CHIEF COMPLAINT: SOB, increasing lower extremity edema

PRESENT ILLNESS: 70 year old female with h/o RA previously on humera and mtx who
was discharged on [**2189-4-11**] when she presented with R shoulder
pain. Her joint was tapped and it demonstrated an inflammatory
joint fluid c/w with RA and negative for septic arthritis.  She
was discharged on ibuprofen prn. Upon return home 3 days prior
to presentation she felt very well but one day later noticed the
gradual onset of dyspnea on exertion.  She also had episodes of
chest twinges overnight which resolved within minutes.  + lower
extremity edema. While in the hospital she was ambulatory.  She
went to [**Country 4754**] over [**Holiday **] and returned on [**2-20**].  She
has not had any long trips or travel rides since then.  At home
she climbed 13 steps twice a day to get to her bedroom. She last
had a mammogram one year ago and it was normal. Her last
colonoscopy was in [**2187-4-12**] and it was normal. + difficulty
swallowing solids which began a few weeks ago.
She saw her rheumatologist Dr. [**Last Name (STitle) 1839**] today who referred her to
the emergency room.
.

MEDICAL HISTORY: RA on adalimumab and MTX
HTN
Hyperlipidemia
s/p left bunionectomy/1st MT osteotomy
Atrophic vaginitis on premarin
R eye scleritis

MEDICATION ON ADMISSION: Confirmed medications with patient.
Amlodipine 5 mg Tablet 1 Tablet(s) by mouth once a day
Esomeprazole Magnesium [Nexium]  40 mg Capsule, Delayed
Release(E.C.)
1 Capsule(s) by mouth once a day
Folic Acid 1 mg Tablet 1 Tablet(s) by mouth once a day
(Prescribed by Other Provider)  [**2189-1-12**]
Ibuprofen 800 mg Tablet 1 Tablet(s) by mouth three times a day
PRN
Lisinopril 40 mg Tablet 1 Tablet(s) by mouth once a day
Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
1 Tablet(s) by mouth once a day
Pravastatin [Pravachol] 20 mg Tablet 1 Tablet(s) by mouth at
bedtime  [**2189-1-13**]
    * OTCs *
Aspirin 81 mg Tablet, Chewable 1 Tablet(s) by mouth once a day
Calcium Citrate-Vitamin D3 [Citracal + D] - 2 T [**Hospital1 **].

ALLERGIES: Penicillins / Shellfish Derived / Simvastatin

PHYSICAL EXAM: Vitals: T99.2  125/80  93  18  93%RA
Pain: denies
Access: TLC R IJ site c/d/i
Gen: nad, obese female, sitting up in chair
HEENT: mmm
CV: RRR, no m appreciated, no S3, S4
Resp: CTAB, slight bibasilar crackles, no wheezing
Abd; soft, very obese, no tenderness, no ecchymosis,  +BS
Ext; +anasarca, 2+ LLE edema, 1+ RLE edema, 1+ RUE edema
Neuro: A&OX3, grossly nonfocal
Skin: no changes
psych: pleasant

FAMILY HISTORY: Mother had diverticulosis. Father had lung disease. Sister had
DM. No family h/o malignancy. First cousin with cancer of
unknown type.

SOCIAL HISTORY: Originally from [**Country 4754**]. Lives in [**Location 3307**] with her husband.
Social ETOH. No tobacco. She works as [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4761**]
housecleaner 3x per week. No falls. Her huband drives otherwise
she is indpendent of IADLS and ADLS. She has a son who lives in
[**Name (NI) 108**]. She walks without a walker or cane. + Glasses. No
dentures or hearing aides. No recent falls. 1 glass/2 < once per
month. 1 pk per week tobacco but quit "many years ago."
Other pulmonary embolism and infarction,Hemoperitoneum (nontraumatic),Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Primary hypercoagulable state,Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Injury to bladder and urethra, without mention of open wound into cavity,Acute diastolic heart failure,Rheumatoid arthritis,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Nontraumatic hematoma of soft tissue,Iron deficiency anemia, unspecified,Unspecified accident
Pulm embol/infarct NEC,Hemoperitoneum,Ac DVT/emb prox low ext,Prim hypercoagulable st,Ac posthemorrhag anemia,Acute kidney failure NOS,Bladder/urethra inj-clos,Ac diastolic hrt failure,Rheumatoid arthritis,Hypertension NOS,Hyperlipidemia NEC/NOS,Nontrauma hema soft tiss,Iron defic anemia NOS,Accident NOS
Admission Date:  [**2189-4-13**]              Discharge Date:   [**2189-4-27**]

Date of Birth:  [**2119-2-12**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Shellfish Derived / Simvastatin

Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
SOB, increasing lower extremity edema

Major Surgical or Invasive Procedure:
IVC filter placement [**4-17**]
10U prbc transfusion
Midline placement [**2189-4-27**]


History of Present Illness:
70 year old female with h/o RA previously on humera and mtx who
was discharged on [**2189-4-11**] when she presented with R shoulder
pain. Her joint was tapped and it demonstrated an inflammatory
joint fluid c/w with RA and negative for septic arthritis.  She
was discharged on ibuprofen prn. Upon return home 3 days prior
to presentation she felt very well but one day later noticed the
gradual onset of dyspnea on exertion.  She also had episodes of
chest twinges overnight which resolved within minutes.  + lower
extremity edema. While in the hospital she was ambulatory.  She
went to [**Country 4754**] over [**Holiday **] and returned on [**2-20**].  She
has not had any long trips or travel rides since then.  At home
she climbed 13 steps twice a day to get to her bedroom. She last
had a mammogram one year ago and it was normal. Her last
colonoscopy was in [**2187-4-12**] and it was normal. + difficulty
swallowing solids which began a few weeks ago.
She saw her rheumatologist Dr. [**Last Name (STitle) 1839**] today who referred her to
the emergency room.
.


Past Medical History:
RA on adalimumab and MTX
HTN
Hyperlipidemia
s/p left bunionectomy/1st MT osteotomy
Atrophic vaginitis on premarin
R eye scleritis

Social History:
Originally from [**Country 4754**]. Lives in [**Location 3307**] with her husband.
Social ETOH. No tobacco. She works as [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4761**]
housecleaner 3x per week. No falls. Her huband drives otherwise
she is indpendent of IADLS and ADLS. She has a son who lives in
[**Name (NI) 108**]. She walks without a walker or cane. + Glasses. No
dentures or hearing aides. No recent falls. 1 glass/2 < once per
month. 1 pk per week tobacco but quit "many years ago."


Family History:
Mother had diverticulosis. Father had lung disease. Sister had
DM. No family h/o malignancy. First cousin with cancer of
unknown type.

Physical Exam:
Vitals: T99.2  125/80  93  18  93%RA
Pain: denies
Access: TLC R IJ site c/d/i
Gen: nad, obese female, sitting up in chair
HEENT: mmm
CV: RRR, no m appreciated, no S3, S4
Resp: CTAB, slight bibasilar crackles, no wheezing
Abd; soft, very obese, no tenderness, no ecchymosis,  +BS
Ext; +anasarca, 2+ LLE edema, 1+ RLE edema, 1+ RUE edema
Neuro: A&OX3, grossly nonfocal
Skin: no changes
psych: pleasant

Pertinent Results:
wbc 7.3->26.6->9.6
H/H 9.7/27.8 (s/p 1U [**4-21**])
(total 10U prbc, nadir HCT 20, admission HCT 31.2)
INR 1.2
Chem panel: BUN 48->18, Creat 3.2->1.5->0.7 (baseline)
BNP 576
.
UA [**4-16**] 106 wbc, 826 rbc, no bacteria, UCx negative
UA [**4-20**] 32wbc, trace LE, no bacteria, Ucx negative
UA [**4-21**] 4wbc, no LE
blood cx [**4-20**] X2 NTD
.
.
Imaging/results:
.
LENIs [**4-14**]: No evidence of lower extremity DVT.
.
LENIs [**4-21**]: IMPRESSION: Nonocclusive thrombus within the left
common femoral and left superficial femoral vein, new when
compared to prior exam. No evidence of thrombus within the right
lower extremity
.
UE dopplers (R) [**4-22**]: negative
.
CTA [**4-13**]: CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST:
There are bilateral segmental and subsegmental pulmonary emboli
involving the right upper, middle and lower lobe pulmonary
arteries, and the pulmonary arteries supplying the left upper
lobe, lingula and the left lower lobe. No saddle pulmonary
embolus is seen, and no evidence of right heart strain
.
TTE [**4-14**]: The left atrium is elongated. The estimated right
atrial pressure is 0-10mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF 70%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
.
CT abd/pelvis [**4-15**]:
1. Moderate-size left rectus sheath hematoma with
extraperitoneal extension inferiorly along the left piriformis
muscle. Evidence of IV contrast extravasation suggesting active
bleeding. No evidence of retroperitoneal hematoma. If serial
hemacrit continues to drop, the bleeding site may be amenable to
catheter embolization by interventional radiology.
2. Large gallstone without evidence of acute cholecystitis.
.
CT a/p [**4-23**]:

1. Left retroperitoneal hematoma likely arises from the left
psoas muscle and
tracks along the left posterior pararenal fascia. There is no
evidence of
acute extravasation.

2. Left rectus sheath hematoma is similar to [**2189-4-15**].

3. Cholelithiasis without evidence of cholecystitis..
Renal US [**4-16**]:  No right hydronephrosis. Pelvic hematoma.
Otherwise, extremely limited exam, did not visualize L kidney
.
CXR [**4-16**]: no pulm edema
.
CXR [**4-20**]:  In comparison with the study of [**4-16**], the patient has
been a very lordotic position which most likely accounts for the
increasing prominence of the transverse diameter of the heart.
No evidence of vascular congestion or pleural effusion. Right IJ
catheter tip extends to the lower portion of the SVC, and there
is no evidence of pneumothorax.
.
CT Head [**4-26**] (prelim): No ICH or mass.

Brief Hospital Course:
70year old female with h/o RA, HTN, obesity, recent d/c [**4-10**]
after acute RA flare,  presented [**4-13**] with DOE/LE edema, found to
have bilateral/multifocal PE. LENIs were negative and TTE was
unremarkable for evidence of cardiac strain. She was started on
a heparin drip on admission but subsequently developed a rectus
sheath hematoma on [**4-15**]. Given the large clot burden, she was
hemodynamically stable, and the thought that the hematoma was
likely to tamponade itself off, heparin was not initially
stopped, although the target PTT was changed to the lower end of
therapeutic (althought PTTs remained elevated up to 90s). She
eventually developed worsening bleeding (extended
retroperitoneum) with tachycardia and hypotension and dropping
HCT (nadir 20), and was tranferred to ICU.  She ended up
requiring 9U prbc for the acute bleed (10U total during hospital
course). Heparin was stopped and pt underwent IVC filter
placement on [**4-17**] by IR without complications. Her HCT stabilized
and she was transferred out of ICU on [**4-18**]. She remained stable
in terms of her HCT. However, developed asymmetrical L>R
swelling and had a fever on [**4-20**]. LE dopplers checked which
showed NEW L prox DVT. Heme was consulted to help with decision
on safety of resuming anticoagulation given significant clot
burder and ongoing hypercoag that may not be protected by IVC
filter alone. CT scan was repeated on [**4-23**] which showed large L
retroperitoneal bleed (resulting in above HCT drop), but no
active bleeding.  She was given an additional 1U prbc (10 total)
for HCT 23.6 though it was not believed she had ongoing
bleeding. After discussion with patient/husband regarding
risks/benefit of anticoagulation, decision was made to resume
heparin. As for her PEs, she remained hemodynamically stable and
was weaned off of O2. For her LE edema and risk of posthrombotic
complications, she was placed on TEDs and reccommeded to keep
her legs elevated. As for the cause of her hypercoagubility, No
clear precipitant: no self-reported history of immobility (last
flight [**2-20**]), no history of malignancy (up to date with
[**Last Name (un) 3907**]/pap/cscope), no personal or family history of blood clots,
no recent surgery. Only possible trigger identified was her
recent RA flare, but this was no longer an issue so did not
explain her ongoing hypercoaguable state (LLE DVT formed
in-hosp). Another concern was her longstanding use of humira,
which can be associated with secondary malignancy. Her CT c/a/p
did not mention any abnormal masses or LAD to suggest lymphoma,
and as per above she is up to date on cancer screening. She
needs outpt further w/u for malignancy and hyper coag w/u.
Hospital course also complicated by ARF, thought to be prerenal,
s/p IVFs and blood tranfusions, now back to baseline.
Her Fe studies were c/w low Fe stores, however she likely got
enough Fe load with the blood transfusions and this can be
rechecked as outpt. Her B12 was low normal and she was started
on supplementation.
Her humira and MTx were held in the acute setting but were
resumed once pt stabilized.
Her BP meds were kept the same except norvasc was not resumed
due to well controlled BP off this.
.
.
See note below for details.

# Bilateral PEs/VTE: significant clot burden on CTA but Echo w/o
RV strain. LE doppler/CT a/p w/o thrombus on [**4-14**]. As above,
taken off heparin given significant rectus sheath/RP hematoma.
underwent IVC filter [**4-17**]. Repeat dopplers [**4-20**] (feverw w/u) with
L fem DVT suggesting she continues to be hypercoaguable which is
concerning. Heme consulted to assess whether appropriate to
resume heparin. HCT stable and CT [**4-23**] with subacute hematoma
(known bleed) but no active bleeding.  Weaned off O2. Heme felt
risk outweighed benefit, and pt was agreeable to resuming
heparin gtt on [**4-24**]. She was monitored over 2 days and coumadin
was started the evening of [**4-26**]. She will need to be bridged
with heparin gtt (titrate to PTT 60-80) until therapeutic on
coumadin. Discharged on heparin gtt at 1700 U/hr. Should have
twice daily PTTs given recent massive bleed. Given no clear
precipitant of VTE episode (except perhaps prior RA flare) and
clot formation while here in her left leg, she will need an
outpatient hypercoaguable work up. She also should wear TEDs for
at least 6 months to prevent post-DVT complications. Likely will
need lifelong anticoagulation. Phone number for outpatient
hematology follow up in 6 months was given in the discharge
paperwork.
.
.
# Rectus sheath and RP hematoma: spontaneous bleed while on
heparin gtt (highest PTT 97). No recent injury, trauma, or
surgery in that site. Hemodynamic unstable bleed (transferred to
ICU), heparin gtt stopped, required 9U prbc at the time.  No IR
intervention, appears to have tamponaded finally. Last t/f [**4-21**]
for slowly drifting HCT. Has been stable.  Repeat CT ab/pelvis
on  [**4-23**] as above showing new RP bleed as of [**4-14**], which
represents the 10U bleed [**4-16**] (subacute) rather than active
bleed. Heparin gtt was restarted on [**4-23**] with close monitoring.
Pt will need close monitoring of her PTT/INR while titrating in
coumadin (twice daily PTT, daily INR). Will not resume ASA or
NSAIDs on discharge. Would transfuse for hct less than 23 and
repeat CT scan abdomen/pelvis to eval for new bleed if hct drops
to less than 22. Hct was 28 at discharge.
.

# Fever: temp spike [**4-20**]. UA/CXR unremarkable. Blood cx X2
negative (TLC and peripheral). no leukocytosis. Did have some
loose stools, but C diff negative.  Another concern was for DVT
and LE dopplers confirm L prox DVT which may be cause. Low grade
temp of 100.1 on [**4-26**].  Again, no clear source other than blood
clots. Afebrile completely on night prior to and day of
discharge.
.
# Anasarca: likely [**3-16**] large IVFs and blood in ICU. CXR w/o pulm
edema though does have significant anasarca (especially L>R LE,
R>L UE edema).  Albumin low at 2.5. Started nutrition
supplements.
.
# ARF: normal creat at baseline. Developed ARF in ICU, peak
creat 3.2, BUN 50s. ddx: prerenal vs hematoma resorption vs CIN
vs ATN from hypotension. Received fluids/blood, improved to
baseline of 0.6-0.7 at discharge.
.
# Nausea:  CT head negative for mass, LFTs/lipase normal.
Written for zofran as needed. Vomiting/nausea noted after pt
received her MTX on [**4-24**], which is felt to  be the likely
etiology of her symptoms.
.
#Acute diastolic CHF: Noted wheezing and elevated JVP on [**4-24**],
s/p 10 U PRBC in the days prior. She was given Lasix 10 mg IV
daily on [**4-20**] with resolution of wheezing and good urine
output.
.
# HTN: Resumed home dose of lisinopril 40, toprol 50, BP well
controlled. not resuming amlodipine
.
# RA: Humira and MTX held since last admission ([**4-7**]) given
concern at that time for septic shoulder joints (negative fluid
cx). Were not resumed on last discharge with plan for f/u rheum
for resuming. Rheum/Dr. [**Last Name (STitle) 1839**] does not feel there is any
contraindication as of [**4-15**], so humira and MTX were resumed on
[**4-24**] (MTX received [**4-24**], humira received [**4-25**]).
.
# Anemia, acute and chronic: see above for acute drop 2/2
hematoma. Also has h/o Fe def and B12 def (93 in [**3-23**]). Received
good Fe load with transfusion for now, f/u Fe studies in 2
months. Continued B12 supplements. Hct stable at 28 at time of
discharge.
.
# Hyperlipidemia: Continued pravastatin 20, holding asa 81
.
# NAC study: ED protocol. infusion finished [**4-15**]
.
# Access: Midline placed [**2189-4-26**]

Medications on Admission:
Confirmed medications with patient.
Amlodipine 5 mg Tablet 1 Tablet(s) by mouth once a day
Esomeprazole Magnesium [Nexium]  40 mg Capsule, Delayed
Release(E.C.)
1 Capsule(s) by mouth once a day
Folic Acid 1 mg Tablet 1 Tablet(s) by mouth once a day
(Prescribed by Other Provider)  [**2189-1-12**]
Ibuprofen 800 mg Tablet 1 Tablet(s) by mouth three times a day
PRN
Lisinopril 40 mg Tablet 1 Tablet(s) by mouth once a day
Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
1 Tablet(s) by mouth once a day
Pravastatin [Pravachol] 20 mg Tablet 1 Tablet(s) by mouth at
bedtime  [**2189-1-13**]
    * OTCs *
Aspirin 81 mg Tablet, Chewable 1 Tablet(s) by mouth once a day
Calcium Citrate-Vitamin D3 [Citracal + D] - 2 T [**Hospital1 **].





Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet
PO twice a day.
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO
once a day.
9. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Methotrexate Sodium 2.5 mg Tablet Sig: Eight (8) Tablet PO
QFRI (FR).
11. Heparin Flush (10 units/ml) 1 mL IV PRN
12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as
needed.
13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
15. Humira 40 mg/0.8 mL Kit Sig: 0.8 ML Subcutaneous every 2
weeks ().
16. Warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
17. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 1700 (1700) units Intravenous per hour: titrate to
PTT of 60-80.
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
19. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

Discharge Diagnosis:
Bilateral pulmonary embolism
Severe rectus sheath and retroperitoneal hematoma s/p 10U prbc
Hypercoag state of unclear etiology
Rheumatoid arthritis
Anemia [**3-16**] chronic disease, Fe def, and acute blood loss


Discharge Condition:
STABLE


Discharge Instructions:
You were admitted with leg swelling and shortness of breath. You
were diagnosed with multiple pulmonary embolisms.
.
You were started on heparin for anticoagulation but developed a
complication of massive bleeding into your muscle and within the
abdomen for which you recieved 10 Units of blood. Your heparin
was held for several days and you underwent IVC filter for
protection from further pulmonary embolism. You developed
another Left Leg clot while here. Hematology was consulted and
after careful consideration and discussions with you, decision
was made to restart heparin.
.
You need to have your blood counts carefully monitored. You will
be followed by Hematology after discharge for further workup of
why you developed these clots.
You are started on some new medications. From your previous
list, you will not restart norvasc. You also were started on
coumadin to help thin your blood. Also your RA meds, humira and
methotrexate were held for the most part, but were restarted
prior to discharge.
.
Call your doctor or return to the ER for any worsening shortness
of breath, new leg or arm swelling, chest pain, fainting,
palpitations, fevers, lightheadedness, or any other concerning
symptoms.

Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) **] 2 weeks after discharge from
rehab
.
2. Please follow up with Dr. [**Last Name (STitle) 4762**] of hematology in 6 months
to help work up the reason why you formed all of these blood
clots. His number is ([**Telephone/Fax (1) 4763**] and you can call in 5 months
to arrange for follow up.
.
3. Please follow up with Dr. [**Last Name (STitle) 1839**] of rheumtology after your
discharge from rehab. fax [**Telephone/Fax (1) 4764**]; phone [**Telephone/Fax (1) 4759**]
{'Other pulmonary embolism and infarction,Hemoperitoneum (nontraumatic),Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Primary hypercoagulable state,Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Injury to bladder and urethra, without mention of open wound into cavity,Acute diastolic heart failure,Rheumatoid arthritis,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Nontraumatic hematoma of soft tissue,Iron deficiency anemia, unspecified,Unspecified accident'}


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: SOB, increasing lower extremity edema

PRESENT ILLNESS: 70 year old female with h/o RA previously on humera and mtx who
was discharged on [**2189-4-11**] when she presented with R shoulder
pain. Her joint was tapped and it demonstrated an inflammatory
joint fluid c/w with RA and negative for septic arthritis.  She
was discharged on ibuprofen prn. Upon return home 3 days prior
to presentation she felt very well but one day later noticed the
gradual onset of dyspnea on exertion.  She also had episodes of
chest twinges overnight which resolved within minutes.  + lower
extremity edema. While in the hospital she was ambulatory.  She
went to [**Country 4754**] over [**Holiday **] and returned on [**2-20**].  She
has not had any long trips or travel rides since then.  At home
she climbed 13 steps twice a day to get to her bedroom. She last
had a mammogram one year ago and it was normal. Her last
colonoscopy was in [**2187-4-12**] and it was normal. + difficulty
swallowing solids which began a few weeks ago.
She saw her rheumatologist Dr. [**Last Name (STitle) 1839**] today who referred her to
the emergency room.
.

MEDICAL HISTORY: RA on adalimumab and MTX
HTN
Hyperlipidemia
s/p left bunionectomy/1st MT osteotomy
Atrophic vaginitis on premarin
R eye scleritis

MEDICATION ON ADMISSION: Confirmed medications with patient.
Amlodipine 5 mg Tablet 1 Tablet(s) by mouth once a day
Esomeprazole Magnesium [Nexium]  40 mg Capsule, Delayed
Release(E.C.)
1 Capsule(s) by mouth once a day
Folic Acid 1 mg Tablet 1 Tablet(s) by mouth once a day
(Prescribed by Other Provider)  [**2189-1-12**]
Ibuprofen 800 mg Tablet 1 Tablet(s) by mouth three times a day
PRN
Lisinopril 40 mg Tablet 1 Tablet(s) by mouth once a day
Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
1 Tablet(s) by mouth once a day
Pravastatin [Pravachol] 20 mg Tablet 1 Tablet(s) by mouth at
bedtime  [**2189-1-13**]
    * OTCs *
Aspirin 81 mg Tablet, Chewable 1 Tablet(s) by mouth once a day
Calcium Citrate-Vitamin D3 [Citracal + D] - 2 T [**Hospital1 **].

ALLERGIES: Penicillins / Shellfish Derived / Simvastatin

PHYSICAL EXAM: Vitals: T99.2  125/80  93  18  93%RA
Pain: denies
Access: TLC R IJ site c/d/i
Gen: nad, obese female, sitting up in chair
HEENT: mmm
CV: RRR, no m appreciated, no S3, S4
Resp: CTAB, slight bibasilar crackles, no wheezing
Abd; soft, very obese, no tenderness, no ecchymosis,  +BS
Ext; +anasarca, 2+ LLE edema, 1+ RLE edema, 1+ RUE edema
Neuro: A&OX3, grossly nonfocal
Skin: no changes
psych: pleasant

FAMILY HISTORY: Mother had diverticulosis. Father had lung disease. Sister had
DM. No family h/o malignancy. First cousin with cancer of
unknown type.

SOCIAL HISTORY: Originally from [**Country 4754**]. Lives in [**Location 3307**] with her husband.
Social ETOH. No tobacco. She works as [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4761**]
housecleaner 3x per week. No falls. Her huband drives otherwise
she is indpendent of IADLS and ADLS. She has a son who lives in
[**Name (NI) 108**]. She walks without a walker or cane. + Glasses. No
dentures or hearing aides. No recent falls. 1 glass/2 < once per
month. 1 pk per week tobacco but quit "many years ago." 

### Response:
{'Other pulmonary embolism and infarction,Hemoperitoneum (nontraumatic),Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Primary hypercoagulable state,Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Injury to bladder and urethra, without mention of open wound into cavity,Acute diastolic heart failure,Rheumatoid arthritis,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Nontraumatic hematoma of soft tissue,Iron deficiency anemia, unspecified,Unspecified accident'}
