CHIEF COMPLAINT: Increased Dyspnea

PRESENT ILLNESS: 78 y/o woman with CAD multiple PCIs (9 stents), CHF with
preserved ejection fraction, mild pulm hypertension, CVA, HTN,
NIDDM, PVD, and microscopic colitis who presented to [**Hospital1 **] [**Location (un) 620**]
on the night of [**9-26**] with fever, severe dyspnea, wheezing,
malaise, nausea, and one episode of watery diarrhea. On
presentation, she was hypoxemic to 70% on RA. She had crackles
and wheezing on lung exam. CXR showed possible LLL infiltrate,
pulmonary edema. The patient received aspirin, 40mg IV lasix,
and 750mg IV Cipro. Initially, the patient was given metoprolol
and the rest of her home meds including losartan, aspirin,
[**Date Range 4532**], and lipitor were continued. She was placed on BiPap.
Overnight, she developed more dyspnea and hypoxemia and O2 sat
dropped to 82% on NRB. ABG was 7.32/32/54 on BiPap. The patient
was intubated started on lasix gtt, nitro gtt, and heparin gtt.

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

MEDICATION ON ADMISSION: The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 150 mg PO BID
2. Losartan Potassium 50 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Mirtazapine 45 mg PO HS
5. HydrALAzine 50 mg PO TID
6. Furosemide 20 mg PO DAILY
7. Atorvastatin 80 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
9. Omeprazole 20 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Amlodipine 10 mg PO DAILY
12. traZODONE 75 mg PO HS:PRN insomnia
13. Levothyroxine Sodium 100 mcg PO DAILY
14. Zolpidem Tartrate 5 mg PO HS
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
16. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
17. Pristiq *NF* (desvenlafaxine) 50 mg Oral daily

ALLERGIES: Penicillins / Univasc / Tetanus & Diphtheria Tox,Adult / Zoloft
/ Remeron

PHYSICAL EXAM: On Admission:
VS: 99.4, 111/49, 64, 15, 100% on 100% FIO2.
GENERAL: 78yo female. Intubated but awake and in NAD. Able to
answer questions and follow commands.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP 8cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 1/6 systolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: mechanical ventilations. Decreased lung sounds at left
lung base, crackles in LLL.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Trace edema. Palpable DP pulses. No femoral bruits.

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

SOCIAL HISTORY: Widowed, daughter lives with her. Previously independent.
-Tobacco history: Denies
-ETOH: Will have one drink when she goes out to dinner.
Subendocardial infarction, initial episode of care,Acute on chronic diastolic heart failure,Acute respiratory failure,Pneumonia, organism unspecified,Celiac artery compression syndrome,Bipolar I disorder, most recent episode (or current) depressed, unspecified,Delirium due to conditions classified elsewhere,Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Acute gouty arthropathy,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Peripheral vascular disease, unspecified,Other chronic pulmonary heart diseases,Unspecified acquired hypothyroidism,Diverticulosis of colon (without mention of hemorrhage),Restless legs syndrome (RLS),Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Iron deficiency anemia, unspecified,Insomnia, unspecified,Anemia of other chronic disease,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Long-term (current) use of aspirin,Percutaneous transluminal coronary angioplasty status
Subendo infarct, initial,Ac on chr diast hrt fail,Acute respiratry failure,Pneumonia, organism NOS,Celiac art compress syn,Bipol I cur depres NOS,Delirium d/t other cond,Hyp ht/kd NOS I-IV w hf,Crnry athrscl natve vssl,Acute gouty arthropathy,Chronic kidney dis NOS,DMII wo cmp nt st uncntr,Periph vascular dis NOS,Chr pulmon heart dis NEC,Hypothyroidism NOS,Dvrtclo colon w/o hmrhg,Restless legs syndrome,Osteoarthros NOS-unspec,Iron defic anemia NOS,Insomnia NOS,Anemia-other chronic dis,Migrne unsp wo ntrc mgrn,Long-term use of aspirin,Status-post ptca
Admission Date:  [**2174-9-27**]              Discharge Date:   [**2174-10-5**]

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

Service: MEDICINE

Allergies:
Penicillins / Univasc / Tetanus & Diphtheria Tox,Adult / Zoloft
/ Remeron

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Increased Dyspnea

Major Surgical or Invasive Procedure:
Pulmonary intubation (at OSH)


History of Present Illness:
78 y/o woman with CAD multiple PCIs (9 stents), CHF with
preserved ejection fraction, mild pulm hypertension, CVA, HTN,
NIDDM, PVD, and microscopic colitis who presented to [**Hospital1 **] [**Location (un) 620**]
on the night of [**9-26**] with fever, severe dyspnea, wheezing,
malaise, nausea, and one episode of watery diarrhea. On
presentation, she was hypoxemic to 70% on RA. She had crackles
and wheezing on lung exam. CXR showed possible LLL infiltrate,
pulmonary edema. The patient received aspirin, 40mg IV lasix,
and 750mg IV Cipro. Initially, the patient was given metoprolol
and the rest of her home meds including losartan, aspirin,
[**Date Range 4532**], and lipitor were continued. She was placed on BiPap.
Overnight, she developed more dyspnea and hypoxemia and O2 sat
dropped to 82% on NRB. ABG was 7.32/32/54 on BiPap. The patient
was intubated started on lasix gtt, nitro gtt, and heparin gtt.

On arrival to the floor, patient was intubated but awake, able
to answer questions and follow commands, and in no acute
distress. She denied any chest pain or abdominal pain. Vitals on
transfer were 99.4, 111/49, 64, 15, 100% on 100% FIO2.

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

2. CARDIAC HISTORY:
-Extensive CAD s/p multiple stents
-CABG: 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
# Hypertension
# Migraine headaches
# Gastritis - no peptic ulcer disease history.
# Depression x30 years, initially reactive

Social History:
Widowed, daughter lives with her. Previously independent.
-Tobacco history: Denies
-ETOH: Will have one drink when she goes out to dinner.

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

Physical Exam:
On Admission:
VS: 99.4, 111/49, 64, 15, 100% on 100% FIO2.
GENERAL: 78yo female. Intubated but awake and in NAD. Able to
answer questions and follow commands.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP 8cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 1/6 systolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: mechanical ventilations. Decreased lung sounds at left
lung base, crackles in LLL.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Trace edema. Palpable DP pulses. No femoral bruits.

SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

On Discharge:
GENERAL: 78yo female. Alert and oriented x3 and in NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP 7cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 systolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: trace fine bibasilar crackles, normal work of breathing,
no accessory muscle use
ABDOMEN: Soft, NTND. No HSM or tenderness. + BS
EXTREMITIES: No edema. Palpable DP pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

Pertinent Results:
Labs on Admission:
[**2174-9-27**] 10:27AM BLOOD WBC-16.0*# RBC-2.46*# Hgb-7.5*#
Hct-23.1*# MCV-94 MCH-30.6 MCHC-32.5 RDW-14.2 Plt Ct-266#
[**2174-9-28**] 01:57AM BLOOD PT-15.0* PTT-54.3* INR(PT)-1.4*
[**2174-9-28**] 01:57AM BLOOD Ret Aut-1.2
[**2174-9-27**] 10:27AM BLOOD Glucose-191* UreaN-46* Creat-2.2* Na-141
K-4.5 Cl-111* HCO3-21* AnGap-14
[**2174-9-27**] 10:27AM BLOOD Calcium-8.2* Phos-4.7* Mg-1.9
[**2174-9-27**] 02:06PM BLOOD Type-ART pO2-69* pCO2-37 pH-7.33*
calTCO2-20* Base XS--5
[**2174-9-27**] 10:24PM BLOOD Type-ART PEEP-5 FiO2-40 pO2-94 pCO2-28*
pH-7.42 calTCO2-19* Base XS--4 Intubat-INTUBATED
[**2174-9-27**] 02:06PM BLOOD Lactate-1.0

Hemeatology Labs:
[**2174-9-28**] 01:57AM BLOOD Ret Aut-1.2
[**2174-9-28**] 05:40PM BLOOD calTIBC-140* Ferritn-842* TRF-108*

Cardiac Labs:
[**2174-9-27**] 10:27AM BLOOD CK-MB-17* cTropnT-1.17*
[**2174-9-27**] 02:28PM BLOOD CK-MB-19* MB Indx-6.9* cTropnT-1.25*
[**2174-9-27**] 02:28PM BLOOD CK(CPK)-277*
[**2174-9-27**] 07:52PM BLOOD CK-MB-19* MB Indx-7.1* cTropnT-1.32*
[**2174-9-27**] 07:52PM BLOOD CK(CPK)-267*
[**2174-9-28**] 01:57AM BLOOD CK-MB-12* MB Indx-6.0 cTropnT-1.34*
[**2174-9-28**] 01:57AM BLOOD CK(CPK)-200
[**2174-9-28**] 09:53AM BLOOD CK-MB-11* cTropnT-1.32*
[**2174-9-28**] 05:40PM BLOOD CK-MB-9 cTropnT-1.37*
[**2174-9-28**] 05:40PM BLOOD CK(CPK)-174
[**2174-9-30**] 06:11AM BLOOD CK-MB-6 cTropnT-1.59*
[**2174-9-30**] 06:11AM BLOOD CK(CPK)-77
[**2174-10-1**] 04:03AM BLOOD CK-MB-5 cTropnT-1.55*
[**2174-10-1**] 04:03AM BLOOD CK(CPK)-51

UA:
[**2174-9-27**] 11:35PM URINE Blood-SM  Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2174-9-27**] 11:35PM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE Epi-1
[**2174-9-27**] 11:35PM URINE CastHy-17*
[**2174-9-29**] 05:36PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2174-9-27**] 11:35PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.009
[**2174-9-29**] 05:36PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007

Microbiology:
[**2174-9-27**] 11:35 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2174-9-29**]**

   URINE CULTURE (Final [**2174-9-29**]):    NO GROWTH.

[**2174-9-27**] 10:27 am BLOOD CULTURE      Source: Venipuncture.

                            **FINAL REPORT [**2174-10-3**]**

   Blood Culture, Routine (Final [**2174-10-3**]):    NO GROWTH.

[**2174-9-27**] 2:27 pm BLOOD CULTURE      Source: Venipuncture.

                            **FINAL REPORT [**2174-10-3**]**

   Blood Culture, Routine (Final [**2174-10-3**]):    NO GROWTH.

[**2174-9-27**] 11:35 pm BLOOD CULTURE      Source: Venipuncture.

                            **FINAL REPORT [**2174-10-3**]**

   Blood Culture, Routine (Final [**2174-10-3**]):    NO GROWTH.

[**2174-9-28**] 1:00 am SPUTUM     Site: ENDOTRACHEAL

                            **FINAL REPORT [**2174-9-30**]**

   GRAM STAIN (Final [**2174-9-28**]):
      >25 PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2174-9-30**]):    NO GROWTH.

Blood Culture [**2174-9-28**]: NGTD x 6 days

Images/Studies:
EKG [**2174-9-27**]: Sinus rhythm. Slight ST segment elevation with T
wave inversions in the anterior leads raises concern for
evolving myocardial infarction. Clinical correlation is
suggested. Inferior ST-T wave changes may also be due to
ischemia. Compared to tracing #1 there are now deep T waves seen
in leads V3-V6 raising concern for ischemia. Clinical
correlation is suggested.

EKG [**2174-9-28**]: Sinus rhythm. ST segment elevation with T wave
inversions seen in the anterior precordial leads raises concern
for ischemia. Inferior ST-T wave changes also raise some concern
for ischemia. Compared to tracing #2 no interim change.

EKG [**2174-10-1**]:Sinus rhythm. Left atrial abnormality. Compared to
the previous tracing  of [**2174-9-28**] there is further evolution of
recent or ongoing anterolateral and apical myocardial
infarctions. Clinical correlation is suggested.

EKG [**2174-10-2**]: Sinus rhythm with increase in rate as compared to
the previous tracing  of [**2174-10-1**]. There is further evolution of
acute anterolateral and apical myocardial infarctions. Followup
and clinical correlation are suggested. The Q-T interval remains
prolonged.

CXR [**2174-9-27**]: Endotracheal tube with distal tip in the right
mainstem bronchus. Unchanged bilateral pulmonary edema and left
lower lung atelectasis with possible pleural fluid.

CXR [**2174-9-28**]: The left mid and lower lung consolidation is
redemonstrated, concerning for large infectious process
associated with pleural effusion.  Patient continues to be in
interstitial pulmonary edema, moderate in severity.  The ET tube
tip is 4 cm above the carina.  NG tube is in the stomach.

CXR [**2174-9-29**]: Small right and moderate left pleural effusions
are grossly unchanged allowing the difference in position of the
patient.  Cardiomediastinal contours are unchanged, partially
obscured by the pleural and parenchymal abnormalities.  Moderate
pulmonary edema is stable.  Left mid and left lower lobe
consolidations are unchanged.

Labs on Discharge:
[**2174-10-5**] 06:00AM BLOOD WBC-11.3* RBC-2.40* Hgb-7.3* Hct-22.6*
MCV-94 MCH-30.6 MCHC-32.5 RDW-14.2 Plt Ct-424
[**2174-10-5**] 06:00AM BLOOD Glucose-201* UreaN-58* Creat-1.9* Na-142
K-4.0 Cl-111* HCO3-18* AnGap-17
[**2174-10-5**] 06:00AM BLOOD Mg-2.2

Brief Hospital Course:
78 y/o woman with CAD s/p multiple PCIs (9 stents), CHF with
preserved ejection fraction, mild pulmonary hypertension, CVA,
HTN, NIDDM, PVD, and microscopic colitis who presented to [**Hospital1 18**]
[**Location (un) 620**] with dyspnea and hypoxemia c/b acute respiratory failure
requiring intubation and tranferred to [**Hospital1 18**].

# NSTEMI/CAD: Patient with significant prior history of 3 vessel
CAD s/p multiple PCIs and stents. Enzymes positive and trending
up at [**Hospital1 18**] [**Location (un) 620**], EKG upon arrival here with T-wave
inversions in V3-V6. Cardiac enzymes were trended and peaked and
plauteued on HOD 2. She was continued on a heparin gtt to
complete 48 hour treatment. Home ASA, [**Location (un) 4532**], statin, and
metoprolol were continued. On HOD 4 there was concern for
evolving changes on EKG. Cardiac enzymes at that time were
elevated to trop of 1.59, however with flat CK and CKMB. A cath
was considered, however it was determined not to be acute
evolution and not urgent. Will likely need cath as an
outpatient.

# Diastolic Heart Failure: Patient with history of diastolic CHF
with preserved ejection fraction. Initially not significantly
volume overloaded on exam, weight is similar from recent
cardiology visit. Likely flash pulmonary edema due to sustained
hypertension and tachycardia (patient with another recent
admission to [**Location (un) 620**] for flash pulmonary edema in setting of
gastritis). The patient was diuresed with IV lasix bolus prn.
She recieved 40 mg IV on HOD 1 with poor response. She recieved
80mg IV x 2 on HOD 2 with ok response. On HOD 4 she recieved
120mg IV lasix in the AM with poor UOP and then recieved 5 mg
metolazone followed by 120 mg IV lasix with good UOP response.
On HOD 6 patient appeared dry and required 500 cc of fluids. The
patient was initially managed with nitro gtt for afterload
reduction, but then was transitioned to home hydralazine,
amlodipine, losartan, and imdur. The medications were adjusted
and patient was discharged on the following regimen: hydralazine
50mg TID, isosorbide 120mg daily, and losartan 50mg daily for
afterload and 20mg lasix daily for diuresis.

# Pneumonia: Elevated WBC with LLL opacity on CXR on admission.
Patient recieved 750 of cipro at OSH and was initially started
on levofloxacin 500mg q48h upon arrival to [**Hospital1 18**]. The patient
then spiked a fever on HOD 1 and she was broadened to cefepime
and vanc to cover for HCAP given recent hospitalization. She was
treated for 8 days with day 1 of treatment 10/09/10/10, patient
completed antibiotics on day of discharge ([**10-5**]).

# Hypoxic respiratory failure: Likely due to a combination of
pulmonary edema and pneumonia. Patient was intubated on arrival.
Propofol and fentanyl were used for sedation. The patient was
successfully extubated on HOD 2.

# Gout Flair: The patient developed gout flare (right podagra)
on [**10-3**]. She was started on oxycodone 2.5 mg Q6H for pain.
Secondary to patient's renal function colchicine and NSAIDs were
avoided. She was therefore started on prednisone 30 mg x 1 day,
20 mg AM x 1 day, and then will complete slow taper over 7 days.

# Normocytic Anemia: Patient with Anemia dating back to [**2163**]. As
low as this admission previously in [**2171**]. Patient with Hct of 23
on admission. Patient with normal reticulocyte count and iron
studies consistent with anemia of chronic disease (low iron, low
TIBC, high ferritin). Patient was started on iron
supplementation and will need GI workup as an outpatient to rule
out GI loss as part of low iron. Patient's Hct was trended and
she remained stable and asymptomatic and did not require blood
transfusion. Hct on discharge of 22.6.

# CKD: The patient has a history of CKD with Cr ranging from 1.7
- 3.3 over the last 1.5 years. Baseline appears to be low 2's.
Cr on admission of 2.2. Medications were renally dosed and
nephrotoxins were avoided when possible. Cr was trended and 1.9
on discharge.

# Type II diabetes: The patient's home metformin was held and
the patient was maintained on humalog ISS.

# Hypertension: The patient's home medications were initially
held and she was on nitro gtt on arrival. She was weaned off
nitro gtt and home medications were restarted as tolerated.
Eventually she was on home amlodipine, losartan, hydralazine,
metoprolol, and Imdur.

# Hyperlipidemia: Home atorvastatin was continued.

# Depression: Home mirtazapine was continued. Patient on
desvenlafaxine at home, not on formulary at [**Hospital1 18**], gave
venlafaxine in the meantime to avoid SSRI withdrawl.

# Hypothyroidism: Home levothyroxine continued.

Transitional Issues:
- [**Month (only) 116**] need outpatient Cath.
- Needs GI work up as an outpatient.
- Patient insturcted to weigh self every morning, and call Dr
[**Last Name (STitle) 2903**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3
days.
-Patient to have chem-7 on Monday [**2174-10-10**] with results sent to
Dr. [**Last Name (STitle) 2903**]

Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 150 mg PO BID
2. Losartan Potassium 50 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Mirtazapine 45 mg PO HS
5. HydrALAzine 50 mg PO TID
6. Furosemide 20 mg PO DAILY
7. Atorvastatin 80 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
9. Omeprazole 20 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Amlodipine 10 mg PO DAILY
12. traZODONE 75 mg PO HS:PRN insomnia
13. Levothyroxine Sodium 100 mcg PO DAILY
14. Zolpidem Tartrate 5 mg PO HS
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
16. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
17. Pristiq *NF* (desvenlafaxine) 50 mg Oral daily


Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Mirtazapine 45 mg PO HS
8. traZODONE 100 mg PO HS:PRN insomnia
9. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
10. Nitroglycerin SL 0.3 mg SL PRN chest pain
11. Omeprazole 20 mg PO DAILY
12. Escitalopram Oxalate 5 mg PO DAILY
13. Furosemide 20 mg PO DAILY
14. HydrALAzine 50 mg PO TID
15. Losartan Potassium 50 mg PO DAILY
16. PredniSONE 10 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg one tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
17. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth daily
Disp #*45 Tablet Refills:*2
18. Outpatient Lab Work
Please check chem-7 on Monday [**2174-10-10**] with results to Dr. [**Last Name (STitle) 2903**]
at Phone: [**Telephone/Fax (1) 2205**]
Fax: [**Telephone/Fax (1) 7922**]
ICD9: 428
19. Ferrous Sulfate 325 mg PO DAILY


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Non ST elevation myocardial precautions
Hospital Acquired Pneumonia
Acute on Chronic Diastolic congestive heart failure
Anemia


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mrs. [**Known lastname 34407**],

You were transferred to [**Hospital1 18**] a fever and trouble breathing. You
were found to have a pneumonia and were treated with 8 days of
intravenous antibiotics. You also were in heart failure with too
much fluid on board and we gave you diuretics to remove the
extra fluid.

Changes to your home medications include:
-CHANGE metoprolol to once daily formulation (metoprolol
succinate XL 150mg daily)
-START prednisone for your gout flare. You will take 3 more days
of prednisone at home. Please call Dr. [**Last Name (STitle) 2903**] if the gout returns.
-START iron for your anemia

Weigh yourself every morning, call Dr [**Last Name (STitle) 2903**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.  Please take all
of your medicines as directed.

It was a pleasure taking care of your during your
hospitalization and we wish you the best going forward.

Followup Instructions:
Please make an appt to see Dr. [**Last Name (STitle) **] in 1 month.
.
Department: [**State **]When: Thursday [**2174-10-13**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: On Street Parking



Completed by:[**2174-10-6**]
{'Subendocardial infarction, initial episode of care,Acute on chronic diastolic heart failure,Acute respiratory failure,Pneumonia, organism unspecified,Celiac artery compression syndrome,Bipolar I disorder, most recent episode (or current) depressed, unspecified,Delirium due to conditions classified elsewhere,Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Acute gouty arthropathy,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Peripheral vascular disease, unspecified,Other chronic pulmonary heart diseases,Unspecified acquired hypothyroidism,Diverticulosis of colon (without mention of hemorrhage),Restless legs syndrome (RLS),Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Iron deficiency anemia, unspecified,Insomnia, unspecified,Anemia of other chronic disease,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Long-term (current) use of aspirin,Percutaneous transluminal coronary angioplasty status'}


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: Increased Dyspnea

PRESENT ILLNESS: 78 y/o woman with CAD multiple PCIs (9 stents), CHF with
preserved ejection fraction, mild pulm hypertension, CVA, HTN,
NIDDM, PVD, and microscopic colitis who presented to [**Hospital1 **] [**Location (un) 620**]
on the night of [**9-26**] with fever, severe dyspnea, wheezing,
malaise, nausea, and one episode of watery diarrhea. On
presentation, she was hypoxemic to 70% on RA. She had crackles
and wheezing on lung exam. CXR showed possible LLL infiltrate,
pulmonary edema. The patient received aspirin, 40mg IV lasix,
and 750mg IV Cipro. Initially, the patient was given metoprolol
and the rest of her home meds including losartan, aspirin,
[**Date Range 4532**], and lipitor were continued. She was placed on BiPap.
Overnight, she developed more dyspnea and hypoxemia and O2 sat
dropped to 82% on NRB. ABG was 7.32/32/54 on BiPap. The patient
was intubated started on lasix gtt, nitro gtt, and heparin gtt.

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

MEDICATION ON ADMISSION: The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 150 mg PO BID
2. Losartan Potassium 50 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Mirtazapine 45 mg PO HS
5. HydrALAzine 50 mg PO TID
6. Furosemide 20 mg PO DAILY
7. Atorvastatin 80 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Do Not Crush
9. Omeprazole 20 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Amlodipine 10 mg PO DAILY
12. traZODONE 75 mg PO HS:PRN insomnia
13. Levothyroxine Sodium 100 mcg PO DAILY
14. Zolpidem Tartrate 5 mg PO HS
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
16. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
17. Pristiq *NF* (desvenlafaxine) 50 mg Oral daily

ALLERGIES: Penicillins / Univasc / Tetanus & Diphtheria Tox,Adult / Zoloft
/ Remeron

PHYSICAL EXAM: On Admission:
VS: 99.4, 111/49, 64, 15, 100% on 100% FIO2.
GENERAL: 78yo female. Intubated but awake and in NAD. Able to
answer questions and follow commands.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP 8cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 1/6 systolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: mechanical ventilations. Decreased lung sounds at left
lung base, crackles in LLL.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Trace edema. Palpable DP pulses. No femoral bruits.

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

SOCIAL HISTORY: Widowed, daughter lives with her. Previously independent.
-Tobacco history: Denies
-ETOH: Will have one drink when she goes out to dinner. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute on chronic diastolic heart failure,Acute respiratory failure,Pneumonia, organism unspecified,Celiac artery compression syndrome,Bipolar I disorder, most recent episode (or current) depressed, unspecified,Delirium due to conditions classified elsewhere,Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Acute gouty arthropathy,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Peripheral vascular disease, unspecified,Other chronic pulmonary heart diseases,Unspecified acquired hypothyroidism,Diverticulosis of colon (without mention of hemorrhage),Restless legs syndrome (RLS),Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Iron deficiency anemia, unspecified,Insomnia, unspecified,Anemia of other chronic disease,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Long-term (current) use of aspirin,Percutaneous transluminal coronary angioplasty status'}
