CHIEF COMPLAINT: SOB, chest burning

PRESENT ILLNESS: 75 yo F with PMH of DM2, HTN, distant CVA now presenting with
SOB and chest burning x 1 day. She presented to [**Hospital **] hospital
today after waking up with SOB and some chest burning primarily
across the anterior left part of her chest. Rated sensation as
[**5-29**]. Per pt she has never had this before.
.
She states she's noticed increased lower extremity swelling over
the last week. Additionally, her daughters note that she has
been occasionally disoriented over the last several weeks which
is not her baseline. Patient states that she felt like her
thinking has been 'fuzzy' over the last 2 days.
.
After experiencing the chest burning, her daughter noticed that
she was gurgling as she talked and EMS was called. They noted on
arrival that her sats were mid- 70s. She was placed on NRB, and
improved to the mid-90s. Burning was releived with SL nitro in
the field, down to 0/10. At OSH ED, she received a 600cc fluid
bolus, but then received ? 40 + 20 mg of IV lasix after deciding
she was in CHF. Also recieved 162mg ASA, sL nitro and 0.5" inch
of nitropaste. Noted to be in ARF with K of 6.1, for which she
received kayexylate. Foley was placed and put out 300cc. ABG was
7.37/32/90/18 on 100% FiO2. Patient placed on CPAP with good
effect. The BiPAP was titrated off at 1:30PM but sats dropped to
92% so re-started. Transferred to [**Hospital1 18**] for further care.
.
In the ED, initial vitals were 99.5 91 143/78 18 94-95% on. She
was noted to have rales but trace peripheral edema on exam. Labs
revealed elevated WBC ct to 12.4 but no bandemia. Was noted to
have ARF to 3.4 and pro BNP elevated to 10,238. A CXR was
performed which was revealing for interval development of
bilateral pleural effusions, also new hilar prom c/w CHF,
possible retrocardiac density seen. EKG showed NSR, no peaked T
waves, but ? <1mm in V3-V5, I, II. First set of CE's revealed
flat CKs with elevated trop to 0.05 in the setting of ARF.
Lactate and U/A were normal. Spiked a temp of 100.8 in ED. Blood
and urine cultures were sent, she received vanc 1g, CTX 1g,
levoquin 750mg, tylenol, and morphine. She was placed on BiPAP
and a nitro gtt and was admitted to the CCU for presumed CHF
exacerbation +/- PNA. Foley had put out an additional 700cc
prior to transfer, when most recent VS were temp 100.8 (not
rechecked since tmax) HR 99 BP 150/49 22 99% on CPAP.
.
On review of systems, she reports a prior history of stroke over
10 years ago, denies deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. She does report recent
chills though she states she is ofte cold. Denies recent fevers,
or rigors. She endorses exertional buttock or calf pain and
reports a prior hx of PVD. Additionally, she reports
intermittent diarrhea which has been life long. Finally, she
reports pain in her lower back ad thing where she fell 2 days
ago. All of the other review of systems were negative. Cardiac
review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
She does endorse a fall yesterday for which she had a head
laceration sutured (2 stitches). A CT head at that time was
negative per family report.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Hyperlipidemia, Hypertension

MEDICATION ON ADMISSION: aspirin 81 mg daily
clopidogrel 95 daily
atenolol 100mg daily
atorvastatin unknown dose
benicar 40mg daily
gabapentin 600mg tid
glipizide 5mg daily
HCTZ 25mg daily
metformin 500mg daily
nifedipine 90mg daily
trazodone 150mg daily

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: T= 100.1 BP= 146/61 HR= 100 RR= 23 O2 sat= 99% on [**7-24**] CPAP
GENERAL: Elerly female wearing bipap, breathing comfortably.
NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry MMM. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
NECK: Supple, JVP difficult to assess give mask ventilation, but
does not appear grossly elevated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. S2/6 SEM thoughout precordium. No S3 or
S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles to mid lung
fields bilaterally. No rhonchi or wheeze.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Typanitic to
percussion, no fluid wave or dullness at flanks.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ Radial 2+
Left: Carotid 2+ DP 2+ Radial 2+
NEURO: A/o to person, place, time and purpose, strength 5/5 UE
and LE, sensation intact throughout

FAMILY HISTORY: Mother had CAD and MI. Father died at a young age of MI.

SOCIAL HISTORY: Widowed and lives alone. No tobacco, ETOH, or Illicit drugs:
Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Hyperpotassemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Iron deficiency anemia, unspecified,Peripheral vascular disease, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Ac on chr diast hrt fail,Pneumonia, organism NOS,Ac kidny fail, tubr necr,Hyperpotassemia,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,DMII wo cmp nt st uncntr,Iron defic anemia NOS,Periph vascular dis NOS,Hx TIA/stroke w/o resid
Admission Date:  [**2171-5-12**]              Discharge Date:   [**2171-5-16**]

Date of Birth:  [**2096-3-12**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
SOB, chest burning

Major Surgical or Invasive Procedure:
None

History of Present Illness:
75 yo F with PMH of DM2, HTN, distant CVA now presenting with
SOB and chest burning x 1 day. She presented to [**Hospital **] hospital
today after waking up with SOB and some chest burning primarily
across the anterior left part of her chest. Rated sensation as
[**5-29**]. Per pt she has never had this before.
.
She states she's noticed increased lower extremity swelling over
the last week. Additionally, her daughters note that she has
been occasionally disoriented over the last several weeks which
is not her baseline. Patient states that she felt like her
thinking has been 'fuzzy' over the last 2 days.
.
After experiencing the chest burning, her daughter noticed that
she was gurgling as she talked and EMS was called. They noted on
arrival that her sats were mid- 70s. She was placed on NRB, and
improved to the mid-90s. Burning was releived with SL nitro in
the field, down to 0/10. At OSH ED, she received a 600cc fluid
bolus, but then received ? 40 + 20 mg of IV lasix after deciding
she was in CHF. Also recieved 162mg ASA, sL nitro and 0.5" inch
of nitropaste. Noted to be in ARF with K of 6.1, for which she
received kayexylate. Foley was placed and put out 300cc. ABG was
7.37/32/90/18 on 100% FiO2. Patient placed on CPAP with good
effect. The BiPAP was titrated off at 1:30PM but sats dropped to
92% so re-started. Transferred to [**Hospital1 18**] for further care.
.
In the ED, initial vitals were 99.5 91 143/78 18 94-95% on. She
was noted to have rales but trace peripheral edema on exam. Labs
revealed elevated WBC ct to 12.4 but no bandemia. Was noted to
have ARF to 3.4 and pro BNP elevated to 10,238. A CXR was
performed which was revealing for interval development of
bilateral pleural effusions, also new hilar prom c/w CHF,
possible retrocardiac density seen. EKG showed NSR, no peaked T
waves, but ? <1mm in V3-V5, I, II. First set of CE's revealed
flat CKs with elevated trop to 0.05 in the setting of ARF.
Lactate and U/A were normal. Spiked a temp of 100.8 in ED. Blood
and urine cultures were sent, she received vanc 1g, CTX 1g,
levoquin 750mg, tylenol, and morphine. She was placed on BiPAP
and a nitro gtt and was admitted to the CCU for presumed CHF
exacerbation +/- PNA. Foley had put out an additional 700cc
prior to transfer, when most recent VS were temp 100.8 (not
rechecked since tmax) HR 99 BP 150/49 22 99% on CPAP.
.
On review of systems, she reports a prior history of stroke over
10 years ago, denies deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. She does report recent
chills though she states she is ofte cold. Denies recent fevers,
or rigors. She endorses exertional buttock or calf pain and
reports a prior hx of PVD. Additionally, she reports
intermittent diarrhea which has been life long. Finally, she
reports pain in her lower back ad thing where she fell 2 days
ago. All of the other review of systems were negative. Cardiac
review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
She does endorse a fall yesterday for which she had a head
laceration sutured (2 stitches). A CT head at that time was
negative per family report.


Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Hyperlipidemia, Hypertension

2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
# H/o CVA [**2157**]
# Visceral stenosis (70% stenosis of the celiac, SMA, and
[**Female First Name (un) 899**] followed by [**Doctor Last Name **])
# PVD
# DM II - not on insulin, most recent A1c 7.1 in [**6-26**]
# Hypertension
# Migraine headaches
# Gastritis - no peptic ulcer disease history.
# Depression x30 years, initially reactive.


Social History:
Widowed and lives alone. No tobacco, ETOH, or Illicit drugs:

Family History:
Mother had CAD and MI. Father died at a young age of MI.

Physical Exam:
VS: T= 100.1 BP= 146/61 HR= 100 RR= 23 O2 sat= 99% on [**7-24**] CPAP
GENERAL: Elerly female wearing bipap, breathing comfortably.
NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry MMM. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
NECK: Supple, JVP difficult to assess give mask ventilation, but
does not appear grossly elevated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. S2/6 SEM thoughout precordium. No S3 or
S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles to mid lung
fields bilaterally. No rhonchi or wheeze.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Typanitic to
percussion, no fluid wave or dullness at flanks.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ Radial 2+
Left: Carotid 2+ DP 2+ Radial 2+
NEURO: A/o to person, place, time and purpose, strength 5/5 UE
and LE, sensation intact throughout


Pertinent Results:
EKG ([**2171-5-12**]):  Sinus rhythm. Consider left atrial abnormality
although is nondiagnostic. Nonspecific ST-T wave changes. Since
previous tracing of [**2162-3-1**], sinus tachycardia rate slower.

CXR 1V ([**2171-5-12**]):  Findings compatible with congestive heart
failure. Left retrocardiac density also noted and pneumonia is
therefore considered. Recommend correlation with lateral view to
further assess.

CXR 2V ([**2171-5-13**]):  Small right and moderate left pleural
effusion are unchanged allowing the differences in positioning
of the patient. Increased retrocardiac opacities likely
atelectasis. No other interval change.

TTE ([**2171-5-14**]):  The left atrium is normal in size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild symmetric left ventricular hypertrophy with normal
cavity size. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are moderately thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
left ventricular inflow pattern suggests impaired relaxation.
There is borderline pulmonary artery systolic hypertension.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Impaired left ventricular relaxation. Mild aortic regurgitation.
Minimal aortic stenosis.
Compared with the report of the prior study (images unavailable
for review) of [**2166-7-16**], there is minimal aortic stenosis.
Borderline elevated pulmonary artery pressures are slightly
higher.

On admission ([**2171-5-12**]):
WBC-12.4* Hgb-9.6* Hct-28.2* MCV-86 Plt Ct-372
Neuts-84.4* Lymphs-10.3* Monos-4.6 Eos-0.4 Baso-0.2
PT-12.5 PTT-27.0 INR(PT)-1.1
Glucose-183* UreaN-59* Creat-3.4*# Na-135 K-5.3* Cl-103 HCO3-18*
Calcium-8.7 Phos-6.1*# Mg-2.0
Iron-14* calTIBC-247* Ferritn-120 TRF-190*

CK(CPK)-179* > 151*
CK-MB-4 > 4
proBNP-[**Numeric Identifier **]*
cTropnT-0.05* > 0.15*

On discharge ([**2171-5-16**]):
WBC-8.0 Hgb-8.5* Hct-25.6* MCV-86 Plt Ct-399
Glucose-59* UreaN-44* Creat-1.6* Na-140 K-3.7 Cl-102 HCO3-23
Mg-2.0

Blood cultures:  No growth, final
Urine culture:  No growth, final
Urine legionella:  Negative
MRSA screen:  Negative

Brief Hospital Course:
75 year-old female with diabetes mellitus type II, hypertension,
CVA admitted [**2171-5-12**] with dyspnea and fever. Hospital course was
as follows.

1. Acute on chronic diastolic heart failure:  On admission,
clinically volume overloaded with bibasilar crackles and
pulmonary edema on chest radiograph. In [**2165**], TTE showed
EF65-70% with likely impaired LV relaxation suggesting diastolic
dysfunction at that time. Repeat TTE during this hospitalization
again revealed impaired LV relaxation with LVH and preserved
systolic function. Precipitant was not clear; no indication of
cardiac ischemia. Differential included dietary indiscretion and
possible infectious etiology, as discussed below. In the
emergency department, patient was placed on BiPAP and a nitro
gtt given hypertension and respiratory distress. She was
effectively diuresed with Lasix 80-100mg IV doses, and on
discharge was transitioned to Lasix 40mg PO. On discharge, her
medication regimen includes [**First Name8 (NamePattern2) **] [**Last Name (un) **], Lasix, and a beta-blocker.
She was instructed on taking her medications and following a
low-salt diet. She was asked to weigh herself on a daily basis.

2. Acute on chronic renal failure:  Creatinine 3.4 on admission,
last in our system was 1.5 in 7/[**2169**]. Fe(UN) 58% indicated
likely not prerenal. Other likely cause was ATN from
hypoperfusion in setting of acute heart failure. GFR improved by
greater than 50% during hospital course with heart failure
management, as above.

3. Pneumonia:  T100.8 on admission. Noted to have leukocytosis
and left shift. Retrocardiac density was seen on chest
radiograph. Patient was treated with vancomycin, ceftriaxone,
and levofloxacin in the emergency department, and narrowed to
levofloxacin in the CCU.

4. Diabetes mellitus:  Metformin and glipizide were held in
house and blood glucose management with Humalog sliding scale
insulin. On discharge, patient was restarted on glipizide. Given
low blood glucose at times, metformin was help and patient was
requested to follow-up with her PCP regarding when/if to restart
this medication. Patient was continued on aspirin.

5. s/p Fall:  Patient fell 2 days prior to admission. Mechanical
fall. Had small head laceration. CT head negative per family
report. Patient a/o x3, neuro exam non-focal. Pain controlled
with acetaminophen and morphine, as needed. Patient was
evaluated by physical therapy; recommendation was home with cane
and home PT.

6. Iron-deficiency anemia:  Hct 28 on admission, per old
records, here has been normal (35-40) in [**2162**], though suspect
may be anemia of chronic disease with some element of effect
from chronic renal failure. Started on iron supplementation.
Stool guaiac negative x1. Had colonoscopy ([**2171-5-7**], [**Location (un) 620**]):
Diverticulosis; small colon polyp; history of multiple polyps;
rule out microscopic colitis; hemorrhoids.

7. Hypertension:  As above, initially required nitro gtt. On
discharge, was restarted on [**Last Name (un) **], beta-blocker.

8. Dyslipidemia:  Continued on statin per home regimen.

9. Peripheral [**Last Name (un) 1106**] disease:  Continued Plavix, aspirin per
home regimen. Initially held gapapentin given renal failure;
restarted on discharge.

**COMMUNICATION: Daughter [**Name (NI) **] [**Name (NI) 34407**] (HCP) [**Telephone/Fax (1) 99912**].
Other daughter [**Name (NI) **] [**Name (NI) 1968**] [**Telephone/Fax (1) 99913**], son [**Name (NI) **] [**Name (NI) 34407**],
brother-in-law [**Name (NI) **] [**Name (NI) 37307**].

Medications on Admission:
aspirin 81 mg daily
clopidogrel 95 daily
atenolol 100mg daily
atorvastatin unknown dose
benicar 40mg daily
gabapentin 600mg tid
glipizide 5mg daily
HCTZ 25mg daily
metformin 500mg daily
nifedipine 90mg daily
trazodone 150mg daily


Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Trazodone 150 mg Tablet Sig: One (1) Tablet PO once a day as
needed for Insomnia.
5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Glipizide 5 mg Tablet Extended Rel 24 hr (2) Sig: One (1)
Tablet Extended Rel 24 hr (2) PO once a day.
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Benicar 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Acute on Chronic Diastolic Congestive Heart Failure
Hypertension
Left Lower Lobe Pneumonia
Acute on Chronic Kidney Disease
Iron Deficiency Anemia
Diabetes Mellitus


Discharge Condition:
stable. Dry weight 124 pounds


Discharge Instructions:
You were admitted with congestive heart failure which caused
fluid overload and trouble breathing. Additionally, you may have
a pneumonia and you had antibiotics to treat this. You have been
started on lasix daily to keep the fluid from reaccumulating.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in three days. Adhere to 2 gm sodium diet. Please
call Dr. [**Last Name (STitle) 2903**] if you have any further trouble breathing, fluid
in the legs, chest pains, nausea, light headedness or any other
concerning symptoms. Please get a blood pressure cuff and check
your blood pressure at home, keep a log and bring to your
doctor's appts.
Medication changes:
1. Your atenolol was changed to Metoprolol which is better for
heart failure. STOP taking Atenolol
2. Furosemide (Lasix): to prevent fluid from accumulating
3. Ferrous Sulfate: to treat your anemia
4. Levofloxacin: 1 dose at home to finish a 7 day course to
treat your pneumonia
5. DISCONTINUE your hydrochlorothiazide
6. DISCONTINUE your metformin as your blood sugars have been low
in the hospital. Please check your blood sugars immediately
after waking in the morning and restart metformin on Monday [**5-20**].

Followup Instructions:
[**Month (only) **]:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2171-7-3**] 10:30
Provider: [**Name10 (NameIs) 14633**],EQUIPMENT  Date/Time:[**2171-7-3**] 10:30
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2171-7-3**] 11:30
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] K. Phone: [**Telephone/Fax (1) 2205**] Date/time: [**5-23**] at
10:15am.
Cardiology:
[**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**], MD Phone: [**Telephone/Fax (1) 62**] Date/time: [**6-20**] at 2:00pm.
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**].


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

Completed by:[**2171-5-22**]
{'Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Hyperpotassemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Iron deficiency anemia, unspecified,Peripheral vascular disease, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}


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: SOB, chest burning

PRESENT ILLNESS: 75 yo F with PMH of DM2, HTN, distant CVA now presenting with
SOB and chest burning x 1 day. She presented to [**Hospital **] hospital
today after waking up with SOB and some chest burning primarily
across the anterior left part of her chest. Rated sensation as
[**5-29**]. Per pt she has never had this before.
.
She states she's noticed increased lower extremity swelling over
the last week. Additionally, her daughters note that she has
been occasionally disoriented over the last several weeks which
is not her baseline. Patient states that she felt like her
thinking has been 'fuzzy' over the last 2 days.
.
After experiencing the chest burning, her daughter noticed that
she was gurgling as she talked and EMS was called. They noted on
arrival that her sats were mid- 70s. She was placed on NRB, and
improved to the mid-90s. Burning was releived with SL nitro in
the field, down to 0/10. At OSH ED, she received a 600cc fluid
bolus, but then received ? 40 + 20 mg of IV lasix after deciding
she was in CHF. Also recieved 162mg ASA, sL nitro and 0.5" inch
of nitropaste. Noted to be in ARF with K of 6.1, for which she
received kayexylate. Foley was placed and put out 300cc. ABG was
7.37/32/90/18 on 100% FiO2. Patient placed on CPAP with good
effect. The BiPAP was titrated off at 1:30PM but sats dropped to
92% so re-started. Transferred to [**Hospital1 18**] for further care.
.
In the ED, initial vitals were 99.5 91 143/78 18 94-95% on. She
was noted to have rales but trace peripheral edema on exam. Labs
revealed elevated WBC ct to 12.4 but no bandemia. Was noted to
have ARF to 3.4 and pro BNP elevated to 10,238. A CXR was
performed which was revealing for interval development of
bilateral pleural effusions, also new hilar prom c/w CHF,
possible retrocardiac density seen. EKG showed NSR, no peaked T
waves, but ? <1mm in V3-V5, I, II. First set of CE's revealed
flat CKs with elevated trop to 0.05 in the setting of ARF.
Lactate and U/A were normal. Spiked a temp of 100.8 in ED. Blood
and urine cultures were sent, she received vanc 1g, CTX 1g,
levoquin 750mg, tylenol, and morphine. She was placed on BiPAP
and a nitro gtt and was admitted to the CCU for presumed CHF
exacerbation +/- PNA. Foley had put out an additional 700cc
prior to transfer, when most recent VS were temp 100.8 (not
rechecked since tmax) HR 99 BP 150/49 22 99% on CPAP.
.
On review of systems, she reports a prior history of stroke over
10 years ago, denies deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. She does report recent
chills though she states she is ofte cold. Denies recent fevers,
or rigors. She endorses exertional buttock or calf pain and
reports a prior hx of PVD. Additionally, she reports
intermittent diarrhea which has been life long. Finally, she
reports pain in her lower back ad thing where she fell 2 days
ago. All of the other review of systems were negative. Cardiac
review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
She does endorse a fall yesterday for which she had a head
laceration sutured (2 stitches). A CT head at that time was
negative per family report.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Hyperlipidemia, Hypertension

MEDICATION ON ADMISSION: aspirin 81 mg daily
clopidogrel 95 daily
atenolol 100mg daily
atorvastatin unknown dose
benicar 40mg daily
gabapentin 600mg tid
glipizide 5mg daily
HCTZ 25mg daily
metformin 500mg daily
nifedipine 90mg daily
trazodone 150mg daily

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: T= 100.1 BP= 146/61 HR= 100 RR= 23 O2 sat= 99% on [**7-24**] CPAP
GENERAL: Elerly female wearing bipap, breathing comfortably.
NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry MMM. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
NECK: Supple, JVP difficult to assess give mask ventilation, but
does not appear grossly elevated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. S2/6 SEM thoughout precordium. No S3 or
S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles to mid lung
fields bilaterally. No rhonchi or wheeze.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Typanitic to
percussion, no fluid wave or dullness at flanks.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ Radial 2+
Left: Carotid 2+ DP 2+ Radial 2+
NEURO: A/o to person, place, time and purpose, strength 5/5 UE
and LE, sensation intact throughout

FAMILY HISTORY: Mother had CAD and MI. Father died at a young age of MI.

SOCIAL HISTORY: Widowed and lives alone. No tobacco, ETOH, or Illicit drugs: 

### Response:
{'Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Hyperpotassemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Iron deficiency anemia, unspecified,Peripheral vascular disease, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}
