CHIEF COMPLAINT: SOB/hypoxia

PRESENT ILLNESS: [**Hospital Unit Name 20719**] NOTE:
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**]
CC: SOB, hypoxia
.
HPI: Ms. [**Known lastname 15427**] is a 69 yo F with h/o COPD (4L NC at home at
baseline; frequent admissions for exacerbations) and s/p small
cell lung CA with post-XRT fibrosis of the right lung.  She
presented to the ED this morning c/o 2-3 days of SOB, especially
at night when she was sleeping.  She has also had worsening of
sputum production in the last day with change in color to green
as well as decreased ability to cough up secretions.  She denied
fevers at home.
.
In the ED, VS were T 98.9, HR 73, BP 107/72, RR 20, 93% 6L.  She
was started on CPAP with sats in the upper 90's, but she then
refused to continue wearing the mask.  Chest x-ray did not show
an infiltrate.  No studies were ordered to rule out PE because
the ED felt this was low probability in the setting of an INR
2.0.  She was given solumedrol 125 mg IV,
[**Known lastname **]/ceftriaxone, and albuterol nebulizers.

MEDICAL HISTORY: PMH:
1. Small cell lung CA
-- diagnosed ~14 years ago
-- s/p XRT and chemo (cisplatinum).
2. COPD, on 4L NC home oxygen.
3. History of atrial fibrillation
4. History of perforated diverticulum status post colostomy.
5. History of peptic ulcer disease.
6. Hypertension.
7. Severe pulmonary hypertension on Viagra.
8. Status post ASD repair.
9. Status post ventral hernia repair.
10. Status post appendectomy.
11. Depression
12. Chronic PE in the right middle lobe of the PA

MEDICATION ON ADMISSION: Coumadin 3 mg QD
Furosemide 80 mg PO daily
Sildenafil 50 mg PO TID
Digoxin 125 mcg PO DAILY
Paroxetine HCl 10 mg PO DAILY
Combivent 18-103 mcg/Actuation Aerosol Sig: [**11-26**] sprays TID
Albuterol PRN
Montelukast 10 mg PO DAILY
Alprazolam 0.5 mg PO QHS
Sotalol 40 mg PO QPM
Sotalol 80 mg PO QAM
Calcium Carbonate 500 mg PO DAILY
Cholecalciferol (Vitamin D3) 400 unit PO DAILY
Ascorbic Acid 500 mg PO DAILY

ALLERGIES: Bactrim Ds

PHYSICAL EXAM: VS in the ED: T 98.9, HR 73, BP 107/72, RR 20, 93% 6L
GENERAL: elderly appearing, frail; very vocal about her
discomfort & frustration with being in the ICU; speaking in full
sentences
SKIN: No rashes; scattered ecchymoses on hands
HEENT: JVD to midneck, neck supple.
CHEST: decreased BS on right; crackles at right base; minimal
wheezing throughout; minimal accessry muscle use.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: + Ostomy, overall NT/ND
EXTREMITIES:1+ LE edema, warm without cyanosis
NEUROLOGIC: AA, Ox3; CN II - XII in tact; moving all
extremities.
.
LABS: see below; notable for WBC 11.5, 94% PMN's, 0 bands; INR
2.0; Na 128
.
MICROBIOLOGY: 2 sets of BCx sent from ED; pending
.
IMAGING:
[**2167-5-25**] ADMISSION CXR:
FINDINGS: The extensive post-treatment changes (post-surgery and
radiation) involving the right lung are similar. There is
significant radiation fibrosis at the right lung base with
persistent right pleural effusion and atelectasis. The known
spiculated right upper lobe nodule is not well seen on today's
radiograph. The cardiomediastinal silhouette is similar. The
cerclage wires and surgical clips are unchanged. The bones are
unremarkable.
IMPRESSION: Post-surgical and radiation changes in the right
lung are stable.  No evidence of pneumonia.
.
[**6-/2166**] SPIROMETRY (most recent):
FEV1 0.56 (29% predicted); FVC 1.12 (41% predicted)
.
[**11/2166**] ECHO (most recent):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild to moderate ([**11-26**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2164-9-20**],
the RV has further dilated and systolic function has
deteriorated. The estimated PASP has increased. The LVEF remains
normal.
.
.
.
ASSESSMENT/PLAN:
69 yo F w/ multiple medical problems including severe COPD,
right-sided pulm fibrosis, and atrial fibrillation, presenting
with SOB x 2-3 days in setting of increased (green) sputum
production.
.
#. SOB: unclear whether bronchitis-driven COPD exacerbation vs.
cardiac/pulmonary edema. CXR not especially concerning for
volume overload and patient with EF 55% on recent echo in
[**11/2166**]; however, history of worsening SOB with recumbency is c/f
cardiac source.  Patient refusing additional lasix PO tonight
given she does not have a foley and does not want to be up all
night.  Decreased CO in setting of poorly controlled AFib less
likely given that her HR not elevated on admission.  Said she
feels better after "treatments" in the ED; on 4 - 6 L NC now,
speaking in full sentences with minimal accessory muscle use.
-- albuterol and combivent nebs standing overnight; will change
to PRN in the am if stable
-- received solumedrol 125 mg IV in the ED; will continue
prednisone 30 mg QD with taper beginning in next 1 - 2 days
pending stability
-- will wean to 4L NC (home baseline) as tolerated; no need for
CPAP currently.
-- will continue [**Year (4 digits) **] x 4 days.
-- continue home dose lasix 80 mg QD; will consider additional
dose if with continued O2 requirement > 4LNC in am or volume
overloaded on exam.
.
#. ATRIAL FIBRILLATION: rate well controlled currently
-- will cont home regimen of digxoin and sotalol
-- INR 2.0 --> will continue coumadin 3 mg QD; recheck INR in am
.
#. PULMONARY HYPERTENSION:
-- will continue sildenafil 50 mg Q8 hours
.
#. CHRONIC BACK PAIN: [**Last Name 20720**] problem in [**Name (NI) **]; on Tylenol
#3 at home
-- continue home regimen
.
#. PPX:
-- bowel regimen
-- will hold on protonix given low risk for stress ulcers (not
acutely ill currently) and eating a regular diet
-- will consider starting pneumoboots or SQH in am pending
patient agrees
.
#. FEN: no evidence of dehydration; will place on regular diet
.
#. CODE: full
.
#. DISPO: to remain in ICU overnight for observation and further
treatment; will likely transfer to floor in am

FAMILY HISTORY: Non-contributory.
.
ADMISSION PHYSICAL EXAM:
VS in the ED: T 98.9, HR 73, BP 107/72, RR 20, 93% 6L
GENERAL: elderly appearing, frail; very vocal about her
discomfort & frustration with being in the ICU; speaking in full
sentences
SKIN: No rashes; scattered ecchymoses on hands
HEENT: JVD to midneck, neck supple.
CHEST: decreased BS on right; crackles at right base; minimal
wheezing throughout; minimal accessry muscle use.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: + Ostomy, overall NT/ND
EXTREMITIES:1+ LE edema, warm without cyanosis
NEUROLOGIC: AA, Ox3; CN II - XII in tact; moving all
extremities.
.
LABS: see below; notable for WBC 11.5, 94% PMN's, 0 bands; INR
2.0; Na 128
.
MICROBIOLOGY: 2 sets of BCx sent from ED; pending
.
IMAGING:
[**2167-5-25**] ADMISSION CXR:
FINDINGS: The extensive post-treatment changes (post-surgery and
radiation) involving the right lung are similar. There is
significant radiation fibrosis at the right lung base with
persistent right pleural effusion and atelectasis. The known
spiculated right upper lobe nodule is not well seen on today's
radiograph. The cardiomediastinal silhouette is similar. The
cerclage wires and surgical clips are unchanged. The bones are
unremarkable.
IMPRESSION: Post-surgical and radiation changes in the right
lung are stable.  No evidence of pneumonia.
.
[**6-/2166**] SPIROMETRY (most recent):
FEV1 0.56 (29% predicted); FVC 1.12 (41% predicted)
.
[**11/2166**] ECHO (most recent):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild to moderate ([**11-26**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2164-9-20**],
the RV has further dilated and systolic function has
deteriorated. The estimated PASP has increased. The LVEF remains
normal.
.
.
.
ASSESSMENT/PLAN:
69 yo F w/ multiple medical problems including severe COPD,
right-sided pulm fibrosis, and atrial fibrillation, presenting
with SOB x 2-3 days in setting of increased (green) sputum
production.
.
#. SOB: unclear whether bronchitis-driven COPD exacerbation vs.
cardiac/pulmonary edema. CXR not especially concerning for
volume overload and patient with EF 55% on recent echo in
[**11/2166**]; however, history of worsening SOB with recumbency is c/f
cardiac source.  Patient refusing additional lasix PO tonight
given she does not have a foley and does not want to be up all
night.  Decreased CO in setting of poorly controlled AFib less
likely given that her HR not elevated on admission.  Said she
feels better after "treatments" in the ED; on 4 - 6 L NC now,
speaking in full sentences with minimal accessory muscle use.
-- albuterol and combivent nebs standing overnight; will change
to PRN in the am if stable
-- received solumedrol 125 mg IV in the ED; will continue
prednisone 30 mg QD with taper beginning in next 1 - 2 days
pending stability
-- will wean to 4L NC (home baseline) as tolerated; no need for
CPAP currently.
-- will continue [**Year (4 digits) **] x 4 days.
-- continue home dose lasix 80 mg QD; will consider additional
dose if with continued O2 requirement > 4LNC in am or volume
overloaded on exam.
.
#. ATRIAL FIBRILLATION: rate well controlled currently
-- will cont home regimen of digxoin and sotalol
-- INR 2.0 --> will continue coumadin 3 mg QD; recheck INR in am
.
#. PULMONARY HYPERTENSION:
-- will continue sildenafil 50 mg Q8 hours
.
#. CHRONIC BACK PAIN: [**Last Name 20720**] problem in [**Name (NI) **]; on Tylenol
#3 at home
-- continue home regimen
.
#. PPX:
-- bowel regimen
-- will hold on protonix given low risk for stress ulcers (not
acutely ill currently) and eating a regular diet
-- will consider starting pneumoboots or SQH in am pending
patient agrees
.
#. FEN: no evidence of dehydration; will place on regular diet
.
#. CODE: full
.
#. DISPO: to remain in ICU overnight for observation and further
treatment; will likely transfer to floor in am

SOCIAL HISTORY: History of tobacco; quit over 10 years ago. Drinks a glass of
wine a day. Immigrated from [**Location (un) 311**] in [**2120**].  Used ot be a nanny.
 Has one son
.
Family History:
Non-contributory.
.
ADMISSION PHYSICAL EXAM:
VS in the ED: T 98.9, HR 73, BP 107/72, RR 20, 93% 6L
GENERAL: elderly appearing, frail; very vocal about her
discomfort & frustration with being in the ICU; speaking in full
sentences
SKIN: No rashes; scattered ecchymoses on hands
HEENT: JVD to midneck, neck supple.
CHEST: decreased BS on right; crackles at right base; minimal
wheezing throughout; minimal accessry muscle use.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: + Ostomy, overall NT/ND
EXTREMITIES:1+ LE edema, warm without cyanosis
NEUROLOGIC: AA, Ox3; CN II - XII in tact; moving all
extremities.
.
LABS: see below; notable for WBC 11.5, 94% PMN's, 0 bands; INR
2.0; Na 128
.
MICROBIOLOGY: 2 sets of BCx sent from ED; pending
.
IMAGING:
[**2167-5-25**] ADMISSION CXR:
FINDINGS: The extensive post-treatment changes (post-surgery and
radiation) involving the right lung are similar. There is
significant radiation fibrosis at the right lung base with
persistent right pleural effusion and atelectasis. The known
spiculated right upper lobe nodule is not well seen on today's
radiograph. The cardiomediastinal silhouette is similar. The
cerclage wires and surgical clips are unchanged. The bones are
unremarkable.
IMPRESSION: Post-surgical and radiation changes in the right
lung are stable.  No evidence of pneumonia.
.
[**6-/2166**] SPIROMETRY (most recent):
FEV1 0.56 (29% predicted); FVC 1.12 (41% predicted)
.
[**11/2166**] ECHO (most recent):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild to moderate ([**11-26**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2164-9-20**],
the RV has further dilated and systolic function has
deteriorated. The estimated PASP has increased. The LVEF remains
normal.
.
.
.
ASSESSMENT/PLAN:
69 yo F w/ multiple medical problems including severe COPD,
right-sided pulm fibrosis, and atrial fibrillation, presenting
with SOB x 2-3 days in setting of increased (green) sputum
production.
.
#. SOB: unclear whether bronchitis-driven COPD exacerbation vs.
cardiac/pulmonary edema. CXR not especially concerning for
volume overload and patient with EF 55% on recent echo in
[**11/2166**]; however, history of worsening SOB with recumbency is c/f
cardiac source.  Patient refusing additional lasix PO tonight
given she does not have a foley and does not want to be up all
night.  Decreased CO in setting of poorly controlled AFib less
likely given that her HR not elevated on admission.  Said she
feels better after "treatments" in the ED; on 4 - 6 L NC now,
speaking in full sentences with minimal accessory muscle use.
-- albuterol and combivent nebs standing overnight; will change
to PRN in the am if stable
-- received solumedrol 125 mg IV in the ED; will continue
prednisone 30 mg QD with taper beginning in next 1 - 2 days
pending stability
-- will wean to 4L NC (home baseline) as tolerated; no need for
CPAP currently.
-- will continue [**Year (4 digits) **] x 4 days.
-- continue home dose lasix 80 mg QD; will consider additional
dose if with continued O2 requirement > 4LNC in am or volume
overloaded on exam.
.
#. ATRIAL FIBRILLATION: rate well controlled currently
-- will cont home regimen of digxoin and sotalol
-- INR 2.0 --> will continue coumadin 3 mg QD; recheck INR in am
.
#. PULMONARY HYPERTENSION:
-- will continue sildenafil 50 mg Q8 hours
.
#. CHRONIC BACK PAIN: [**Last Name 20720**] problem in [**Name (NI) **]; on Tylenol
#3 at home
-- continue home regimen
.
#. PPX:
-- bowel regimen
-- will hold on protonix given low risk for stress ulcers (not
acutely ill currently) and eating a regular diet
-- will consider starting pneumoboots or SQH in am pending
patient agrees
.
#. FEN: no evidence of dehydration; will place on regular diet
.
#. CODE: full
.
#. DISPO: to remain in ICU overnight for observation and further
treatment; will likely transfer to floor in am
Obstructive chronic bronchitis with (acute) exacerbation,Hyposmolality and/or hyponatremia,Primary pulmonary hypertension,Malignant neoplasm of other parts of bronchus or lung,Postinflammatory pulmonary fibrosis,Atrial fibrillation
Obs chr bronc w(ac) exac,Hyposmolality,Prim pulm hypertension,Mal neo bronch/lung NEC,Postinflam pulm fibrosis,Atrial fibrillation
Admission Date:  [**2167-5-25**]              Discharge Date:   [**2167-5-26**]

Date of Birth:  [**2097-12-31**]             Sex:   F

Service: MEDICINE

Allergies:
Bactrim Ds

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
SOB/hypoxia

Major Surgical or Invasive Procedure:
None


History of Present Illness:
[**Hospital Unit Name 20719**] NOTE:
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**]
CC: SOB, hypoxia
.
HPI: Ms. [**Known lastname 15427**] is a 69 yo F with h/o COPD (4L NC at home at
baseline; frequent admissions for exacerbations) and s/p small
cell lung CA with post-XRT fibrosis of the right lung.  She
presented to the ED this morning c/o 2-3 days of SOB, especially
at night when she was sleeping.  She has also had worsening of
sputum production in the last day with change in color to green
as well as decreased ability to cough up secretions.  She denied
fevers at home.
.
In the ED, VS were T 98.9, HR 73, BP 107/72, RR 20, 93% 6L.  She
was started on CPAP with sats in the upper 90's, but she then
refused to continue wearing the mask.  Chest x-ray did not show
an infiltrate.  No studies were ordered to rule out PE because
the ED felt this was low probability in the setting of an INR
2.0.  She was given solumedrol 125 mg IV,
[**Known lastname **]/ceftriaxone, and albuterol nebulizers.

Social History:
History of tobacco; quit over 10 years ago. Drinks a glass of
wine a day. Immigrated from [**Location (un) 311**] in [**2120**].  Used ot be a nanny.
 Has one son
.
Family History:
Non-contributory.
.
ADMISSION PHYSICAL EXAM:
VS in the ED: T 98.9, HR 73, BP 107/72, RR 20, 93% 6L
GENERAL: elderly appearing, frail; very vocal about her
discomfort & frustration with being in the ICU; speaking in full
sentences
SKIN: No rashes; scattered ecchymoses on hands
HEENT: JVD to midneck, neck supple.
CHEST: decreased BS on right; crackles at right base; minimal
wheezing throughout; minimal accessry muscle use.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: + Ostomy, overall NT/ND
EXTREMITIES:1+ LE edema, warm without cyanosis
NEUROLOGIC: AA, Ox3; CN II - XII in tact; moving all
extremities.
.
LABS: see below; notable for WBC 11.5, 94% PMN's, 0 bands; INR
2.0; Na 128
.
MICROBIOLOGY: 2 sets of BCx sent from ED; pending
.
IMAGING:
[**2167-5-25**] ADMISSION CXR:
FINDINGS: The extensive post-treatment changes (post-surgery and
radiation) involving the right lung are similar. There is
significant radiation fibrosis at the right lung base with
persistent right pleural effusion and atelectasis. The known
spiculated right upper lobe nodule is not well seen on today's
radiograph. The cardiomediastinal silhouette is similar. The
cerclage wires and surgical clips are unchanged. The bones are
unremarkable.
IMPRESSION: Post-surgical and radiation changes in the right
lung are stable.  No evidence of pneumonia.
.
[**6-/2166**] SPIROMETRY (most recent):
FEV1 0.56 (29% predicted); FVC 1.12 (41% predicted)
.
[**11/2166**] ECHO (most recent):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild to moderate ([**11-26**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2164-9-20**],
the RV has further dilated and systolic function has
deteriorated. The estimated PASP has increased. The LVEF remains
normal.
.
.
.
ASSESSMENT/PLAN:
69 yo F w/ multiple medical problems including severe COPD,
right-sided pulm fibrosis, and atrial fibrillation, presenting
with SOB x 2-3 days in setting of increased (green) sputum
production.
.
#. SOB: unclear whether bronchitis-driven COPD exacerbation vs.
cardiac/pulmonary edema. CXR not especially concerning for
volume overload and patient with EF 55% on recent echo in
[**11/2166**]; however, history of worsening SOB with recumbency is c/f
cardiac source.  Patient refusing additional lasix PO tonight
given she does not have a foley and does not want to be up all
night.  Decreased CO in setting of poorly controlled AFib less
likely given that her HR not elevated on admission.  Said she
feels better after "treatments" in the ED; on 4 - 6 L NC now,
speaking in full sentences with minimal accessory muscle use.
-- albuterol and combivent nebs standing overnight; will change
to PRN in the am if stable
-- received solumedrol 125 mg IV in the ED; will continue
prednisone 30 mg QD with taper beginning in next 1 - 2 days
pending stability
-- will wean to 4L NC (home baseline) as tolerated; no need for
CPAP currently.
-- will continue [**Year (4 digits) **] x 4 days.
-- continue home dose lasix 80 mg QD; will consider additional
dose if with continued O2 requirement > 4LNC in am or volume
overloaded on exam.
.
#. ATRIAL FIBRILLATION: rate well controlled currently
-- will cont home regimen of digxoin and sotalol
-- INR 2.0 --> will continue coumadin 3 mg QD; recheck INR in am
.
#. PULMONARY HYPERTENSION:
-- will continue sildenafil 50 mg Q8 hours
.
#. CHRONIC BACK PAIN: [**Last Name 20720**] problem in [**Name (NI) **]; on Tylenol
#3 at home
-- continue home regimen
.
#. PPX:
-- bowel regimen
-- will hold on protonix given low risk for stress ulcers (not
acutely ill currently) and eating a regular diet
-- will consider starting pneumoboots or SQH in am pending
patient agrees
.
#. FEN: no evidence of dehydration; will place on regular diet
.
#. CODE: full
.
#. DISPO: to remain in ICU overnight for observation and further
treatment; will likely transfer to floor in am

Past Medical History:
PMH:
1. Small cell lung CA
-- diagnosed ~14 years ago
-- s/p XRT and chemo (cisplatinum).
2. COPD, on 4L NC home oxygen.
3. History of atrial fibrillation
4. History of perforated diverticulum status post colostomy.
5. History of peptic ulcer disease.
6. Hypertension.
7. Severe pulmonary hypertension on Viagra.
8. Status post ASD repair.
9. Status post ventral hernia repair.
10. Status post appendectomy.
11. Depression
12. Chronic PE in the right middle lobe of the PA


Social History:
History of tobacco; quit over 10 years ago. Drinks a glass of
wine a day. Immigrated from [**Location (un) 311**] in [**2120**]. Used ot be a nanny.
Has one son

Family History:
Non-contributory.

Physical Exam:
VS in the ED: T 98.9, HR 73, BP 107/72, RR 20, 93% 6L
GENERAL: elderly appearing, frail; very vocal about her
discomfort & frustration with being in the ICU; speaking in full
sentences
SKIN: No rashes; scattered ecchymoses on hands
HEENT: JVD to midneck, neck supple.
CHEST: decreased BS on right; crackles at right base; minimal
wheezing throughout; minimal accessry muscle use.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: + Ostomy, overall NT/ND
EXTREMITIES:1+ LE edema, warm without cyanosis
NEUROLOGIC: AA, Ox3; CN II - XII in tact; moving all
extremities.


Pertinent Results:
[**2167-5-25**] ADMISSION CXR:
FINDINGS: The extensive post-treatment changes (post-surgery and
radiation) involving the right lung are similar. There is
significant radiation fibrosis at the right lung base with
persistent right pleural effusion and atelectasis. The known
spiculated right upper lobe nodule is not well seen on today's
radiograph. The cardiomediastinal silhouette is similar. The
cerclage wires and surgical clips are unchanged. The bones are
unremarkable.
IMPRESSION: Post-surgical and radiation changes in the right
lung are stable. No evidence of pneumonia.
.
[**6-/2166**] SPIROMETRY (most recent):
FEV1 0.56 (29% predicted); FVC 1.12 (41% predicted)
.
[**11/2166**] ECHO (most recent):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild to moderate ([**11-26**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2164-9-20**],
the RV has further dilated and systolic function has
deteriorated. The estimated PASP has increased. The LVEF remains
normal.

Labs:
[**2167-5-25**] 01:15PM   WBC-11.5* RBC-4.37 HGB-11.7* HCT-38.0 MCV-87
MCH-26.8* MCHC-30.7* RDW-15.9*
[**2167-5-25**] 01:15PM   CK(CPK)-39
[**2167-5-25**] 01:15PM   cTropnT-0.04*
[**2167-5-25**] 01:15PM   CK-MB-NotDone
[**2167-5-25**] 01:15PM   GLUCOSE-194* UREA N-27* CREAT-0.9 SODIUM-128*
POTASSIUM-4.8 CHLORIDE-83* TOTAL CO2-38* ANION GAP-12
[**2167-5-26**] 03:52AM BLOOD CK-MB-3 cTropnT-0.03*
[**2167-5-26**] 03:52AM BLOOD CK(CPK)-42
[**2167-5-26**] 03:52AM BLOOD WBC-6.7 RBC-4.09* Hgb-10.9* Hct-35.2*
MCV-86 MCH-26.7* MCHC-31.0 RDW-16.0* Plt Ct-382

Brief Hospital Course:
Ms. [**Known lastname 15427**] is a 69 yo F w/multiple medical problems including
severe COPD, right-sided pulm fibrosis, and atrial fibrillation,
presenting with SOB x 2-3 days in setting of increased (green)
sputum production.

1)Shortness of breath: Most likely due to bronchitis-driven COPD
exacerbation.  She improved overnight with minimal intervention
and was breathing comfortably on her home level of O2 at 4LNC by
the morning following admission.  She had a chest xray that was
unremarkable.  She was give solumedrol 125mg IV in the ED and
then her prednisone was increased to 30mg daily.  She was
started on [**Known lastname **] for suspected COPD exacerbation to
complete a 5 day course.  Otherwise she was continued on her
home regimen of combivent and albuterol on discharge.  She was
advised to taper her prednisone every 3 days back to her home
dose of 10mg daily.  She will follow up with Dr. [**Last Name (STitle) **] in
pulmonary clinic.

2)hyponatremia - most likely hypovolemic however she did have
slight lower extremity edema on exam.  Her sodium improved with
holding her lasix overnight so she was discharged on half her
home dose of lasix to follow up with her PCP by the end of the
week for a repeat sodium level.

3) ATRIAL FIBRILLATION: rate well controlled with no acute
issues during her admission.  She was continued on home regimen
of digxoin and sotalol.  Her INR was theraputic at 2.3 and she
was continued on coumadin 3mg daily.

4) PULMONARY HYPERTENSION:  She was continued on home dose
sildenafil, to follow up with her pulmonologist.

5)CHRONIC BACK PAIN: [**Last Name 20720**] problem in [**Name (NI) **]; she was
continued on Tylenol #3

6) CODE: full

Medications on Admission:
Coumadin 3 mg QD
Furosemide 80 mg PO daily
Sildenafil 50 mg PO TID
Digoxin 125 mcg PO DAILY
Paroxetine HCl 10 mg PO DAILY
Combivent 18-103 mcg/Actuation Aerosol Sig: [**11-26**] sprays TID
Albuterol PRN
Montelukast 10 mg PO DAILY
Alprazolam 0.5 mg PO QHS
Sotalol 40 mg PO QPM
Sotalol 80 mg PO QAM
Calcium Carbonate 500 mg PO DAILY
Cholecalciferol (Vitamin D3) 400 unit PO DAILY
Ascorbic Acid 500 mg PO DAILY


Discharge Medications:
1. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO QAM (once a day
(in the morning)).
2. Sildenafil 25 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8
Hours).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Paroxetine HCl 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).

5. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) spray
Inhalation three times a day.
6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. Sotalol 80 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
10. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in
the evening)).
11. CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
12. Prednisone 10 mg Tablet Sig: variable Tablet PO DAILY
(Daily) for 9 days: . Take the following:
- 3 tabs daily x3d
- 2 tabs daily x3d
- 1 tab daily x3d.
[**Month/Day (2) **]:*18 Tablet(s)* Refills:*0*
13. [**Month/Day (2) 11396**] 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 6
days: . take 40 daily x6d then can resume 80 daily after you see
your PCP.
[**Name Initial (NameIs) **]:*6 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
Please have a chemistry panel checked by your PCP
16. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
- Acute COPD exacerbation
- hyponatremia thought [**12-27**] hypovolemia.  Lasix initially held
and it improved.
Secondary:
- small cell lung ca s/p XRT and chemo
- hx of atrial fibrillation
- hx PUD
- HTN
- severe pulm HTN


Discharge Condition:
at baseline O2 requirement


Discharge Instructions:
You came in with worsening shortness of breath.  You were
treated with a breathing mask as tolerated.  We also treated you
with antibiotics, nebulizers, and steroids.

Please take your medications as prescribed.  Please followup
with your PCP within the next 1 week.  We have made the
following changes to your medications:
- lasix 40 daily (instead of 80) - until you see your PCP
[**Name Initial (PRE) **] [**Name Initial (NameIs) **] x3 more days
- prednisone taper as written

Please contact your PCP or return to the [**Name (NI) **] if you experience
worsening chest pain, shortness of breath, fevers.

Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2167-6-23**]
11:00
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Date/Time:[**2167-6-26**] 9:10
Provider: [**Name10 (NameIs) 13368**] [**Last Name (NamePattern4) 13369**], MD Phone:[**Telephone/Fax (1) 1652**]
Date/Time:[**2167-7-29**] 2:10
.
Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3029**] to schedule an appointment for
early next week.  You will need a chemistry panel.


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Obstructive chronic bronchitis with (acute) exacerbation,Hyposmolality and/or hyponatremia,Primary pulmonary hypertension,Malignant neoplasm of other parts of bronchus or lung,Postinflammatory pulmonary fibrosis,Atrial fibrillation'}


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/hypoxia

PRESENT ILLNESS: [**Hospital Unit Name 20719**] NOTE:
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**]
CC: SOB, hypoxia
.
HPI: Ms. [**Known lastname 15427**] is a 69 yo F with h/o COPD (4L NC at home at
baseline; frequent admissions for exacerbations) and s/p small
cell lung CA with post-XRT fibrosis of the right lung.  She
presented to the ED this morning c/o 2-3 days of SOB, especially
at night when she was sleeping.  She has also had worsening of
sputum production in the last day with change in color to green
as well as decreased ability to cough up secretions.  She denied
fevers at home.
.
In the ED, VS were T 98.9, HR 73, BP 107/72, RR 20, 93% 6L.  She
was started on CPAP with sats in the upper 90's, but she then
refused to continue wearing the mask.  Chest x-ray did not show
an infiltrate.  No studies were ordered to rule out PE because
the ED felt this was low probability in the setting of an INR
2.0.  She was given solumedrol 125 mg IV,
[**Known lastname **]/ceftriaxone, and albuterol nebulizers.

MEDICAL HISTORY: PMH:
1. Small cell lung CA
-- diagnosed ~14 years ago
-- s/p XRT and chemo (cisplatinum).
2. COPD, on 4L NC home oxygen.
3. History of atrial fibrillation
4. History of perforated diverticulum status post colostomy.
5. History of peptic ulcer disease.
6. Hypertension.
7. Severe pulmonary hypertension on Viagra.
8. Status post ASD repair.
9. Status post ventral hernia repair.
10. Status post appendectomy.
11. Depression
12. Chronic PE in the right middle lobe of the PA

MEDICATION ON ADMISSION: Coumadin 3 mg QD
Furosemide 80 mg PO daily
Sildenafil 50 mg PO TID
Digoxin 125 mcg PO DAILY
Paroxetine HCl 10 mg PO DAILY
Combivent 18-103 mcg/Actuation Aerosol Sig: [**11-26**] sprays TID
Albuterol PRN
Montelukast 10 mg PO DAILY
Alprazolam 0.5 mg PO QHS
Sotalol 40 mg PO QPM
Sotalol 80 mg PO QAM
Calcium Carbonate 500 mg PO DAILY
Cholecalciferol (Vitamin D3) 400 unit PO DAILY
Ascorbic Acid 500 mg PO DAILY

ALLERGIES: Bactrim Ds

PHYSICAL EXAM: VS in the ED: T 98.9, HR 73, BP 107/72, RR 20, 93% 6L
GENERAL: elderly appearing, frail; very vocal about her
discomfort & frustration with being in the ICU; speaking in full
sentences
SKIN: No rashes; scattered ecchymoses on hands
HEENT: JVD to midneck, neck supple.
CHEST: decreased BS on right; crackles at right base; minimal
wheezing throughout; minimal accessry muscle use.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: + Ostomy, overall NT/ND
EXTREMITIES:1+ LE edema, warm without cyanosis
NEUROLOGIC: AA, Ox3; CN II - XII in tact; moving all
extremities.
.
LABS: see below; notable for WBC 11.5, 94% PMN's, 0 bands; INR
2.0; Na 128
.
MICROBIOLOGY: 2 sets of BCx sent from ED; pending
.
IMAGING:
[**2167-5-25**] ADMISSION CXR:
FINDINGS: The extensive post-treatment changes (post-surgery and
radiation) involving the right lung are similar. There is
significant radiation fibrosis at the right lung base with
persistent right pleural effusion and atelectasis. The known
spiculated right upper lobe nodule is not well seen on today's
radiograph. The cardiomediastinal silhouette is similar. The
cerclage wires and surgical clips are unchanged. The bones are
unremarkable.
IMPRESSION: Post-surgical and radiation changes in the right
lung are stable.  No evidence of pneumonia.
.
[**6-/2166**] SPIROMETRY (most recent):
FEV1 0.56 (29% predicted); FVC 1.12 (41% predicted)
.
[**11/2166**] ECHO (most recent):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild to moderate ([**11-26**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2164-9-20**],
the RV has further dilated and systolic function has
deteriorated. The estimated PASP has increased. The LVEF remains
normal.
.
.
.
ASSESSMENT/PLAN:
69 yo F w/ multiple medical problems including severe COPD,
right-sided pulm fibrosis, and atrial fibrillation, presenting
with SOB x 2-3 days in setting of increased (green) sputum
production.
.
#. SOB: unclear whether bronchitis-driven COPD exacerbation vs.
cardiac/pulmonary edema. CXR not especially concerning for
volume overload and patient with EF 55% on recent echo in
[**11/2166**]; however, history of worsening SOB with recumbency is c/f
cardiac source.  Patient refusing additional lasix PO tonight
given she does not have a foley and does not want to be up all
night.  Decreased CO in setting of poorly controlled AFib less
likely given that her HR not elevated on admission.  Said she
feels better after "treatments" in the ED; on 4 - 6 L NC now,
speaking in full sentences with minimal accessory muscle use.
-- albuterol and combivent nebs standing overnight; will change
to PRN in the am if stable
-- received solumedrol 125 mg IV in the ED; will continue
prednisone 30 mg QD with taper beginning in next 1 - 2 days
pending stability
-- will wean to 4L NC (home baseline) as tolerated; no need for
CPAP currently.
-- will continue [**Year (4 digits) **] x 4 days.
-- continue home dose lasix 80 mg QD; will consider additional
dose if with continued O2 requirement > 4LNC in am or volume
overloaded on exam.
.
#. ATRIAL FIBRILLATION: rate well controlled currently
-- will cont home regimen of digxoin and sotalol
-- INR 2.0 --> will continue coumadin 3 mg QD; recheck INR in am
.
#. PULMONARY HYPERTENSION:
-- will continue sildenafil 50 mg Q8 hours
.
#. CHRONIC BACK PAIN: [**Last Name 20720**] problem in [**Name (NI) **]; on Tylenol
#3 at home
-- continue home regimen
.
#. PPX:
-- bowel regimen
-- will hold on protonix given low risk for stress ulcers (not
acutely ill currently) and eating a regular diet
-- will consider starting pneumoboots or SQH in am pending
patient agrees
.
#. FEN: no evidence of dehydration; will place on regular diet
.
#. CODE: full
.
#. DISPO: to remain in ICU overnight for observation and further
treatment; will likely transfer to floor in am

FAMILY HISTORY: Non-contributory.
.
ADMISSION PHYSICAL EXAM:
VS in the ED: T 98.9, HR 73, BP 107/72, RR 20, 93% 6L
GENERAL: elderly appearing, frail; very vocal about her
discomfort & frustration with being in the ICU; speaking in full
sentences
SKIN: No rashes; scattered ecchymoses on hands
HEENT: JVD to midneck, neck supple.
CHEST: decreased BS on right; crackles at right base; minimal
wheezing throughout; minimal accessry muscle use.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: + Ostomy, overall NT/ND
EXTREMITIES:1+ LE edema, warm without cyanosis
NEUROLOGIC: AA, Ox3; CN II - XII in tact; moving all
extremities.
.
LABS: see below; notable for WBC 11.5, 94% PMN's, 0 bands; INR
2.0; Na 128
.
MICROBIOLOGY: 2 sets of BCx sent from ED; pending
.
IMAGING:
[**2167-5-25**] ADMISSION CXR:
FINDINGS: The extensive post-treatment changes (post-surgery and
radiation) involving the right lung are similar. There is
significant radiation fibrosis at the right lung base with
persistent right pleural effusion and atelectasis. The known
spiculated right upper lobe nodule is not well seen on today's
radiograph. The cardiomediastinal silhouette is similar. The
cerclage wires and surgical clips are unchanged. The bones are
unremarkable.
IMPRESSION: Post-surgical and radiation changes in the right
lung are stable.  No evidence of pneumonia.
.
[**6-/2166**] SPIROMETRY (most recent):
FEV1 0.56 (29% predicted); FVC 1.12 (41% predicted)
.
[**11/2166**] ECHO (most recent):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild to moderate ([**11-26**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2164-9-20**],
the RV has further dilated and systolic function has
deteriorated. The estimated PASP has increased. The LVEF remains
normal.
.
.
.
ASSESSMENT/PLAN:
69 yo F w/ multiple medical problems including severe COPD,
right-sided pulm fibrosis, and atrial fibrillation, presenting
with SOB x 2-3 days in setting of increased (green) sputum
production.
.
#. SOB: unclear whether bronchitis-driven COPD exacerbation vs.
cardiac/pulmonary edema. CXR not especially concerning for
volume overload and patient with EF 55% on recent echo in
[**11/2166**]; however, history of worsening SOB with recumbency is c/f
cardiac source.  Patient refusing additional lasix PO tonight
given she does not have a foley and does not want to be up all
night.  Decreased CO in setting of poorly controlled AFib less
likely given that her HR not elevated on admission.  Said she
feels better after "treatments" in the ED; on 4 - 6 L NC now,
speaking in full sentences with minimal accessory muscle use.
-- albuterol and combivent nebs standing overnight; will change
to PRN in the am if stable
-- received solumedrol 125 mg IV in the ED; will continue
prednisone 30 mg QD with taper beginning in next 1 - 2 days
pending stability
-- will wean to 4L NC (home baseline) as tolerated; no need for
CPAP currently.
-- will continue [**Year (4 digits) **] x 4 days.
-- continue home dose lasix 80 mg QD; will consider additional
dose if with continued O2 requirement > 4LNC in am or volume
overloaded on exam.
.
#. ATRIAL FIBRILLATION: rate well controlled currently
-- will cont home regimen of digxoin and sotalol
-- INR 2.0 --> will continue coumadin 3 mg QD; recheck INR in am
.
#. PULMONARY HYPERTENSION:
-- will continue sildenafil 50 mg Q8 hours
.
#. CHRONIC BACK PAIN: [**Last Name 20720**] problem in [**Name (NI) **]; on Tylenol
#3 at home
-- continue home regimen
.
#. PPX:
-- bowel regimen
-- will hold on protonix given low risk for stress ulcers (not
acutely ill currently) and eating a regular diet
-- will consider starting pneumoboots or SQH in am pending
patient agrees
.
#. FEN: no evidence of dehydration; will place on regular diet
.
#. CODE: full
.
#. DISPO: to remain in ICU overnight for observation and further
treatment; will likely transfer to floor in am

SOCIAL HISTORY: History of tobacco; quit over 10 years ago. Drinks a glass of
wine a day. Immigrated from [**Location (un) 311**] in [**2120**].  Used ot be a nanny.
 Has one son
.
Family History:
Non-contributory.
.
ADMISSION PHYSICAL EXAM:
VS in the ED: T 98.9, HR 73, BP 107/72, RR 20, 93% 6L
GENERAL: elderly appearing, frail; very vocal about her
discomfort & frustration with being in the ICU; speaking in full
sentences
SKIN: No rashes; scattered ecchymoses on hands
HEENT: JVD to midneck, neck supple.
CHEST: decreased BS on right; crackles at right base; minimal
wheezing throughout; minimal accessry muscle use.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: + Ostomy, overall NT/ND
EXTREMITIES:1+ LE edema, warm without cyanosis
NEUROLOGIC: AA, Ox3; CN II - XII in tact; moving all
extremities.
.
LABS: see below; notable for WBC 11.5, 94% PMN's, 0 bands; INR
2.0; Na 128
.
MICROBIOLOGY: 2 sets of BCx sent from ED; pending
.
IMAGING:
[**2167-5-25**] ADMISSION CXR:
FINDINGS: The extensive post-treatment changes (post-surgery and
radiation) involving the right lung are similar. There is
significant radiation fibrosis at the right lung base with
persistent right pleural effusion and atelectasis. The known
spiculated right upper lobe nodule is not well seen on today's
radiograph. The cardiomediastinal silhouette is similar. The
cerclage wires and surgical clips are unchanged. The bones are
unremarkable.
IMPRESSION: Post-surgical and radiation changes in the right
lung are stable.  No evidence of pneumonia.
.
[**6-/2166**] SPIROMETRY (most recent):
FEV1 0.56 (29% predicted); FVC 1.12 (41% predicted)
.
[**11/2166**] ECHO (most recent):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild to moderate ([**11-26**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2164-9-20**],
the RV has further dilated and systolic function has
deteriorated. The estimated PASP has increased. The LVEF remains
normal.
.
.
.
ASSESSMENT/PLAN:
69 yo F w/ multiple medical problems including severe COPD,
right-sided pulm fibrosis, and atrial fibrillation, presenting
with SOB x 2-3 days in setting of increased (green) sputum
production.
.
#. SOB: unclear whether bronchitis-driven COPD exacerbation vs.
cardiac/pulmonary edema. CXR not especially concerning for
volume overload and patient with EF 55% on recent echo in
[**11/2166**]; however, history of worsening SOB with recumbency is c/f
cardiac source.  Patient refusing additional lasix PO tonight
given she does not have a foley and does not want to be up all
night.  Decreased CO in setting of poorly controlled AFib less
likely given that her HR not elevated on admission.  Said she
feels better after "treatments" in the ED; on 4 - 6 L NC now,
speaking in full sentences with minimal accessory muscle use.
-- albuterol and combivent nebs standing overnight; will change
to PRN in the am if stable
-- received solumedrol 125 mg IV in the ED; will continue
prednisone 30 mg QD with taper beginning in next 1 - 2 days
pending stability
-- will wean to 4L NC (home baseline) as tolerated; no need for
CPAP currently.
-- will continue [**Year (4 digits) **] x 4 days.
-- continue home dose lasix 80 mg QD; will consider additional
dose if with continued O2 requirement > 4LNC in am or volume
overloaded on exam.
.
#. ATRIAL FIBRILLATION: rate well controlled currently
-- will cont home regimen of digxoin and sotalol
-- INR 2.0 --> will continue coumadin 3 mg QD; recheck INR in am
.
#. PULMONARY HYPERTENSION:
-- will continue sildenafil 50 mg Q8 hours
.
#. CHRONIC BACK PAIN: [**Last Name 20720**] problem in [**Name (NI) **]; on Tylenol
#3 at home
-- continue home regimen
.
#. PPX:
-- bowel regimen
-- will hold on protonix given low risk for stress ulcers (not
acutely ill currently) and eating a regular diet
-- will consider starting pneumoboots or SQH in am pending
patient agrees
.
#. FEN: no evidence of dehydration; will place on regular diet
.
#. CODE: full
.
#. DISPO: to remain in ICU overnight for observation and further
treatment; will likely transfer to floor in am 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Hyposmolality and/or hyponatremia,Primary pulmonary hypertension,Malignant neoplasm of other parts of bronchus or lung,Postinflammatory pulmonary fibrosis,Atrial fibrillation'}
