CHIEF COMPLAINT: Shortness of Breath

PRESENT ILLNESS: 74 yo woman with past medical history of CHF, coronary artery
disease s/p CABG in [**2190**] who presents to the hospital with
shortness of breath that started 3-4 days ago and acutely
worsened around 5 am this morning. She increased her home 02
from 2L to 10L, took a nitro and took 40 mg Lasix without
improvement.
.
Of note, the patient was recently hospitalized in CCU for CHF
exacerbation between [**2203-10-23**] and [**2203-10-27**]. During that admission,
she was diuresed with Lasix and sent home on PO Lasix.
Amlodipine was stopped, Quinapril was decreased in dose to 5 mg
daily and she was started on aspirin. She saw her cardiologist,
Dr. [**First Name (STitle) 2031**], after admission who started Carvedilol (dose
unknown.) Three days ago when she started to feel short of
breath, Dr. [**First Name (STitle) 2031**] increased her Lasix from 20 mg daily to 40 mg
daily.
.
At baseline, the patient is quite limited by exertional dyspnea
and shortness of breath at baseline. She has 23 steps at home,
and is able to get up those stairs but only very slowly. Her
exertional dyspnea is predictable and rapidly resolves with
cessation of activities. She also had a recent admission to [**Hospital 2586**] for a CHF exacerbation in [**Month (only) 956**], at which time
she also had a cardiac catherization which per the patient
showed patency in 3 of her 4 bypass grafts. After that
admission, she was weaned off of her lasix by [**Month (only) 547**] due to drops
in blood pressure- as noted above, this was restarted on last
admission. She had a stress test in [**Month (only) 216**] which showed possible
perfusion abnormalities.
.
On review of systems, she denies recent fever. She also has a
history of DVTs x2 and had previously been on coumadin, but has
been off of coumadin for at least 2 years. She has 3 pillow
orthopnea. She denies fevers, chills or rigors. No change in
bowel habits. No symptoms of claudication. No recent weight gain
or change in eating habits.
.
On arrival to the ED, her BP was 200/100 with O2 saturations 95%
on NRB and 100% on bipap breathing in 40s with rales bilaterally
half way up the lungs on exam. In the ED, the patient was given
80 mg IV Lasix and a Nitro drip was started. Pressure dropped to
101/64 and O2 sats improved to 93% on 5L NC with RR 25.

MEDICAL HISTORY: Coronary artery disease s/p coronary artery bypass
graft in [**2190**], (stress test [**2199-8-12**] @[**Hospital3 **], under Dr.
[**First Name (STitle) 2031**] [**Telephone/Fax (1) 98231**] shows mild ischemia LV RCA distribution
consistent with old finding.)
2. Carcinoid tumor of right middle lobe s/p resection.
3. Diabetes mellitus, type 2, HbA1c=8.8 ([**6-/2198**])
4. Obesity.
5. Deep venous thrombosis, [**2176**], on Coumadin X6 months. Stopped
Coumadin, had another DVT,[**2176**] placed on Coumadin since, s/p IVC
filter, [**2197**]
6. Oxygen dependent since lung surgery and for obstructive sleep
apnea, uses 2L nasal cannula 02 at night at home. NO Bpap
7. obstructive sleep apnea.
8. restrictive lung disease
9. carpel tunnel syndrome b/l, [**2179**]
10. congestive heart failure (left atrium is mildly dilated.
LVEF 67%/[**2199**])
11.Anemia of Chronic disease, baseline Hct=30-33.0/Hb=10.
12.HTN
13.hypercholesterolemia

MEDICATION ON ADMISSION: atorvastatin 40mg
Ascorbic acid 500mg [**Hospital1 **]
Vit E 400U daily
Esomeprazole Magnesium 40mg [**Hospital1 **]
Mag Oxide 400mg [**Hospital1 **]
Sucralfate 1g [**Hospital1 **]
Nitroglycerin 0.4mg prn
Metformin 500mg- 2 tabs [**Hospital1 **]
Ferrous sulfate 325mg TID
Omeprazole 20mg, 2 tabs [**Hospital1 **]
Isosorbide Mononitrate 30mg daily
Klorcon 8 MEQ once daily
Carvedilol 3.125mg [**Hospital1 **] (Was recent started at once daily then
increased to [**Hospital1 **] as of [**2203-11-1**] appt with Dr [**First Name (STitle) 2031**]
furosemide 40 mg daily
Quinipril 5mg daily
Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension; 50 U
once daily
Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension; 20 U
at bedtime
XIBROM 0.09 % Drops; one drop daily

ALLERGIES: Ampicillin / Ceftin / Bactrim / Zocor / Lopressor

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

FAMILY HISTORY: Mother - diabetes

SOCIAL HISTORY: -Tobacco history:  None
-ETOH:  None
-Illicit drugs:  None
Is married, lives with husband, daughter and 1 of her sons.  [**Name (NI) **]
2 other children.
She lives with her husband, adult daughter and son (38 yo) in a
Acute on chronic diastolic heart failure,Other pulmonary insufficiency, not elsewhere classified,Intermediate coronary syndrome,Aortic valve disorders,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Obstructive sleep apnea (adult)(pediatric),Aortocoronary bypass status,Obesity, unspecified,Other dependence on machines, supplemental oxygen,Long-term (current) use of insulin,Personal history of venous thrombosis and embolism,Esophageal reflux,Anemia of other chronic disease,Pure hypercholesterolemia
Ac on chr diast hrt fail,Other pulmonary insuff,Intermed coronary synd,Aortic valve disorder,Hyperpotassemia,DMII wo cmp uncntrld,Obstructive sleep apnea,Aortocoronary bypass,Obesity NOS,Depend-supplement oxygen,Long-term use of insulin,Hx-ven thrombosis/embols,Esophageal reflux,Anemia-other chronic dis,Pure hypercholesterolem
Admission Date:  [**2203-11-20**]              Discharge Date:   [**2203-11-25**]

Date of Birth:  [**2129-3-14**]             Sex:   F

Service: MEDICINE

Allergies:
Ampicillin / Ceftin / Bactrim / Zocor / Lopressor

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Shortness of Breath

Major Surgical or Invasive Procedure:
none


History of Present Illness:
74 yo woman with past medical history of CHF, coronary artery
disease s/p CABG in [**2190**] who presents to the hospital with
shortness of breath that started 3-4 days ago and acutely
worsened around 5 am this morning. She increased her home 02
from 2L to 10L, took a nitro and took 40 mg Lasix without
improvement.
.
Of note, the patient was recently hospitalized in CCU for CHF
exacerbation between [**2203-10-23**] and [**2203-10-27**]. During that admission,
she was diuresed with Lasix and sent home on PO Lasix.
Amlodipine was stopped, Quinapril was decreased in dose to 5 mg
daily and she was started on aspirin. She saw her cardiologist,
Dr. [**First Name (STitle) 2031**], after admission who started Carvedilol (dose
unknown.) Three days ago when she started to feel short of
breath, Dr. [**First Name (STitle) 2031**] increased her Lasix from 20 mg daily to 40 mg
daily.
.
At baseline, the patient is quite limited by exertional dyspnea
and shortness of breath at baseline. She has 23 steps at home,
and is able to get up those stairs but only very slowly. Her
exertional dyspnea is predictable and rapidly resolves with
cessation of activities. She also had a recent admission to [**Hospital 2586**] for a CHF exacerbation in [**Month (only) 956**], at which time
she also had a cardiac catherization which per the patient
showed patency in 3 of her 4 bypass grafts. After that
admission, she was weaned off of her lasix by [**Month (only) 547**] due to drops
in blood pressure- as noted above, this was restarted on last
admission. She had a stress test in [**Month (only) 216**] which showed possible
perfusion abnormalities.
.
On review of systems, she denies recent fever. She also has a
history of DVTs x2 and had previously been on coumadin, but has
been off of coumadin for at least 2 years. She has 3 pillow
orthopnea. She denies fevers, chills or rigors. No change in
bowel habits. No symptoms of claudication. No recent weight gain
or change in eating habits.
.
On arrival to the ED, her BP was 200/100 with O2 saturations 95%
on NRB and 100% on bipap breathing in 40s with rales bilaterally
half way up the lungs on exam. In the ED, the patient was given
80 mg IV Lasix and a Nitro drip was started. Pressure dropped to
101/64 and O2 sats improved to 93% on 5L NC with RR 25.


Past Medical History:
 Coronary artery disease s/p coronary artery bypass
graft in [**2190**], (stress test [**2199-8-12**] @[**Hospital3 **], under Dr.
[**First Name (STitle) 2031**] [**Telephone/Fax (1) 98231**] shows mild ischemia LV RCA distribution
consistent with old finding.)
2. Carcinoid tumor of right middle lobe s/p resection.
3. Diabetes mellitus, type 2, HbA1c=8.8 ([**6-/2198**])
4. Obesity.
5. Deep venous thrombosis, [**2176**], on Coumadin X6 months. Stopped
Coumadin, had another DVT,[**2176**] placed on Coumadin since, s/p IVC
filter, [**2197**]
6. Oxygen dependent since lung surgery and for obstructive sleep
apnea, uses 2L nasal cannula 02 at night at home. NO Bpap
7. obstructive sleep apnea.
8. restrictive lung disease
9. carpel tunnel syndrome b/l, [**2179**]
10. congestive heart failure (left atrium is mildly dilated.
LVEF 67%/[**2199**])
11.Anemia of Chronic disease, baseline Hct=30-33.0/Hb=10.
12.HTN
13.hypercholesterolemia


Social History:
-Tobacco history:  None
-ETOH:  None
-Illicit drugs:  None
Is married, lives with husband, daughter and 1 of her sons.  [**Name (NI) **]
2 other children.
She lives with her husband, adult daughter and son (38 yo) in a

[**Location (un) 1773**] apartment in [**Location (un) 538**], Mass. The indicates
that she has 31 steps to climb. Her family is very supportive.
Daughter,
[**Name (NI) 98232**], is the contact @ Cell [**Telephone/Fax (1) 98233**]/Home [**Telephone/Fax (1) 98234**].
Retired office asst. Pt is a native of [**Country 5881**], where she used to
work as a nurse. [**First Name (Titles) **] [**Last Name (Titles) **] currently or in past. No Etoh
intake.


Family History:
Mother - diabetes

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

NECK: Supple with JVP of 6 cm.
CARDIAC: Slightly muffled S1.  3/6 systolic murmur radiating to
apex, possible [**2-2**] diastolic murmur.  Normal S2. No S3/S4
LUNGS: Bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Mild bilateral edema L>R.  Vein harvest scar on
left
leg. Warm and well perfused.
PULSES:  1+ radial pulses bilaterally.  DP and PT Pulses not
palpable.

Pertinent Results:
STUDIES:
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-10mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with focal
hypokinesis of the mid-septum. The remaining segments contract
normally (LVEF = 55 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area
0.8-1.0cm2). Mild to moderate ([**1-29**]+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
to severe (3+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.

IMPRESSION: Severe aortic valve stenosis. Pulmonary artery
systolic hypertension. Moderate to severe mitral regurgitation.
Symmetric left ventricular hypertrophy with regional systolic
dysfunction suggestive of CAD. Mild-moderate aortic
regurgitation.

CLINICAL IMPLICATIONS:
The patient has severe aortic stenosis. Based on [**2199**] ACC/AHA
Valvular Heart Disease Guidelines, if the patient is a surgical
candidate, surgical intervention has been shown to improve
survival.

CT chest:
IMPRESSIONS:

1. Longstanding sternal nonunion following prior sternotomy,
with
fragmentation of multiple sternal closure wires, and
well-corticated bony
fragments in the sternotomy defect.

2. Extensive atherosclerotic disease involving both the native
and graft
coronary vessels.

3. Prior CABG with graft vessels arising from the anterior
aspect of the
ascending aorta. No atherosclerotic calcification involving the
ascending
aorta.

4. Small bilateral pleural effusions with associated
atelectasis.

5. Small hiatal hernia.

6. Cholelithiasis without cholecystitis.

Carotid US:
IMPRESSION:
1. Heterogeneous plaque at the ostium of the right internal
carotid artery as
well as slightly more significantly in the proximal left
internal and external
carotid arteries.
2. No significant stenosis noted on the right side.
3. Suspected 60-69% stenosis involving the proximal left
internal carotid
artery.
4. Prograde flow in both vertebral arteries.

Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study Date of
[**2203-11-24**]  8:06 AM


SPIROMETRY 8:06 AM Pre drug Post drug
    Actual Pred %Pred Actual %Pred %chg
FVC   1.23 2.10 58
FEV1   1.00 1.42 70
MMF   1.00 1.84 54
FEV1/FVC   81 68 121

LUNG VOLUMES 8:06 AM Pre drug Post drug
    Actual Pred %Pred Actual %Pred
TLC   2.36 3.62 65
FRC   1.33 2.12 63
RV   1.20 1.52 79
VC   1.16 2.10 55
IC   1.03 1.51 68
ERV   0.14 0.60 23
RV/TLC   51 42 121
He Mix Time   2.13

DLCO 8:06 AM
    Actual Pred %Pred
DSB   9.39 15.68 60
VA(sb)   1.98 3.62 55
HB   10.70
DSB(HB)   10.37 15.68 66
DL/VA   5.25 4.32 121







Brief Hospital Course:
74 y.o woman with history of CABG and CHF, also DVT who presents
with acute onset of dyspnea and evidence of pulmonary edema,
consistent with a severe exacerbation of congestive heart
failure.
.
# Acute on chronic diastolic Congestive Heart Failure
exacerbation: CHF exacerbation was attributed to severe Aortic
Stenosis seen on echo. Pt was initially diuresed with lasix and
had improved symptoms. Carvedilol and quinapril were initially
held and then restarted. Furosemide was continued at previous
dose of 40 mg daily. Weight at discharge was 184 pounds and pt
appeared euvolemic.
.
# Severe Aortic stenosis: Pt found to have severe Aortic
Stenosis with aortic valve area: 0.8-1.0cm2. Echo also revealed
mod-severe MR. CT surgery was consulted and reccomended surgery.
Pre-op workup was initiated. Pt had CT chest (revealing small
bilateral pleural effusions and extensive atherosclerosis).
Carotid US performed which showed 89% stenosis on left side and
no sig stenosis on right side. PFTs returned showing mixed
restrictive and obstructive disease. Cardiac surgeon Dr. [**First Name (STitle) **]
[**Name (STitle) **] will schedule surgery.
.
# Coronary Artery Disease: R/O'd. No significant chest pain
during hospital stay. Continued ASA 81 mg, Atorvastatin 40 mg
daily. Given her marginal BP, Imdur was not given during
hospital stay and not restarted at discharge. The RCA may be
bypassed during the AVR surgery. If so, vein mapping will be
needed and will be arranged by the cardiac surgeon.
.
# Hypertension: Restarted carvedilol and quinapril. Held Imdur.
SBP 98-103 on day of discharge.
.
# Diabetes Mellitus: Sugars in the 170-350 range. Family
requested [**Last Name (un) **] consult. She was started on 75/25 humalog here
in the hospital with daily [**Last Name (un) **] oversight. She will go home on
a new regimen of 70/30 Novalog (humalog with NPH) of 36 units in
the morning and 24 units at night. She will also do fingersticks
before each meal and has a new Humalog sliding scale. Metformin
was held but restarted at discharge. She will f.u with [**Last Name (un) **]
outpatient.
.
# GERD: Continued Esomeprazole
.
# Dispo: She will go home and return for surgery. She has an
appt in 4 days with her cardiologist Dr. [**First Name (STitle) 2031**].

Pt refuses VNA despite encouraging.
Pt noted to have enlarged flat tongue with MCV in low 80s. Might
have B12 def. Pts B12 levels should be checked and followed
outpatient.

Medications on Admission:
atorvastatin 40mg
Ascorbic acid 500mg [**Hospital1 **]
Vit E 400U daily
Esomeprazole Magnesium 40mg [**Hospital1 **]
Mag Oxide 400mg [**Hospital1 **]
Sucralfate 1g [**Hospital1 **]
Nitroglycerin 0.4mg prn
Metformin 500mg- 2 tabs [**Hospital1 **]
Ferrous sulfate 325mg TID
Omeprazole 20mg, 2 tabs [**Hospital1 **]
Isosorbide Mononitrate 30mg daily
Klorcon 8 MEQ once daily
Carvedilol 3.125mg [**Hospital1 **] (Was recent started at once daily then
increased to [**Hospital1 **] as of [**2203-11-1**] appt with Dr [**First Name (STitle) 2031**]
furosemide 40 mg daily
Quinipril 5mg daily
Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension; 50 U
once daily
Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension; 20 U
at bedtime
XIBROM 0.09 % Drops; one drop daily


Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
3. vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a
day.
4. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day.
5. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
6. Carafate 1 gram Tablet Sig: One (1) Tablet PO twice a day: do
not take with other medicines.
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
8. metformin 500 mg Tablet Sig: Two (2) Tablet PO twice a day.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. XIBROM 0.09 % Drops Sig: One (1) drop Ophthalmic one drop
daily ().
11. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Outpatient Lab Work
please check Chem-7 at Dr.[**Name (NI) 13610**] office on [**2203-11-29**] with
results to Dr. [**First Name (STitle) 2031**] at [**Telephone/Fax (1) 77385**]
13. potassium chloride 8 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
14. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Thirty
Six (36) units Subcutaneous before breakfast.
Disp:*1 bottle* Refills:*2*
15. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Twenty
Four (24) units Subcutaneous before dinner.
16. Humalog 100 unit/mL Solution Sig: as per sliding scale units
Subcutaneous four times a day: check fingersticks 4 times a day
before meals and at bedtime. .
Disp:*1 bottle* Refills:*2*
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. quinapril 5 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Acute on Chronic Diastolic Congestive Heart Failure
Critical Aortic Stenosis
Coronary Artery Disease
Diabetes Mellitus Type 2
Hypertension


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You had an acute exacerbation of congestive heart failure that
was a result of a very tight aortic valve. You will need to have
that valve replaced in the near future. You will be [**Telephone/Fax (1) 653**] by
the cardiac surgery department at [**Hospital1 18**] to schedule and plan for
this surgery. We have done many tests here to get you ready for
the surgery including a CT scan of the chest, Pulmonary function
tests, a sleep study, and a carotid ultrasound. You will need to
have an sleep study after the surgery and should make an appt in
the sleep clinic here to have that arranged.
.
Please get blood drawn while you are seeing Dr. [**First Name (STitle) 2031**] on [**11-29**].
A prescription was given to you for that lab work.
.
Weigh yourself every morning, call Dr. [**First Name (STitle) 2031**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Stop taking omeprazole, Vitamin E, potassium (Kdur) and Imdur
(isosorbide mononitrate)
2. Change insulin to 70/30 Novalog at 36 units in the morning
and 24 units at night. You will also have a new sliding scale of
humalog insulin to use before each meal.
3. Decrease ferrous sulfate to once daily
4. Start aspirin 81 mg (baby aspirin)


Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to schedule an appointment
within the next week #[**Telephone/Fax (1) 917**] to discuss the upcomming
surgery. At this appointment, you will discuss: the surgery,
your questions, your concerns, the date of surgery.



[**Hospital **] Clinic

[**Last Name (un) 3911**], [**Location (un) 86**] MA

Phone: [**Telephone/Fax (1) 2378**]

Date/time: [**2203-12-6**] at 1:30pm

.

Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**]

Phone: [**Telephone/Fax (1) 77385**]

Date/time: Tuesday [**11-29**] at 2:30pm

[**Hospital 1263**] Hospital

.

Please make an appt in the Sleep study clinic here at [**Hospital1 18**]
after the surgery. PHONE: (66)7.LUNG (5864) ?????? Sleep [**Hospital 6920**]
Clinic
{'Acute on chronic diastolic heart failure,Other pulmonary insufficiency, not elsewhere classified,Intermediate coronary syndrome,Aortic valve disorders,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Obstructive sleep apnea (adult)(pediatric),Aortocoronary bypass status,Obesity, unspecified,Other dependence on machines, supplemental oxygen,Long-term (current) use of insulin,Personal history of venous thrombosis and embolism,Esophageal reflux,Anemia of other chronic disease,Pure hypercholesterolemia'}


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: 74 yo woman with past medical history of CHF, coronary artery
disease s/p CABG in [**2190**] who presents to the hospital with
shortness of breath that started 3-4 days ago and acutely
worsened around 5 am this morning. She increased her home 02
from 2L to 10L, took a nitro and took 40 mg Lasix without
improvement.
.
Of note, the patient was recently hospitalized in CCU for CHF
exacerbation between [**2203-10-23**] and [**2203-10-27**]. During that admission,
she was diuresed with Lasix and sent home on PO Lasix.
Amlodipine was stopped, Quinapril was decreased in dose to 5 mg
daily and she was started on aspirin. She saw her cardiologist,
Dr. [**First Name (STitle) 2031**], after admission who started Carvedilol (dose
unknown.) Three days ago when she started to feel short of
breath, Dr. [**First Name (STitle) 2031**] increased her Lasix from 20 mg daily to 40 mg
daily.
.
At baseline, the patient is quite limited by exertional dyspnea
and shortness of breath at baseline. She has 23 steps at home,
and is able to get up those stairs but only very slowly. Her
exertional dyspnea is predictable and rapidly resolves with
cessation of activities. She also had a recent admission to [**Hospital 2586**] for a CHF exacerbation in [**Month (only) 956**], at which time
she also had a cardiac catherization which per the patient
showed patency in 3 of her 4 bypass grafts. After that
admission, she was weaned off of her lasix by [**Month (only) 547**] due to drops
in blood pressure- as noted above, this was restarted on last
admission. She had a stress test in [**Month (only) 216**] which showed possible
perfusion abnormalities.
.
On review of systems, she denies recent fever. She also has a
history of DVTs x2 and had previously been on coumadin, but has
been off of coumadin for at least 2 years. She has 3 pillow
orthopnea. She denies fevers, chills or rigors. No change in
bowel habits. No symptoms of claudication. No recent weight gain
or change in eating habits.
.
On arrival to the ED, her BP was 200/100 with O2 saturations 95%
on NRB and 100% on bipap breathing in 40s with rales bilaterally
half way up the lungs on exam. In the ED, the patient was given
80 mg IV Lasix and a Nitro drip was started. Pressure dropped to
101/64 and O2 sats improved to 93% on 5L NC with RR 25.

MEDICAL HISTORY: Coronary artery disease s/p coronary artery bypass
graft in [**2190**], (stress test [**2199-8-12**] @[**Hospital3 **], under Dr.
[**First Name (STitle) 2031**] [**Telephone/Fax (1) 98231**] shows mild ischemia LV RCA distribution
consistent with old finding.)
2. Carcinoid tumor of right middle lobe s/p resection.
3. Diabetes mellitus, type 2, HbA1c=8.8 ([**6-/2198**])
4. Obesity.
5. Deep venous thrombosis, [**2176**], on Coumadin X6 months. Stopped
Coumadin, had another DVT,[**2176**] placed on Coumadin since, s/p IVC
filter, [**2197**]
6. Oxygen dependent since lung surgery and for obstructive sleep
apnea, uses 2L nasal cannula 02 at night at home. NO Bpap
7. obstructive sleep apnea.
8. restrictive lung disease
9. carpel tunnel syndrome b/l, [**2179**]
10. congestive heart failure (left atrium is mildly dilated.
LVEF 67%/[**2199**])
11.Anemia of Chronic disease, baseline Hct=30-33.0/Hb=10.
12.HTN
13.hypercholesterolemia

MEDICATION ON ADMISSION: atorvastatin 40mg
Ascorbic acid 500mg [**Hospital1 **]
Vit E 400U daily
Esomeprazole Magnesium 40mg [**Hospital1 **]
Mag Oxide 400mg [**Hospital1 **]
Sucralfate 1g [**Hospital1 **]
Nitroglycerin 0.4mg prn
Metformin 500mg- 2 tabs [**Hospital1 **]
Ferrous sulfate 325mg TID
Omeprazole 20mg, 2 tabs [**Hospital1 **]
Isosorbide Mononitrate 30mg daily
Klorcon 8 MEQ once daily
Carvedilol 3.125mg [**Hospital1 **] (Was recent started at once daily then
increased to [**Hospital1 **] as of [**2203-11-1**] appt with Dr [**First Name (STitle) 2031**]
furosemide 40 mg daily
Quinipril 5mg daily
Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension; 50 U
once daily
Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension; 20 U
at bedtime
XIBROM 0.09 % Drops; one drop daily

ALLERGIES: Ampicillin / Ceftin / Bactrim / Zocor / Lopressor

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

FAMILY HISTORY: Mother - diabetes

SOCIAL HISTORY: -Tobacco history:  None
-ETOH:  None
-Illicit drugs:  None
Is married, lives with husband, daughter and 1 of her sons.  [**Name (NI) **]
2 other children.
She lives with her husband, adult daughter and son (38 yo) in a 

### Response:
{'Acute on chronic diastolic heart failure,Other pulmonary insufficiency, not elsewhere classified,Intermediate coronary syndrome,Aortic valve disorders,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Obstructive sleep apnea (adult)(pediatric),Aortocoronary bypass status,Obesity, unspecified,Other dependence on machines, supplemental oxygen,Long-term (current) use of insulin,Personal history of venous thrombosis and embolism,Esophageal reflux,Anemia of other chronic disease,Pure hypercholesterolemia'}
