CHIEF COMPLAINT: Shortness of Breath

PRESENT ILLNESS: 76F with history of CAD s/p CABG x 4, HTN, Asthma who was
transferred from [**Hospital 882**] Hospital for management of respiratory
distress/Pneumonia. Pt was visiting from [**Location (un) 50955**], [**State 2690**]. She
arrived into [**Location (un) 86**] last Sun. According to the daughters, their
mother had +chest pain on Tuesday night. She took NTG with
relief of her pain, then experienced an "asthma attack". On [**11-2**]
they were walking with her mother outside when she began to
experience worsening SOB, +chest pain, took NTG x 2. She was
then taken to the [**Hospital1 882**] for further management. According to
the daughters, the patient has had +dry cough over the past few
days. They deny any recent fevers, N/V, abdominal pain or
diarrhea. +fevers in grandson. no [**Name2 (NI) **] contacts in [**Name (NI) 50955**].

MEDICAL HISTORY: CAD s/p CABG x 4: marekdly positive stress c/w 3VD in [**2128**] and
refused cath at that time. EF last year was >40%.
HTN
Asthma
Gout

MEDICATION ON ADMISSION: unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals - T: 99.5 HR: 76 BP: 108/72 RR:22 02 sat:95RA
GENERAL: NAD
HEENT: NCAT, PERRLA, MMM
CARDIAC: +S1/S2, +II/VI SEM LUSB, RRR
LUNG: +b/l basilar crackles, no wheezes or ronchi
ABDOMEN: +obese, soft, NT/ND, +BS
EXT: +1 pitting edema of ankles, +tophaceous gout of bilateral
1st toes
DERM: no rashes

FAMILY HISTORY: Brother with Stroke, Sister with CAD s/p CABG, Sister with
Angina

SOCIAL HISTORY: Lives in [**Location (un) 50955**] with husband (step-father to daughters in
[**Name (NI) 86**]). No tobacco, EtOH or illicit drug use.
Subendocardial infarction, initial episode of care,Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Atrioventricular block, complete,Coronary atherosclerosis of autologous vein bypass graft,Chronic obstructive asthma with (acute) exacerbation,Urinary tract infection, site not specified,Acidosis,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Gout, unspecified,Other iatrogenic hypotension,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Nonspecific abnormal electrocardiogram [ECG] [EKG],Other specified antibiotics causing adverse effects in therapeutic use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Leukocytosis, unspecified
Subendo infarct, initial,Acute respiratry failure,Pneumonia, organism NOS,Ac on chr syst hrt fail,Acute kidney failure NOS,Atriovent block complete,Crn ath atlg vn bps grft,Ch obst asth w (ac) exac,Urin tract infection NOS,Acidosis,Hemorrhage complic proc,Ac posthemorrhag anemia,Atrial fibrillation,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Gout NOS,Iatrogenc hypotnsion NEC,Elev transaminase/ldh,Abnorm electrocardiogram,Adv eff antibiotics NEC,Abn react-procedure NEC,Leukocytosis NOS
Admission Date:  [**2131-11-3**]              Discharge Date:   [**2131-11-21**]

Date of Birth:  [**2055-8-12**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 7881**]
Chief Complaint:
Shortness of Breath

Major Surgical or Invasive Procedure:
intubation on ventilator, cardiac catheterization, pacemaker
placement, PICC line placement


History of Present Illness:
76F with history of CAD s/p CABG x 4, HTN, Asthma who was
transferred from [**Hospital 882**] Hospital for management of respiratory
distress/Pneumonia. Pt was visiting from [**Location (un) 50955**], [**State 2690**]. She
arrived into [**Location (un) 86**] last Sun. According to the daughters, their
mother had +chest pain on Tuesday night. She took NTG with
relief of her pain, then experienced an "asthma attack". On [**11-2**]
they were walking with her mother outside when she began to
experience worsening SOB, +chest pain, took NTG x 2. She was
then taken to the [**Hospital1 882**] for further management. According to
the daughters, the patient has had +dry cough over the past few
days. They deny any recent fevers, N/V, abdominal pain or
diarrhea. +fevers in grandson. no [**Name2 (NI) **] contacts in [**Name (NI) 50955**].

.
At [**Hospital 882**] hospital, A CXR was done which per report showed
pulmonary infiltrates consistent with PNA. She was given
Vanco/Zosyn/solumedrol. Patient experienced worsening
respiratory distress and was intubated. She was transferred on
[**11-3**] with Trop T 0.9, ECG with LBBB. BNP from [**Hospital1 882**] was >
[**Numeric Identifier 2249**] so concern was for PE. CTA was done and showed no PE but
confirmed RLL consolidation. Cardiology was consulted and
reviewed ECG, believed Troponin leak [**1-29**] demand ischemia in
setting of PNA/Sepsis, did not recommend anticoagulation.
Patient was admitted to MICU for further management. Pt
subsequently tachycardic to 130s, then ~115, then abruptly comp
heart block with conversion of LBBB to RBBB morphology and shift
of axis from 20 to 116. Tracings reviewed by EP fellow
(&[**Doctor Last Name **]). Thought to be profound vagal episode with no clear
trigger. Change of bundle as her escape rhythm is fascicular in
origin. Subsequently tachy/brady. Had introducer placed in RIJ
and temp pacer floated into RV apex (rescue rate =60). In the
interim, CK's started climbing, likely [**1-29**] to rate and s/p
extubation. Started on esmolol initially with limited effect,
but as of this AM, pacer dependent at rate of 60. TEE without
endocarditis or root abcess, 1+AR and [**12-29**]+MR. [**First Name (Titles) **] [**Last Name (Titles) 100787**]
negative. [**Last Name (Titles) 7792**] was substantial with CKMB 131, Trp up to 7.3,
was placed on heparin drip, ASA, lipitor 80, plavix (continued
from home); esmolol/pacer for rate control. had IJ pulled due to
persistent oozing and HCT 27, stopped heparin gtt, also guaiac
positive, cdiff neg. next, went into Afib with rate in 100-120s,
treated with IV lopressor boluses and po metoprolol 37.5 tid.
received 4U pRBC transfusions in MICU for HCT in mid/high 20s.
completed course of vanc/CFTX, although for unclear reasons WBC
increasing, temp pacer pulled (tip not cultured).
.
The patient was transferred to the floor and underwent cath (no
interventions performed) and pacer placement, then became
hypotensive on the floor ([**11-16**]) with limited IV access while
working with PT though per report, recovered when supine. She
was also noted to have oliguria. She was transferred back to the
MICU for hypotension not responsive to fluid boluses on the
floor. She was initially restarted on broad spectrum abx but
these were discontinued as she did not have any localizing signs
of infection. In the ICU, she received approximately 5 L of IVF
in total as she was not responsive to intermittent boluses. She
also rec'd 2 units of prbcs for her continued anemia and likely
slow GI bleed. She became significantly volume overloaded and
required a lasix gtt with pressor support up until the day prior
to transfer back to [**Hospital1 1516**]. She was 1.5L negative since midnight
last night and 3.5L positive LOS in the MICU. She has maintained
her pressures over the last 24 hours. On transfer, she denies
any pain, SOB, abdominal pain, nausea, vomiting, constipation,
diarrhea, or other symptoms.
.


Past Medical History:
CAD s/p CABG x 4: marekdly positive stress c/w 3VD in [**2128**] and
refused cath at that time. EF last year was >40%.
HTN
Asthma
Gout


Social History:
Lives in [**Location (un) 50955**] with husband (step-father to daughters in
[**Name (NI) 86**]). No tobacco, EtOH or illicit drug use.

Family History:
Brother with Stroke, Sister with CAD s/p CABG, Sister with
Angina

Physical Exam:
Vitals - T: 99.5 HR: 76 BP: 108/72 RR:22 02 sat:95RA
GENERAL: NAD
HEENT: NCAT, PERRLA, MMM
CARDIAC: +S1/S2, +II/VI SEM LUSB, RRR
LUNG: +b/l basilar crackles, no wheezes or ronchi
ABDOMEN: +obese, soft, NT/ND, +BS
EXT: +1 pitting edema of ankles, +tophaceous gout of bilateral
1st toes
DERM: no rashes

Pertinent Results:
[**2131-11-2**] 09:30PM BLOOD WBC-10.9 RBC-3.97* Hgb-11.4* Hct-35.2*
MCV-89 MCH-28.7 MCHC-32.4 RDW-14.5 Plt Ct-210
[**2131-11-4**] 05:46PM BLOOD WBC-10.4 RBC-3.60* Hgb-10.7* Hct-31.8*
MCV-88 MCH-29.6 MCHC-33.5 RDW-15.1 Plt Ct-240
[**2131-11-5**] 05:37AM BLOOD WBC-10.3 RBC-3.17* Hgb-9.0* Hct-27.4*
MCV-87 MCH-28.4 MCHC-32.8 RDW-15.2 Plt Ct-245
[**2131-11-6**] 04:24AM BLOOD WBC-21.3*# RBC-3.55* Hgb-10.4* Hct-30.7*
MCV-86 MCH-29.2 MCHC-33.8 RDW-15.6* Plt Ct-230
[**2131-11-7**] 04:07AM BLOOD WBC-14.8* RBC-2.84* Hgb-8.3* Hct-24.5*
MCV-86 MCH-29.3 MCHC-34.0 RDW-15.5 Plt Ct-176
[**2131-11-8**] 03:42AM BLOOD WBC-15.0* RBC-2.81* Hgb-8.5* Hct-24.7*
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.9* Plt Ct-180
[**2131-11-14**] 05:30AM BLOOD WBC-17.9* RBC-2.77* Hgb-8.3* Hct-25.5*
MCV-92 MCH-30.1 MCHC-32.8 RDW-16.2* Plt Ct-234
[**2131-11-15**] 10:30AM BLOOD WBC-28.0*# RBC-2.74* Hgb-8.4* Hct-25.7*
MCV-94 MCH-30.6 MCHC-32.5 RDW-16.8* Plt Ct-337
[**2131-11-16**] 06:03PM BLOOD WBC-19.2* RBC-3.46* Hgb-10.1* Hct-31.1*
MCV-90 MCH-29.1 MCHC-32.3 RDW-17.7* Plt Ct-286
[**2131-11-20**] 08:15AM BLOOD WBC-7.9 RBC-3.35* Hgb-10.2* Hct-30.2*
MCV-90 MCH-30.5 MCHC-33.8 RDW-18.4* Plt Ct-172
[**2131-11-2**] 09:30PM BLOOD Neuts-94.7* Lymphs-3.5* Monos-1.2*
Eos-0.4 Baso-0.2
[**2131-11-19**] 07:37AM BLOOD Neuts-88.3* Lymphs-5.6* Monos-4.0 Eos-1.9
Baso-0.1
[**2131-11-20**] 08:15AM BLOOD PT-15.5* PTT-32.7 INR(PT)-1.4*
[**2131-11-2**] 09:30PM BLOOD PT-12.2 PTT-25.7 INR(PT)-1.0
[**2131-11-2**] 09:30PM BLOOD Glucose-287* UreaN-21* Creat-1.0 Na-140
K-3.3 Cl-104 HCO3-23 AnGap-16
[**2131-11-3**] 02:54AM BLOOD Glucose-191* UreaN-19 Creat-1.1 Na-141
K-3.6 Cl-107 HCO3-21* AnGap-17
[**2131-11-5**] 05:37AM BLOOD Glucose-154* UreaN-41* Creat-1.9* Na-137
K-4.7 Cl-106 HCO3-22 AnGap-14
[**2131-11-6**] 04:24AM BLOOD Glucose-168* UreaN-64* Creat-2.7* Na-139
K-4.6 Cl-104 HCO3-22 AnGap-18
[**2131-11-13**] 07:10AM BLOOD Glucose-119* UreaN-22* Creat-1.5* Na-137
K-4.1 Cl-98 HCO3-29 AnGap-14
[**2131-11-15**] 10:30AM BLOOD Glucose-113* UreaN-48* Creat-2.3* Na-138
K-5.2* Cl-100 HCO3-17* AnGap-26*
[**2131-11-20**] 08:15AM BLOOD Glucose-106* UreaN-35* Creat-1.5* Na-145
K-3.9 Cl-108 HCO3-27 AnGap-14
[**2131-11-2**] 09:30PM BLOOD Lipase-17
[**2131-11-17**] 04:47AM BLOOD Lipase-89*
[**2131-11-2**] 09:30PM BLOOD cTropnT-0.90*
[**2131-11-2**] 09:30PM BLOOD CK-MB-7
[**2131-11-3**] 02:54AM BLOOD CK-MB-7 cTropnT-0.86* proBNP-[**Numeric Identifier **]*
[**2131-11-3**] 04:20PM BLOOD CK-MB-15* MB Indx-8.3* cTropnT-0.84*
[**2131-11-3**] 09:32PM BLOOD CK-MB-65* MB Indx-14.2* cTropnT-1.83*
[**2131-11-4**] 05:35AM BLOOD CK-MB-122* MB Indx-17.5* cTropnT-2.99*
[**2131-11-4**] 11:28AM BLOOD CK-MB-131* MB Indx-17.3* cTropnT-5.51*
[**2131-11-4**] 05:46PM BLOOD CK-MB-113* MB Indx-17.4* cTropnT-7.30*
[**2131-11-5**] 05:37AM BLOOD CK-MB-53* MB Indx-13.3* cTropnT-7.21*
[**2131-11-5**] 04:48PM BLOOD CK-MB-26* MB Indx-9.4* cTropnT-7.80*
[**2131-11-16**] 05:44AM BLOOD CK-MB-NotDone cTropnT-2.02*
[**2131-11-20**] 08:15AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.1
[**2131-11-14**] 05:30AM BLOOD calTIBC-226* Ferritn-1249* TRF-174*
[**2131-11-7**] 04:07AM BLOOD Hapto-195
[**2131-11-11**] 03:24AM BLOOD TSH-6.5*
[**2131-11-15**] 10:30AM BLOOD Cortsol-59.2*
[**2131-11-14**] 05:30AM BLOOD CRP-172.9*
[**2131-11-21**] Digoxin 0.4
.
.
CDiff neg on [**10-12**]
BCX neg to date (11/6,7,10,16,19)
UCx neg to date (11/7,9,14,20 w/ yeast)
[**Month/Year (2) **] serology neg [**11-4**]
Flu A/B neg [**11-3**]
MRSA screen neg 11.7
.
.
STUDIES:
EKG: NSR, LBBB, 1mm STE V1, V3, downsloping STD V6
.
Admission CXR
Final Report
AP PORTABLE CHEST, [**2131-11-2**] AT 2137 HOURS.
HISTORY: Non-ST segment elevation MI and presumed pneumonia.
COMPARISON: None.
FINDINGS: There is a relatively [**Name2 (NI) 15410**] consolidation of the right
lung base
with air bronchograms consistent with the given diagnosis of
pneumonia.
Further, there is extensive ill-defined opacity throughout the
left lower lobe
as well. An endotracheal tube has been placed with the distal
tip
approximately 3 cm from the carina. A nasogastric tube is in
appropriate
position with the sidehole projecting over the gastric body.
There is a
rounded density projecting within the right upper quadrant and
extensive
splenic artery calcifications noted in the left upper quadrant.
There is a
tortuous aorta with severe calcified plaque of the aortic arch.
Clips
consistent with prior CABG are noted, as are median sternotomy
wires. The
cardiac silhouette is enlarged. No definite effusion or
pneumothorax is seen.
Significant degenerative disease is noted throughout the
thoracic spine.
IMPRESSION:
1. Presumed right lower lobe pneumonia.
2. Question diffuse patchy opacity throughout the left lower
lobe, which may
be indicative of multifocal pneumonia.
3. Support tubes in appropriate position.
4. Probable gallstone.
.
.
CTA CHEST
Final Report
HISTORY: 76-year-old woman with chest pain and shortness of
breath after
flying. Rule out PE.

TECHNIQUE: CTA chest without and with contrast and coronal and
sagittal
reformatted images.

COMPARISON: Compared to chest radiograph from [**2131-11-2**].

FINDINGS: No filling defects seen in the pulmonary artery to
suggest
pulmonary embolism. There is no dissection of the thoracic
aorta.

Evaluation of lungs suboptimal, due to breathing motion. Airways
are patent
up to subsegmental level. There is airspace opacification in the
right lower
lobe, and in the left lower lobe, with some focal area of
opacification in the
upper lobes, concerning for multifocal pneumonia in appropriate
clinical
setting. No pathologically enlarged lymph nodes are seen in the
mediastinum,
hilum, or axilla. There are moderate atherosclerotic changes
through the
aorta. An endotracheal tube has been placed with distal tip
approximately 3
cm above carina. Nasogastric tube is seen in place. There is no
pleural
effusion, or pneumothorax. There is no pericardial effusion.
Heart is
enlarged. The patient is status post CABG with sternotomy wires
in place.

OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are
seen.

This study is not tailored for evaluation of subdiaphragmatic
contents.

IMPRESSION:

1. No PE, or thoracic aorta dissection.

2. Multifocal airspace opacities, most prominent at the lower
lobes of the
lungs, more on the right, concerning for multifocal pneumonia in
appropriate
clinical setting.

Findings posted on the ED dashboard.



The study and the report were reviewed by the staff radiologist.


DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: SAT [**2131-11-3**] 9:22 PM
.
.
.
TTE
EF25-30. The left atrium is dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is top
normal/borderline dilated. There is moderate regional left
ventricular systolic dysfunction with inferior and inferolateral
akinesis and hypokinesis of the septum and lateral wall. The
anterior wall has normal function. The right ventricular cavity
is mildly dilated with borderline normal free wall function. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.

IMPRESSION: Severely reduced LV ejection fraction with
inferior/inferolateral akinesis and lateral and septal
hypokinesis. The right ventricle is mildly dilated/hypokinetic.
Mild mitral regurgitation.
  Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2131-11-3**] 15:39
.
.
TEE
No atrial septal defect is seen by 2D or color Doppler. There is
regional left ventricular systolic dysfunction with inferior and
inferoseptal akinesis. There is severe complex (>4mm) atheroma
in the descending thoracic aorta ("porcelain aorta"). The aortic
valve leaflets (3) are moderately thickened. No masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. No mass or vegetation is seen on the mitral valve.
Mild to moderate ([**12-29**]+) mitral regurgitation is seen. There is
no pericardial effusion. Left pleural effusion is present.

IMPRESSION: No valvular vegetations seen. Regional LV
dysfunction c/w RCA disease. Mild aortic regurgitation. Mild to
morerate mitral regurgitation. Severe descending aortic
atherosclerosis.
  I certify that I was present for this procedure in compliance
with HCFA regulations.

Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2131-11-6**] 16:51
.
.
[**2131-11-12**]
Cardiac Cath
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
three vessel native coronary artery disease. The LMCA had a 90%
stenosis
filling a small ramus branch. The LAD had a total occlusion at
the
origin. The LCx had a total occlusion at the origin. The RCA was
totally
occluded at the mid-vessel.
2. Limited resting hemodynamics revealed a normal systemic blood

pressure of 121/57 mmHg.
3. Saphenous vein graft angiography revealed the SVG-PDA was
occluded
proximally. The SVG-LAD was widely patent and fills antegrade
and
retrograde. There were collaterals to the PDA and faintly to the
OMB.
the LVG-OMB was occluded proximally.
4. ARterial conduit angiography revealed the LIMA-diagonal to be
patent
with supplies a collateral to the OMB.
5. There was a 60% stenosis of the left subclavian artery with a
[**10-11**]
mmHg gradient.

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA-diagonal.
3. Patent SVG-LAD.
4. Occluded SVG-OM, SVG-RCA.
5. Normal systemic blood pressure.
6. Mild Left subclavian stenosis.
7. Medical Management.

ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Doctor Last Name 28713**],[**Doctor First Name 28714**]
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] J.
.
.
CXR
Final Report
INDICATION: Assessment of new PPM implant lead placement.

COMPARISON: Chest radiograph from [**2131-11-14**].

PA AND LATERAL CHEST RADIOGRAPHS: In comparison to the prior
study, there has
been no significant change. A left pectoral pacemaker with leads
in the
expected position of the right atrium and right ventricle are
seen. There is
no evidence of post-procedural complications, especially no
pneumothorax or
widening of the mediastinum. Moderate cardiomegaly is stable
since the prior
study. Blunting of the left lateral costophrenic sulcus with
some
retrocardiac opacity, may be due to small left pleural effusion
and
atelectasis.

Intact sternotomy wires are again noted.

IMPRESSION: Left pectoral pacemaker with leads in satisfactory
position.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name (STitle) 17414**] [**Name (STitle) 17415**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: [**Doctor First Name **] [**2131-11-15**] 12:47 PM
.
.
.
TTE
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. There is an inferobasal left ventricular aneurysm.
There is severe regional left ventricular systolic dysfunction
with inferior, inferolateral and inferoseptal akinesis. There is
mild hypokinesis of the remaining segments (LVEF = 25-30%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate ([**12-29**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.

IMPRESSION: Severe regional left ventricular systolic
dysfunction, c/w CAD. Mild to moderate mitral regurgitation.
Moderate pulmonary hypertension.

Compared with the prior study (images reviewed) of [**2131-11-3**],
the findings are similar. Pulmonary hypertension is better
assessed on today's study, but is not necessarily a new finding.

  Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2131-11-16**] 11:13
.
.
.
Renal U/S
Final Report
RENAL SON[**Name (NI) **]

INDICATION: 76-year-old woman with renal failure.

COMPARISON: Not available at the [**Hospital1 18**].

FINDINGS: The right kidney measures 9.8 cm and the left kidney
measures 9.4
cm. There is no hydronephrosis or calculus in either kidney. The
exam was
performed at the bedside, and is not adequate for evaluation of
focal
space-occupying lesions. The urinary bladder is decompressed
around the
catheter.

IMPRESSION:

1. Normal size kidneys, no hydronephrosis or nephrolithiasis.

2. Inadequate assessment for focal lesion.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: FRI [**2131-11-16**] 8:11 PM
.
.
.
LUE U/S
Final Report
HISTORY: 76-year-old female with asymmetric swelling of the left
upper
extremity.

FINDINGS: Duplex ultrasound examination of the left upper
extremity was
performed. The left internal jugular vein, subclavian vein,
axillary vein,
brachial veins, basilic and cephalic veins demonstrate normal
color Doppler
flow and response to compression and augmentation without
evidence of deep
venous thrombosis.

IMPRESSION:

No evidence of deep venous thrombosis in the left upper
extremity.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39944**]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: SUN [**2131-11-18**] 9:59 AM
.
.


Brief Hospital Course:
76 yo F transferred from [**Hospital 882**] Hospital with ischemic
cardiomyopathy EF=25-30%, CAD s/ CABG & s/p [**Hospital 7792**], heart block
w/in the last week while in the ICU now s/p dual-chamber pacer,
cath with medical management, then transferred back to ICU for
hypotension, ARF, anemia, and poor IV access. Transferred back
to the floor doing well.
.
# Systolic CHF: Has ischemic CM with EF of 25-30% with new
documentation of inferior LV aneurysm on most recent ECHO [**11-16**]
(she is not yet anticoagulated on coumadin due to occult GIB see
below). The pt has h/o CHF which was unclear, but due to
intubation and [**Name (NI) 7792**] with heartblock/AFib pt became initially
volume overloaded and was diuresed with lasix gtt. She became
volume depleted and developed hypotension and [**Doctor First Name 48**] which was
relieved with fluid resuscitation. She was started on digoxin
0.0625 mg in the ICU for heart failure which she has tolerated
well. She should have her digoxin level checked as an outpatient
in 6 wks, it was still below normal range at 0.4 upon discharge.
She was discharged on lasix 40mg [**Hospital1 **] and spirinolactone 25mg qd.

.
# CAD: [**Hospital1 7792**] with significant trop leak to 7.80 in the setting
of ICU extubation (see H&P), downtrended since, no ST changes on
EKG. Subsequent cath showed 3 vessel CAD, patent LIMA-diagonal,
patent SVG-LAD, occluded SVG-OM and SVG-RCA, normal systemic
blood pressure, mild left subclavian stenosis. There was no
revascularization. She was medically managed with asa 325,
plavix 75, lipitor 80, lopressor 37.5 TID, spirinolactone 25
daily, lisinopril 2.5.
.
# Arrythmias: The pt had tachy-brady/complete heart block likely
in the setting of [**Hospital1 7792**], now s/p dual chamber pacer. Per
report, changed to VVI set at 60, this can be followed up in
device clinic next week in case there needs to be readjustment.
Also with atrial fibrillation, not anticoagulated at this time
due to occult GI bleed that required multiple transfusions. We
recomend an outpatient GI workup before starting coumadin for
afib / new LV aneurysm. She is also discharged on digoxin per
above.
.
# Leukocytosis/PNA: Initially imaging was concerning for
multifocal PNA. She was intubated in the ICU and completed
course for hosp acquired PNA with Vanc/ceftriaxone x8 days.
Initially WBC around 15-20 (left shift), peaked at 28, but then
resolved back to normal range. She remained afebrile throughout,
and her blood/urine cultures remained neg, C diff neg on
multiple checks. Her WBC may have been secondary to 4 days of
solumedrol in ICU, as well as large [**Hospital1 7792**] and undergoing cath
and pacer placement. Upon discharge it was in the normal range.
.
# Oliguric [**Last Name (un) **]: Cr 1.6 on discharge down from 2.2. Was likely
prerenal in the setting of over-diuresis and poor PO intake.
Renal US unremarkable. We continued her on 60 lasix po qd and
spirinolactone 25mg daily.
.
# Elevated PTT: Was likely elevated due to subcu heparin. She
was DVT prophylaxed with pneumoboots.
.
# Anemia: Guaiac positive on exam, concerning for occult GI
bleed. has required 6 transfusions since admission. Hct now
stable at 30.7 (last tx on [**11-16**]). Iron studies this admission
consistent with anemia of chronic disease. Recommened outpt GI
workup and potential colonoscopy in order to be cleared before
starting coumadin for Afib and LV aneurysm.
.
# Transaminitis: unclear etiology, but may have been due to CHF.
LFTs downtrended on discharge and there was concern for any
acute pathology.
.
# Hypothyroidism: stable. we continued her home levothyroxine.
her TSH 6.5 on the floor after her course in the ICU, but this
was thought to be due to [**Month/Year (2) **] euthyroid.
.
# IV access: pt has poor IV access. she required placement of a
R PICC line.
.
# CONTACT:
[**Name (NI) 100788**] cardiologists: Dr [**Last Name (STitle) 100789**] and Dr. [**Last Name (STitle) 100790**]
[**Telephone/Fax (1) 100791**]
fax: [**Telephone/Fax (1) 100792**]
CODE: Full
.

Medications on Admission:
unknown

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for rash.
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for rash.
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
11. Maalox 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID
(4 times a day) as needed for tongue sores.
12. Digoxin 125 mcg Tablet Sig: .5 Tablet PO DAILY (Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for SOB.
15. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
16. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
17. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
19. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
20. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
21. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
22. Furosemide 40 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**]

Discharge Diagnosis:
Primary:
multifocal pneumonia
asthma exacerbation
[**Hospital1 7792**]
atrial fibrillation
AV heart block
acute on chronic renal insufficiency
.
Secondary:
gout
hypertension
CAD


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair


Discharge Instructions:
You were admitted due to a pneumonia and asthma exacerbation.
You had complications in the ICU including a heart attack,
arrythmia, and gastrointestinal bleed. You required broad
spectrum antibiotics, multiple blood transfusions, a cardiac
catheterization, and pacemaker placement. Your kidneys also had
dysfunction which improved. Your blood counts improved as well.
You will need an outpatient workup for your GI bleed before you
can start coumadin for your atrial fibrillation and your
aneurysm in your heart ventricle. There were many changes to
your medications. Please take all medications as prescribed
(please see attached sheet).
.
Please follow up with all appointments.
Please do not hesitate to return to the hospital for any
concerning symptoms at all.

Followup Instructions:
Please make an appointment to see a GI doctor in the next [**1-30**]
weeks for workup of your GI bleed before starting coumadin for
atrial fibrillation/LV aneurysm. If you wish to make an
appointment here you may call ([**Telephone/Fax (1) 2233**].
.
Please see your primary care doctor in the next 2-3 weeks.
Please follow up with your cardiologist in the next 2-3 weeks,
please have your digoxin level checked in 6 weeks.
.
Please follow up with all appointments as below:
Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2131-11-23**]
11:00
{'Subendocardial infarction, initial episode of care,Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Atrioventricular block, complete,Coronary atherosclerosis of autologous vein bypass graft,Chronic obstructive asthma with (acute) exacerbation,Urinary tract infection, site not specified,Acidosis,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Gout, unspecified,Other iatrogenic hypotension,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Nonspecific abnormal electrocardiogram [ECG] [EKG],Other specified antibiotics causing adverse effects in therapeutic use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Leukocytosis, unspecified'}


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: 76F with history of CAD s/p CABG x 4, HTN, Asthma who was
transferred from [**Hospital 882**] Hospital for management of respiratory
distress/Pneumonia. Pt was visiting from [**Location (un) 50955**], [**State 2690**]. She
arrived into [**Location (un) 86**] last Sun. According to the daughters, their
mother had +chest pain on Tuesday night. She took NTG with
relief of her pain, then experienced an "asthma attack". On [**11-2**]
they were walking with her mother outside when she began to
experience worsening SOB, +chest pain, took NTG x 2. She was
then taken to the [**Hospital1 882**] for further management. According to
the daughters, the patient has had +dry cough over the past few
days. They deny any recent fevers, N/V, abdominal pain or
diarrhea. +fevers in grandson. no [**Name2 (NI) **] contacts in [**Name (NI) 50955**].

MEDICAL HISTORY: CAD s/p CABG x 4: marekdly positive stress c/w 3VD in [**2128**] and
refused cath at that time. EF last year was >40%.
HTN
Asthma
Gout

MEDICATION ON ADMISSION: unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals - T: 99.5 HR: 76 BP: 108/72 RR:22 02 sat:95RA
GENERAL: NAD
HEENT: NCAT, PERRLA, MMM
CARDIAC: +S1/S2, +II/VI SEM LUSB, RRR
LUNG: +b/l basilar crackles, no wheezes or ronchi
ABDOMEN: +obese, soft, NT/ND, +BS
EXT: +1 pitting edema of ankles, +tophaceous gout of bilateral
1st toes
DERM: no rashes

FAMILY HISTORY: Brother with Stroke, Sister with CAD s/p CABG, Sister with
Angina

SOCIAL HISTORY: Lives in [**Location (un) 50955**] with husband (step-father to daughters in
[**Name (NI) 86**]). No tobacco, EtOH or illicit drug use. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Atrioventricular block, complete,Coronary atherosclerosis of autologous vein bypass graft,Chronic obstructive asthma with (acute) exacerbation,Urinary tract infection, site not specified,Acidosis,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Gout, unspecified,Other iatrogenic hypotension,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Nonspecific abnormal electrocardiogram [ECG] [EKG],Other specified antibiotics causing adverse effects in therapeutic use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Leukocytosis, unspecified'}
