CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: Ms. [**Known lastname 1007**] is a 74 yo woman with a history of ESRD on
hemodialysis, DM, HTN, PVD, afib, and hyperlipidemia who
presents to ED with respiratory distress. Of note, patient was
discharged on [**9-27**] by this ICU team. That admission she was
treated for acute CHF as well, requiring Bipap, which resolved
with dialysis. That admission she was noted to have
tacharrhythmia to 150s briefly during HD which improved
spontaneously and the decision was made to given verapamil prior
to dialysis. Also here INR was supratherapeutic and her [**Month/Day (4) **]
was held. This was thought to be [**1-23**] increased dose of
amiodarone. That admission was after being discharged from [**Hospital1 18**]
hours prior in which she was treated for hypotension with
dialysis, a typical presentation for her on multiple admission
in the past.
.
In the ED, thought to be in heart failure based on tachypnea to
the 40s. She was given 2 sprays of nitro and cpap. Dialysis
session completed today per resident but [**Name8 (MD) **] RN endorsed that she
had not completed dialysis. No CP or fevers. Admission vitals
98.1 106 159/93 30 30 100%. CXR wet. She was given nitro gtt,
enalapril 0.625mg, and asa 325mg. Her trop was at [**Name8 (MD) 5348**].
Weaned off bipap. Recent vitals 84 141/7 20 100%4L. 20G EJ was
placed.
.
Currently, the patient was in no distress. She described going
home and feeling fine. She went to dialysis the day before
admission but it was stoppped early due to the fact she was
having diarrhea. She says the diarrhea has since resolved. She
denied N/V, abd pain, fever, chills or cough. Per patient she
denied chest pain and her blood pressure did not drop during
dialysis. After dialysis she went home and played cards with her
friends, ate a hot saugage and layed down. Upon doing so, she
felt acutely short of breath and called 911. No associated
symtoms with this episode.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.

MEDICAL HISTORY: 1. Hypertension.
2. Atrial flutter, status post ablation with recurrent atrial
fibrillation.
3. Significant left ventricular hypertrophy with LVOT gradient
and severe diastolic dysfunction.
4. End-stage renal disease on hemodialysis.
5. Diabetes.
6. COPD - home O2, 2-3L
7. Hyperlipidemia
8. PVD s/p bilateral BKAs
9. glaucoma, left eye blindness
10. GERD

MEDICATION ON ADMISSION: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tmax: 36.9 ??????C (98.5 ??????F)

FAMILY HISTORY: Father with DM2, Mother deceased of stroke.  Siblings died of
cancer (unknown type), stroke and brain cancer.  Seven health
children.  Extended family history positive for CAD, cancer and
DM.

SOCIAL HISTORY: -EtOH: Denies use
-Tobacco: 30 pack year history, now smokes about 6 cigarettes
per day, re-lighting the butts intermittantly throughout the
day.
-Drugs: IV drug use.
She lives alone in [**Hospital3 **], has once weekly [**Location (un) 86**] [**Location (un) 269**]
and 5 days a week home health aide. Is mobile with prostheses
and walker or her wheelchair.
Acute on chronic diastolic heart failure,End stage renal disease,Subaortic stenosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atrial flutter,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Peripheral vascular disease, unspecified,Below knee amputation status,Long-term (current) use of anticoagulants
Ac on chr diast hrt fail,End stage renal disease,Cong subaortic stenosis,Hyp kid NOS w cr kid V,Atrial flutter,DMII wo cmp nt st uncntr,Chr airway obstruct NEC,Periph vascular dis NOS,Status amput below knee,Long-term use anticoagul
Admission Date:  [**2164-9-29**]              Discharge Date:   [**2164-9-30**]

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

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 30201**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
Dialysis


History of Present Illness:
Ms. [**Known lastname 1007**] is a 74 yo woman with a history of ESRD on
hemodialysis, DM, HTN, PVD, afib, and hyperlipidemia who
presents to ED with respiratory distress. Of note, patient was
discharged on [**9-27**] by this ICU team. That admission she was
treated for acute CHF as well, requiring Bipap, which resolved
with dialysis. That admission she was noted to have
tacharrhythmia to 150s briefly during HD which improved
spontaneously and the decision was made to given verapamil prior
to dialysis. Also here INR was supratherapeutic and her [**Month/Day (4) **]
was held. This was thought to be [**1-23**] increased dose of
amiodarone. That admission was after being discharged from [**Hospital1 18**]
hours prior in which she was treated for hypotension with
dialysis, a typical presentation for her on multiple admission
in the past.
.
In the ED, thought to be in heart failure based on tachypnea to
the 40s. She was given 2 sprays of nitro and cpap. Dialysis
session completed today per resident but [**Name8 (MD) **] RN endorsed that she
had not completed dialysis. No CP or fevers. Admission vitals
98.1 106 159/93 30 30 100%. CXR wet. She was given nitro gtt,
enalapril 0.625mg, and asa 325mg. Her trop was at [**Name8 (MD) 5348**].
Weaned off bipap. Recent vitals 84 141/7 20 100%4L. 20G EJ was
placed.
.
Currently, the patient was in no distress. She described going
home and feeling fine. She went to dialysis the day before
admission but it was stoppped early due to the fact she was
having diarrhea. She says the diarrhea has since resolved. She
denied N/V, abd pain, fever, chills or cough. Per patient she
denied chest pain and her blood pressure did not drop during
dialysis. After dialysis she went home and played cards with her
friends, ate a hot saugage and layed down. Upon doing so, she
felt acutely short of breath and called 911. No associated
symtoms with this episode.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.


Past Medical History:
1. Hypertension.
2. Atrial flutter, status post ablation with recurrent atrial
fibrillation.
3. Significant left ventricular hypertrophy with LVOT gradient
and severe diastolic dysfunction.
4. End-stage renal disease on hemodialysis.
5. Diabetes.
6. COPD - home O2, 2-3L
7. Hyperlipidemia
8. PVD s/p bilateral BKAs
9. glaucoma, left eye blindness
10. GERD


Social History:
-EtOH: Denies use
-Tobacco: 30 pack year history, now smokes about 6 cigarettes
per day, re-lighting the butts intermittantly throughout the
day.
-Drugs: IV drug use.
She lives alone in [**Hospital3 **], has once weekly [**Location (un) 86**] [**Location (un) 269**]
and 5 days a week home health aide. Is mobile with prostheses
and walker or her wheelchair.


Family History:
Father with DM2, Mother deceased of stroke.  Siblings died of
cancer (unknown type), stroke and brain cancer.  Seven health
children.  Extended family history positive for CAD, cancer and
DM.


Physical Exam:
Tmax: 36.9 ??????C (98.5 ??????F)

Tcurrent: 36.9 ??????C (98.5 ??????F)

HR: 83 (83 - 86) bpm

BP: 154/83(101) {135/65(78) - 154/83(101)} mmHg

RR: 23 (14 - 23) insp/min

SpO2: 100%

Heart rhythm: SR (Sinus Rhythm)

General Appearance: Well nourished, No acute distress, Thin

Eyes / Conjunctiva: PERRL

Head, Ears, Nose, Throat: Normocephalic

Lymphatic: Cervical WNL

Cardiovascular: (S1: Normal), (S2: Normal), S4, (Murmur:
Systolic)

Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)

Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : B/L)

Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended, No(t) Tender:

Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, b/l BKA

Skin:  Warm

Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): x3, Movement: Purposeful, Tone:
Not assessed


Pertinent Results:
[**2164-9-29**] 01:20AM BLOOD WBC-10.9 RBC-3.21* Hgb-9.2* Hct-31.3*
MCV-97 MCH-28.7 MCHC-29.5* RDW-19.0* Plt Ct-287
[**2164-9-29**] 09:55AM BLOOD WBC-10.0 RBC-3.13* Hgb-8.8* Hct-30.7*
MCV-98 MCH-28.2 MCHC-28.8* RDW-18.9* Plt Ct-274
[**2164-9-30**] 08:45AM BLOOD WBC-9.9 RBC-3.71* Hgb-10.8* Hct-36.3
MCV-98 MCH-29.2 MCHC-29.8* RDW-18.7* Plt Ct-242
[**2164-9-30**] 11:00PM BLOOD WBC-10.8 RBC-3.82* Hgb-10.9* Hct-37.1
MCV-97 MCH-28.6 MCHC-29.5* RDW-17.8* Plt Ct-294
[**2164-9-29**] 01:20AM BLOOD Neuts-86.1* Lymphs-7.0* Monos-4.3 Eos-2.2
Baso-0.5
[**2164-9-30**] 11:00PM BLOOD Neuts-84.2* Lymphs-9.2* Monos-3.4 Eos-3.0
Baso-0.3
[**2164-9-28**] 06:00AM BLOOD PT-24.5* INR(PT)-2.3*
[**2164-9-29**] 01:20AM BLOOD PT-21.7* PTT-29.0 INR(PT)-2.0*
[**2164-9-29**] 01:20AM BLOOD Plt Ct-287
[**2164-9-29**] 09:55AM BLOOD PT-25.2* PTT-45.6* INR(PT)-2.4*
[**2164-9-29**] 09:55AM BLOOD Plt Ct-274
[**2164-9-30**] 08:45AM BLOOD PT-29.0* PTT-33.4 INR(PT)-2.9*
[**2164-9-30**] 08:45AM BLOOD Plt Ct-242
[**2164-9-30**] 11:00PM BLOOD PT-31.1* PTT-31.0 INR(PT)-3.1*
[**2164-9-30**] 11:00PM BLOOD Plt Ct-294
[**2164-9-29**] 01:20AM BLOOD Glucose-137* UreaN-27* Creat-4.2* Na-146*
K-3.9 Cl-106 HCO3-30 AnGap-14
[**2164-9-29**] 09:55AM BLOOD Glucose-100 UreaN-32* Creat-4.7* Na-145
K-4.0 Cl-104 HCO3-32 AnGap-13
[**2164-9-30**] 08:45AM BLOOD Glucose-114* UreaN-45* Creat-5.9*# Na-139
K-5.0 Cl-102 HCO3-23 AnGap-19
[**2164-9-30**] 11:00PM BLOOD Glucose-176* UreaN-56* Creat-7.0*# Na-140
K-5.0 Cl-101 HCO3-23 AnGap-21*
[**2164-9-29**] 01:20AM BLOOD CK(CPK)-58
[**2164-9-29**] 09:55AM BLOOD CK(CPK)-47
[**2164-9-29**] 09:00PM BLOOD CK(CPK)-65
[**2164-9-30**] 11:00PM BLOOD CK(CPK)-57
[**2164-9-29**] 01:20AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 109115**]*
[**2164-9-29**] 01:20AM BLOOD cTropnT-0.09*
[**2164-9-29**] 09:55AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2164-9-29**] 09:00PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2164-9-30**] 11:00PM BLOOD CK-MB-6 proBNP-[**Numeric Identifier **]*
[**2164-9-30**] 11:00PM BLOOD cTropnT-0.09*
[**2164-9-29**] 01:20AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.7
[**2164-9-29**] 09:55AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.6
[**2164-9-30**] 08:45AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.9
[**2164-9-30**] 11:00PM BLOOD Calcium-9.1 Phos-5.1*# Mg-2.2
[**2164-9-29**] 01:32AM BLOOD Lactate-1.0
[**2164-9-30**] 11:04PM BLOOD Glucose-174* K-5.0
[**2164-9-29**] 01:32AM BLOOD Type-ART pO2-215* pCO2-48* pH-7.43
calTCO2-33* Base XS-7
[**2164-9-30**] 11:43PM BLOOD Type-ART pO2-55* pCO2-42 pH-7.38
calTCO2-26 Base XS-0

Chest X-ray ([**9-29**])- IMPRESSION: Findings consistent with
pulmonary edema.

Chest X-ray ([**9-30**])- IMPRESSION: Moderate pulmonary edema is
perhaps slightly improved compared to one day prior, but
persistent. Probable bilateral tiny pleural effusions


Brief Hospital Course:
MICU COURSE:

Ms. [**Known lastname 1007**] was admitted to the medical ICU for acute diastolic
CHF. The preceeding day she had dropped her blood pressures at
HD and had some fluid returned. She was managed with
nitroglycerin drip briefly and then underwent hemodialysis in
the morning. She required noninvasive ventilation in the ED
though this weaned down to nasal cannula with the interventions.
ECG did not suggest pneunomia, only volume overload. Her
symptoms improved and she was transferred to the floor.

FLOOR COURSE:

# Hypoxia/respiratory distress:  Patient did well on the floor.
Her exacerbation most likely was due to dietary indiscretion as
she reports additional salt load (ate sausage recently) in
combination with underdiuresis in dialysis.  She was
fluid-overloaded on exam (rales on lung exam, overload on CXR
and elevated BNP).  She required CPAP while in ED but was easily
weaned to nasal cannula.  Patient did not complain of chest pain
and EKG changes were absent.  PE was low on the differential as
she was therapeutic on [**Known lastname **] and CXR was consistent overload.
She does have a history of COPD and requires 2L of NC oxygen at
home.  She underwent dialysis here and had fluid removed.  Her
blood pressures tolerated the procedure well and her shortness
of breath resolved.  After dialysis she was back at her [**Known lastname 5348**]
oxygen requirement.  Upon discharge, patient was heomdynamically
stable and asymptomatic.

# Hypertension- Patient has history of [**Last Name (un) 15970**] blood pressures.
She was hemodynamically stable while here.  Continued her on her
home metoprolol, lisinopril, and verapamil.  She denied chest
pain and her cardiac enzymes were at patient's [**Last Name (un) 5348**].  EKGs
were unchaged.

# ESRD: Patient was volume overloaded on exam.  She received HD
with UF x 1 and fluid status improved.  She did well and was
stable on discharge.  Renal was following patient throughout
admission.  She is to continue her outpatient dialysis schedule
(M, W, F).

# Afib: She was found to be in a tachyarrhythmia with rates into
150 on admission.  She was given an increased dose of amiodarone
(400mg daily) and converted into sinus with a normal rate.  Her
INR was therapeutic on admission so her [**Last Name (un) **] was continued
at home doses.  Upon discharge, she is to continue amiodarone
400mg PO daily for rhythm control with plans to taper to 200mg
PO daily on [**10-7**].  She will also continue home verapamil and
metoprolol for rate control.

# COPD: See above.  Shortness of breath improved after HD with
UF.  Patient does require oxygen at home.  She was continued on
home PRN albuterol with standing [**Month/Year (2) 35480**] and fluticasone.

# DM2: continued on NPH 4 units [**Hospital1 **], add on RISS with QID FS
with good control of her sugars.  She was also continued on home
aspirin and statin

# Glaucoma: continued home eye drops

# GERD: continued home PPI and H2 blocker

# FEN: no IVFs / replete lytes with dialysis / regular diet

# PPX: home PPI, therapeutic on [**Hospital1 **], bowel regimen

# CODE: full

# CONTACT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DAUGHTER Phone: [**Telephone/Fax (1) 109114**]


Medications on Admission:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:

1-2 Puffs Inhalation Q6H (every 6 hours) as needed for cough,

2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap


PO DAILY (Daily).

Disp:*30 Cap(s)* Refills:*2*

3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2


times a day).

Disp:*1 * Refills:*2*

4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*

5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at

bedtime).

Disp:*30 Tablet(s)* Refills:*2*

6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY

(Daily).

Disp:*30 Tablet(s)* Refills:*2*

7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:

One (1) Cap Inhalation DAILY (Daily).

Disp:*30 Cap(s)* Refills:*2*

8. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8

hours). Disp:*90 Tablet(s)* Refills:*2*

9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID

W/MEALS (3 TIMES A DAY WITH MEALS).

Disp:*90 Capsule(s)* Refills:*2*

10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID

(2 times a day).

Disp:*60 Capsule(s)* Refills:*2*

11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).


Disp:*30 Tablet(s)* Refills:*2*

12. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)


Spray Nasal [**Hospital1 **] (2 times a day).

Disp:*1 1* Refills:*2*

13. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop

Ophthalmic [**Hospital1 **] (2 times a day).

Disp:*1 1 bottle* Refills:*2*

14. Lidocaine-Prilocaine 2.5-2.5 % Cream Sig: One (1) Appl

Topical ASDIR (AS DIRECTED).

Disp:*1 1* Refills:*2*

15. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS

(at bedtime): 1 DROP LEFT EYE HS . Disp:*1 1 bottle* Refills:*2*


16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).


Disp:*30 Tablet(s)* Refills:*2*

17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID


(2 times a day).

Disp:*60 Tablet(s)* Refills:*2*

18. Acetaminophen 500 mg Capsule Sig: One (1) Capsule PO once a


day as needed for headache.

Disp:*30 Capsule(s)* Refills:*0*

19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.

Disp:*30 Tablet(s)* Refills:*2*

20. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day

for 2 weeks: After 2 weeks, please decrease back to 200mg daily.


Disp:*14 Tablet(s)* Refills:*0*

21. Warfarin Oral

22. Novolin N 100 unit/mL Suspension Sig: Four (4) unit

Subcutaneous twice a day.


Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for cough.
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
13. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
14. Lidocaine-Prilocaine 2.5-2.5 % Cream Sig: One (1) Appl
Topical ASDIR (AS DIRECTED).
15. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Acetaminophen 500 mg Capsule Sig: One (1) Capsule PO once a
day as needed for headache.
19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
20. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day:
for 2 weeks (day 1- [**9-27**]): After 2 weeks, please decrease back
to 200mg daily. .
21. Warfarin  Oral
22. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
23. Novolin N 100 unit/mL Suspension Sig: Four (4) units
Subcutaneous twice a day: subcutaneous twice a day.


Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
Primary:
Acute Diastolic CHF
Supratherapeutic INR
Tachyarrhythmia

Secondary:
ESRD on dialysis
Diabetes


Discharge Condition:
Good.  Vital signs stable.


Discharge Instructions:
You were admitted to the hospital with a heart failure
exacerbation.  While here, you received dialysis and your
symptoms improved dramatically.  You were transferred to the
floor and did well.

No changes were made to your medications.  Please resume them as
prescribed by your outpatient physicians.

If you experience any fevers, chills, chest pain, shortness of
breath, or any other medically concerning symptoms, please
contact your primary care physician or go to the emergency
department immediately.

You should continue taking the amiodarone 400mg by mouth daily
until [**10-7**] at which point you should start taking 200mg
daily.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L per day

Followup Instructions:
Continue your dialysis every Monday, Wednesday, Friday.  You are
scheduled to get dialysis on [**2164-10-1**]

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2164-10-24**]
1:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2164-10-29**] 9:00



Completed by:[**2164-11-7**]

Admission Date:  [**2164-9-30**]              Discharge Date:   [**2164-10-6**]

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

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 30201**]
Chief Complaint:
Shortness of Breath

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Ms. [**Known lastname 1007**] is a 74 y.o. F with ESRD on HD, DM, HTN, atrial
fibrillation on [**Known lastname **], and diastolic CHF ([**Known lastname 113**] [**1-/2164**]), who
presents with shortness of breath after a discharge earlier in
the day.  The patient noted that she had shortness of breath at
home after trying to take her medications.  She then called an
ambulance.  Per ED resident, pt was given 20 sprays of NTG in
the field and arrived on CPAP.
.
In the ED, initial VS: T 97.5  HR 115  BP 171/100  RR 34  100%
CPAP.
Labs, including cardiac enzymes, were drawn.  Nitro gtt was
started as sbp in 180s.  BP trended to 164/90 and NTG increased
to 4.4 ml/hour. Given Captopril 25 mg po x 1.  ABG sent on CPAP.
 Vent settings on transfer PS 15/PEEP 5/ O2 24%.
.
Currently, the patient feels much better and her SOB is much
improved.


Past Medical History:
1. Hypertension.
2. Atrial flutter, status post ablation with recurrent atrial
fibrillation.
3. Significant left ventricular hypertrophy with LVOT gradient
and severe diastolic dysfunction.
4. End-stage renal disease on hemodialysis.
5. Diabetes.
6. COPD - home O2, 2-3L
7. Hyperlipidemia
8. PVD s/p bilateral BKAs
9. glaucoma, left eye blindness
10. GERD

Social History:
- EtOH: Denies use
- Tobacco: 30 pack year history, now smokes about 6 cigarettes
per day, re-lighting the butts intermittantly throughout the
day.
- Drugs: IV drug use. She lives alone in [**Hospital3 **], has
once weekly [**Location (un) 86**] [**Location (un) 269**] and 5 days a week home health aide. Is
mobile with prostheses and walker or her wheelchair.

Family History:
Father with DM2, Mother deceased of stroke.  Siblings died of
cancer (unknown type), stroke and brain cancer.  Seven healthy
children.  Extended family history positive for CAD, cancer and
DM.

Physical Exam:
Vitals - T: 95.5  BP: 94/56  HR: 82  RR: 11  02 sat: 100% on
CPAP 30%  PEEP 5
GENERAL: elderly malaised appearing female on NC
HEENT: EOMI, anicteric, no cervical LAD
CARDIAC: RRR, nl S1, S2, no m/r/g
LUNG: bibasilar crackles to mid lung fields, no wheezes/rhonchi
ABDOMEN: NDNT, soft, NABS
EXT: no c/c/e, bilateral BKAs
NEURO: A&O
DERM: no rashes noted

Pertinent Results:
[**2164-9-30**] 11:43PM   TYPE-ART PO2-55* PCO2-42 PH-7.38 TOTAL CO2-26
BASE XS-0
[**2164-9-30**] 11:04PM   GLUCOSE-174* K+-5.0
[**2164-9-30**] 11:00PM   GLUCOSE-176* UREA N-56* CREAT-7.0*#
SODIUM-140 POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-23 ANION GAP-21*
[**2164-9-30**] 11:00PM   CK(CPK)-57
[**2164-9-30**] 11:00PM   cTropnT-0.09*
[**2164-9-30**] 11:00PM   CK-MB-6 proBNP-[**Numeric Identifier **]*
[**2164-9-30**] 11:00PM   CALCIUM-9.1 PHOSPHATE-5.1*# MAGNESIUM-2.2
[**2164-9-30**] 11:00PM   WBC-10.8 RBC-3.82* HGB-10.9* HCT-37.1 MCV-97
MCH-28.6 MCHC-29.5* RDW-17.8*
[**2164-9-30**] 11:00PM   NEUTS-84.2* LYMPHS-9.2* MONOS-3.4 EOS-3.0
BASOS-0.3
[**2164-9-30**] 11:00PM   PLT COUNT-294
[**2164-9-30**] 11:00PM   PT-31.1* PTT-31.0 INR(PT)-3.1*
[**2164-9-30**] 08:45AM   GLUCOSE-114* UREA N-45* CREAT-5.9*#
SODIUM-139 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-23 ANION GAP-19
[**2164-9-30**] 08:45AM   CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-1.9
[**2164-9-30**] 08:45AM   WBC-9.9 RBC-3.71* HGB-10.8* HCT-36.3 MCV-98
MCH-29.2 MCHC-29.8* RDW-18.7*
[**2164-9-30**] 08:45AM   PLT COUNT-242
[**2164-9-30**] 08:45AM   PT-29.0* PTT-33.4 INR(PT)-2.9*
[**2164-9-29**] 09:00PM   CK(CPK)-65
[**2164-9-29**] 09:00PM   CK-MB-NotDone cTropnT-0.09*
[**2164-9-29**] 09:55AM   GLUCOSE-100 UREA N-32* CREAT-4.7* SODIUM-145
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-32 ANION GAP-13
[**2164-9-29**] 09:55AM   CK(CPK)-47
[**2164-9-29**] 09:55AM   CK-MB-NotDone cTropnT-0.09*
[**2164-9-29**] 09:55AM   CALCIUM-8.3* PHOSPHATE-3.6 MAGNESIUM-1.6
[**2164-9-29**] 09:55AM   WBC-10.0 RBC-3.13* HGB-8.8* HCT-30.7* MCV-98
MCH-28.2 MCHC-28.8* RDW-18.9*
[**2164-9-29**] 09:55AM   PLT COUNT-274
[**2164-9-29**] 09:55AM   PT-25.2* PTT-45.6* INR(PT)-2.4*
[**2164-9-29**] 01:20AM   PT-21.7* PTT-29.0 INR(PT)-2.0*
[**2164-9-29**] 01:20AM   PLT COUNT-287
[**2164-9-29**] 01:20AM   NEUTS-86.1* LYMPHS-7.0* MONOS-4.3 EOS-2.2
BASOS-0.5
[**2164-9-29**] 01:20AM   WBC-10.9 RBC-3.21* HGB-9.2* HCT-31.3* MCV-97
MCH-28.7 MCHC-29.5* RDW-19.0*
[**2164-9-29**] 01:20AM   CALCIUM-8.7 PHOSPHATE-3.5 MAGNESIUM-1.7
[**2164-9-29**] 01:20AM   CK-MB-NotDone proBNP-[**Numeric Identifier 109115**]*
[**2164-9-29**] 01:20AM   cTropnT-0.09*
[**2164-9-29**] 01:20AM   CK(CPK)-58
[**2164-9-29**] 01:20AM   GLUCOSE-137* UREA N-27* CREAT-4.2*
SODIUM-146* POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-30 ANION GAP-14
[**2164-9-29**] 01:32AM   LACTATE-1.0

EKG [**2164-9-30**]: sinus tach at 100 bpm, nl axis, nl intervals, no Q
waves, no acute ST changes (no changes compared to prior on
[**2164-9-26**])

Chest X-ray ([**2164-9-29**])- IMPRESSION: Findings consistent with
pulmonary edema. Repeat radiograph after treatment is
recommended.

Chest X-ray ([**2164-10-1**]) : IMPRESSION: Improved pulmonary edema,
with unchanged cardiomegaly and tiny bilateral pleural
effusions.

Chest X-ray ([**2164-10-4**])-  IMPRESSION: Further improvement and
practical normalization of chest findings in patient who
suffered from advanced pulmonary edema on multiple previous
chest examinations.



Brief Hospital Course:
****MICU course****
Admitted with shortness of breath, with increased pulm edema on
CXR, responsive to nitro gtt and CPAP which was discontinued
upon arrival to the ICU.  She was dialyzed and 1.5L was removed
but she dropped her pressure and had some substernal chest
discomfort. EKG showed Afib/flutter at the time. CP resolved
with 500cc fluid given back.

****Floor course*****
That patient was transferred to the floor after doing well in
the unit.  While on the floor, she denied any shortness of
breath.  She was comfortable and did well on RA.  She had an
[**Month/Day/Year **] on [**10-2**] which showed an EF of >55% and "severe symmetric
left ventricular hypertrophy with small cavity and hyperdynamic
systolic function. Moderate mitral stenosis from mitral annular
calcifications. At least mild mitral regurgitation. Mild
pulmonary hypertension".  Her verapamil dose was increased from
40mg to 60mg Q8hr to improve ventricular filling.  Due to the
high volume of admissions in the last week or so, the decision
was made to monitor her overnight and on a second session of
dialysis before considering discharging her.  Overnight on
[**10-2**], she developed flash pulmonary edema with elevated
pressures so she was transferred to the MICU.  Shortness of
breath resolved after receiving BiPAP and patient stablized in
the unit.  She was transferred back to the floor on [**10-3**].
Course is as below.

# Hypoxia/respiratory distress:  Given recent admissions,
patient kept and dialyzed daily while here.  Fluid was removed
each day and patient tolerated it well.  She has a history of
[**Last Name (un) 15970**] blood pressures but her BP's remained stable during this
admission.  Fluid status improved and shortness of breath
resolved.  She returned to [**Last Name (un) 5348**] oxygen requirements and was
asymptomatic.  She was weaned off nitro drip in ICU.  No signs
of pneumonia (afebrile, no cough, normal WBC).  INR therapeuatic
at 3.1 making PE unlikely.  Denied any chest pain, dizziness,
headaches, or syncopal-like events.  Ruled out for MI (cardiac
enzymes negative x 3, no EKG changes).
- continue home metoprolol, lisinopril, verapamil

# ESRD: Patient mildly volume overloaded on admission.  Renal
followed patient throughout stay.  She was dialyzed daily and
fluid was removed each time.  Patient remained hemodynamically
stable and symptoms resolved by discharge.  She is to continue
outpatient dialysis schedule on discharge.

# Atrial fibrillation:  She was in sinus rhythm and
rate-controlled on transfer to the floor.  Her INR was slightly
supratherapeutic on admission.  [**Last Name (un) 197**] was held on admission
but was resumed prior to discharge.  She was continued on
amiodarone 400mg PO daily for rhythm control as well as her rate
control medications (verapamil and metoprolol).  Patient
monitored on telemetry.  On discharge, her amiodarone was
decreased to 200mg daily.

# Hypertension: SBP [**Last Name (un) 5348**] 140-160s.  She was on nitro drip in
ICU, which was weaned.  She remained hemodynamically stable on
the floor.  She was continued on home verapamil, lisinopril and
metoprolol.  She was taking verapamil 60mg TID.  In order to
simply her medication regimen, we switched her to verapamil SR
180mg daily.

# COPD: She requires oxygen at home.  She was continued on PRN
albuterol and standing [**Last Name (un) 35480**], fluticasone

# DM2: Continued on regimen of NPH 4 units [**Hospital1 **], add on RISS with
QID FS as well as daily aspirin and statin.  Sugars
well-controlled.

# Glaucoma: continued on home eye drops

# GERD: Patient on both PPI and H2 blocker.  H2 blocker was
discontinued on this admission per pharmacy recs.

# FEN: no IVFs / replete lytes with dialysis / NPO except meds
overnight

# PPX: home PPI / ranitidine, supratherapeutic on [**Hospital1 **],
bowel regimen

# CODE: FULL

# CONTACT: [**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) 10123**] (daughter) Phone: [**Telephone/Fax (1) 109114**]


Medications on Admission:
Albuterol Sulfate 90 mcg 1-2 puffs inhlation q6 hours prn cough
B Complex-Vitamin C-Folic Acid 1 caposule po daily
Brimonidine 0.15% 1 drop opth [**Hospital1 **]
Pantoprazole 40 mg po daily
Ranitidine 150 mg po [**Hospital1 **]
Simvastatin 40 mg po daily
Tiotropium bromide 18 mcg 1 capsule INH daily
Verapamil 40 mg po q8 hours
Calcium Acetate 667 mg po TID
Colace 100 mg po BID
Lisinopril 5 mg po daily
Fluticasone 50 mcg 1 spral nasal [**Hospital1 **]
Dorzolamide-Timolol 2-0.5% 1 drop opth [**Hospital1 **]
Lidocaine-Prilocaine 2.5-2.5% 1 applicaiton topical ASDIR
Latanoprost 0.005% 1 drop opth [**Hospital1 **]
Folic acid 1 mg po daily
Metoprolol Tartrate 25 mg po BID
Acetaminophen 500 mg po daily prn headache
Aspirin 81 mg po daily
Amiodarone 400 mg po daily for 2 weeks (day 1 [**9-27**]), after 2
weeks decrease back to 200 mg daily
[**Month/Day (4) 197**]
Novolin 4 units SQ [**Hospital1 **]

Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for cough.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Lidocaine-Prilocaine 2.5-2.5 % Cream Sig: One (1) APP
Topical ASDIR.
18. Acetaminophen 500 mg Capsule Sig: One (1) Tablet PO once a
day as needed for headache.
19. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day:
Take up to 4 tablets daily.
20. Novolin N 100 unit/mL Suspension Sig: Four (4) units
Subcutaneous twice a day.
21. Verapamil 180 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*


Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
Primary:
Acute Diastolic CHF
Tachyarrhythmia

Secondary:
ESRD on dialysis
Diabetes


Discharge Condition:
Good.  Vital signs stable.


Discharge Instructions:
You were admitted to the hospital because of shortness of breath
that required noninvasive ventilation to support your breathing.
 We felt that this was most likely because of not getting enough
dialysis.  You were dialyzed here daily and your breathing
improved.  Upon discharge, you were stable and doing well.

The following changes were made to your medications:

1.  Please take amiodarone 200mg by mouth ONCE per day
2.  Please resume your [**Location (un) **] as prescribed by your primary
care physican (4mg per day on Sunday, Tuesday, Thursday and
Saturday/ 3mg per day on Monday, Wednesday and Friday)
3.  Please take verapamil SR 180mg by mouth ONCE per day.  You
were taking the immediate release form three times a day, but we
want you to now take the sustained release form ONCE per day.
STOP taking the 60mg tablets of verapamil three times per day.

If you experience any chest pain, shortness of breath, fevers,
chills, abdominal pain or any other medically concerning
symptoms, please contact your primary care physician or go to
the emergency department immediately.

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

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2164-10-24**]
1:40

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2164-10-29**] 9:00



Completed by:[**2164-11-7**]
{'Acute on chronic diastolic heart failure,End stage renal disease,Subaortic stenosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atrial flutter,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Peripheral vascular disease, unspecified,Below knee amputation status,Long-term (current) use of anticoagulants'}


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: Ms. [**Known lastname 1007**] is a 74 yo woman with a history of ESRD on
hemodialysis, DM, HTN, PVD, afib, and hyperlipidemia who
presents to ED with respiratory distress. Of note, patient was
discharged on [**9-27**] by this ICU team. That admission she was
treated for acute CHF as well, requiring Bipap, which resolved
with dialysis. That admission she was noted to have
tacharrhythmia to 150s briefly during HD which improved
spontaneously and the decision was made to given verapamil prior
to dialysis. Also here INR was supratherapeutic and her [**Month/Day (4) **]
was held. This was thought to be [**1-23**] increased dose of
amiodarone. That admission was after being discharged from [**Hospital1 18**]
hours prior in which she was treated for hypotension with
dialysis, a typical presentation for her on multiple admission
in the past.
.
In the ED, thought to be in heart failure based on tachypnea to
the 40s. She was given 2 sprays of nitro and cpap. Dialysis
session completed today per resident but [**Name8 (MD) **] RN endorsed that she
had not completed dialysis. No CP or fevers. Admission vitals
98.1 106 159/93 30 30 100%. CXR wet. She was given nitro gtt,
enalapril 0.625mg, and asa 325mg. Her trop was at [**Name8 (MD) 5348**].
Weaned off bipap. Recent vitals 84 141/7 20 100%4L. 20G EJ was
placed.
.
Currently, the patient was in no distress. She described going
home and feeling fine. She went to dialysis the day before
admission but it was stoppped early due to the fact she was
having diarrhea. She says the diarrhea has since resolved. She
denied N/V, abd pain, fever, chills or cough. Per patient she
denied chest pain and her blood pressure did not drop during
dialysis. After dialysis she went home and played cards with her
friends, ate a hot saugage and layed down. Upon doing so, she
felt acutely short of breath and called 911. No associated
symtoms with this episode.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.

MEDICAL HISTORY: 1. Hypertension.
2. Atrial flutter, status post ablation with recurrent atrial
fibrillation.
3. Significant left ventricular hypertrophy with LVOT gradient
and severe diastolic dysfunction.
4. End-stage renal disease on hemodialysis.
5. Diabetes.
6. COPD - home O2, 2-3L
7. Hyperlipidemia
8. PVD s/p bilateral BKAs
9. glaucoma, left eye blindness
10. GERD

MEDICATION ON ADMISSION: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tmax: 36.9 ??????C (98.5 ??????F)

FAMILY HISTORY: Father with DM2, Mother deceased of stroke.  Siblings died of
cancer (unknown type), stroke and brain cancer.  Seven health
children.  Extended family history positive for CAD, cancer and
DM.

SOCIAL HISTORY: -EtOH: Denies use
-Tobacco: 30 pack year history, now smokes about 6 cigarettes
per day, re-lighting the butts intermittantly throughout the
day.
-Drugs: IV drug use.
She lives alone in [**Hospital3 **], has once weekly [**Location (un) 86**] [**Location (un) 269**]
and 5 days a week home health aide. Is mobile with prostheses
and walker or her wheelchair. 

### Response:
{'Acute on chronic diastolic heart failure,End stage renal disease,Subaortic stenosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Atrial flutter,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic airway obstruction, not elsewhere classified,Peripheral vascular disease, unspecified,Below knee amputation status,Long-term (current) use of anticoagulants'}
