CHIEF COMPLAINT: chest pain and shortness of breath

PRESENT ILLNESS: 81 year old female with type II diabetes, HTN, and
hyperlipidemia who presented to OSH with intermittent chest pain
and shortness of breath for several weeks, worse in past 3 days.
 The chest pain was substernal/epigastric, and would last for
2-3 hours.  The patient saw her PCP and was started on Prevpak
and an US showed gallstones.  However, three days before
admission to [**Hospital3 **], around [**2187-8-15**], the patient's chest
pain began to worsen.  The chest pain was assoicated with
palpitations, diaphoresis, dizziness, and shortness of breath.
She went to the [**Hospital3 **] ED and on admission, vital signs
were as follows:  HR 98, BP:  146/68 RR:  18, O2sat:  97% on 2L.
 Exam showed lungs CTAB and no lower extremity edema.  EKG
showed LBBB but no ST segment changes.  Cardiac enzymes were
cycled and found to be negative.  The patient's symptoms were
attributed GI sources and she was started on Protonix 40mg PO
BID and Maalox.
.
On [**2187-8-19**], the patient's chest pain worsened and was accompanied
by palpitations, nausea, diaphoresis, and shortness of breath.
Vital signs were as follows:  HR :  100-130, BP:  150/70, RR:
20-35, and O2sat:  82-89% on 2-3L.  Exam was notable for a JVP
of 8-10cm, crackles on respiratory exam, and trace lower
extremity edema.  The patient's EKG was unchanged but cardiac
enzymes became positive (CK-74 on admission 198 on [**8-20**], Trop I
going from 0.01 on admission to 1.03 on [**8-20**], and BNP of 922.)
CXR showed bilateral infiltrates.  The patient was placed on
non-rebreath O2 with sats in the 80%, given a total of 120mg IV
Lasix with 1L urine output, ASA, beta blocker, heparin drip,
plavix 600mg PO, nitro, and prn morphine.  She was transfered to
the [**Hospital1 **] for futher management.

MEDICAL HISTORY: 1) PVD s/p cath
2) HTN
3) DMII-HgAlc 6.1% on [**2187-8-20**] at OSH
4) hypercholesterolemia
5) Rheumatic Fever
6) hypothyroidism
7) peptic ulcer disease
8) Recent Urinary Tract Infection-On admission to OSH, patient
moderate leukocyte esterase and 30-40 WBC.  Treated with
bactrim.
9) s/p thyroidectomy
10) s/p hysterectomy
11) s/p R mastectomy [**3-16**] breast ca
[**92**]) Chronic renal insufficency-Baseline Cr of 2.0.  At OSH, Cr
trended upwards from 2.0 on admission to 2.6 at discharge.

MEDICATION ON ADMISSION: HOME MEDS:
prevpac
metformin 500mg po bid
levothyroxine 150mcg daily
nifedical 60mg daily
lisinopril 40mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:  Temp  97.8     HR 108  BP 136/108  RR 28  94% on 14L face
mask  Wt:  69.4kg
Gen: Awake, alert. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 10-11cm.
CV: Regular rate.  Prominent S2.  II/VI systolic murmur loudest
at left sternal border.
Chest: Right mastectomy.   Bilateral crackles.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No lower extermity edema.  Warm and well perfused.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Ms. [**Known lastname **] is a widow who lives alone.  She denies current
tobacco, alcohol, or drug use.  In the past, she smoked and has
a thirty pack year history.
Subendocardial infarction, initial episode of care,Diastolic heart failure, unspecified,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Effusion of joint, forearm,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Subendo infarct, initial,Diastolc hrt failure NOS,Acute kidney failure NOS,Chronic kidney dis NOS,Urin tract infection NOS,Hy kid NOS w cr kid I-IV,Joint effusion-forearm,Anemia NOS,DMII wo cmp nt st uncntr
Admission Date:  [**2187-8-20**]              Discharge Date:   [**2187-9-3**]

Date of Birth:  [**2105-9-13**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
chest pain and shortness of breath

Major Surgical or Invasive Procedure:
Right external jugular line placement
PICC line placement

History of Present Illness:
81 year old female with type II diabetes, HTN, and
hyperlipidemia who presented to OSH with intermittent chest pain
and shortness of breath for several weeks, worse in past 3 days.
 The chest pain was substernal/epigastric, and would last for
2-3 hours.  The patient saw her PCP and was started on Prevpak
and an US showed gallstones.  However, three days before
admission to [**Hospital3 **], around [**2187-8-15**], the patient's chest
pain began to worsen.  The chest pain was assoicated with
palpitations, diaphoresis, dizziness, and shortness of breath.
She went to the [**Hospital3 **] ED and on admission, vital signs
were as follows:  HR 98, BP:  146/68 RR:  18, O2sat:  97% on 2L.
 Exam showed lungs CTAB and no lower extremity edema.  EKG
showed LBBB but no ST segment changes.  Cardiac enzymes were
cycled and found to be negative.  The patient's symptoms were
attributed GI sources and she was started on Protonix 40mg PO
BID and Maalox.
.
On [**2187-8-19**], the patient's chest pain worsened and was accompanied
by palpitations, nausea, diaphoresis, and shortness of breath.
Vital signs were as follows:  HR :  100-130, BP:  150/70, RR:
20-35, and O2sat:  82-89% on 2-3L.  Exam was notable for a JVP
of 8-10cm, crackles on respiratory exam, and trace lower
extremity edema.  The patient's EKG was unchanged but cardiac
enzymes became positive (CK-74 on admission 198 on [**8-20**], Trop I
going from 0.01 on admission to 1.03 on [**8-20**], and BNP of 922.)
CXR showed bilateral infiltrates.  The patient was placed on
non-rebreath O2 with sats in the 80%, given a total of 120mg IV
Lasix with 1L urine output, ASA, beta blocker, heparin drip,
plavix 600mg PO, nitro, and prn morphine.  She was transfered to
the [**Hospital1 **] for futher management.

 .
On review of symptoms, denies any prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. Denies
recent fevers, chills or rigors.  All of the other review of
systems were negative.
.
*** Cardiac review of systems is notable for presence of chest,
fatigue on exertion, orthopnea, absence of PND, palpitations,
syncope or presyncope.


Past Medical History:
1) PVD s/p cath
2) HTN
3) DMII-HgAlc 6.1% on [**2187-8-20**] at OSH
4) hypercholesterolemia
5) Rheumatic Fever
6) hypothyroidism
7) peptic ulcer disease
8) Recent Urinary Tract Infection-On admission to OSH, patient
moderate leukocyte esterase and 30-40 WBC.  Treated with
bactrim.
9) s/p thyroidectomy
10) s/p hysterectomy
11) s/p R mastectomy [**3-16**] breast ca
[**92**]) Chronic renal insufficency-Baseline Cr of 2.0.  At OSH, Cr
trended upwards from 2.0 on admission to 2.6 at discharge.

Social History:
Ms. [**Known lastname **] is a widow who lives alone.  She denies current
tobacco, alcohol, or drug use.  In the past, she smoked and has
a thirty pack year history.

Family History:
Non-contributory

Physical Exam:
VS:  Temp  97.8     HR 108  BP 136/108  RR 28  94% on 14L face
mask  Wt:  69.4kg
Gen: Awake, alert. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 10-11cm.
CV: Regular rate.  Prominent S2.  II/VI systolic murmur loudest
at left sternal border.
Chest: Right mastectomy.   Bilateral crackles.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No lower extermity edema.  Warm and well perfused.

Pulses:
Right: Carotid 2+ without bruit;   2+ DP
Left: Carotid 2+ without bruit;   2+ DP

Pertinent Results:
EKG at OSH:  NSR, LBBB
.
CXR [**2187-8-20**]:  Bilateral infiltrates and blunting of the left
costophrenic angle read as more suggestive of an infectious
process.
.
CXR [**2187-8-23**]:  Improving pulmonary edema.  PICC line in place.

.
2D-ECHOCARDIOGRAM performed on [**2187-8-20**]:  Symmetric LVH with nml
LV cavity size and LVEF>55%.  [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] size.  RA nml size.  RV nml
size with free wall paradoxic septal motion consistent with
conduction abnormality.  No AS, AR, trivial MR, trivial TR.
.
Renal US [**2187-8-23**]:  No masses, stones, or hydropnephrosis.  There
is a 5mm echogenic focus in the mid pole of the left kidney
cortex that may represent an angiomyolipoma.
.
[**2187-8-20**]  WBC-10.7 RBC-3.72* Hgb-10.3* Hct-29.6* MCV-80*
MCH-27.8 MCHC-35.0 RDW-14.6 Plt Ct-468*  Neuts-78.2*
Lymphs-15.3* Monos-6.1 Eos-0.3 Baso-0.1
[**2187-8-24**] WBC-8.9 RBC-3.56* Hgb-9.8* Hct-29.2* MCV-82 MCH-27.4
MCHC-33.4 RDW-14.5 Plt Ct-493
.
[**2187-8-20**] PT-13.5* PTT-101.6* INR(PT)-1.2*
[**2187-8-24**] PT-12.6 PTT-53.3* INR(PT)-1.1
.
[**2187-8-20**]  Glucose-203* UreaN-36* Creat-3.0* Na-132* K-4.4 Cl-96
HCO3-21*
Calcium-8.7 Phos-4.6* Mg-2.6
[**2187-8-21**] UreaN-43* Creat-3.3*
[**2187-8-22**] UreaN-53* Creat-3.6*
[**2187-8-23**] UreaN-79* Creat-4.5*
[**2187-8-24**] UreaN-90* Creat-4.8*
.
[**2187-8-20**] 05:28PM BLOOD ALT-11 AST-21
.
[**2187-8-20**] 05:28PM CK(CPK)-231*  CK-MB-8 cTropnT-0.19*
proBNP-[**Numeric Identifier 98206**]*
[**2187-8-21**] 05:00AM  CK(CPK)-346* CK-MB-6 cTropnT-0.26*
[**2187-8-21**] 02:07PM  CK(CPK)-361* CK-MB-5 cTropnT-0.25*
[**2187-8-21**] 10:21PM  CK(CPK)-337* CK-MB-5
.
[**2187-8-21**]  calTIBC-196* VitB12-211* Folate-17.9 Ferritn-241*
TRF-151*
[**2187-8-20**]  %HbA1c-6.3*
[**2187-8-21**]  Triglyc-143 HDL-46 CHOL/HD-4.0 LDLcalc-109
[**2187-8-20**]  TSH-0.68
.
[**2187-8-20**] Urine cx-no growth
[**2187-8-22**] Urine cx-no growth
.
[**2187-8-20**] BNP:  [**Numeric Identifier 98206**]
7/13/07BNP: [**Numeric Identifier 98207**]

After transfer to medicine:

  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2187-9-3**] 07:00AM    10.3 3.29* 9.0* 27.8* 85 27.5 32.5 15.8*
738

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na   K Cl HCO3 AnGap
[**2187-9-3**] 07:00AM  84      21* 1.3* 141 4.8 106 24 16

[**2187-8-31**]  WBC-12.2* RBC-3.34* Hgb-9.0* Hct-27.8* MCV-83
                       MCHC-32.6 RDW-15.3 Plt Ct-667*
[**2187-8-24**]  Glucose-104 UreaN-90* Creat-4.8* Na-130* K-4.2 Cl-89*
          HCO3-27   AnGap-18
[**2187-8-27**]  Glucose-96 UreaN-92* Creat-3.4* Na-137 K-4.4 Cl-99
          HCO3-28 AnGap-14
[**2187-8-30**]  Glucose-185* UreaN-57* Creat-2.1* Na-135 K-4.3 Cl-101
           HCO3-25 AnGap-13
[**2187-8-31**]  Calcium-8.6 Phos-3.3 Mg-2.4
[**2187-8-26**]  Calcium-9.3 Phos-5.0*# Mg-3.3*
[**2187-8-21**]  calTIBC-196* VitB12-211* Folate-17.9 Ferritn-241*
TRF-151*

Studies:
Right wrist film:
Three radiographs of the right wrist demonstrate normal
mineralization. There is marked irregular joint space narrowing
with associated periarticular erosion involving the first CMC
joint. Chondrocalcinosis is seen to involve the proximal and
middle carpal compartments. Chondrocalcinosis likely involves
the second, third, fourth, and fifth MCP joints. Ulnar styloid
is normal. Mild joint space narrowing and marginal osteophyte
formation involves the interphalangeal joint of the thumb. The
interphalangeal joints of the second through fifth digits are
excluded on these wrist radiographs. No discrete fracture. There
is likely mild subchondral cyst formation involving the lunate,
capitate, and triquetral bones
.
[**2187-8-29**]  Stress mibi:
IMPRESSION: Anginal type symptoms with an uninterpretable EKG
for
ischemia.
Nuclear report:
Septal hypokinesis, likely related to the patient's known LBBB.
2. Normal myocardial perfusion of the left ventricle. 3. EF 55%.
.
[**2187-8-30**]:
CT abd/pelvis
No evidence of retroperitoneal hematoma. No specific CT finding
to explain episode of hypotension and hematocrit drop.
2. Cholelithiasis, without evidence of cholecystitis.
3. Small hiatal hernia.
4. Likely left breast fibroadenoma. Status post right
mastectomy.

Microbiology:
[**2187-8-30**]
: URINE CULTURE (Preliminary):
      YEAST.    >100,000 ORGANISMS/ML..
      ENTEROCOCCUS SP..    >100,000 ORGANISMS/ML.
AMPICILLIN------------   <=2 S
NITROFURANTOIN--------  <=16 S
TETRACYCLINE----------  =>16 R
VANCOMYCIN------------   <=1 S
.

[**2187-9-1**] 4:54 am URINE      Source: CVS.

                            **FINAL REPORT [**2187-9-2**]**

   URINE CULTURE (Final [**2187-9-2**]):
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
      AND/OR GENITAL CONTAMINATION.

[**2187-8-30**] 12:10 pm BLOOD CULTURE      Source: Line-PICC.

   AEROBIC BOTTLE (Pending):

   ANAEROBIC BOTTLE (Pending):
.
[**2187-8-28**] 5:35 pm BLOOD CULTURE

   AEROBIC BOTTLE (Pending):

   ANAEROBIC BOTTLE (Pending):
No growth at the time of discharge.


Brief Hospital Course:
81 year old female with history of type II diabetes, HTN, and
hyperlipidemia who was transferred from an OSH with chest pain,
shortness of breath found to have non ST elevation MI and
infiltrates on CXR.

#NSTEMI:  CK peaked at 361 on [**8-21**] and trended down.  CK-MB
peaked on [**2187-8-20**] and was 8 and has since trended downward.
Patient has left bundle branch block at baseline making EKG
interpretation difficult for ST changes difficult.  An Echo was
done, but without focal wall motion abnormality and with a
preserved ejection fraction.  The patient was continued on
aspirin 325mg, plavix 75mg, heparin drip, nitro drip, morphine,
metoprolol, and atrovastatin 80mg.  Catheterization was delayed
due to the patient's worsening renal function and her inability
to lay flat eventually cardiology decided to perform a Stress
mibi.
.
The stress mibi showed Anginal type symptoms with an
uninterpretable EKG for ischemia and Septal hypokinesis, likely
related to the patient's known LBBB. Normal myocardial perfusion
of the left ventricle. 3. EF 55%. She will be followed up by Dr
[**Last Name (STitle) 171**] from cardiology as an outpatient.  Cardiology have
decided to postpone a cardiac catherterization for now.  Given
the poor study determined by inadequate maximal heart rate,
cardiology has advised that another stress test should be
repeated in [**3-17**] weeks.
.
#CHF:  The patient was found to have diastolic CHF.  On
admission, she presented in respiratory distress with bilateral
infiltrates on chest x-ray and a BPN in the 16,000's.  ECHO
showed a left ventricular ejection fraction of greater than 55%
and left ventricular hypertrophy.  She was on lasix drip which
was transitioned over to IV lasix. She was weaned off oxygen to
room air. Her metoprolol dose was optimized.  A most recent BNP
was  4309 on [**2187-8-30**].

#A-fib: She had single documented evidence of AFib while in the
CCU. An extensive appraisal of her past medical record which
involved calling her PCP's office and looking through OSH
records did not reveal any history of Afib.  The decision was
made by cardiology to anticoagulate her, however it should be
noted that she has had no other episode of Afib.  In the future
her cardiologist can decide if she needs to remain
anticoagulated.  Of note patient had short runs of SVT
presumably MAT,while on the medicine floor with up to three
differing p-waves.
 .
#Acute on chronic renal failure:  The patient has a baseline Cr
of 2.0.  On admission, the patient's Cr was 2.6 and gradually
rose to 4.8 while on diuresis. Subsequently, her lasix was held
and her creatinine came down to 1.3 on discharge. Her Lisinopril
was also held during the hospitalization.
.
#UTI: She was intially covered by Levofloxacin which she
responded to. She developed another UTI which showed
enterococcus and was placed on ampcillin for 7 day course.

.
#HCt drop: On [**8-29**]: Pt was found to have a drop in her
hematocrit from 27 to 25 after some fluid repletion and then to
22 following 500 cc of fluid.  Pt was transfused with 1 unit
PRBC, a CT of abdomen was negative for retroperitoneal bleed,
she was guiac negative.  Her hct was stable at a hematocrit of
27.8 on discharge.
.
#Hypotension: On [**8-30**], Ms. [**Known lastname **] had a hypotensive episode with
systolic BP in the 80's, she was asymptomatic during this
period.  On that same day, she had a low grade temp af a 100.1,
Blood cultures were collected and sent from the peripheral and
from her PICC line and sent, cultures are still pending with no
growth.  She received 500 cc of fluid and her blood pressure
subsequently was stable in the 100's.
.
#Metal Status Changes:  Ms. [**Known lastname **] became increasingly frightened
and paranoid at night while in the  Cardiac care unit.  She was
seen by psych on [**2187-8-23**] and started on Olanzapine 2.5mg [**Hospital1 **]
with improvement.  She had no more episodes of paranoia and
Olanzapine was discontinued.

.
#Diabetes Type II-During this hospitalization, the patient's
HbAlc was found to be 6.3%.  She was managed on sliding scale
insulin and was switched back to her metformin 500 [**Hospital1 **] on
discharge.
.
#Hypothyroidism-The patient is status post thyroidectomy.  Her
TSH was found to be normal at 0.68.  Ms. [**Known lastname **] continued on her
home dose of 150mcg levothyroxine PO Daily.
.
#Right wrist pseudogout: On [**2187-8-25**], she c/o of pain in her
right wrist and fore arm and had some swelling, xrays were taken
that showed no acute fracture. A rheumatology consult was
obtained, a fluid aspiration was done and pseudogout was
diagnosed.  She no longer has any signs of wrist pain.

On discharge patient was afebrile with stable vital signs.
.

Code:  Full code with her son [**Name (NI) 32342**] as her health care proxy




Medications on Admission:
HOME MEDS:
prevpac
metformin 500mg po bid
levothyroxine 150mcg daily
nifedical 60mg daily
lisinopril 40mg daily

Discharge Medications:
1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous once a day for 3 days.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1)  Injection
QMOWEFR (Monday -Wednesday-Friday).
7. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for Wrist pain.
9. Atorvastatin 80 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
12. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q4H (every 4 hours) as needed.
14. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-13**] Sprays Nasal
QID (4 times a day) as needed.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
17. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 701**] VNA

Discharge Diagnosis:
NSTEMI
Pulmonary Edema
Acute renal failure
Anemia
Urinary Tract Infection

Secondary
Hypertension
Diabetes Mellitus


Discharge Condition:
Good


Discharge Instructions:
You were admitted for a small heart attack and fluid in your
lungs
You also suffered from acute renal failure while in the
hospital, your kidney function improved during your stay has
returned back to baseline. You received 1 unit of Packed red
blood cells for a low blood count.  Your blood count has
remained stable since the transfusion.
.
You will be followed by a cardiologist who will continue to
monitor your heart.
.
Please take all your medications as prescribed and follow up
with all your appointments.
.
If you experience any chest pain, shortness of breath not
improved by nebulizer and inhaler, fevers, sweats, a worsening
headache, leg swelling or any other symptoms that concern you,
please call your PCP or go to the emergency room.

Followup Instructions:
You have an appointment with a cardiologist who saw you in the
hospital, Dr [**Last Name (STitle) 98208**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD
Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2187-9-17**] 8:40

 Please make an appointment to see your PCP in the next 1 week.


                             [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]

Completed by:[**2187-9-4**]
{'Subendocardial infarction, initial episode of care,Diastolic heart failure, unspecified,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Effusion of joint, forearm,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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 and shortness of breath

PRESENT ILLNESS: 81 year old female with type II diabetes, HTN, and
hyperlipidemia who presented to OSH with intermittent chest pain
and shortness of breath for several weeks, worse in past 3 days.
 The chest pain was substernal/epigastric, and would last for
2-3 hours.  The patient saw her PCP and was started on Prevpak
and an US showed gallstones.  However, three days before
admission to [**Hospital3 **], around [**2187-8-15**], the patient's chest
pain began to worsen.  The chest pain was assoicated with
palpitations, diaphoresis, dizziness, and shortness of breath.
She went to the [**Hospital3 **] ED and on admission, vital signs
were as follows:  HR 98, BP:  146/68 RR:  18, O2sat:  97% on 2L.
 Exam showed lungs CTAB and no lower extremity edema.  EKG
showed LBBB but no ST segment changes.  Cardiac enzymes were
cycled and found to be negative.  The patient's symptoms were
attributed GI sources and she was started on Protonix 40mg PO
BID and Maalox.
.
On [**2187-8-19**], the patient's chest pain worsened and was accompanied
by palpitations, nausea, diaphoresis, and shortness of breath.
Vital signs were as follows:  HR :  100-130, BP:  150/70, RR:
20-35, and O2sat:  82-89% on 2-3L.  Exam was notable for a JVP
of 8-10cm, crackles on respiratory exam, and trace lower
extremity edema.  The patient's EKG was unchanged but cardiac
enzymes became positive (CK-74 on admission 198 on [**8-20**], Trop I
going from 0.01 on admission to 1.03 on [**8-20**], and BNP of 922.)
CXR showed bilateral infiltrates.  The patient was placed on
non-rebreath O2 with sats in the 80%, given a total of 120mg IV
Lasix with 1L urine output, ASA, beta blocker, heparin drip,
plavix 600mg PO, nitro, and prn morphine.  She was transfered to
the [**Hospital1 **] for futher management.

MEDICAL HISTORY: 1) PVD s/p cath
2) HTN
3) DMII-HgAlc 6.1% on [**2187-8-20**] at OSH
4) hypercholesterolemia
5) Rheumatic Fever
6) hypothyroidism
7) peptic ulcer disease
8) Recent Urinary Tract Infection-On admission to OSH, patient
moderate leukocyte esterase and 30-40 WBC.  Treated with
bactrim.
9) s/p thyroidectomy
10) s/p hysterectomy
11) s/p R mastectomy [**3-16**] breast ca
[**92**]) Chronic renal insufficency-Baseline Cr of 2.0.  At OSH, Cr
trended upwards from 2.0 on admission to 2.6 at discharge.

MEDICATION ON ADMISSION: HOME MEDS:
prevpac
metformin 500mg po bid
levothyroxine 150mcg daily
nifedical 60mg daily
lisinopril 40mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:  Temp  97.8     HR 108  BP 136/108  RR 28  94% on 14L face
mask  Wt:  69.4kg
Gen: Awake, alert. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 10-11cm.
CV: Regular rate.  Prominent S2.  II/VI systolic murmur loudest
at left sternal border.
Chest: Right mastectomy.   Bilateral crackles.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No lower extermity edema.  Warm and well perfused.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Ms. [**Known lastname **] is a widow who lives alone.  She denies current
tobacco, alcohol, or drug use.  In the past, she smoked and has
a thirty pack year history. 

### Response:
{'Subendocardial infarction, initial episode of care,Diastolic heart failure, unspecified,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Effusion of joint, forearm,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
