability; etiology unclear
8. prior renal calculus
9. BPH

MEDICATION ON ADMISSION: tamsulosin 0.4 mg once daily
simvastatin 20 mg daily
ASA 325 mg daily
oxygen 2L NC

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GENERAL: Well appearing adult male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: The patient's father had several strokes and passed away at a 72
from his first known MI. The patient's mother died in her 90s
from CHF. The patient has three decesed sisters: one died from
food poisoning, on from lung cancer and one from a probable
stroke. The patient his three children; all are healthy.

SOCIAL HISTORY: The patient lives at home with his daughter. [**Name (NI) **] is generally
independent with his ADLs although has been somewhat less so
with his recent fatige. He is a retired English teacher.
-Tobacco history: 70 year history of pipe smoking
-ETOH: [**2-14**] hard drinks per week 

### Response:
{'Atrioventricular block, complete,Acute diastolic heart failure,Unspecified transient mental disorder in conditions classified elsewhere,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Obstructive sleep apnea (adult)(pediatric),Abnormality of gait,Surgical or other procedure not carried out because of contraindication,Heart valve replaced by transplant,Personal history of urinary calculi'}
