CHIEF COMPLAINT: Chest pain, total body pain

PRESENT ILLNESS: [**Age over 90 **] y/o F with PMHx of CAD, CHF with EF of 40%, recent admission
with respiratory failure requiring intubation who presents with
total body pain and chest pain.  The patient's current symptoms
began on Saturday with nausea.  The following day (one day prior
to admission), the patient experienced aching throughout her
body, including her back, chest, and the back of her head.  This
morning, the patient awoke from sleep at 6am due to right index
finger pain, erythema, swelling, and calor which then spread to
the rest of her body (back, chest, back of head).  Finger pain
is described as stiff, sore, and achy with associated calor.
Total body pain is described as sharp body aches which is
generalized, which lasted until she received Morphine in the ED.
 The patient describes chest pain along with her total body
pain, and received SL Nitro x3 without relief.  The pain had
similar features to her prior anginal equivalent, during which
she experienced chest pain, shortness of breath, and upper back
pain, but her current pain consists of nausea without dyspnea or
lightheadedness.
.
In the ER, vitals were T99.9  BP 156/61  P76  R18  PO2 100% 2L.
Chest pain was [**7-18**] on arrival and she was started on a nitro
gtt without significant relief of symptoms.  However, symptoms
resolved with morphine, currently 0/10.  EKG revealed sinus
rhythm with baseline LBBB and no acute EKG changes.  She
received Morphine and a 500cc bolus while en route with EMS, and
received additional Morphine in the ED.
.
On evaluation on the floor, pt was asymptomatic and complaining
of thirst.  She denies PND, reports 2 pillow orthopnea which has
remained unchanged for years.
.
.
REVIEW OF SYSTEMS:
She denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. Denies fevers/chills,
night-sweats, abdominal pain, diarrhea, dysuria, rash.  She does
report (+) congestion/cough with white sputum since
hospitalization, helped by albuterol.  All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema,
palpitations, syncope or presyncope.

MEDICAL HISTORY: # Diabetes
# Dyslipidemia
# Hypertension
# Coronary Disease - s/p NSTEMI [**9-16**] medically managed and Cath
s/p stent in [**3-20**].
# Chronic systolic/diastolic congestive heart failure, most
recent EF>60%
# Chronic renal failure, stage III CKD - Dr [**Last Name (STitle) **]
# Hypertension
# Hyperlipidemia, intolerant of statins
# Type 2 diabetes, diet-controlled
# GERD
# Breast Cancer - diagnosed in [**2145**], s/p lumpectomy in [**State 108**]
# s/p total abdominal hysterectomy [**2094**] for fibroids
# Cataracts

MEDICATION ON ADMISSION: 1. Senna 8.6 mg [**Hospital1 **]
2. Famotidine 20 mg Tablet
3. Calcitriol 0.25 mcg Capsule PO QMOWEFR
4. Aspirin 162mg daily
5. Clopidogrel 75 mg daily
6. Cyanocobalamin 500 mcg daily
**7. Hydralazine 10 mg q6hr
**8. Isosorbide Mononitrate 20 mg [**Hospital1 **]
9. Docusate Sodium 100 mg [**Hospital1 **]
10. Felodipine 10 mg daily
11. Carvedilol 12.5 mg [**Hospital1 **]
**12. Furosemide 40 mg Tablet [**Hospital1 **]
13. Iron (Ferrous Sulfate) 325 mg daily
14. Nitrostat 0.4 mg Tablet, Sublingual prn

ALLERGIES: Atorvastatin / Tylenol / Ibuprofen / Rosuvastatin

PHYSICAL EXAM: On admission
VS: T=98.6   BP=146/70   HR=75   R=20   PO2 sat= 100% 2L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death. Her father had hypertension. Her sister is
alive and healthy at 93.

SOCIAL HISTORY: She lives at home alone, but has family in the area. Social
history is significant for the absence of current tobacco use,
remote social tobacco use in college.  There is no history of
alcohol abuse. Has home [**Year (4 digits) 269**] w tele reports daily and PT.
Presents from rehab following multiple admissions.
Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Chronic kidney disease, Stage IV (severe),Ostium secundum type atrial septal defect,Hyposmolality and/or hyponatremia,Other and unspecified angina pectoris,Chronic airway obstruction, not elsewhere classified,Encounter for palliative care,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Gout, unspecified,Anemia in chronic kidney disease,Abdominal pain, unspecified site,Unspecified psychosis,Cervicalgia,Backache, unspecified,Atherosclerosis of renal artery,Mitral valve disorders,Esophageal reflux,Other left bundle branch block,Unspecified cataract,Personal history of malignant neoplasm of breast
Ac/chr syst/dia hrt fail,Acute kidney failure NOS,Chr kidney dis stage IV,Secundum atrial sept def,Hyposmolality,Angina pectoris NEC/NOS,Chr airway obstruct NEC,Encountr palliative care,Hy kid NOS w cr kid I-IV,Crnry athrscl natve vssl,Status-post ptca,Old myocardial infarct,DMII wo cmp nt st uncntr,Atrial fibrillation,Gout NOS,Anemia in chr kidney dis,Abdmnal pain unspcf site,Psychosis NOS,Cervicalgia,Backache NOS,Renal artery atheroscler,Mitral valve disorder,Esophageal reflux,Left bb block NEC,Cataract NOS,Hx of breast malignancy
Admission Date:  [**2165-4-29**]              Discharge Date:   [**2165-5-15**]


Service: MEDICINE

Allergies:
Atorvastatin / Tylenol / Ibuprofen / Rosuvastatin

Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Chest pain, total body pain

Major Surgical or Invasive Procedure:
None


History of Present Illness:
[**Age over 90 **] y/o F with PMHx of CAD, CHF with EF of 40%, recent admission
with respiratory failure requiring intubation who presents with
total body pain and chest pain.  The patient's current symptoms
began on Saturday with nausea.  The following day (one day prior
to admission), the patient experienced aching throughout her
body, including her back, chest, and the back of her head.  This
morning, the patient awoke from sleep at 6am due to right index
finger pain, erythema, swelling, and calor which then spread to
the rest of her body (back, chest, back of head).  Finger pain
is described as stiff, sore, and achy with associated calor.
Total body pain is described as sharp body aches which is
generalized, which lasted until she received Morphine in the ED.
 The patient describes chest pain along with her total body
pain, and received SL Nitro x3 without relief.  The pain had
similar features to her prior anginal equivalent, during which
she experienced chest pain, shortness of breath, and upper back
pain, but her current pain consists of nausea without dyspnea or
lightheadedness.
.
In the ER, vitals were T99.9  BP 156/61  P76  R18  PO2 100% 2L.
Chest pain was [**7-18**] on arrival and she was started on a nitro
gtt without significant relief of symptoms.  However, symptoms
resolved with morphine, currently 0/10.  EKG revealed sinus
rhythm with baseline LBBB and no acute EKG changes.  She
received Morphine and a 500cc bolus while en route with EMS, and
received additional Morphine in the ED.
.
On evaluation on the floor, pt was asymptomatic and complaining
of thirst.  She denies PND, reports 2 pillow orthopnea which has
remained unchanged for years.
.
.
REVIEW OF SYSTEMS:
She denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. Denies fevers/chills,
night-sweats, abdominal pain, diarrhea, dysuria, rash.  She does
report (+) congestion/cough with white sputum since
hospitalization, helped by albuterol.  All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema,
palpitations, syncope or presyncope.

Past Medical History:
# Diabetes
# Dyslipidemia
# Hypertension
# Coronary Disease - s/p NSTEMI [**9-16**] medically managed and Cath
s/p stent in [**3-20**].
# Chronic systolic/diastolic congestive heart failure, most
recent EF>60%
# Chronic renal failure, stage III CKD - Dr [**Last Name (STitle) **]
# Hypertension
# Hyperlipidemia, intolerant of statins
# Type 2 diabetes, diet-controlled
# GERD
# Breast Cancer - diagnosed in [**2145**], s/p lumpectomy in [**State 108**]
# s/p total abdominal hysterectomy [**2094**] for fibroids
# Cataracts


Social History:
She lives at home alone, but has family in the area. Social
history is significant for the absence of current tobacco use,
remote social tobacco use in college.  There is no history of
alcohol abuse. Has home [**Year (4 digits) 269**] w tele reports daily and PT.
Presents from rehab following multiple admissions.

Family History:
There is no family history of premature coronary artery disease
or sudden death. Her father had hypertension. Her sister is
alive and healthy at 93.

Physical Exam:
On admission
VS: T=98.6   BP=146/70   HR=75   R=20   PO2 sat= 100% 2L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of <9 cm.
CARDIAC: RRR, normal S1, S2. GII systolic murmer at LSB, no
gallops, rubs. S4 present at LSB and apex.  No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at bases b/l;
no egophany.  No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. NABS.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
 Right: Carotid 2+  DP 2+  PT 2+
 Left: Carotid 2+  DP 2+  PT 2+

On discharge
VS: 97.3, 120/47, 52, 18, 100%RA
I/O: 120/350 today, [**Telephone/Fax (1) 93520**] yesterday
GENERAL: AAOx3, pleasant elderly female in NAD. Fatigued, but
interactive.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP of <9 cm while sitting at 90 degrees
CARDIAC: RRR, normal S1, S2. S4 present at LSB and apex.
LUNGS: mild kyphosis. Resp were unlabored, no accessory muscle
use. soft crackles bibasilarly, breath sounds at bases decreased

ABDOMEN: Soft, NTND. No HSM or tenderness. NABS.
EXTREMITIES: No c/c/e.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+


Pertinent Results:
CXR ([**4-29**]): Two views are compared with the bedside examination
obtained some 10 hours earlier, as well as previous examinations
of [**4-16**] and [**2165-4-19**]. There has been clearing of the findings of
CHF and bilateral pleural effusions, with residual rounded LV
enlargement and atherosclerotic change involving the thoracic
aorta. The lungs appear hyperinflated, suggestive of underlying
obstructive disease; however, there is no focal airspace
opacity. There is diffuse osteopenia with slight anterior
wedging of several thoracic vertebrae and resultant slight
kyphosis. There is no acute abnormality of the thoracic
skeleton.
.
CXR ([**5-5**]):
1. Worsening pulmonary edema and increasing small pleural
effusions.
2. Bilateral lower lobe airspace opacities, which may be due to
dependent
areas of pulmonary edema or superimposed secondary process such
as aspiration or infectious pneumonia. Followup radiographs
after diuresis may be helpful in this regard.
.
CXR ([**5-6**])
CHEST, AP: Mild interstitial edema has slightly worsened. Mild
cardiomegaly and small bilateral pleural effusions are
unchanged. Bibasilar consolidation is stable. The cardiac
silhouette is normal. The aorta is calcified and tortuous.
IMPRESSION: Slightly increased vascular congestion.
.
SUPINE ABDOMEN ([**5-6**])
Limited study with partially imaged left abdomen. Bowel gas
pattern present is nonobstructive with air seen in non-dilated
loops of small and large bowel. There is no free intraperitoneal
air or pneumatosis. The cardiac silhouette is moderately
enlarged. There is a questionable deep sulcus sign in the right
hemithorax, which in the right clinical setting, may represent a
pneumothorax. There is small opacification in the left lower
lung.
.
CBC
[**2165-5-13**] 05:15AM BLOOD WBC-8.3 RBC-3.41* Hgb-10.1* Hct-30.1*
MCV-88 MCH-29.7 MCHC-33.7 RDW-15.2 Plt Ct-402
[**2165-5-12**] 04:35AM BLOOD WBC-8.4 RBC-3.45* Hgb-10.5* Hct-30.3*
MCV-88 MCH-30.5 MCHC-34.7 RDW-14.9 Plt Ct-355
[**2165-5-11**] 06:10AM BLOOD WBC-7.8 RBC-3.28* Hgb-9.7* Hct-28.7*
MCV-88 MCH-29.5 MCHC-33.7 RDW-15.0 Plt Ct-369
[**2165-5-10**] 05:20AM BLOOD WBC-6.0 RBC-3.09* Hgb-9.1* Hct-27.1*
MCV-88 MCH-29.5 MCHC-33.7 RDW-14.9 Plt Ct-389
[**2165-5-9**] 05:30AM BLOOD WBC-5.6 RBC-3.16* Hgb-9.1* Hct-27.2*
MCV-86 MCH-28.9 MCHC-33.5 RDW-14.7 Plt Ct-341
[**2165-5-8**] 05:15AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.1* Hct-26.5*
MCV-87 MCH-29.7 MCHC-34.4 RDW-14.7 Plt Ct-286
[**2165-5-7**] 06:02AM BLOOD WBC-6.6 RBC-3.02* Hgb-9.0* Hct-26.2*
MCV-87 MCH-29.9 MCHC-34.5 RDW-14.8 Plt Ct-305
[**2165-5-6**] 12:48AM BLOOD WBC-7.4# RBC-3.03* Hgb-8.9* Hct-25.7*
MCV-85 MCH-29.4 MCHC-34.7 RDW-14.8 Plt Ct-239
[**2165-5-5**] 04:10AM BLOOD WBC-4.5 RBC-2.71* Hgb-8.3* Hct-23.8*
MCV-88 MCH-30.6 MCHC-35.0 RDW-14.9 Plt Ct-248
[**2165-5-4**] 07:30AM BLOOD WBC-4.9 RBC-3.01* Hgb-9.1* Hct-26.6*
MCV-88 MCH-30.3 MCHC-34.3 RDW-15.0 Plt Ct-239
[**2165-5-3**] 05:05AM BLOOD WBC-5.7 RBC-3.06* Hgb-9.4* Hct-27.2*
MCV-89 MCH-30.6 MCHC-34.4 RDW-15.3 Plt Ct-242
[**2165-5-2**] 05:25AM BLOOD WBC-5.8 RBC-3.36* Hgb-10.1* Hct-29.2*
MCV-87 MCH-30.0 MCHC-34.6 RDW-15.0 Plt Ct-225
[**2165-5-1**] 07:30AM BLOOD WBC-8.6 RBC-3.31* Hgb-9.9* Hct-29.5*
MCV-89 MCH-30.1 MCHC-33.7 RDW-15.4 Plt Ct-245
[**2165-4-30**] 10:50AM BLOOD WBC-7.8 RBC-3.29* Hgb-9.8* Hct-28.6*
MCV-87 MCH-29.7 MCHC-34.1 RDW-15.2 Plt Ct-215
[**2165-4-30**] 07:25AM BLOOD WBC-9.9 RBC-3.36* Hgb-10.3* Hct-29.9*
MCV-89 MCH-30.7 MCHC-34.5 RDW-15.5 Plt Ct-245
[**2165-4-29**] 07:55AM BLOOD WBC-16.0*# RBC-3.75* Hgb-11.3* Hct-32.3*
MCV-86 MCH-30.0 MCHC-34.9 RDW-15.6* Plt Ct-269

Coags
[**2165-5-11**] 06:10AM BLOOD PT-12.7 PTT-30.2 INR(PT)-1.1
[**2165-5-10**] 05:20AM BLOOD PT-12.1 PTT-27.4 INR(PT)-1.0
[**2165-5-9**] 05:30AM BLOOD PT-12.0 PTT-28.0 INR(PT)-1.0
[**2165-5-8**] 05:15AM BLOOD PT-12.8 PTT-28.9 INR(PT)-1.1
[**2165-5-7**] 06:02AM BLOOD PT-12.6 PTT-31.4 INR(PT)-1.1
[**2165-5-6**] 01:01AM BLOOD PT-13.1 PTT-26.5 INR(PT)-1.1
[**2165-4-30**] 07:25AM BLOOD PT-13.2 PTT-28.4 INR(PT)-1.1

Chemistry
[**2165-5-13**] 05:15AM BLOOD Glucose-117* UreaN-116* Creat-3.7*
Na-131* K-3.5 Cl-78* HCO3-40* AnGap-17
[**2165-5-12**] 04:35AM BLOOD Glucose-121* UreaN-117* Creat-3.5*
Na-131* K-3.7 Cl-78* HCO3-39* AnGap-18
[**2165-5-11**] 06:10AM BLOOD Glucose-131* UreaN-117* Creat-3.7*
Na-130* K-3.8 Cl-79* HCO3-38* AnGap-17
[**2165-5-10**] 05:20AM BLOOD Glucose-118* UreaN-119* Creat-3.7*
Na-130* K-4.0 Cl-79* HCO3-37* AnGap-18
[**2165-5-9**] 05:30AM BLOOD Glucose-109* UreaN-119* Creat-3.7*
Na-129* K-3.2* Cl-79* HCO3-35* AnGap-18
[**2165-5-8**] 05:15AM BLOOD Glucose-111* UreaN-118* Creat-3.9*
Na-128* K-3.4 Cl-77* HCO3-34* AnGap-20
[**2165-5-7**] 06:02AM BLOOD Glucose-115* UreaN-116* Creat-4.1*
Na-125* K-3.3 Cl-76* HCO3-34* AnGap-18
[**2165-5-6**] 04:08PM BLOOD UreaN-112* Creat-4.2* Na-129* K-3.7
Cl-81* HCO3-32 AnGap-20
[**2165-5-6**] 12:48AM BLOOD Glucose-137* UreaN-108* Creat-4.4*
Na-123* K-3.8 Cl-75* HCO3-29 AnGap-23*
[**2165-5-5**] 04:10AM BLOOD Glucose-107* UreaN-105* Creat-4.3*
Na-125* K-3.9 Cl-80* HCO3-30 AnGap-19
[**2165-5-4**] 07:30AM BLOOD Glucose-127* UreaN-95* Creat-3.9* Na-126*
K-3.9 Cl-80* HCO3-29 AnGap-21*
[**2165-5-3**] 05:10PM BLOOD Glucose-202* UreaN-93* Creat-3.8* Na-125*
K-4.2 Cl-81* HCO3-28 AnGap-20
[**2165-5-5**] 04:10AM BLOOD Glucose-107* UreaN-105* Creat-4.3*
Na-125* K-3.9 Cl-80* HCO3-30 AnGap-19
[**2165-5-4**] 07:30AM BLOOD Glucose-127* UreaN-95* Creat-3.9* Na-126*
K-3.9 Cl-80* HCO3-29 AnGap-21*
[**2165-5-3**] 05:10PM BLOOD Glucose-202* UreaN-93* Creat-3.8* Na-125*
K-4.2 Cl-81* HCO3-28 AnGap-20
[**2165-5-3**] 05:05AM BLOOD Glucose-136* UreaN-91* Creat-3.6* Na-127*
K-4.1 Cl-85* HCO3-29 AnGap-17
[**2165-5-2**] 05:25AM BLOOD Glucose-135* UreaN-84* Creat-3.1* Na-135
K-4.0 Cl-92* HCO3-28 AnGap-19
[**2165-5-1**] 07:30AM BLOOD Glucose-110* UreaN-82* Creat-3.0* Na-136
K-4.3 Cl-94* HCO3-32 AnGap-14
[**2165-4-30**] 10:50AM BLOOD Glucose-186* UreaN-81* Creat-2.9* Na-135
K-3.4 Cl-92* HCO3-32 AnGap-14
[**2165-4-30**] 07:25AM BLOOD Glucose-109* UreaN-81* Creat-2.9* Na-136
K-3.4 Cl-92* HCO3-32 AnGap-15
[**2165-4-29**] 07:55AM BLOOD Glucose-163* UreaN-84* Creat-2.9* Na-138
K-3.5 Cl-94* HCO3-30 AnGap-18
[**2165-5-13**] 05:15AM BLOOD Calcium-9.0 Phos-5.1* Mg-3.8*
[**2165-5-12**] 04:35AM BLOOD Calcium-9.0 Phos-4.7* Mg-4.0*
[**2165-5-11**] 06:10AM BLOOD Calcium-8.7 Phos-4.2 Mg-4.0*
[**2165-5-10**] 05:20AM BLOOD Calcium-8.5 Phos-4.1 Mg-4.0*
[**2165-5-9**] 05:30AM BLOOD Calcium-8.8 Phos-5.3* Mg-3.8*
[**2165-5-8**] 05:15AM BLOOD Calcium-8.6 Phos-5.4* Mg-4.0*
[**2165-5-7**] 06:02AM BLOOD Calcium-9.2 Phos-6.5* Mg-4.1*
[**2165-5-6**] 12:48AM BLOOD Albumin-3.6 Calcium-9.2 Phos-5.8* Mg-3.6*
[**2165-5-5**] 04:10AM BLOOD Calcium-8.9 Phos-6.1* Mg-3.3*
[**2165-5-4**] 07:30AM BLOOD Calcium-9.1 Phos-5.1* Mg-3.0*
[**2165-5-3**] 05:05AM BLOOD Calcium-9.1 Phos-4.2 Mg-3.0*
[**2165-5-2**] 05:25AM BLOOD Calcium-9.6 Phos-4.8* Mg-2.7*
[**2165-5-1**] 07:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.9*
[**2165-4-30**] 10:50AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.6
[**2165-4-30**] 07:25AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.5
[**2165-4-29**] 07:55AM BLOOD Calcium-9.9 Phos-4.2 Mg-2.5

Cardiac Enzymes
[**2165-5-6**] 12:48AM BLOOD CK(CPK)-17*
[**2165-5-5**] 04:10AM BLOOD CK(CPK)-11*
[**2165-5-2**] 05:25AM BLOOD CK(CPK)-16*
[**2165-5-1**] 09:14PM BLOOD CK(CPK)-20*
[**2165-4-30**] 07:25AM BLOOD CK(CPK)-17*
[**2165-4-30**] 03:40AM BLOOD CK(CPK)-15*
[**2165-4-29**] 03:05PM BLOOD CK(CPK)-19*
[**2165-4-29**] 07:55AM BLOOD CK(CPK)-20*
[**2165-5-6**] 12:48AM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2165-5-5**] 04:10AM BLOOD CK-MB-1 cTropnT-0.19*
[**2165-5-2**] 05:25AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2165-5-1**] 09:14PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2165-4-30**] 07:25AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2165-4-30**] 03:40AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2165-4-29**] 03:05PM BLOOD CK-MB-NotDone cTropnT-0.03* proBNP-[**Numeric Identifier 93521**]*
[**2165-4-29**] 07:55AM BLOOD cTropnT-0.03*


Brief Hospital Course:
[**Age over 90 **]yoF with CAD s/p stent to mid-[**Name (NI) **], PTCA of jailed OM1, IVUS of
LMCA with MLA presenting with body pain and chest pain.
.
# CORONARIES:  Patient has h/o prior stent to [**Name (NI) **] and PTCA of
jailed OM1 presenting with atypical chest pain not concerning
for ACS.  There were no significant EKG changes in light of LBBB
(by Sgarbossa criteria), and CE's were negative.  The patient
was continued on Aspirin 162mg daily and Clopidogrel 75 mg daily
per outpatient regimen.
.
# PUMP/CHF:  Patient has a history of chronic systolic and
diastolic heart failure with EF 40% [**3-/2165**], moderate (2+) MR,
small secundum ASD with left-to-right shunt across the
interatrial septum at rest.  She appeared clinically fluid
overloaded without hypoxia, with BNP >45,000.  Pt had complex
course on the medicine floor with multiple episodes of worsening
resp status thought due to flash pulm edema.  Initially, her
symptoms responded to lasix and additional BP control.  However,
the renal function slowly worsened and she had a decreasing
response to diuresis.  Pt became progressively uremic and
confused on [**5-5**] with mild respiratory distress.  She was
transferred to the CCU on [**5-6**] and received 240mg Lasix IV bolus
followed by gtt.  She was aggressively diuresed, per renal recs,
started on Lasix 80mg PO BID.  She has had good volume output
with the lasix.  Patient has been in good volume status since,
has not had any further episodes of flash pulmonary edema.  Has
had fluctuating O2 requirements, at times saturating well on
room air and other times requiring 2L of O2.
.
# Chronic renal failure: Stage III CKD, followed by Dr [**Last Name (STitle) **].
Patient has baseline Cr of 1.5 until [**Month (only) 956**] when baseline
increased to 2.4.  On this admission patient had worsening renal
function with creatinine rising from 2.9 to 4.3.  It was unclear
whether the patient's increasing creatinine was due to
dehydration vs volume overload - particularly given her
recurrent episodes of flash pulmonary edema and CXR showing
evidence of fluid overload.  She was aggressively diuresed in
the CCU and her volume status has been stable on 80 mg of PO
lasix [**Hospital1 **].  Patient and family have decided to decline
hemodialysis and focus more on comfort measures.

# Renal Artery Stenosis:  Patient with atrophic right kidney,
left renal artery stenosis.  Very likely that this is the reason
that she is very difficult to diurese and the reason why she
flashes easily.  She was originally planned for renal artery
stenting, but the procedure was held off because she was
unstable, requiring CCU transfer.  Goals of care were discussed
with patient and renal stenting was tabled as patient decided
against aggressive management and to focus more on comfort.
.
#  Body Pain:  Patient describes body pain since waking up in
the morning of her admission.  Unclear etiology, but likely
viral symptoms vs non-specific findings [**3-12**] CHF exacerbation.
Infectious workup was negative.  Leukocytosis resolved on
discharge.  Patient has had 2 transient episodes of chest pain
on this admission which was reproducible with palpation and
worse with movement, likely of musculoskeletal etiology,
relieved with 0.5 mg of PO morphine.
.
# Right Finger Pain:  Pt initially presented with right index
finger with erythema, swelling, calor consistent with gout;
septic arthritis or osteomyelitis was less likely given no
fevers, no effusion, no nidus of infection.  Resolved without
intervention.
.
# Hypertension:  Patient's home antihypertensives were initially
continued, but following her CCU transfer for recurrent flash
pulmonary edema, she was changed to amlodipine, carvedilol,
furosemide, and imdur.  Following her CCU admission she has been
stable with SBP ranging in 110s-130s.
.
# Hyperlipidemia:  Pt is intolerant of statins, and was not
given statins after discussion with her PCP [**Last Name (NamePattern4) **]: goals of the
patient's care.
.
# Type 2 diabetes:  diet-controlled.  Covered with SSI in-house.
.
# GERD:  Continued Famotidine 20 mg Tablet per outpatient
regimen
.
# Goals of care: patient was made DNR/DNI while in the CCU.
Patient and family decided against starting hemodialysis,
preference was for comfort directed care.  Just prior to
discharge from the hospital, patient was asked to sign a DNR/DNI
form which would continue her DNR/DNI status during transport
and at the nursing facility, which she refused to sign.  Patient
repeatedly stated that she DID NOT want to be resuscitated,
however refused to sign the form.  She is amenable to her
daughter (HCP) signing the DNR/DNI forms for her, however the
daughter was not available prior to discharge to sign the
papers.  The daughter understands that she would be able to sign
the DNR/DNI papers at the nursing facility.  At the nursing
facility, patient's care should be focused on comfort care.

Medications on Admission:
1. Senna 8.6 mg [**Hospital1 **]
2. Famotidine 20 mg Tablet
3. Calcitriol 0.25 mcg Capsule PO QMOWEFR
4. Aspirin 162mg daily
5. Clopidogrel 75 mg daily
6. Cyanocobalamin 500 mcg daily
**7. Hydralazine 10 mg q6hr
**8. Isosorbide Mononitrate 20 mg [**Hospital1 **]
9. Docusate Sodium 100 mg [**Hospital1 **]
10. Felodipine 10 mg daily
11. Carvedilol 12.5 mg [**Hospital1 **]
**12. Furosemide 40 mg Tablet [**Hospital1 **]
13. Iron (Ferrous Sulfate) 325 mg daily
14. Nitrostat 0.4 mg Tablet, Sublingual prn

Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
up to 3 tablets as needed for chest pain 5 minutes apart.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath, wheezing.
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).

10. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS
OFF ().
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
16. Miralax 17 gram Powder in Packet Sig: Seventeen (17) grams
PO once a day as needed for constipation.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
20. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every
six (6) hours as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]

Discharge Diagnosis:
Primary Diagnosis:
Acute on Chronic Systolic and Diastolic Heart Failure
Pulmonary Edema
Left Renal Artery Stenosis

Secondary Diagnosis:
Hypertension
Diabetes
Coronary Artery Disease


Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Lethargic but arousable
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)


Discharge Instructions:
You presented to the hospital for body pain and chest pain.
Your EKG and blood tests did not show any evidence of a heart
attack, but you were found to be in heart failure.  While in the
hospital, you had frequent episodes of shortness of breath was
improved with starting you on Lasix to help remove fluid.
During this admission, we had many discussions about whether or
not to start dialysis.  Your final  decision was for dialysis
not to be started, but instead to pursue hospice care instead.
You will be discharged to a nursing facility where they can help
with treating your symptoms and making you comfortable.
.
Your medications have changed, please only take the medications
as
listed below:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
up to 3 tablets as needed for chest pain 5 minutes apart.
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath, wheezing.
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).

10. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS
OFF ().
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
16. Miralax 17 gram Powder in Packet Sig: Seventeen (17) grams
PO once a day as needed for constipation.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
20. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every
six (6) hours as needed for pain.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Please call and schedule an appointment to see your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**] ([**Telephone/Fax (1) 250**]), as needed.
{'Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Chronic kidney disease, Stage IV (severe),Ostium secundum type atrial septal defect,Hyposmolality and/or hyponatremia,Other and unspecified angina pectoris,Chronic airway obstruction, not elsewhere classified,Encounter for palliative care,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Gout, unspecified,Anemia in chronic kidney disease,Abdominal pain, unspecified site,Unspecified psychosis,Cervicalgia,Backache, unspecified,Atherosclerosis of renal artery,Mitral valve disorders,Esophageal reflux,Other left bundle branch block,Unspecified cataract,Personal history of malignant neoplasm of breast'}


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: Chest pain, total body pain

PRESENT ILLNESS: [**Age over 90 **] y/o F with PMHx of CAD, CHF with EF of 40%, recent admission
with respiratory failure requiring intubation who presents with
total body pain and chest pain.  The patient's current symptoms
began on Saturday with nausea.  The following day (one day prior
to admission), the patient experienced aching throughout her
body, including her back, chest, and the back of her head.  This
morning, the patient awoke from sleep at 6am due to right index
finger pain, erythema, swelling, and calor which then spread to
the rest of her body (back, chest, back of head).  Finger pain
is described as stiff, sore, and achy with associated calor.
Total body pain is described as sharp body aches which is
generalized, which lasted until she received Morphine in the ED.
 The patient describes chest pain along with her total body
pain, and received SL Nitro x3 without relief.  The pain had
similar features to her prior anginal equivalent, during which
she experienced chest pain, shortness of breath, and upper back
pain, but her current pain consists of nausea without dyspnea or
lightheadedness.
.
In the ER, vitals were T99.9  BP 156/61  P76  R18  PO2 100% 2L.
Chest pain was [**7-18**] on arrival and she was started on a nitro
gtt without significant relief of symptoms.  However, symptoms
resolved with morphine, currently 0/10.  EKG revealed sinus
rhythm with baseline LBBB and no acute EKG changes.  She
received Morphine and a 500cc bolus while en route with EMS, and
received additional Morphine in the ED.
.
On evaluation on the floor, pt was asymptomatic and complaining
of thirst.  She denies PND, reports 2 pillow orthopnea which has
remained unchanged for years.
.
.
REVIEW OF SYSTEMS:
She denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. Denies fevers/chills,
night-sweats, abdominal pain, diarrhea, dysuria, rash.  She does
report (+) congestion/cough with white sputum since
hospitalization, helped by albuterol.  All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema,
palpitations, syncope or presyncope.

MEDICAL HISTORY: # Diabetes
# Dyslipidemia
# Hypertension
# Coronary Disease - s/p NSTEMI [**9-16**] medically managed and Cath
s/p stent in [**3-20**].
# Chronic systolic/diastolic congestive heart failure, most
recent EF>60%
# Chronic renal failure, stage III CKD - Dr [**Last Name (STitle) **]
# Hypertension
# Hyperlipidemia, intolerant of statins
# Type 2 diabetes, diet-controlled
# GERD
# Breast Cancer - diagnosed in [**2145**], s/p lumpectomy in [**State 108**]
# s/p total abdominal hysterectomy [**2094**] for fibroids
# Cataracts

MEDICATION ON ADMISSION: 1. Senna 8.6 mg [**Hospital1 **]
2. Famotidine 20 mg Tablet
3. Calcitriol 0.25 mcg Capsule PO QMOWEFR
4. Aspirin 162mg daily
5. Clopidogrel 75 mg daily
6. Cyanocobalamin 500 mcg daily
**7. Hydralazine 10 mg q6hr
**8. Isosorbide Mononitrate 20 mg [**Hospital1 **]
9. Docusate Sodium 100 mg [**Hospital1 **]
10. Felodipine 10 mg daily
11. Carvedilol 12.5 mg [**Hospital1 **]
**12. Furosemide 40 mg Tablet [**Hospital1 **]
13. Iron (Ferrous Sulfate) 325 mg daily
14. Nitrostat 0.4 mg Tablet, Sublingual prn

ALLERGIES: Atorvastatin / Tylenol / Ibuprofen / Rosuvastatin

PHYSICAL EXAM: On admission
VS: T=98.6   BP=146/70   HR=75   R=20   PO2 sat= 100% 2L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death. Her father had hypertension. Her sister is
alive and healthy at 93.

SOCIAL HISTORY: She lives at home alone, but has family in the area. Social
history is significant for the absence of current tobacco use,
remote social tobacco use in college.  There is no history of
alcohol abuse. Has home [**Year (4 digits) 269**] w tele reports daily and PT.
Presents from rehab following multiple admissions. 

### Response:
{'Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Chronic kidney disease, Stage IV (severe),Ostium secundum type atrial septal defect,Hyposmolality and/or hyponatremia,Other and unspecified angina pectoris,Chronic airway obstruction, not elsewhere classified,Encounter for palliative care,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Gout, unspecified,Anemia in chronic kidney disease,Abdominal pain, unspecified site,Unspecified psychosis,Cervicalgia,Backache, unspecified,Atherosclerosis of renal artery,Mitral valve disorders,Esophageal reflux,Other left bundle branch block,Unspecified cataract,Personal history of malignant neoplasm of breast'}
