CHIEF COMPLAINT: Drop in HCT and generalized weakness

PRESENT ILLNESS: Ms. [**Known lastname 48684**] was admitted to the medical floor after presenting
with a drop in her Hct and generalized weakness x 1 week. In the
ED her initial vitals were T 98 BP 134/73 AR 82 RR 18 O2 sat 98%
RA. Denies bloody or black tarry stools. Upon transfer to the
medical floor, she became acutely SOB. Her BP was 170/90 with
oxygen saturation of 84-85% on RA. Cxray at the time consistent
with pulmonary edema. She was given Lasix 20mg IV x2 and
Morphine with mild improvement in her symptoms. She was
transferred to the MICU for non-invasive ventilation and closer
monitoring. ABG at this time was 7.34/44/56. She was immediately
placed on non-invasive ventilation.
.
Upon further questioning the patient denies any fevers, chills,
chest pain, SOB, PND, or orthopnea. She does admit to increasing
LE edema over the past several days. She has been compliant with
all her medications.

MEDICAL HISTORY: 1)CAD s/p MI ([**2115**], [**2120**])
2)Monomorphic VT s/p ablation
3)Hypertension
4)Hyperlipidemia
5)OSA on BiPap
6)Diabetes mellitus, type 2
7)Osteoporosis
8)Recent shingles
10)Vertigo

MEDICATION ON ADMISSION: Atorvastatin 40 mg
Aspirin 81 mg QD
Metoprolol Tartrate 25 [**Hospital1 **]
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Lorazepam 0.5 mg QHS
Amiodarone 400 mg QD
Rosiglitazone 2mg PO daily
Warfarin 2.5mg PO HS
Glyburide-Metformin 5-500mg PO daily
Lasix 3x/week

ALLERGIES: Coreg Cr

PHYSICAL EXAM: Physical Exam:
vitals T 93 BP 153/85 AR 101 RR 26 O2 sat 87% NRB
Gen: Patient in severe respiratory distress, breathing rapidly
HEENT: MMM
Heart: Distant heart sounds
Lungs: Course breath sounds throughout
Abdomen: soft, NT/ND, +BS
Extremities: [**11-27**]+ pitting edema bilaterally
Rectal: Guiac positive

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.

SOCIAL HISTORY: No history of alcohol use. Smoked 3pks/day for 30yrs, quit 25yrs
ago.
Subendocardial infarction, initial episode of care,Other pulmonary embolism and infarction,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Osteoporosis, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Dizziness and giddiness,Other specified disease of white blood cells,Anemia in chronic kidney disease,Unspecified acquired hypothyroidism,Herpes zoster without mention of complication
Subendo infarct, initial,Pulm embol/infarct NEC,Hyposmolality,CHF NOS,Atrial fibrillation,Crnry athrscl natve vssl,Hypertension NOS,Obstructive sleep apnea,Osteoporosis NOS,DMII wo cmp nt st uncntr,Dizziness and giddiness,Wbc disease NEC,Anemia in chr kidney dis,Hypothyroidism NOS,Herpes zoster NOS
Admission Date:  [**2143-7-22**]              Discharge Date:   [**2143-8-2**]


Service: MEDICINE

Allergies:
Coreg Cr

Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
Drop in HCT and generalized weakness

Major Surgical or Invasive Procedure:
Selective coronary artery angiography with right and left heart
catheterization and percutaneous coronary intervention


History of Present Illness:
Ms. [**Known lastname 48684**] was admitted to the medical floor after presenting
with a drop in her Hct and generalized weakness x 1 week. In the
ED her initial vitals were T 98 BP 134/73 AR 82 RR 18 O2 sat 98%
RA. Denies bloody or black tarry stools. Upon transfer to the
medical floor, she became acutely SOB. Her BP was 170/90 with
oxygen saturation of 84-85% on RA. Cxray at the time consistent
with pulmonary edema. She was given Lasix 20mg IV x2 and
Morphine with mild improvement in her symptoms. She was
transferred to the MICU for non-invasive ventilation and closer
monitoring. ABG at this time was 7.34/44/56. She was immediately
placed on non-invasive ventilation.
.
Upon further questioning the patient denies any fevers, chills,
chest pain, SOB, PND, or orthopnea. She does admit to increasing
LE edema over the past several days. She has been compliant with
all her medications.

Past Medical History:
1)CAD s/p MI ([**2115**], [**2120**])
2)Monomorphic VT s/p ablation
3)Hypertension
4)Hyperlipidemia
5)OSA on BiPap
6)Diabetes mellitus, type 2
7)Osteoporosis
8)Recent shingles
10)Vertigo

Social History:
No history of alcohol use. Smoked 3pks/day for 30yrs, quit 25yrs
ago.

Family History:
 There is no family history of premature coronary artery disease
or sudden death.

Physical Exam:
Physical Exam:
vitals T 93 BP 153/85 AR 101 RR 26 O2 sat 87% NRB
Gen: Patient in severe respiratory distress, breathing rapidly
HEENT: MMM
Heart: Distant heart sounds
Lungs: Course breath sounds throughout
Abdomen: soft, NT/ND, +BS
Extremities: [**11-27**]+ pitting edema bilaterally
Rectal: Guiac positive

Pertinent Results:
[**2143-7-23**] 10:15AM BLOOD WBC-6.4 RBC-3.59* Hgb-10.5* Hct-31.2*
MCV-87 MCH-29.2 MCHC-33.6 RDW-15.3 Plt Ct-190
[**2143-7-24**] 05:00AM BLOOD PT-15.5* PTT-35.7* INR(PT)-1.4*
[**2143-7-23**] 04:41PM BLOOD Glucose-165* UreaN-15 Creat-0.8 Na-128*
K-3.4 Cl-90* HCO3-29 AnGap-12
[**2143-7-23**] 12:40AM BLOOD CK(CPK)-48
[**2143-7-23**] 10:15AM BLOOD CK(CPK)-57
[**2143-7-23**] 04:41PM BLOOD CK(CPK)-54
[**2143-7-22**] 02:40PM BLOOD Calcium-8.8 Phos-4.0 Mg-1.9
[**2143-7-23**] 12:40AM BLOOD VitB12-839
[**2143-7-23**] 01:19AM BLOOD Type-ART pO2-56* pCO2-44 pH-7.34*
calTCO2-25 Base XS--2
.
[**2143-7-22**] EKG:
Technically difficult study
Probable sinus arrhythmia
First degree A-V block - intraventricular conduction delay
Late R wave progression - consider anterior myocardial
infarction
QT interval prolonged for rate
ST-T wave changes are nonspecific
Since previous tracing of [**2143-5-13**], QTc interval may be
miscalulated on last tracing
.
[**7-23**] CXR:
FINDINGS: Comparison to the previous study from [**2143-7-23**] at
8:16 a.m. Interstitial densities in the lungs bilaterally are
essentially unchanged or slightly worse compared to the previous
exam, possibly reflecting mild worsening in pulmonary edema. The
cardiomediastinal silhouette is unchanged. Retrocardiac opacity
is compatible with consolidation and/or atelectasis. There is a
left-sided pleural effusion. No pneumothorax is seen. Hilar
contours are stable. Osseous structures are within normal
limits.

IMPRESSION:
Slight increase in interstitial markings is compatible with
slightly worsened pulmonary edema. Retrocardiac opacity
compatible with consolidation and/or atelectasis. Left-sided
pleural effusion, stable.
.
[**2143-7-24**] Cardiac cath:
COMMENTS:
1.  Coronary angiography in this right-dominant system revealed
two-vessel disease.
--The LMCA had no angiographically apparent disease.
--The mid-LAD had a 60% tubular lesion with a small aneurysm.
--The LCx had no angiographically apparent disease.
--The RCA was a large dominant vessel with a complex 90%
stenosis in the
mid-RCA.
2.  Resting hemodynamics revealed mildly elevated RVEDP of 9
mmHg.
Elevated left-sided filling pressures were observed, with a PCWP
mean of
20 mmHg.  There was mild pulmonary arterial systolic
hypertension with
PASP of 39 mmHg.  The PVR was mildly elevated at 168
dynes-sec/cm5.  The
SVR was within normal limits at 1053 dynes-sec/cm5.  Systemic
arterial
pressures were normal.  The cardiac index was preserved at 2.6
L/min/m2.
3. Successful PTCA and stenting of the mid RCA with a Driver
(3.5x24mm)
bare metal stent which was postdilated to 3.75 mm.  Final
angiography
revealed a focal 10% residual stenosis, no angiographically
apparent
dissection and TIMI III flow (See PTCA comments).

FINAL DIAGNOSIS:
1.  Two-vessel coronary artery disease.
2.  Elevated left-sided filling pressures
3.  Mild pulmonary arterial systolic hypertension.
4.  Successful PTCA and stenting of the mid RCA vessel with a
bare metal
stent.
5.  Patient should be maintained on aspirin 325mg daily.
Patient should
also remain on plavix 75mg po daily for a minimum of 1 month,
preferably
3-6 months.
.
[**2143-7-25**] ECHO:
The left atrium is mildly dilated. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed (LVEF= 25 %). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be determined. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2143-5-2**],
left ventricular function appears similar.
.
[**7-29**] CXR:
There is continued mild congestive failure, although this
appears to be slightly improved since the prior study. There is
continued moderate opacification of the right upper lobe, which
could represent focal pneumonia. The heart is mildly enlarged.
Small right pleural effusion, improved with residual minimal
blunting of the right costophrenic angle.

IMPRESSION:
1. Improved congestive failure.
2. Right upper lobe infiltrate concerning for pneumonia.
.
Labs on discharge:
WBC 3.8
HCT 30.2
PLTs 205
INR 2.1
Glucose UreaN Creat Na    K  Cl  HCO3 AnGap
119*     18    0.8  130* 3.4 91* 30    12
HgA1c 6.7
TSH 28
Ft4 0.78


Brief Hospital Course:
Ms. [**Known lastname 48684**] is an 84yo female with PMH significant for CAD, DM
2, and HTN who originally presented for work up for low Hct and
weakness. She subsequently became acutely SOB on the floor and
was found to have flash pulmonary edema. Pt was transferred to
the MICU. An EKG showed new ST depressions in the inferior leads
suggestive of underlying ischemia. Pt was started on heparin
gtt, and her asa, BB were continued. At that time, pt refused
any interventional measures such as a cath.  Subsequently, pt
had a recurrent episode of SOB and tachypnea and found to have a
recurrent episode of pulmonary edema.  The EKG showed new T wave
inversions in teh anterior/septal leads. Pt was treated with
Lasix, morphine, nitro and asa and the heparin gtt continued. Pt
evaluated by cardiology and an echo was performed she went to
cath were a BMS was placed in her RCA.
.
NSTEMI: BMS to RCA.  Peak CK 57, peak trop 0.07.  Initially on
ASA/plavix/heparin but was crossed over from heparin to coumadin
(given h/o PE) and ASA stopped as her hct was trending down and
she was found to have guiac + stool (has not had a colonoscopy).
 Never had chest pain during her hospital course.  Continued on
Atorvastatin 40 mg daily.
.
Blood-loss and iron-deficiency anemia: Patient was initially
admitted to [**Hospital1 **] given drop in Hct from low 30's to 28. In
addition, she has been feeling more weak and tired.  Per OMR and
patient, she has not had a colonscopy. Vitamin B12 levels
suboptimal in the past (<200) but currently not on any
supplements. Guiac positive on admission.  She was transfused 2
U PRBC w/ appropriate bump in hct.  Iron supplementation was
started.  MMA level pending on discharge.  Hematocrit should be
followed as an outpatient and consideration for colonscopy
should be discussed.
.
Leukopenia: she was noted to be leukopenic with WBC count as low
as 2.4 during hospital course (ANC 1650).  Hematology was
consulted and no cause for her leukopenia could be identified
except for possibly captopril use.
- Her WBC could should continue to be followed as an outpatient
w/ hematology follow-up.
.
Hypothyroidism: she was found to have TSH of 20 with a FT4 of
0.78.  Endocrine was consulted and she was started on
Levothyroxine 25 mcg daily, to be increased to 50 mcg daily in 2
weeks.  Likely from amiodarone.  Will follow-up with Dr.
[**Last Name (STitle) **] in clinic in 8 weeks.  Anti TPO and anti TG antibodies
were neg.  Antiparietal cell AB neg.
.
Hyponatremia: Patient presented with Na of 123. Per OMR, this is
a chronic problem for the patient and likely [**12-28**] CHF.  Her Na
has decreased to as low as 122 on a prior admission. Her level
improves once she is appropriately free water restricted.
- Free water restriction~1-1.5L/day
.
DM2: Oral agents held until 2 days after cath at which point
metformin/glyburide was re-started.  SSI was continued prn.
Last HgA1c 6.7.
.
Chronic pulmonary emboli: Patient was found to have incident
pulmonary embolus prior to admission and was subsequently
started on anticoagulation with Coumadin. Concerned whether
acute respiratory decline is due to extension of her PE given
subtherapeutic INR, but less likely now given setting of acute
ischemia that may account for decline in respiratory status.
Therapeutic on coumadin on D/C.  O2 sats 98% on RA on discharge.
.
Hypertension: Patient on beta-blocker as outpatient.
Uncontrolled SBPs may have resulted in her acute respiratory
distress.
-switched from metoprolol [**Hospital1 **] to XL, valsartan added with
excellent BP control by discharge.
.
OSA: BiPAP at night with home mask.
.
Anxiety: low dose ativan prn w/ buspirone


Medications on Admission:
Atorvastatin 40 mg
Aspirin 81 mg QD
Metoprolol Tartrate 25 [**Hospital1 **]
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Lorazepam 0.5 mg QHS
Amiodarone 400 mg QD
Rosiglitazone 2mg PO daily
Warfarin 2.5mg PO HS
Glyburide-Metformin 5-500mg PO daily
Lasix 3x/week

Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Buspirone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): It is very important that you take this every day.
Disp:*30 Tablet(s)* Refills:*2*
4. Valsartan 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Glyburide-Metformin 5-500 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
7. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO once a day.

10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)): as prescribed for goal INR [**12-29**].
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
12. Oxycodone 5 mg Tablet Sig: [**11-27**] - 1 Tablet PO Q6H (every 6
hours) as needed for pain.
13. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): until [**8-11**], then increase to 50 mcg daily.
Disp:*60 Tablet(s)* Refills:*2*
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. Outpatient Lab Work
Please check TSH, Free T4 one week prior to appointment with Dr.
[**Last Name (STitle) **] and fax result to ([**Telephone/Fax (1) 86540**].
18. Outpatient Lab Work
INR on [**2143-8-5**]
Please fax to Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 107964**]


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
1)CAD s/p MI ([**2115**], [**2120**]), now s/p PCI with BMS to RCA
2)Monomorphic VT s/p ablation
3)Hypertension
4)Hyperlipidemia
5)OSA on BiPap
6)Diabetes mellitus, type 2
7)Osteoporosis
8)Recent shingles
10)Vertigo
11)Hypothyroidism
12) Leukopenia
13) Blood-loss Anemia
14) Chronic Pulmonary Emboli


Discharge Condition:
Hemodynamically stable. Ambulatory.


Discharge Instructions:
You were admitted with heart failure, which was treated by both
revascularizing your right coronary artery and by diuretics to
improve your breathing.

Please check your weight daily and call your doctor if your
weight increases by more than 3 pounds.

You had a bare metal stent placed in your coronary artery. You
must take Plavix every day for at least the next month to
prevent a clot from forming and causing a severe heart attack or
even death because of this stent. Continue taking the Plavix
until your cardiologist recommends stopping it.

Please seek medical attention immediately if you develop fever,
chills, shortness of breath, chest pain or any other concerning
symptoms.

Followup Instructions:
Call Dr [**Last Name (STitle) **] when you get home for an appointment within the
next week. [**0-0-**].

Please make a follow-up appointment with Dr. [**Last Name (STitle) **]
(Endocrinologist) in 8 weeks to manage your hypothyroidism. Tel
([**Telephone/Fax (1) 9072**].  Please have thyroid function labs drawn 1 week
prior and faxed to ([**Telephone/Fax (1) 86540**].
{'Subendocardial infarction, initial episode of care,Other pulmonary embolism and infarction,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Osteoporosis, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Dizziness and giddiness,Other specified disease of white blood cells,Anemia in chronic kidney disease,Unspecified acquired hypothyroidism,Herpes zoster without mention of complication'}


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: Drop in HCT and generalized weakness

PRESENT ILLNESS: Ms. [**Known lastname 48684**] was admitted to the medical floor after presenting
with a drop in her Hct and generalized weakness x 1 week. In the
ED her initial vitals were T 98 BP 134/73 AR 82 RR 18 O2 sat 98%
RA. Denies bloody or black tarry stools. Upon transfer to the
medical floor, she became acutely SOB. Her BP was 170/90 with
oxygen saturation of 84-85% on RA. Cxray at the time consistent
with pulmonary edema. She was given Lasix 20mg IV x2 and
Morphine with mild improvement in her symptoms. She was
transferred to the MICU for non-invasive ventilation and closer
monitoring. ABG at this time was 7.34/44/56. She was immediately
placed on non-invasive ventilation.
.
Upon further questioning the patient denies any fevers, chills,
chest pain, SOB, PND, or orthopnea. She does admit to increasing
LE edema over the past several days. She has been compliant with
all her medications.

MEDICAL HISTORY: 1)CAD s/p MI ([**2115**], [**2120**])
2)Monomorphic VT s/p ablation
3)Hypertension
4)Hyperlipidemia
5)OSA on BiPap
6)Diabetes mellitus, type 2
7)Osteoporosis
8)Recent shingles
10)Vertigo

MEDICATION ON ADMISSION: Atorvastatin 40 mg
Aspirin 81 mg QD
Metoprolol Tartrate 25 [**Hospital1 **]
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **]
Lorazepam 0.5 mg QHS
Amiodarone 400 mg QD
Rosiglitazone 2mg PO daily
Warfarin 2.5mg PO HS
Glyburide-Metformin 5-500mg PO daily
Lasix 3x/week

ALLERGIES: Coreg Cr

PHYSICAL EXAM: Physical Exam:
vitals T 93 BP 153/85 AR 101 RR 26 O2 sat 87% NRB
Gen: Patient in severe respiratory distress, breathing rapidly
HEENT: MMM
Heart: Distant heart sounds
Lungs: Course breath sounds throughout
Abdomen: soft, NT/ND, +BS
Extremities: [**11-27**]+ pitting edema bilaterally
Rectal: Guiac positive

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.

SOCIAL HISTORY: No history of alcohol use. Smoked 3pks/day for 30yrs, quit 25yrs
ago. 

### Response:
{'Subendocardial infarction, initial episode of care,Other pulmonary embolism and infarction,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Osteoporosis, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Dizziness and giddiness,Other specified disease of white blood cells,Anemia in chronic kidney disease,Unspecified acquired hypothyroidism,Herpes zoster without mention of complication'}
