CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: Ms. [**Known lastname 28003**] is a 44 year old female with Factor V Leiden and
multiple prior pulmonary emboli who was transferred from [**Hospital1 **]
to [**Hospital1 18**] ED for evaluation of pleuritic chest pain radiating to
the back and dyspnea. Per the record she also had two days of
flank pain radiating to the groin, and dysuria.  She was
transferred for a study to rule out pulmonary embolism. She is
anticoagulated on coumadin, currently with an INR of 2.2. Vitals
at [**Hospital1 **]: bp 149/96, p 72, rr 18, sat 98%, t 98.4
.
Her initial [**Hospital1 18**] ED vitals were: 98.1 76 184/83 16 98%. Based
on her symptomotology, aortic dissection became a concern. In
the ED she was electively intubated because she is clautrophobic
and needed the MRI. An MRA was contraindicated due to the risk
for gadolinium induced nephrogenic systemic sclerosis. A TEE was
considered; however, this would not interrogate the entire aorta
and there is report that the patient also had two days of flank
pain. Transfer vitals: 136/84, p 74, bp 136/84, rr 16, o2 sat
99% on cmv/ac
.
On arrival to the MICU, she was intubated and sedated.

MEDICAL HISTORY: 1. Factor V Leiden gene mutation
2. Pulmonary emboli
3. IDDM
4. Hypertension
5. ESRD on HD via left subclavian HD line, schedule unknown
6. Hypothyroidism
7. Atrial myxoma s/p resention
8. atrial fibrillation
9. Reflex sympathetic dystrophy/chronic regional pain syndrone
10. Fasciotomy of right forearm [**2180-5-16**], left forearm [**2194-4-15**]
11. Permanent IVF filter placed on [**2186-7-10**]

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. HYDROmorphone (Dilaudid) 20 mg PO Q3H pain
2. Nephro-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg Oral
daily
3. Lisinopril 40 mg PO BID
4. Digoxin 0.125 mg PO MWF
5. sevelamer CARBONATE 1600 mg PO TID W/MEALS
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Propranolol LA 120 mg PO DAILY
8. Montelukast Sodium 10 mg PO DAILY
9. Aciphex *NF* (RABEprazole) 20 mg Oral daily
10. Lantus Solostar *NF* (insulin glargine) 30 units
Subcutaneous HS
11. NovoLOG *NF* (insulin aspart) sliding scale  Subcutaneous
slidinc scale
12. Doxazosin 2 mg PO HS
13. Lorazepam 1 mg PO Q6H:PRN anxiety
14. Promethazine 25 mg PO Q6H:PRN nausea
15. Ondansetron 8 mg PO BID:PRN nausea
16. Frova *NF* (frovatriptan) 2.5 mg Oral PRN migraines
17. Xopenex Neb *NF* 1.25 mg/0.5 mL Inhalation Q4H PRN
18. Ferrous Sulfate 325 mg PO DAILY
19. DiphenhydrAMINE 50 mg PO Q4H:PRN itching
20. Docusate Sodium 100 mg PO BID
21. Denavir *NF* (penciclovir) 1 % Topical q6h rash
22. Warfarin Dose is Unknown  PO DAILY16
Based on INR
23. Metoprolol Succinate XL 25 mg PO DAILY

ALLERGIES: multiple / Amoxicillin / baclofen / Cephalexin / doxycycline /
Erythromycin Base / Hydralazine / Meperidine / Polystyrene
Sulfonate / povidone-iodine / valproic acid / Verapamil /
Nifedipine / cefuroxime / Labetalol / ciprofloxacin / omeprazole
/ loratadine / loratadine / amlodipine / metformin / sumatriptan
/ fexofenadine / bee venom (honey bee) / esomeprazole /
Penicillins / Sulfa(Sulfonamide Antibiotics) / IV Dye, Iodine
Containing Contrast Media

PHYSICAL EXAM: ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
General: NAD AOx3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
+CVA tenderness on left that is stable x4 days
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation

FAMILY HISTORY: She denies a family history of kidney disease.  Father had MI
and CABG in his 50's.  No FH of premature CAD, SCD, or
arrhythmia.

SOCIAL HISTORY: Patient is from [**Location (un) 15739**], NY.  She is currently on disability.
Lifelong nonsmoker. Denies EtOH or illicits
Acute respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Primary hypercoagulable state,Urinary tract infection, site not specified,Reflex sympathetic dystrophy, unspecified,Other chronic pain,Other chest pain,Anemia, unspecified,Renal dialysis status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Atrial fibrillation,Orthostatic hypotension,Obstructive sleep apnea (adult)(pediatric),Personal history of pulmonary embolism,Long-term (current) use of insulin
Acute respiratry failure,Hyp kid NOS w cr kid V,End stage renal disease,Prim hypercoagulable st,Urin tract infection NOS,Unsp rflx sympth dystrph,Chronic pain NEC,Chest pain NEC,Anemia NOS,Renal dialysis status,DMII wo cmp nt st uncntr,Hypothyroidism NOS,Atrial fibrillation,Orthostatic hypotension,Obstructive sleep apnea,Hx pulmonary embolism,Long-term use of insulin
Admission Date:  [**2194-7-27**]              Discharge Date:   [**2194-8-8**]

Date of Birth:  [**2149-8-20**]             Sex:   F

Service: MEDICINE

Allergies:
multiple / Amoxicillin / baclofen / Cephalexin / doxycycline /
Erythromycin Base / Hydralazine / Meperidine / Polystyrene
Sulfonate / povidone-iodine / valproic acid / Verapamil /
Nifedipine / cefuroxime / Labetalol / ciprofloxacin / omeprazole
/ loratadine / loratadine / amlodipine / metformin / sumatriptan
/ fexofenadine / bee venom (honey bee) / esomeprazole /
Penicillins / Sulfa(Sulfonamide Antibiotics) / IV Dye, Iodine
Containing Contrast Media

Attending:[**First Name3 (LF) 16851**]
Chief Complaint:
chest pain


Major Surgical or Invasive Procedure:
intubation
right femoral cvc
[**2194-7-30**]- RIGHT CHEST PORT CATHETER FIBRIN SHEATH STRIPPING AND
REMOVAL OF RIGHT GROIN
CVL


History of Present Illness:
Ms. [**Known lastname 28003**] is a 44 year old female with Factor V Leiden and
multiple prior pulmonary emboli who was transferred from [**Hospital1 **]
to [**Hospital1 18**] ED for evaluation of pleuritic chest pain radiating to
the back and dyspnea. Per the record she also had two days of
flank pain radiating to the groin, and dysuria.  She was
transferred for a study to rule out pulmonary embolism. She is
anticoagulated on coumadin, currently with an INR of 2.2. Vitals
at [**Hospital1 **]: bp 149/96, p 72, rr 18, sat 98%, t 98.4
.
Her initial [**Hospital1 18**] ED vitals were: 98.1 76 184/83 16 98%. Based
on her symptomotology, aortic dissection became a concern. In
the ED she was electively intubated because she is clautrophobic
and needed the MRI. An MRA was contraindicated due to the risk
for gadolinium induced nephrogenic systemic sclerosis. A TEE was
considered; however, this would not interrogate the entire aorta
and there is report that the patient also had two days of flank
pain. Transfer vitals: 136/84, p 74, bp 136/84, rr 16, o2 sat
99% on cmv/ac
.
On arrival to the MICU, she was intubated and sedated.

Past Medical History:
1. Factor V Leiden gene mutation
2. Pulmonary emboli
3. IDDM
4. Hypertension
5. ESRD on HD via left subclavian HD line, schedule unknown
6. Hypothyroidism
7. Atrial myxoma s/p resention
8. atrial fibrillation
9. Reflex sympathetic dystrophy/chronic regional pain syndrone
10. Fasciotomy of right forearm [**2180-5-16**], left forearm [**2194-4-15**]
11. Permanent IVF filter placed on [**2186-7-10**]

Social History:
Patient is from [**Location (un) 15739**], NY.  She is currently on disability.
Lifelong nonsmoker. Denies EtOH or illicits

Family History:
She denies a family history of kidney disease.  Father had MI
and CABG in his 50's.  No FH of premature CAD, SCD, or
arrhythmia.

Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
General: NAD AOx3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
+CVA tenderness on left that is stable x4 days
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation

Pertinent Results:
ADMISSION LABS:
[**2194-7-27**] 04:55PM BLOOD WBC-5.3 RBC-3.50* Hgb-10.2* Hct-31.5*
MCV-90 MCH-29.0 MCHC-32.3 RDW-19.4* Plt Ct-176
[**2194-7-27**] 04:55PM BLOOD Neuts-59.7 Lymphs-20.2 Monos-5.0
Eos-14.2* Baso-1.0
[**2194-7-27**] 04:55PM BLOOD PT-23.5* PTT-33.7 INR(PT)-2.2*
[**2194-7-27**] 04:55PM BLOOD Glucose-132* UreaN-29* Creat-6.2* Na-136
K-5.3* Cl-100 HCO3-23 AnGap-18
[**2194-7-27**] 04:55PM BLOOD cTropnT-<0.01
[**2194-7-28**] 06:08AM BLOOD CK-MB-3 cTropnT-0.22*
[**2194-7-28**] 12:12PM BLOOD CK-MB-4 cTropnT-0.20*
[**2194-7-27**] 04:55PM BLOOD CK(CPK)-39
[**2194-7-28**] 06:08AM BLOOD CK(CPK)-90
[**2194-7-28**] 12:12PM BLOOD CK(CPK)-103
.
DISCHARGE LABS:
.
[**2194-8-3**]
   URINE CULTURE (Final [**2194-8-5**]):
      ENTEROCOCCUS SP..    >100,000 ORGANISMS/ML..

[**2194-8-8**] 06:04AM BLOOD WBC-4.5 RBC-3.36* Hgb-10.4* Hct-31.0*
MCV-92 MCH-31.0 MCHC-33.6 RDW-18.3* Plt Ct-211
[**2194-8-8**] 06:04AM BLOOD PT-19.9* PTT-40.9* INR(PT)-1.9*
[**2194-8-7**] 06:48AM BLOOD PT-21.8* PTT-133.1* INR(PT)-2.1*
[**2194-8-6**] 05:12AM BLOOD PT-20.9* PTT-147.1* INR(PT)-2.0*
[**2194-8-8**] 06:04AM BLOOD Glucose-140* UreaN-52* Creat-8.6*# Na-138
K-5.4* Cl-98 HCO3-28 AnGap-17
[**2194-8-8**] 06:04AM BLOOD Calcium-9.8 Phos-8.0* Mg-2.3
.
IMAGING:
[**2194-7-27**] CXR: Single portable view of the chest. No prior.
Endotracheal tube is seen with tip approximately 5 cm from the
carina. Nasogastric tube is also seen with side port in the
region of the GE junction. Left-sided central venous catheter is
seen with tip in the right atrium. Right-sided subclavian line
is seen with tip in the mid SVC. Lungs are grossly clear, given
significant rotation and portable supine technique. Median
sternotomy wires again seen. Cardiac silhouette is enlarged but
likely accentuated due to technique and positioning. Osseous and
soft tissue structures are unremarkable.
IMPRESSION: Endotracheal tube tip approximately 5 cm from the
carina.
.
[**2194-7-28**] MRA Torso:
1. No MR evidence for aortic dissection.
2. No central pulmonary embolism in the main, right or left
pulmonary arteries, the lobar and smaller order pulmonary
arteries cannot be assessed on this non-contrast study.
3. Right lower lobe atelectasis or consolidation.
4. Multiple renal cysts with small shrunken kidneys consistent
with the patient's chronic renal disease.
5. Positioning of the central venous catheters is not clear, at
least one catheter appears to terminate in the right atrium or
extend into the IVC.  Recommend a chest radiograph to confirm
catheter tip placement.

TTE (Complete) Done [**2194-7-29**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is probably
mildly depressed with mid anteroseptal hypokinesis but views are
suboptimal for assessment of wall motion. Right ventricular
chamber size is normal with mildly depressed function (but views
are subopitmal). The aortic valve leaflets (probably 3) appear
structurally normal with good leaflet excursion. The mitral
valve leaflets are mildly thickened. No mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion. An
small (approximately 1 cm diameter) echodense structure is
visualized posterior to the left atrium in a modified four
chamber view which represent a portion of a wall of a pulmonary
vein. No definite intracardiac mass identified but views are
suboptimal. If clinically indicated, a transesophageal
echocardiographic examination is recommended.

CHEST (PORTABLE AP) Study Date of [**2194-7-28**]
INDICATION:  Evaluate right Port-A-Cath and central venous
catheter locations due to positioning within the right atrium
noted prior MRI of the chest.

COMPARISON:  Chest radiogram from [**2194-7-27**] and MRA of the
torso from [**2194-7-28**].

FINDINGS:  A bedside AP radiograph of the chest demonstrates
that the
double-lumen catheter terminates well within the right atrium,
approximately 7 cm below the expected location of the cavoatrial
junction.  It is unchanged in position from the prior study.
The right subclavian line terminates in the mid SVC, also
unchanged.  The patient has been extubated.  The lungs are
clear.  There continues to be enlargement of the right atrium.
There is no pneumothorax or pleural effusion.  Pulmonary
vascularity is normal.
Sternotomy cerclage wires are intact.

IMPRESSION:  The double-lumen Port-A-Cath should be retracted
approximately 7 cm to ensure proper positioning in the lower
one-third of the SVC.

[**2194-7-31**] Radiology RENAL U.S.
FINDINGS:  The right kidney measures 9 cm.  The left kidney
measures 9.5 cm.  Several cysts are seen in both kidneys.  A 1.9
cm left upper pole cyst has a single septation.  The bladder is
clear.  There is no stone, mass or hydronephrosis in either
kidney.
IMPRESSION:  No hydronephrosis, stone or perinephric fluid
collection.

[**2194-8-1**] Radiology CHEST (PA & LAT)
Two views of the chest were obtained.  The lungs are well
expanded and clear without pleural effusion or pneumothorax.
The heart is normal in size with normal cardiomediastinal
contours.  Right-sided Port-A-Cath and left-sided hemodialysis
catheter are in unchanged position.  Cardiac size is stably
enlarged.


Brief Hospital Course:
HOSPITAL COURSE:
Ms. [**Known lastname 28003**] is a 44 year old female with Factor V Leiden and
multiple prior pulmonary emboli who was transferred from [**Hospital1 **]
for evaluation of pleuritic chest pain radiating to the back and
dyspnea. Ruled out for serious thoracic pathology
(PE/dissection/ACS). MWF HD was continued throughout stay on
floors. Given hx of Factor V Leiden, started on Heparin drip
with bridging to warfarin. Reported constant left flank pain. In
conjunction with falling hemoglobin, this prompted CT Abd/Pelv
which ruled out retroperitoneal bleed. Transfused one unit and
hemoglobin was stabilized for remainder of admission. While
waiting for INR to become therapeutic, previous UCx grew
>100,000 CFUs Enterococcus, treated with vancomycin at HD. INR
became therapeutic x3 days, heparin gtt stopped and pt was
discharged on day 14 of admission with followup with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] MD [**First Name8 (NamePattern2) **] [**Last Name (Titles) 15739**].

ACTIVE ISSUES:
Chest Pain: The patient described substernal chest pain
radiating to her back that was worrisome for PE, acute MI, or
aortic dissection. Patient was electively intubated in the ED
and subsequent MRI negative for aortic dissection or large
pulmonary embolism. Recurrent subsegmental pulmonary embolism
possible as patient has had this occur on warfarin with
therapeutic INR and with IVC filter in place. Acute myocardial
infarction was also a concern.  Initial ECG was within normal
limits; however, serial ECG showed development of IVCD with no
overt ischemic changes. Troponin was initially negative;
however, cTropnT < 0.01 --> 0.22 --> 0.20 with negative CK-MB
index. Other points in the differential would include
pericarditis or myocarditis given troponin leak. Non-cardiac or
pulmonary etiologies could be esophageal spasm. The patient has
a history of an atrial myxoma so that was also on the
differential.  An ECHO was performed given concern for ischemia
or atrial myxoma and showed mild symmetric LVH with LV systolic
function probably mildly depressed with mid anteroseptal
hypokinesis, mildly depressed RV funtion and no definite
intracardiac mass.  Views were all suboptimal though.  The
patient was evaluated by cardiology who recommended that the
patient follow up as an outpatient for possible stress test.

Flank Pain: The patient complained or left sided flank pain.
She has a history of pyelonephritis.  UA and culture on
admission were normal, however the patient continued to have
flank pain so a renal ultrasound was ordered and a repeat
urinalysis and culture. A renal ultrasound revealed no
hydronephrosis, stone or perinephric fluid collection.
Subsequent UCx grew >100,000 Enterococcus but patient clinically
stable and afebrile. Regardless, treated with vancomycin at HD.

Hypertension/Hypotension:  Home anti-hypertensive medications
were initially held due to borderline blood pressures.  She was
started on metoprolol 25 mg XL per cardiology recommendation for
history of atrial fibrillation as well and tolerated this well
initially. However, complaints of dizziness on standing prompted
reduction of antihypertensive dosing. At d/c Lisinopril was 20mg
daily, Metoprolol was 12.5mg daily.

Factor V Leiden gene mutation with multiple pulmonary emboli: We
initially held warfarin while ruling out aortic dissection, but
then restarted it after MRI was negative. The patient was
subsequently started on a heparin drip due to high risk of clot
and subtherapeutic INR. INR increased slowly and became
therapeutic x3 days before discharge.

ESRD: Patient was seen and evaluated by renal and dialyzed per
home M/W/F schedule without complication.

INACTIVE ISSUES:
Pain control: Patient tolerated home dose of q3h 20mg Dilaudid.

IDDM: The patient was placed on a sliding scale.

Atrial fibrillation- The patient has history of atrial
fibrillation related to atrial myxoma in the past.  She was seen
and evaluated by cardiology who recommended metoprolol xl 25 mg.
 EKG's performed and telemetry monitoring revealed sinus rhythm.
 The patient was anticoagulated as described above.

Hypothyroidism: There was no evidence of clinical hypothyroidism
and the patient was continued levothyroxine.

TRANSITIONAL ISSUES:
f/u dosing on antihypertensives/cardiac meds
*Please note we discontinued digoxin and propranolol and went
down on lisinopril and metoprolol.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. HYDROmorphone (Dilaudid) 20 mg PO Q3H pain
2. Nephro-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg Oral
daily
3. Lisinopril 40 mg PO BID
4. Digoxin 0.125 mg PO MWF
5. sevelamer CARBONATE 1600 mg PO TID W/MEALS
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Propranolol LA 120 mg PO DAILY
8. Montelukast Sodium 10 mg PO DAILY
9. Aciphex *NF* (RABEprazole) 20 mg Oral daily
10. Lantus Solostar *NF* (insulin glargine) 30 units
Subcutaneous HS
11. NovoLOG *NF* (insulin aspart) sliding scale  Subcutaneous
slidinc scale
12. Doxazosin 2 mg PO HS
13. Lorazepam 1 mg PO Q6H:PRN anxiety
14. Promethazine 25 mg PO Q6H:PRN nausea
15. Ondansetron 8 mg PO BID:PRN nausea
16. Frova *NF* (frovatriptan) 2.5 mg Oral PRN migraines
17. Xopenex Neb *NF* 1.25 mg/0.5 mL Inhalation Q4H PRN
18. Ferrous Sulfate 325 mg PO DAILY
19. DiphenhydrAMINE 50 mg PO Q4H:PRN itching
20. Docusate Sodium 100 mg PO BID
21. Denavir *NF* (penciclovir) 1 % Topical q6h rash
22. Warfarin Dose is Unknown  PO DAILY16
Based on INR
23. Metoprolol Succinate XL 25 mg PO DAILY


Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. HYDROmorphone (Dilaudid) 20 mg PO Q3H pain
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Lisinopril 20 mg PO DAILY
hold for SBP < 100
6. Lorazepam 1 mg PO Q6H:PRN anxiety
7. Metoprolol Succinate XL 12.5 mg PO DAILY
hold for SBP < 100 or HR < 60
8. Warfarin 8 mg PO DAILY16
9. Xopenex Neb *NF* 1.25 mg/0.5 mL Inhalation Q4H PRN
10. Aspirin 81 mg PO DAILY
11. Aciphex *NF* (RABEprazole) 20 mg Oral daily
12. Denavir *NF* (penciclovir) 1 % Topical q6h rash
13. DiphenhydrAMINE 50 mg PO Q4H:PRN itching
14. Doxazosin 2 mg PO HS
15. Frova *NF* (frovatriptan) 2.5 mg Oral PRN migraines
16. Lantus Solostar *NF* (insulin glargine) 30 units
Subcutaneous HS
17. Montelukast Sodium 10 mg PO DAILY
18. Nephro-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg
Oral daily
19. Ondansetron 8 mg PO BID:PRN nausea
20. Promethazine 25 mg PO Q6H:PRN nausea
21. Propranolol LA 120 mg PO DAILY


Discharge Disposition:
Home

Discharge Diagnosis:
Atypical chronic chest pain
Factor V Leiden with history of PEs (+IVC filter)


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


Discharge Instructions:
Dear Ms. [**Known lastname 28003**],

Thank you for choosing us for your care. You were admitted for
chest pain that, in conjunction with your Factor V Leiden, was
concerning for a pulmonary embolism. We have done many tests to
rule out this possibility, as well as other dangerous conditions
causing chest pain including aortic dissection and heart attack.
To do one of these tests, we needed to sedate and intubate you.
Despite the extensive workup we are unsure what is causing your
chest pain and shortness of breath at this time.

You also reported burning on urination and left sided flank
pain. We performed a CT scan to make sure there was no bleeding
into your flank. This was negative. We performed several tests
to rule out a UTI or an infection of your kidney, which can
present with flank pain. Your urine grew some bacteria, but this
can be common in people dependent on dialysis. Regardless, we
have treated it with vancomycin.

In the hospital we have continued to give you dialysis to
compensate for your chronic kidney disease. Please continue to
do so at your usual dialysis center.

We had been anticoagulating you on heparin while we waited for
your warfarin to raise your INR above 2.0. Please continue to
take your warfarin after discharge to maintain an INR above 2.0.

We have made an appointment with your primary care doctor
[**First Name8 (NamePattern2) 11320**] [**Last Name (NamePattern1) **] in [**Location (un) 15739**]. Please see her to adjust your
medications.

We have lowered your dose of Lisinopril to 20mg daily and your
dose of Metoprolol to 12.5mg daily.
We have STOPPED your digoxin. Please do not continue to take it.
Please continue to take your other medications as you had before
you went to [**Hospital3 **].

Followup Instructions:
[**First Name8 (NamePattern2) 11320**] [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 94080**] Creek Family Medicine
[**Apartment Address(1) 112512**]
[**Location (un) 15739**], [**Numeric Identifier 112513**]
Appointment: (585) 275-URMC
Fax: ([**Telephone/Fax (1) 112514**]
Date: Thursday [**8-14**]
Time:  2PM



Completed by:[**2194-8-8**]
{'Acute respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Primary hypercoagulable state,Urinary tract infection, site not specified,Reflex sympathetic dystrophy, unspecified,Other chronic pain,Other chest pain,Anemia, unspecified,Renal dialysis status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Atrial fibrillation,Orthostatic hypotension,Obstructive sleep apnea (adult)(pediatric),Personal history of pulmonary embolism,Long-term (current) use of insulin'}


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

PRESENT ILLNESS: Ms. [**Known lastname 28003**] is a 44 year old female with Factor V Leiden and
multiple prior pulmonary emboli who was transferred from [**Hospital1 **]
to [**Hospital1 18**] ED for evaluation of pleuritic chest pain radiating to
the back and dyspnea. Per the record she also had two days of
flank pain radiating to the groin, and dysuria.  She was
transferred for a study to rule out pulmonary embolism. She is
anticoagulated on coumadin, currently with an INR of 2.2. Vitals
at [**Hospital1 **]: bp 149/96, p 72, rr 18, sat 98%, t 98.4
.
Her initial [**Hospital1 18**] ED vitals were: 98.1 76 184/83 16 98%. Based
on her symptomotology, aortic dissection became a concern. In
the ED she was electively intubated because she is clautrophobic
and needed the MRI. An MRA was contraindicated due to the risk
for gadolinium induced nephrogenic systemic sclerosis. A TEE was
considered; however, this would not interrogate the entire aorta
and there is report that the patient also had two days of flank
pain. Transfer vitals: 136/84, p 74, bp 136/84, rr 16, o2 sat
99% on cmv/ac
.
On arrival to the MICU, she was intubated and sedated.

MEDICAL HISTORY: 1. Factor V Leiden gene mutation
2. Pulmonary emboli
3. IDDM
4. Hypertension
5. ESRD on HD via left subclavian HD line, schedule unknown
6. Hypothyroidism
7. Atrial myxoma s/p resention
8. atrial fibrillation
9. Reflex sympathetic dystrophy/chronic regional pain syndrone
10. Fasciotomy of right forearm [**2180-5-16**], left forearm [**2194-4-15**]
11. Permanent IVF filter placed on [**2186-7-10**]

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. HYDROmorphone (Dilaudid) 20 mg PO Q3H pain
2. Nephro-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg Oral
daily
3. Lisinopril 40 mg PO BID
4. Digoxin 0.125 mg PO MWF
5. sevelamer CARBONATE 1600 mg PO TID W/MEALS
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Propranolol LA 120 mg PO DAILY
8. Montelukast Sodium 10 mg PO DAILY
9. Aciphex *NF* (RABEprazole) 20 mg Oral daily
10. Lantus Solostar *NF* (insulin glargine) 30 units
Subcutaneous HS
11. NovoLOG *NF* (insulin aspart) sliding scale  Subcutaneous
slidinc scale
12. Doxazosin 2 mg PO HS
13. Lorazepam 1 mg PO Q6H:PRN anxiety
14. Promethazine 25 mg PO Q6H:PRN nausea
15. Ondansetron 8 mg PO BID:PRN nausea
16. Frova *NF* (frovatriptan) 2.5 mg Oral PRN migraines
17. Xopenex Neb *NF* 1.25 mg/0.5 mL Inhalation Q4H PRN
18. Ferrous Sulfate 325 mg PO DAILY
19. DiphenhydrAMINE 50 mg PO Q4H:PRN itching
20. Docusate Sodium 100 mg PO BID
21. Denavir *NF* (penciclovir) 1 % Topical q6h rash
22. Warfarin Dose is Unknown  PO DAILY16
Based on INR
23. Metoprolol Succinate XL 25 mg PO DAILY

ALLERGIES: multiple / Amoxicillin / baclofen / Cephalexin / doxycycline /
Erythromycin Base / Hydralazine / Meperidine / Polystyrene
Sulfonate / povidone-iodine / valproic acid / Verapamil /
Nifedipine / cefuroxime / Labetalol / ciprofloxacin / omeprazole
/ loratadine / loratadine / amlodipine / metformin / sumatriptan
/ fexofenadine / bee venom (honey bee) / esomeprazole /
Penicillins / Sulfa(Sulfonamide Antibiotics) / IV Dye, Iodine
Containing Contrast Media

PHYSICAL EXAM: ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
General: NAD AOx3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
+CVA tenderness on left that is stable x4 days
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation

FAMILY HISTORY: She denies a family history of kidney disease.  Father had MI
and CABG in his 50's.  No FH of premature CAD, SCD, or
arrhythmia.

SOCIAL HISTORY: Patient is from [**Location (un) 15739**], NY.  She is currently on disability.
Lifelong nonsmoker. Denies EtOH or illicits 

### Response:
{'Acute respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Primary hypercoagulable state,Urinary tract infection, site not specified,Reflex sympathetic dystrophy, unspecified,Other chronic pain,Other chest pain,Anemia, unspecified,Renal dialysis status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Atrial fibrillation,Orthostatic hypotension,Obstructive sleep apnea (adult)(pediatric),Personal history of pulmonary embolism,Long-term (current) use of insulin'}
