CHIEF COMPLAINT: Shortness of breath, tachycardia

PRESENT ILLNESS: 56 yo male with pmhx significant for MDS, has been on Revlimid,
who was referred to the ED for rule out pulmonary embolism after
complaining of acute on chronic dypsnea and being found to be in
afib with RVR while in the hematology/oncology office afternoon
of admission.
.
Patient states that he was found to be in afib about 10 days ago
while having blood transfusion. Denies any associated chest
pain, has had progressive dyspnea for the past two weeks. States
that his dyspnea usually improves following a blood transfusion,
however, last transfusion was Wednesday without significant
improvement. Also notes a chronic cough for the past few months,
non-productive. Denies any recent fevers or chills, no sick
contacts, no recent travel. Has not been treated with any
antibiotics other than his Bactrim prophylaxis. Of note, his
prednisone was recently increased from 10 to 20 mg 3 weeks ago.
On further ROS he denies orthopnea, no PND. Denies LE edema, has
noticed increased DOE with a decrease in exercise tolerance.
States today he could only walk 20 feet before becoming SOB,
able to hike with his daughters one month ago, but notes stairs/
vertical climb has been difficult for a few months. All other
ROS negative. pt also states that he may have had afib in [**2180**]
that was treated with medicine and it resolved. he states having
had multiple cardiac work ups in the past including stress mibi
that were all negative.
.
In the ED the patient was given 20 mg IV diltiazem x 2 with
temporary effect and was then started on a dilt drip. He
underwent a chest CTA, preliminary read shows no PE, and was
admitted to the [**Hospital Unit Name 153**] for further management. In the [**Name (NI) 153**] pt was
switched from dilt drip to po dilt. his heart rate has since
been in the 80-100s. he denies any chest pain/sob/orthpnea.
.

MEDICAL HISTORY: myelofibrosis/ MDS
anemia
BPH

MEDICATION ON ADMISSION: Bactrim DS once daily
Prednisone 15 mg daily
Naproxen 375 mg x2 as needed
Revlimid 10 mg daily
Hydroxyurea 500 ml every other day

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: vitals: temp 98.4, hr 80s-110s, bp 118/70, rr 16/min, sats 96%
GEN: awake, alert, sitting upright in bed, tachypneic
HEENT: atraumatic, anicteric, EOMI, mmm, oropharynx clear
NECK: no LAD, JVP mildly distended
CV: tachy, irregular, no murmurs appreciated, no rubs
LUNGS: mild crackles in both bases, no wheeze.
ABDOMEN: + splenomegaly, hypoactive BS, soft, NT, ND
EXT: no LE edema, DP pulses faint but palpable B/L
SKIN: warm, dry, no rash
NEURO: A/O X3, CN II-XII grossly intact, no focal deficits.
Normal muscle strength and tone

FAMILY HISTORY: Father deceased 25 years ago from "enlarged heart", denies other
significant history, no siblings.

SOCIAL HISTORY: Lives with his wife, has two children with whom he is close.
Works as a manager of a furniture manufacturing business. Denies
tobacco, last drink 4 months ago, no illicits.
Atrial fibrillation,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Unspecified pleural effusion,Other primary cardiomyopathies,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Anemia in neoplastic disease,Long-term (current) use of steroids,Myelodysplastic syndrome, unspecified
Atrial fibrillation,Pneumonia, organism NOS,CHF NOS,Pleural effusion NOS,Prim cardiomyopathy NEC,BPH w/o urinary obs/LUTS,Anemia in neoplastic dis,Long-term use steroids,Myelodysplastic synd NOS
Admission Date:  [**2187-6-27**]              Discharge Date:   [**2187-7-10**]

Date of Birth:  [**2130-7-14**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Shortness of breath, tachycardia

Major Surgical or Invasive Procedure:
None

History of Present Illness:
 56 yo male with pmhx significant for MDS, has been on Revlimid,
who was referred to the ED for rule out pulmonary embolism after
complaining of acute on chronic dypsnea and being found to be in
afib with RVR while in the hematology/oncology office afternoon
of admission.
.
Patient states that he was found to be in afib about 10 days ago
while having blood transfusion. Denies any associated chest
pain, has had progressive dyspnea for the past two weeks. States
that his dyspnea usually improves following a blood transfusion,
however, last transfusion was Wednesday without significant
improvement. Also notes a chronic cough for the past few months,
non-productive. Denies any recent fevers or chills, no sick
contacts, no recent travel. Has not been treated with any
antibiotics other than his Bactrim prophylaxis. Of note, his
prednisone was recently increased from 10 to 20 mg 3 weeks ago.
On further ROS he denies orthopnea, no PND. Denies LE edema, has
noticed increased DOE with a decrease in exercise tolerance.
States today he could only walk 20 feet before becoming SOB,
able to hike with his daughters one month ago, but notes stairs/
vertical climb has been difficult for a few months. All other
ROS negative. pt also states that he may have had afib in [**2180**]
that was treated with medicine and it resolved. he states having
had multiple cardiac work ups in the past including stress mibi
that were all negative.
.
In the ED the patient was given 20 mg IV diltiazem x 2 with
temporary effect and was then started on a dilt drip. He
underwent a chest CTA, preliminary read shows no PE, and was
admitted to the [**Hospital Unit Name 153**] for further management. In the [**Name (NI) 153**] pt was
switched from dilt drip to po dilt. his heart rate has since
been in the 80-100s. he denies any chest pain/sob/orthpnea.
.


Past Medical History:
myelofibrosis/ MDS
anemia
BPH


Social History:
Lives with his wife, has two children with whom he is close.
Works as a manager of a furniture manufacturing business. Denies
tobacco, last drink 4 months ago, no illicits.

Family History:
Father deceased 25 years ago from "enlarged heart", denies other
significant history, no siblings.

Physical Exam:
vitals: temp 98.4, hr 80s-110s, bp 118/70, rr 16/min, sats 96%
GEN: awake, alert, sitting upright in bed, tachypneic
HEENT: atraumatic, anicteric, EOMI, mmm, oropharynx clear
NECK: no LAD, JVP mildly distended
CV: tachy, irregular, no murmurs appreciated, no rubs
LUNGS: mild crackles in both bases, no wheeze.
ABDOMEN: + splenomegaly, hypoactive BS, soft, NT, ND
EXT: no LE edema, DP pulses faint but palpable B/L
SKIN: warm, dry, no rash
NEURO: A/O X3, CN II-XII grossly intact, no focal deficits.
Normal muscle strength and tone


Pertinent Results:
[**2187-6-27**] 09:30AM   WBC-16.2*# RBC-2.71* HGB-8.2* HCT-25.4*
MCV-94 MCH-30.4 MCHC-32.4 RDW-22.2*
[**2187-6-27**] 09:30AM   NEUTS-33* BANDS-6* LYMPHS-12* MONOS-7 EOS-14*
BASOS-12* ATYPS-0 METAS-5* MYELOS-3* PROMYELO-1* BLASTS-7* NUC
RBCS-14*
[**2187-6-27**] 09:30AM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
PENCIL-NORMAL
[**2187-6-27**] 09:30AM   PLT SMR-NORMAL PLT COUNT-395#
[**2187-6-27**] 09:30AM   GRAN CT-6804
.
[**2187-6-27**] 09:30AM   GLUCOSE-110* UREA N-21* CREAT-1.2 SODIUM-135
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-23 ANION GAP-17
[**2187-6-27**] 09:30AM   ALT(SGPT)-21 AST(SGOT)-17 LD(LDH)-977* ALK
PHOS-140* TOT BILI-0.7 DIR BILI-0.2 INDIR BIL-0.5
[**2187-6-27**] 09:30AM   ALBUMIN-3.8 CALCIUM-8.8 PHOSPHATE-3.3
MAGNESIUM-2.7*
.
[**2187-6-27**] 02:00PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
[**2187-6-27**] 01:00PM   CK(CPK)-44
[**2187-6-27**] 01:00PM   cTropnT-<0.01
.
[**2187-6-27**] 01:00PM   TSH-3.2
[**2187-6-27**] 01:00PM   FREE T4-1.5

Brief Hospital Course:
Mr [**Known lastname 48168**] is a 56 year old with myelofibrosis who presented
with acute on chronic dyspnea and relatively new-onset atrial
fibrillation with rapid ventricular response.
.
ATRIAL FIBRILLATION/CONGESTIVE HEART FAILURE
With this shortness of breath and a.fib, and concern for his
cardiac well-being and hemodynamic stability, he was admitted on
the [**2187-6-27**]. In the ED he had ruled out for PE by
CTA, although CT did show findings consistent with congestive
heart failure. Cardiac enzymes were negative and TSH and T4 were
within normal limits. He was transferred from the ED to the
[**Hospital Ward Name 332**] ICU on the [**Hospital1 18**] [**Hospital Ward Name 516**] for rate control and cardiac
monitoring. He was started on a diltiazem drip which was
effective in reducing his rate somewhat. He got an
echocardiogram; in summary it showed global wall motion
abnormality and reduced ejection fraction of 30-35%.
.
He was transferred to the BMT service on the night of [**6-28**] once
the [**Hospital Unit Name 153**] team was able to transition his diltiazem drip to PO
diltiazem, 90 mg QID. He remained short of breath and had an 02
sat of 98% on 4L. His heart rates remained above 100 at this
time.
.
Given that he seemed to have a CHF component he had been started
on captopril 6.25 mg. He was also given lasix as aggressively as
his often-low blood pressures would tolerate. He was started on
metoprolol 12.5 mg po BID. On [**2187-7-1**] after some success in
diuresis, he was started on lasix 60 mg PO BID, but this was not
uncommonly held for low blood pressures over the next few days.
.
Cardiology was consulted on [**2187-7-2**]. Their overall
recommendation was to attempt to increase metoprolol and
continue diuresis while titrating down diltiazem dose, as
diltiazem was less likely to have a direct benefit for the heart
failure element of his cardiac picture. The team worked on this
plan, titrating metoprolol up to 12.5 TID and then to 25 [**Hospital1 **],
while holding off on rhythm control because of potential dual
benefit of beta-blocker for rate control and heart failure.
However, this failed to get Mr [**Known lastname 48169**] heart rate
well-controlled, although it declined from its peaks earlier in
the admission.
.
On [**2187-7-5**], as rates remained in the 100s with occasional spikes
up to the 150s, team and cardiology agreed on a plan to start
digoxin. He was loaded with two doses of 0.25 mg and rate
improved; he was put on a standing dose of 0.125 mg with levels
checked. His rates and his clinical well-being both improved
with this. Because his pressures were often low we began holding
diuresis during this same period, d/c'ing the standing
furosemide and following ins and outs and daily weights with a
goal of running approximately even. Chest x-rays showed steady
improvement in pulmonary edema.
.
We did not anticoagulate Mr [**Known lastname 48168**], after discussing with him
the relative risks of splenic injury while anticoagulated versus
the ongoing risk of embolic stroke as a result of atrial
fibrillation. He did take aspirin during much of the admission.
Cardiology suggested the possibility of TEE and cardioversion as
a later consideration; this was deferred during this admission,
again because of concerns about anticoagulation.
.
We were not able to conclusively determine the origins of Mr
[**Known lastname 48169**] cardiac issues. For a conclusive diagnosis of his
cardiomyopathy, a biopsy of cardiac muscle would be required; we
judged this to be too invasive and risky a procedure for its
potential benefits at this point in his course, and treated his
symptoms. We considered viral causes but his history was not
easily consistent with this explanation; most such viral sources
would again only be able to be conclusively diagnosed by tissue,
and it was not clear how we might intervene even in the event of
a positive tissue diagnosis. We considered the possibility that
Revlimid might have caused this decline in cardiac function, and
removed the drug; we were unable to find support in the
literature for other reports of similar phenomena associated
with this drug. Finally, the possibility exists that he has iron
deposits in his cardiac muscle as a result of ongoing
transfusions; this can be followed and considered as an
outpatient. His thyroid function tests were normal and we
detected no clear signs of ongoing infection.
.
He was discharged on digoxin and Toprol XL dose corresponding to
his hospital metoprolol dosing, as well as captopril, with
instructions to follow up with Dr [**First Name (STitle) 437**] of cardiology.
.
MDS
Has marrow matches in NMDP, and Mr [**Known lastname 48168**] is considering this
as a possibility, Dr. [**First Name (STitle) 1557**] is his primary oncologist. As
above, we held, then briefly restarted, then again held Revlimid
for concerns that it might be having an impact on his cardiac
picture, although we had no direct evidence other than a
coincidence of the timing of his cardiac worsening around the
time he was taking Revlimid. As his cell counts rose, we
increased his hydroxyurea dose to 500 mg daily from an every
other day schedule, and his white blood cell count declined
accordingly; he was discharged on this regimen, and instructed
to follow up further as an outpatient.
.
LOCULATED EFFUSION
X-ray and CT showed a loculated effusion on the right with fluid
extending into the major fissure. We consulted the pulmonary
interventionalist on call as well as IR; IP felt that they would
be unable to do a bedside procedure; discussed with IR, felt
that improvement in clinical symptoms would be unlikely to be
considerable. Given the potential risks of the procedure,
including that this finding could represent a site of
extramedullary hematopoeisis, we deferred tapping this effusion.
It shrunk on CXR over the course of the admission.
.
DISPOSITION
Mr [**Known lastname 48168**] was feeling much improved by the end of his
admission, and was discharged to home with plans to follow up,
as detailed below.


Medications on Admission:
Bactrim DS once daily
Prednisone 15 mg daily
Naproxen 375 mg x2 as needed
Revlimid 10 mg daily
Hydroxyurea 500 ml every other day

Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
Disp:*60 Troche(s)* Refills:*2*
6. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough .
Disp:*30 Capsule(s)* Refills:*2*
[[10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days. Disp:*2 Tablet(s)*
Refills:*0*]]--INSURANCE COMPANY WOULD NOT REIMBURSE, CHANGED TO
AUGMENTIN 875 MG [**Hospital1 **] FOR 2 DAYS BY PHONE TO PT'S PHARMACY.
11. Loperamide 2 mg Capsule Sig: One (1) Capsule PO INITIAL DOSE
4 MG, THEN 2 MG AFTER EACH LOOSE STOOL, MAXIMUM 16 MG/DAY. () as
needed for diarrhea.
Disp:*30 Capsule(s)* Refills:*0*
12. Hydrocortisone 2.5 % Ointment Sig: One (1) application
Topical 2-4 times a day as needed for rash.
Disp:*2 tubes* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Atrial fibrillation with congestive heart failure.

Discharge Condition:
Good

Discharge Instructions:
Follow up closely with Dr [**First Name (STitle) 1557**].
.
You have atrial fibrillation, an irregular rhythm in your heart.
Atrial fibrillation can cause your heart to beat too fast. You
are now taking digoxin and Toprol XL (a long-acting version of
the drug metoprolol) to control your heart rate.
.
Many people with atrial fibrillation use blood-thinning drugs to
reduce their risk of stroke. As we've discussed with you, we
have not given these drugs to you (other than daily aspirin)
because of our concern about the possibility of bleeding in your
spleen if you had any trauma. You should continue to discuss the
balance of risks and benefits of this decision with your
physicians.
.
If you have light-headedness, feel as if you are going to pass
out, have an episode of fainting, have difficulty thinking, have
shortness of breath or new cough, feel your heart fluttering in
your chest, or feel your heart beating very fast, contact your
physician's office or come into the emergency department.

Followup Instructions:
Follow up closely with Dr [**First Name (STitle) 1557**] as well as with Dr [**First Name (STitle) 437**] in the
cardiology department. You have two appointments in the coming
days, one with Dr [**First Name (STitle) 1557**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and the other with Dr
[**First Name (STitle) 437**] of cardiology:
.
Hematology/oncology
[**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2187-7-12**] 1:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11755**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2187-7-12**] 1:00
.
Cardiology
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:  ([**Telephone/Fax (1) 13786**] Date/Time:[**2187-7-16**] 9:00 AM
([**Hospital Ward Name **] BUILDING [**Location (un) **])
{'Atrial fibrillation,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Unspecified pleural effusion,Other primary cardiomyopathies,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Anemia in neoplastic disease,Long-term (current) use of steroids,Myelodysplastic syndrome, unspecified'}


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, tachycardia

PRESENT ILLNESS: 56 yo male with pmhx significant for MDS, has been on Revlimid,
who was referred to the ED for rule out pulmonary embolism after
complaining of acute on chronic dypsnea and being found to be in
afib with RVR while in the hematology/oncology office afternoon
of admission.
.
Patient states that he was found to be in afib about 10 days ago
while having blood transfusion. Denies any associated chest
pain, has had progressive dyspnea for the past two weeks. States
that his dyspnea usually improves following a blood transfusion,
however, last transfusion was Wednesday without significant
improvement. Also notes a chronic cough for the past few months,
non-productive. Denies any recent fevers or chills, no sick
contacts, no recent travel. Has not been treated with any
antibiotics other than his Bactrim prophylaxis. Of note, his
prednisone was recently increased from 10 to 20 mg 3 weeks ago.
On further ROS he denies orthopnea, no PND. Denies LE edema, has
noticed increased DOE with a decrease in exercise tolerance.
States today he could only walk 20 feet before becoming SOB,
able to hike with his daughters one month ago, but notes stairs/
vertical climb has been difficult for a few months. All other
ROS negative. pt also states that he may have had afib in [**2180**]
that was treated with medicine and it resolved. he states having
had multiple cardiac work ups in the past including stress mibi
that were all negative.
.
In the ED the patient was given 20 mg IV diltiazem x 2 with
temporary effect and was then started on a dilt drip. He
underwent a chest CTA, preliminary read shows no PE, and was
admitted to the [**Hospital Unit Name 153**] for further management. In the [**Name (NI) 153**] pt was
switched from dilt drip to po dilt. his heart rate has since
been in the 80-100s. he denies any chest pain/sob/orthpnea.
.

MEDICAL HISTORY: myelofibrosis/ MDS
anemia
BPH

MEDICATION ON ADMISSION: Bactrim DS once daily
Prednisone 15 mg daily
Naproxen 375 mg x2 as needed
Revlimid 10 mg daily
Hydroxyurea 500 ml every other day

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: vitals: temp 98.4, hr 80s-110s, bp 118/70, rr 16/min, sats 96%
GEN: awake, alert, sitting upright in bed, tachypneic
HEENT: atraumatic, anicteric, EOMI, mmm, oropharynx clear
NECK: no LAD, JVP mildly distended
CV: tachy, irregular, no murmurs appreciated, no rubs
LUNGS: mild crackles in both bases, no wheeze.
ABDOMEN: + splenomegaly, hypoactive BS, soft, NT, ND
EXT: no LE edema, DP pulses faint but palpable B/L
SKIN: warm, dry, no rash
NEURO: A/O X3, CN II-XII grossly intact, no focal deficits.
Normal muscle strength and tone

FAMILY HISTORY: Father deceased 25 years ago from "enlarged heart", denies other
significant history, no siblings.

SOCIAL HISTORY: Lives with his wife, has two children with whom he is close.
Works as a manager of a furniture manufacturing business. Denies
tobacco, last drink 4 months ago, no illicits. 

### Response:
{'Atrial fibrillation,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Unspecified pleural effusion,Other primary cardiomyopathies,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Anemia in neoplastic disease,Long-term (current) use of steroids,Myelodysplastic syndrome, unspecified'}
